Mechanical thrombectomy (MT) has emerged as the primary treatment for restoring blood flow in acute ischemic stroke (AIS) patients with large vessel occlusion (LVO). The shift from "time is brain" to "tissue is brain" underscores the significance of multimodal imaging in selecting and triaging AIS patients for endovascular reperfusion therapy. Currently, computed tomography (CT) is the preferred imaging modality for evaluating the infarct core and ischemic penumbra, aiding in the identification of suitable MT candidates. However, the abundance of collected imaging data, containing valuable signs, remains largely unexplored in emergency scenarios and follow-up protocols. A comprehensive investigation of these imaging features, known as "stroke imaging biomarkers," is crucial for accurate predictions regarding AIS pathogenesis, treatment, and prognosis. This exploration can provide valuable support to physicians in their diagnostic and treatment decisions. This review presents an overview of imaging biomarkers associated with ischemic core development, thrombus composition, stroke etiology, reperfusion strategy optimization, and clinical prognosis prediction. Beyond summarizing candidate biomarkers, we critically compare overlapping CT signatures, highlight controversies and failure modes, and synthesize the current level of evidence and barriers to clinical translation. Additionally, the utilization of artificial intelligence in this field, alongside emerging applications and future prospects, is discussed.

BACKGROUND:Intracranial atherosclerotic stenosis (ICAS) causes ischemia, predominantly from downstream hemodynamic compromise or perforator artery occlusion. We compared plaque morphology and composition between these mechanisms using high resolution vessel wall imaging (HR-VWI) and optical coherence tomography (OCT). METHODS:We enrolled 39 patients with symptomatic ICAS presenting with cerebral infarction or transient ischemic attack (TIA). All patients underwent HR-VWI and OCT. Based on diffusion weighted imaging (DWI) and CT perfusion (CTP), patients were classified as: (1) hypoperfusion type-watershed infarction on DWI or TIA with distal hypoperfusion on CTP; or (2) perforator type-an infarct confined to a single perforator territory on DWI. Plaque features were compared between groups, and multivariable logistic regression identified imaging markers independently associated with perforator-type events. RESULTS:On HR-VWI, perforator-type plaques more often exhibited intraplaque hemorrhage (IPH; 52.9% vs 13.6%; P=0.008), plaque ulceration (47.1% vs 13.6%; P=0.033), and a higher eccentric index (0.63±0.13 vs 0.48 (IQR 0.34); P=0.028) than hypoperfusion-type plaques. On OCT, perforator-type lesions had thinner fibrous caps (60 µm (IQR 50-80) vs 90±30 µm; P=0.004) and more frequent superficial thrombus (35.3% vs 4.5%; P=0.030) and cholesterol crystals (52.9% vs 18.2%; P=0.022). In multivariable analysis, thinner caps (per 10 µm increase, OR 0.663, 95% CI 0.481 to 0.914, P=0.012) and IPH (OR 9.703, 95% CI 1.508 to 62.429, P=0.017) were independently associated with perforator-type stroke. CONCLUSIONS:Plaques causing perforator artery occlusion showed a vulnerable phenotype characterized by a thin fibrous cap and IPH on multimodal imaging, distinguishing them from plaques underlying hemodynamic ischemia. These features may support mechanism specific risk stratification in ICAS.

