Predictive role of a combined model for futile recanalization in acute ischemic stroke: a retrospective cohort study

The correct objective would be to determine why futile recovery occurs after mechanical thrombectomy!  The goal of every stroke survivor is 100% recovery, they don't care about recanalization unless it leads directly to 100% recovery. Don't any of you know how to think?

Predictive role of a combined model for futile recanalization in acute ischemic stroke: a retrospective cohort study

Yangbin Zhou1†, Yitao Zhou1†, Huijie Yang2, Xiaoyan Wang2, Xiping Zhang2 and Ganying Huang1,2*

1School of Nursing, Zhejiang Chinese Medical University, Hangzhou, China

2Department of Emergency, Afliated Hangzhou First People’s Hospital, School of Medicine, Westlake University, Hangzhou, Zhejiang, China

Edited by

Linlin Zhang, Capital Medical University, China

Reviewed by

Abhi Pandhi, University of Tennessee Health Science Center (UTHSC), United States

Dan-Victor Giurgiutiu, Augusta University, United States

*Correspondence

Ganying Huang, ganying3304@163.com

†These authors have contributed equally to this work

Received 25 January 2025

Accepted 30 April 2025

Published 15 May 2025

Citation

Zhou Y, Zhou Y, Yang H, Wang X, Zhang X and Huang G (2025) Predictive role of a combined model for futile recanalization in acute ischemic stroke: a retrospective cohort study. Front. Neurol. 16:1566842. doi: 10.3389/fneur.2025.1566842

Objective: There is a lack of data regarding patients with acute ischemic stroke caused by large vessel occlusions (LVOs) undergoing mechanical thrombectomy (MT) and their predictors of futile recanalization (FR). We sought to investigate the predictors of FR in patients with AIS-LVO undergoing mechanical thrombectomy.

Method: A retrospective analysis was conducted on 229 acute AIS patients who received MT, after eliminating the 31 patients not meet the requirements. The patients were categorized into the FR group and the useful recanalization (UR) group. Multivariate logistic regression analysis was used to explore the factors that influence FR after mechanical thrombectomy. ROC curve was used to plot the ability to predict FR after MT, and then the combined model was constructed and evaluate the predictive ability of this model to FR.

Results: 198 patients who achieved successful recanalization were included in the analysis, of whom 124 experienced UR and 74 experienced FR. Patients with FR had higher Baseline NIHSS; they were more frequently on hypertension history and had longer door-to-puncture time (DPT) and door-to-recanalization time (DRT). Multivariable regression analysis showed that the hypertension history, Admission NIHSS, Admission DBP, Admission blood glucose, ischemic core, and DPT were associated with an increased probability of FR. The combined model was better than the models alone in predicting the risk of FR.

Conclusion: Admission blood pressure, admission NIHSS scores, admission DBP, ischemic core and DPT are independent risk factors for FR after MT in patients with AIS, and the combined model established by them has high predictive efficacy for FR risk after MT.

Keywords

futile recanalization; acute ischemic stroke; ROC curve; mechanical thrombectomy; AIS-LVO

Introduction

As the second-leading cause of death disease, Stroke is a widespread neurological condition and the primary cause of disability worldwide (1). Also, it resulted in approximately 6 million annual fatalities. Ischemic stroke accounts for 71% of all strokes worldwide and 81.9% in China. The proportion of acute ischemic stroke (AIS) caused by large vessel occlusions (LVOs) in Chia was 20% (2). Acute ischemic stroke (AIS) is a sudden neurologic dysfunction caused by focal brain ischemia which is accompanied by imaging evidence of acute infarction (3). AIS occur caused by focal cerebral hypoperfusion, particularly from embolism and atherosclerotic disease. At present, the main effective treatment method for early reperfusion in acute ischemic stroke is intravenous rt-PA thrombolysis (4–6). For AIS-LVOs, the vascular revascularization rate of intravenous thrombolysis is low (13% ~ 18%) and the therapeutic effect is not good (7). The successful recanalization rate of MT has achieved 41–88%, which was much higher than that yielded by traditional therapies, including intravenous thrombolysis (8). Partial randomized clinical trials (RCTs) (9–14) have proven benefits on functional outcomes of endovascular thrombectomy (EVT) compared with intravenous thrombolysis. The functional outcomes of AIS patients with proximal anterior circulation LVO were improved by MT, particularly in those with good collateral circulation (6, 15). Preceding randomized controlled trials (10–12, 14, 16, 17) have consistently demonstrated that, among patients receiving standard care, MT markedly enhances successful reperfusion.

The modified Thrombolysis in Cerebral Infarction (mTICI) score can evaluate the degree of recanalization, which is considered a powerful predictor of good functional prognosis (18, 19). However, FR are not always associated with successful or complete reperfusion. Previous studies have revealed that more than 50% of patients suffer from futile recanalization (FR), which is defined as an adverse functional outcome at 90 days despite successful recanalization (mTICI = 2b-3) (18, 20). FR was linked to age, admission NIHSS, comorbidities, Alberta Stroke Program Early CT Score (ASPECTS), as well as time from symptom onset to recanalization (21, 22). Furthermore, studies have demonstrated that a high mRS score prior to stroke onset, coexisting dyslipidemia, and atrial fibrillation were identified as predictors of FR (23).

