Background Intravenous thrombolysis followed by endovascular thrombectomy (EVT) is a first‐line recommended strategy for thrombolysis‐eligible patients with stroke due to acute large‐vessel occlusion. Tirofiban, one of the most used glycoprotein IIb/IIIa receptor inhibitors, has been increasingly advocated to counteract different stages of thrombosis mediated by activated platelets. It is unclear whether tirofiban could be used as an alternative to thrombolysis as adjuvant medicine for EVT. This trial aims to assess whether intravenous tirofiban plus EVT is noninferior to intravenous thrombolysis bridging with EVT in patients with acute ischemic stroke due to large‐vessel occlusion who are eligible for thrombolysis. Methods ADJUVANT (Intravenous Tirofiban Versus Thrombolysis Before Endovascular Stroke Thrombectomy) is an investigator‐initiated, multicenter, randomized, open‐label, noninferiority trial with blinded end point assessment conducted at 42 thrombectomy‐capable centers in China. This trial will randomize 976 thrombolysis‐eligible stroke patients with confirmed occlusion of the internal carotid artery, M1/M2 segments of the middle cerebral artery, or basilar artery in a 2:1 ratio to receive intravenous tirofiban plus EVT or intravenous thrombolysis bridging with EVT. Results The primary efficacy outcome is functional independence, defined as a score of 0 to 2 on the modified Rankin scale, at 90 days. Safety outcomes are symptomatic intracranial hemorrhage within 48 hours and death within 90 days. Conclusions ADJUVANT will provide unique information about the efficacy and safety of adjuvant intravenous tirofiban before EVT in thrombolysis‐eligible patients with stroke due to acute large‐vessel occlusion. Registration URL: https://clinicaltrials.gov. Unique Identifier: NCT05728333.

Importance:Whether intravenous tenecteplase prior to endovascular treatment (EVT) for ischemic stroke reduces disability in the late time window is unclear. Objective:To investigate the adverse events and efficacy of tenecteplase prior to EVT in patients 4.5 to 24 hours after ischemic stroke onset due to proximal middle cerebral artery (MCA) occlusion. Design, Setting, and Participants:Multicenter, phase 3, randomized, open-label, blinded end point, superiority trial conducted at 40 centers in China. Adult (≥18 years) patients with acute ischemic stroke 4.5 to 24 hours after last known to be well due to MCA-M1 or proximal M2 occlusion with salvageable brain tissue (ischemic core volume <70 mL, mismatch ratio ≥1.8, and mismatch volume ≥15 mL) identified on computed tomography-perfusion or magnetic resonance-perfusion-diffusion imaging were enrolled from January 25, 2024, through July 21, 2025, and followed up for 90 days. Final follow-up occurred on October 14, 2025. Interventions:Eligible patients were randomly assigned in a 1:1 ratio to receive intravenous tenecteplase (0.25 mg/kg; maximum dose, 25 mg) before EVT (n = 199) or EVT alone (n = 192). Main Outcomes and Measures:The primary outcome was functional independence, defined as a score of 0 to 2 on the modified Rankin Scale (range, 0-6, with higher scores indicating greater disability) at 90 days. Adverse events outcomes included symptomatic intracranial hemorrhage and death. Results:All of the 391 patients enrolled (median age, 68 years [IQR, 59-75]; 155 [39.6%] females) completed the trial. Functional independence at 90 days occurred in 88 patients (44.2%) in the tenecteplase before EVT group and 83 patients (43.2%) in the EVT alone group (adjusted relative rate, 1.01 [95% CI, 0.83-1.24]; P = .89; risk difference, 0.99% [95% CI, -8.84% to 10.83%]). Mortality within 90 days was 12.7% (25/197) in the tenecteplase before EVT group and 14.2% (27/190) in the EVT alone group. Symptomatic intracranial hemorrhage within 36 hours was 5.1% (10/197) and 2.6% (5/190), respectively. Conclusions and Relevance:In patients presenting to EVT-capable centers 4.5 to 24 hours after stroke onset with proximal MCA occlusion, intravenous tenecteplase before EVT did not improve clinical outcomes vs EVT alone. Trial Registration:ClinicalTrials.gov Identifier: NCT06221371.

