Study likely to change standard of care for deadly strokes

This is the whole problem in stroke enumerated in one word; 'care' NOT RECOVERY!

YOU have to get involved and chance this failure mindset of 'care' to 100% RECOVERY!

Study likely to change standard of care for deadly strokes

Date:

December 12, 2024

Source:

University of Pittsburgh

Summary:

Endovascular therapy, a minimally invasive surgery performed inside the blood vessels, is preferred to alternative approaches for vessel obstructions in life-sustaining areas of the brain, analysis suggests.

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Endovascular therapy, or EVT, -- a minimally invasive surgery performed inside the blood vessels -- is 2 ½ times more likely than standard medical management to achieve a positive outcome(A positive outcome is 100% RECOVERY, NOTHING LESS!) after vertebrobasilar stroke that affects the back of the brain, including the brain stem. A meta-analysis of four randomized clinical trials, published today in The Lancet, was led by UPMC Stroke Institute director Raul Nogueira, M.D.

Investigators from the U.S., Netherlands and China formed a multi-center collaboration of all four randomized trials of EVT in vertebrobasilar occlusion with data that provides the strongest evidence to date of the benefits of EVT over alternative approaches for complicated vessel obstructions in life-sustaining areas of the brain.

Article Commentary: “Combining Early Ischemic Change and Collateral Extent for Functional Outcomes After Endovascular Therapy”

 My comments suggest these people are fucking incompetent!

Article Commentary: “Combining Early Ischemic Change and Collateral Extent for Functional Outcomes After Endovascular Therapy”

• Kristina A. Rankine , MD

Tanaka K, Kaveeta C, Pensato U, Zhang J, Bala F, Alhabli I, Horn M, Ademola A, Almekhlafi M, Ganesh A, et al. Combining Early Ischemic Change and Collateral Extent for Functional Outcomes After Endovascular Therapy: An Analysis From AcT Trial. Stroke. 2024;55:1758–1766.

Improvements in endovascular therapy (EVT) have increased the rate of successful reperfusion(Survivors don't give a flying fuck about successful reperfusion, that is only the first step to 100% recovery! WHAT EXACTLY ARE YOUR FOLLOWON STEPS TO GET TO 100%?) in patients with acute ischemic stroke caused by large vessel occlusions. This, in turn, is associated with higher rates of functional independence(And somehow you blithering idiots don't understand survivors want 100% recovery, not just functional independence. 

You'll want that recovery when you become the 1 in 4 per WHO that has a stroke!)

  post-EVT in these patients. Despite this, predicting(I'd have everyone fired who works on predicting recovery rather than delivering recovery!) functional outcomes after EVT remains elusive. Previous studies have highlighted the strong prognostic value of computed tomography perfusion (CTP) or diffusion-weighted imaging evaluation of ischemic core volume (ICV) regardless of reperfusion status.^1,2 Further, CTP defined large core has been shown to be a better predictor of poor outcome than the computed tomography (CT) based Alberta Stroke Program Early Computed Tomography Score (ASPECTS) alone.³ However, it may be beneficial to develop methods to leverage more routinely available imaging modalities such as CT and computed tomography angiography in predicting patient outcomes.

In this post hoc analysis, the authors examined the combined impact of early ischemic changes (EIC) and the extent of collateral circulation in influencing functional outcomes post-EVT. This was examined via utilization of ASPECTS and regional leptomeningeal contrast filling of collaterals, as defined by the multiphase CTA (mCTA) collateral extent to generate a 20-point score called the mCTA-ACE score. The authors aimed to find if the mCTA-ACE score was correlated with functional outcomes post-EVT and if the mCTA-ACE score and CTP-derived ICV were correlated in predicting functional outcomes.

They had an intention-to-treat population of 1577 patients with anterior AIS of whom 368 that had a mCTA and underwent EVT were included in their analysis. The median mCTA-ACE score was 17, and those with mCTA-ACE score >17 had lower baseline National Institutes of Health Stroke Scale, more distal occlusions and lower CTP-derived ICV. In multivariable analysis, the probability of mRS score ≤2, return to prestroke level of function and mRS score ≤1 increased for each 1-point increase in the mCTA-ACE score and the probability of mortality, and any PH decreased for each 1-point increase in the mCTA-ACE score. The authors also analyzed 173 patients who had assessable ICV and found there was an inverse correlation between mCTA-ACE score and ICV, with the mCTA-ACE score and ICV showing similar predictive value for estimating outcomes post-EVT. They showed that patients with minimal EIC and robust collateral circulation had significantly better functional outcomes than those with extensive EIC and poor collateral circulation at least at 90 days post-EVT, further emphasizing the utility of the mCTA- ACE score which combines these elements.

These results suggest that leveraging the mCTA-ACE score could potentially allow clinicians to stratify patients and improve the prediction of patient recovery(I'd have everyone fired who works on predicting recovery rather than delivering recovery!)even when unable to access CTP or other ICV measurements. This potentially expands providers’ ability to predict functional outcomes for patients, allowing for optimization of resource allocation and improving prognosis communication and expectation setting for patients and their families.

The study's findings are promising, but they also raise several questions and have some limitations. One potential issue is the need to standardize imaging protocols and provide further training for assessing EIC and collateral extent. This variation has been shown to depend on the imaging modality and radiologist expertise.⁴ The determination of return to prestroke level of function was obtained through standardized telephone interviews and is inherently subjective, which differs from prior studies that employ the modified Rankin Scale. Lastly, it is important to note that the findings may not be generalizable given the AcT trial took place exclusively in Canada, with all patients receiving thrombolysis (tenecteplase or alteplase), and this analysis derived from a small subset of those patients. Further studies in more diverse populations can aid in validating these results. Additionally, while we understand that "time is brain," the optimal time window for employing EVT in patients with different degrees of early ischemic changes and varying degrees of collateral circulation still needs to be determined. This warrants further investigation of the mechanisms by which collateral circulation influences ischemic injury.

