Ji Hoe Heo

Purpose: Estimated pulse wave velocity (ePWV) is a surrogate of arterial stiffness that may influence stroke outcomes and potentially affect collateral circulation. We examined the association of ePWV with collateral status and 3-month functional outcome after successful endovascular thrombectomy and explored the contribution of collateral status to this relationship across blood pressure (BP) management strategies.Materials and Methods: In this secondary analysis of the Outcome in Patients Treated With Intra-Arterial Thrombectomy–Optimal Blood Pressure Control trial, 285 patients were analyzed. Collateral status was assessed using the Tan scale (poor, 0–1; good, 2–3). Poor functional outcome was defined as 3-month modified Rankin Scale score of 3–6. Multivariable logistic and mediation analyses were performed to evaluate the association between ePWV and functional outcomes and to explore direct and indirect pathways.Results: A total of 285 patients were included (mean age, 73.3±11.3 years; 40.4% women). Each 1 m/s increase in ePWV was associated with poor collaterals (adjusted odds ratio [OR] 1.276, 95% confidence interval [CI] 1.083–1.503) and poor functional outcome (adjusted OR 1.338, 95% CI 1.121–1.597). In mediation analyses, collateral status accounted for only a small proportion of the association between ePWV and poor functional outcome (indirect effect: adjusted β 0.022, 95% CI 0.001–0.053), whereas the direct effect remained significant (adjusted β 0.237, 95% CI 0.115–0.359). Neither the direct effect of ePWV on functional outcome nor the indirect effect through collateral status differed according to BP management strategy.Conclusion: Higher ePWV was associated with poor collateral status and unfavorable functional outcome after successful reperfusion. Collateral status accounted for only a small proportion of the observed association between ePWV and functional outcome.

BACKGROUND: The effect of postthrombectomy blood pressure (BP) management on the development of acute kidney injury (AKI) in patients with acute ischemic stroke remains largely unexplored. METHODS: This secondary analysis of the OPTIMAL-BP trial (Outcome in Patients Treated With Intra-Arterial Thrombectomy-Optimal Blood Pressure Control) included patients with acute ischemic stroke due to large-vessel occlusion who achieved successful endovascular thrombectomy and had a systolic BP ≥140 mm Hg. Patients were randomized to intensive (target systolic BP <140 mm Hg) or conventional (target systolic BP 140–180 mm Hg) BP management for 24 hours. The outcomes were AKI within 7 days and within 2 days, defined according to the Kidney Disease: Improving Global Outcomes criteria. In addition, we examined the associations between AKI and functional independence at 3 months, defined as a modified Rankin Scale score of 0 to 2. Multivariable logistic regression analyses were performed with adjustment for age, sex, time from stroke onset to enrollment, baseline National Institutes of Health Stroke Scale score, and baseline estimated glomerular filtration rate. RESULTS: Of 306 patients, 19 were excluded, and 287 patients were included in this analysis (mean age, 73.2 years; 117 [40.8%] women). AKI within 7 days occurred more frequently in the intensive management group than in the conventional group (20/147 [13.6%] versus 9/140 [6.4%]; adjusted odds ratio, 2.54 [95% CI, 1.10–6.35]). Most AKI events were stage 1 (20/29 [69.0%]). Early AKI within 2 days was also more common with intensive BP management. Patients with AKI had significantly lower rates of functional independence (4/29 [13.8%] versus 126/257 [49.0%]; adjusted odds ratio, 0.19 [95% CI, 0.05–0.55]) and higher stroke-related mortality at 3 months (11/29 [37.9%] versus 8/257 [3.1%]; adjusted odds ratio, 13.8 [95% CI, 4.14–49.64]). In a sensitivity analysis with equal creatinine ascertainment, the association with 48-hour AKI did not reach statistical significance (7/76 [9.2%] versus 2/66 [3.0%]; adjusted odds ratio, 4.20 [95% CI, 0.83–32.6]), although the absolute risk difference remained directionally consistent. CONCLUSIONS: Intensive BP lowering after successful endovascular thrombectomy was associated with a higher risk of AKI, even when kidney injury was predominantly mild. In addition, AKI was associated with worse neurological outcomes. These findings suggest that AKI is an important marker of systemic hemodynamic vulnerability after aggressive postendovascular thrombectomy BP lowering. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04205305.

