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There were limited studies comparing the anterior (AC) and posterior (PC) circulation acute ischemic strokes (AIS). Our study aimed to evaluate distinct features of AC and PC strokes regarding clinical, vascular risk, pathogenesis and outcome factors after endovascular procedures. This multicenter prospective study registered 873 patients with acute large occlusion of anterior circulation stroke (ACS) and posterior circulation stroke (PCS). Patients who underwent endovascular procedures were included in this study. The differences in ACS and PCS regarding baseline characteristics, post-operative intracranial hemorrhage and outcomes were evaluated. A total of 741 patients were included in the data analysis. Intravenous thrombolysis (31.5%), atrial fibrillation (22.7%) and stent thrombectomy (82.4%) were more frequently observed in ACS patients. While higher NIHSS score, hypertension (67.6%) and balloon angioplasty (20.7%) were more prevalent in PCS patients. Symptomatic intracranial hemorrhage was more common in ACS (7.4% vs 2.8%). However, a 3-month follow-up outcomes were better in ACS with higher functional independence and low mortality rate than PCS (46.8% vs 30.3% and 16.4% vs 33.8%, respectively, P < 0.01). In this large prospective study, there were significant differences in the pathogenesis of stroke and treatment procedure between ACS and PCS which influence the clinical outcome. These findings could lead to a tailored clinical procedures and treatment strategies to improve the prognosis in both groups.

Background: In patients with posterior circulation stroke, the association between National Institutes of Health Stroke Scale (NIHSS) scores after thrombectomy and 90-day functional outcomes remains unclear. Objectives: We aimed to explore which factors among the 24-h NIHSS score, ΔNIHSS (baseline NIHSS minus 24-h NIHSS), and NIHSS score change rate (ΔNIHSS/baseline NIHSS × 100%) are associated with favorable functional outcomes at 90 days postoperatively in patients with posterior circulation stroke. Design: We performed a post hoc analysis of a prospective observational study utilizing key techniques of endovascular treatment and emergency workflow improvements from the acute ischemic stroke registry. The study included a cohort of 353 patients who underwent thrombectomy due to posterior circulation stroke. For all patients, we collected baseline characteristics, lesion locations, NIHSS scores, ΔNIHSS (baseline NIHSS minus 24-h NIHSS), NIHSS score change rate (ΔNIHSS/baseline NIHSS × 100), and 90-day postoperative modified Rankin Scale (mRS) score. Methods: A 90-day postoperative mRS score of 0–2 was defined as a favorable functional outcome, while a score of 3–6 was defined as an unfavorable functional outcome. The 24-h NIHSS score and ΔNIHSS score were converted into binary variables based on the Youden index to determine the optimal thresholds that best predict favorable functional outcomes at 90 days postoperatively. Adjusted logistic regression analysis was used to assess the predictive efficacy of the 24-h NIHSS score, ΔNIHSS (baseline NIHSS minus 24-h NIHSS), and NIHSS score change rate (ΔNIHSS/baseline NIHSS × 100) for the 90-day mRS. Subsequently, patients were categorized into cardioembolic embolism (CE) and large artery atherosclerosis (LAA) subgroups according to the Trial of Org 10172 in Acute Stroke Treatment classification, and the predictive efficacy of the optimal thresholds was examined within these subgroups. Results: Multivariate logistic regression analysis revealed that the 24-h NIHSS score was an independent predictor of 90-day functional outcomes (odds ratio (OR): 10.61, 95% confidence interval: 6.44–17.46, p < 0.001). The Youden index identified a 24-h NIHSS score of ⩽9 as the threshold for predicting an mRS score of 0–2, demonstrating good sensitivity (78.5%) and specificity (76.3%). The receiver operating characteristic curve indicated that the predictive model had good discriminative ability (area under the ROC curve = 0.8223). In subgroup analysis, a 24-h NIHSS score of ⩽9 also showed superior predictive efficacy in both the CE (sensitivity 67.8%, specificity 73.5%) and LAA (sensitivity 81.1%, specificity 74.4%) groups. Conclusion: The 24-h postoperative NIHSS score is a reliable predictor of 90-day functional outcomes in patients with posterior circulation stroke undergoing endovascular treatment. The predictive efficacy is optimal when the NIHSS score is ⩽9.