This study demonstrates that integrating early ischemic changes and collateral extent, as assessed through the mCTA-ACE score, can offer an alternate approach to ICV in predicting functional outcomes post-EVT. While the findings are promising, they also highlight the need for further research to validate and expand upon these results.

Cognitive outcomes improved with endovascular therapy in acute ischemic stroke

 Survivors don't want just 'improves'; they want 100% recovery you blithering idiots! GET THERE! You just might want 100% recovery when you are the 1 in 4 per WHO that has a stroke Might be too late then for you to solve the 100% problem!

Cognitive outcomes improved with endovascular therapy in acute ischemic stroke

Key takeaways:

• Researchers engaged in a secondary analysis of the ESCAPE clinical trial in patients with acute ischemic stroke.
• Higher odds of favorable outcome were recorded across all five cognitive tests.

Endovascular therapy was linked with improved outcomes across five cognitive tests in those with acute ischemic stroke, according to research published in Neurology.

“The incidence of dementia is estimated at 8.2% at 1 year after minor stroke and 34% after severe stroke,” Raed A. Joundi, MD, DPhil, a stroke neurologist at Hamilton Health Sciences in Ontario, Canada, and colleagues wrote. “As such, interventions to reduce cognitive impairment has been identified as a priority by stroke survivors.

Latest research found that cognitive outcomes in acute ischemic stroke were improved with endovascular therapy. Image: Adobe Stock

Joundi and colleagues aimed to evaluate the effect of endovascular therapy (EVT) on cognitive function by analyzing results of the Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion with Emphasis on Minimizing CT to Recanalization Times (ESCAPE) trial.

Their study examined data from 315 individuals with acute ischemic stroke, roughly half of whom received EVT (n = 165) and the other cohort as matched controls. Participants underwent cognitive assessments 90 days post-stroke via the Montreal Cognitive Assessment (MoCA), Sunnybrook Neglect Assessment Procedure (SNAP), Boston Naming Test (BNT), Trail-making test A (Trails A), and Trail-making test B (Trails B). Not all participants were able to complete the testing due to cognitive impairment or death and were subsequently placed in the unfavorable performance group.

The researchers utilized logistic regression to evaluate the association between EVT and favorable outcomes based on scores of the five cognitive tests, adjusting for demographic and clinical factors. They additionally employed generalized estimating equations and ordinal regression to determine odds of favorable outcome with EVT on global cognition based on scores from the tests, adding final infarct volume (FIV) on MRI or computerized tomography 24 to 48 hours post stroke to the models to assess its relationship with cognitive outcome.

The researchers reported higher odds of favorable outcome with EVT for all five cognitive tests: MoCA (adjusted OR = 2.32; 95% CI, 1.3–4.16), SNAP (aOR = 3.85; 95% CI, 2–7.45), BNT (aOR = 2.33; 95% CI, 1.3–4.17), trails A (aOR = 3.50; 95% CI, 1.93–6.36), and trails B (aOR = 2.56; 95% CI, 1.46–4.48).

In addition, higher odds of favorable outcome with EVT were recorded with global binary (aOR = 2.57; 95% CI, 1.67–3.94) and ordinal analyses (aOR = 2.83; 95% CI, 1.68–4.76) of cognitive function. Upon further analyses, both FIV and EVT were also significantly associated with cognitive outcome.

“We believe the results represent compelling randomized trial evidence for the cognitive benefit of acute stroke therapy because they are consistent across domains of cognitive function,” Joundi and colleagues wrote.

Sources/Disclosures

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Source:

Joundi RA, et al. Neurology. 2024;doi:10.1212/WNL0000000000209270.

Disclosures: Joundi reports no relevant financial disclosures. Please see the study for all other authors’ relevant financial disclosures.

Endovascular therapy improved ischemic stroke outcomes at 1 year

 Anytime I see the word 'improves' I know the stroke medical world is using the tyranny of low expectations to justify failure. 100% recovery is the only goal in stroke; ANYTHING LESS IS COMPLETE FAILURE!

Endovascular therapy improved ischemic stroke outcomes at 1 year

Key takeaways:

• The study examined 352 individuals with stroke randomized to EVT and medical care or medical care alone.
• EVT intervention led to improved functional independence and better ambulation.

DENVER — In patients with ischemic stroke, treatment with endovascular therapy with medical care led to better functional outcomes at 1 year compared with medical care alone. according to a speaker.

“In 2023, we had several trials that were groundbreaking in our field, that showed significant benefit for endovascular therapy for patients who present with large core ischemic stroke,” Amanda Opaskar, MD, a vascular neurologist and assistant professor of neurology at Case Western Reserve University, said during her presentation at the American Academy of Neurology annual meeting.

Recent research has determined benefits of endovascular therapy for ischemic stroke outcomes at 1 year. Image: Adobe Stock

“The question was how do these patients recover over that longer term, first year.”

Opaskar and colleagues sought to evaluate safety and efficacy of endovascular therapy (EVT) for ischemic stroke in the SELECT2 trial using clinical outcomes at 1-year follow-up. SELECT2 was a phase 3, international, multicenter, prospective, randomized, open-label trial with blinded endpoint assessment.

It included 352 individuals diagnosed with a large ischemic core on non-contrast CT (ASPECTS 3-5) scan, perfusion or MRI who received either EVT and best medical management (n = 178; median age 66 years; 71% female) or best medical management only (n = 174; median age 67 years; 74% female).

The study’s primary outcome was modified Rankin Scale (mRS) score at 1-year follow-up, evaluated using generalized odds ratio (GOR), with secondary outcomes including functional independence (0 to 2 mRS score), independent ambulation (mRS 0 to 3) and quality of life scores at 1-year follow-up.

A total of 93% (329 of 352) of enrollees completed the follow-up, with 23% of those who received EVT recording an mRS score of 0 to 2 compared with 8% of those who received medical care only.

