Huaiming Wang

Predictors for Symptomatic Intracranial Hemorrhage After Endovascular Treatment of Acute Ischemic Stroke

Background and Purpose— Symptomatic intracranial hemorrhage (SICH) pose a major safety concern for endovascular treatment of acute ischemic stroke. This study aimed to evaluate the risk and related factors of SICH after endovascular treatment in a real-world practice. Methods— Patients with stroke treated with stent-like retrievers for recanalizing a blocked artery in anterior circulation were enrolled from 21 stroke centers in China. Intracranial hemorrhage was classified as symptomatic and asymptomatic ones according to Heidelberg Bleeding Classification. Logistic regression was used to identify predictors for SICH. Results— Of the 632 enrolled patients, 101 (16.0%) were diagnosed with SICH within 72 hours after endovascular treatment. Ninety-day mortality was higher in patients with SICH than in patients without SICH (65.3% versus 18.8%; P<0.001). On multivariate analysis, baseline neutrophil ratio >0.83 (odds ratio [OR], 2.07; 95% confidence interval [CI], 1.24–3.46), pretreatment Alberta Stroke Program Early Computed Tomography Score of <6 (OR, 2.27; 95% CI, 1.24–4.14), stroke of cardioembolism type (OR, 1.91; 95% CI, 1.13–3.25), poor collateral circulation (OR, 1.97; 95% CI, 1.16–3.36), delay from symptoms onset to groin puncture >270 minutes (OR, 1.70; 95% CI, 1.03–2.80), >3 passes with retriever (OR, 2.55; 95% CI, 1.40–4.65) were associated with SICH after endovascular treatment. Conclusions— Incidence of SICH after thrombectomy is higher in Asian patients with acute ischemic stroke. Cardioembolic stroke, poor collateral circulation, delayed endovascular treatment, multiple passes with stent retriever device, lower pretreatment Alberta Stroke Program Early Computed Tomography Score, higher baseline neutrophil ratio may increase the risk of SICH.

Clinical Effectiveness and Safety Outcomes of Endovascular Treatment for Acute Anterior Circulation Ischemic Stroke in China

Backgrounds and Purpose: This study was aimed at investigating the outcomes and predictors for the poor functional outcome after endovascular treatment (EVT) in a large, mostly Asian population. Methods: Between January 2014 and June 2016, acute stroke patients with anterior circulation occlusion and EVT were retrospectively enrolled from 21 stroke centers in China. The main outcomes were modified Rankin Scale (0-2 as functional independence, 3-6 as poor) at 90 days, symptomatic intracranial hemorrhage (sICH) at 72 h, and death at 90 days. Logistic regression was used to identify predictors for poor functional outcome at 90 days. Results: Of the 698 patients, 304 (43.6%) patients had functional independence at 90 days. The sICH rate was 15.5% (108/698) and mortality rate at 90 days was 25.4% (177/698). Age (OR 1.04, 95% CI 1.02-1.07), National Institutes of Health Stroke Scale score at admission (11-20 vs. ≤10, OR 2.38, 95% CI 1.23-4.59; ≥21 vs. ≤10, OR 3.66, 95% CI 1.72-7.80), baseline glucose level (OR 1.09, 95% CI 1.01-1.18), onset to groin puncture >6 h (OR 1.88, 95% CI 1.06-3.31), sICH (OR 15.49, 95% CI 5.16-46.43), and pneumonia (OR 3.15, 95% CI 1.86-5.32) were independent predictors of poor functional outcomes, while good recanalization (OR 0.26, 95% CI 0.13-0.54), preoperative Alberta Stroke Program Early CT Score 8-10 (OR 0.48, 95% CI 0.28-0.83), and good collateral flow (OR 0.50, 95% CI 0.32-0.79) were protective factors. Conclusions: This study provides evidence in real world to support the performance of EVT in acute anterior circulation stroke patients in Chinese population. Patients with small infarct core, successful recanalization, good collateral status, and short treatment delay without sICH or pneumonia may benefit from EVT.

