Hesham Elmiselhy Masoud

BACKGROUND: The optimal management of isolated posterior cerebral artery occlusion (iPCAO) remains unclear. We investigated whether baseline perfusion imaging parameters are associated with clinical outcomes and whether they modify the association between endovascular therapy (EVT) and outcomes in iPCAO. METHODS: This prespecified secondary analysis of the international, multicenter, observational PLATO (Posterior Cerebral Artery Occlusion) registry (35 centers, 10 countries, 2015–2025) included consecutive adults with unilateral iPCAO and baseline perfusion imaging (computed tomography or magnetic resonance imaging) with reconstructed parameters. The primary end point was an excellent 90-day outcome (modified Rankin Scale score, 0–1). Perfusion parameters included hypoperfusion volume, infarct core volume, and mismatch ratio. The primary analysis used multivariable mixed-effects regression models (center as random effect) to assess associations between perfusion parameters and outcomes, adjusting for age, sex, treatment year, prestroke modified Rankin Scale score, baseline National Institutes of Health Stroke Scale score, diabetes, stroke cause, posterior circulation Acute Stroke Prognosis Early Computed Tomography Score, occlusion site, intravenous thrombolysis, and onset-to-door time. To test whether the association between EVT and outcomes varies according to baseline perfusion parameters, we evaluated treatment-by-perfusion interactions by including interaction terms (treatment×perfusion parameter) in inverse probability of treatment weighting–adjusted models, with results expressed as ratios of odds ratios (ORs). RESULTS: Of 1811 patients with iPCAO, 443 met inclusion criteria (median age, 74 years; 41.8% female). Larger hypoperfusion volume was associated with lower odds of excellent outcome (adjusted OR, 0.72 [95% CI, 0.58–0.89] per 1-unit increase in natural logarithm–transformed volume). No interaction between perfusion parameters and EVT was observed for the primary outcome. However, increasing core volume was associated with a progressively less favorable modified Rankin Scale score shift (ratio of OR, 0.66 [95% CI, 0.48–0.90]; P _interaction =0.009) and higher mortality (ratio of OR, 1.82 [95% CI, 1.10–3.03]; P _interaction =0.021) with EVT compared with medical management. Increasing hypoperfusion volume was associated with a higher risk of symptomatic intracranial hemorrhage with EVT (ratio of OR, 10.15 [95% CI, 1.06–96.93]; P _interaction =0.044). CONCLUSIONS: In iPCAO, perfusion imaging provides independent prognostic information but does not identify patients with potential benefit from EVT and may instead indicate those at higher procedural risk. REGISTRATION: URL: https://osf.io/62mwt ; Unique identifier: NCT05291637.

Stroke has become the single leading neurological illness that results in neurological disability and is the second most common cause of death worldwide. Approximately 85% of strokes are ischemic, whereas the remaining 15% are hemorrhagic. With the advent of increasingly effective treatment modalities, such as intravenous thrombolytics and endovascular mechanical thrombectomy, there has been a growing disparity in the ability to provide standard of care, despite substantial efforts made in lower- and middle-income countries. substantial effort in high-income countries to provide the current standard of care to patients with stroke, with the hope of improving outcomes. Extensive research has shown that the disparities in treatment among various countries stem from multiple sociocultural barriers and the lack of robust healthcare infrastructure. The societal influences in play include the lack of knowledge of stroke symptoms, cultural beliefs, health, and spiritual fatalism, which are then associated with delayed healthcare-seeking behaviors. As a result, it is imperative to increase access to treatment for patients with stroke to address inequities in stroke care and diminish the global burden of stroke. This narrative review highlights causes of major gaps in stroke treatment infrastructure in several global communities and examines the pertinent sociocultural factors that impede progress in stroke treatment.

Stroke is a leading cause of neurological disability and mortality worldwide, with acute ischemic strokes caused by large-vessel occlusions presenting significant health care challenges. While endovascular thrombectomy has emerged as a gold standard treatment, access to timely stroke care remains severely limited, especially in low- and middle-income countries. This review examines the multifaceted social, cultural, and systemic barriers that impede effective stroke care globally. We performed a comprehensive search of PubMed from 2004 to 2024, using keywords of acute stroke care, low-middle-income countries, social barriers, cultural barriers, and access. There are several recognized obstacles to stroke treatment, especially in the acute settings, including health fatalism, spiritual and religious beliefs that discourage medical intervention, and widespread lack of public awareness about stroke symptoms and urgency. Cultural misconceptions often lead individuals to delay or avoid seeking medical care, with some communities attributing stroke to supernatural forces or divine punishment. Language barriers, insufficient health care infrastructure, and socioeconomic challenges further compound these issues, particularly in regions such as sub-Saharan Africa and parts of Asia. Furthermore, there are critical infrastructural barriers to delivering acute stroke in a timely manner, including limited transportation to health care facilities and inadequate stroke centers in rural areas. A comprehensive strategy to address these challenges should focus on culturally sensitive education, community engagement, and infrastructure development. Recommendations include cooperating with religious and community leaders, developing targeted awareness campaigns, and creating inclusive health care approaches that respect local cultural contexts. Overall, addressing the global stroke burden not only requires technological interventions but also demands a holistic approach that bridges cultural understanding, challenges misconceptions, and empowers communities to recognize and respond to stroke as a critical medical emergency.

