Background Complete common carotid artery (CCA) occlusion (CCAO) lacks standardised treatment guidelines and is frequently associated with severe complications. Subclavian artery-to-CCA bypass grafting (SCBG) provides a viable revascularisation strategy, yet its neurosurgical application remains underexplored. This study evaluated the clinical efficacy and technical nuances of SCBG from a neurosurgical perspective. Methods This retrospective study enrolled 20 symptomatic patients with CCAO demonstrating ipsilateral hypoperfusion on CT perfusion (CTP). Preoperative evaluations included CT angiography, CTP and high-resolution MRI. Surgical indications comprised recurrent ischaemic events and significant ipsilateral hypoperfusion. SCBG was performed using prosthetic grafts (PGs), with intraoperative patency verified via indocyanine green angiography. Postoperative protocols for anticoagulation, antiplatelet and statin therapies were standardised. Results The median operative duration was 255.5 min (IQR 202.25–319.75 min), with a median estimated blood loss of 50 mL (IQR 20–50 mL). The primary patency rate was 85%, with initial graft occlusion occurring in three cases. Two cases were managed conservatively, and one underwent successful emergency thrombectomy, restoring patency (final secondary patency 90%). Complications included asymptomatic acute ischaemic strokes (2/20), pleural effusion (1/20) and extended intensive care unit stay (1/20). During follow-up, the median postoperative modified Rankin Scale was 0. CTP volumetric analysis confirmed a significant reduction in the time to maximum>6 s hypoperfusion volume (p=0.004) in the patent cohort. Conclusions Our findings suggest that SCBG presents a high-flow revascularisation option for symptomatic CCAO, with initial evidence suggesting acceptable safety and an 85% primary and 90% final patency rate using PGs. It may address a therapeutic gap when endovascular techniques or superficial temporal artery-to-middle cerebral artery bypasses are unsuitable. However, these conclusions are limited by our small sample size and lack of a control group and should be considered preliminary until confirmed by larger studies with long-term follow-up.
Background A considerable number of patients with acute ischaemic stroke (AIS) are ineligible for standard reperfusion therapy due to time window constraints and contraindications. Human urinary kallidinogenase (HUK), a tissue kallikrein, has been demonstrated to promote vasodilation and improve cerebral blood flow (CBF) in ischaemic regions. Although clinical evidence suggests its favourable efficacy in such patients with AIS, the specific effects of HUK on early cerebral perfusion and its correlation with functional outcomes remain incompletely elucidated.Aim TK-SPEED aims to investigate the effects of HUK on early cerebral perfusion improvement and functional outcomes in patients with AIS, providing robust evidence for HUK.Methods and design TK-SPEED is a multicentre, prospective, randomised, open-label, blinded-endpoint controlled trial. Approximately 540 participants with acute anterior circulation ischaemic stroke will be recruited from about 20 participating sites across China. Eligible patients will be randomly assigned in a 1:1 ratio to either the intervention group (HUK plus standard therapy) or the control group (standard therapy).Study outcomes The primary endpoint is the proportion of patients with a modified Rankin Scale (mRS) of 0–2 at day 90. The secondary outcomes include changes in the Tmax (time-to-maximum)>6 s volume and regional CBF in the Tmax>6 s area on CT perfusion from baseline to day 5 after treatment, the ordinal distribution of mRS, the proportion of patients with mRS of 0–1 at day 90 and changes in the National Institutes of Health Stroke Scale score from baseline to days 5 and 10 after treatment.Discussion This trial will provide crucial evidence elucidating the impact of HUK on early cerebral perfusion and its correlation with the 90-day neurological outcomes in patients with AIS, offering guidance for optimising AIS treatment strategies and improving patient prognosis.Trial registration number NCT06132880.
Objective To investigate whether rescue mechanical thrombectomy (MT) was associated with improved clinical outcomes for patients with anterior circulation large-vessel occlusion (LVO) who developed early neurological deterioration (END) beyond the conventional thrombectomy time window.Methods We prospectively enrolled anterior circulation LVO cases who initially showed mild deficits (National Institutes of Health Stroke Scale score 1–5) but subsequently developed END between 24 and 72 hours post symptom onset in our stroke centre. Eligible patients underwent multidisciplinary evaluation and received either rescue MT or best medical management (BMM). Functional independence at 90 days (modified Rankin Scale (mRS) score 0–2) was the primary endpoint.Results From October 2022 to October 2024, 187 patients were enrolled and 180 completed follow-up (121 MT, 59 BMM). The MT group showed significantly higher rates of 90-day mRS 0–2 37.2% (45/121) vs 20.3% (12/59); adjusted risk ratio (aRR) 1.97, 95% CI 1.01 to 3.82, p=0.044. MT also correlated with reduced 90-day all-cause mortality (aRR 0.49, 95% CI 0.24 to 0.99, p=0.048) and higher rate of 90-day mRS 0–3: aRR 2.09 (95% CI 1.38 to 3.18; p=0.001). Logistic regression showed MT independently associated with mRS 0–2 at 90 days.Conclusion Rescue MT was associated with a higher likelihood of favourable functional outcome compared with BMM in an extended time window for patients with anterior circulation LVO and END. These observational findings require confirmation in randomised controlled trials.