Prolonged microvascular cerebral circulation time (mCCT) after endovascular thrombectomy (EVT) may reflect microvascular cerebral circulation impairment. The associations among mCCT, the development of malignant brain edema (MBE), and the functional outcome after successful recanalization (mTICI ≥ 2b) in large vessel occlusion stroke (LVOS) remain unclear. We performed a retrospective analysis of 358 consecutive anterior circulation LVOS patients who achieved successful EVT. mCCT was measured intraprocedurally on DSA using syngo iFlow (Siemens Healthineers). MBE was assessed on follow-up imaging within 72 h. Functional outcome was modified Rankin Scale (mRS) score ≤ 2 at 90 days. Associations were tested using logistic regression and mediation analysis. MBE occurred in 42 patients (11.7

Background Acute ischaemic stroke with large vessel occlusion (AIS-LVO) is a significant subtype of ischaemic stroke which always requires endovascular treatment (EVT). Although EVT has a high recanalisation rate, nearly 40% of AIS-LVO patients experience futile recanalisation. Studying the occlusion microenvironment (OME), comprising thrombus and intracranial arterial blood, is essential to understand the localised markers of stroke and futile recanalisation. Design Cerebral Large Vessel Occlusion Stroke Multiomics Biosample Cohort (CLOMB) is a multicentre, multiomics ambispective cohort study conducted in five stroke centres in China. A total of 500 patients with AIS-LVO who undergo EVT will be included in the study. After enrolment, each participant undergoes a comprehensive clinical assessment including questionnaires, physical examinations, laboratory tests and imaging. We collect matched peripheral (arterial and venous) blood, thrombus and innovatively intracranial blood by microcatheter or aspiration catheter when first passing through the occlusion site. All biosamples are collected for subsequent multi-omics analysis (metabolomic, proteomic and transcriptomic). A 3-month and 1-year follow-up will be performed to collect the outcome data. Methods Systemic and local samples undergo untargeted metabolomic and proteomic analysis. For a representative subset (10%–15%), single-cell RNA sequencing (Switching Mechanism at 5′ End of the RNA Transcript) is performed. Targeted omics will be selectively implemented to further clarify their contents. To minimise selection bias, patients without retrieved thrombi remain in the cohort for clinical analysis. Conclusion CLOMB establishes a standardised protocol for OME biosampling and multiomics profiling. It aims to explore candidate biological pathways and provide a foundation for developing hypothesis-generating models for improving stroke outcomes, facilitating AIS-LVO diagnosis and classification. Trial registration number NCT06963489 .

BACKGROUND: Carotid artery stenting (CAS) is conventionally performed via transfemoral access (TFA), which requires prolonged postoperative immobilization and is associated with access-site complications. Transradial access (TRA) has emerged as an alternative to TFA for suitable vessel caliber and improved patient comfort. However, high-quality evidence directly comparing TRA and TFA for CAS in patients with carotid artery stenosis is still lacking. This trial aims to determine whether TRA is noninferior to TFA in patients treated with CAS due to carotid artery stenosis. METHODS: The RACE-CAS (Radial Versus Femoral Access for Carotid Artery Stenting in Patients With Carotid-Artery Stenosis) is a prospective, randomized, open-label, blinded-end point, multicenter trial. Up to 3000 patients with carotid artery stenosis will be randomly assigned in a 1:1 ratio to receive CAS treatment via either TRA or TFA across 70 centers in China. RESULTS: The primary end point is the incidence of death, new-onset stroke, myocardial infarction, or severe hemorrhage events within 30 days post-procedure, analyzed in the full analysis set using risk differences with 2-sided 95% CIs for noninferiority testing. Key secondary outcomes include the successful rate of CAS and angiography, patient comfort, and each individual component of the primary end point within 48 hours or 30 days post-procedure. Safety outcomes include all adverse events and severe adverse events. The RACE-CAS trial enrolled its first patient on July 3, 2022, and recruitment is ongoing. At the time of manuscript submission, the sample size required for the first planned interim analysis had been completed. CONCLUSIONS: The RACE-CAS trial will provide definitive, high-level evidence on the comparative efficacy and safety of TRA versus TFA for carotid artery stenting in patients with carotid artery stenosis, with the goal of guiding clinical practice. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT05416853.