Therefore, it is of paramount importance to better understand the therapeutic effect of patients after MT and determine the factors that may help predict the occurrence of FR in patients. Predictive models for the occurrence of FR following MT surgery in patients are relatively scarce. Such models are necessary to accurately convey potential risks and benefits to the patients themselves or the proxies, and facilitate patient-oriented informed decision-making. The advent of reliable prediction models is capable of adapting to the continuously escalating healthcare demands and costs in China.

We conducted an observational retrospective study aiming to explore the predictors of futile recanalization in patients with LVO undergoing MT. Therefore, this study aims to utilize the National Stroke Center Construction Management Information System (NSCCMI) registry to clarify the predictive ability of admission blood pressure, baseline NIHSS scores, admission DBP, ischemic core and DPT for the risk of FR after MT in patients with AIS.

Methods

Study design and participants

The cohort was comprised of patients enrolled in the NSCCMI registry (National Stroke Center Construction Management Information System), a cohort study registering AIS patients in China which includes a hospital-based follow-up study. We enrolled 229 AIS-LVO patients from Hangzhou First People’s Hospital who were treated with mechanical thrombectomy between March 2022 and February 2024. The sample size met the principle of 10 Events Per Variable (EPV) (24). Inclusion criteria were 198 patients who achieved successful recanalization were included in the analysis, of whom 124 (62.63%) experienced UR and 74 (37.37%) experienced FR. The sample size met the principle of 10 Events Per Variable (EPV). All participating subcenters were obligated to recruit consecutive patients, and all patients or their legal representatives supplied informed consent. All patients used computed tomography and/or magnetic resonance imaging to diagnose AIS. According to TOAST criteria (25), AIS can be divided into four subtypes: (1) large-artery atherosclerosis (LAA), (2) cardioembolism (CE), (3) small-artery occlusion, (SAO), (4) stroke of other determined etiology, and (5) stroke of undetermined etiology (25). Categories 4 to 5 were defined as “other causes” in this study. This study included patients with subtypes according to TOAST criteria. All patients were followed for 3 months after AIS onset.

The present study enrolled patients with AIS-LVO undergoing MT between March 2022 and February 2024. Patients met the following inclusion criteria: (1) Age 18–90 years; (2) meet the diagnostic criteria for AIS (26); (3) patients treated with MT; (4) mTICI of 2b-3 after MT (27); (5) without rheumatoid immune disorders, severe hepatic or renal disorders, hematological disorders, or malignant tumors; (6) without any systemic infections that occurred at the time of specimen collection or 2 weeks before stroke onset; (7) finish 90-day follow-up.

MT was selected for patients meeting the following criteria: (1) confirmed AIS, and bleeding or other pathological brain diseases ruled out by CT; (2) LVO confirmed by CTA or digital subtraction angiography; (3) MT treatment can be initiated between 6 and 16 h of stroke onset (28); (4) obtaining informed consent from family members. Exclusion criteria: (1) confirmed intracranial hemorrhage or intracranial tumor on admission; (2) inability to take care of oneself; (3) previous psychiatric disorders that would interfere with neurologic evaluation; (4) Other serious, advanced, or terminal illness (investigator judgment) or life expectancy is less than 6 months; (5) Any other condition that, in the investigator’s judgment, precludes an endovascular procedure or poses a considerable risk to the subject in the event that an endovascular procedure is performed; (6) incomplete baseline data.

More at link.

Cerebrolysin as an adjuvant therapy after mechanical thrombectomy in large vessel occlusion cardioembolic stroke: a propensity score matching analysis

 

Your competent? doctor has been using Cerebrolysin for years now, correct?

Cerebrolysin (14 posts to June 2014)

Cerebrolysin as an adjuvant therapy after mechanical thrombectomy in large vessel occlusion cardioembolic stroke: a propensity score matching analysis

Ahmed ElBassiouny¹Mohamed S. A. Shehata^2,3*Amr S. Zaki¹Rady Y. Bedros¹Ayman Hassan El-Sudany¹Azza Abdel Nasser¹

• ¹Department of Neurology, Faculty of Medicine, Ain Shams University, Cairo, Egypt
• ²Faculty of Medicine, Zagazig University, Zagazig, Egypt
• ³Egyptian Fellowship of Neurology, Ministry of Health, Cairo, Egypt

Introduction: Endovascular recanalization therapy has demonstrated considerable efficacy in the treatment of acute ischemic stroke (AIS). However, not all patients appear to benefit on the long term from this therapy. No studies have assessed the role of Cerebrolysin following mechanical thrombectomy (MT). The present study was conducted to evaluate the safety and efficacy of Cerebrolysin as add-on treatment to MT in patients with cardioembolic AIS.

Methods: This study evaluated 150 patients admitted to the stroke unit. Data were prospectively collected from 75 patients with cardioembolic AIS and National Institutes of Health Stroke Scale (NIHSS) ≥10, who underwent successful MT ± recombinant tissue plasminogen activator (rt-PA). Patients fulfilling inclusion criteria were consecutively enrolled and treated with Cerebrolysin at a daily dose of 30 ml for 14 days, with treatment initiated within 8 h following MT. Patients were compared with a historical control group of 75 well-matched patients who underwent MT ± rt-PA but did not receive Cerebrolysin. The primary outcome measure was a favorable modified Rankin Scale (mRS = 0–2) at day 90. Secondary parameters included the NIHSS, the Montreal Cognitive Assessment (MoCA), the rate of hemorrhagic transformation, mortality, and adverse events. Propensity score matching was performed to match the variables between the compared groups.