Previous studies have revealed that Galectin-9 (Gal-9) acts as an apoptosis modulator in autoimmunity and rheumatic inflammation. In the present study, we investigated the potential role of Gal-9 as a biomarker in patients with rheumatoid arthritis (RA), especially as an indicator of functional limitations and radiographic joint damage. A total of 146 patients with RA and 52 age- and sex-matched healthy controls were included in this study. Clinical data including disease activity, physical function, and radiographic joint damage were assessed. Functional limitation was defined as the Stanford Health Assessment Questionnaire (HAQ) disability index >1. Subjects with joint erosion >0 or joint space narrowing >0 were considered to have radiographic joint damage. Serum Gal-9 levels were detected by an enzyme-linked immunosorbent assay. Univariate and multivariate logistic regression analysis were used to evaluate the association between Gal-9 and high disease activity and functional limitations, and a prediction model was established to construct predictive nomograms. Serum levels of Gal-9 were significantly increased in patients with RA compared to those in healthy controls (median 13.1 ng/mL vs. 7.6 ng/mL). Patients with RA who were older (>65 years), had a longer disease duration (>5 years), longer morning stiffness (>60mins), elevated serum erythrocyte sedimentation rate and C-reactive protein, and difficult-to-treat RA had significantly higher Gal-9 levels than those in the corresponding control subgroups (all p <0.05). Patients with RA were divided into two subgroups according to the cut-off value of Gal-9 of 11.6 ng/mL. Patients with RA with Gal-9 >11.6 ng/mL had a significantly higher core clinical disease activity index, HAQ scores, Sharp/van der Heijde modified Sharp scores, as well as a higher percentage of advanced joint damage (all p<0.05) than patients with Gal-9 ≤11.6 ng/mL. Accordingly, patients with RA presenting either functional limitations or radiographic joint damage had significantly higher serum Gal-9 levels than those without (both p <0.05). Furthermore, multivariate logistic regression analysis showed that a serum level of Gal-9 >11.6 ng/mL was an independent risk factor for high disease activity (OR=3.138, 95% CI 1.150-8.567, p=0.026) and presence of functional limitations (OR=2.455, 95% CI 1.017-5.926, p=0.046), respectively. Gal-9 could be considered as a potential indicator in patients with RA, especially with respect to functional limitations and joint damage.

The value of intravascular ultrasound (IVUS) in the diagnosis and treatment of the venous system is not well established. Introducing a novel approach to utilizing IVUS to evaluate cerebral venous sinus (CVS) stenosis and select stent. Idiopathic intracranial hypertension (IIH) patients with CVS stenosis who underwent IVUS-guided stenting were included in the data analysis from January 2014 to February 2022. The degree of maximum stenosis was determined based on the cross-sectional area (CSA) measured by IVUS, and a stent selection method was applied in the study. Follow-up evaluations were conducted at 6 months to 1 year after endovascular treatment to assess symptom improvement. Additionally, repeated digital subtraction angiography (DSA) or Magnetic resonance venography (MRV) / CT venography（CTV） was performed to evaluate the stent patency at 6 months to 1 year post-procedure. The study included 61 patients. IVUS indicated a lower degree of stenosis compared to conventional DSA measurements when evaluating the degree of stenotic segments preprocedure (74.84 ± 10.12% vs. 78.48 ± 8.72%, p  = 0.035). Post-procedural CSA of the most severe stenotic segments showed significant improvement (36.44 ± 8.07 mm 2 vs. 7.42 ± 3.28 mm 2 , p  < 0.001). The stent achieved complete expansion (mean stent expansion index, 0.93 ± 0.20) with no significant change in the structure of the reference segment. The trans-stenotic mean pressure gradients (MPGs) across 61 patients significantly decreased from 11.00 ± 6.23 mmHg to 2.09 ± 2.34 mmHg. 47 out of 61 patients received imaging follow-up; among them, 44 (93.6%) demonstrated stent patency in the follow-up imaging. IVUS has great potential to evaluate the degree and extent of CVS stenosis, assist stent selection, and optimize stent position during the interventional procedure in conjunction with DSA.

IntroductionAs a neuroprotective medication, butylphthalide (NBP) may help protect against cerebral ischaemic injury. However, evidence on whether NBP influences the outcomes of patients who had acute ischaemic stroke who are receiving revascularisation treatment is limited. This study aims to evaluate whether additional NBP therapy can improve the functional outcome of patients who receive intravenous recombinant tissue plasminogen activator and/or endovascular treatment (EVT).Methods and analysisThe study will be a randomised, double-blind, placebo-controlled, multiple-centre, parallel group trial. The sample size is estimated at 1200 patients. Eligible patients will be randomised at a 1:1 ratio to receive either NBP or placebo daily for 90 days, which will include 14 days of injections and 76 days of capsules. The first use of NBP/placebo will be started within 6 hours of onset of ischaemic stroke. The primary outcome is the functional outcome as assessed by the 90-day modified Rankin Scale, adjusted for baseline scores on the National Institutes of Health Stroke Scale. The primary safety outcome is the percentage of serious adverse events during the 90 days of treatment. This trial will determine whether NBP medication benefits patients who had acute ischaemic stroke who receive intravenous thrombolysis or EVT.Ethics and disseminationThe protocol was written according to the general ethical guidelines of the Declaration of Helsinki and approved by the Institutional Review Board/Ethics Committee of Beijing Tiantan Hospital, Capital Medical University with approval number KY 2018-003-02. Ethics committees of all participating sites have approved the study . Results of the study will be published in peer-reviewed scientific journals and shared in scientific presentations.Trial registration numberNCT03539445.

