Stroke (Hoboken, N.J.)最新文献

Background: Current evidence on differential outcomes of endovascular therapy for the different pathological subtypes of vertebrobasilar artery occlusion is still limited. The study aimed to compare characteristics and clinical outcomes among distinct pathological subtypes of vertebrobasilar artery occlusion undergoing endovascular therapy.

Methods: This was a posthoc pooled analysis of 1320 patients from the BASILAR (Endovascular Treatment for Acute Basilar Artery Occlusion Study; 2014-2019) and the PERSIST (Posterior Circulation Ischemic Stroke Registries; 2015-2018) registries. This analysis included adults (≥18 years) with moderate to severe vertebrobasilar artery occlusion who underwent endovascular therapy within 24 hours of their last known well. Patients were stratified by stroke mechanism: group 1 (embolism without vertebral stenosis), group 2 (tandem embolism from vertebral stenosis/occlusion), and group 3 (in situ atherosclerotic thrombosis). Baseline characteristics, procedural details, and clinical outcomes were compared across these 3 groups. The primary outcome was a favorable functional outcome, defined as a modified Rankin Scale score of 0 to 3 at 90 days. Baseline characteristics, procedural details, and clinical outcomes were compared across these 3 groups. Because the primary independent variable was categorical with no single referent category, all comparisons among the 3 groups were conducted as exploratory analyses.

Results: A total of 1067 patients were included (group 1, n=257 [24.08%]; group 2, n=176 [16.49%]; group 3, n=634 [59.42%]). The overall successful recanalization rate was 84.72% (904/1067), and the favorable functional outcome (90-day modified Rankin Scale score of 0-3) rate was 33.40% (275/1063). The procedure time in group 1 was significantly shorter than that in groups 2 and 3 (median time, 90 versus 135 and 110 minutes, P<0.001). There was no significant difference in the primary outcome of a favorable functional outcome among the 3 groups. After adjusting for potential confounders, group 1 exhibited a significantly higher proportion of patients achieving excellent outcomes at 90 days (modified Rankin Scale score, 0-1) compared with groups 2 and 3 (21.9% versu 17.1%, adjusted odds ratio, 0.57 [95% CI, 0.32-0.99]; 21.9% versus 16.5%, adjusted odds ratio, 0.59 [95% CI, 0.37-0.95]). No significant differences were observed in recanalization rates, favorable functional outcome, symptomatic intracranial hemorrhage, or mortality among the 3 groups.

Conclusions: The outcome of endovascular therapy for vertebrobasilar artery occlusion may vary based on the stroke mechanism; patients with embolism without vertebral artery steno-occlusion may achieve excellent outcomes compared with other causes.

Registration: URL: http://www.chictr.org.cn; Unique identifier: CTR1800014759 and CTR2000033211.

Background: Arteriovenous malformation (AVM) recurrence after complete surgical resection is a rare but significant clinical event. The underlying mechanisms and factors that predict recurrence remain incompletely defined.

Methods: We conducted a systematic review and meta-analysis in accordance with Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 guidelines. We included case series reporting on AVM recurrence following an angiographically documented complete resection. Data on initial clinical presentation, patients' demographics, AVM features, and patterns of recurrence were extracted and analyzed.

Results: We included 15 studies with a total of 1287 patients in our meta-analysis. The overall estimated recurrence rate was 5.4%. Hemorrhagic presentation appeared as a major predictor: in fact, 94% of recurrences occurred in patients with a prior rupture, corresponding to a 7.3% (95% CI, 0.049-0.098) recurrence rate within this high-risk subgroup. Ruptured AVMs were associated with 4-fold higher odds of recurrence compared with unruptured AVMs (odds ratio, 4.072 [95% CI, 1.492-11.113]). Younger age was also found to be a key factor, with pediatric patients accounting for 89% of all recurrences. Deep venous drainage was associated with a nearly 5-fold increased risk of recurrence (odds ratio, 4.96 [95% CI, 1.801-13.662]), while eloquent brain location was not found as a statistically significant predictor. The mean time to recurrence was 39.6 (95% CI, 27.80-51.41) months, while follow-ups varied among patients.

Conclusions: Hemorrhagic presentation, younger age, and deep venous drainage demonstrated to be significant predictors of AVM recurrence after complete resection, whereas vascular aging appears protective. In older individuals, proangiogenic mediators (VEGF [vascular endothelial growth factor], HIF-1 [hypoxia-inducible factor-1] α, eNOS [endothelial nitric oxide synthase], and MMPs [matrix metalloproteinases]) are downregulated via aging-related pathways, limiting neovascularization and making recurrence biologically less likely. These findings underscore the need for prolonged, risk-adapted surveillance protocols, particularly for high-risk pediatric patients who present with hemorrhage.

