Min Chen

Introduction: Procedural sedation during EVT for acute ischaemic stroke is widely used, but factors associated with analgosedative drug requirements remain poorly characterised. We aimed to identify patient and procedural factors associated with analgosedative drug requirements during EVT and explore their association with clinical outcomes. Patients and methods: We performed a post hoc analysis of the randomised INDIVIDUATE trial, including patients with anterior circulation ischaemic stroke undergoing EVT under procedural sedation. Sedation exposure was quantified using mean propofol, remifentanil and esketamine dose rates derived from protocolised 5-min medication records. Multivariable linear regression analyses were used to identify factors associated with sedation requirements. Sensitivity analyses were performed using body weight-normalised dose rates in patients with available body weight data. Exploratory analyses assessed associations between sedation requirements and procedural and clinical outcomes. Results: Of 250 patients enrolled in the INDIVIDUATE trial, 239 were included. In multivariable analyses, male sex was associated with higher propofol and esketamine dose rates; however, after body weight-normalisation, the association with propofol was no longer statistically significant. In weight-normalised sensitivity analyses including 198 patients (82.8%), male sex, ICA + M2 occlusion compared with M1 occlusion and pre-stroke disability remained associated with higher weight-normalised esketamine dose rates (β = 2.39 μg/kg/min, P = .021; β = 13.56 μg/kg/min, P < .001; and β = 2.82 μg/kg/min, P = .028, respectively). Additionally, the number of thrombectomy attempts was associated with higher remifentanil dose rates (β = 0.56 ng/kg/min, P = .010). Higher body weight-normalised esketamine dose rates were associated with less favourable NIHSS change at 24 h (β = 0.17, P = .022). Sedation requirements were not associated with 3-month functional outcome or mortality. Conclusion: Sedation requirements during EVT appeared to vary according to patient- and procedure-related factors, including sex, occlusion pattern, pre-stroke disability and procedural complexity. Sedation intensity was not associated with long-term clinical outcomes, supporting the use of adequate procedural sedation when clinically indicated. Clinical Trial Registration: Clinicaltrials.gov; NCT04578288.

Background: Intracerebral haemorrhage with ventricular extension is associated with poor neurological outcome and high mortality. External ventricular drainage (EVD) is a standard intervention for acute hydrocephalus in such patients, yet the role of an additional early lumbar drainage (LD) remains uncertain. Aim: To evaluate whether early LD leads to improved functional outcomes in patients suffering from ICH with intraventricular haemorrhage (IVH) who require an EVD, compared to patients not receiving early LD. Study design: DRAIN IVH is a multi-centre, parallel-group, open-label randomised controlled trial with blinded endpoint evaluation. Key inclusion criteria are ICH with IVH in the third and/or fourth ventricle with the need for EVD placement due to acute hydrocephalus, age ≥ 18 years and LD insertion within 72 h after symptom onset or last-seen-well. Sample size: A total of 354 patients will be randomised for either early LD plus standard of care (comprising EVD) or standard of care alone. Study endpoints: The primary outcome is the rate of modified Rankin Scale score 0–3 at 180 days. Secondary outcomes include need for VP shunt, need for tracheostomy and EQ-5D. Safety outcomes include mortality, bacterial ventriculitis/meningitis, EVD complications and LD complications. Summary: DRAIN IVH will provide evidence for physicians whether early LD in addition to standard of care treatment leads to better outcomes in ICH with IVH compared to standard of care alone. Trial Registration: Clinicaltrials.gov; NCT06510842.

