Lilan Wang

Background: This study aimed to investigate whether renal insufficiency (RI) modifies the effectiveness and safety of endovascular treatment (EVT) in patients with acute ischemic stroke and large infarct in a real‐world setting. Methods: This study was a post hoc analysis of a prospective multicenter cohort study. RI was defined as an estimated glomerular filtration rate 2 on admission. Patients were treated with EVT plus standard medical treatment or standard medical treatment alone and were stratified by RI status. The primary effectiveness outcome was favorable outcome (modified Rankin scale 0–3) at 90 days. Safety outcomes included symptomatic intracranial hemorrhage and 90‐day mortality. Results: Among 745 patients with acute ischemic stroke and large infarct, 343 (46.0%) had RI and 490 (65.8%) underwent EVT. Compared with standard medical treatment, EVT was associated with improved functional outcomes (modified Rankin scale 0–3) in both the RI (adjusted odds ratio [OR] 2.55 [95% CI, 1.15–5.68], P =0.022) and the non‐RI group (adjusted OR 2.65 [95% CI, 1.49–4.73], P =0.001). EVT was also associated with higher risks of symptomatic intracranial hemorrhage in both groups ( P =0.002 and 0.007, respectively), whereas no significant difference in mortality was observed. Results were consistent in the inverse probability‐weighted analyses. No statistically significant interaction was observed between RI status and treatment effect for effectiveness or safety outcomes. Conclusions: In patients with acute ischemic stroke and large infarct, EVT was associated with improved functional outcomes but a higher risk of hemorrhagic complications. We did not find statistically significant evidence of interaction between EVT and RI status for 90‐day outcomes.

Objective: The benefit of intravenous thrombolysis (IVT) before endovascular treatment (EVT) in patients with acute ischemic stroke due to large vessel occlusion (LVO) who present directly to EVT‐capable centers remains uncertain, and the effect may differ according to underlying stroke etiology. We assessed whether the benefit of IVT plus EVT versus EVT alone varied by stroke etiologies (large‐artery atherosclerosis, cardioembolism, or other/undetermined). Methods: We performed an individual participant data meta‐analysis of 6 randomized controlled trials (RCTs) that compared IVT plus EVT to EVT alone in patients with LVO within 4.5 hours of stroke onset or time last known well. The heterogeneity of treatment effect was assessed using ordinal logistic regression models with interaction terms for stroke etiology and treatment in the intention‐to‐treat population, followed by subsequent mixed‐effects meta‐analysis. An additional analysis was performed to assess whether the treatment effect of IVT plus EVT differed by atrial fibrillation status. Results: Among 2,313 eligible patients from 6 RCTs, 1,160 were randomized to the IVT plus EVT group and 1,153 to the EVT alone group. Median age was 71 years (interquartile range [IQR] = 62–78 years), and 44.3% of patients were women. Stroke etiology was classified as cardioembolism in 977 of 2,313 patients (42%), large artery atherosclerosis in 430 (19%), and other or unknown/undetermined in 906 (39%). No evidence of treatment effect modification by stroke etiologies on the association between IVT and 90‐day functional outcome was observed ( P for interaction = 0.60). For patients with other/undetermined stroke etiology, IVT plus EVT was associated with better 90‐day functional prognosis (adjusted common odds ratio for a lower level of disability = 1.34, 95% confidence interval [CI] = 1.05–1.69). No treatment effect modification by stroke etiology was found for safety outcomes. No treatment effect heterogeneity by atrial fibrillation was found for all outcomes. Interpretation: Among patients with LVO presenting directly to EVT‐capable centers, stroke etiologies do not modify the overall efficacy or safety of IVT before EVT. The isolated benefit observed in the other/undetermined subgroup requires confirmation. ANN NEUROL 2026;100:180–190

Background: Endovascular treatment (EVT) achieves high rates of recanalization in acute large‐vessel occlusion (LVO) stroke, but functional recovery remains heterogeneous. While symptomatic intracranial hemorrhage ( sICH ) has been well studied, the prognostic impact of asymptomatic intracranial hemorrhage ( aICH ) after EVT is less certain. Methods: We performed a pooled analysis of individual patient data from three randomized clinical trials ( DEVT , RESCUE BT , MARVEL ). Patients with anterior circulation LVO treated with EVT within 24 h were included. Hemorrhagic events were adjudicated by a blinded core laboratory using the modified Heidelberg Bleeding Classification. The primary outcome was 90‐day modified Rankin Scale ( mRS ) distribution. Analyses included multivariable ordinal logistic regression, propensity score matching ( PSM ), and inverse probability of treatment weighting ( IPTW ). Exploratory analyses used LASSO ‐based selection to develop a risk model for a composite endpoint of aICH with poor outcome ( mRS ≥ 4). Results: Among 2562 eligible patients, 721 (28.1%) developed aICH , the median age was 68 years ( IQR , 58–76), and 57% were women. aICH was significantly associated with worse functional outcomes (adjusted odds ratio, 0.51; 95% CI , 0.44–0.60) and higher mortality (adjusted odds ratio, 1.64; 95% CI , 1.28–2.0). These associations were consistent across analytic methods and subgroups. Parenchymal hematoma carried the greatest prognostic burden. Older age, higher baseline NIHSS scores, lower baseline ASPECTS , elevated admission glucose, and unsuccessful reperfusion are independently associated with aICH combined with poor prognosis. Conclusions: AICH after EVT is independently associated with poorer functional recovery and higher mortality, highlighting its clinical significance beyond radiological detection. Trial Registration: ChiCTR.org.cn Identifier: ChiCTR‐IOR‐17013568; ChiCTR‐IOR‐17014167; ChiCTR2100051729