A fully automatic method for vascular tortuosity feature extraction in the supra-aortic region: unraveling possibilities in stroke treatment planning

Vascular tortuosity of supra-aortic vessels is widely considered one of the main reasons for failure and delays in endovascular treatment of large vessel occlusion in patients with acute ischemic stroke. Characterization of tortuosity is a challenging task due to the lack of objective, robust and effective analysis tools. We present a fully automatic method for arterial segmentation, vessel labelling and tortuosity feature extraction applied to the supra-aortic region. A sample of 566 computed tomography angiography scans from acute ischemic stroke patients (aged 74.8 ± 12.9, 51.0% females) were used for training, validation and testing of a segmentation module based on a U-Net architecture (162 cases) and a vessel labelling module powered by a graph U-Net (566 cases). Successively, 30 cases were processed for testing of a tortuosity feature extraction module. Measurements obtained through automatic processing were compared to manual annotations from two observers for a thorough validation of the method. The proposed feature extraction method presented similar performance to the inter-rater variability observed in the measurement of 33 geometrical and morphological features of the arterial anatomy in the supra-aortic region. This system will contribute to the development of more complex models to advance the treatment of stroke by adding immediate automation, objectivity, repeatability and robustness to the vascular tortuosity characterization of patients

Granulocytes-Rich Thrombi in Cerebral Large Vessel Occlusion Are Associated with Increased Stiffness and Poorer Revascularization Outcomes

Altres ajuts: acords transformatius de la UABWe aim to identify a profile of intracranial thrombus resistant to recanalization by mechanical thrombectomy (MT) in acute stroke treatment. The first extracted clot of each MT was analyzed by flow cytometry obtaining the composition of the main leukocyte populations: granulocytes, monocytes, and lymphocytes. Demographics, reperfusion treatment, and grade of recanalization were registered. MT failure (MTF) was defined as final thrombolysis in cerebral infarction score IIa or lower and/or need of permanent intracranial stenting as a rescue therapy. To explore the relationship between stiffness of intracranial clots and cellular composition, unconfined compression tests were performed in other cohorts of cases. Thrombi obtained in 225 patients were analyzed. MTF were observed in 30 cases (13%). MTF was associated with atherosclerosis etiology (33.3% vs. 15.9%; p = 0.021) and higher number of passes (3 vs. 2; p < 0.001). Clot analysis of MTF showed higher percentage of granulocytes [82.46 vs. 68.90% p < 0.001] and lower percentage of monocytes [9.18% vs.17.34%, p < 0.001] in comparison to successful MT cases. The proportion of clot granulocytes (aOR 1.07; 95% CI 1.01-1.14) remained an independent marker of MTF. Among thirty-eight clots mechanically tested, there was a positive correlation between granulocyte proportion and thrombi stiffness (Pearson's r = 0.35, p = 0.032), with a median clot stiffness of 30.2 (IQR, 18.9-42.7) kPa. Granulocytes-rich thrombi are harder to capture by mechanical thrombectomy due to increased stiffness, so a proportion of intracranial granulocytes might be useful to guide personalized endovascular procedures in acute stroke treatment. Supplementary Information: The online version contains supplementary material available at 10.1007/s13311-023-01385-1

Tratamiento endovacular en el ictus isquémico: fisiopatología y factores del procedimiento asociados a un buen pronóstico funcional