Introduction: Neurocritical care patients with neurovascular disease often face poor long-term outcomes, highlighting the pivotal role of evidence-based interventions. Although International Guidelines emphasize managing basic physiological parameters like temperature, blood glucose, blood pressure, and oxygen levels, physician adherence to these targets remains uncertain. This study aimed to assess adherence to guideline-based treatment targets for basic physiological parameters in neurocritical care. Patients and Methods: This multicenter observational study was conducted across eight tertiary University Hospitals in Germany analyzed 474 patients requiring mechanical ventilation (between January 1st and December 31st, 2021). Adherence was defined as the rate of measurements within therapeutic ranges for systolic blood pressure (situation-adapted), mean blood pressure (MAP, 60–90 mmHg), glucose levels (80–180 mg/dl), body temperature (<37.5°C), partial arterial pressure of oxygen (PaO2) 80–120 mmHg und partial arterial pressure of carbon dioxide (PaCO2) 35–45 mmHg during the initial 96 h of hospitalization in 4 hour-intervals. Results: Overall, 70.7% of all measurements were within the predetermined therapeutic ranges including SBP (71.3%), temperature (68.3%), MAP (71.4%), PaO2 (65.2%), PaCO2 (75.0%) and blood glucose (80.7%). Discussion and Conclusion: This multicenter study demonstrates adherence to guideline-based treatment targets, underscoring the high standards maintained by neurological intensive care units. Our study offers valuable insights into adherence to guideline-based treatment targets for neurocritical care patients in Germany. To improve patient care and optimize therapeutic strategies in neurovascular diseases, further research is needed to examine the impact of these adherence parameters on long-term outcomes.

Background: Higher blood pressure variability (BPV) in patients suffering from acute ischemic stroke were shown to be associated with worse functional outcome and hemorrhagic transformation. Objectives: To assess the influence of blood pressure variability during endovascular stroke treatment on functional outcome and parenchymal hemorrhage. Design: We performed a post-hoc exploratory analysis of the individualized blood pressure management during endovascular thrombectomy under procedural sedation in acute ischemic stroke (INDIVIDUATE) study, which was a randomized clinical trial investigating an individualized blood pressure management strategy in comparison to a standardized treatment strategy during endovascular stroke treatment. Methods: Several BPV parameters, such as procedure time of systolic blood pressure (SBP) in a range of a preprocedural baseline SBP ± 10 mmHg and ±20 mmHg, maximal and minimal SBP, variance and average real variability of intraprocedural SBP values were tested for association with functional outcome and PH1/PH2 hemorrhages in the current post-hoc analysis. Results: Regression analyses were performed in 250 patients and revealed an association of variance of intraprocedural SBP (aOR, 1.002 (95% CI, 1.0004–1.004); p = 0.016) and average real variability of SBP (aOR, 1.105 (95% CI, 1.019–1.199); p = 0.016) with favorable outcome (modified Rankin Scale 0–2). Conclusion: In our study, intraprocedural BPV parameters during endovascular stroke treatment were positively associated with favorable clinical outcomes. Potential underlying mechanisms should be further explored to better understand the effects of hemodynamics during the hyperacute time frame of endovascular stroke therapy. Trial registration: Clinicaltrials.gov; NCT04578288.

Introduction: Mechanical thrombectomy is a highly effective treatment for acute ischemic stroke (AIS) caused by large vessel occlusions (LVO). However, our understanding of the pathophysiology of AIS is still limited, particularly regarding the ischemic microenvironment distal to the occlusion. Aim: To investigate the relationship between the intracerebral blood pressure (BP) distal to an LVO and clinical and imaging parameters. Methods: In this single-center prospective study, intracerebral BPs proximal and distal to the occluding clot were measured during thrombectomy in patients with AIS of the anterior circulation caused by LVO. BPs were correlated with imaging parameters and clinical data using Spearman’s rank correlation and linear regression. Results: 25 patients were included. A significant correlation was found between the mean arterial pressure (MAP) distal to the occlusion and the baseline Alberta Stroke Program Early CT Score (Spearman r=0.503, P=0.014) and baseline National Institutes of Health Stroke Scale score (r=−0.439, P=0.036). No significant correlation was observed between the MAP distal to the occlusion and collateral scores (eg, MAP vs American Society of Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology score (r=0.307, P=0.165) or modified Rankin Scale (mRS) score (pre-mRS vs 90-day mRS; r=0.013, P=0.952)). Systemic MAPs did not correlate with the MAP distal to the clot (eg, R ² =0.029, P=0.593). Conclusion: The intracerebral BP measured in the ischemic vasculature distal to the LVO correlates with the extent of the ischemic core and the clinical severity at baseline, but not with collateral scores, systemic BPs, or functional outcome. These results shed light on the pathophysiology of BP mechanisms in AIS and can be the basis for further research in this field.

