Valley Baptist Medical Center

Introduction: Intracranial stenting during endovascular thrombectomy (EVT) is a common practice in the setting of failed reperfusion or severe stenosis. Immediate stent patency requires periprocedural antiplatelet therapy (APT). How APT intensity interacts with prior intravenous thrombolysis (IVT) to influence hemorrhagic risk remains uncertain. We aimed to assess whether the APT regimen modifies the association of IVT with early intracranial hemorrhage after intracranial stenting during EVT. Methods: This was a subanalysis of the RESISTANT registry, a multicenter, international, retrospective cohort (2016 to 2023) of adults with acute ischemic stroke who underwent intracranial stenting during EVT. APT regimens were categorized as conservative (intravenous or oral aspirin alone, or aspirin plus an oral P2Y12 inhibitor) and aggressive (any regimen including intravenous GPIIb/IIIa inhibitor or intravenous cangrelor). Four main groups were compared according to the APT regimen (conservative/aggressive) and the use of IVT (+/-). The primary outcome was a composite of sICH and parenchymal hematoma types 1 and 2 (sICH-PH2-PH1). Multivariable logistic regression models were used to evaluate the interaction between IVT and APT, adjusting for clinically relevant covariates. Results: Among the 823 included patients, 44 (5.3%) received conservative APT with IVT, 130 (15.8%) received conservative APT without IVT, 145 (17.6%) received aggressive APT with IVT, and 504 (61.2%) received aggressive APT without IVT. Among patients who received IVT, sICH-PH2-PH1 rates were 9.3% with conservative APT and 10.7% with aggressive APT; among those without IVT, rates were 3.2% and 9.9%, respectively. Administration of IVT (adjusted odds ratio [aOR] 5.84, 95%CI 1.07 to 43.92; p=0.05) and aggressive APT (aOR 4.81, 95% CI 1.41 to 30.22; p=0.03) were each associated with higher odds of hemorrhagic complications, with a significant IVT by APT interaction (P interaction =0.05; Figures 1 and 2 ). Within the aggressive APT plus IVT subgroup, sICH-PH2-PH1 occurred in 20% of patients treated with cangrelor and 6.1% treated with a glycoprotein IIb/IIIa inhibitor ( Figure 3 ). Conclusion: Among patients requiring intracranial stenting, aggressive periprocedural APT and prior IVT are each associated with higher hemorrhagic risk, with the combination showing the worst observed crude outcome. Prospective evaluation of protocolized APT pathways in the IVT setting is warranted.

Background Intracranialatheroscleroticdisease(ICAD) isa majorcause of recurrent stroke. Previousstudieshave suggested demographicdisparitiesinoutcomes after stenting.Thisstudy evaluatedrecurrence of cerebrovascular events and mortalityby race/ethnicityand sex, witha particularfocus on Hispanicfemales. Thissubgroup was emphasizeddue to health disparities,whichareimpactedby socioeconomicbarriersand cultural factors that impactaccess to care and adherenceto medicalmanagement. Methods We analyzed 114 patients with ICAD who underwent stenting. Outcomes included transientischemicattack (TIA), stroke, and death inthe same arterialterritory. Logisticand Coxregressionanalyses were performed to assess the impact of race/ethnicityand sex. Multivariablemodels were adjustedfor age, sex, race, hypertension, diabetes, hyperlipidemia, smoking, dualantiplatelettherapy (DAPT) before stenting, affected artery, qualifying cerebrovascular event, arterial stenosis ratio, and stenosis length. Results Of 114 patients(52 White,8 AfricanAmerican,54 Hispanic;76 male, 38 female), 13 (11.4%)experiencedTIA, 13 (11.4%) had stroke, and 13 (11.4%) died.TIAs occurred most frequently inHispanics(20.4%), especiallyamong Hispanicfemales, compared withWhitefemales (3.8%, p = .016). Mortalitywas also higheramong Hispanicfemales (18.5%) compared withWhitefemales (5.8%), although not statisticallysignificant( p = .068). Stroke recurrence didnotsignificantlydiffer by ethnicityor sex. Multivariablelogisticregressiondemonstrated thatHispanicethnicitywas independentlyassociatedwithhigherodds of TIA compared withWhitepatients(OR 498.35, 95% CI 5.09–48,745.02, p = .008). Female sex was directlyassociatedwithincreasedmortality(HR 5.15, 95% CI 1.08–24.64, p = .040). Together, these findingsdemonstrate that Hispanicfemales have an elevated riskof both recurrent TIA and mortality. Conclusion Hispanicpatients—particularlyHispanicfemales—experiencea significantlyhigherriskofrecurrent TIA after ICAD stenting,and show a trend toward highermortality. Whilestrokerecurrence rates didnot have a significantdifference, the prevalence of TIA inHispanicsisclinicallyimportant,as recurrent TIA isa strong predictorof future stroke and poor long‐termoutcomes. These findingshighlightthe need for focused strategiesto improvesecondary prevention,adherence to medicalmanagement, and healthcare access inHispanicfemales, agroup whose outcomes are shaped by socioeconomicdisadvantageand cultural barriersto care. Key Words: Hispanic, Female, Outcomes, Diet, Restenosis