Background and Aims: Although noninferior to stent retriever (SR) as first-line approach for endovascular treatment (EVT) of acute large vessel occlusion (LVO) stroke, little is known about the current status of direct aspiration (DA) as first-line thrombectomy in China. This analysis of a prospective, nationwide registry (ANGEL-ACT) aimed to investigate the prevalence and comparative effectiveness of DA-first thrombectomy in a real-world practice in China. Methods: All patients receiving thrombectomy were screened from a prospective cohort of LVO patients undergoing EVT at 111 hospitals in China between November 2017 and March 2019, and divided into two groups based upon which type of thrombectomy was attempted first (“DA-first” and “SR-first”). The following outcome measures were compared using logistic regression models with adjustment: successful recanalization after first-device alone and all procedures, use of rescue treatment, intracranial hemorrhage (ICH) within 24 h, and modified Rankin Scale (mRS) score at 90 days. Results: A total of 1225 patients, 102 (8.3%) in DA-first group and 1123 (91.7%) in SR-first group, were included. Patients receiving DA-first had less often successful recanalization after first-device alone [30.4 versus 66.4%; odds ratio (OR) = 0.23, 95% confidence interval (CI) = 0.15–0.37], more frequent rescue treatment (62.8 versus 27.0%; OR = 4.55, 95% CI = 2.92–7.08) and ICH (35.4 versus 22.1%; OR = 1.78, 95% CI = 1.12–2.83) than those receiving SR-first; however, no significant difference was found in successful recanalization after all procedures (84.3 versus 90.3%; p = 0.18) and 90-day mRS (median: 3 versus 3 points; p = 0.90) between both groups. Conclusion: This real-world registry suggested that DA-first thrombectomy for acute stroke patients lagged behind in China during the study period. Far fewer DA-first than SR-first thrombectomies were performed, and DA-first was associated with lower first-device recanalization, more frequently requiring rescue treatment, and increased ICH risk. Clinical Trial Registration: ClinicalTrials.gov, NCT03370939.

BackgroundPrevious studies have indicated that a subset of patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) experience spontaneous recanalization (SR), but the prognosis and factors associated with SR in these individuals are not well characterized.MethodsWe conducted a post hoc secondary analysis of the Study of Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients with a Large Infarct Core (ANGEL-ASPECT) trial. SR in the medical management group was defined as a modified arterial occlusive lesion (AOL) grade of 2 or 3 on computed tomography angiography (CTA) or magnetic resonance angiography (MRA) at 36 hours (±12 hours).ResultsSR was detected in 67 out of 184 patients (36.4%) in the medical management (MM) group. The median age of patients was 67 years (interquartile range (IQR) 58–72), and 48 (71.6%) were male. The adjusted odds ratio (aOR) for 90-day modified Rankin Scale (mRS) score shift toward better outcomes of the MM with SR group vs the MM without SR group was 1.83, with marginally significant difference (95% confidence interval (CI) 0.992 to 3.36; P=0.053). No significant difference was found between the MM with SR group and EVT recanalization group (aOR 1.45; 95% CI 0.86 to 2.43; P=0.16) with similar findings in the inverse probability treatment weighting analysis (OR 0.85; 95% CI 0.49 to 1.48; P=0.57). Multivariable regression analysis showed that hypertension, atherothrombotic stroke and higher clot burden score were factors associated with SR.ConclusionsSR in medically managed patients with acute large ischemic stroke caused by LVO was associated with good functional outcome. An improved understanding of SR patients may be helpful to develop therapeutic strategy in patients with large infarct due to LVO in anterior circulation.Trial registration numberNCT04551664.