Thrombectomy significantly improved the 1-year mRS score distribution (WMW probability of superiority = 0.59; 95% CI, 0.53-0.64; GOR = 1.43; 95% CI, 1.14-1.78), functional independence (EVT: 24% vs MM: 6%, RR = 3.17; 95% CI, 1.73-5.79) and independent ambulation (EVT: 37% vs MM: 18%, RR =1.85; 95% CI, 1.3-2.63) compared with medical care alone.

Data additionally showed EVT led to better QoL scores in functional independence, mobility, ambulation, sociability, cognition and depression compared with medical care alone.

“It is important to note we think about the potential recovery of these patients both in clinical trial design as well as when we are counseling (them),” Opaskar said. “That their recovery extends not just in 3 months, but it goes longer, up to a full year.”

Sources/Disclosures

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Source:

Opaskar A, et al. Long-term outcomes and EVT treatment effect from randomized controlled trial of endovascular thrombectomy for large ischemic strokes (SELECT2). Presented at: American Academy of Neurology annual meeting; April 13-18, 2024; Denver.

Disclosures: Opaskar reports no relevant financial disclosures.

Endovascular therapy improved ischemic stroke outcomes at 1 year

 You blithering idiots actually think 'improves' is what survivors want? They want 100% recovery; nothing less! WHEN THE HELL WILL YOU START TRYING TO GET THERE?

I'd have you all fired for incompetence!

Endovascular therapy improved ischemic stroke outcomes at 1 year 

Key takeaways:

• The study examined 352 individuals with stroke randomized to EVT and medical care or medical care alone.
• EVT intervention led to improved functional independence and better ambulation.

DENVER — In patients with ischemic stroke, treatment with endovascular therapy with medical care led to better functional outcomes at 1 year compared with medical care alone. according to a speaker.

“In 2023, we had several trials that were groundbreaking in our field, that showed significant benefit for endovascular therapy for patients who present with large core ischemic stroke,” Amanda Opaskar, MD, a vascular neurologist and assistant professor of neurology at Case Western Reserve University, said during her presentation at the American Academy of Neurology annual meeting.

Recent research has determined benefits of endovascular therapy for ischemic stroke outcomes at 1 year. Image: Adobe Stock

“The question was how do these patients recover over that longer term, first year.”

Opaskar and colleagues sought to evaluate safety and efficacy of endovascular therapy (EVT) for ischemic stroke in the SELECT2 trial using clinical outcomes at 1-year follow-up. SELECT2 was a phase 3, international, multicenter, prospective, randomized, open-label trial with blinded endpoint assessment.

It included 352 individuals diagnosed with a large ischemic core on non-contrast CT (ASPECTS 3-5) scan, perfusion or MRI who received either EVT and best medical management (n = 178; median age 66 years; 71% female) or best medical management only (n = 174; median age 67 years; 74% female).

The study’s primary outcome was modified Rankin Scale (mRS) score at 1-year follow-up, evaluated using generalized odds ratio (GOR), with secondary outcomes including functional independence (0 to 2 mRS score), independent ambulation (mRS 0 to 3) and quality of life scores at 1-year follow-up.

A total of 93% (329 of 352) of enrollees completed the follow-up, with 23% of those who received EVT recording an mRS score of 0 to 2 compared with 8% of those who received medical care only.

Thrombectomy significantly improved the 1-year mRS score distribution (WMW probability of superiority = 0.59; 95% CI, 0.53-0.64; GOR = 1.43; 95% CI, 1.14-1.78), functional independence (EVT: 24% vs MM: 6%, RR = 3.17; 95% CI, 1.73-5.79) and independent ambulation (EVT: 37% vs MM: 18%, RR =1.85; 95% CI, 1.3-2.63) compared with medical care alone.

Data additionally showed EVT led to better QoL scores in functional independence, mobility, ambulation, sociability, cognition and depression compared with medical care alone.

“It is important to note we think about the potential recovery of these patients both in clinical trial design as well as when we are counseling (them),” Opaskar said. “That their recovery extends not just in 3 months, but it goes longer, up to a full year.”

Sources/Disclosures

Collapse

Source:

Opaskar A, et al. Long-term outcomes and EVT treatment effect from randomized controlled trial of endovascular thrombectomy for large ischemic strokes (SELECT2). Presented at: American Academy of Neurology annual meeting; April 13-18, 2024; Denver.

Disclosures: Opaskar reports no relevant financial disclosures.

Computed tomography perfusion deficit volume predicts the functional outcome of endovascular therapy for basilar artery occlusion

 Predicting high risk is totally fucking useless without protocols to address and alleviate that risk! Does anyone in stroke actually have two functioning neurons to rub together?

Computed tomography perfusion deficit volume predicts the functional outcome of endovascular therapy for basilar artery occlusion

Author links open overlay panel

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https://doi.org/10.1016/j.jstrokecerebrovasdis.2024.107677Get rights and content

Abstract

Objectives

To investigate the relationship between baseline computed tomography perfusion deficit volumes and functional outcomes in patients with basilar artery occlusion (BAO) undergoing endovascular therapy.

Methods

This was a single-center study in which the data of 64 patients with BAO who underwent endovascular therapy were retrospectively analyzed. All the patients underwent multi-model computed tomography on admission. The posterior-circulation Acute Stroke Prognosis Early Computed Tomography Score was applied to assess the ischemic changes. Perfusion deficit volumes were obtained using Syngo.via software. The primary outcome of the analysis was a good functional outcome (90-day modified Rankin Scale score ≤ 3). Logistic regression and correlation analyses were used to explore predictors of functional outcome.

Results

A total of 64 patients (median age, 68 years; 72% male) were recruited, of whom 26 (41%) patients achieved good functional outcomes, while 38 (59%) had poor functional outcomes. Tmax > 10 seconds, Tmax > 6 seconds, and rCBF < 30% volume were independent predictors of good functional outcomes (odds ratio range, 1.0–1.2; 95% confidence interval [CI], 1.0–1.4]) and performed well in the receiver operating characteristic curve analyses, exhibiting positive prognostic value; the areas under the curve values were 0.85 (95% CI, 0.75–0.94), 0.81 (95% CI, 0.70–0.90), and 0.78 (95% CI, 0.67–0.89).