Background: The CASONI study (Carotid Artery Stenting Outcomes by Neurointerventional Surgeons) showed that proceduralist experience significantly reduces complications in carotid artery stenting. The CASSH study (Carotid Artery Stenting Outcomes in Comprehensive Stroke Hospitals) prospectively evaluates real-world carotid artery stenting outcomes by fellowship-trained neurointerventionalists at comprehensive stroke centers across the United States to validate and expand on CASONI's findings.

Methods: CASSH is a multicenter, prospective observational study conducted across 15 US comprehensive stroke centers from January 2023 to December 2024. Adults with symptomatic ≥50% or asymptomatic ≥70% carotid stenosis undergoing carotid artery stenting by fellowship-trained neurointerventionalists were included. The primary outcome was a 30-day composite of procedure-related death, stroke, or myocardial infarction. Secondary outcomes included nonprocedural mortality, access site complications, stent thrombosis, and other adverse events. Logistic regression identified predictors of adverse outcomes.

Results: Among 889 patients (mean age 70.3±9.9 years; 61.4% male), 87.1% had hypertension and 63.1% were symptomatic. The 30-day composite primary outcome occurred in 1.2% (mortality 0.8%, ischemic stroke 0.3%, hemorrhagic stroke 0.2%, myocardial infarction 0.2%). Composite secondary outcome occurred in 5.4%, most commonly access site complications (1.7%) and nonprocedural mortality (1.5%). Higher preprocedural modified Rankin Scale (odds ratio [OR], 1.42), National Institutes of Health Stroke Scale score (OR, 1.09), and longer fluoroscopy times (OR, 1.02) were associated with increased complication risk. Mortality was independently predicted by elevated modified Rankin Scale (OR, 1.72), higher National Institutes of Health Stroke Scale score (OR, 1.15), older age (OR, 1.05 per year), and lower ejection fraction (OR, 0.96). Postprocedural antiplatelet therapy was protective, reducing both complications (OR, 0.03) and mortality (OR, 0.07).

Conclusions: Carotid artery stenting performed by fellowship-trained neurointerventionalists at comprehensive stroke centers is associated with low rates of periprocedural stroke, myocardial infarction, and death. These outcomes align with the landmark CREST-2 trial (Carotid Revascularization and Medical Management for Asymptomatic Carotid Stenosis Trial), particularly in asymptomatic patients, and are strongly influenced by preprocedural disability, stroke severity, age, and cardiac function, underscoring the importance of patient selection and optimized perioperative care.

Background: Intracranial atherosclerotic disease is associated with up to 10% of ischemic strokes and a high risk of recurrence. Endovascular treatments including percutaneous transluminal angioplasty and stenting have failed to demonstrate improved outcomes compared with medical therapy alone. Drug-coated balloon (DCB) angioplasty has emerged as a promising alternative, though its safety and durability remain uncertain.

Methods: This single-center retrospective study analyzed consecutive patients with refractory intracranial atherosclerotic disease treated with AGENT drug-coated balloon submaximal angioplasty. Stenosis was quantified according to the WASID criteria (Warfarin-Aspirin Symptomatic Intracranial Disease). Patients were treated either for refractory large-vessel occlusion during thrombectomy (emergency rescue) or for recurrent ischemic symptoms from high-grade stenosis (elective primary). Primary outcome was technical success, defined as <50% residual stenosis after DCB angioplasty without the need for adjunctive percutaneous transluminal angioplasty and stenting. Safety outcomes included periprocedural intracranial hemorrhage, vessel dissection, symptomatic reocclusion, ischemic stroke, and mortality at 1 month and 3 months.

Results: Of the 11 identified patients, 9 underwent successful DCB angioplasty, 5 for emergent rescue therapy, and 4 for elective primary therapy. There was a combined technical success rate of 78%, with no major procedural complications. Mean stenosis reduction was 53.6% (paired Wilcoxon P=0.014; preprocedure mean [SD] stenosis 90.8% [±8.6%] to postprocedure 37.3% [±33.4%]). Restenosis occurred in 3 of the 4 (75%) elective primary patients on follow-up imaging at a mean of 64 days postprocedure, without recurrent ischemic events. Follow-up angiographic data for the emergent rescue cohort was unavailable, though no symptomatic ischemic events were reported.

Conclusions: Paclitaxel-coated AGENT DCB submaximal angioplasty was safe and yielded immediate improvements in luminal diameter. However, high rates of restenosis emphasize the need for innovative devices and larger prospective studies to define its therapeutic role for refractory intracranial atherosclerotic disease.

Background: Collateral blood flow is a critical determinant of successful recanalization in acute ischemic stroke caused by large vessel occlusion. Head down tilt -15° (HDT15), similar to Trendelenburg positioning, is a simple, low-cost positional therapy that may augment cerebral collateral blood flow and penumbral survival. The aim of the study is to assess the safety, feasibility, and efficacy of HDT15 in improving cerebral collateral circulation and clinical outcomes in patients with large vessel occlusion-acute ischemic stroke treated with mechanical thrombectomy (MT).