BackgroundFunctional outcomes in patients with acute ischemic stroke (AIS) with large vessel occlusion (LVO) undergoing endovascular treatment (EVT) with successful reperfusion (expanded Thrombolysis In Cerebral Infarction (eTICI) 2b-3) complicated by symptomatic intracranial hemorrhage (sICH) were compared with patients with unsuccessful reperfusion (eTICI 0–2a) without sICH.MethodsPatients enrolled in this post hoc analysis were from two Chinese multicenter, randomized controlled trials: the DEVT and the RESCUE BT registries. Patients with AIS who underwent EVT were categorized into two groups according to the state of reperfusion: eTICI 2b-3 with sICH and eTICI 0–2a without sICH. The primary outcome was the modified Rankin Scale (mRS) scores at 90 days. The safety outcomes included early neurological deterioration and 90-day mortality.Results161 patients were included in this cohort analysis, among whom 71 experienced eTICI 2b-3 with sICH, and 90 had eTICI 0–2a without sICH. After adjusting for potential confounding factors, patients in the eTICI 2b-3 with sICH group had worse mRS at 90 days compared with those in the eTICI 0–2a without sICH group in the adjusted analysis (median 6 (IQR 4–6) vs median 4 (IQR 3–6); adjusted common OR 0.39, 95% CI 0.17 to 0.66). There were also higher rates of very poor outcome (mRS 5–6, 70.4% vs 42.2%; OR 2.90, 95% CI 1.38 to 6.11), mortality (66.2% vs 32.2%; OR 0.48, 95% CI 0.30 to 0.79), and early neurological deterioration (81.7% vs 40.0%; OR 0.16, 95% CI 0.07 to 0.35) in the eTICI 2b-3 with sICH group versus the eTICI 0–2a without sICH group.ConclusionsSuccessful reperfusion complicated by sICH after EVT was associated with worse outcomes and higher mortality than unsuccessful reperfusion without sICH. These findings emphasize the need for additional efforts in assessing and managing post-EVT-associated sICH to optimize treatment strategies and improve outcomes.Trial registration numberDirect Endovascular Treatment for Large Vessel Occlusion Stroke;https://www.chictr.org.cn; ChiCTR-IOR-17013568.Intravenous Tirofiban Before Endovascular Thrombectomy for Acute Ischemic Stroke;https://www.chictr.org.cn; ChiCTR-INR-17014167.

BACKGROUND:To develop and validate a novel scoring system for predicting successful endovascular recanalization in patients with non-acute symptomatic carotid artery occlusion (NASCAO). METHODS:We analyzed consecutive patients from a nationwide prospective registry who underwent endovascular treatment for NASCAO. Patients were divided into derivation and validation cohorts based on the enrolling centers. Technical success was defined as Thrombolysis in Cerebral Infarction score 3 and <50% residual stenosis. A NASCAO score was developed using stepwise logistic regression based on the Bayesian information criterion. The performance of the score was examined in terms of discrimination and calibration. RESULTS:Among the 511 included patients, successful recanalization was achieved in 61.3% (192/313) of the derivation cohort and 54.5% (108/198) of the validation cohort. Four independent predictors of technical success were used to construct a 6-point NASCAO score: ischemic stroke (1 point), time from last event to intervention within 1-30 days (1 point), tapered proximal stump (1 point), and number of occluded segments (1-2: 3 points, 3-4: 2 points, 5-7: 0 points). The area under the receiver operating curve (AUC) of the NASCAO score was 0.780 (95% CI 0.729 to 0.832) in the derivation cohort and 0.758 (95% CI 0.692 to 0.824) in the validation cohort. Patients with a score of 4-6 had 6.3 times higher odds of successful recanalization than those with a score of 0-3 (95% CI 4.29 to 9.38, P<0.001). CONCLUSIONS:The NASCAO score is a reliable tool for predicting successful endovascular recanalization in patients with NASCAO.