Conclusion

Computed tomography perfusion deficit volume represents a valuable tool in predicting high risk of disability and mortality in patients with BAO after basilar endovascular treatment.

Introduction

Basilar artery occlusion (BAO) is estimated to have an annual incidence of 4 cases per 100,000¹, accounting for 1% of all ischemic strokes. BAO results in death and disability in approximately 80% of affected patients who do not undergo intervention and it is currently a prominent cause of disability and death in stroke^2,3. Guidelines recommend endovascular treatment (EVT) as a treatment for anterior circulation occlusion⁴. The results of recent randomized trials, including the Basilar Artery Occlusion Chinese Endovascular trials (BAOCHE)⁵, Acute Basilar Artery Occlusion Study (BASILAR)⁶, and Trial of Endovascular Treatment of Acute Basilar-Artery Occlusion (ATTENTION) ⁷, showed that EVT led to a higher percentage of good functional status 90 days post-procedure compared with medical therapy among patients with stroke due to BAO. EVT is expected to benefit patients with BAO; however, it requires an effective patient selection strategy^8,9.

Using a correct imaging method could help predict the functional outcomes for patients with BAO10, 11, 12. The most commonly used imaging method for stroke is non-contrast computed tomography (NCCT), which can effectively exclude hemorrhagic strokes. Computed tomography angiography (CTA) is valuable for detecting vascular occlusions and is often used to select patients for EVT. The posterior-circulation Acute Stroke Prognosis Early Computed Tomography Score (pc-ASPECTS) ¹³ is a predictor of clinical functional outcome of posterior circulation in ischemic patients. The pc-ASPECTS score based on computed tomography perfusion (CTP) images has higher value than the pc-ASPECTS score based on conventional NCCT and CTA source images (CTA-SI) for ultra-early stroke exploration and prognosis prediction¹⁴.Notably, CTP deficit volume is closely related to the functional prognosis of patients with ischemic stroke. Patients with an ischemic core of ≥70 mL do not benefit from EVT regardless of the imaging method used¹⁵. The DAWN¹⁶ and DEFUSE 3¹⁵ studies conditionally extended the window of time for EVT of ischemic stroke in the anterior circulation through perfusion deficit volume from the original 6 hours to 24 hours. However, few studies on posterior circulation hypoperfusion volumes exist, and the criteria, such as the DAWN¹⁶ and DEFUSE 3¹⁵ studies, that can be used for selecting patients with BAO for EVT beyond this window of time are not uniform. To date, no large, randomized trials of EVT in patients with BAO has used CTP deficit volumes as an inclusion criteria for patient screening.

Our study aimed to determine CTP parameters that can support clinical decision-making, using the automated software Syngo.via (Siemens) to explore the relationship between perfusion deficit volume and functional outcomes in patients with BAO undergoing EVT.

More at link.

Endovascular thrombectomy improves functional outcomes in large ischemic stroke

But it doesn't improve it enough to 100% recovery, so as such it is still a failure as survivors would describe it. Don't use your tyranny of low expectations to declare success on this failure.

Endovascular thrombectomy improves functional outcomes in large ischemic stroke

Key takeaways:

• Endovascular thrombectomy with medical care resulted in better functional outcomes than standard care alone in patients with large ischemic stroke.
• Procedural vascular complications occurred with thrombectomy.

Endovascular thrombectomy with standard medical care was associated with better functional outcomes than medical care alone in patients with acute ischemic stroke due to large-vessel occlusion, according to study results.

“Endovascular thrombectomy has been shown to be more effective in reducing disability than medical therapy alone in selected patients with ischemic stroke due to a large cerebral vessel occlusion,” Amrou Sarraj, MD, director of the Cerebrovascular Center and Comprehensive Stroke Center at University Hospitals Cleveland Medical Center, and colleagues wrote in The New England Journal of Medicine. “However, patients with large strokes on non-contrast CT or perfusion imaging have been underrepresented in thrombectomy trials, despite that such strokes account for approximately one fifth of large-vessel occlusion strokes.”

A multi-site study found endovascular thrombectomy improves functional outcomes in large ischemic stroke. Image: Adobe Stock

Researchers sought to evaluate the effectiveness of endovascular thrombectomy within 24 hours following onset of ischemic stroke compared with standard medical care alone.

Their prospective randomized, open-label trial was conducted at 31 sites in five countries across the globe and included 352 individuals aged 18 to 85 years with acute ischemic stroke due to occlusion of the internal carotid artery or the M1 segment of the middle cerebral artery. Eligible patients had a large ischemic-core volume, defined by an Alberta Stroke Program Early Computed Tomography Score of 3 to 5 (lower scores indicating larger infarction) or a core volume of at least 50 mL on CT perfusion or diffusion-weighted MRI.

Participants were assigned 1:1 to receive either endovascular thrombectomy plus medical care (n = 178) or medical care alone (n = 174). The primary outcome for the study was modified Rankin scale (mRS) score at 90 days, with higher scores indicating greater disability. Functional independence and independent ambulation, also measured by mRS, were among secondary outcomes. Researchers assessed participants at baseline and at 24 hours, 5 to 7 days, 30 days and 90 days following randomization.

The study was halted early for efficacy. At 90 days, the median mRS score for thrombectomy patients was 4 compared with 5 in those given standard medical care alone (generalized OR = 1.51; 95% CI, 1.2-1.89).

Researchers reported functional independence in 20.3% of patients in the thrombectomy group vs. 7% in the medical-care group (RR = 2.97; 95% CI, 1.6-5.51), and independent ambulation in 37.9% and 18.7%, respectively (RR = 2.06; 95% CI, 1.43-2.96).