Background and ObjectivesEnlarged perivascular spaces (EPVSs) in the basal ganglia (BG-EPVS) are an important marker of cerebral small vessel disease (cSVD), and EPVS in the centrum semiovale (CSO-...

BACKGROUND: Intensive blood pressure (BP) lowering after successful reperfusion has resulted in short-term harm in acute ischemic stroke. However, it remains unclear whether these adverse effects persist over the long term. METHODS: The OPTIMAL-BP (Outcome in Patients Treated With Intra-Arterial Thrombectomy–Optimal Blood Pressure Control) was a phase 3, multicenter, prospective, open-label, blinded end point, randomized controlled trial with 19 centers throughout South Korea. Patients who underwent endovascular thrombectomy for acute ischemic stroke caused by large vessel occlusion, achieved successful reperfusion of the occluded artery, and exhibited elevated BP (systolic BP ≥140 mm Hg) on 2 measurements obtained 2 minutes apart within 2 hours after recanalization were randomly assigned to receive intensive BP management (systolic BP target P =0.051). Consistent findings were observed in the per-protocol analysis (41.1% versus 54.7%; adjusted odds ratios, 0.56 [95% CI, 0.32–0.97]; P =0.040). One-year mortality and distribution of modified Rankin Scale changes from 3 months to 1 year did not differ between groups. CONCLUSIONS: Intensive BP lowering targeting a systolic BP of <140 mm Hg resulted in worse functional outcomes at 1 year compared with conventional BP management. These randomized data suggest that early postthrombectomy BP management has durable effects on recovery and support current recommendations against intensive BP lowering. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04205305.

Blood pressure (BP) management following successful reperfusion after endovascular thrombectomy (EVT) is critical in achieving favorable clinical outcomes. Individualized BP management using predictive modeling by machine learning may further improve prediction of functional outcomes. This study was a retrospective analysis of data from the Outcome in Patients Treated with Intra-Arterial Thrombectomy–Optimal Blood Pressure Control (OPTIMAL-BP) trial, a randomized controlled trial comparing between intensive and conventional BP management during the 24 h after successful recanalization by EVT from June 18, 2020, to November 28, 2022. The trial was conducted across 19 centers in South Korea. Machine learning models were developed to predict functional independence (90-day modified Rankin Scale 0 to 2). Model performance was compared between clinical variables only and systolic blood pressure (SBP) metrics in addition to clinical variables. In addition, the Shapley additive explanations (SHAP) analysis was performed to provide model explanation and understand the importance of SBP metrics. A total of 288 patients (61.1% men, median age 75 years [interquartile range, 65–81]) were included. Among the six algorithms, the deep neural network model incorporating SBP metrics performed best on validation, achieving an area under the curve of 0.86 (95% confidence interval, 0.76–0.92) which was significantly better than the model using only clinical variables (area under the curve 0.80 [95% confidence interval, 0.69–0.88], P = .037). Among SBP metrics, SHAP analysis identified time rate of SBP and minimum SBP as important features, with time rate showing greater influence in the intensive group and minimum SBP in the conventional group. Integrating SBP metrics with clinical variables significantly improved machine learning performance in predicting functional outcomes after successful EVT. Explainable artificial intelligence (AI) identified time rate and minimum SBP as key predictors of outcome. Trial Registration Information: ClinicalTrials.gov (NCT04205305; registered December 17, 2019).