Introducció: El tractament endovascular ha demostrat ser una teràpia d’alta eficàcia en el tractament de l’ictus isquèmic agut secundari a oclusió de gran vas (LVO). Tot i això, aproximadament el 50% dels pacients no té bon pronòstic de recuperació. Diversos estudis han mostrat la influència de certs paràmetres del procediment, com el nombre de passades de trombectomia realitzats o el grau final de recanalització en el pronòstic funcional d’aquests pacients. Objectius: Analitzar la influència de diversos factors del tractament endovascular en el pronòstic funcional dels pacients i investigar els mecanismes fisiopatològics implicats. Mètodes: Es va realitzar una anàlisi retrospectiva d’una base mantinguda prospectivament de l’Hospital Universitari Vall d’Hebron. Es va investigar la influència del nombre de passades, el grau final de recanalització i el patró de recanalització en el pronòstic funcional dels pacients. A més, es van evaluar els diversos factors associats a aquests paràmetres del procediment. Es va valorar la influència del fluxe col·lateral en els factors del procediment. L’anàlisi estadística es va realitzar aplicant models de regressió logística binària o ordinal depenent de la naturalesa de la variable dependent. Resultats: En un model de regressió logística, tant la recanalització en la primera passada (odds ratio (OR) 2.5, interval de confiança (IC) 1.4-4.4, p <0.005) com obtenir un grau de recanalització modified Thrombolysis in Cerebral Infarction (mTICI) 3 (OR 2.63, CI 1.47-4.76, p <0.005) van ser els predictors més potents de bon pronòstic funcional i clínic. En els pacients que van aconseguir la recanalització, es va observar una associació lineal entre el nombre de passades i bon pronòstic funcional: 1 passada (58.6%), 2 passades (50.5%), 3 passades (48.4%), 4 passades (38.5%) o 5 o més passades (25,6%) (p <0,001), en comparació amb els pacients que no van aconseguir la recanalització (16,9%). La proporció de pacients amb bon pronòstic funcional va ser similar entre pacients amb recanalització sobtada (SR) en la primera passada (57.5%) i SR en múltiples passades (57.1%) (OR 0.9 CI 0.53-1.54, p = 0.7), i millor en comparació que aquells amb recanalització progressiva (29.8%) (OR 3 .33 CI 1.71-5.63, p <0.01). Els pacients amb recanalització progressiva van tenir millor pronòstic funcional que els pacients que no van obtener recanalizació (17%) (OR2.93 CI1.42-6.15, p <0.01). Un major nombre de passades de trombectomia es va associar amb pitjor pronòstic funcional en pacients amb recanalització (OR0.75, CI0.66-0.85, p <0.01) però no en aquells amb SR (OR0.94 CI0.59-1.61, p = 0937). Un bon fluxe col·lateral es va associar de forma independent amb un millor grau de recanalització final (anàlisi de regressió ordinal per mTICI0-2A / 2B / 2C-3%, pobre CF 19/38/43 vs bon CF 15/32/53, OR 1,51; IC 1,08-2,11). Un pobre fluxe col·lateral es va associar de forma independent amb un major nombre de passades de dispositiu realitzats per aconseguir una recanalització substancial (mTICI2B-3) (anàlisi de regressió ordinal per passades de dispositiu 1/2/3/4 +, OR 1.59, CI1. 09-2.31) i recanalització completa (mTICI2C-3) (anàlisi de regressió ordinal per passades de dispositiu 1/2/3/4 +, OR 1.70, CI1.04-1.2.9). Conclusions: Un major nombre de passades de trombectomia i un menor grau de recanalització final s’associen, en pacients sotmesos a tractament endovascular, a un pitjor pronòstic funcional. La recanalització sobtada és un predictor independent de bon pronòstic funcional en pacients sotmesos a tractament endovascular, fins i tot després de diverses passades de trombectomia fallits. La recanalització progressiva pot ser un biomarcador de la taxa de fragmentació del trombe i la seva embolització distal causa d’una composició més friable, el que comporta a pitjors resultats angiogràfics. Els pacients amb bon fluxe col·lateral tractats amb tractament endovascular experimenten millors taxes de recanalització sobtada i completa en un menor nombre de passades de trombectomia.Introducción: El tratamiento endovascular ha demostrado ser una terapia de alta eficacia en el tratamiento del ictus isquémico agudo secundario a oclusión de gran vaso (LVO). A pesar de ello, aproximadamente el 50% de los pacientes no tiene buen pronóstico de recuperación. Diversos estudios han mostrado la influencia de ciertos parámetros del procedimiento, como el número de pases de trombectomía realizados o grado final de recanalización, en el pronóstico funcional de estos pacientes. Objetivos: Analizar la influencia de diversos factores del tratamiento endovascular en el pronóstico funcional de los pacientes e investigar los mecanismos fisiopatológicos implicados. Métodos: Se realizó un análisis retrospectivo de una base mantenida prospectivamente del Hospital Universitari Vall d’Hebron. Se investigó la influencia del número de pases, el grado final de recanalización y el patrón de recanalización en el pronóstico funcional de los pacientes y los diversos factores asociados a estos parámetros del procedimiento. Se valoró la influencia del flujo colateral en las variables del procedimiento. El análisis estadístico se realizó aplicando modelos de regresión logística binaria u ordinal dependiendo de la naturaleza de la variable dependiente. Resultados: En un modelo de regresión logística, tanto la recanalización en el primer pase (odds ratio (OR) 2.5, intervalo de confianza (IC) 1.4-4.4, p <0.005) como obtener un grado de recanalización modified Thrombolysis in Cerebral Infarction (mTICI) 3 (OR 2.63, CI 1.47-4.76, p <0.005) fueron los predictores más potentes de buen pronóstico funcional y clínico. En los pacientes que lograron la recanalización, se observó una asociación lineal entre el número de pases y buen pronóstico funcional: 