Background Futile recanalization—when patients have a successful recanalization but fail to achieve a satisfactory functional outcome— is a common phenomenon of endovascular treatment of acute ischemic stroke (AIS). The present study aimed to identify the predictors of futile recanalization in AIS patients who received endovascular treatment. Methods This is a post-hoc analysis of the DIRECT-MT trial. Demographics, clinical characteristics, acute stroke workflow interval times, biochemical parameters, and imaging characteristics were compared between futile and meaningful recanalization groups. Multivariate analysis was performed to identify the predictors of futile recanalization. Results Futile recanalization was observed in 277 patients. In multivariable logistic regression analysis, older age (p<0.001), higher baseline systolic blood pressure (SBP) (p=0.032), incomplete reperfusion defined by extended Thrombolysis In Cerebral Infarction (eTICI) grades (p=0.020), and larger final infarct volume (FIV) (p<0.001) were independent predictors of futile recanalization. Conclusions Old age, high baseline SBP, incomplete reperfusion defined by eTICI, and large FIV were independent predictors of futile recanalization after endovascular therapy for AIS.

The optimal management of acute ischemic stroke (AIS) patients with large vessel occlusion and large ischemic core is uncertain. We aimed to evaluate the safety and efficacy of endovascular thrombectomy (EVT) compared with best medical treatment (BMT) for AIS through a study-level meta-analysis and meta-regression of 6 randomized controlled trials (RCTs). PubMed, Embase, and the Cochrane databases were searched from January 1, 1980, to June 30, 2024. We limited search results to RCTs which compared EVT vs BMT among large-core AIS. The Preferred Reporting Items for Systematic Reviews and Meta-analyses reporting guideline was used for abstracting and assessing data quality and validity. The risk ratio (RR) with 95% CI was used to measure the association of EVT vs BMT with outcomes. Univariable meta-regression analyses were conducted to evaluate possible moderating effects of onset to randomization time (OTR) on outcomes when comparing EVT with BMT. The primary outcome was the 90-day ordinal modified Rankin Scale (mRS). Secondary outcomes were independent ambulation (mRS 0-3) at 90 days, and symptomatic intracranial hemorrhage (sICH) and mortality at 90 days. Six RCTs comprising 1,887 patients with large core AIS were included. Pooled results showed that EVT compared with BMT was associated with improved mRS score at 90 days (generalized OR, 1.6, 95% CI 1.4-1.8) and higher odds of independent ambulation (RR 1.9; 95% CI 1.5-2.5). Although the risk of sICH was higher in the EVT group (RR 1.7; 95% CI 1.1-2.7), there was a reduction in mortality in the EVT group (RR 0.9; 95% CI 0.8-1.0). Meta-regression showed that the benefit of EVT decreased with the extension of OTR (mRS 0-3, regression slope, -0.11, 95% CI -0.12 to -0.10; mRS 0-2, regression slope, -0.15, 95% CI -0.16 to -0.14). For patients with Alberta Stroke Program Early CT Score (ASPECTS) 0-2, EVT was associated with increased 90-day mRS 0-3 (RR 2.1, 95% CI 1.4-3.3) and mRS 0-2 (RR 2.8, 95% CI 1.2-6.7). EVT improved clinical outcomes among patients with large-core AIS assessed by ASPECTS of 3-5 or volumetric methods. Patients with ASPECTS 0-2 also had benefit from EVT and require further study. These results support expansion of the routine application of EVT.

Background Despite successful reperfusion after thrombectomy for large vessel occlusion (LVO) stroke, up to half of patients are dependent or dead at 3-month follow-up. The aim of the current study is to demonstrate safety and efficacy of administering adjunct intra-arterial (IA) tenecteplase in anterior circulation LVO patients who have achieved successful reperfusion defined as eTICI 2b50 to 3. Methods ANGEL-TNK is a multicentre, open-label, assessor-blinded endpoint, prospective randomised, controlled trial that will enrol up to 256 patients. Patients who meet inclusion criteria with anterior circulation LVO stroke and successful reperfusion will be randomised to receive IA tenecteplase or best medical management at 1:1 ratio. Results The primary endpoint is a 90-day excellent outcome defined as modified Rankin Scale (mRS) 0–1. The primary safety endpoint is symptomatic intracranial haemorrhage within 48 hours from randomisation. Secondary endpoints include 90-day ordinal mRS, mRS 0–2, mRS 0–3, all-cause mortality and any intracranial haemorrhage. Conclusion In patients with anterior circulation LVO stroke, the ANGEL-TNK trial will inform whether adjunct IA tenecteplase administered after successful thrombectomy reperfusion improves patient outcomes. Trial registration number NCT05624190.