Direct endovascular treatment: an alternative for bridging therapy in anterior circulation large-vessel occlusion stroke

Whether intravenous thrombolysis prior to endovascular treatment in patients with anterior circulation large‐vessel occlusion (LVO) is indispensable remains unclear. The aim was to retrospectively compare, in a Chinese population, the effectiveness and safety of direct endovascular treatment (DEVT) initiated within 4.5 h after onset with bridging therapy in acute anterior circulation LVO stroke patients.

Lower Serum Caveolin-1 Is Associated with Cerebral Microbleeds in Patients with Acute Ischemic Stroke

Caveolin-1 (Cav-1) plays pivotal roles in the endothelial damage following stroke. The present study aimed to investigate whether serum Cav-1 level is associated with the presence of cerebral small vessel disease (cSVD) in patients with acute ischemic stroke. To this end, 156 patients were consecutively enrolled. Cranial magnetic resonance imaging was analyzed to determine the surrogates of cSVD, including cerebral microbleeds (CMBs), silent lacunar infarcts (SLIs), and white matter hyperintensities (WMHs). After adjusting for potential confounders, patients with low Cav-1 level had a higher risk of CMBs than patients with high Cav-1 level (OR: 4.05, 95% CI: 1.77–9.30). However, there was no relationship between Cav-1 and the presence of SLIs or WMHs. When CMBs were stratified by location and number, a similar association was found in patients with deep or infratentorial CMBs (OR: 4.04, 95% CI: 1.59–10.25) and with multiple CMBs (OR: 3.18, 95% CI: 1.16–8.72). These results suggest lower serum Cav-1 levels may be associated with CMBs, especially those that are multiple and located in deep brain or infratentorial structures, in patients with acute ischemic stroke. Cav-1 may be involved in the pathophysiology of CMBs, and may act as a potential target for treating cSVD.

Early Prediction of Poor Outcome Despite Successful Recanalization After Endovascular Treatment for Anterior Large Vessel Occlusion Stroke

OBJECTIVE Successful recanalization (SR) of the occluded artery does not always translate into a good outcome for patients with acute anterior circulation large-vessel occlusion stroke. This study aimed to develop a scale to predict poor outcome early despite SR after endovascular treatment (EVT) for candidates identified using current guidelines. METHODS The eligible patients with SR were retrospectively enrolled between 2014 and 2016. Poor outcome was defined as modified Rankin Scale of 3 to 6 at 90 days. Multivariable logistic regression was used to derive a PooR outcomE of enDovascular treatment wIth suCcessful recanalizaTion (PREDICT) scale. The discrimination and calibration of the scale were assessed. RESULTS A total of 332 patients were enrolled. The PREDICT scale consisted of 5 items (prior intravenous thrombolysis, collateral status, blood glucose, blood neutrophil-to-lymphocyte ratio, and baseline National Institutes of Health Stroke Scale score). The scale had good discrimination and calibration. The risk of poor outcome was stratified into very low (PREDICT scale score ≤5), low (6-8), moderate (9-11), and high (≥12). Compared with patients with a score of ≤5, patients with a score of ≥12 had an 18.33-fold (95% confidence interval [CI], 6.36-52.89) increased risk of poor outcome. CONCLUSIONS The PREDICT scale is a practical tool for early prediction of poor outcome despite SR after EVT in our patients and, if validated in other patient populations, may serve as a scale for identifying which patients are most, and least, likely to benefit from EVT.

Effects of mechanical thrombectomy for acute stroke patients with etiology of large artery atherosclerosis

