BACKGROUND: When treating acute ischemic stroke due to large-vessel occlusion, both mechanical thrombectomy and intravenous (IV) thrombolysis carry the risk of intracerebral hemorrhage. PURPOSE: This study aimed to delve deeper into the risk of intracerebral hemorrhage and its subtypes associated with mechanical thrombectomy with or without IV thrombolysis to contribute to better decision-making in the treatment of acute ischemic stroke due to large-vessel occlusion. DATA SOURCES: PubMed, EMBASE, and Scopus databases were searched for relevant studies from inception to September 6, 2023. STUDY SELECTION: The eligibility criteria included randomized clinical trials or post hoc analysis of randomized controlled trials that focused on patients with acute ischemic stroke in the anterior circulation. After screening 4870 retrieved records, we included 9 studies (6 randomized controlled trials and 3 post hoc analyses of randomized controlled trials) with 3241 patients. DATA ANALYSIS: The interventions compared were mechanical thrombectomy + IV thrombolysis versus mechanical thrombectomy alone, with the outcome of interest being any form of intracerebral hemorrhage and symptomatic intracerebral hemorrhage after intervention. A common definition for symptomatic intracerebral hemorrhage was pooled from various classification systems, and subgroup analyses were performed on the basis of different definitions and anatomic descriptions of hemorrhage. The quality of the studies was assessed using the revised version of Cochrane Risk of Bias 2 assessment tool. Meta-analysis was performed using the random effects model. DATA SYNTHESIS: Eight studies had some concerns, and 1 study was considered high risk. Overall, the risk of symptomatic intracerebral hemorrhage was comparable between mechanical thrombectomy + IV thrombolysis and mechanial thrombectomy alone (risk ratio, 1.24 [95% CI, 0.89–1.72]; P = .20), with no heterogeneity across studies. Subgroup analysis of symptomatic intracerebral hemorrhage showed a non-significant difference between 2 groups based on the National Institute of Neurological Disorders and Stroke (P = .3), the Heidelberg Bleeding Classification (P = .5), the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (P = .4), and the European Cooperative Acute Stroke Study III (P = .7) criteria. Subgroup analysis of different anatomic descriptions of intracerebral hemorrhage showed no difference between the 2 groups. Also, we found no difference in the risk of any intracerebral hemorrhage between two groups (risk ratio, 1.10 [95% CI, 1.00–1.21]; P = .052) with no heterogeneity across studies. LIMITATIONS: There was a potential for performance bias in most studies. CONCLUSIONS: In this systematic review and meta-analysis, the risk of any intracerebral hemorrhage and symptomatic intracerebral hemorrhage, including its various classifications and anatomic descriptions, was comparable between mechanical thrombectomy + IV thrombolysis and mechanical thrombectomy alone.

Background Transcranial Doppler (TCD) is a non-invasive, bedside tool that allows for real-time monitoring of the patient’s hemodynamic status following mechanical thrombectomy (MT). This systematic review and meta-analysis aims to evaluate the predictive value of TCD parameters following successful MT (Thrombolysis in Cerebral Infarction 2b–3). Methods In July 2024, we searched PubMed, Embase, and Scopus, to identify observational studies in which TCD parameters were measured within 48 hours of MT. Using random-effects models, we compared four TCD parameters (mean flow velocity (MFV), MFV index, pulsatility index (PI), and peak systolic velocity (PSV) among groups with vs without hemorrhagic transformation (HT) and favorable vs poor functional recovery (modified Rankin Scale 0–2 vs 3–6). Results Eleven studies comprising 1432 patients (59% male; mean age range: 63–73 years) were included. The MFV and MFV index were higher in patients with HT (Hedges' g=0.42 and 0.54, P=0.015 and 0.005, respectively). Patients with MFV index ≥1.3 showed a higher risk of all HT (RR 1.97; 95% confidence interval (CI) 1.28 to 3.03, P=0.002), symptomatic HT (RR 4.68; 95% CI 1.49 to 14.65, P=0.008), and poor functional status at 90 days (RR 1.65; 95% CI 1.27 to 2.14, P=0.029), respectively. There was no difference in mean PSV (P=0.1) and PI (P=0.3) among groups with and without HT. Conclusion This study underscores the prognostic value of the MFV index in predicting HT, symptomatic HT, and poor functional recovery after successful MT in the anterior circulation. Large-scale, multi-center studies are necessary to confirm these findings and to validate the MFV index as a reliable predictor for improving post-thrombectomy care.