Symptomatic intracranial hemorrhage occurrence within 24 hours was low in both groups (0.6% and 1.1%, respectively); however, some patients in the thrombectomy group experienced procedural vascular complications.

“Our results, which reflect outcomes in geographic populations that are different from those in previous trials, may support extending the indication for thrombectomy to patients with a large ischemic core on baseline imaging,” Sarraj and colleagues wrote.

Fewer Poststroke Functional Improvement Seen in EVT-Treated Patients With Lower ASPECTS Scores

So what are the next steps to prevent these problems and WHO IS DOING THEM? Nothing will occur, we have fucking failures of stroke associations  and NO stroke leadership.

Fewer Poststroke Functional Improvement Seen in EVT-Treated Patients With Lower ASPECTS Scores

More than 40% of patients with ASPECTS scores between 4 and 5 treated with EVT showed functional outcome improvements, whereas slightly over 20% of those with scores between 0 to 3 demonstrated the same.

Takeshi Morimoto, MD, PhD, MPH

Findings from a secondary analysis of the RESCUE-Japan LIMIT study (NCT03702413) showed that endovascular therapy (EVT) was not associated with improvement in functional outcomes at 90 days in patients post stroke with Alberta Stroke Program Early Computed Tomography Scores (ASPECTS) 3 or less and was associated with a significantly higher incidence of intracranial hemorrhage within 48 hours.¹

Of patients with ASPECTS scores of 3 or less, 21.4% (n = 12) of those in the EVT group and 18.0% (n = 9) of those who did not receive EVT had a modified Rankin Scale (mRS) score of 0 to 3, considered good functional outcome (odds ratio [OR], 1.24; 95% CI, 0.47-3.26). In comparison, for those with ASPECTS scores of 4 to 5, 43.2% (n = 19) of patients on EVT and 7.7% (n = 4) of those without EVT achieved similar scores at 90 days (OR, 9.12; 95% CI, 2.80-29.70; P = .01).

Led by Takeshi Morimoto, MD, PhD, MPH, professor of medicine, Hyogo College of Medicine, Japan, the study aimed to compare the efficacy and safety of EVT according to ASPECTS scores of 3 or less vs those of 4 to 5. The original findings from RESCUE-Japan LIMIT suggested efficacy of EVT in patients with a large ischemic core—ASPECTS scores of 3 to 5—however, there was still a difference in disease severity in patients within that score range, and thus, the goal of this new assessment was to understand the threshold of when EVT stops being beneficial.

The study enrolled 203 patients from November 2018 to September 2021, with follow-up ending in December 2021. Consistent with the main report, the primary outcome of the study was an mRS score of 0 to 3 at 90 days after onset. After 1 patient withdrew consent, the final sample included 106 individuals (52%) with ASPECTS scores of 3 or less and 96 with ASPECTS scores of 4 to 5. The characteristics between the groups were numerically similar, although those with ASPECTS scores of 3 or less had larger infarction volume (126 mL vs 89 mL; P <.001) and higher median C-reactive protein values (0.25 mg/dL vs 0.13 mg/dL; P = .008).

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Achievment of mRS score between 0 to 2 was also significant in those with ASPECTS scores of 4 to 5 (OR, 8.33; 95% CI, 1.73-40.0) but not in those with ASPECTS scores of 3 or less (OR, 0.42; 95% CI, 0.10-1.77; P = .003). The ordinal shift across the range of mRS scores toward a better outcome was also significant in those with ASPECTS scores of 4 to 5 (common OR, 4.48; 95% CI, 2.07-9.71) but not in those with ASPECTS scores of 3 or less (common OR, 1.56; 95% CI 0.79-3.10), and the differences in the effect were significant (P = .046). Additionally, at 48 hours posttreatment, improvement in National Institutes of Stroke Scale score in those with ASPECTS scores of 3 or less (OR, 3.83; 95%, 1.17-12.6) or scores of 4 to 5 (OR, 5.92; 95% CI, 1.96-17.8; P = .60).

For ASPECTS scores of 3 or less, symptomatic intracranial hemorrhage (sICH) occurred in 10.7% of those on EVT vs 6.0% of those without (OR, 1.88; 95% CI, 0.44-7.95). Of those with ASPECTS scores of 4 to 5, 6.8% experienced sICH in the EVT group compared with 3.8% in the no EVT group (OR, 1.83; 95% CI, 0.29-11.5). Conversely, the risk of ICH was more prominent in those with lower ASPECTS scores when EVT was conducted (OR, 4.14; 95% CI, 1.84-9.32) than those with ASPECTS scores of 4 to 5 (OR, 2.05; 95% CI, 0.89-4.73), but the interaction was not significant (P = .24).

REFERENCE
1. Uchida K, Shindo S, Yoshimura S, et al. Association between Alberta Stroke Program Early Computed Tomography Score and efficacy and safety outcomes with endovascular therapy in patients with stroke from large-vessel occlusion: a secondary analysis of the recovery by endovascular salvage for cerebral ultra-acute embolism-Japan large ischemic core trial (RESCUE-Japan LIMIT). JAMA Neurol. Published online October 10, 2022. doi:10.1001/jamaneurol.2022.3285.

Basilar Stroke Thrombectomy Finally Wins for Efficacy in Randomized Trials

This is the low bar for efficacy in stroke; 'good functional status', NOT 100% RECOVERY!  Until we get survivors in charge we will never get past the tyranny of low expectations the stroke medical world wants us to accept as good.

Basilar Stroke Thrombectomy Finally Wins for Efficacy in Randomized Trials

Promising results of endovascular therapy outside the anterior circulation

by Nicole Lou, Senior Staff Writer, MedPage Today October 12, 2022

Renewed attempts to show that endovascular therapy can work in basilar artery occlusion stroke did pan out in China, justifying further study in other populations.