1 pase (58.6%), 2 pases (50.5%), 3 pases (48.4%), 4 pases (38.5%) o 5 o más pases (25,6%) (p <0,001), en comparación con los pacientes que no lograron la recanalización (16,9%). La proporción de pacientes con buen pronóstico funcional fue similar entre pacientes con recanalización súbita (SR) en el primer pase (57.5%) y SR en múltiples pases (57.1%) (OR0.9 CI0.53-1.54, p = 0.7), y mejor en comparación que aquellos con recanalización progresiva (29.8%) (OR3 .33 CI1.71-5.63, p <0.01). Los pacientes con recanalización progresiva tuvieron mejor pronóstico funcional que los pacientes que no recanalizaron (17%) (OR2.93 CI1.42-6.15, p <0.01). Un mayor número de pases de trombectomía se asoció con peor pronóstico funcional en pacientes con recanalización (OR0.75, CI0.66-0.85, p <0.01) pero no en aquellos con SR (OR0.94 CI0.59-1.61, p = 0.937). Un buen CF se asoció de forma independiente con un mejor grado final de recanalización final (análisis de regresión ordinal para mTICI0-2A / 2B / 2C-3%, pobre CF 19/38/43 vs buen CF 15/32/53, OR 1,51; IC 1,08-2,11). Un pobre CF se asoció de forma independiente con un mayor número de pases de dispositivo realizados para lograr una recanalización exitosa (mTICI2B-3) (análisis de regresión ordinal para pases de dispositivo 1/2/3/4 +, OR 1.59, CI1.09-2.31) y recanalización completa (mTICI2C-3) (análisis de regresión ordinal para pases de dispositivo 1/2/3/4 +, OR 1.70, CI1.04-1.2.9). Conclusiones: Un mayor número de pases de trombectomía y un menor grado de recanalización final se asocian, en pacientes sometidos a tratamiento endovascular, a un peor pronóstico funcional. La recanalización repentina es un predictor independiente de buen pronóstico funcional en pacientes sometidos a tratamiento endovascular, incluso después de diversos intentos de pase de trombectomía fallidos. La recanalización progresiva puede ser un biomarcador de la tasa de fragmentación del trombo y su embolización distal debido a una composición más friable, lo que conlleva a peores resultados. Los pacientes con buen CF tratados con tratamiento endovascular experimentan mejores tasas de recanalización repentina y completa en un menor número de pases de trombectomía.Introduction: Endovascular treatment has proven to be a highly effective therapy in the treatment of acute ischemic stroke secondary to LVO. Despite this, approximately 50% of patients do not achieve good functional outcome. Various studies have shown the influence of certain procedure parameters, such as the number of thrombectomy passes performed or the final degree of recanalization, on the functional prognosis of these patients. Purpose: To analyze the influence of various factors of endovascular treatment on the functional prognosis of patients and to investigate the pathophysiological mechanisms involved. Methods: A retrospective analysis of a prospectively maintained database of the Hospital Universitari Vall d’Hebron was performed. The influence of the number of passes, the final degree of recanalization and the recanalization pattern on the functional prognosis of patients and the various factors associated with these procedure parameters were investigated. The influence of collateral flow on the variables of the procedure was assessed. Results: In a logistic regression model, both recanalization in the first pass (OR 2.5, IC 1.4-4.4, p <0.005) and obtaining a degree of recanalization mTICI 3 (OR 2.63, CI 1.47-4.76, p <0.005) were the more powerful predictors of good functional and clinical prognosis In patients who achieved recanalization, a linear association was observed between the number of passes and a good functional result: 1 pass (58.6%), 2 passes (50.5%), 3 passes (48.4 %), 4 passes (38.5%) or 5 or more passes (25.6%) (p <0.001), compared to patients who did not achieve recanalization (16.9%). The proportion of patients with a good functional prognosis was similar between patients with SR in the first pass (57.5%) and SR in multiple passes (57.1%) (OR0.9 CI0.53-1.54, p = 0.7), and better in comparison than those with progressive recanalization (29.8%) (OR3 .33 CI1.71-5.63, p <0.01). Patients with progressive recanalization had a better functional prognosis than patients who did not recanalize (17%) (OR2.93 CI1.42-6.15, p <0.01). A greater number of thrombectomy passes was associated with a worse functional prognosis in patients with recanalization (OR0.75, CI0.66-0.85, p <0.01) but not in those with SR (OR0.94 CI0.59-1.61, p = 0.937). Patients with good CF was independently associated with better final degree of reperfusion (shift analysis for mTICI0-2A/2B/2C-3 %, poor CF 19/38/43 vs good CF 15/32/53, adjusted odds ratio (aOR) 1.51, 95% confidence interval(CI) 1.08-2.11). Poor CF was independently associated with higher number of device-passes performed to achieve successful reperfusion (mTICI2B-3) (shift analysis for 1/2/3/4+ device passes, aOR 1.59, CI1.09-2.31) and complete reperfusion (mTICI2C-3) (shift analysis for 1/2/3/4+ device passes, aOR 1.70, CI1.04-1.2.9). Conclusions: A higher number of thrombectomy passes and a lower degree of final recanalization are associated, in patients undergoing endovascular treatment, with a poorer functional prognosis. Sudden recanalization is an independent predictor of good functional prognosis in patients undergoing endovascular treatment, even after various failed thrombectomy pass attempts. Progressive recanalization may be a biomarker of the thrombus fragmentation rate and its distal embolization due to a more friable composition, leading to poorer results. Patients with good CF treated with endovascular treatment experience better rates of sudden and complete recanalization in fewer thrombectomy passes.Universitat Autònoma de Barcelona. Programa de Doctorat en Medicin