BACKGROUND: The efficacy and safety profiles of surgical and embolization techniques for cerebrospinal venous fistulas (CVFs) in patients with spontaneous intracranial hypotension (SIH) are not well-defined due to limited data and a lack of randomized trials. PURPOSE: This systematic review and meta-analysis aims to compare the efficacy and safety of surgical treatment and transvenous embolization for CVFs in patients with SIH. DATA SOURCES: PubMed, Embase, and Scopus were searched from inception to September 2024. STUDY SELECTION: Clinical studies involving adults with confirmed CVFs, treated either surgically or through transvenous embolization, were included. Endpoints analyzed included headache response, overall symptom resolution, radiologic treatment response, and complications. Meta-analyses were performed using R software, applying random effects models to calculate prevalence rates and their 95% confidence intervals (CIs). Subgroups of surgery and embolization were compared using Chi-square test. The quality of the studies was assessed using appropriate checklists. DATA ANALYSIS: Fifteen studies involving 321 patients and 354 CVFs were included, all of good quality. Both treatment modalities led to over 90% partial or complete headache response, with no significant difference between embolization (93.9%; 95% CI 88.3% to 96.9%) and surgery (90.1%; 95% CI 75.6% to 96.4%) (p=0.43). Overall symptom resolution (complete response) was also comparable between embolization (59.1%; 95% CI 50.5% to 67.1%) and surgery (70.7%; 95% CI 44.7% to 87.8%) (p=0.38). Radiologic response, measured by the Bern score, showed significant improvement post-embolization, with no corresponding data from surgical literature. The retreatment/recurrence rate was 14% (95% CI: 9.9% to 19.3%), with no significant difference between embolization (15.3%; 95% CI 10.3% to 22.1%) and surgery (11.3%; 95% CI 5.7% to 20.9%) (p=0.63). There was no publication bias among the reported endpoints. LIMITATIONS: Lack of direct comparative effectiveness and small sample sizes heighten the risk of selection and confounding bias. CONCLUSIONS: In conclusion, our systematic review and meta-analysis indicate that both surgical treatment and transvenous embolization for CVFs in patients with SIH provide comparable efficacy and safety profiles. Future research should employ uniform definitions, standardized radiologic and clinical endpoints, and long-term follow-up to more rigorously evaluate the relative efficacy and safety of these approaches. ABBREVIATIONS: SIH =Spontaneous intracranial hypotension; CVF =CSF-venous fistulas; EBP =Epidural blood patching.

Objective To develop a comprehensive assessment tool to evaluate the Quality of Care (QoC) in managing individuals with traumatic spinal cord injuries (TSCI). Method At first, the concepts of QoC for TSCI were identified by conducting a qualitative interview along with re-evaluation of the results of a published scoping review (conceptualization). After operationalization of indicators, they were valued by using the expert panel method. Afterward, the content validity index (CVI) and content validity ratio (CVR) were calculated and served as cut-offs for indicator selection. Then specific questions were developed for each indicator and classified into three categories: pre-hospital, in-hospital, and post-hospital. Data availability of the National Spinal Cord Injury Registry of Iran (NSCIR-IR) was subsequently used to design questions that represent indicators in an assessment tool format. The comprehensiveness of the tool was evaluated using a 4-item Likert scale by the expert panel. Result Twelve experts participated in conceptualization and 11 experts participated in operationalization phase. Overall, 94 concepts for QoC were identified from published scoping review (87 items) and qualitative interviews (7 items). The process of operationalization and indicator selection led to the development of 27 indicators with acceptable content validity. Finally, the assessment tool contained three pre-hospital, twelve in-hospital, nine post-hospital, and three mixed indicators. Ninety-one percent of experts evaluated the entire tool as comprehensive. Conclusion Our study presents a health-related QoC tool that contains a comprehensive set of indicators to assess the QoC for individuals with TSCI. However, this tool should be used in various situations to establish construct validity further.