Background The outcomes of self-expanding stenting for symptomatic middle cerebral artery (MCA) M2 segment stenosis remain unclear. We aimed to analyze whether the safety and efficacy of M2 and M1 segment stenting procedures differ.Methods This multicenter retrospective cohort study analyzed data from three stroke centers involving patients who underwent self-expanding stent placement for symptomatic M1 or M2 stenosis between January 2017 and August 2024. Patients were stratified into two groups: M1 stenting (M1S) and M2 stenting (M2S). Safety outcomes included 30-day peri-procedural complications, while efficacy outcomes comprised ipsilateral stroke beyond 30 days through 6 months and in-stent restenosis (ISR) at 6 months. Propensity score matching (PSM) was used to balance baseline characteristics between groups.Results A total of 318 patients were enrolled. Compared with the M1S group, the M2S group had a similar incidence of 30-day periprocedural complications (5.0% vs 5.4%; odds ratio (OR) 1.08, 95% confidence interval (CI) 0.24 to 4.93; P=0.917), incidence of ipsilateral stroke between 30 days and 6 months postprocedure (3.1% vs 3.9%; OR 1.27, 95% CI 0.16 to 10.40; P=0.821) and ISR rate (25.0% vs 15.8%; OR 0.56, 95% CI 0.23 to 1.35; P=0.193). After a 2:1 PSM (78 vs 39 patients), the two groups remained comparable in terms of 30-day complications, the incidence of ipsilateral stroke beyond 30 days through 6 months, and the ISR rate.Conclusion Self-expanding stenting for symptomatic M2 stenosis is technically feasible, with a safety and efficacy profile comparable to those of M1 interventions. These preliminary findings warrant validation in randomized trials.

Background: Cross-patient comparisons of culprit versus non-culprit plaques are prone to confounding from clinical heterogeneity. To minimize interpatient bias, we compared mirrored middle cerebral artery (MCA) plaques within individuals using high-resolution vessel wall imaging (HR-VWI). Methods: We screened consecutive patients with intracranial atherosclerotic disease (ICAD) who had bilateral MCA luminal stenosis >50% and underwent HR-VWI between June 2023 and November 2025. Patients with symptomatic (culprit) plaques in the M1 segment of MCA associated with an index ischemic stroke were included. Lumen stenosis and plaque features were compared between the culprit and the contralateral non-culprit sides. Results: Twenty-two patients were analyzed (mean age 63 ± 9 years; 77.3% male). Percent luminal stenosis did not differ between culprit and non-culprit sides (74.95±12.00% vs. 74.45 ± 11.88%; P=0.086). In contrast, culprit plaques exhibited greater normalized wall index (NWI; 81.34 ± 9.54% vs. 72.47 ± 10.31% ; P=0.004), a higher plaque-to-pituitary stalk contrast ratio (CR; 0.66 ± 0.50 vs. 0.30 ± 0.28; P=0.005), and a wider circumferential extent (P=0.021) than non-culprit plaques. In an exploratory analysis of culprit lesions, plaques with ≥180° circumferential involvement had significantly higher CR than those with <180° involvement CR (0.80 ± 0.53 vs. 0.38 ± 0.29; P=0.028). Conclusions: Among patients with moderate-to-severe bilateral MCA stenosis, culprit plaques exhibit greater wall burden, stronger enhancement, and more extensive circumferential involvement on HR-VWI despite similar percent stenosis. These features may improve identification of culprit plaques and support risk stratification beyond degree of luminal narrowing.

Accurate assessment of vascular status, collateral circulation, and occlusive thrombus is essential for acute ischemic stroke (AIS) management. This study evaluated the diagnostic performance and clinical value of CT perfusion–derived CT angiography (CTPA) reconstructed using a deep learning (DL) framework. This retrospective study included 288 patients who underwent both CTP and CTA examinations at two hospitals between November 2022 and May 2023. CTPA images were automatically reconstructed from CTP data using a DL-based workflow. Radiologists independently assessed CTPA and CTA image quality and diagnostic findings. Using digital subtraction angiography as reference, diagnostic performance was compared using the area under the curve (AUC) and the DeLong test. Associations between thrombus measurements, collateral score and stroke etiology were analyzed using regression models. No statistically significant difference was found in the subjective quality of axial images, although a trend favoring CTA was observed (p = 0.082); CTPA yielded higher maximum intensity projection and volume rendering scores (p < 0.05). CTPA achieved similar accuracy to CTA for ≥50% stenosis (AUC = 0.96 vs 0.95; p = 0.148) and superior accuracy for ≥70% stenosis (AUC = 0.98 vs 0.94; p = 0.006) and occlusion (AUC = 0.97 vs 0.94; p = 0.013) at vessel-level analysis. CTPA revealed higher thrombus attenuation and longer thrombus length (both p < 0.05), which were negatively associated with collateral score and stroke etiology (both p < 0.05). DL–derived CTPA provides comparable diagnostic performance to CTA while offering additional insights into thrombus and collateral evaluation, supporting CTPA as a valuable adjunct imaging tool for comprehensive AIS assessment.