Background: Optimal blood pressure management during endovascular stroke treatment is not certain. We hypothesized that time or proportion of intraprocedural systolic blood pressure spent in a range around admission blood pressure might be associated with better clinical outcome. Methods: We conducted a retrospective observational study at a single center at a university hospital, which included patients from August 2018 to September 2020 suffering from acute ischemic stroke with anterior circulation vessel occlusion and treated with endovascular therapy. Time and proportion of procedure time where systolic blood pressure (SBP) was near the baseline SBP on admission (bSBP) were used as exposure variables. The primary outcome was the occurrence of mRS score 0–2 three months after stroke. The primary analysis was performed by fitting a logistic regression model adjusted for baseline NIHSS, pre-stroke mRS, mTICI score, intubation, age and sex. Results: We included 589 patients in the analysis. Mean (SD) age was 76 (12) years, 315 were women (53%) and mean (SD) NIHSS score at admission was 15 (7.5). Mean (SD) bSBP was 167 (28) mmHg and mean (SD) intraprocedural SBP was 147 (21) mmHg. The proportion of time where intraprocedural SBP was in range of bSBP ± 20% was associated with a slightly higher odds of achieving favorable outcome (adjusted OR, 1.007; 95% CI, 1.0003–1.013). Conclusion: A higher proportion of intraprocedural time with systolic blood pressure in range of ± 20% of the admission level is associated with higher odds of favorable functional outcome. Trial Registration: Not applicable.

BACKGROUND: Optimal blood pressure (BP) management during endovascular stroke treatment is not well established. We studied whether an individualized approach for managing BP during endovascular stroke treatment gives a better clinical outcome than an approach with standardized systolic BP targets. METHODS: The INDIVIDUATE study (Individualized Blood Pressure Management During Endovascular Treatment of Acute Ischemic Stroke Under Procedural Sedation) is a randomized clinical trial with a prospective randomized open blinded end point (PROBE) design. Patients were recruited between October 1, 2020 and July 7, 2022 at a single center at a tertiary care university hospital. Patients were eligible, when they were suffering from acute ischemic stroke of the anterior circulation with occlusions of the internal carotid artery and middle cerebral artery and a National Institutes of Health Stroke Scale score of ≥8 receiving endovascular stroke treatment in procedural sedation. The intervention consists of an individualized BP management strategy, where preinterventional baseline systolic BP (SBP) values are used as intraprocedural BP targets. As a control, the standard treatment aims to maintain the intraprocedural SBP between 140 and 180 mm Hg. The main prespecified outcome is the proportion of favorable functional outcomes 90 days after stroke, defined as a modified Rankin Scale score of 0 to 2. RESULTS: Two hundred fifty patients were enrolled and included in the analysis, mean (SD) age was 77 (12) years, 142 (57%) patients were women, and mean (SD) National Institutes of Health Stroke Scale score on admission was 17 (5.2). In all, 123 (49%) patients were treated with individualized and 127 (51%) with standard BP management. Mean (SD) intraprocedural SBP was similar in the individualized versus standard BP management group (157 [19] versus 154 [18] mm Hg; P =0.16). The rate of favorable functional outcome after 3 months was not significantly different between the individualized versus the standard BP management group (25% versus 24%; adjusted odds ratio, 0.81 [95% CI, 0.41–1.61]; P =0.56). CONCLUSIONS: Among patients treated with endovascular stroke treatment due to an acute ischemic stroke of the anterior circulation, no significant difference was seen between the individualized BP management strategy, where intraprocedural SBP was targeted to baseline values, and the standardized regimen of targeting SBP between 140 and 180 mm Hg. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04578288.