Background: The first-pass effect (FPE) refers to the complete or near-complete revascularization with a single pass of mechanical thrombectomy devices. While previous claims suggest a link between larger catheters and the effectiveness of contact aspiration (CA) thrombectomy, no extensive research has confirmed if larger distal inner diameter (ID) catheters achieve higher FPE rates. Methods: We searched PubMed, Scopus, and Web of Science to assess the impact of aspiration catheter distal ID size on FPE. The primary outcome was FPE rate, defined as thrombolysis in cerebral ischemia (TICI) grades 2c-3 at first pass, and the secondary outcome was modified FPE (TICI 2b-3 in a single pass). Aspiration catheters were categorized based on distal ID: 0.060–0.069 (medium bore), 0.070–0.074 (large bore), and greater than 0.074 inches (super-large bore). Rates of FPE were pooled using random effect models and compared using a Chi-square test. Results: Our study included 34 articles with 4831 patients. FPE rates were 27.7% (95% CI, 15.1–45.3) for medium bore, 46.6% (95% CI, 33.7–59.9) for large, and 58.3% (95% CI, 44.8–70.7) for super-large catheters. The FPE rate was significantly higher for super-large bore catheters compared with other groups (χ² = 7.26, p = 0.03). A similar trend was observed for modified FPE rates, which were 51.1% (95% CI, 45.3–56.8) for medium bore, 60.0% (95% CI, 52.8–66.8) for large bore, and 80% (95% CI, 56.3–94.2) for super-large bore catheters (χ² = 8.14, p = 0.03). Conclusion: Our analysis indicates that larger CA catheters are correlated with higher FPE rates.

Background: The hypoperfusion intensity ratio (HIR) has emerged as a vital measure of tissue-level collateral blood flow, helping to identify patients who are likely to benefit from mechanical thrombectomy (MT). We aimed to assess the HIR’s predictive accuracy for clinical outcomes following MT in patients with acute ischemic stroke. Methods: PubMed, Embase, and Scopus were searched to identify studies comparing good versus poor HIR groups based on studies’ reported cut-offs. We pooled binary outcomes to calculate odds ratios (OR) and continuous outcomes to calculate mean differences (MD) with 95% confidence intervals (95% CI) using random-effects models. PROSPERO registration code: CRD42024609185. Results: 14 studies with 2987 patients, 1553 with good HIR and 1434 with poor HIR, were included in this meta-analysis. Patients with poor HIR exhibited a significantly higher baseline infarct volume compared with those with good HIR (MD 30.6 mL, 95% CI 20.8 mL to 40.3 mL, P<0.01), though baseline National Institutes of Health Stroke Scale (NIHSS) (P=0.12) and Alberta Stroke Program Early CT Score (ASPECTS) (P=0.35) were comparable between groups. The rates of infarct growth (MD 22.4 mL, 95% CI 6.7 mL to 38.0 mL, P<0.01) and 3-month mortality (OR 2.18, 95% CI 1.04 to 4.58, P=0.04) were higher among the poor HIR group and good functional recovery (modified Rankin Scale 0–2 at 3 months) was lower (OR 0.58, 95% CI 0.42 to 0.80, P<0.01). The rates of symptomatic intracranial hemorrhage (P=0.37) and successful reperfusion (P=0.47) were comparable among groups. Conclusion: This meta-analysis highlights the significant negative impact of poor HIR on patient outcomes. These findings emphasize the need for personalized treatment strategies for patients with poor HIR.