Background and objectives Non-functional transverse sinus (NFTS) represents a markedly narrowed but non-thrombosed transverse sinus that may impair cerebral venous outflow. Its influence on the clinical course and outcomes of cerebral venous sinus thrombosis (CVST) remains unclear. This study aimed to evaluate the prevalence and prognostic significance of NFTS among patients with CVST. Methods Data from consecutively enrolled patients with confirmed CVST in multicentre databases were retrospectively analysed. NFTS was defined as a transverse sinus showing severe luminal reduction compared with the contralateral side in the absence of thrombosis. Patients with and without NFTS were compared for clinical and radiological features and 90-day excellent functional outcome, defined as a modified Rankin Scale score of 0–1. A preplanned secondary analysis included only patients with unilateral transverse sinus thrombosis sparing the NFTS to isolate its haemodynamic impact. Results Among 443 CVST patients (mean age 41.4±18.2 years; 64.3% female), 49 (11%) had NFTS. Compared with those without NFTS, affected patients had higher rates of papilledema (50% vs 23%, p<0.001) and multiple cerebral vein involvement (43% vs 22%, p=0.002), with a trend towards lower rates of excellent 90-day outcome (78% vs 87%, p=0.067). In the secondary analysis of 299 patients with unilateral transverse sinus thrombosis not involving NFTS, NFTS (n=29) was associated with more papilledema (51.3% vs 24.3%, p<0.001), multiple vein involvement (51.3% vs 31.9%, p=0.017) and superior sagittal sinus thrombosis (48.7% vs 28.9%, p=0.013). NFTS patients with contralateral transverse sinus thrombosis had poorer outcomes (excellent outcome 74.4% vs 89.7%, p=0.006). NFTS independently predicted non-excellent outcome (OR 4.37; 95% CI 1.5 to 13; p=0.008). Conclusions NFTS identifies a subset of CVST patients with impaired venous drainage, greater thrombotic extent, increased papilledema and poorer functional recovery. Recognition of NFTS on baseline imaging may assist in risk stratification and tailored monitoring in CVST.
Importance Large-vessel occlusion (LVO) strokes cause substantial morbidity and mortality. Reperfusion within 4.5 hours (intravenous thrombolysis (IVT), endovascular thrombectomy (EVT) or bridging strategies (EVT following IVT)) is critical, but the relative effectiveness and safety of different thrombolytic agents/doses and strategies remain debated. Objective To compare the relative effectiveness and safety of different IVT regimens (alteplase (rt-PA) and tenecteplase (TNK) at commonly studied doses), EVT alone and bridging strategies within 4.5 hours after symptom onset for LVO stroke using a network meta-analysis. Design, setting and participants Frequency-based network meta-analysis of randomised clinical trials (RCTs). We included RCTs enrolling adults (≥18 years) with imaging-confirmed LVO treated within 4.5 hours. Trials were identified through systematic searches of PubMed, Embase and Cochrane CENTRAL (through 27 August 2025). Exposures Treatment strategies categorised as (a) rt-PA 0.9 mg/kg, (b) TNK 0.4 mg/kg, (c) rt-PA 0.6 mg/kg+EVT, (d) rt-PA 0.9 mg/kg+EVT, (e) TNK 0.25 mg/kg+EVT, (f) TNK 0.4 mg/kg+EVT and (g) EVT. Main outcomes and measures Primary outcome: 90-day excellent functional outcome (modified Rankin scale (mRS) 0–1). Secondary outcomes: 90-day independence (mRS 0–2). Safe outcomes: 90-day all-cause mortality, symptomatic intracerebral haemorrhage (sICH) and any intracranial haemorrhage (ICH). Relative effects were estimated as RRs with 95% CIs and treatments were ranked by the surface under the cumulative ranking curve (SUCRA). Results 20 RCTs (5602 patients) were included. By SUCRA ranking for the primary outcome, TNK 0.25 mg/kg+EVT had the highest probability of being best (SUCRA 83.8%), followed by rt-PA 0.9 mg/kg+EVT (72.2%). Single-agent rt-PA 0.9 mg/kg and TNK 0.4 mg/kg ranked lowest for functional benefit (SUCRA 14.4% and 8.5%, respectively). For safety endpoints, rt-PA 0.6 mg/kg+EVT and EVT alone tended to rank better in reducing sICH, any ICH and mortality; TNK 0.4 mg/kg (alone or with EVT) frequently occupied lower safety rankings. Most pairwise comparisons did not achieve statistical significance, and many CIs included the null, indicating uncertainty. Conclusions and relevance In the available RCT network, TNK 0.25 mg/kg+EVT had the highest probability of best functional outcome in the 4.5-hour window, while lower-dose rt-PA strategies or EVT alone may be preferable from a safety perspective. Interpretation is limited by imprecision, heterogeneity between trials and the small number of events for some safety outcomes. Additional large, direct head-to-head RCTs and individual-patient data meta-analyses are warranted.