Tratamiento endovacular en el ictus isquémico : fisiopatología y factores del procedimiento asociados a un buen pronóstico funcional

Introducció: El tractament endovascular ha demostrat ser una teràpia d'alta eficàcia en el tractament de l'ictus isquèmic agut secundari a oclusió de gran vas (LVO). Tot i això, aproximadament el 50% dels pacients no té bon pronòstic de recuperació. Diversos estudis han mostrat la influència de certs paràmetres del procediment, com el nombre de passades de trombectomia realitzats o el grau final de recanalització en el pronòstic funcional d'aquests pacients. Objectius: Analitzar la influència de diversos factors del tractament endovascular en el pronòstic funcional dels pacients i investigar els mecanismes fisiopatològics implicats. Mètodes: Es va realitzar una anàlisi retrospectiva d'una base mantinguda prospectivament de l'Hospital Universitari Vall d'Hebron. Es va investigar la influència del nombre de passades, el grau final de recanalització i el patró de recanalització en el pronòstic funcional dels pacients. A més, es van evaluar els diversos factors associats a aquests paràmetres del procediment. Es va valorar la influència del fluxe col·lateral en els factors del procediment. L'anàlisi estadística es va realitzar aplicant models de regressió logística binària o ordinal depenent de la naturalesa de la variable dependent. Resultats: En un model de regressió logística, tant la recanalització en la primera passada (odds ratio (OR) 2.5, interval de confiança (IC) 1.4-4.4, p <0.005) com obtenir un grau de recanalització modified Thrombolysis in Cerebral Infarction (mTICI) 3 (OR 2.63, CI 1.47-4.76, p <0.005) van ser els predictors més potents de bon pronòstic funcional i clínic. En els pacients que van aconseguir la recanalització, es va observar una associació lineal entre el nombre de passades i bon pronòstic funcional: 1 passada (58.6%), 2 passades (50.5%), 3 passades (48.4%), 4 passades (38.5%) o 5 o més passades (25,6%) (p <0,001), en comparació amb els pacients que no van aconseguir la recanalització (16,9%). La proporció de pacients amb bon pronòstic funcional va ser similar entre pacients amb recanalització sobtada (SR) en la primera passada (57.5%) i SR en múltiples passades (57.1%) (OR 0.9 CI 0.53-1.54, p = 0.7), i millor en comparació que aquells amb recanalització progressiva (29.8%) (OR 3 .33 CI 1.71-5.63, p <0.01). Els pacients amb recanalització progressiva van tenir millor pronòstic funcional que els pacients que no van obtener recanalizació (17%) (OR2.93 CI1.42-6.15, p <0.01). Un major nombre de passades de trombectomia es va associar amb pitjor pronòstic funcional en pacients amb recanalització (OR0.75, CI0.66-0.85, p <0.01) però no en aquells amb SR (OR0.94 CI0.59-1.61, p = 0937). Un bon fluxe col·lateral es va associar de forma independent amb un millor grau de recanalització final (anàlisi de regressió ordinal per mTICI0-2A / 2B / 2C-3%, pobre CF 19/38/43 vs bon CF 15/32/53, OR 1,51; IC 1,08-2,11). Un pobre fluxe col·lateral es va associar de forma independent amb un major nombre de passades de dispositiu realitzats per aconseguir una recanalització substancial (mTICI2B-3) (anàlisi de regressió ordinal per passades de dispositiu 1/2/3/4 +, OR 1.59, CI1. 09-2.31) i recanalització completa (mTICI2C-3) (anàlisi de regressió ordinal per passades de dispositiu 1/2/3/4 +, OR 1.70, CI1.04-1.2.9). Conclusions: Un major nombre de passades de trombectomia i un menor grau de recanalització final s'associen, en pacients sotmesos a tractament endovascular, a un pitjor pronòstic funcional. La recanalització sobtada és un predictor independent de bon pronòstic funcional en pacients sotmesos a tractament endovascular, fins i tot després de diverses passades de trombectomia fallits. La recanalització progressiva pot ser un biomarcador de la taxa de fragmentació del trombe i la seva embolització distal causa d'una composició més friable, el que comporta a pitjors resultats angiogràfics. Els pacients amb bon fluxe col·lateral tractats amb tractament endovascular experimenten millors taxes de recanalització sobtada i completa en un menor nombre de passades de trombectomia.Introducción: El tratamiento endovascular ha demostrado ser una terapia de alta eficacia en el tratamiento del ictus isquémico agudo secundario a oclusión de gran vaso (LVO). A pesar de ello, aproximadamente el 50% de los pacientes no tiene buen pronóstico de recuperación. Diversos estudios han mostrado la influencia de ciertos parámetros del procedimiento, como el número de pases de trombectomía realizados o grado final de recanalización, en el pronóstico funcional de estos pacientes. Objetivos: Analizar la influencia de diversos factores del tratamiento endovascular en el pronóstico funcional de los pacientes e investigar los mecanismos fisiopatológicos implicados. Métodos: Se realizó un análisis retrospectivo de una base mantenida prospectivamente del Hospital Universitari Vall d'Hebron. Se investigó la influencia del número de pases, el grado final de recanalización y el patrón de recanalización en el pronóstico funcional de los pacientes y los diversos factores asociados a estos parámetros del procedimiento. Se valoró la influencia del flujo colateral en las variables del procedimiento. El análisis estadístico se realizó aplicando modelos de regresión logística binaria u ordinal dependiendo de la naturaleza de la variable dependiente. Resultados: En un modelo de regresión logística, tanto la recanalización en el primer pase (odds ratio (OR) 2.5, intervalo de confianza (IC) 1.4-4.4, p <0.005) como obtener un grado de recanalización modified Thrombolysis in Cerebral Infarction (mTICI) 3 (OR 2.63, CI 1.47-4.76, p <0.005) fueron los predictores más potentes de buen pronóstico funcional y clínico. En los pacientes que lograron