AIMS Atherosclerosis is more prevalent in Asian population. This distinct etiology of stroke might disadvantage Asian patients when applying. mechanical thrombectomy (MT). The purpose of this research was to evaluate the efficacy and safety of MT in a cohort of Chinese patients with acute ischemic stroke. due to large artery atherosclerosis (LAA). METHODS AND RESULTS A total of 649 patients treated with MT were included. Patients were classified according to etiology of stroke as LAA and cardioembolism ones. Successful revascularization was defined as modified Thrombolysis in Cerebral Infarction (mTICI) grade ≥ 2b. Favorable outcome was defined as modified Rankin Scale (mRS) score ≤ 2 at 90 days. Logistic regression was used to identify predictors for functional outcomes. The patients with stroke of LAA etiology had significantly higher rate of favorable functional outcome (50.2% vs 36.5%, p < .001) and good collateral (grade of ASITN/SIRI: 2-3) (58.8% versus 43.2%, p < .001), and lower median baseline National Institutes of Health Stroke Scale score (NIHSS) (15.6 versus 18.2, p < .001), compared to patients with stroke of cardioembolism etiology. There was no significant difference in the rate of successful postprocedural mTICI between groups (84.5% versus 83.2%, p = .671). Rates of symptomatic intracranial hemorrhage (20.0% versus 11.7%, p = .004) and mortality (31.8% versus 18.8%, p < .001) within 3 months were notably higher in the cardioembolism group than that in the LAA group. CONCLUSION Mechanical thrombectomy may be more efficacious in treating acute ischemic stroke of LAA etiology than that of cardioembolism etiology.

Impact of Relative Blood Glucose Changes on Mortality Risk of Patient with Acute Ischemic Stroke and Treated with Mechanical Thrombectomy

BACKGROUND AND PURPOSE The impacts of stress hyperglycemia and hypoglycemia on mortality of acute ischemic stroke patients treated with mechanical thrombectomy (MT) are largely unclear. This study aimed to use stress hyperglycemia ratio (SHR) to evaluate the influence of pretreatment relative blood glucose changes on mortality risk after MT. METHODS The study retrospectively enrolled 321 acute ischemic stroke patients treated with MT. SHR was calculated as random blood glucose at admission divided by average blood glucose which estimated by glycosylated hemoglobin (HbA1c). Patients with HbAlc greater than or equal to 6.5% were considered to have background hyperglycemia, patients were tertiled according to their SHR. Binary logistic regression was used to analyze 90 days mortality between SHR categories. RESULTS Compared with the middle tertiles group (Q2) which the blood glucose is closet to baseline glycaemia, patients in the lowest tertiles group (Q1) and highest tertiles group (Q3) have a higher mortality risk (odds ratio [OR], 3.80; 95% confidence interval [CI], 1.31-11.06) (OR, 3.18; 95% CI, 1.25-8.12), the differences is still significant after further adjusted for admission hyperglycemia (≥11.1 mmol/L). In patients without background hyperglycemia, the mortality risk is significantly higher in Q3 group (OR, 3.01; 95% CI, 1.06-8.53), no significant differences was found between three groups after adjusted for admission hyperglycemia (≥11.1 mmol/L). CONCLUSIONS SHR identified acute ischemic stroke patients with relative hyperglycemia and hypoglycemia may have higher mortality risk after MT.

Prognosis of asymptomatic intracranial hemorrhage after endovascular treatment

Objective Asymptomatic intracranial hemorrhage (aSICH) is a common phenomenon after endovascular treatment of acute ischemic stroke, but its prognostic impacts remain unclear. This study evaluated functional outcomes of thrombectomy in patients with and without aSICH. Methods Patients with acute ischemic stroke due to large artery occlusion in the anterior circulation who were treated with thrombectomy were enrolled in 21 centers. According to CT scans performed within 72 hours of endovascular procedures, patients with aSICH or without intracranial hemorrhage were included while patients with symptomatic intracranial hemorrhage (SICH) were excluded. Baseline data and functional outcomes were compared between patients with aSICH and those without intracranial hemorrhage. Logistic regression analysis was applied to evaluate the impacts of aSICH on functional outcomes. Results Of the 632 patients with endovascular treatment, 101 (16.0%) were classified as having SICH, 212 (33.5%) as having aSICH, and 319 (50.5%) as being without intracranial hemorrhage. Patients with aSICH after endovascular treatment had a lower ratio of excellent outcome (mRS 0–1, OR 0.53; 95% CI 0.33 to 0.84, P=0.007) than those without intracranial hemorrhage. There were no significant differences concerning favorable outcome (mRS 0–2, OR 0.76; 95% CI 0.50 to 1.14, P=0.185) or mortality (OR 0.64; 95% CI 0.38 to 1.09, P=0.101) between patients with aSICH and those without intracranial hemorrhage. Conclusions In an Asian population, aSICH after thrombectomy may decrease the likelihood of an excellent functional outcome but does not influence a favorable outcome and mortality in patients with ischemic stroke due to large artery occlusion in the anterior circulation.