Results and discussion: The overall results demonstrated that patients treated with Cerebrolysin exhibited a significantly higher proportion of mRS scores of 0–2 at day 90 (64% vs. 34.7%) in comparison to the control group. This finding was consistent with lower NIHSS and mRS scores at all study visits, and a lower any hemorrhagic transformation rate (20% vs. 57.3%). Furthermore, the logistic regression analysis revealed that patients with favorable mRS scores were less likely to undergo hemorrhagic transformation (odds ratio = 2.75, 95% confidence interval = 1.17, 6.45; p = 0.002). The administration of Cerebrolysin as an add-on treatment resulted in a significant benefit for AIS patients following MT, characterized by an improvement in mRS and NIHSS scores, along with a reduced rate of hemorrhagic transformation. The administration of Cerebrolysin was safe and well tolerated. Further studies are required to confirm these results.

Day 3 neutrophil-to-lymphocyte ratio and its derived indices predict 90-day poor outcomes following mechanical thrombectomy in acute ischemic stroke patients

 This doesn't get survivors recovered, does it? So useless research!

Day 3 neutrophil-to-lymphocyte ratio and its derived indices predict 90-day poor outcomes following mechanical thrombectomy in acute ischemic stroke patients

Weiwei Gao^1†Arslan Annadurdyyev^1†Lingfeng Yu²Rong Huang¹Bin Liu²Yixiong Lin³Huaiyi Li⁴Renjing Zhu^1*

• ¹Department of Neurology, Zhongshan Hospital of Xiamen University, School of Medicine, Xiamen University, Xiamen, China
• ²School of Medicine, Xiamen University, Xiamen, China
• ³Department of Cardiology, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China
• ⁴Department of Radiology, The Second Affiliated Hospital of Xiamen Medical College, Xiamen, China

Objective: To investigate the dynamic changes in neutrophil–to–lymphocyte ratio (NLR) and its derived indices following mechanical thrombectomy (MT) in patients with acute ischemic stroke (AIS) and evaluate their predictive value for prognosis.

Methods: This single-center retrospective cohort study included AIS patients who underwent MT at Zhongshan Hospital of Xiamen University from January 2018 to February 2024. Peripheral blood samples were collected on admission, day 1, and day 3 after MT to determine the NLR, derived NLR (dNLR), and neutrophil–monocyte–to–lymphocyte ratio (NMLR). The primary endpoint was poor functional outcome at 90 days (modified Rankin scale score 3–6). The secondary endpoints included post-operative hemorrhagic transformation, malignant cerebral edema, in-hospital mortality, and 90-day all-cause mortality. Receiver operating characteristic (ROC) curve analysis was used to evaluate predictive performance, and multivariate logistic regression models were employed to explore the independent associations between inflammatory markers and prognosis.

Results: A total of 423 eligible patients were included. Both groups showed similar dynamic trends in inflammatory markers, peaking on day 1 post-MT and subsequently declining. However, the poor outcome group (n = 255, 60.28%) maintained higher levels on day 3, whereas the good outcome group showed a significant decreasing trend. ROC curve analysis revealed that the NLR (AUC = 0.85, 95% CI: 0.81–0.89), dNLR (AUC = 0.86, 95% CI: 0.82–0.89), and NMLR (AUC = 0.85, 95% CI: 0.81–0.89) on day 3 post-MT had the strongest predictive power for 90-day poor outcomes. After comprehensive adjustment for confounders, these inflammatory markers were independently associated with 90-day poor outcomes: for each unit increase in the NLR, the risk of poor outcome increased by 38% (OR = 1.38, 95% CI: 1.28–1.49, p < 0.001); for dNLR, it increased by 104% (OR = 2.04, 95% CI: 1.73–2.40, p < 0.001); and for NMLR, it increased by 35% (OR = 1.35, 95% CI: 1.26–1.45, p < 0.001).

Conclusion: Inflammatory markers (NLR, dNLR, and NMLR) on day 3 post-MT can serve as independent predictors of prognosis in AIS patients treated with MT. Dynamic monitoring of inflammatory markers may facilitate early risk stratification and guide individualized treatment strategies.

1 Introduction

Acute ischemic stroke (AIS) is a leading cause of mortality and disability worldwide. According to statistics from the World Health Organization, approximately 12 million new stroke cases occur globally each year, with ischemic strokes accounting for a staggering 62.4%, resulting in nearly 6 million deaths or severe disabilities (1). Large vessel occlusion (LVO) strokes constitute one-third of AIS cases and often present with significant neurological impairments and poorer prognoses (2).

In recent years, mechanical thrombectomy (MT) has emerged as the standard treatment for LVO patients because of its remarkable clinical benefits (3). Compared with intravenous thrombolysis alone, MT significantly improves functional outcomes and reduces mortality and disability rate (4). However, despite advancements in MT techniques, a considerable proportion of patients still experience unfavorable outcomes. A prospective study revealed that among LVO patients undergoing MT, only 49% reached functional independence (defined as a modified Rankin Scale score [mRS] ≤ 2) at 90 days (5). Poor outcomes not only increase the burden on patients and their families but also place substantial pressure on society and healthcare systems. Therefore, identifying key factors influencing MT outcomes is crucial for early recognition of high-risk patients and optimization of clinical management strategies.