la recanalización, se observó una asociación lineal entre el número de pases y buen pronóstico funcional: 1 pase (58.6%), 2 pases (50.5%), 3 pases (48.4%), 4 pases (38.5%) o 5 o más pases (25,6%) (p <0,001), en comparación con los pacientes que no lograron la recanalización (16,9%). La proporción de pacientes con buen pronóstico funcional fue similar entre pacientes con recanalización súbita (SR) en el primer pase (57.5%) y SR en múltiples pases (57.1%) (OR0.9 CI0.53-1.54, p = 0.7), y mejor en comparación que aquellos con recanalización progresiva (29.8%) (OR3 .33 CI1.71-5.63, p <0.01). Los pacientes con recanalización progresiva tuvieron mejor pronóstico funcional que los pacientes que no recanalizaron (17%) (OR2.93 CI1.42-6.15, p <0.01). Un mayor número de pases de trombectomía se asoció con peor pronóstico funcional en pacientes con recanalización (OR0.75, CI0.66-0.85, p <0.01) pero no en aquellos con SR (OR0.94 CI0.59-1.61, p = 0.937). Un buen CF se asoció de forma independiente con un mejor grado final de recanalización final (análisis de regresión ordinal para mTICI0-2A / 2B / 2C-3%, pobre CF 19/38/43 vs buen CF 15/32/53, OR 1,51; IC 1,08-2,11). Un pobre CF se asoció de forma independiente con un mayor número de pases de dispositivo realizados para lograr una recanalización exitosa (mTICI2B-3) (análisis de regresión ordinal para pases de dispositivo 1/2/3/4 +, OR 1.59, CI1.09-2.31) y recanalización completa (mTICI2C-3) (análisis de regresión ordinal para pases de dispositivo 1/2/3/4 +, OR 1.70, CI1.04-1.2.9). Conclusiones: Un mayor número de pases de trombectomía y un menor grado de recanalización final se asocian, en pacientes sometidos a tratamiento endovascular, a un peor pronóstico funcional. La recanalización repentina es un predictor independiente de buen pronóstico funcional en pacientes sometidos a tratamiento endovascular, incluso después de diversos intentos de pase de trombectomía fallidos. La recanalización progresiva puede ser un biomarcador de la tasa de fragmentación del trombo y su embolización distal debido a una composición más friable, lo que conlleva a peores resultados. Los pacientes con buen CF tratados con tratamiento endovascular experimentan mejores tasas de recanalización repentina y completa en un menor número de pases de trombectomía.Introduction: Endovascular treatment has proven to be a highly effective therapy in the treatment of acute ischemic stroke secondary to LVO. Despite this, approximately 50% of patients do not achieve good functional outcome. Various studies have shown the influence of certain procedure parameters, such as the number of thrombectomy passes performed or the final degree of recanalization, on the functional prognosis of these patients. Purpose: To analyze the influence of various factors of endovascular treatment on the functional prognosis of patients and to investigate the pathophysiological mechanisms involved. Methods: A retrospective analysis of a prospectively maintained database of the Hospital Universitari Vall d'Hebron was performed. The influence of the number of passes, the final degree of recanalization and the recanalization pattern on the functional prognosis of patients and the various factors associated with these procedure parameters were investigated. The influence of collateral flow on the variables of the procedure was assessed. Results: In a logistic regression model, both recanalization in the first pass (OR 2.5, IC 1.4-4.4, p <0.005) and obtaining a degree of recanalization mTICI 3 (OR 2.63, CI 1.47-4.76, p <0.005) were the more powerful predictors of good functional and clinical prognosis In patients who achieved recanalization, a linear association was observed between the number of passes and a good functional result: 1 pass (58.6%), 2 passes (50.5%), 3 passes (48.4 %), 4 passes (38.5%) or 5 or more passes (25.6%) (p <0.001), compared to patients who did not achieve recanalization (16.9%). The proportion of patients with a good functional prognosis was similar between patients with SR in the first pass (57.5%) and SR in multiple passes (57.1%) (OR0.9 CI0.53-1.54, p = 0.7), and better in comparison than those with progressive recanalization (29.8%) (OR3 .33 CI1.71-5.63, p <0.01). Patients with progressive recanalization had a better functional prognosis than patients who did not recanalize (17%) (OR2.93 CI1.42-6.15, p <0.01). A greater number of thrombectomy passes was associated with a worse functional prognosis in patients with recanalization (OR0.75, CI0.66-0.85, p <0.01) but not in those with SR (OR0.94 CI0.59-1.61, p = 0.937). Patients with good CF was independently associated with better final degree of reperfusion (shift analysis for mTICI0-2A/2B/2C-3 %, poor CF 19/38/43 vs good CF 15/32/53, adjusted odds ratio (aOR) 1.51, 95% confidence interval(CI) 1.08-2.11). Poor CF was independently associated with higher number of device-passes performed to achieve successful reperfusion (mTICI2B-3) (shift analysis for 1/2/3/4+ device passes, aOR 1.59, CI1.09-2.31) and complete reperfusion (mTICI2C-3) (shift analysis for 1/2/3/4+ device passes, aOR 1.70, CI1.04-1.2.9). Conclusions: A higher number of thrombectomy passes and a lower degree of final recanalization are associated, in patients undergoing endovascular treatment, with a poorer functional prognosis. Sudden recanalization is an independent predictor of good functional prognosis in patients undergoing endovascular treatment, even after various failed thrombectomy pass attempts. Progressive recanalization may be a biomarker of the thrombus fragmentation rate and its distal embolization due to a more friable composition, leading to poorer results. Patients with good CF treated with endovascular treatment experience better rates of sudden and complete recanalization in fewer thrombectomy passes

