Sami Curtze

BACKGROUND: Successful target vessel recanalization in patients with large vessel occlusion stroke is associated with favorable clinical outcomes. Conversely, unsuccessful recanalization (UR) is associated with higher chances of poor outcomes. UR occurs in up to 30% of endovascular thrombectomy (EVT) procedures, and there are significant knowledge gaps in identifying factors associated with UR. METHODS: Prospectively enrolled EVT-treated patients from the EVATRISP registry, which included patients from 18 academic medical centers across Europe between the years 2015 and 2024, were retrospectively studied. Patients had to have data on prestroke and 3-month functional status and recanalization status at the end of EVT. UR was defined as a modified Thrombolysis in Cerebral Infarction score P <0.001). CONCLUSIONS: UR is frequent among patients undergoing EVT and is associated with poor clinical outcomes. Although several pre-EVT factors were independently associated with UR, accurately predicting which patients will experience UR remains highly challenging. Our findings suggest that all eligible patients should undergo EVT.

BACKGROUND: The best revascularization strategy for acute ischemic stroke from isolated vertebral artery occlusion remains unclear. METHODS: This retrospective, international, multicenter cohort study included patients from 30 comprehensive stroke centers across Europe (n=23), North America (n=5), and Asia (n=2) between 2016 and 2022. Eligible patients presented with acute ischemic stroke within 24 hours of last seen well and had imaging-confirmed isolated vertebral artery occlusion. Two treatment comparisons were analyzed: intravenous thrombolysis (IVT)-only versus conservative treatment (Cx), and endovascular treatment (EVT)±IVT versus medical management (Cx and IVT). The primary outcome was the shift in 3-month modified Rankin Scale (mRS) score; secondary outcomes included early neurological improvement (24-hour-delta National Institutes of Health Stroke Scale score), recanalization, early neurological deterioration of ischemic origin, symptomatic intracerebral hemorrhage, and 3-month mortality. Analyses were adjusted using inverse probability of treatment weighting (IPTW). RESULTS: Among 494 patients, 143 (29%) received Cx, 218 (44%) IVT-only, and 133 (27%) EVT±IVT. Compared with Cx, IVT-only showed similar 3-month mRS score (IPTW-adjusted odds ratio [aOR] mRS shift score, 1.32 [95% CI, 0.80–2.18]), greater early neurological improvement (IPTW-adjusted-β coefficient, −1 [95% CI, −2.05 to 0.05]), and higher recanalization rates (IPTW-aOR, 4.33 [95% CI, 1.36–13.78]). Compared with MM (=IVT+Cx), EVT±IVT was associated with an unfavorable mRS shift score (IPTW-aOR mRS shift score, 0.51 [95% CI, 0.35–0.74]), higher early neurological deterioration of ischemic origin (IPTW-aOR, 9.06 [95% CI, 2.86–28.67]), and symptomatic intracerebral hemorrhage (IPTW-aOR, 6.05 [95% CI, 1.14–32.1]) though recanalization was over 4-fold higher (OR, 4.64 [95% CI, 1.90–11.33]). Patients with National Institutes of Health Stroke Scale score ≥10 showed point estimates favoring EVT+IVT ( P _interaction =0.025). CONCLUSIONS: IVT-only appeared safe and was associated with better early recovery and recanalization. EVT±IVT showed overall worse outcomes, potentially due to increased early neurological deterioration of ischemic origin and symptomatic intracerebral hemorrhage rates, but may confer benefit in moderate-to-severe strokes, warranting prospective trials in symptomatic isolated vertebral artery occlusion.