BACKGROUND:Malignant cerebral edema (MCE) following basilar artery occlusion (BAO) thrombectomy is a critical, yet understudied, complication. OBJECTIVE:To investigate the incidence, predictors, and clinical impact of MCE in patients with BAO after endovascular thrombectomy (EVT). METHODS:In this retrospective analysis of the national multicenter PERSIST Registry (2422 patients with BAO treated with EVT recruited from 65 Chinese centers, 2015-2022), MCE was defined as Jauss score ≥4 on follow-up imaging. Multivariable logistic regression identified predictors of MCE and its association with 90-day outcomes. A favorable outcome was defined as achieving a modified Rankin Scale score of 0-3 at 90 days. RESULTS:A total of 1883 patients who met the eligibility requirements were included. MCE occurred in 39.6% (746/1883) of patients. Independent predictors included admission systolic blood pressure ≥160 mm Hg (aOR=1.26, 95% CI 1.02 to 1.54), prolonged procedure time (aOR=1.01, 95% CI 1.01 to 1.01), BATMAN score ≥7 (aOR=0.68, 95% CI 0.55 to 0.84), and vertebral V4 occlusion (vs proximal BA: aOR=0.68, 95% CI 0.52 to 0.89). Successful reperfusion reduced MCE risk (aOR=0.57, 95% CI 0.42 to 0.75). Diabetes mellitus exhibited an inverse association (aOR=0.78, 95% CI 0.61 to 0.99). MCE predicted lower odds of favorable outcome (aOR=2.41, 95% CI 1.94 to 3.01; P<0.001) and higher mortality (aOR=1.85, 95% CI 1.51 to 2.27; P<0.001) at 90 days. CONCLUSIONS:MCE complicates 39.6% of patients with BAO after EVT and portends catastrophic outcomes despite successful recanalization. Shortening the procedure time, increasing the likelihood of first-pass success, and optimal admission blood pressure management might be targets to decrease MCE for patients with BAO undergoing EVT.

Identifying new imaging markers may refine risk stratification and guide clinical management for endovascular thrombectomy (EVT). We observed a phenomenon that on a subset of patients’ post-procedural TOF-MRA, the successfully recanalized vessels demonstrated marked vasodilatation in the middle cerebral artery (MCA) territory. The association between global vasodilatation in the MCA territory and clinical outcomes has not yet been investigated. We aimed to characterize the incidence and radiological characteristics of global vasodilatation in the MCA territory, and to investigate its associated risk factors and prognostic implications. Retrospective analysis of 494 consecutive anterior circulation large vessel occlusion stroke (LVOS) patients with successful EVT. In patients with recanalization, global vasodilatation in the MCA territory can be defined if either of the following criteria is met: displayable distal branching number exceeded the contralateral side by > 50

OBJECTIVES:Early prognosis prediction is challenging after endovascular treatment (EVT) for acute posterior circulation ischemic stroke (PCIS). We evaluated the frequency and prognostic impact of competitive blood flow from the contralateral vertebral artery (CBF-cVA), observed post-recanalization. MATERIALS AND METHODS:We retrospectively screened patients with acute PCIS who underwent EVT with successful recanalization. CBF-cVA was defined as the rapid clearing of the basilar artery and posterior cerebral arteries previously opacified by antegrade reperfusion. The good functional outcomes are defined as a score of 0-3 on the modified Rankin scale (mRS) at 90 days. Logistic regression was used to investigate the association of CBF-cVA and good functional outcomes at 90 days. RESULTS:A total of 259 patients (median age, 64 years, 74.9% male) were included. CBF-cVA was observable in 44.0% of patients and more frequently in patients with good status of the non-operated vertebral artery which was categorized as good or bad based on the presence of hypoplasia, occlusion, slow flow, or lack of opacification (14.9% vs. 62.1%; p < 0.001) and better collateral score (median 6 vs. 4; p < 0.001). CBF-cVA was associated with good functional outcomes (adjusted OR [95% CI], 3.410 [1.636, 7.105]; p = 0.001), but not with 90-day mortality and symptomatic intracranial hemorrhage (both p > 0.05). CONCLUSION:CBF-cVA was associated with better functional outcomes in patients with PCIS who underwent EVT with successful recanalization. The presence of CBF-cVA was related to the status of the non-operated vertebral artery and better collateral flow. KEY POINTS:Question The prediction of early prognosis continues to pose a significant challenge in the clinical management of patients undergoing thrombectomy for posterior circulation strokes. Findings The presence of competitive blood flow from the contralateral vertebral artery (CBF-cVA) was significantly associated with more favorable 90-day functional outcomes. Clinical relevance CBF-cVA provided a practical, binary imaging assessment after endovascular treatment in patients with acute posterior circulation ischemic stroke. This straightforward tool improved the prediction of favorable clinical outcomes, aiding in guiding treatment strategies after recanalization.