BACKGROUND: Intensive blood pressure (BP) management after successful endovascular thrombectomy (EVT) worsens outcomes in acute ischemic stroke. White matter hyperintensity (WMH), associated with impaired cerebral autoregulation, is associated with poor outcomes after EVT; however, its role in modifying BP management effects remains unclear. We investigated whether WMH severity modifies the effect of post-EVT BP management on outcomes. METHODS: This secondary analysis of the OPTIMAL-BP trial (Outcome in Patients Treated With Intra-Arterial Thrombectomy–Optimal Blood Pressure Control; conducted at 19 South Korean stroke centers, 2020–2022) included patients with available fluid-attenuated inversion recovery images. The trial compared intensive (P =0.011). In contrast, no significant difference was observed in patients with mild WMH (55.8% versus 69.6%; adjusted odds ratio, 0.77 [95% CI, 0.31–1.95]; P =0.584). Symptomatic intracerebral hemorrhage and stroke-related death rates did not differ by BP management in either group. CONCLUSIONS: Intensive BP management post-EVT was associated with poorer functional outcomes, particularly in patients with severe WMH. WMH burden may modify BP control effects, supporting individualized BP targets based on WMH severity. REGISTRATION: URL: https://clinicaltrials.gov ; Unique identifier: NCT04205305.

Anisocytosis, indicated by an elevated red blood cell distribution width (RDW), has been associated with poor cardiovascular outcomes. However, its relevance to thrombus composition and long-term outcomes in stroke patients undergoing thrombectomy remains unclear. We investigated whether anisocytosis is associated with histologic thrombus characteristics and long-term prognosis in this population. This retrospective multicenter cohort study included 401 patients with acute ischemic stroke who underwent intra-arterial thrombectomy between September 2014 and December 2020. Thrombus composition was assessed using immunohistochemistry to quantify the proportions of fibrin, red blood cells, platelets, and thrombin. Patients were followed for major adverse cardiovascular events, including all-cause mortality, ischemic heart disease, and recurrent ischemic stroke. Among the 401 patients (mean age, 73.1 years; 50.1% male), anisocytosis (RDW > 15.7%) was present in 67 (16.7%). Thrombi from patients with anisocytosis had higher platelet content (12.2% vs. 9.1%; P = 0.008) and lower erythrocyte content (30.0% vs. 37.3%; P = 0.007) than those without anisocytosis. During a median follow-up of 38.5 months, anisocytosis was independently associated with increased risk of recurrent ischemic stroke (hazard ratio, 2.61; 95% confidence interval, 1.12–6.10; P = 0.027), but not with overall major adverse cardiovascular events, mortality, or ischemic heart disease. Anisocytosis was associated with platelet-rich thrombi and an increased risk of stroke recurrence after thrombectomy. These findings suggest a possible role of red blood cells in platelet-mediated thrombosis and indicate that RDW may have potential prognostic value for identifying patients at higher risk for recurrent events.

Early neurologic deterioration (END) is common and occurs within a few hours to days after an ischemic stroke. Traditionally, END has been treated as a collective entity, including the occurrence of new deficits (recurrence) and the aggravation of pre-existing neurologic deficits (progression). END arises from distinct mechanisms that require different therapeutic approaches. We reviewed clinical and experimental studies addressing the epidemiology, mechanisms, and treatment of END, focusing on differentiating END due to recurrence from END due to progression and on interventions including antiplatelet therapy, direct thrombin inhibition, and induced hypertension. Early recurrence is closely associated with thrombus growth and new ischemic events, particularly in atherothrombotic disease. Early recurrence is also common in patients with cancer-associated stroke. Thrombin and platelet activation play central roles under both conditions. In contrast, progression is mainly driven by infarct growth, that is, the evolution from incomplete infarction to complete infarction due to impaired perfusion, especially in lesions involving the subcortical fiber tracts. Therapeutic implications differ accordingly. Recurrence may respond to potent antithrombotic strategies, including combined antiplatelet and direct thrombin inhibition, whereas progression may benefit from induced hypertension. However, recurrence and progression often occur simultaneously, making clinical differentiation challenging. END should be conceptualized as a spectrum of clinical presentations arising from distinct mechanisms. Recognizing recurrence and progression as separate processes is essential for mechanism-oriented treatments. Future trials should adopt this framework to develop individualized strategies and improve outcomes in patients with acute stroke.

Choi JK, et al. Yonsei Med J. 2026 ;67:e31. https://doi.org/10.3349/ymj.2025.0248