The ATTENTION and BAOCHE randomized trials found significantly greater odds of good functional status in people with moderate or severe stroke due to basilar artery occlusion who underwent thrombectomy at experienced Chinese centers. The incidence of people achieving modified Rankin scale (mRS) scores of 0-3 at 90 days reached:

• 46% with thrombectomy vs 23% with medical therapy alone (adjusted RR 2.06, 95% CI 1.46-2.91) in ATTENTION

• 46% vs 24% (adjusted RR 1.81, 95% CI 1.26-2.60) in BAOCHE

ATTENTION counted 340 participants and BAOCHE, 217. Both trials had full manuscripts published in the New England Journal of Medicine.

Notably, unlike some stroke populations in the West, the two Chinese cohorts tended to have a relatively high prevalence of intracranial large artery atherosclerosis -- typically treated with angioplasty or stenting atop any planned thrombectomy -- and low use of IV thrombolysis.

Investigators had also allowed endovascular therapy to be tested relatively late after stroke onset, unlike the older BEST and BASICS trials that had failed to prove a significant benefit to endovascular therapy over best medical care alone.

Based on ATTENTION and BAOCHE, endovascular therapy "appears to be effective in patients with basilar-artery occlusion who have moderate-to-severe neurologic deficits and have limited early ischemic changes up to 24 hours after stroke onset," concluded Wouter Schonewille, MD, of Sint Antonius Hospital in Nieuwegein, the Netherlands.

"Further randomized, controlled trials in basilar-artery stroke are warranted in broader populations to test the efficacy of endovascular therapy in patients with mild deficit and to test the efficacy of intravenous thrombolysis in the extended time window (>4.5 hours after stroke onset)," he wrote in an accompanying editorial.

As for safety, the feared complication of symptomatic intracranial hemorrhage occurred in 5% of the thrombectomy group (and none among controls) in ATTENTION; in BAOCHE, the incidence was 6% (vs 1%). Overall procedural complications occurred in 14% and 11%, respectively, of thrombectomy patients in these two trials.

Mortality at 90 days was significantly reduced with thrombectomy in ATTENTION (37% vs 55%, adjusted RR 0.66, 95% CI 0.52-0.82) but not in BAOCHE (31% vs 42%, adjusted RR 0.75, 95% CI 0.54-1.04).

Schonewille noted that basilar artery occlusion strokes may account for a minority of strokes in clinical practice, but are associated with the highest morbidity and mortality.

ATTENTION was conducted in 2021-2022 at 36 centers in China. Patients were randomized to thrombectomy (n=226) or medical therapy alone (n=114). Mean age was around 67 years, and men accounted for approximately 70% of patients. Median NIH Stroke Scale (NIHSS) score was 24 in both groups at baseline.

Eligible stroke patients were randomized within 12 hours after the estimated time of basilar artery occlusion; ultimately, the delay was a median 5 hours. IV thrombolysis was used in 31% of the patients in the thrombectomy group and in 34% of controls in the trial.

The BAOCHE trial was conducted separately in 2016-2021 and had 217 people randomized 1:1 to thrombectomy or medical therapy alone. Median age was 65 years, and women constituted 27% of the cohort. The median NIHSS score was 20 at baseline.

Eligibility criteria included presentation 6-24 hours after stroke onset; the median was just over 11 hours. IV alteplase was given to 14% of the thrombectomy arm and 21% of those getting medical therapy alone.

The BAOCHE authors cautioned about protocol changes during their trial, namely the change in primary outcome from the original of mRS 0-4 -- an endpoint that would have been neutral for endovascular therapy (adjusted RR 1.21, 95% CI 0.95-1.54). What's more, the trial had been terminated early for efficacy.

• 

  Nicole Lou is a reporter for MedPage Today, where she covers cardiology news and other developments in medicine. Follow

Disclosures

ATTENTION was supported by the Program for Innovative Research Team of the First Affiliated Hospital of the University of Science and Technology of China, the Beijing Dingyi Foundation (China Special Fund for Stroke Prevention and Treatment), and the Beijing Healthunion Cardio-Cerebrovascular Disease Prevention and Treatment Foundation.

BAOCHE was funded by a grant from the Chinese National Ministry of Science and Technology.

Schonewille reported personal fees from Nanjing University.

Primary Source

New England Journal of Medicine

Source Reference: Tao C, et al "Trial of endovascular treatment of acute basilar-artery occlusion" New Engl J Med 2022; DOI: 10.1056/NEJMoa2206317.

Secondary Source

New England Journal of Medicine

Source Reference: Jovin TG, et al "Trial of thrombectomy 6 to 24 hours after stroke due to basilar-artery occlusion" New Engl J Med 2022; DOI: 10.1056/NEJMoa2207576.

Additional Source

New England Journal of Medicine

Source Reference: Schonewille WJ "Favorable outcomes in endovascular therapy for basilar-artery occlusion" New Engl J Med 2022; DOI: 10.1056/NEJMe2210737.

Women were less likely to return to work after a severe stroke, new study finds

 Wrong endpoint measured. Return to work is not anywhere close to 100% recovery.  How many of those returnees were fired or had to quit because they couldn't handle the job? Bad research followthru. I blame the mentors and senior researchers for such crapola.  Misleading research since it would have excluded the older retirees not needing to go back to work. Does no one in stroke actually know how to do research?

Women were less likely to return to work after a severe stroke, new study finds

Stroke Journal Report

Research Highlights:

• A new study in Germany found that after a severe stroke treated with mechanical clot removal, about one third of stroke survivors resumed work three months later.
• Women were about half as likely to return to work three months after a severe stroke compared to men.
• The likelihood of returning to work for both men and women after a severe stroke was higher if they were treated with combined mechanical clot removal and clot-busting stroke medications as compared to mechanical clot removal alone.

Embargoed until 4 a.m. CT/5 a.m. ET Thursday, April 21, 2022

DALLAS, April 21, 2022 — According to new research, about one third of people who had a large vessel (severe) ischemic stroke, treated with mechanical clot removal, resumed work three months after stroke treatment. However, women were about half as likely to return to work after a severe stroke compared to men, according to the study published today in Stroke, the peer-reviewed, flagship journal of the American Stroke Association, a division of the American Heart Association.

