Background and Objectives: A machine learning technique for identifying hidden coronary artery disease (CAD) might be useful. We developed and validated machine learning models to predict patients with hidden CAD and assess long-term outcomes in patients with acute ischemic stroke. Methods: Multidetector coronary computed tomography was performed for patients without known history of CAD. Primary outcomes were defined as having any degree of CAD and having obstructive CAD (≥50% stenosis). Demographic variables, risk factors, laboratory results, Trial of ORG 10172 in Acute Stroke Treatment (TOAST) classification, NIH Stroke Scale score, blood pressure, and carotid artery stenosis were used to develop and validate machine learning models to predict CAD. Area under the receiver operating characteristic curves (AUC) was calculated for performance analysis, and Kaplan–Meier and Cox survival analyses of long-term outcomes were performed. Major adverse cardiovascular events (MACE) were defined as ischemic stroke, myocardial infarction, unstable angina, urgent coronary revascularization, and cardiovascular mortality. Results: Overall, 1,710 patients were included for the training dataset and 348 patients for the validation dataset. An Extreme Gradient Boosting model was developed to predict any degree of CAD, which showed an AUC of 0.763 (95% CI 0.711–0.814) on validation. A logistic regression model was used to predict obstructive CAD and had an AUC of 0.714 (95% CI 0.692–0.799). During the first 5 years of follow-up, MACE occurred more frequently when predicted of any CAD (P = 0.022) or obstructive CAD (P < 0.001). Cox proportional analysis showed that the hazard ratio of MACE was 1.5 (95% CI 1.1–2.2; P = 0.016) when predicted of any CAD, whereas it was 1.9 (95% CI 1.3–2.6; P < 0.001) for obstructive CAD. Discussion: We demonstrated that machine learning may help identify hidden CAD in patients with acute ischemic stroke. Long-term outcomes were also associated with prediction results. Classification of Evidence: This study provides Class II evidence that in patients with acute ischemic stroke with CAD risk factors but no known history of CAD, a machine learning model predicts CAD on multidetector coronary computed tomography with an AUC of 0.763 (95% CI 0.711-0.814).

Background: A high and low estimated glomerular filtration rate (eGFR) could affect outcomes after reperfusion therapy for ischemic stroke. This study aimed to determine whether renal function based on eGFR affects mortality risk in patients with ischemic stroke within 6 months following reperfusion therapy. Methods: This prospective registry–based cohort study included 2266 patients who received reperfusion therapy between January 2000 and September 2019 and were registered in the SECRET (Selection Criteria in Endovascular Thrombectomy and Thrombolytic Therapy) study or the Yonsei Stroke Cohort. A high and low eGFR were based on the Chronic Kidney Disease Epidemiology Collaboration equation and defined, respectively, as the 5th and 95th percentiles of age- and sex-specific eGFR. Occurrence of death within 6 months was compared among the groups according to their eGFR such as low, normal, or high eGFR. Results: Of the 2266 patients, 2051 (90.5%) had a normal eGFR, 110 (4.9%) a low eGFR, and 105 (4.6%) a high eGFR. Patients with high eGFR were younger or less likely to have hypertension, diabetes, or atrial fibrillation than the other groups. Active cancer was more prevalent in the high-eGFR group. During the 6-month follow-up, there were 24 deaths (22.9%) in the high-eGFR group, 37 (33.6%) in the low-eGFR group, and 237 (11.6%) in the normal-eGFR group. After adjusting for variables with P <0.10 in the univariable analysis, 6-month mortality was independently associated with high eGFR (hazard ratio, 2.22 [95% CI, 1.36–3.62]; P =0.001) and low eGFR (HR, 2.29 [95% CI, 1.41–3.72]; P =0.001). These associations persisted regardless of treatment modality or various baseline characteristics. Conclusions: High eGFR as well as low eGFR were independently associated with 6-month mortality after reperfusion therapy. Kidney function could be considered a prognostic factor in patients with ischemic stroke after reperfusion therapy.

Background: Intensive blood pressure (BP) management within 24 h after successful reperfusion following endovascular thrombectomy (EVT) is associated with worse functional outcomes than conventional BP management in Asian randomized controlled trials. Given the high prevalence of intracranial atherosclerotic stenosis (ICAS) in Asia, ICAS may influence these outcomes. Aims: We aimed to assess whether ICAS affects the outcomes of intensive BP management after successful EVT. Methods: We conducted a secondary analysis of the Outcome in Patients Treated With Intra-Arterial Thrombectomy–Optimal Blood Pressure Control trial, which enrolled participants from June 2020 to November 2022. Patients with anterior circulation large vessel occlusion (LVO) were stratified into ICAS-related and embolic LVO groups. Clinical outcomes for intensive (target systolic BP < 140 mm Hg) and conventional BP management (target systolic BP = 140–180 mm Hg) were analyzed in each group. The primary outcome was a favorable outcome, defined as a modified Rankin Scale score of 0 to 2 at 3 months. Safety outcomes included symptomatic intracerebral hemorrhage within 36 h and stroke-related death within 3 months. Results: Among 192 patients, 59 were in the ICAS-related LVO group, and 133 were in the embolic LVO group. In the ICAS-related LVO group, the rate of achieving a favorable outcome at 3 months was 37.5% with intensive BP management and 55.6% with conventional management (adjusted odds ratio (OR) = 0.49 (95% confidence interval (CI) = 0.14 to 1.75); P = 0.27). In the embolic LVO group, these rates were 29.9% and 42.4%, respectively (adjusted OR = 0.64 (95% CI = 0.28 to 1.45); P = 0.29). No significant interaction was found ( P for interaction = 0.68). In addition, the ICAS-related LVO group receiving intensive BP management had lower rates of successful reperfusion at 24 h compared to conventional management (67.7% vs. 91.7%; P = 0.03), while no significant difference was found in the embolic LVO group. A significant interaction effect on successful reperfusion at 24 h was observed between ICAS-related and embolic LVO groups ( P for interaction = 0.04). No significant differences in safety outcomes were observed between intensive BP management and conventional management within both ICAS-related LVO and embolic LVO groups. Conclusions: ICAS did not significantly affect outcomes of intensive BP management within 24 h after successful EVT. After successful reperfusion by EVT, intensive BP management should be avoided regardless of ICAS presence. Data access statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.