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

Dengue virus infection is increasingly recognized in South Texas, particularly in areas bordering Mexico. Although many cases are mild and self-limiting, dengue can present with atypical features, including hematological abnormalities and bleeding, even in the absence of plasma leakage. A 22-year-old Hispanic woman presented to a hospital in South Texas with hematemesis, fever, and gastrointestinal symptoms following travel to northeastern Mexico (Monterrey, Nuevo Leon). Initial laboratory workup revealed severe leukopenia and neutropenia, mild thrombocytopenia, and elevated liver enzymes, but no evidence of plasma leakage. A bone marrow biopsy was performed due to persistent cytopenias, revealing a reactive process consistent with viral infection. The patient improved with supportive care, including hydration, antipyretics, and symptom management, which reflects the mainstay of dengue management. This case illustrates an atypical dengue presentation marked by hematological derangements without classic features, such as hemoconcentration or plasma leakage. It underscores the diagnostic challenge dengue poses in non-typical cases, the importance of maintaining clinical suspicion in endemic areas, and the need for judicious use of invasive investigations and blood product support. Dengue may present atypically with severe cytopenias and bleeding without plasma leakage. Clinicians in endemic areas such as South Texas should consider dengue in febrile patients with cytopenias, even in the absence of plasma leakage, and avoid unnecessary interventions when supportive care suffices.

Abstract Introduction Managing atherosclerotic large vessel occlusion is procedurally challenging. Prior literature pertaining to technical considerations remain heterogenous and further research is necessary to highlight important differences. As such, first-line thrombectomy technique remains an active area of debate with respect to rate of recanalization, need for rescue stenting, and hemorrhagic complications. Methods This is a pre-planned analysis of the prospective RESCUE-ICAS registry which included atherosclerotic large vessel occlusions treated with mechanical thrombectomy from 25 sites. Patients were excluded if they had missing data on first-line technique or primary outcomes. Patients were dichotomized into two cohorts based on whether their first-line thrombectomy technique was with aspiration alone or a stentriever (SR). Primary procedural outcome was first-pass effect while primary safety outcome was mortality at 90 days. Propensity score matching and inverse probability weighted analysis were performed with respect to primary and secondary outcomes. Results 419 were patients included in this analysis with 266 and 153 patients in the aspiration and stentriever cohorts, respectively. The cohort’s mean age was 68 (SD ±13) years, and the majority of patients were white (59%) and male (62%). There were no significant baseline demographic differences between cohorts; however, ICA occlusions were more common in the stentriever cohort (52% vs 31%), while MCA occlusions were more frequent in the aspiration cohort (35% vs 15%). In the un-adjusted model, first pass effect was higher in stentriever versus aspiration (35.3% vs 23.7%, p = 0.01) with equivalent mortality rates (31% vs 26%, p = 0.31). Distal embolization rates were higher in the aspiration cohort (9.8% vs 3.9%, p = 0.03), yet aspiration was associated with lower composited procedural complications (6% vs 11%, p = 0.01). Propensity score matching and weighted analysis demonstrated that differences in primary clinical efficacy and safety outcomes were insignificant between cohorts. Conclusion In patients with atherosclerotic large vessel occlusions, first line stentriever utilization was associated with higher first-pass effect rates, lower rates of distal embolization and shorter procedural length compared to aspiration. However, no clinical outcome difference was appreciated between the two groups and aspiration was associated with lower complication rates.

