Semmes Murphey Foundation

Introduction Among patients with emergent large vessel occlusion due to intracranial stenosis (ICAS‐LVO), the effect of reperfusion status following thrombectomy remains unknown. In this secondary analysis of the RESCUE‐ICAS registry, we evaluated the impact of baseline reperfusion status on outcomes of mechanical thrombectomy with and without bailout stenting. Methods We conducted a secondary analysis of the RESCUE‐ICAS registry which included patients who underwent thrombectomy with or without bailout stenting for acute ICAS‐LVO. Patients were classified into four groups based on baseline reperfusion status and stenting use. Successful recanalization was defined as modified Thrombolysis in Cerebral Infarction (mTICI) ≥2B. The primary outcome was 90‐day functional independence (mRS 0‐2). Associations were analyzed using multivariable logistic regression with inverse probability of treatment weighting (IPTW). Results A total of 413 patients were analyzed across four groups: MT alone with failed recanalization (n=55), MT alone with successful recanalization (n=184), MT with stent after failed pre‐stent recanalization (n=108), and MT with stent after successful pre‐stent recanalization (n=66). Baseline characteristics were similar, except for age (p=0.004) and hyperlipidemia (p=0.003). On multivariable analysis, there was no difference in 90‐day outcome between patients with MT + bailout stenting with and without successful pre‐stent reperfusion. However, MT + bailout stenting with successful pre‐stenting reperfusion was associated with better 90‐day outcome compared to MT alone with successful reperfusion. Conclusion Adjunct stenting was associated with improved 90‐day functional outcomes in ICAS‐LVO patients even in patients with successful pre‐stenting reperfusion. These findings support early consideration of stenting in ICAS‐LVO to reduce re‐occlusion risk and improve long‐term outcomes. image

Introduction The influence of collateral circulation on outcomes in intracranial atherosclerotic stenosis‐related large vessel occlusion (ICAS‐LVO) treated with mechanical thrombectomy (MT) with or without rescue stenting is not well defined. We aimed to determine whether collateral status modifies the effect of stenting on angiographic and clinical outcomes. Methods We analyzed patients with ICAS‐LVO in the RESCUE‐ICAS registry who underwent MT alone or with rescue stenting in the anterior circulation. Collaterals were graded as good or bad based on ASITN/SIR score. Outcomes included functional independence (mRS 0‐2 at 90 days), mortality, successful recanalization, sICH, and 24‐hour DWI infarct volume. Regression models evaluated stenting and collateral status interaction, adjusted using inverse probability weighting for age, sex, race, diabetes, hypertension, atrial fibrillation, hyperlipidemia, prior stroke, smoking, pre‐stroke mRS, admission NIHSS, IV tPA, and baseline ASPECTS, with weights trimmed at ≤4. Results A total of 324 patients were included (MT alone, n=182; stent+MT, n=142). Median age was 67 years, 57% were male, and vascular comorbidities were frequent. Good collaterals were present in 27% of cases. Interaction analysis between stenting and collateral status showed no significant effect modification for functional independence (adjusted OR 0.78, 95% CI 0.33‐1.82, p =0.560), mortality (adjusted OR 1.56, 95% CI 0.52‐4.68, p =0.425), sICH (adjusted OR 0.22, 95% CI 0.04‐1.42, p =0.112), or infarct volume (β = ‐10.1 mL, 95% CI ‐32.9 to 12.7, p =0.656). A borderline interaction was observed for successful recanalization, with stenting in the setting of good collaterals associated with higher odds of reperfusion (adjusted OR 5.34, 95% CI 0.90‐31.7, p =0.065). Conclusions In patients with anterior circulation ICAS‐LVO, collateral status did not significantly modify the benefit of rescue stenting. These findings suggest that good collaterals alone do not obviate the need for stenting, and highlight the need for prospective studies to define optimal medical management strategies in this population. image image

Whether syngo DynaCT Sine Spin non-contrast flat detector CT (FDCT) imaging is sufficient to rule out intracranial hemorrhage in suspected acute stroke patients is unknown. To determine if syngo DynaCT Sine Spin non-contrast FDCT imaging is non-inferior to conventional multidetector CT (MDCT) imaging for the detection and exclusion of intracranial hemorrhages in suspected acute stroke patients. To enroll 252 participants in three buckets (126 ischemic stroke patients, 126 hemorrhagic stroke patients (including 14 patients with an isolated infratentorial hemorrhage). A multicenter, international, prospective, cross-sectional, endpoint assessor blinded, non-inferiority trial. The primary outcome is the occurrence of an intracranial hemorrhage (yes versus no). This will be used to calculate the sensitivity and specificity of FDCT imaging for the detection of intracranial hemorrhages. All FDCT images will be rated by six independent raters in a blinded imaging core-lab. The rating of the MDCT images will be deemed as ground-truth. FDCT imaging will be deemed non-inferior if the lower bound of the 95%-Confidence Interval of the sensitivity and specificity is above 95%. This trial will inform physicians whether syngo DynaCT Sine Spin non-contrast FDCT imaging can reliably exclude intracranial hemorrhages in patients with suspected acute stroke. ClinicalTrials.gov NCT05458908.

Objective The Bicêtre score is a clinical tool used to guide the timing of intervention in Vein of Galen Aneurysmal Malformation (VGAM). However, it relies on the presence of end-organ damage. This study aimed to determine if an echocardiographic parameter, the Aortic Flow Reversal Ratio (AoFRr), can quantify significant systemic steal in clinically stable neonates (Bicêtre score ≥12) and to evaluate its utility in predicting treatment outcomes. Methods We conducted a single-center retrospective study in patients with VGAM who underwent endovascular embolizations. Transthoracic echocardiography was used to calculate the AoFRr (diastolic reversal VTI / systolic forward VTI) before and after intervention. We analyzed the prevalence and degree of pre-intervention flow reversal. Linear regression was used to correlate the pre-intervention AoFRr with the Bicêtre score. The change in AoFRr post-intervention was evaluated for its association with the likelihood of requiring subsequent embolizations using Wilcoxon signed-rank and Chi-square tests. Results In the cohort of 12 patients with a median total Bicêtre score of 18 (IQR 15.5 - 20), 83.3% demonstrated pre-intervention aortic diastolic flow reversal. The median pre-intervention AoFRr was 0.81 (IQR 0.49 - 1.05), indicating substantial systemic steal. Pre-intervention AoFRr moderately correlated with the Bicêtre score (R² = 0.4546). The initial embolization resulted in a statistically significant mean decrease in the AoFRr of 52.80% (p = 0.0232). A post-intervention reduction in AoFRr of ≥85% was significantly associated with a lower likelihood of requiring re-intervention (p = 0.0253). Conclusion Significant hemodynamic steal, quantified by the AoFRr, is evident on echocardiography in VGAM patients even when they are considered clinically stable by the Bicêtre score. The AoFRr provides a valuable, non-invasive measure of hemodynamic compromise that correlates with clinical severity scores. Its reduction following embolization predicts a more favorable clinical course. The AoFRr may serve as a critical adjunct to the Bicêtre score for risk stratification and for optimizing the timing of endovascular intervention.