Methods: The DOWN-SUITE trial (Head Down Tilt 15° to Increase Collateral Flow in Acute Ischemic Stroke) is a multicenter, randomized, open-label, phase 2a/b clinical trial with blinded outcome assessment, conducted across 7 Italian stroke centers. A total of 118 patients with acute ischemic stroke due to M1 segment middle cerebral artery occlusion will be randomized 1:1 in the emergency department to receive HDT15 or standard positioning (head-of-bed 0° to +30°) before and during MT.

Results: The primary end point is good collateral status (American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology grade 3-4), assessed on the first angiographic sequence during MT by a blinded imaging core laboratory. Secondary end points include feasibility (proportion maintaining HDT15, admission-to-MT time), safety (symptomatic intracranial hemorrhage, pneumonia, vomiting, neurological deterioration, vital signs), and efficacy (neurological improvement before MT, at 24 hours, and at 7 days or discharge, modified Rankin Scale score at 90 days).

Conclusions: The DOWN-SUITE trial will provide evidence on the acute cerebrovascular effect of HDT15 in large vessel occlusion-acute ischemic stroke, potentially establishing a cost-effective, practice-changing intervention to improve collaterals for global stroke care.

Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT06297863.

Background: Recent randomized controlled trials of endovascular treatment (EVT) for distal and medium vessel occlusion (DMVO) stroke did not demonstrate clinical benefit over best medical therapy and suggested potential safety concerns. We aimed to compare baseline characteristics of patients with DMVO stroke enrolled in these trials with those treated with EVT in routine clinical practice (RCP).

Methods: We conducted a retrospective cohort study of a prospectively recorded dual-center database including all consecutive patients with an acute ischemic stroke due to isolated primary DMVO (distal or nondominant M2, M3, A1, A2, A3, P1, P2) between January 2022 and July 2024 who fulfilled trials inclusion/exclusion criteria. Both centers participated in the DMVO trials during the study period. Patients were categorized in 2 groups: those who underwent EVT under RCP (RCP group) versus those randomized in a trial for DMVO stroke (clinical trial, computed tomography group). The 2 groups were evaluated and compared based on demographic, clinical, imaging, and treatment characteristics.

Results: Among 182 patients (median age, 79 years; interquartile range [IQR], 69-86; 46.2% female), 53 (29.1%) were included in a trial, and 129 (70.9%) were treated in RCP. Compared with RCP patients, those in the computed tomography group presented lower baseline stroke severity (median NIHSS, 5 [IQR, 4-7] versus 10 [IQR,7-15]; P<0.001), smaller admission hypoperfusion volumes (27 mL [IQR, 16-42] versus 48 mL [IQR, 24-70]; P<0.001) and a trend toward more vascular risk factors (2, [IQR, 1-3] versus 1 [1-2] in RCP patients; P=0.062) was observed. Angiographic outcomes among patients undergoing EVT trended toward higher successful reperfusion in the RCP group (87.6% versus 72.0%; P=0.051).

Conclusions: In our study, conducted at 2 centers participating in DMVO clinical trials, randomized patients presented milder clinical severity and smaller hypoperfusion areas compared with those treated in daily practice, suggesting a potential selection bias. Our findings highlight the importance of consecutive recruitment in future DMVO trials to clarify the role of EVT.

Endovascular therapy has revolutionized the treatment of acute ischemic stroke with large vessel occlusion, becoming the standard of care across anterior and posterior circulation. With expanding indications, including large infarct cores, extended time windows, and older patients, the number and complexity of procedures are steadily increasing worldwide. Although overall rates of successful reperfusion approach 90%, the remaining 10% of failed endovascular therapy highlight the technical challenges still confronting interventionalists. Procedural failure may occur at multiple stages, from arterial puncture to supra-aortic catheterization, intracranial navigation, or closure, each requiring tailored strategies. This review gathers advanced tips and tricks to manage demanding situations, reflecting both published evidence and the long-standing oral transmission that often occurs during fellowships. Practical solutions are described for frequent challenges, including complex femoral access and closure, tortuous supra-aortic vessels, difficult carotid siphons, and hostile intracranial anatomy. Techniques such as buddy-wire, balloon anchoring, stent-anchoring, balloon tracking, direct carotid puncture, and the flossing technique are detailed, alongside structured escalation strategies. Beyond technical skills, this review emphasizes the importance of comprehensive training. Mastery of complex diagnostic cerebral angiographies, supported by simulation-based learning, is considered more relevant than procedural counts to determine readiness for on-call independence. Ultimately, competence is defined not by the number of endovascular therapies performed, but by the ability to anticipate and safely manage complications in unpredictable anatomic settings. Future training should integrate procedural volume, case complexity, and simulation to prepare the next generation of interventionalists to perform endovascular therapy and navigate the unexpected with safety and confidence.