Inflammatory responses play a pivotal role in the occurrence, progression, and prognosis of AIS (6). Ischemic brain injury rapidly activates the innate immune responses, leading to the release and recruitment of inflammatory cells and mediators, which further exacerbates brain tissue damage and disrupts blood–brain barrier (BBB) integrity (7). The neutrophil-to-lymphocyte ratio (NLR), an emerging inflammatory marker in peripheral blood, has been shown to be closely associated with the prognosis of AIS patients (8, 9). However, previous studies have primarily focused on baseline levels or single measurements of the NLR, and a systematic evaluation of its dynamic changes and prognostic value is lacking.

Furthermore, the derived neutrophil-to-lymphocyte ratio (dNLR) and neutrophil-monocyte-to-lymphocyte ratio (NMLR), which are derived indices of the NLR, have demonstrated significant prognostic predictive value in various inflammatory and immune diseases (10, 11) as well as acute myocardial infarction (12). Nevertheless, the clinical utility of these novel inflammatory markers in AIS patients has not been fully validated, and whether their predictive performance is superior to that of the traditional NLR remains to be elucidated.

Given this background, we conducted this retrospective cohort study to investigate the dynamic changes in NLR and its derived indices following MT in AIS patients and evaluate their prognostic predictive value. By systematically assessing the dynamic changes in peripheral immune markers, this study aimed to provide new clinical insights into prognostic assessment for AIS patients and evidence-based guidance for individualized treatment strategies.

e at link. Mother

SOFIA Aspiration System as first-line Technique (SOFAST): a prospective, multicenter study to assess the efficacy and safety of the 6 French SOFIA Flow Plus aspiration catheter for endovascular stroke thrombectomy

Really? Survivors want to know your 100% recovery statistics, NOT safety and efficacy! Don't you fucking know what survivors want? 100% recovery? And you're completely ignoring that? I'd have you all fired!

 SOFIA Aspiration System as first-line Technique (SOFAST): a prospective, multicenter study to assess the efficacy and safety of the 6 French SOFIA Flow Plus aspiration catheter for endovascular stroke thrombectomy

    Dheeraj Gandhi1, http://orcid.org/0000-0003-2455-748XHuanwen Chen1,2, Syed Zaidi3, Daniel H Sahlein4, Lucian Maidan5, Kenneth Kreitel6, http://orcid.org/0000-0003-1784-3402Timothy R Miller1, Scott Rahimi7, http://orcid.org/0000-0003-4887-4930Amer Al Shekhlee8, Henry H Woo9, http://orcid.org/0000-0002-3646-3635Gabor Toth10, Clemens Schirmer11, Yince Loh12, http://orcid.org/0000-0002-2677-8780David Fiorella13

    Correspondence to Dr Dheeraj Gandhi, Interventional Neuroradiology, Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, Baltimore, MD 21201, USA; dgandhi@umm.edu

Abstract

Background 

 

Mechanical thrombectomy (MT) is the standard of care for acute ischemic stroke (AIS) patients with large vessel occlusion (LVO). The SOFAST study collected clinical evidence on the safety and efficacy of the 6 French SOFIA Flow Plus aspiration catheter (SOFIA 6F) when used as first-line treatment.

Methods 

 

This was a prospective, multicenter investigation to assess the safety and efficacy of SOFIA 6F used for first-line aspiration. Anterior circulation LVO stroke patients were enrolled. The primary endpoint was the final modified Thrombolysis in Cerebral Infarction (mTICI)≥2b rate. Secondary endpoints included first-pass and first-line mTICI≥2b rates, times from arteriotomy to clot contact and mTICI≥2b, and 90-day modified Rankin Scale (mRS)≤2. First-line and final mTICI scores were adjudicated by an independent imaging core lab. Safety events were assessed by an independent clinical events adjudicator.

Results 

 

A total of 108 patients were enrolled across 12 centers from July 2020 to June 2022. Median age was 67 years, median National Institutes of Health Stroke Scale (NIHSS) was 15.5, and 56.5% of patients received intravenous thrombolytics. At the end of the procedure, 97.2%, 85.2%, and 55.6% of patients achieved mTICI≥2b, ≥2c, and 3, respectively. With SOFIA 6F first-line aspiration, 87.0%, 79.6%, and 52.8% achieved mTICI≥2b, ≥2c, and 3, respectively. After the first pass, 75.0%, 70.4%, and 50.9% achieved mTICI≥2b, ≥2c, and 3, respectively. Median times from arteriotomy to clot contact and successful revascularization were 12 and 17 min, respectively. At 90 days, 66.7% of patients achieved mRS≤2.

Conclusions 

 

First-line aspiration with SOFIA 6F is safe and effective with high revascularization rates and short procedure times.
Data availability statement

No data are available.
http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/jnis-2024-021811

National Medical Director Professor Sir Stephen Powis visits the Queens Medical Centre (QMC)

 If the director didn't ask how many patients 100% recovered you have idiots in charge!