BACKGROUND AND OBJECTIVES:The impact of ischemic extent on the efficacy and safety of intravenous thrombolysis before thrombectomy remains uncertain. The aim of this study was to evaluate whether the baseline ischemic extent, measured by the Alberta Stroke Program Early Computed Tomography Score (ASPECTS), modifies outcomes of intravenous tenecteplase administered before endovascular thrombectomy. METHODS:This was a post hoc analysis of the BRIDGE-TNK (thrombectomy with vs without rhTNK-tPA in stroke) trial, conducted across China from May 2022 to September 2024. We compared the efficacy and safety of intravenous tenecteplase plus thrombectomy vs thrombectomy alone in acute large-vessel occlusion stroke patients within 4.5 hours of last known well, stratified by baseline ASPECTS (<8 vs 8-10). The outcomes included 90-day functional independence (modified Rankin Scale score of 0-2), 48-hour symptomatic intracranial hemorrhage (sICH), and 90-day mortality. Regression models incorporating a treatment-by-ASPECTS interaction term were used for analysis. RESULTS:Among 550 patients, 241 (43.8%) had ASPECTS <8 (median [interquartile range, IQR] age, 69 [61-77] years; 56.4% male) and 309 had ASPECTS 8-10 (median [IQR] age, 70 [61-77] years; 59.5% male). The rate of functional independence was significantly higher in the tenecteplase plus thrombectomy group than in the thrombectomy-alone group in the ASPECTS <8 subgroup (adjusted risk ratio [aRR], 1.67; 95% CI 1.18-2.35), but not in the ASPECTS 8-10 subgroup (aRR, 0.99; 95% CI 0.84-1.17; pinteraction = 0.007). Rates of sICH did not differ significantly between treatment groups in either ASPECTS subgroups (ASPECTS <8: 10.0% vs 11.2%; ASPECTS 8-10: 7.5% vs 2.8%; pinteraction = 0.11). Ninety-day mortality was comparable between treatment groups in the ASPECTS <8 subgroup, but numerically higher with tenecteplase plus thrombectomy in the ASPECTS 8-10 subgroup (aRR = 1.89, 95% CI 0.99-3.61, pinteraction = 0.04). DISCUSSION:In this exploratory post hoc analysis, a signal of benefit was observed in patients with ASPECTS <8 who received intravenous tenecteplase before thrombectomy, whereas no functional improvement and possible safety concerns were seen in those with ASPECTS 8-10. Prospective confirmation in randomized trials is required before practice change. TRIAL REGISTRATION INFORMATION:ClinicalTrials.gov; Unique identifier: NCT04733742.

Background Current clinical decision tools for assessing the risk of symptomatic intracranial hemorrhage (sICH) in patients with vertebrobasilar artery occlusion (VBAO) who received endovascular treatment (EVT) have limited performance. This study develops and validates a clinical risk score to precisely estimate the risk of sICH in VBAO patients.Methods The derivation cohort recruited patients with VBAO who received EVT from the Posterior Circulation IschemIc Stroke Registry in China. Based on the posterior circulation-Alberta Stroke Program Early CT Score (pc-ASPECTS) evaluation method, the cohort was further divided into non-contrast CT (NCCT) and diffusion weighted imaging (DWI) cohorts to construct predictive models. sICH was diagnosed according to the Heidelberg Bleeding Classification within 48 hours of EVT. Clinical signature was constructed in the derivation cohort using machine learning and was validated in two additional cohorts from Asia and Europe.Results We enrolled 1843 patients who underwent EVT and had complete data. pc-ASPECTS of 1710 patients was evaluated on NCCT and 699 patients on DWI. In the NCCT cohort, 1364 individuals made up the training set, of whom 101 (7.4%) developed sICH. In the DWI cohort, the training set consisted of 560 individuals, with 44 (7.9%) experiencing sICH. Predictors of sICH were: glucose, pc-ASPECTS, time from estimated occlusion to groin puncture (EOT), poor collateral circulation, and modified Thrombolysis in Cerebral Infarction (mTICI) score. From these predictors, we derived the weighted poor collateral circulation-EOT-pc-ASPECTS-mTICI-glucose (PEACE) score. The PEACE score showed good discrimination in the training set (area under the curve (AUC)NCCT=0.85; AUCDWI=0.86), internal validation set (AUCNCCT=0.81; AUCDWI=0.82), and two additional external validation set (Asia: AUCNCCT=0.78, AUCDWI=0.80; Europe: AUCNCCT=0.74, AUCDWI=0.78).Conclusion The PEACE score reliably predicted the risk of sICH in VBAO patients who underwent EVT.