INTRODUCTION:The lenticulostriate arteries (LSAs) demonstrate developmental variability that is linked to the A1 segment of the anterior cerebral artery (ACA) anatomy. In acute ischaemic stroke (AIS) with MCA occlusion, basal ganglia (BG) infarction extent and haemorrhagic transformation (HT) correlate with LSA involvement. This study aimed to assess whether ipsilateral A1-ACA variations influence BG infarction severity and thrombectomy outcomes. PATIENTS AND METHODS:A control cohort (n = 300) undergoing catheter angiography from September 2023 to November 2024 was used to define anatomical relationships between the A1-ACA and the medial LSA (mLSA). A thrombectomy cohort (n = 236; MCA occlusion) from January 2019 to November 2024 was stratified by A1-ACA status (normal vs hypoplastic/absent) on pre-intervention CTA. Final basal ganglia infarct volume (FIVBG) was quantified on 72-h post-procedure MRI/NCCT. Associations between A1-ACA status, FIVBG, HT and outcomes were analysed via multivariable regression. Mediation analysis evaluated FIVBG's role in A1-ACA anatomy and HT relationships. RESULTS:Hypoplastic/absent A1 segments occurred in 16.3% (49/300) of controls, who had a reduced mLSA presence (6.1% vs 20.7%, P = .016) and increased predominant lateral LSAs (71.4% vs 50.6%, P = .007) compared to those with a normal A1. Among thrombectomy patients, hypoplastic/absent A1 (15.3%, 36/236) predicted larger FIVBG (median: 29.01 cm3 [24.4-37.8] vs median: 25.80 cm3 [21.5-32.5], P = .004) and higher HT rates (66.67% vs 34%, P < .01). Multivariable analyses confirmed A1 hypoplasia/absence was independently associated with FIVBG (β = 5.714; 95% CI, 2.860-8.569; P < .01) and HT (aOR = 3.059; 95% CI, 1.284-7.288; P = .012). Furthermore, FIVBG mediated 44% of the indirect effect of A1 development on HT post-EVT. CONCLUSIONS:Hypoplastic/absent A1 segments correlate with impaired mLSA development, thereby exacerbating BG infarction and HT risk post-thrombectomy. As one of several predictors, A1 segment morphology on preprocedural CTA may help stratify patients at risk for larger BG infarcts and haemorrhagic complications.

ObjectiveTo develop and validate an interpretable machine learning (ML) model integrating computed tomography angiography (CTA)-derived radiomics features of carotid plaque and perivascular adipose tissue (PVAT) for predicting ipsilateral stroke recurrence in patients with carotid atherosclerosis.MethodsIn this retrospective study, patients with unilateral carotid atherosclerosis who underwent head and neck CTA between May 2016 and March 2024 were included and followed for recurrent ischemic stroke detected by follow-up MRI. Radiomics features of carotid plaque and PVAT were automatically extracted using a deep learning-based segmentation model and then gathered to constructed a ML model to predict stroke risk. A conventional clinical model based on carotid stenosis degree and clinical factors was also developed. Additionally, a combined model incorporating both radiomics and clinical factors was constructed. The optimal predictive model was chosen among five ML algorithms based on the area under receiver operating characteristics curve (AUC). Model performance was validated through repeated 10-fold cross-validation and tested in an independent testing cohort. Model interpretability was examined using Shapley Additive Explanations (SHAP).ResultsOf 162 patients (mean age, 69.28 years ± 8.30 [SD]; 136 [83.95%] male) were included, of whom 63 (38.9%) experienced ipsilateral stroke recurrence during follow-up (median, 1 years). The combined model using support vector machines achieved the highest AUC of 0.87(95% CI: 0.74–0.97) in the testing set, higher than the radiomics-only model (AUC, 0.80; 0.63–0.94) and the clinical model (AUC, 0.77; 0.58–0.91; all p < 0.05). SHAP analysis demonstrated that plaque texture features contributed strongly to recurrence risk, while PVAT-derived features provided complementary inflammatory information.ConclusionAn ML model including both radiomics features of carotid plaque and PVAT can improve performance in predicting ipsilateral stroke recurrence risk than clinical factors alone, offering a promising tool for stroke prevent in clinical practice.