National Medical Director Professor Sir Stephen Powis visits the Queens Medical Centre (QMC)

NHS England’s Medical Director Professor Sir Stephen Powis recently visited Nottingham University Hospitals NHS Trust’s (NUH) mechanical thrombectomy service.  

Professor Stephen Powis along with the National Clinical Director for Stroke, David Hargroves, Doctor Maeva May from the Stroke Association and other regional and national colleagues spent the morning at the Queen’s Medical Centre (QMC) visiting the service and discussing the upcoming developments.  

Mechanical thrombectomy is a minimally invasive procedure that removes blood clots from arteries within the brain for patients who have suffered a stroke. The intervention has been shown to significantly increase positive patient outcomes(NOT GOOD ENOUGH! You do realize survivors want 100% recovery? And you're DOING NOTHING TO GET THERE!) and decrease the risk of long-term disability. NUH’s service treats around 200 patients a year.  

In line with the NHS’s national commitment to expand access(FUCK 'ACCESS'! Deliver recovery!) to mechanical thrombectomy, NUH are working towards a 24/7 service, which will see an increase in the number of trained professionals who can carry out the procedure and more patients being able to access the treatment.  

Professor Sir Stephen Powis said: “Mechanical thrombectomy is a game-changing treatment for stroke patients, which can dramatically improve outcomes and reduce disability.  

“The NHS Long Term Plan outlined our aim of expanding access to thrombectomy for eligible patients and it was great to hear the progress being made in Nottingham to ensure people have timely access to this vital treatment regardless of when their stroke occurs ”.  

Joined by Lisa Kelly, our Chief Operating Officer, Tim Guyler, our Director of Strategy and Partnership, Dr Manjeet Shehmar , our Medical Director and Tracy Pilcher our Chief Nurse, Sir Stephen and David were shown round the service and patient pathway which included the emergency department, interventional radiology and the stroke unit.  

Tim Guyler, Director of Strategy and Partnership, said: “It was a privilege to host a visit from national colleagues, talking through our exciting plans to expand our treatment for stroke patients across the East Midlands.”  

Dr Maëva May, Associate Director - Systems Engagement at the Stroke Association said: “Mechanical thrombectomy is a game-changer for stroke patients, often making the difference between living with severe disabilities or returning to full independence. I was delighted to visit QMC and see the firm commitment by staff to continue to grow access to this life-changing treatment. Their focus on prioritising patient well-being is inspiring. 

“ While progress is being made, there's still work to do. The Stroke Association's Saving Brains campaign  highlights the need for UK-wide, equitable access to thrombectomy, regardless of location or time of stroke. We must work together to ensure every patient receives this critical treatment, no matter the circumstances. The Nottingham team exemplifies the drive and focus needed to achieve this goal, and we commend their efforts. Let's keep working towards a 24/7 service that reaches all who can benefit."  

Dave Briggs, M edical D irector for the NHS Nottingham and Nottinghamshire Integrated Care Board said: “We are very lucky to have the stroke service based in Nottingham , it’s an amazing procedure taking the clot out of the brain. It will transform countless lives. I would like to thank all the incredible team s for showing me how the new service is working. ”  

Reducing Door-to-Puncture Times for Mechanical Thrombectomy in a Large Tertiary Hospital

 You blithering idiots, door to puncture time means NOTHING to survivors; 100% recovery is the only requirement for survivors!

Reducing Door-to-Puncture Times for Mechanical Thrombectomy in a Large Tertiary Hospital

Zhenghong Liu, MBBS, MRCEM https://orcid.org/0000-0003-3361-3818, Man Qing Leong, BSc https://orcid.org/0000-0002-6299-1685, Nanlan Li, BA, MPP https://orcid.org/0009-0009-3886-2400, Miqi Mavis Teo, MBBS, MMEd (Anaes) https://orcid.org/0000-0003-2759-2563, Wei- Li Rachel Leong, MBBS, MMEd (Anae) https://orcid.org/0000-0003-2329-4235, Steve Chen Pong Wong, MBBS, MMed (Diag Rad), FRCR (UK) https://orcid.org/0000-0003-2936-4054, Jing Si Chew, BN, MN https://orcid.org/0009-0000-6871-0496, Seyed Ehsan Saffari, PhD https://orcid.org/0000-0002-6473-4375, Yee Hau Pang, MBBS, MRCP(UK) https://orcid.org/0000-0002-3957-471X, and Ghim Song Chia, MD, FRCR, MMed (Diag Rad) https://orcid.org/0000-0002-1305-2753Authors Info & Affiliations

October 2024 issue

14 (5)

https://doi.org/10.1212/CPJ.0000000000200325

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Abstract

Background and Objectives

Endovascular therapy (EVT) for stroke has emerged as an important therapy for selected stroke patients, and shorter times to clot removal improve functional outcomes(NOT GOOD ENOUGH! 100% recovery is the goal of survivors.) . EVT requires the close coordination of multiple departments and poses unique challenges to care coordination in large hospitals. We present the results of our quality improvement project that aimed to improve our door-to-groin puncture (DTP) times for patients who undergo EVT after direct presentation to our emergency department.

