Fabian Flottmann

Background: Intracranial stenting (ICS) is used as a rescue strategy in patients with failed reperfusion after endovascular thrombectomy (EVT). However, real-world data on clinical outcomes and safety remain limited. Methods: This retrospective analysis of prospectively collected data from the German Stroke Registry—Endovascular Treatment (GSR-ET) included patients with acute ischemic stroke due to middle cerebral artery (MCA) occlusion treated between June 2015 and December 2023. Patients undergoing ICS were compared with a 1:1 propensity score–matched cohort with failed reperfusion after EVT (final modified Thrombolysis in Cerebral Infarction [mTICI] score p p p p =0.02). Symptomatic intracranial hemorrhage did not differ between groups (4% vs. 5%; p =0.63). Conclusions: Patients treated with ICS had a shift toward better functional outcomes and lower 90-day mortality than those with failed reperfusion who received no further endovascular treatment. Symptomatic intracranial hemorrhage did not differ between groups. These findings support further investigation of ICS after failed EVT, although randomized studies are needed to determine its efficacy and safety.

Background: Delayed cerebral ischaemia remains a major cause of secondary brain injury after aneurysmal subarachnoid haemorrhage (aSAH). Although computed tomography perfusion (CTP) is widely used for vasospasm surveillance, perfusion abnormalities are commonly reported only as present or absent, potentially overlooking the prognostic relevance of their extent. We investigated whether a territory-based perfusion burden score is associated with outcome more closely than binary perfusion deficit assessment. Methods: This retrospective single-centre cohort study included 179 patients with aSAH who underwent at least one CTP examination during hospitalization. CTP was performed according to clinical indication rather than at predefined time points; 448 examinations were evaluated. Two blinded neuroradiologists assigned one point per affected vascular territory (score range 0–12), and the maximum score during hospitalization was analysed. Outcomes were functional outcome at 6 months (modified Rankin Scale 0–2 versus 3–6), new cerebral infarction at discharge, and in-hospital mortality. Multivariable logistic regression models were built by forward selection from prespecified covariates (age, Hunt and Hess grade, modified Fisher grade, intracerebral haemorrhage, external ventricular drainage, and aneurysm treatment modality). Results: Territorial perfusion burden was independently associated with poor functional outcome (adjusted odds ratio 1.17 per point, 95% confidence interval 1.02–1.33) and new cerebral infarction (adjusted odds ratio 1.36 per point, 95% confidence interval 1.19–1.55). Any perfusion deficit was associated with new infarction (odds ratio 8.88, 95% confidence interval 3.31–23.87) but not with functional outcome. Conclusions: In this selected cohort under CTP surveillance, the extent of perfusion impairment was associated with functional outcome and infarction, whereas binary deficit assessment was associated with infarction only. These preliminary findings suggest that territorial perfusion burden may refine risk stratification, but prospective validation with standardized imaging time points is required before the score can be used as a prognostic tool.

Background: The relevance of prior antithrombotic and thrombolytic treatment for decision‐making regarding endovascular thrombectomy (EVT) for acute ischemic stroke due to large vessel occlusion with established large infarcts is uncertain. This study investigates associations of prior antithrombotic medication and thrombolysis with the efficacy and safety of EVT for acute ischemic stroke due to large vessel occlusion with established large infarct. Methods: TENSION (Efficacy and Safety of Thrombectomy in Stroke With Extended Lesion and Extended Time Window) was a prospective randomized open‐label blinded–end point clinical trial. Patients with acute ischemic stroke due to large vessel occlusion and established large infarct were randomized to EVT with medical therapy or medical therapy alone. Exposures were preadmission antithrombotic treatment with antiplatelet agents or anticoagulants and intravenous thrombolysis. The primary efficacy end point was functional outcome at 90 days. Safety outcomes included death and symptomatic intracranial hemorrhage. Results: The study included 246 patients (median age, 74 years; interquartile range, 65 to 80 years; 49% women); 124 (50%) were assigned to EVT. Of 176 patients (72%) with prior antithrombotic therapy, 75 (31%) received antiplatelets, 56 (23%) anticoagulants, and 89 (36%) intravenous thrombolysis. EVT was associated with better functional outcome in patients with (common odds ratio [cOR], 2.40 [95% CI, 1.22–4.99]) and without (cOR, 2.29 [95% CI, 1.53–3.46]) antiplatelet therapy; with (cOR, 2.45 [95% CI, 1.17–5.28]) and without (cOR, 2.12 [95% CI, 1.44–3.15]) anticoagulation; as well as receiving (cOR, 1.46 [95% CI, 0.83–2.61]) and not receiving (cOR, 2.89 [95% CI, 1.87–4.51]) thrombolysis. Interaction analyses were consistent with similar treatment effects across subgroups. Mortality and rates of symptomatic intracranial hemorrhage were similar between groups. Conclusions: Benefit and safety of EVT were not modified by prior antithrombotic/thrombolytic therapy. Preadmission exposure to antiplatelets or anticoagulants or use of intravenous thrombolysis should not exclude eligible patients with stroke from EVT. Registration: URL: https://www.clinicaltrials.gov ; Unique Identifier: NCT03094715.