Background: The effects of blood pressure (BP) lowering in patients treated with intravenous tissue plasminogen activator (IV tPA) before endovascular thrombectomy (EVT) are unclear. Aims: This study aims to investigate whether intensive and conventional BP management affects outcomes differently, depending on IV tPA administration before EVT. Methods: In this subgroup analysis of the Outcome in Patients Treated with Intra-Arterial Thrombectomy–Optimal Blood Pressure Control (OPTIMAL-BP; ClinicalTrials.gov Identifier: NCT04205305) trial, patients were divided into groups based on IV tPA use before EVT. Clinical outcomes of intensive (systolic BP target < 140 mm Hg) or conventional BP management (systolic BP target 140–180 mm Hg) were compared among groups. The primary efficacy outcome was a favorable outcome at 3 months (modified Rankin Scale score of 0–2). Primary safety outcomes included symptomatic intracerebral hemorrhage (sICH) within 36 h and stroke-related death within 3 months. Results: Among the 302 patients, the IV tPA group included 98 (32.5%) and the non-IV tPA group comprised 204 subjects (67.5%). In the IV tPA group, intensive BP management significantly lowered the favorable outcome rate (intensive, 27.3% vs. conventional, 51.9%; adjusted odds ratio [aOR], 0.36; 95% confidence interval [CI], 0.13–0.93; p = 0.04). In the non-IV tPA group, the risk difference rate of favorable outcome was not significantly different between intensive and conventional BP management (44.1% vs. 55.9%; aOR, 0.62; 95% CI, 0.31–1.22; p = 0.17). Notably, the proportion of malignant cerebral edema within 36 h in the IV tPA group was significantly higher in the intensive management group (18.2%) than in the conventional management group (1.9%; aOR, 10.72; 95% CI, 1.24–92.29; p = 0.03). sICH and mortality rates were not significantly different between intensive and conventional BP management in either study groups. Conclusions: Intensive BP management worsens 3-month functional outcomes after successful EVT without reducing sICH among patients who received IV tPA before EVT, indicating that BP lowering in this population should be cautious.

A rupture of a femoral pseudoaneurysm is an extremely rare complication of endovascular procedures, but its outcome can be life-threatening. In this report, we present a case of a femoral pseudoaneursym rupture in a patient in their early 90s following intra-arterial mechanical thrombectomy for acute ischemic stroke. Despite receiving medical and surgical interventions, the patient subsequently developed multiple organ failure, ultimately resulting in death. This case emphasizes the critical role of appropriate selection of vascular closure technique and careful post-procedural monitoring, particularly in high-risk patients.

Background: Multiple attempts of thrombectomy have been linked to a higher risk of intracerebral hemorrhage and worsened functional outcomes, potentially influenced by blood pressure (BP) management strategies. Nonetheless, the impact of intensive BP management following successful recanalization through multiple attempts remains uncertain. Aims: This study aimed to investigate whether conventional and intensive BP managements differentially affect outcomes according to multiple-attempt recanalization (MAR) and first-attempt recanalization (FAR) groups. Methods: In this secondary analysis of the OPTIMAL-BP trial, which was a comparison of intensive (systolic BP target: <140 mm Hg) and conventional (systolic BP target = 140–180 mm Hg) BP managements during the 24 h after successful recanalization, we included intention-to-treat population of the trial. Patients were divided into the MAR and the FAR groups. We examined a potential interaction between the number of thrombectomy attempts (MAR and FAR groups) and the effect of BP managements on clinical and safety outcomes. The primary outcome was functional independence at 3 months. Safety outcomes were symptomatic intracerebral hemorrhage within 36 h and mortality within 3 months. Results: Of the 305 patients (median = 75 years), 102 (33.4%) were in the MAR group and 203 (66.6%) were in the FAR group. The intensive BP management was significantly associated with a lower rate of functional independence in the MAR group (intensive, 32.7% vs conventional, 54.9%, adjusted odds ratio (OR) = 0.33, 95% confidence interval (CI) = 0.12–0.90, p = 0.03). In the FAR group, the proportion of patients with functional independence was not significantly different between the BP managements (intensive, 42.5% vs conventional, 54.2%, adjusted OR = 0.73, 95% CI = 0.38–1.40). Incidences of symptomatic intracerebral hemorrhage and mortality rates were not significantly different according to the BP managements in both MAR and FAR groups. Conclusions: Among stroke patients who received multiple attempts of thrombectomy, intensive BP management for 24 h resulted in a reduced chance of functional independence at 3 months and did not reduce symptomatic intracerebral hemorrhage following successful reperfusion.