Primary angioplasty and stenting may be superior to thrombectomy for acute atherosclerotic large-artery occlusion

Objective The objective of this article is to compare the effectiveness of primary angioplasty and/or stenting with stent retriever thrombectomy in acute anterior large-vessel occlusion due to atherosclerotic disease. Methods Patients were retrospectively reviewed from the endovascular treatment for acute anterior circulation ischemic stroke registry. Patients with large-vessel occlusions due to atherosclerosis were selected. We evaluated modified Rankin Scale (mRS) score at 90 days, modified thrombolysis in cerebral infarction (mTICI) score immediately post-procedure, and symptomatic and asymptomatic intracranial hemorrhage within 72 hours. Results Of 302 patients with acute anterior circulation occlusion due to atherosclerotic disease, 269 were treated with stent retriever thrombectomy as first-line therapy and 33 with angioplasty and/or stenting. Patients who received primary angioplasty treatment showed favorable independent outcome at 90 days (69.7% (23/33) vs 47.6% (128/269), p = 0.02) and lower rate of asymptomatic intracranial hemorrhage (9.1% (3/23) vs 30.5% (82/269), p = 0.01). Recanalization immediately post procedure did not differ (78.8%% (26/33) vs 86.2% (232/269), p = 0.29). Primary angioplasty therapy (OR, 0.27; 95% confidence interval (CI): 0.08–0.90; p = 0.03) and small baseline infarct (OR 0.36: 0.16–0.82; p = 0.02) were protective factors against poor functional outcome, while old age (OR 1.04:1.01–1.07; p = 0.006), severe neurological deficits (OR 3.76: 2.00–7.07; p < 0.001), and high glucose (OR 1.11: 1.01–1.23; p = 0.03) were associated with poor prognosis. Conclusions Patients with acute anterior circulation large-vessel occlusion due to atherosclerosis may benefit from urgent angioplasty and/or stenting as first-line therapy. Randomized controlled trials are warranted.

Endovascular retrograde approach may be a better option for acute tandem occlusions stroke

Objective The endovascular treatment strategy for acute tandem occlusion stroke is challenging, and controversy exists regarding which lesion should be treated first. This study addresses the uncertainty regarding the priority choice for thrombectomy in acute anterior circulation tandem occlusion stroke. Methods We analysed the clinical and angiographic data of tandem stroke patients who underwent interventional therapy from the endovAsCular Treatment of acUte Anterior circuLation ischaemic stroke (ACTUAL) registry. Recanalisation was assessed according to the modified thrombolysis in cerebral infarction score. Clinical outcome was evaluated at 90 days using the modified Rankin scale score. Results Sixty tandem occlusion stroke patients were enrolled. Thirty-one (51.7%) patients received anterograde therapy, while 29 (48.3%) patients underwent the retrograde approach. Successful recanalisation (modified thrombolysis in cerebral infarction score 2b–3) occurred in 78.3% (47/60) of patients, and 50.0% (30/60) of patients achieved a modified Rankin scale score of 0–2 at 90 days. Patients undergoing the retrograde approach spent less time in distal occlusion recanalisation (125 (86–167) vs. 95 (74–122) minutes; P = 0.04) and achieved better functional outcomes at 90 days (69.0% (20/29) vs. 32.3% (10/31); P = 0.004) than patients who received anterograde therapy. The retrograde approach was associated with favourable clinical outcomes (odds ratio 0.21; 95% confidence interval 0.07–0.64; P = 0.006). Conclusion For acute tandem occlusion stroke, favourable outcomes were better in patients undergoing retrograde therapy than in patients who received the anterograde approach. Future randomised trials are warranted to determine the optimal treatment.