Previous antiplatelet therapy (APT) may influence outcomes in patients undergoing direct endovascular therapy (EVT) for anterior circulation large vessel occlusion (LVO) stroke, but evidence on clinical benefits and safety is limited and inconsistent. We aimed to evaluate the effects of previous APT on the outcomes of direct EVT. We conducted a retrospective analysis of consecutive patients treated at 20 high-volume stroke centers across 9 European countries and Israel (EVA-TRISP registry, 2015-2023). We included adults with anterior circulation LVO strokes, without previous use of IV thrombolysis (IVT) or anticoagulants. We compared outcomes of direct EVT patients stratified by previous APT regimen, using propensity score matching based on medical history and multilevel models to address confounders. The primary outcome was the 90-day modified Rankin Scale (mRS) score. The secondary efficacy outcomes were 90-day independence and the rate of successful reperfusion. The secondary safety outcomes were the rate of symptomatic intracranial hemorrhage (sICH) and mortality. Among 12,950 patients, 2,611 met the criteria and 1,308 were matched: 480 without previous APT and 828 with any previous APT, among whom 764 were on single APT and 64 on dual APT. The overall mean age was 75.8 ± 11.4 years, and 49.4% were female; the mean NIH Stroke Scale score was 13.1 ± 7.2 points, the successful reperfusion rate was 74.7%, and the median mRS score was 3 (interquartile range 2-4), with 38.8% of patients independent at 90 days. When compared with no previous APT, any previous APT was associated with a shift toward lower mRS scores at 90 days (odds ratio [OR] 1.30, CI 1.04-1.61, p = 0.018). Independence at 90 days was associated with any previous APT (OR 1.62, CI 1.22-2.16, p = 0.001). Any previous APT was not associated with successful reperfusion (OR 0.96, CI 0.69-1.35, p = 0.821), sICH (OR 1.06, CI 0.47-2.39, p = 0.880), or mortality (OR 0.89, CI 0.66-1.21, p = 0.821). There was no significant interaction between any previous APT and proximal/distal occlusion location (p = 0.213) or time-to-groin earlier/later than 6 hours (p = 0.743). In patients with anterior circulation LVO stroke treated with direct EVT and no previous anticoagulation, pretreatment with any APT was independently linked to better 90-day functional outcomes and higher independence, without increasing sICH risk. This study provides Class III evidence that, in patients with anterior circulation LVO stroke treated with direct EVT, previous APT is associated with better 90-day functional outcomes compared with no previous APT.

Current international guidelines recommend blood pressure (BP) thresholds for patients eligible for endovascular thrombectomy (EVT). Previous studies have suggested that both low and high admission BPs are associated with poor functional outcome after EVT. However, the association between admission BP and outcomes after EVT remains poorly understood.The aim of this study was to investigate the relationship between admission systolic BP (SBP) and outcomes in patients treated with EVT and to assess whether this association is modified by IV thrombolysis (IVT) treatment and recanalization status. In this observational, international, multicenter cohort study, we used data from the EVA-TRISP registry. Consecutive patients treated with EVT with available admission SBP were included. The primary outcome was 90-day functional outcome. Secondary outcomes included 90-day mortality, 24-hour NIH Stroke Scale (NIHSS), successful recanalization, and symptomatic intracranial hemorrhage (sICH). We used multivariable regression to study the relation between admission SBP and outcomes and to assess effect modification by IVT treatment and recanalization status. We included 10.963 EVT patients. At baseline, the mean age was 72.8 years (SD 13.5), 50.2% were female and the median NIHSS at presentation was 15 (interquartile range 9-19). The association between admission SBP and functional outcome, mortality, and 24-hour NIHSS score was U-shaped, and the nadir was around 150 mm Hg. Below 150 mm Hg, every 10 mm Hg decrease in SBP was associated with higher odds of poor functional outcome (adjusted odds ratio (aOR) 1.07 [95% CI 1.02-1.11]) and mortality (aOR 1.17 [1.12-1.23]). Above 150 mm Hg, every 10 mm Hg increase in SBP was associated with higher odds of poor functional outcome (aOR 1.05 [1.01-1.08]), mortality (aOR 1.04 [1.01-1.09]), and higher 24-hour NIHSS score (β-coefficient 0.28 [0.17-0.40]). We found a positive linear relationship between admission SBP and sICH (1.04 [1.01-1.08]). IVT treatment modified the association between admission SBP and outcomes after EVT. In 5544 EVT-only treated patients, there was no longer a clear association between higher admission SBP values and worse outcome. Lower and higher admission SBP was associated with worse outcomes in the complete cohort. In EVT-only patients, this association was less evident, suggesting that high admission BP alone should not always delay or preclude treatment with EVT in otherwise eligible patients.

Introduction: Ischemic stroke is a major global cause of disability and death. Although clot‐removing endovascular treatment (EVT) is the standard treatment for large vessel occlusion, the additional benefit of permanent intracranial stenting during EVT remains uncertain. This study is aimed at comparing outcomes between patients treated with EVT alone and those who also received a permanent stent, focusing on a predominantly Caucasian population. Patients and methods: We analyzed data from 14,435 stroke patients treated with EVT across 16 comprehensive stroke centers in the EVA‐TRISP collaboration. Among them, 386 patients received a permanent intracranial stent. Functional outcomes at 3 months and the occurrence of fatal and symptomatic intracerebral hemorrhage (ICH) were evaluated using ECASS II/III criteria. Results: Stent placement was not initially associated with worse functional outcome in univariable analysis (OR 1.19, 95% CI 0.98–1.43). However, stent placement was associated with worse prognosis after adjusting for age, sex, comorbidities, and Prior IV thrombolysis (OR 1.36, 95% CI 1.13–1.67). There were no significant differences in symptomatic, fatal ICH or 3‐month mortality between the groups. Discussion: Patients treated with EVT alone had better functional recovery and less disability at 3 months. However, the reason for stenting was not documented for this cohort. Conclusion: In this multicenter cohort, EVT alone was associated with better functional outcomes than EVT with stenting. Further randomized studies are needed to identify patients who may benefit from stenting.