Circulating Aquaporin-4 as A biomarker of early neurological improvement in stroke patients: A pilot study

Patients’ outcome prediction after ischemic stroke is still challenging. Aquaporin-4 (AQP4) is a water channel that is up-regulated in the brain after the ischemic event, but its presence in bloodstream of stroke patients has not been previously studied. The aim of this pilot study was to investigate circulating AQP4 levels after stroke and its correlation with infarct growth and neurological outcome. AQP4 level was determined by ELISA in serum from 42 t-PA-treated ischemic stroke patients at admission (before t-PA) and 13 healthy subjects. To assess infarct growth, serial brain diffusion-weighted magnetic resonance images were performed at hospital admission and 1–3 days after. Neurological improvement was defined as a ≥4-point decrease in NIHSS score compared to baseline score. Despite stroke patients and healthy controls had similar baseline circulating AQP4 levels, among strokes AQP4 level negatively correlated with NIHSS score at admission (R= −0.34, p = 0.029) and with infarct growth after 1–3 days of stroke onset (R=−0.36; p = 0.018). Furthermore, baseline AQP4 level was higher in those stroke patients showing a neurological improvement 48 h after stroke onset (p = 0.030) and at hospital discharge (p = 0.037). Baseline AQP4 levels also resulted to be an independent predictor of good neurological outcome at both studied time points (ORadj: 14.33[1.82–112.92], p = 0.012 at 48 h; ORadj: 4.86[0.98–24.12], p = 0.053 at discharge) in logistic regression analysis, adjusted by age, sex, baseline NIHSS and significant variables in the univariate analysis. Overall, we have explored circulating AQP4 levels, and our data suggest that AQP4 could be used as a biomarker of neurological recovery in the acute-subacute phase of ischemic stroke.Neurovascular Research Laboratory acknowledges funding for this project by PI15/00354 and PI18/00804 grants from Fondo de Investigaciones Sanitarias of the Instituto de Salud Carlos III (co-financed by the European Regional Development Fund, FEDER). Neurovascular Research Laboratory also takes part into the Spanish stroke research network INVICTUS+ (RD16/0019). L. Ramiro is supported by a predoctoral fellowship grant from the Instituto de Salud Carlos III (IFI17/00012). In addition, we acknowledge Miriam Echevarría from the Instituto de Biomedicina de Sevilla-IBiS by interesting conversations and advice on the role of Aquaporins in neurological diseases