Methods

We conducted time-motion studies to understand the full process of an EVT activation and conducted Gemba walks in multiple hospitals. We also reviewed the literature and interviewed stakeholders to create interventions that were implemented over 4 Plan-Do-Study-Act (PDSA) cycles. We retrospectively collected data starting from baseline and during every PDSA cycle. During each cycle, we studied the impact of the interventions, adjusted the interventions, and generated further interventions. A variety of interventions were introduced targeting all aspects of the EVT process. This included parallel processing to reduce waiting time, standardization of protocols and training of staff, behavioral prompts in the form of a stroke clock, and push systems to empower staff to facilitate the forward movement of the patient. A novel role-based communication app to facilitate group communications was also used.

Results

Eighty-eight patients spanning across 22 months were analyzed. After the final PDSA cycle, the median DTP time was reduced by 36.5% compared with baseline (130 minutes (interquartile range [IQR] 111–140) to 82.5 minutes (IQR 74.8–100)). There were improvements in all phases of the EVT process with the largest time savings occurring in EVT decision to patient arrival at the angiosuite. Interventions that were most impactful are described.

Discussion

EVT is a complex process involving multiple processes and local factors. Analysis of the process from all angles and intervening on multiple small aspects can add up to significant improvements in DTP times.

 

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The effect of inadvertent systemic hypothermia after mechanical thrombectomy in patients with large-vessel occlusion stroke

 What created protocol is your competent? hospital following in this until further research is done? Do they even have ANY PROTOCOLS FOR STROKE?

The effect of inadvertent systemic hypothermia after mechanical thrombectomy in patients with large-vessel occlusion stroke

Kristina auf dem Brinke¹Fabian Kück²Ala Jamous³Marielle Ernst³Nils Kunze-Szikszay⁴Marios-Nikos Psychogios⁵Ilko L. Maier^1*

• ¹Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
• ²Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
• ³Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
• ⁴Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
• ⁵Department of Neuroradiology, Universitätsspital Basel, Basel, Switzerland

Background and aims: Postinterventional hypothermia is a frequent complication in patients with large-vessel occlusion strokes (LVOS) after mechanical thrombectomy (MT). This inadvertent hypothermia might potentially have neuroprotective but also adverse effects on patients’ outcomes. The aim of the study was to determine the rate of hypothermia in patients with LVOS receiving MT and its influence on functional outcome.

Methods: We performed a monocentric, retrospective study using a prospectively derived databank, including all LVOS patients receiving MT between 2015 and 2021. Predictive values of postinterventional body temperature and body temperature categories (hyperthermia (≥38°C), normothermia (35°C–37.9°C), and hypothermia (<35°C)) on functional outcome were analyzed using multivariable Bayesian logistic regression models. Favorable outcome was defined as modified Rankin Scale (mRS) ≤3.

Results: Of the 480 included LVOS patients with MT (46.0% men; mean ± SD age 73 ± 12.9 years), 5 (1.0%) were hyperthermic, 382 (79.6%) normothermic, and 93 (19.4%) hypothermic. Postinterventional hypothermia was significantly associated with unfavorable functional outcome (mRS > 3) after 90 days (OR 2.06, 95% CI 1.01–4.18, p = 0.045). For short-term functional outcome, patients with hypothermia had a higher discharge NIHSS (OR 1.38, 95% CI 1.06 to 1.79, p = 0.015) and a higher change of NIHSS from admission to discharge (OR 1.35, 95% CI 1.03 to 1.76, p = 0.029).

Conclusion: Approximately a fifth of LVOS patients in this cohort were hypothermic after MT. Hypothermia was an independent predictor of unfavorable functional outcomes. Our findings warrant a prospective trial(WHO EXACTLY ARE YOU CONTACTING TO GET THIS FURTHER RESEARCH DONE? NOBODY? So you're incompetent?) investigating active warming during MT.

The feasibility of mechanical thrombectomy versus medical management for acute stroke with a large ischemic territory

A breathless tweet from @JNIS_BMJ: BREAKTHROUGH in Stroke Treatment! Meta-analysis: Mechanical Thrombectomy >> Medical Management for large infarct stroke! ++ functional recovery & quality-adjusted life-years PLUS more cost-effective over life.

You can decide how breakthrough it is; I don't see full 100% recovery for all!

 The feasibility of mechanical thrombectomy versus medical management for acute stroke with a large ischemic territory

1. http://orcid.org/0000-0001-8797-0808Assala Aslan1,
2. Saad Abuzahra1,
3. Nimer Adeeb2,
4. http://orcid.org/0009-0000-4910-6090Basel Musmar2,
5. http://orcid.org/0000-0002-5208-8425Hamza A Salim2,
6. Sandeep Kandregula3,
7. http://orcid.org/0000-0003-0131-5699Adam A Dmytriw4,5,
8. Christoph J Griessenauer6,
9. Luis De Alba1,
10. Octavio Arevalo1,
11. Jan Karl Burkhardt3,
12. Vitor M Pereira5,
13. http://orcid.org/0000-0002-1544-4910Pascal Jabbour7,
14. http://orcid.org/0000-0001-6668-6656Bharat Guthikonda2,
15. Hugo H Cuellar1,3

1. Correspondence to Dr Hugo H Cuellar, Department of Radiology and Interventional radiology, Ochsner-Louisiana State University, Shreveport, LA 71104, USA; hugo.cuellarsaenz@lsuhs.edu

Abstract

Background Mechanical thrombectomy (MT) for acute ischemic stroke is generally avoided when the expected infarction is large (defined as an Alberta Stroke Program Early CT Score of <6).