BACKGROUND:Rapid local ischemic postconditioning may protect the brain after acute ischemic stroke, but its safety and optimal dosing in successfully reperfused patients after mechanical thrombectomy remain undefined. METHODS:This investigator-initiated, prospective, adaptive, multicenter phase I single-arm dose-finding trial employed a Bayesian Optimal Interval (Bayesian Optimal Interval Phase I/II) design. Patients with anterior circulation large-vessel occlusion and modified Thrombolysis in Cerebral Infarction 2b/3 reperfusion were enrolled without randomization. Within 5 minutes of recanalization, rapid local ischemic postconditioning was delivered via a balloon-guiding catheter positioned at the ipsilateral C1-intracranial internal carotid artery, alternating inflation/deflation to interrupt antegrade flow. Six dose levels were prespecified by inflation/deflation durations and cycles: 15/15s ×5; 1/1, 2/2, 3/3, 4/4, and 5/5 minutes ×4. The dose-limiting toxicity (including malignant infarction, procedure-related complications requiring treatment, or other procedure-attributable serious adverse events) threshold was 15%. The efficacy target (absence of infarct growth >10 mL at 72 hours) was 60%. Doses were eliminated if the posterior probability that toxicity exceeded 15% was ≥0.95 or efficacy <60% was ≥0.90. The dose with the highest utility meeting these criteria was selected. RESULTS:Five cohorts (n=25, 5 each) were enrolled. Four cohorts received 2/2 minutes×4 (n=20): 14 met the efficacy end point (posterior probability true efficacy <60%, ≈0.15), and 1 had a dose-limiting toxicity due to large infarction growth (probability true toxicity >15%, ≈0.16). One cohort received 3/3 minutes×4 (n=5): 3 met the efficacy end point (probability true efficacy <60%, ≈0.31) and 2 had dose-limiting toxicities due to large infarction growth (probability true toxicity >15%, ≈0.95). This triggered the predefined safety rule, preventing further testing at 3/3-minute and higher doses. Bayesian Optimal Interval Phase I/II selected 2/2 minutes×4 as the optimal regimen with a favorable efficacy-toxicity profile. CONCLUSIONS:Rapid local ischemic postconditioning initiated immediately after thrombectomy was feasible. The 2/2 minutes×4 regimen met prespecified safety and efficacy thresholds and warrants evaluation in a larger, definitive trial. REGISTRATION:URL: https://www.clinicaltrials.gov; Unique identifier: NCT06526429.

BACKGROUND:The benefits of endovascular thrombectomy (EVT) over medical treatment for medium vessel occlusion (MeVO) remain uncertain. Understanding how vascular reperfusion leads to favorable outcomes is crucial. This study examines whether penumbra salvage and infarct volume reduction quantify EVT benefits in MeVO patients and assesses their impact on clinical improvement post-reperfusion. METHODS:We conducted a multicenter, observational study analyzing MeVO patients who underwent thrombectomy and received multimodal CT imaging from January 2020 to June 2024. EVT efficacy was evaluated by measuring follow-up infarct volume (FIV) on CT scans 24-48 h post-procedure and calculating the penumbra salvage index (PSI). PSI is the ratio of salvaged tissue volume (difference between baseline delay time (DT) >3 s volume and FIV) to baseline DT >3 s volume. Mediation analysis assessed PSI and FIV's contributions to successful reperfusion and functional outcomes. RESULTS:Of 338 patients, 241 (72%) achieved successful reperfusion. Median FIV was 21 mL (IQR 12-32 mL), and median PSI was 0.68 (IQR 0.50-0.82). Successful reperfusion was linked to a 0.10 increase in PSI (95% CI: 0.05-0.15, p < 0.001) and a 4.36 mL reduction in FIV (95% CI: 1.31-7.20, p = 0.005). Successful reperfusion predicted improved outcomes, with an adjusted odds ratio (aOR) of 1.92 (95% CI: 1.08-3.47, p = 0.020) for excellent outcomes (modified Rankin Scale (mRS) score 0-1) and an aOR of 1.70 (95% CI: 1.01-2.89, p = 0.024) for functional independence (mRS score 0-2). PSI and FIV accounted for 44% and 16%, respectively, of the effect of reperfusion on excellent outcomes. CONCLUSIONS:In acute MeVO patients, penumbra salvage significantly mediates the beneficial relationship between reperfusion and excellent clinical outcomes, more so than infarct volume reduction.