Purpose: The treatment effect of mechanical thrombectomy in patients with mild stroke symptoms and large vessel occlusion remains unclear. Furthermore, it is uncertain whether achieving complete reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] 3) offers additional clinical benefit compared to incomplete reperfusion (mTICI 2b) in patients with mild stroke. Methods: In this retrospective, multicenter analysis, all patients enrolled in the German Stroke Registry—Endovascular Treatment between 2015 and 2023 ( n = 18,069) were evaluated. The study included patients with a National Institutes of Health Stroke Scale (NIHSS) score of < 6 and anterior circulation large vessel occlusion. Clinical outcomes were compared between mTICI 2b and mTICI 3. The primary endpoint was excellent functional outcome at 90 days, defined as a modified Rankin Scale (mRS) score of 0–1. Results: Of the 747 included patients, 37% achieved mTICI 2b and 63% mTICI 3. An excellent functional outcome was observed at similar rates in both groups (mTICI 2b: 59% vs. mTICI 3: 60%; P = 0.83; adjusted OR: 0.96 [95% CI: 0.66–1.40]; P = 0.84). The rates of symptomatic intracranial hemorrhage (4% vs. 3%; P = 0.36) and 90-day mortality (10% vs. 7%; P = 0.26; adjusted OR: 0.80 [95% CI: 0.42–1.50]; P = 0.49) were also comparable between the two groups. Conclusion: Among thrombectomy patients with mild stroke, complete reperfusion was not associated with better functional outcomes than incomplete reperfusion. These findings suggest that mTICI 2b may be an acceptable final angiographic result and raise questions about the risk-benefit ratio of additional retrieval maneuvers aimed at achieving mTICI 3.

The clinical benefits of adjunctive middle meningeal artery embolization (MMAE) are reflected in radiologic outcomes including lower chronic subdural hematoma (cSDH) volumes at follow-up imaging, supporting MMAE alongside surgery for managing cSDHs.

Background: While thrombectomy benefits patients with large infarcts, it is unclear whether this benefit persists across different levels of reperfusion. Aims: This study investigates how the degree of reperfusion influences the effectiveness of endovascular thrombectomy (EVT) combined with best medical treatment (BMT), compared to BMT alone, in patients with large infarcts. Methods: This post hoc analysis of the TENSION trial, a randomized controlled study, assessed EVT versus BMT in patients with extensive infarction (Alberta Stroke Program Early CT Score (ASPECTS) 3–5). Primary outcome was the modified Rankin Scale (mRS) score at 90 days. Secondary outcomes included infarct volume at 24 h, mortality, and symptomatic hemorrhage. Outcomes were stratified by final reperfusion level, measured with the modified thrombolysis in cerebral infarction (mTICI) scale. Confounder-adjusted common odds ratios (cORs) and average treatment effects (ATEs) were estimated using inverse probability weighting with regression adjustment. Results: A total of 246 patients (median age, 74 years (interquartile range (IQR), 65–80); median baseline ASPECTS, 4 (IQR, 3–5)) were included. Compared to BMT alone, unsuccessful EVT (mTICI ⩽ 2a) was not associated with worse functional outcomes (cOR:1.2, 95% CI, 0.95 to 1.52; p = 0.131), higher mortality (ATE: –11.6%; 95% CI, –28.82 to 5.61; p = 0.187), or larger infarct volumes on follow-up (ATE:0.99 mL; 95% CI, –45.30 to 45.32; p = 0.965). First-pass complete reperfusion (mTICI 3) showed the greatest treatment benefit, significantly improving all endpoints, with a cOR of 4.85 (95% CI, 3.74–6.31; p < 0.001) for improved mRS scores and a 29% absolute reduction in mortality. Conclusion: In this post hoc analysis of the TENSION trial, unsuccessful EVT did not worsen outcomes compared to BMT alone. The highest benefit of EVT occurred with first-pass complete reperfusion, emphasizing the importance of achieving optimal reperfusion in this vulnerable stroke subgroup. These findings do not justify general treatment recommendations.