Background: The rate of infarct growth from a yet salvageable penumbra into an ischemic core varies between individuals. Thus, computed tomographic perfusion (CTP) may improve patient selection for intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT). We aimed to assess whether treatment delay and pretreatment CTP parameters are independent predictors of functional outcome. Materials and Methods: Consecutive patients who underwent CTP and received reperfusion therapy with a known stroke onset were identified retrospectively at Helsinki University Hospital between 1/2016 and 12/2023. Ordinal regression was used to analyze the association between the CTP parameters estimated by RAPID, an automated CTP postprocessing software, and onset‐to‐treatment time with an unfavorable shift on the 3‐month modified Rankin Scale (mRS) in the entire cohort, in IVT‐only patients, and in EVT patients with or without reperfusion. Results: In the univariable analyses of the total of 948 patients, increasing onset‐to‐treatment time (odds ratio 1.17, 95% confidence interval 1.11–1.25), ischemic core (12.5, 8.33–20.0), and penumbra (2.27, 1.89–2.70) volumes were associated with worse outcomes. In the multivariable analyses, ischemic core volume (4.76, 2.94–7.69) and onset‐to‐treatment time (1.20, 1.14–1.28) were significant predictors of worse outcomes, but not baseline penumbra volume (1.06, 0.86–1.30), which was compatible in IVT‐only patients and in EVT patients with reperfusion. Also, larger severe hypoperfusion volume, higher hypoperfusion intensity ratio, and cerebral blood volume index were associated with functional outcomes in the total cohort. Conclusions: Both ischemic core and penumbra volumes and onset‐to‐treatment time predicted a worse outcome, but of these, only ischemic core and onset‐to‐treatment time were independent predictors.

Background and Aims: Previous randomized trials, such as CHANCE and POINT, have shown that dual antiplatelet therapy (DAPT) reduces ischemic event recurrence. However, its effectiveness depends on accurate dosage and timely administration. This study is a comprehensive quality assessment of the implementation of the DAPT protocol—specifically, treatment initiation within 48 h of symptom onset in patients with mild stroke or high‐risk TIA—at our center. Methods: For this single‐center, retrospective analysis we screened all 11,180 consecutive patients from the Helsinki Stroke Quality Registry (HSQR) treated at the emergency department between 1st of January 2019 and 25th of January 2023. Patients with DAPT (ASA and clopidogrel) within 2 weeks of admission were included. Patients treated with i.v. thrombolysis, thrombectomy or if already on DAPT prior to admission were excluded. We analyzed the time of DAPT initiation, patient diagnoses and risk scores (NIHSS and ABCD ² ). Results: Of 11,180 patients screened, 299 met the inclusion criteria. Among them, 263 (88.0%) had a final diagnosis of ischemic stroke or TIA, supporting DAPT use. Risk scores were documented in 193 (73.4%), and 197 (65.9%) initiated DAPT within 48 h of symptom onset per our institutional protocol. Overall, 137 (45.8%) fully adhered to all protocol criteria. Conclusions: Fewer than half (45.8%) of patients fully adhered to the HUS protocol, and 65.9% initiated DAPT within 48 h from symptom onset. We propose that DAPT should be considered as part of the acute stroke treatment protocol for eligible patients to minimize delays in treatment initiation.

Background and purpose: Up to 80% of patients diagnosed with reversible cerebral vasoconstriction syndrome (RCVS) experience complications such as ischaemic stroke, intracerebral or subarachnoid haemorrhage or posterior reversible encephalopathy syndrome. The aim was to evaluate the incidence of complications in patients diagnosed with RCVS in our clinic.Patients and methods: All adult patients (age >16 years) diagnosed with RCVS at the Helsinki University Central Hospital during the period between 1 January 2016 and 31 December 2022 were retrospectively identified. Medical and follow‐up data were collected from medical records.Results: Eighty patients diagnosed with RCVS were identified, of whom four patients had parenchymal lesions such as ischaemic stroke, intracerebral haemorrhage, posterior cerebral encephalopathy syndrome, subarachnoid haemorrhage or combinations thereof.Conclusion: The complication rate of RCVS is lower than in previously published cohorts. This may be related to better and earlier diagnostics and earlier withdrawal of possible triggers.