Objective:To determine whether the neutrophil-to-lymphocyte ratio-fibrinogen-to-albumin ratio (NLR-FAR) Index predicts long-term prognosis in acute ischemic stroke patients undergoing endovascular thrombectomy (EVT). Introduction:Systemic inflammatory imbalance contributes to ischemic brain injury, but the combined effect of NLR and FAR on EVT outcomes has remained unclear. Methods:We retrospectively analyzed patients treated with EVT. A composite inflammatory-coagulation index, designated as the NLR-FAR Index, was defined as the product of NLR and FAR. The primary endpoint was 30-day functional outcome defined by the modified Rankin Scale (mRS), with poor outcome as mRS ≥3. Logistic regression and restricted cubic spline analyses were used to assess associations. Results:Of 254 patients, 121 (47.6%) had poor outcomes. Higher NLR, FAR, and especially NLR-FAR Index were significantly associated with poor prognosis. The NLR-FAR Index showed the strongest predictive effect (adjusted OR = 1.910, 95% CI: 1.079-3.384). Restrictive cubic spline analysis shows that when the NLR-FAR index exceeds the threshold of 0.62, the risk of adverse outcomes at 30 days begins to significantly increase. Conclusion:The NLR-FAR Index independently predicts functional outcomes after EVT and outperforms NLR or FAR alone. This accessible biomarker may aid early risk stratification and individualized management in acute ischemic stroke.

An ordered therapeutic sequence in which target engagement precedes site-restricted payload delivery provides a conceptual framework for precision thrombolysis. Guided by this process-level logic, we engineered a multiarmed nanovesicle, termed tPA@CTG, that integrates CREKA-mediated thrombus targeting, thrombin-responsive activation, localized tissue plasminogen activator release, and MRI monitoring. tPA@CTG achieves efficient thrombus targeting under both static and flow conditions, along with thrombin-triggered structural activation and localized tPA release. In a rat carotid artery thrombosis model, tPA@CTG restores near-complete recanalization with a thrombolytic efficiency of 99.5 ± 0.6% and blood flow recovery of 95.1 ± 2.5%, substantially outperforming free tPA. Remarkably, even at half the dose, tPA@CTG remains more effective than full-dose free tPA, highlighting the therapeutic benefit of combining thrombus targeting with thrombin-responsive local release. Transcriptomic analysis reveals modulation of complement and coagulation pathways, indicating active remodeling of the thrombotic microenvironment beyond simple clot dissolution. Biosafety assessments confirm excellent biocompatibility and substantially reduced bleeding risk compared to free tPA. Together, tPA@CTG provides an integrated platform for targeted, thrombin-responsive, and MRI-monitored thrombolysis.

Acute ischemic stroke (AIS) is a leading cause of mortality and long-term disability worldwide. The identification of reliable prognostic determinants and formation of a validated model for AIS is unclear. We retrospectively recruited 210 patients with stroke of anterior circulation large-vessel occlusion who underwent endovascular thrombectomy between March 2021 and March 2024. Participants were aged 18 years or older and had undergone examination and treatment for at least 90 days. We collected baseline demographic characteristics, medical records, and blood biomarkers and tracked the prognosis for 30 days. We used LASSO-logistic regression to identify potential indicators of AIS over a 90 days. After adjusting for age (P = .130), previous stroke or transient ischemic attack (P = .112), admission diastolic pressure (P = .101), glucose (P = .162), and albumin (P = .094), only male (vs female, P = .042), alcohol consumption (P = .013), hypertension (P = .007), trial of acute stroke treatment type "others" versus large artery atherosclerosis, P = .046), leukocytes (P = .013), and neutrophil-to-lymphocyte ratio (P < .001) remained significant predictors of poor clinical endpoints. The prognostic model had a classification accuracy of 77.6%, a sensitivity of 79.3%, a specificity of 73.3%, and a precision of 88.1%. This study identified modifiable risk factors such as alcohol consumption and hypertension, along with inflammatory markers such as leukocyte count and neutrophil-to-lymphocyte ratio, as significant predictors of poor outcomes in patients with AIS undergoing endovascular thrombectomy. These findings could guide clinicians in identifying high-risk patients and in tailoring treatment strategies. Further studies are needed to validate these predictors and to explore their potential roles in therapeutic interventions.