BACKGROUND: It remains unclear whether outcomes of patients treated with endovascular thrombectomy with large-vessel occlusion and unwitnessed onset of stroke differ from those with witnessed onset in the extended time window. METHODS: We enrolled patients with anterior circulation large-vessel occlusion (internal carotid artery, M1, or M2 segment of the middle cerebral artery) undergoing endovascular thrombectomy within 6 to 24 hours from the time last seen well, from 2014 to 2022, at 66 sites in Europe, North America, and Asia. Patients with a prestroke modified Rankin Scale score of >3 or age P =0.022). Mortality was 21.6% among unwitnessed and 22.0% among witnessed ( P =0.847), and symptomatic intracranial hemorrhage rates were 6.6% and 5.8%, respectively ( P =0.623). The primary outcome (modified Rankin Scale shift) showed no difference comparing unwitnessed to witnessed patients (odds ratio, 1.35 [95% CI, 0.82–2.20]; P =0.235) in the inverse probability of treatment weighting. Unwitnessed patients were more likely to achieve functional independence or return of Rankin (1.53 [1.01–2.33]; P =0.045). Other secondary outcomes did not differ between the witnessed and unwitnessed patients. CONCLUSIONS: In the extended time window, unwitnessed patients with large-vessel occlusion undergoing endovascular thrombectomy have at least the same likelihood of favorable outcomes as witnessed patients. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04096248.

BACKGROUND: The Society of Vascular and Interventional Neurology (SVIN) Guidelines and Practice Standards Committee issues Brief Practice Updates to provide concise, evidence-based recommendations and suggestions on focused topics relevant to vascular and interventional neurology. Currently, there is limited published guidance on the technical performance and interpretative parameters of cerebral digital subtraction angiography for the determination of cerebral circulatory arrest in patients being evaluated for brain death/death by neurological criteria. In this Brief Practice Update, we present consensus-based suggestions for standardizing the performance, interpretation, and application of digital subtraction angiography in this context. METHODS: This Brief Practice Update was developed using the SVIN Standards and Parameters for Guideline Development in the classification of evidence and Class of Recommendation when evidence is available and Expert Opinion recommendation when evidence is lacking. The Guidelines and Practice Standards committee convened a multidisciplinary writing group to establish key clinical questions and develop a survey assessing Expert Opinion on the role of digital subtraction angiography in cerebral circulatory arrest determination. Survey items addressed technical considerations, interpretation criteria, and clinical integration. Iterative refinement was achieved through group consensus, and the final survey was distributed to a panel of experts in neurointervention and neurocritical care. The SVIN Guidelines and Practice Standards Quality Committee reviewed the findings for adherence to SVIN’s internal evidence evaluation guidelines before submission to the SVIN board for societal endorsement. RESULTS: Evidence was evaluated by the writing group when available, and Expert Opinion was assessed using survey results. Suggested recommendations follow the established SVIN guideline framework for Class of Recommendation and Level of Evidence, with an Expert Opinion endorsement category for areas lacking high-quality evidence at the time of publication. CONCLUSIONS: This update standardizes how to perform, interpret, and report digital subtraction angiography when used to assess cerebral circulatory arrest in brain death/death by neurological criteria evaluations, aiming to improve reproducibility across centers. It provides a structured framework to improve consistency and reliability among practitioners performing and interpreting cerebral angiography in this setting.

BACKGROUND: There is uncertainty about whether patients with M2 occlusion benefit from endovascular therapy (EVT) in the late (6–24-hour) time window. We evaluated the clinical outcomes of patients with M2 occlusion selected for EVT compared with those who received medical management (MM) in the late window. METHODS: This multinational cohort study was conducted at 66 sites across 10 countries (January 2014 to May 2022). We included consecutive patients with late-window stroke due to M2 occlusion, baseline National Institutes of Health Stroke Scale score of ≥5, and premorbid modified Rankin Scale score of ≤2 who received EVT or MM alone. The primary end point was 90-day ordinal shift in the modified Rankin Scale score. Safety end points were symptomatic intracranial hemorrhage and 90-day mortality. Differences in outcomes were determined using inverse probability of treatment weighting–adjusted logistic regression models. RESULTS: Among 5098 patients, 496 met inclusion criteria (median [interquartile range] age, 74 years [62–81 years]; baseline National Institutes of Health Stroke Scale score, 12 [8–17]), of whom 394 (79.4%) received EVT and 102 (20.6%) MM. In inverse probability of treatment weighting adjusted analyses, there was no favorable 90-day ordinal modified Rankin Scale shift (odds ratio, 1.39 [95% CI, 0.92–2.12]) and no difference of functional independence rates (modified Rankin Scale score of 0–2; odds ratio, 1.72 [95% CI, 0.93–3.15]) with EVT compared with MM. Moreover, symptomatic intracranial hemorrhage risk (odds ratio, 3.46 [95% CI, 0.50–23.92]) and 90-day mortality (odds ratio, 1.11 [95% CI, 0.66–1.87]) were not statistically different between treatment groups. CONCLUSIONS: In patients with M2 occlusion in the 6- to 24-hour time window, there was no difference in disability outcomes or symptomatic intracranial hemorrhage risk between patients treated with EVT compared with MM. Results of ongoing randomized trials will provide further insight. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04096248.