Background: Cerebral small vessel disease (SVD) is common in the aging population. The study aimed to evaluate the effect of SVD on functional outcomes in patients with acute ischemic stroke (AIS) receiving endovascular treatment (EVT). Methods: From a prospective registry, we selected patients with AIS receiving EVT. SVD features, including white matter hyperintensities (WMH), lacunes and brain atrophy, were assessed on MRI and a validated SVD score was calculated to reflect the total SVD burden. Results: Among 137 patients included, 106 had none-mild SVD burden and 31 had moderate-severe SVD burden. The moderate-severe SVD burden group showed a significantly higher modified Rankin Scale score at 90 d (median, 4 versus 1 points, adjusted common odds ratio 0.32 [95% CI, 0.14–0.69], P 0.05). Additionally, for each single SVD feature, brain atrophy and WMH, but not lacunes, were associated with the functional outcome. Conclusion: Moderate-severe SVD burden was associated with poor early and late functional outcomes in patients with AIS receiving EVT. Our results suggest that SVD score may act as a good predictor of outcomes in these patients.

RationaleUnsuccessful thrombectomy of acute large vessel occlusions (LVOs) has been associated with unfavourable outcomes. Multiple randomised controlled trials (RCTs) have reported a failure rate of 12%–41% for thrombectomy procedures. Various factors contribute to failed thrombectomy, including technical difficulties in accessing the occlusion, unsuccessful thrombus retrieval, thrombotic reocclusion and pre-existing intracranial atherosclerotic stenosis. Although some studies have explored balloon dilation or permanent stenting as rescue intracranial angioplasty for failed thrombectomy in individual cases, there is currently no evidence from RCTs on this specific topic.AimTo evaluate the potential superiority of bailout angioplasty over standard treatment in cases of unsuccessful recanalisation (eTICI 0 to 2a) or residual severe stenosis (>70%) after thrombectomy in acute LVO patients within 24 hours of stroke onset.DesignThis study is a multicentre, prospective, randomised, controlled clinical trial designed by investigators. It compares bailout angioplasty with standard therapy and follows an open-label treatment approach while maintaining a blinded outcome assessment (PROBE design). Our objective is to allocate 348 patients in a 1:1 ratio to either receive bailout angioplasty as an intervention or standard therapy as a control, following unsuccessful thrombectomy.OutcomeThe main measure of interest is the modified Rankin Scale (mRS) Score, which will be assessed in a blinded manner at 90 (±14) days following randomisation. The primary effect size will be determined using ordered logistic regression to calculate the common OR, representing the shift on the six-category mRS Scale at the 90-day mark. Additionally, the safety outcomes will be evaluated, including symptomatic intracranial haemorrhage within 18–36 hours, severe procedure-related complications and mortality within 90 (±14) days, among others.DiscussionThe ANGEL-REBOOT study aims to generate substantial evidence regarding the efficacy and safety of bailout intracranial angioplasty as a treatment option for patients with LVO who have experienced unsuccessful thrombectomy.Trial registration number NCT05122286.

ObjectivesTo investigate the safety and efficacy of endovascular treatment (EVT) for acute medium vessel occlusion (MeVO) in the anterior circulation and to explore the independent predictors of the 90-day good outcome for such patients.MethodsData from ANGEL-ACT Registry were analysed in our study. The outcomes, such as the modified Rankin Scale (mRS) at 90 days, successful recanalisation rate and symptomatic intracranial haemorrhage (SICH) rate, were compared between MeVO and acute large vessel occlusions (LVO). Then, the independent predictors of the good outcome at 90 days in MeVO patients were determined by the logistic regression analyses.ResultsWe included 1032 subjects in the analysis, of which, 147 were MeVO and 885 were LVO. mRS at 90 days distribution (3 (0–4) vs 3 (0–5), common odds ratio (OR) =1.00, 95% confidence interval (CI) 0.73 to 1.38, p=0.994), SICH rate (4.8% vs 8.9%; OR=0.59, 95% CI 0.26 to 1.34, p=0.205) and successful recanalisation rate (89.8% vs 89.7%; OR=1.00 95% CI 0.51 to 1.93, p=0.992) were similar between the MeVO and LVO groups after adjusting for the confounders. We identified that baseline neutrophil-to-lymphocyte ratio ≤4.1 (OR=2.13, 95% CI 1.14 to 3.99, p=0.019), baseline National Institutes of Health Stroke Scale ≤14 (OR=1.96, 95% CI 1.02 to 3.80, p=0.045) and mechanical thrombectomy passes ≤1 (OR=2.16, 95% CI 1.14 to 4.11, p=0.021) were independent predictors of the 90-day good outcome in MeVO patients undergoing EVT.ConclusionsPatients with MeVO achieved similar 90-day mRS, SICH rate and successful recanalisation rate after EVT compared with patients with LVO. Several independent predictors of 90-day good outcome in MeVO patients undergoing EVT were determined, which should be highly considered in MeVO stroke management.