This retrospective single-center study evaluates whether high-resolution magnetic resonance vessel wall imaging (HR-VWI) plaque features can predict in-stent restenosis (ISR) before stent implantation. Consecutive intracranial atherosclerotic disease (ICAD) patients undergoing HR-VWI and endovascular treatment from March 2018 to June 2024 were analyzed. ISR was defined as > 50

Esophageal fistulas (EFs) arising from esophageal cancer, trauma, or iatrogenic injury can lead to severe complications. While covered metal stents can effectively occlude EFs, their long-term implantation may result in migration, in-stent stenosis, and bleeding. Biodegradable covered stents offer temporary support followed by self-degradation to circumvent permanent implantation risks, therefore can act as local biotherapeutic platforms. We have developed a novel biodegradable, biomimetic stent composed of polydioxanone with a hydrogel coating and oriented, TGF-β1-loaded nanofiber membrane. It provides up to 6.92 N of radial support force and maintains integrity for 30 days. Employing microsol oriented electrospinning technology, TGF-β1-loaded nanofibers are applied to the stent's surface, not only occluding the EF but also creating a directional matrix for stem cell migration and tissue repair. Additionally, GelMA laden with autologous BMSCs encapsulates the PLGA nanofibers, with BMSCs showing oriented growth and differentiation into myoblasts upon TGF-β1 stimulation. In a rabbit EF model, this biomimetic esophageal stent significantly lowered fistula incidence. Esophagography and histopathological assessments revealed complete EF occlusion in 78 % of subjects. These findings suggest that our biomimetic esophageal stent not only supports and seals the esophagus but also promotes self-repair and tissue regeneration, advancing the application of biodegradable stents for EF treatment.

Purpose: To investigate the effectiveness of prophylactic embolization of the internal iliac artery (IIA) or superior gluteal artery (SGA) before open reduction and internal fixation (ORIF) in reducing intraoperative blood loss (IBL) in hemodynamically stable patients with complex acetabular fractures. Materials and Methods: A total of 136 patients with complex acetabular fractures were retrospectively included and divided into the prophylactic transcatheter arterial embolization (PTAE) group and non-PTAE group, depending on whether ipsilateral IIA or SGA was embolized using coils within 3 days before ORIF. Demographic characteristics, injury severity score, fracture classification, and intraoperative and postoperative data were compared between the 2 groups. Propensity score matching (PSM) was also performed to balance the baseline characteristics of the patients. The determinants of IBL were investigated using multivariate linear regression analysis. Results: The PTAE and non-PTAE groups consisted of 64 and 72 patients, respectively. PSM yielded 43 matched pairs. After matching, IBL in the PTAE group was less than that in the non-PTAE group (median [interquartile range], 800 [400-1,200] mL vs 1,300 [1,000-1,600] mL; P < .001). Furthermore, the PTAE group showed a shorter ORIF duration and lower intraoperative and 24-hour postoperative blood transfusion requirements (all P < .05). Multivariate analysis revealed that PTAE and the duration of surgery were associated with IBL (PTAE: beta = -0.407; P < .001; duration of surgery: beta = 0.237; P = .021). Conclusions: Prophylactic IIA or SGA embolization may be beneficial in reducing IBL during ORIF in hemodynamically stable patients with complex acetabular fractures.