RATIONALE AND OBJECTIVES:This study aimed to investigate the impact of different imaging screening paradigms on outcomes in patients with large vessel occlusion (LVO) stroke who underwent endovascular therapy (EVT) in real-world settings. MATERIALS AND METHODS:In this retrospective study, patients were categorised into two groups according to preprocedural imaging: Basic Imaging Group (Noncontrast computed tomography ± computed tomographic angiography) and Advanced Imaging Group (computed tomography perfusion). A favourable outcome was defined as a modified Rankin scale score between 0-2 at 90 days. Multivariable logistic regression was used to assess the impact of imaging paradigms on outcomes and to examine the heterogeneity of this effect across different treatment windows (0-6 vs. 6-24 h). RESULTS:Despite longer workflow times with computed tomography perfusion, no significant differences were found in 90-day mortality (19.86% vs. 15.84%, P=0.143), symptomatic intracranial haemorrhage (6.53% vs. 6.98%, P=0.801), or favourable outcomes (mRS 0-2: 49.75% vs. 48.51%, P=0.728) among the 892 patients included. Multivariate analyses confirmed that imaging modality was not an independent predictor of unfavourable functional outcomes (aOR=0.86; 95% CI 0.62-1.21), mortality (aOR=0.96; 95% CI 0.59-1.55), or haemorrhage transformation (aOR=0.82; 95% CI 0.46-1.47). CONCLUSION:In this real-world study, the imaging modality used for patient selection was not associated with 90-day outcomes after EVT. These findings support the safety and efficacy of a simplified noncontrast computed tomography-based paradigm for selecting anterior circulation LVO stroke patients for thrombectomy across all time windows.

BackgroundThe prognostic relevance of early peripheral immune profiles after successful endovascular thrombectomy (EVT) remains incompletely characterized. We evaluated whether associations between lymphocyte-subset percentages and 90-day functional outcome differed according to early post-EVT white blood cell (WBC) count.Materials and methodsThis retrospective single-center study included acute anterior-circulation large-vessel occlusion who achieved successful reperfusion (mTICI 2b or 3) after EVT between January 2021 and December 2023. Blood samples obtained within 24 hours after EVT were classified as normal WBC (4.0–10.0 ×10^9/L) or elevated WBC (>10.0 ×10^9/L). The primary outcome was unfavorable 90-day functional status (mRS 3–6). Prespecified multivariable logistic models adjusted for age, sex, admission NIHSS, ASPECTS, ICA versus MCA occlusion, collateral status, and mTICI grade. Interaction, nonlinear, and sensitivity analyses were also performed.ResultsA total of 334 patients met the eligibility criteria; after excluding one patient without a valid 90-day mRS assessment, 333 patients were included in the primary outcome analysis, including 205 (61.6%) in the normal-WBC group and 128 (38.4%) in the elevated-WBC group. In the normal-WBC group, lower CD19+ B-cell percentage (adjusted odds ratio [aOR] 0.918, 95% CI 0.864–0.976; P = 0.006) and higher NLR (aOR 1.170, 95% CI 1.043–1.311; P = 0.007) were associated with unfavorable outcome. In the elevated-WBC group, lower CD3+ T-cell percentage (aOR 0.960, 95% CI 0.926–0.995; P = 0.026) and lower CD8+ T-cell percentage (aOR 0.943, 95% CI 0.896–0.992; P = 0.024) were associated with unfavorable outcome. Biomarker-by-WBC interactions were significant for CD19, NLR, CD3, and CD8. Addition of these biomarkers numerically increased AUCs, but paired DeLong comparisons were not statistically significant.ConclusionEarly post-EVT WBC count modified the associations between selected peripheral immune-cell percentages and 90-day functional outcome. These exploratory findings require prospective validation.Trial registrationwww.chictr.org.cn, identifier ChiCTR2300070650.