Intravenous thrombolysis (IVT) followed by endovascular thrombectomy (EVT) improves functional outcomes in patients with acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). There are limited data on the effect of thrombolysis-to-puncture time (TTP) on outcomes in patients with AIS undergoing IVT plus EVT. We selected 1,104 patients receiving IVT + EVT for anterior circulation LVO stroke from 2 prospective nationwide registries (259 cases from ANGEL-ACT in China: November 2017 to March 2019, 845 cases from German Stroke Registry-Endovascular Treatment in Germany: June 2015 to December 2019). Based on the TTP, eligible patients were divided into 4 groups (≤30 min, 31-50 min, 51-70 min, and >70 min). The radiologic and clinical outcomes (e.g., successful recanalization [modified Thrombolysis in Cerebral Infarction score of 2b-3] at final angiogram, modified Rankin Scale [mRS] score of 0-2 at 90 days, any intracranial hemorrhage [ICH], and symptomatic ICH within 24 hours) among the 4 groups were compared by χ² tests for trend and using multivariable logistic regression models. In the 4 groups from ≤30 min to >70 min, 226, 282, 230, and 366 patients were included, respectively. An increased TTP was associated with a lower chance of successful recanalization (p = 0.016) and mRS score 0-2 (p = 0.002). Compared with the group of ≤30 min, the group of >70 min was less likely to achieve successful recanalization (adjusted odds ratio [OR] = 0.47, 95% CI 0.25-0.89) and the groups of 50-70 min and >70 min had a reduced probability of mRS score 0-2 (adjusted OR = 0.50, 95% CI 0.33-0.78; adjusted OR = 0.56, 95% CI 0.37-0.85). No significant differences were found for any ICH or symptomatic ICH among the 4 groups after adjustment with potential confounders. Delay from thrombolysis to puncture should be minimized when considering bridging IVT before EVT for patients with AIS due to anterior circulation LVO. Further studies are warranted to verify and expand on these findings. ClinicalTrials.gov, NCT03370939 and NCT03356392.

BACKGROUND: The optimal anesthetic approach for patients with acute ischemic stroke with large vessel occlusion but low National Institutes of Health Stroke Scale receiving mechanical thrombectomy remains unclear. We aimed to evaluate the association of anesthetic strategies with procedural and clinical outcomes, hypothesizing that conscious sedation/local anesthesia (CS/LA) may offer a more favorable risk-benefit ratio than general anesthesia (GA). METHODS: Multicenter cohort study screening all thrombectomy patients prospectively enrolled in GSR-ET (German Stroke Registry-Endovascular Treatment) across 25 centers between 2015 and 2021. Patients with an admission National Institutes of Health Stroke Scale score of P =0.043), had lower National Institutes of Health Stroke Scale scores at admission (median, 3 versus 4; P =0.002), and the M1 segment of the middle cerebral artery was more often occluded (51% versus 39%; P P =0.14). However, complete recanalization (modified Thrombolysis in Cerebral Infarction score of 3) was less often observed in CS/LA patients (45% versus 61%; P P P =0.005; adjusted odds ratio, 1.99 [95% CI, 1.34–2.95]; P =0.001). CONCLUSIONS: In thrombectomy patients with minor stroke, the rate of successful recanalization was comparable between CS/LA and GA. However, our results suggest a more favorable risk-benefit ratio of CS/LA, with an increased rate of excellent functional outcomes.

BACKGROUND: Recent randomized trials demonstrated the beneficial effect of endovascular therapy in patients with low Alberta Stroke Program Early CT Score. Despite large follow-up infarct volumes, a significantly increased rate of good functional outcomes was observed, challenging the role of infarct volume as a predictive imaging marker. This analysis evaluates the extent to which the effects of endovascular thrombectomy on functional outcomes are explained by (1) follow-up infarct volume and (2) early neurological status in patients with stroke with low Alberta Stroke Program Early CT Score. METHODS: TENSION (Efficacy and Safety of Thrombectomy in Stroke With Extended Lesion and Extended Time Window) was a randomized trial conducted from February 2018 to January 2023 across 41 stroke centers. Two hundred fifty-three patients with ischemic stroke due to anterior circulation large vessel occlusion and Alberta Stroke Program Early CT Score of 3 to 5 were randomized to endovascular thrombectomy plus medical treatment or medical treatment alone. All patients with the availability of relevant data points were included in this secondary as-treated analysis. The primary outcome was the 90-day modified Rankin Scale score. Confounder-adjusted mediation analysis was performed to quantify the proportion of the treatment effect on a 90-day modified Rankin Scale score explained by (1) 24-hour follow-up infarct volume and (2) 24-hour National Institutes of Health Stroke Scale scores. RESULTS: One hundred eighty-eight patients were included; thereof, 87 (46%) were female patients. Median age was 72 (interquartile range, 63–79) years. The endovascular thrombectomy cohort had a 20.5 (95% CI, 8.3–33.7) percentage points higher probability of achieving independent ambulation (modified Rankin Scale, 0–3) and a 24.2 (95% CI, 13.4–35.8) percentage points lower mortality at 90 days compared with medical treatment alone. The reduction in 24-hour follow-up infarct volume explained 30% of the treatment effect on functional outcomes, while the 24-hour National Institutes of Health Stroke Scale score explained 61%. CONCLUSIONS: In patients with low Alberta Stroke Program Early CT Score, infarct volume demonstrated limited explanatory power for functional outcomes compared with the early neurological status, which may more effectively reflect factors such as the involvement of specific brain regions, disruption of structural networks, and selective neuronal loss.

In patients with large ischemic stroke, thrombectomy within 12 hours after onset was superior to best medical treatment in reducing 90-day functional disability irrespective of the collateral status on single-phase CT angiography images.