Objective To perform a meta-analysis of recent trials comparing MT with best medical management (BMM) for treatment of acute ischemic stroke with large infarction territory, and then to determine the cost-effectiveness associated with those treatments.

Methods A meta-analysis of the RESCUE-Japan, SELECT2, and ANGEL-ASPECT trials was conducted using R Studio. Statistical analysis employed the weighted average normal method for calculating mean differences from medians in continuous variables and the risk ratio for categorical variables. TreeAge software was used to construct a cost-effectiveness analysis model comparing MT with BMM in the treatment of ischemic stroke with large infarction territory.

Results The meta-analysis showed significantly better functional outcomes, with higher rates of patients achieving a modified Rankin Scale score of 0–3 at 90 days with MT as compared with BMM. In the base-case analysis using a lifetime horizon, MT led to a greater gain in quality-adjusted life-years (QALYs) of 3.46 at a lower cost of US$339 202 in comparison with BMM, which led to the gain of 2.41 QALYs at a cost of US$361 896. The incremental cost-effectiveness ratio was US$−21 660, indicating that MT was the dominant treatment at a willingness-to-pay of US$70 000.

Conclusions This study shows that, besides having a better functional outcome at 90-days' follow-up, MT was more cost-effective than BMM, when accounting for healthcare cost associated with treatment outcome.

Data availability statement

Data are available upon reasonable request.

https://doi.org/10.1136/jnis-2023-021368

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Subarachnoid iodine leakage on dual-energy computed tomography after mechanical thrombectomy is associated with malignant brain edema

Sounds like your competent? doctor needs to create a testing protocol for this and then an intervention to prevent this edema from happening! At least leaders in stroke would do that. IS YOUR DOCTOR A LEADER?  Or a mouse?

Subarachnoid iodine leakage on dual-energy computed tomography after mechanical thrombectomy is associated with malignant brain edema

1. http://orcid.org/0000-0002-4478-0251Atsushi Ogata1,
2. Kuniaki Ogasawara2,
3. Masashi Nishihara3,
4. Ayako Takamori4,
5. Takashi Furukawa1,
6. Toshihiro Ide5,
7. Hiroshi Ito1,
8. Fumitaka Yoshioka1,
9. Yukiko Nakahara1,
10. Jun Masuoka1,
11. Haruki Koike5,
12. Hiroyuki Irie3,
13. Tatsuya Abe1

1. Correspondence to Dr Atsushi Ogata, Department of Neurosurgery, Saga University, Saga, 849-8501, Japan; ogata.a24@gmail.com

Abstract

Background Dual-energy computed tomography (DE-CT) can differentiate between hemorrhage and iodine contrast medium leakage following mechanical thrombectomy (MT) for acute ischemic stroke (AIS). We determined whether subarachnoid hemorrhage (SAH) and subarachnoid iodine leakage (SAIL) on DE-CT following MT were associated with malignant brain edema (MBE).

Methods We analyzed the medical records of 81 consecutive anterior circulation AIS patients who underwent MT. SAH or SAIL was diagnosed via DE-CT performed immediately after MT. We compared the procedural data, infarct volumes, MBE, and modified Rankin scale 0–2 at 90 days between patients with and without SAH and between patients with and without SAIL. Furthermore, we evaluated the association between patient characteristics and MBE.

Results A total of 20 (25%) patients had SAH and 51 (63%) had SAIL. No difference in diffusion-weighted imaging (DWI)-infarct volume before MT was observed between patients with and without SAH or patients with and without SAIL. However, patients with SAIL had larger DWI-infarct volumes 1 day following MT than patients without SAIL (95 mL vs 29 mL; p=0.003). MBE occurred in 12 of 81 patients (15%); more patients with SAIL had MBE than patients without SAIL (22% vs 3%; p=0.027). Severe SAIL was significantly associated with MBE (OR, 12.5; 95% CI, 1.20–131; p=0.006), whereas SAH was not associated with MBE.

Conclusion This study demonstrated that SAIL on DE-CT immediately after MT was associated with infarct volume expansion and MBE.

Data availability statement

Data sharing not applicable as no datasets generated and/or analyzed for this study.

https://doi.org/10.1136/jnis-2023-021413

Early technique switch following failed passes during mechanical thrombectomy for ischemic stroke: should the approach change and when?

You do realize by not measuring the only goal in stroke; 100% recovery, you'll never get there? Survivors don't give a flying fuck about reperfusion, that's only the first step to 100% recovery!

 You're not even measuring 100% recovery! I'd fire all of you!

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

 Early technique switch following failed passes during mechanical thrombectomy for ischemic stroke: should the approach change and when?