Importance:Tirofiban is a nonpeptide antagonist of the glycoprotein IIb/IIIa receptor that inhibits platelet aggregation selectively. Despite widespread use in acute ischemic stroke in conjunction with endovascular treatment, the role of tirofiban is uncertain. Objective:To assess whether intravenous tirofiban initiated before endovascular thrombectomy improves thrombectomy outcomes by achieving first-pass recanalization without intracranial hemorrhagic risk. Design, Setting, and Participants:This was a multicenter, prospective, open-label, blinded, end point phase 2 randomized clinical trial that enrolled patients from 7 Chinese hospital stroke centers between April 30, 2021, and July 16, 2023. Eligible patients were aged 18 to 85 years with large vessel occlusion (internal carotid artery or M1 or M2 segment of middle cerebral artery) and were considered for endovascular thrombectomy within 24 hours of ischemic stroke onset or last known well time. Patients with a history of atrial fibrillation or treated with intravenous thrombolysis were excluded. Intervention:Patients were randomly assigned (1:1) to intravenous tirofiban (10 μg/kg bolus plus 0.1 μg/kg per minute infusion for 24 hours) or standard care before endovascular thrombectomy using a web-based, computer-generated randomization procedure. Main Outcomes and Measures:The primary outcome was the proportion of patients achieving first-pass recanalization without symptomatic intracranial hemorrhage. First-pass recanalization was assessed by reviewers blinded to treatment allocation and predefined as successful recanalization of a targeted vessel after a single pass of thrombectomy. The primary outcome was analyzed by modified Poisson regression with robust error estimation, adjusting for time from onset or last known well time to randomization and vessel occlusion site. Results:Among 200 patients randomized (median age, 66 years [IQR, 58-72 years]; 146 male [73%]), 102 were allocated to receive intravenous tirofiban, and 98 were allocated to receive standard care before endovascular thrombectomy. In the intention-to-treat analysis, 64 of 99 patients receiving tirofiban (65%) and 46 of 95 control patients (48%) achieved the primary outcome of first-pass recanalization without symptomatic intracranial hemorrhage (adjusted risk ratio, 1.34 [95% CI, 1.04-1.73]; P = .03). Incidence of symptomatic intracranial hemorrhage was 0% (0 of 101 patients) in the tirofiban group vs 6% (6 of 98 patients) in the control group (unadjusted risk difference, -0.06 [95% CI, -0.11 to -0.01]). Conclusions and Relevance:In this randomized clinical trial of patients who had acute ischemic stroke with no history of atrial fibrillation and no prior intravenous thrombolysis, intravenous tirofiban administered before endovascular thrombectomy increased the likelihood of first-pass recanalization without symptomatic intracranial hemorrhage. These findings suggest that neurointerventionalists may consider this pre-procedure antiplatelet treatment to facilitate endovascular thrombectomy. Trial Registration:ClinicalTrials.gov Identifier: NCT04851457.

OBJECTIVE:The results of the TRACE-III trial demonstrated that tenecteplase (TNK) might be comparable to TNK combined with mechanical thrombectomy (MT) for large vessel occlusion (LVO) stroke within 4.5 to 24 h of onset, as tested in the TIMELESS trial. We aimed to evaluate the safety and effectiveness of MT alone in TRACE-III-eligible patients in routine clinical settings, comparing the results of both trials. METHODS:This retrospective multicenter cohort study involved consecutive patients who underwent MT alone at three stroke centers between March 2021 and July 2024. Only those meeting the inclusion and exclusion criteria of TRACE-III were included. Safety, clinical, and imaging outcomes were compared with the TRACE-III and TIMELESS trial data. RESULTS:336 TRACE-III-eligible patients were enrolled in our cohort. MT alone had a higher percentage of patients with a modified Rankin scale (mRS) score of 0-2 at 90 days (58.9%) compared to the TNK group in TRACE-III, TNK and placebo groups in TIMELESS (43.6%, 46.0%, and 42.4%, respectively; all p < 0.01). Additionally, MT achieved a higher rate of early-stage reperfusion (86.0%) compared to the TRACE-III TNK, TIMELESS TNK, and TIMELESS placebo groups (27.9%, 76.7%, and 63.9%; all p < 0.05). The mRS 0-1 at 90 days, incidence of symptomatic intracerebral hemorrhage, and mortality at 90 days were 36.0%, 5.4%, and 14.9%, respectively, similar to those in the three groups (all p > 0.05). INTERPRETATION:In clinical practice, MT can achieve higher rate of early-stage reperfusion and tended to yield better functional outcomes than intravenous TNK, with similar safety, in TRACE-III-eligible patients.