Incarcerated individuals in state and federal prisons demonstrate disproportionately high rates of cardiovascular disease, especially hypertension and tobacco use. 1 As a result, in comparison with the United States general population, inmates are faced with a more than three-fold risk of acute ischemic stroke (AIS). 2 Unfortunately, some evidence suggests that incarcerated individu-als receive suboptimal medical care due to structural barriers in healthcare delivery as well as discrimination based on incarcerated status, 3 which underscores a public health and human rights concern.To the best of our knowledge, no studies to date have evaluated treatment rates and clinical outcomes of AIS in this specialized population, in whom healthcare outcomes in general are woefully understudied.Herein, we aim to evaluate treatment rates of reperfusion therapies as well as clinical outcomes of in-

BackgroundTandem lesions pose unique challenges in the endovascular treatment of acute ischemic stroke. We aimed to compare the clinical and procedural outcomes of patients with tandem lesions and extracranial internal carotid artery (ICA) complete occlusion versus those with moderate to severe stenosis.MethodsThis is a subanalysis of a multicenter cohort of patients with acute anterior circulation tandem lesions treated with intracranial mechanical thrombectomy and carotid artery stenting, between January 2015 and December 2020. The patients were categorized into 2 groups: extracranial ICA stenosis >70% to 99% and complete occlusion. Outcomes included successful and excellent recanalization, functional independence, symptomatic intracranial hemorrhage, and puncture‐to‐recanalization time. Sensitivity analyses were conducted based on varying degrees of stenosis, and we explored interactions with age, Alberta Stroke Program Early CT [Computed Tomography] Score, National Institutes of Health Stroke Scale, procedural antiplatelets, ICA treatment approach, ICA lesion etiology, Intravenous thrombolysis, and use of a balloon‐guide catheter.ResultsThe study included 323 patients; 166 (51.4%) of whom presented with ICA occlusion and 157 (48.6%) with severe stenosis. Patients with ICA occlusion had significantly higher rates of previous stroke/transient ischemic attack, and antegrade ICA treatment approach. The comparison between both groups in univariable and multivariable analysis revealed no significant differences in the rates of successful and excellent recanalization, functional independence, symptomatic intracranial hemorrhage, and additional outcomes. The median puncture‐to‐recanalization time was longer in the occlusion group (adjusted coefficient, 1.21 [95% CI 1.01–1.46], P = 0.05). When categorized into 3 groups (occlusion, severe, and moderate stenosis), median puncture‐to‐recanalization time was significantly higher in patients with occlusion (adjusted coefficient, 1.34 [95% CI, 1.04–1.71], P = 0.022), and a trend toward statistical significance was observed in patients with severe stenosis (adjusted coefficient, 1.29 [95% CI, 0.98–1.71], P = 0.068), compared with patients with moderate stenosis. Interaction analysis did not yield significant differences.ConclusionIn patients with tandem lesions, those with ICA occlusion presented longer puncture‐to‐recanalization time than patients with cervical stenosis. This observation might be linked to higher rates of an antegrade approach in patients with ICA occlusion.