Background and purpose: Vasospasm is a common complication of endovascular therapy (EVT). There is a lack of understanding of risk factors for periprocedural vasospasm. Here, we aimed to identify factors associated with vasospasm in patients with acute ischemic stroke who undergo EVT. Methods: We conducted a retrospective single-center analysis of patients receiving EVT for anterior circulation vessel occlusion between January 2015 and December 2021. Patients were excluded if they showed signs of intracranial atherosclerotic disease (ICAD) or if they underwent intra-arterial thrombolysis. Study groups were defined as patients developing vasospasm during EVT (V+) and patients who did not (V−). The study groups were compared in univariable analysis. Multivariable regression models were developed to predict the patient’s risk for developing vasospasm based on pre-identified potential prognostic factors. The secondary endpoint was clinical outcome defined as the modified Rankin Scale (mRS) difference between pre-stroke mRS and discharge mRS (delta mRS) and likelihood of successful reperfusion (TICI 2b/3). Results: In total, 132/1768 patients (7.5%) developed vasospasm during EVT. Vasospasm was more likely to occur in EVT with multiple thrombectomy attempts and after several stent retriever maneuvers. Factors associated with developing vasospasm were younger age (OR = 0.967, 95% CI = 0.96–0.98) and lower pre-stroke mRS (OR = 0.759, 95% CI = 0.63–0.91). The prediction model incorporating patient age, pre-stroke mRS, stent retriever thrombectomy attempts, and total attempts as prognostic factors was found to predict vasospasm with good accuracy (AUC = 0.714, 95% CI = 0.709–0.720). V+ patients showed higher median (IQR) delta mRS (2 (1–4) vs 2 (1–3); p = 0.014). There was no difference in successful reperfusion (TICI 2b-3) between those with or without vasospasm. Conclusion: Vasospasm was a common complication in EVT affecting younger and previously healthy patients. Presence of vasospasm did not reduce the likelihood of successful reperfusion. As independent predictors, patient age, pre-stroke mRS, thrombectomy maneuvers, and stent retriever attempts predict the occurrence of vasospasm during EVT with good accuracy.

Background and Aims Elderly patients, especially octogenarians, are underrepresented in recently published studies, that showed a benefit of endovascular stroke treatment (EST) for patients with acute basilar artery occlusion (BAO). We aimed to compare the clinical outcome of octogenarians with BAO and EST compared to younger patients and to identify independent outcome predictors. Methods This is a retrospective, single-center analysis of patients treated for BAO with EST from 01/2013 until 06/2021 in a tertiary stroke center. Octogenarians (≥ 80 years) were compared to younger patients. Study endpoint was the clinical outcome as per modified Rankin Scale (mRS) 90d after stroke onset. The study groups were compared in univariate analysis and a multivariable logistic regression analysis was performed to define independent predictors for clinical outcome. Results In this study cohort, 74/191 (38.7 %) octogenarians had a higher pre-stroke mRS (Median, IQR: 2, 1 – 3 octogenarians vs. 0, 0 – 1 younger patients, p < 0.001) and a comparable NIHSS before EST (Median, IQR: 21, 8 – 34 vs. 22, 10 – 38 younger, p = 0.712). They showed a comparable mRS 90d after stroke onset (Median, IQR: 5, 2 – 6 younger vs. 5, 3 – 6 octogenarians, p = 0.194), but less often a good clinical outcome (mRS 0-2: n = 27, 23% younger vs. n = 9, 11.7% octogenarians, p = 0.004). The rate of bad clinical outcome was comparable (mRS 5-6, n = 63, 46.7% younger vs. 39, 50.6 % octogenarians, p = 0.194). Baseline NIHSS was a stable independent predictor for clinical outcome in both study groups (e.g. for bad clinical outcome: in octogenarians OR 1.04, CI 100 – 10.85, p = 0.0019, in younger OR 1.061, CI 1.027-1.098, p = 0.005) Conclusion Octogenarians with acute BAO eligible for EST are less likely to be functionally independent at 90 days after stroke onset, but the rate of death or severe handicap is comparable to younger patients. The admission NIHSS predicts clinical outcome in both age groups.