1. http://orcid.org/0000-0002-5760-6869Pedro N Martins1,2,
2. Raul G Nogueira1,2,3,
3. Mohamed A Tarek1,2,
4. Jaydevsinh N Dolia1,2,
5. Sunil A Sheth4,
6. http://orcid.org/0000-0002-3408-1297Santiago Ortega-Gutierrez5,
7. Sergio Salazar-Marioni4,
8. Ananya Iyyangar4,
9. http://orcid.org/0000-0002-8107-9632Milagros Galecio-Castillo5,
10. http://orcid.org/0000-0002-8413-6954Aaron Rodriguez-Calienes5,6,
11. Aqueel Pabaney1,2,
12. http://orcid.org/0000-0002-1152-8826Jonathan A Grossberg1,2,
13. Diogo C Haussen1,2

1. Correspondence to Dr Diogo C Haussen, Department of Neurology and Radiology, Emory University School of Medicine, Atlanta, GA 30303, USA; diogo.haussen@emory.edu

Abstract

Background Fast and complete reperfusion in endovascular therapy (EVT) for ischemic stroke leads to superior clinical outcomes(Superior is 100% recovery!). The effect of changing the technical approach following initially unsuccessful passes remains undetermined.

Objective To evaluate the association between early changes to the EVT approach and reperfusion.

Methods Multicenter retrospective analysis of prospectively collected data for patients who underwent EVT for intracranial internal carotid artery, middle cerebral artery (M1/M2), or basilar artery occlusions. Changes in EVT technique after one or two failed passes with stent retriever (SR), contact aspiration (CA), or a combined technique (CT) were compared with repeating the previous strategy. The primary outcome was complete/near-complete reperfusion, defined as an expanded Thrombolysis in Cerebral Infarction (eTICI) of 2c–3, following the second and third passes.

Results Among 2968 included patients, median age was 66 years and 52% were men. Changing from SR to CA on the second or third pass was not observed to influence the rates of eTICI 2c–3, whereas changing from SR to CT after two failed passes was associated with higher chances of eTICI 2c–3 (OR=5.3, 95% CI 1.9 to 14.6). Changing from CA to CT was associated with higher eTICI 2c–3 chances after one (OR=2.9, 95% CI 1.6 to 5.5) or two (OR=2.7, 95% CI 1.0 to 7.4) failed CA passes, whereas switching to SR after one failed CA pass was associated with greater chance of eTICI 2c–3 (OR=6.9, 95% CI 1.6 to 30.0). Following one or two failed CT passes, switching to SR was not associated with different reperfusion rates, but changing to CA after two failed CT passes was associated with lower chances of eTICI 2c–3 (OR=0.3, 95% CI 0.1 to 0.9). Rates of functional independence were similar.

Conclusions Early changes in EVT strategies were associated with higher reperfusion and should be contemplated following failed attempts with stand-alone CA or SR.

Data availability statement

Data are available upon reasonable request. Data will be shared upon reasonable request to the corresponding author.

https://doi.org/10.1136/jnis-2024-021545

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Exploring the use of ChatGPT in predicting anterior circulation stroke functional outcomes after mechanical thrombectomy: a pilot study

What stupidity, survivors don't want to know about your predictions of failing to recover. They want recovery! DO THE GODDAMN RESEARCH THAT GETS THERE!

 Exploring the use of ChatGPT in predicting anterior circulation stroke functional outcomes after mechanical thrombectomy: a pilot study

1. Tiago Pedro1,
2. José Maria Sousa1,
3. Luísa Fonseca2,3,
4. Manuel G. Gama2,3,
5. Goreti Moreira2,3,
6. Mariana Pintalhão2,3,
7. Paulo C. Chaves2,3,
8. Ana Aires3,4,
9. Gonçalo Alves1,5,
10. Luís Augusto1,5,
11. Luís Pinheiro Albuquerque1,5,
12. Pedro Castro4,6,
13. Maria Luís Silva1,5

1. Correspondence to Dr Tiago Pedro, Department of Neuroradiology, Centro Hospitalar Universitário de São João, Porto, 4200-319, Portugal; tiagoliveirapedro@hotmail.com

Abstract

Background Accurate prediction of functional outcomes is crucial in stroke management, but this remains challenging.(No it's not! Where the fuck did you get that stupid idea? Survivors don't give a fuck about your predictions of recovery failure! They want recovery! GET THERE!)

Objective To evaluate the performance of the generative language model ChatGPT in predicting the functional outcome of patients with acute ischemic stroke (AIS) 3 months after mechanical thrombectomy (MT) in order to assess whether ChatGPT can used to be accurately predict the modified Rankin Scale (mRS) score at 3 months post-thrombectomy.

Methods We conducted a retrospective analysis of clinical, neuroimaging, and procedure-related data from 163 patients with AIS undergoing MT. The agreement between ChatGPT’s exact and dichotomized predictions and actual mRS scores was assessed using Cohen’s κ. The added value of ChatGPT was measured by evaluating the agreement of predicted dichotomized outcomes using an existing validated score, the MT-DRAGON.

Results ChatGPT demonstrated fair (κ=0.354, 95% CI 0.260 to 0.448) and good (κ=0.727, 95% CI 0.620 to 0.833) agreement with the true exact and dichotomized mRS scores at 3 months, respectively, outperforming MT-DRAGON in overall and subgroup predictions. ChatGPT agreement was higher for patients with shorter last-time-seen-well-to-door delay, distal occlusions, and better modified Thrombolysis in Cerebral Infarction scores.

Conclusions ChatGPT adequately predicted short-term functional outcomes in post-thrombectomy patients with AIS and was better than the existing risk score. Integrating AI models into clinical practice holds promise for patient care, yet refining these models is crucial for enhanced accuracy in stroke management.

Data availability statement

Data are available upon reasonable request.

https://doi.org/10.1136/jnis-2024-021556