Tirofiban is a nonpeptide antagonist of the glycoprotein IIb/IIIa receptor that inhibits platelet aggregation selectively. Despite widespread use in acute ischemic stroke in conjunction with endovascular treatment, the role of tirofiban is uncertain. To assess whether intravenous tirofiban initiated before endovascular thrombectomy improves thrombectomy outcomes by achieving first-pass recanalization without intracranial hemorrhagic risk. This was a multicenter, prospective, open-label, blinded, end point phase 2 randomized clinical trial that enrolled patients from 7 Chinese hospital stroke centers between April 30, 2021, and July 16, 2023. Eligible patients were aged 18 to 85 years with large vessel occlusion (internal carotid artery or M1 or M2 segment of middle cerebral artery) and were considered for endovascular thrombectomy within 24 hours of ischemic stroke onset or last known well time. Patients with a history of atrial fibrillation or treated with intravenous thrombolysis were excluded. Patients were randomly assigned (1:1) to intravenous tirofiban (10 μg/kg bolus plus 0.1 μg/kg per minute infusion for 24 hours) or standard care before endovascular thrombectomy using a web-based, computer-generated randomization procedure. The primary outcome was the proportion of patients achieving first-pass recanalization without symptomatic intracranial hemorrhage. First-pass recanalization was assessed by reviewers blinded to treatment allocation and predefined as successful recanalization of a targeted vessel after a single pass of thrombectomy. The primary outcome was analyzed by modified Poisson regression with robust error estimation, adjusting for time from onset or last known well time to randomization and vessel occlusion site. Among 200 patients randomized (median age, 66 years [IQR, 58-72 years]; 146 male [73%]), 102 were allocated to receive intravenous tirofiban, and 98 were allocated to receive standard care before endovascular thrombectomy. In the intention-to-treat analysis, 64 of 99 patients receiving tirofiban (65%) and 46 of 95 control patients (48%) achieved the primary outcome of first-pass recanalization without symptomatic intracranial hemorrhage (adjusted risk ratio, 1.34 [95% CI, 1.04-1.73]; P = .03). Incidence of symptomatic intracranial hemorrhage was 0% (0 of 101 patients) in the tirofiban group vs 6% (6 of 98 patients) in the control group (unadjusted risk difference, −0.06 [95% CI, −0.11 to −0.01]). In this randomized clinical trial of patients who had acute ischemic stroke with no history of atrial fibrillation and no prior intravenous thrombolysis, intravenous tirofiban administered before endovascular thrombectomy increased the likelihood of first-pass recanalization without symptomatic intracranial hemorrhage. These findings suggest that neurointerventionalists may consider this pre-procedure antiplatelet treatment to facilitate endovascular thrombectomy. ClinicalTrials.gov Identifier: NCT04851457

The purpose of this study is to investigate whether patients with symptomatic severe intracranial atherosclerotic stenosis (ICAS) and downstream perfusion deficit could benefit from adding percutaneous transluminal angioplasty and stenting (PTAS) to medical therapy. We retrospectively reviewed patients with symptomatic severe ICAS and an Alberta Stroke Program Early CT score of < 6 on mean transit time map who received either medical plus PTAS therapy (PTAS group) or medical therapy alone (medical group) between January 2016 and December 2019 at a single center. After 1:1 propensity score matching, we analyzed the primary outcome—cumulative event rate (defined as ischemic stroke in the qualifying artery)—along with four secondary outcomes (any intracranial hemorrhage within 30 days; disabling stroke or death; any stroke, transient ischemic attack, or cardiovascular events; and death by the end of follow-up). A total of 145 patients (79 in the PTAS group, 66 in the medical group) were included. After PSM, during a median follow-up of 43 months, the cumulative event rate was significantly lower in the PTAS group (11.6