Background The influence of leukoaraiosis in patients with acute ischemic stroke (AIS) given intra-arterial treatment (IAT) with or without preceding intravenous thrombolysis (IVT) remains unknown. Objective To assess the clinical and radiological outcomes of IAT in patients with or without leukoaraiosis. Methods Patients of the direct mechanical thrombectomy trial (DIRECT-MT) whose leukoaraiosis grade could be assessed were included. DIRECT-MT was a randomized clinical trial performed in China to assess the effect of direct IAT compared with intravenous thrombolysis plus IAT. We employed the Age-Related White Matter Changes Scale for grading leukoaraiosis (ARWMC, 0 indicates no leukoaraiosis, 1–2 indicates mild-to-moderate leukoaraiosis, and 3 indicates severe leukoaraiosis) based on brain CT. The primary outcome was the score on the modified Rankin Scale (mRS) assessed at 90 days. Results There were 656 patients in the trial, 649 patients who were included, with 432 patients without leukoaraiosis, and 217 (33.4%) patients with leukoaraiosis divided into mild-to-moderate (n=139) and severe groups (n=78). Leukoaraiosis was a predictor of a worse mRS score (adjusted OR (aOR)=0.7 (95% CI 0.5 to 0.8)) and higher mortality (aOR=1.4 (1.1 to 1.9)), but it was not associated with symptomatic intracranial hemorrhage (sICH) (aOR=0.9 (0.5 to 1.5)). IVT preceding IAT did not increase sICH risk for patients with no (aOR=1.4 (0.6 to 3.4)), mild-to-moderate (aOR=1.5 (0.3 to 7.8)), or severe (aOR=1.5 (0.1 to 21.3)) leukoaraiosis. Conclusion Patients with leukoaraiosis with AIS due to large vessel occlusion are at increased risk of a poor functional outcome after IAT but demonstrate similar sICH rates, and IVT preceding IAT does not increase the risk of sICH in Chinese patients with leukoaraiosis.

BACKGROUND: Randomized trials have demonstrated the benefit of endovascular treatment (EVT) in moderate-to-severe acute basilar artery occlusion (BAO), but its benefit in acute mild BAO remains uncertain. This multicenter, retrospective cohort study aimed to explore the efficacy of EVT in acute BAO with a low National Institutes of Health Stroke Scale. METHODS: Patients with acute BAO and National Institutes of Health Stroke Scale <10, hospitalized at 5 stroke centers in China between January 2020 and December 2023, were included and divided into EVT and standard medical treatment groups. The primary outcome was 90-day functional independence, defined as a modified Rankin Scale score of 0 to 2. Secondary outcomes include proportions of 90-day modified Rankin Scale score of 0 to 1 and 0 to 3. Symptomatic intracerebral hemorrhage within 48 hours and 90-day mortality were assessed as safety outcomes. RESULTS: Three hundred fifteen patients with BAO with National Institutes of Health Stroke Scale <10 were enrolled (229 [72.7%] male; median [interquartile range] age, 65 [58–72] years; median [interquartile range] baseline National Institutes of Health Stroke Scale score, 6 [3–8] points), 161 (51.1%) of whom underwent EVT and 154 (48.9%) received standard medical treatment. The EVT group had a higher rate of 90-day functional independence (68.9% versus 44.8%; adjusted odds ratio, 3.69 [95% CI, 2.04–6.68]; P <0.001). There was no significant difference in 90-day mortality (4.3% versus 4.5%; adjusted odds ratio, 1.22 [95% CI, 0.37–4.03]; P =0.80). However, EVT was associated with a higher risk of symptomatic intracerebral hemorrhage (8.2% versus 3.9%; adjusted odds ratio, 3.86 [95% CI, 1.18–12.61]; P =0.03). CONCLUSIONS: In this cohort of patients with acute mild BAO, EVT was associated with an improved 90-day functional outcome compared with standard medical treatment alone, although the risk of symptomatic intracerebral hemorrhage was increased.

BACKGROUND: We aim to assess the efficacy of rapid local ischemic postconditioning (RL-IPostC) following successful reperfusion in patients with acute ischemic stroke with anterior circulation large vessel occlusion who underwent endovascular thrombectomy. METHODS: We conducted an ambidirectional cohort study with 78 prospectively enrolled patients with RL-IPostC and endovascular thrombectomy and 129 retrospectively enrolled patients with endovascular thrombectomy. The RL-IPostC procedure involved 5 cycles of 15-s balloon inflation and deflation in the ipsilateral internal carotid artery. The primary outcome was functional independence, defined as a modified Rankin Scale score of 0 to 2. Secondary outcomes included excellent outcomes (modified Rankin Scale score, 0–1) and early therapeutic response. Imaging outcomes involved infarct volume changes and cerebral edema measurements. Outcomes were compared with postpropensity score matching (1:1) and assessed using univariable and multivariable regression models. RESULTS: In the matched cohort of 136 patients (mean age, 71±14 years; 70 men [51%]), RL-IPostC was associated with a higher rate of functional independence (adjusted odds ratio, 2.47 [95% CI, 1.10–5.68]; P =0.030). The RL-IPostC group exhibited significantly reduced infarct volumes at 24 hours (difference, −12.2 [95% CI, −23.9 to −0.53]; P =0.041) and less infarct growth (difference, −12.2 [95% CI, −23.9 to −0.45]; P =0.042). Furthermore, RL-IPostC correlated with lower increases in net water uptake (difference, −0.04 [95% CI, −0.07 to −0.01]; P =0.018), lower decrease cerebrospinal fluid volume (difference, −7.75 [95% CI, −11.7 to −3.84]; P <0.001), and reduced midline shift at 24 hours (difference, −1.39 [95% CI, −2.48 to −0.30]; P =0.013). CONCLUSIONS: RL-IPostC tends to promote functional independence and reduces infarct growth and cerebral edema in patients with acute ischemic stroke post-reperfusion.