Enhancing blood pressure management protocol implementation in patients with acute intracerebral haemorrhage through a nursing-led approach : A retrospective cohort study

Altres ajuts: acords transformatius de la UABAim: To evaluate the impact of nurse care changes in implementing a blood pressure management protocol on achieving rapid, intensive and sustained blood pressure reduction in acute intracerebral haemorrhage patients. Design: Retrospective cohort study of prospectively collected data over 6 years. Methods: Intracerebral haemorrhage patients within 6 h and systolic blood pressure ≥ 150 mmHg followed a rapid (starting treatment at computed tomography suite with a target achievement goal of ≤60 min), intensive (target systolic blood pressure < 140 mmHg) and sustained (maintaining target stability for 24 h) blood pressure management plan. We differentiated six periods: P1, stroke nurse at computed tomography suite (baseline period); P2, antihypertensive titration by stroke nurse; P3, retraining by neurologists; P4, integration of a stroke advanced practice nurse; P5, after COVID-19 impact; and P6, retraining by stroke advanced practice nurse. Outcomes included first-hour target achievement (primary outcome), tomography-to-treatment and treatment-to-target times, first-hour maximum dose of antihypertensive treatment and 6-h and 24-h systolic blood pressure variability. Results: Compared to P1, antihypertensive titration by stroke nurses (P2) reduced treatment-to-target time and increased the rate of first-hour target achievement, retraining of stroke nurses by neurologists (P3) maintained a higher rate of first-hour target achievement and the integration of a stroke advanced practice nurse (P4) reduced both 6-h and 24-h systolic blood pressure variability. However, 6-h systolic blood pressure variability increased from P4 to P5 following the impact of the COVID-19 pandemic. Finally, compared to P1, retraining of stroke nurses by stroke advanced practice nurse (P6) reduced tomography-to-treatment time and increased the first-hour maximum dose of antihypertensive treatment. Conclusion: Changes in nursing care and continuous education can significantly enhance the time metrics and blood pressure outcomes in acute intracerebral haemorrhage patients. Reporting Method: STROBE guidelines. Patient and Public Contribution: No Patient or Public Contribution

Complete Sudden Recanalization: There Is Hope Beyond the First Pass Effect

Background In the endovascular treatment of stroke, achieving complete recanalization in a minimum number of attempts is the main procedural objective. We aimed to explore the effect of the per pass recanalization pattern in patients with final complete recanalization. Methods We analyzed all patients admitted in our center from 2014 to 2022 with a terminal internal carotid artery or M1‐middle cerebral artery occlusion who received endovascular treatment and achieved complete recanalization (expanded thrombolysis in cerebral infarction 2c–3) in our center. Complete sudden recanalization (cSR) was considered when expanded thrombolysis in cerebral infarction improved from 0–1 to 2c–3 in a single pass as opposed to complete progressive recanalization when partial recanalization (2a or 2b) was observed after interim passes. Results Among the 400 included patients with final complete recanalization, 301 (75%) showed a cSR pattern. There were no differences in baseline demographic characteristics between patients with cSR and complete progressive recanalization, including intravenous tissue plasminogen activator treatment (42.2% versus 44.4%; P=0.69). The rate of terminal carotid artery occlusion (28.6% versus 44.4%; P=0.003), median number of passes (1 [interquartile range 1—2] versus 2 [2–3]; P2 passes: 63.6%; P=0.825). Conclusion Among stroke patients with a large vessel occlusion, the cSR pattern predicted favorable outcome independently of the number of thrombectomy passes