A stroke due to a blockage in a large blood vessel is an indicator of a severe stroke and the potential for continuing loss of function, which makes it less likely people will return to work. According to the American Heart Association, while ischemic stroke accounts for 87% of strokes in the United States, large vessel occlusions only account for approximately 24% - 46% of ischemic strokes.

Endovascular therapy (mechanical clot removal) and clot-busting medications are now a standard treatment for select patients with severe stroke. Endovascular therapy involves threading a slim catheter through a vessel in the leg to mechanically remove a clot blocking a brain vessel. In 2018, the American Heart Association stroke treatment guidelines were updated to recommend mechanical clot removal for select stroke patients to improve the odds of functional recovery.

“Returning to work after a severe stroke is a sign of successful rehabilitation. Resuming pre-stroke levels of daily living and activities is highly associated with a better quality of life,” said Marianne Hahn, M.D., lead study author and a clinician scientist in the department of neurology at Johannes Gutenberg University in Mainz, Germany. “In contrast to most return-to-work studies, we included a large cohort of only people treated with mechanical clot removal; they are a subgroup of stroke patients at high risk for severe, persisting deficits.”

Researchers examined data from the German Stroke Registry - Endovascular Treatment Study Group. The analysis included more than 600 men and women (28% women), ages 18- to 64-years-old who had a large vessel ischemic stroke between 2015 and 2019.

All study participants were employed prior to their stroke and were treated with mechanical thrombectomy. More than half of the study participants also received intravenous thrombolysis (clot-busting medication).

Researchers compared the people who returned to work 90 days after being treated with mechanical thrombectomy to those who did not resume work. After accounting for age, sex, health conditions, type and severity of stroke, and treatment characteristics, the analysis found:

• About one-third of the stroke survivors resumed work three months later.
• The amount of persistent functional deficits after stroke was the main reason people were not able to return to work.
• Women were 58% less likely to return to work three months after mechanical thrombectomy compared to men.
• Individuals who were treated with both mechanical thrombectomy and intravenous thrombolysis were almost twice as likely to return to work compared to the individuals who had undergone mechanical thrombectomy only.

“After examining the data further, we also found that women in our cohort were younger at the time of their stroke, were more likely to be non-smokers and were more likely to have no existing significant disability when discharged from the hospital compared to the men in our study. Despite having more of these favorable characteristics for return to work, we did not observe a higher re-employment rate among women before considering these differences,” Hahn said.

The researchers noted further study is needed to explain the discrepancy between men and women re-entering the workforce after a major stroke. More intensive and supportive vocational rehabilitation programs may be valuable to help women return to work.

“There is more to re-employment after mechanical thrombectomy than functional outcomes,” Hahn said. “Targeted vocational and workplace rehabilitation interventions have been shown to improve rates of return to work. And previous studies have also found that returning to work is associated with increased well-being, self-esteem and life satisfaction.”

The study authors believe their findings may be transferable to other countries with similar health care and rehabilitation systems. However, confirmation and in-depth analyses of national policies are necessary to explain the observation since there may be differences, such as social services and benefits, which have been shown to influence return to work.

The study was limited in that the data lacked detailed information about types of jobs and available employment opportunities. The German Stroke Registry does not include social determinants of health, and whether an individual was re-employed at the same job or working full- or part-time. Researchers noted these limitations may help explain and play a role in whether people returned to work after a severe stroke.

In the U.S., stroke is the fifth leading cause of death and a leading cause of disability, according to the latest data from the American Heart Association. To recognize stroke symptoms requiring immediate medical attention, the American Stroke Association recommends everyone remember the acronym F.A.S.T. for Face drooping, Arm weakness, Speech difficulty, Time to call 9-1-1.

Co-authors are Sonja Gröschel, M.D.; Eyad Hayani, M.D.; Marc A. Brockmann, M.D.; Muthuraman Muthuraman, Ph.D.; Klaus Gröschel, M.D.; and Timo Uphaus, M.D. Authors’ disclosures are listed in the manuscript.

The researchers reported no outside funding sources for this study.

Studies published in the American Heart Association’s scientific journals are peer-reviewed. The statements and conclusions in each manuscript are solely those of the study authors and do not necessarily reflect the Association’s policy or position. The Association makes no representation or guarantee as to their accuracy or reliability. The Association receives funding primarily from individuals; foundations and corporations (including pharmaceutical, device manufacturers and other companies) also make donations and fund specific Association programs and events. The Association has strict policies to prevent these relationships from influencing the science content. Revenues from pharmaceutical and biotech companies, device manufacturers and health insurance providers and the Association’s overall financial information are available here.

 

Incidence, clinical spectrum, and immunotherapy of non-ischemic cerebral enhancing lesions after endovascular therapy

 So you described a problem, but did nothing to solve it. USELESS!

Incidence, clinical spectrum, and immunotherapy of non-ischemic cerebral enhancing lesions after endovascular therapy

Show all authors

Antonios Bayas*, Monika Christ*, Ansgar Berlis, ...

First Published January 31, 2022 Research Article 

https://doi.org/10.1177/17562864211072372

Article information

Abstract

Background:

Symptomatic and asymptomatic delayed non-ischemic cerebral enhancing (NICE) lesions in magnetic resonance imaging (MRI) have been reported as a rare complication after endovascular therapy (EVT) in recent years with incidence rates between 0.05% and 0.9% in most studies. Information on long-term clinical course and immunotherapies is scarce or has not been reported in detail in the literature.

Objective:

Aims of our study were to assess the incidence of NICE lesions in patients after cerebral EVT over a period of more than 12 years, describe clinical and EVT characteristics, and immunotherapies applied.