Spontaneous systolic blood pressure drop early after mechanical thrombectomy predicts dramatic neurological recovery in ischaemic stroke patients

Introduction: Spontaneous blood pressure drop within the first 24 h has been reported following arterial recanalisation in ischaemic stroke patients. We aimed to assess if spontaneous blood pressure drop within the first hour after mechanical thrombectomy is a marker of early neurological recovery. Patients and methods: Retrospective observational single-centre study including ischaemic stroke patients treated with mechanical thrombectomy. Blood pressure parameters from admission, mechanical thrombectomy start, mechanical thrombectomy end and hourly within 24 h after mechanical thrombectomy were reviewed. Primary outcome was early dramatic neurological recovery (8-point-reduction in NIHSS or NIHSS ≤ 2 at 24 h). Secondary outcome was functional independence at 90 days (mRankin 0-2). Results: We included 458 patients in our analysis. Two-hundred (43.7%) patients achieved dramatic neurological recovery following mechanical thrombectomy. One hour after mechanical thrombectomy end, median systolic blood pressure was significantly different between outcome groups (129 vs. 138 mmHg, p = 0.005) and a higher drop in median systolic blood pressure was seen in the dramatic neurological recovery group (15 vs. 9 mmHg). Optimal cut-off for predicting dramatic neurological recovery was a systolic blood pressure drop of 10.5 mmHg (sensitivity 0.54, specificity 0.55, AUC 0.55). On multivariate analysis, spontaneous systolic blood pressure drop was associated with higher odds of achieving dramatic neurological recovery (OR for 10 mmHg blood pressure drop 1.14, 95% CI 1.01-1.29, p = 0.04). No significative association between any blood pressure parameter drop and functional independence at 90 days was found. Discussion: We hypothesised that spontaneous systolic blood pressure drop is a marker of successful reperfusion and, therefore, a marker of improvement of cerebral autoregulation due to the reduced final ischaemic core. Conclusion: Spontaneous systolic blood pressure drop after mechanical thrombectomy is an early predictor of dramatic neurological recovery.info:eu-repo/semantics/publishedVersio

Balloon‐Expandable Stenting as a Bridging Therapy in Patients With Acute Stroke and Tandem Occlusions

Background Stenting extracranial internal carotid artery (ICA) lesions in acute ischemic stroke with tandem lesions is technically challenging. Its safety is highly debated because of the requirement of dual‐antiplatelet therapy. The optimal stenting device, timing, and periprocedural antiplatelet therapy for extracranial ICA stenting in the setting of acute tandem occlusion are still unclear. Methods We performed a retrospective study of patients with acute ischemic stroke attributable to tandem lesions who underwent endovascular treatment during a 5‐year period receiving either conventional self‐expanding carotid stents (SX) or balloon‐expandable carotid stent (BX). BX stents were restented with an SX in the subacute phase. Primary outcomes of interest were extracranial ICA patency at follow‐up and symptomatic intracranial hemorrhage. Results A total of 112 patients admitted from April 2016 to April 2021 were included. Dual‐antiplatelet therapy immediately following endovascular treatment was more frequently administered in the SX group (35/39 [89.7%]) compared with the BX group (20/73 [27.4%]) (P<0.001). Patients in the BX stent group (3/73 [4.1%]) developed a lower rate of symptomatic intracranial hemorrhage compared with patients in the SX stent group (7/39 [17.9%]) (P=0.031). No differences in extracranial ICA high‐grade restenosis or reocclusion were found between groups at 24 hours after procedure (BX: 20/73 [27.4%]; SX: 9/39 [23.1%]; P=0.673). Conclusions In patients with acute ischemic stroke and tandem occlusions, a bridging therapy including BX stents with less‐aggressive antiplatelet therapy and subsequent definitive SX stenting to treat extracranial ICA lesions resulted in a lower rate of symptomatic hemorrhagic transformation and no differences in stent patency