Methods:

A retrospective chart review of all patients treated by endovascular therapy for symptomatic or asymptomatic aneurysms at the University Hospital of Augsburg from May 1, 2008 to December 31, 2020 was performed. Patients were identified retrospectively and followed-up prospectively where appropriate. In addition, one case treated at another institution was included.

Results:

Five out of 746 patients, 0.67%, developed NICE lesions after EVT, all with non-ruptured aneurysms and all symptomatic upon detection of NICE lesions by MRI. In total, the disease course of 6 female patients is reported. Symptoms occurred after a mean time of 15 days (±13.42, SD) after EVT with headache (6/6 patients), focal neurological signs (6/6 patients), epileptic seizures (2/6 patients) and cognitive deficits (3/6 patients). All 6 patients received glucocorticosteroids (GCS), 1/6 azathioprine (AZA), 4/6 mycophenolate mofetil (MMF), 1/6 methotrexate (MTX), 1/6 rituximab (RTX), 2/6 cyclophosphamide (CYC) and 3/6 tocilizumab (TCZ). A treatment response could be observed for GCS, TCZ and MMF (in two of four cases), RTX and AZA did not result in disease stabilization.

Conclusions:

Delayed NICE lesions are a rare complication after EVT, requiring immunotherapies in all patients reported here. Physicians should be aware(What good does being aware do if there is no solution to the problem? Oh you have this problem, but I know nothing about treating it.) of this disorder in case of new symptoms or contrast enhancing lesions after EVT.

Keywords

aneurysm, endovascular therapy, MRI, NICE, non-ischemic cerebral enhancing lesions

Introduction

Standard of care for treatment of cerebral aneurysms has been dominated by endovascular therapy (EVT) in recent years. Main complications of endovascular coiling are procedural aneurysm perforations and thromboembolic events.¹ Delayed non-ischemic cerebral enhancing (NICE) lesions in magnetic resonance imaging (MRI) have rarely been reported as a complication after EVT.^2–8 Punctate, nodular or annular foci of leptomeningeal, cortical, and subcortical enhancements and perilesional edema⁸ in the territory of the endovascular access of EVT represent characteristics of NICE lesions. The disorder has also been termed as delayed cerebral hypersensitivity,⁴ leukoencephalopathy⁹ or descriptively as reversible intracranial parenchymal changes.⁷ Incidence rates after EVT are reported to be as high as 0.05%¹⁰ to 0.9%,¹¹ except for one study reporting a higher incidence rate of 2.3%.¹² Several studies have been published on the pathogenesis of NICE lesions: Besides foreign body emboli, in some patients identified as hydrophilic polymer coating emboli, and subsequent granulomatous reactions,^{2,3,5,6,8,13,14} cerebral metallic hypersensitivity and nickel allergy^4,7,15 have been reported. Successful treatment with glucocorticosteroids (GCS) has been described in many cases, other immunosuppressants like mycophenolate mofetil (MMF) or azathioprine (AZA) in few cases only.^13,16,17 However, data on long-term follow-up and response to long-term treatments are scarce and have not been reported in detail in many cases.

Main aims of our study were (a) to compute the incidence of NICE lesions in patients undergoing cerebral EVT over 12 years and 8 months, (b) describe clinical and EVT characteristics of patients affected, and (c) immunotherapies used, including long-term follow-up.

More at link.

 

Endovascular Therapy is Effective for Large Vessel Occlusion Despite Concurrent Cancer

 Since your definition of effective is wrong, will you please get out of stroke and let better persons in? Effective is 100% recovery, not recanalization. 

Recanalization is only the first step in stroke recovery, there are many needed to follow. WHERE THE FUCK ARE THEY?

Endovascular Therapy is Effective for Large Vessel Occlusion Despite Concurrent Cancer

• Thomas K. Mattingly, MD, MSc
• Jorge E. Risco, MD
• Jaclyn E. Burch, MD
• 
  
• Stephen Susa, BS
• Tarun Bhalla, MD, PhD
• Matthew T. Bender, MD
• Show all authors

Published:March 18, 2022DOI:https://doi.org/10.1016/j.jstrokecerebrovasdis.2022.106439

Abstract

Objectives

Ischemic stroke and concurrent cancer is increasingly recognized. However, optimal management is uncertain. As mechanical thrombectomy has become the standard of care for large vessel occlusion, more patients with cancer are presenting for embolectomy. However, it is unknown whether this subgroup has the same benefit profile described in multiple randomized trials for thrombectomy for large vessel occlusion. Our objective was to retrospectively evaluate a North American embolectomy database for safety and outcomes in patients with active cancer.

Materials and methods

A case series of 284 embolectomies over 30 months at a single North American stroke center were divided into thrombectomy patients with active cancer(n=25) and those without active cancer (n=259). We compared patient characteristics, procedural characteristics, and procedural outcomes between patients with and without active cancer. Univariate and multivariate analysis of angiographic outcomes, postoperative hemorrhage, and functional outcome was performed.

Results

Of the 284 thrombectomy cases, 9% were performed on patients with active cancer. Active cancer patients had a similar recanalization grade and post-operative hemorrhage rate, compared to patients without cancer. Active cancer patients had a significantly higher 90 day mortality (40% vs 20%, p=0.018). On multivariate analysis, good functional outcome (mRS 0-2) was not impacted by active cancer. However, when mRS was evaluated as an ordinal shift analysis, worse functional outcome was associated with active cancer (OR 2.98; 95% CI, 1.29 to 6.59), greater age, NIHSS> 10, and ASPECTS<9.

Conclusions

This single center retrospective series of active cancer patients undergoing thrombectomy for large vessel occlusion demonstrates similar rates of recanalization, post-operative hemorrhage, and good outcomes. While the active cancer group has a high short-term mortality, the potential to maintain quality of life in the survivors makes thrombectomy reasonable in this patient population. Awareness of ischemic stroke as a complication of cancer and the safety of thrombectomy in this population are important as this population subtype is expected to grow with improved oncology and stroke care