BACKGROUND AND PURPOSE:In patients with acute large vessel occlusion (LVO) of the MCA and underlying intracranial artery stenosis (ICAS), rescue stenting (RS) has been associated with better angiographic outcomes and higher rates of functional independence compared with mechanical thrombectomy (MT) alone. However, uncertainty exists regarding safety of RS in patients at higher risk for intracranial bleeding. The primary aim of this retrospective multicenter study was to compare safety outcomes between patients with acute ICAS-LVO of the MCA who underwent MT and RS with or without prior intravenous thrombolysis (IVT). Efficacy outcomes were assessed as a secondary aim. MATERIALS AND METHODS:We screened the prospective databases of 26 stroke centers across Europe, the United States, and China for consecutive patients with acute MCA ICAS-LVO who received RS. Patients were divided into 2 groups based on prior administration of IVT: IVT/RS and no-IVT/RS. Propensity score matching (PSM), based on a set of covariates that also included periprocedural antiplatelet therapies, was used to estimate the effect of IVT treatment. Primary safety outcomes were the occurrence of symptomatic intracranial hemorrhage (sICH) and 90-day mortality. RESULTS:After PSM, 52 pairs of patients were available for analysis. No significant differences were observed between the 2 groups regarding rates of sICH (11.5% in IVT/RS group versus 9.6% in no-IVT/RS group; OR = 1.2; 95% CI, 0.4-4.3; P = .75) and 90-day mortality (14.3% in the IVT/RS group versus 11.7% in the no-IVT/RS group; OR = 1.3; 95% CI, 0.4-4.2; P = .71). There were also no significant differences in the occurrence of parenchymal hemorrhage types 1 and 2, successful recanalization rates, and 90-day functional outcome. CONCLUSIONS:The safety of RS in ICAS-LVO is not significantly affected by prior IVT administration. Furthermore, IVT does not result in improved recanalization and clinical outcome. These findings should be interpreted with caution and require validation through future randomized controlled studies.

Rescue stenting (RS) can achieve durable recanalization in cases of acute large vessel occlusion due to underlying intracranial artery stenosis (ICAS), but its clinical effects may be influenced by procedural factors. This study aimed to evaluate whether the severity of stenosis affects the outcomes after RS. In this multicenter retrospective study, patients with acute middle cerebral artery occlusion and underlying ICAS were divided into two groups based on the treatment they received: mechanical thrombectomy (MT) + RS (n = 172) or MT-only (n = 131). Inverse probability of treatment weighting was used to balance baseline characteristics. We systematically evaluated stenosis thresholds from 40

Objectives Acute silent ischemic lesions (ASIL) detected post-carotid artery stenting (CAS) closely related to the plaque characteristics. Optical coherence tomography (OCT), enables accurate assessment of plaque characteristics and microstructure. We aimed to investigate the correlation between OCT-identified plaque characteristics and the occurrence of ASIL following CAS. Methods 107 patients undergoing CAS at the xxxxx Hospital of xxxxx University were included in this study. All participants underwent Diffusion weighted imaging (DWI) before and after CAS, and OCT examination was performed before stent placement. The characteristics of new ischemic lesions and plaque were evaluated at DWI and OCT, respectively. Multivariate logistic regression analysis was performed to identify predictors of new acute ischemic lesions. Results Among 107 patients (96 included; median age 69.5 years, IQR 62–74; 81 men), postoperative ASIL: 64 (66.7%). The DWI+ group had higher proportions of lipid-rich plaques (79.7% vs. 40.6%, p < 0.001), macrophage infiltration (51.6% vs. 12.5%, p < 0.001), plaque rupture (65.6% vs. 25.0%, p < 0.001), and RADS IV plaques (75.0% vs. 31.2%, p < 0.001). Multivariate analysis identified fibrous plaque (aOR 0.024, 95% CI 0.001–0.512; p = 0.017), plaque rupture (aOR 8.191, 95% CI 2.078–32.289; p = 0.003), macrophage infiltration (aOR 6.046, 95% CI 1.480–24.691; p = 0.012), and Plaque-RADS IV plaque (aOR 8.154, 95% CI 2.347–28.329; p < 0.001) as independent predictors of ASIL. Conclusions OCT identifies high-risk plaque characteristics as key predictors of ASIL following CAS. This preoperative assessment effectively stratifies embolization risk, thereby guiding optimized therapeutic planning.

Importance Whether intravenous tenecteplase prior to endovascular treatment (EVT) for ischemic stroke reduces disability in the late time window is unclear. Objective To investigate the adverse events and efficacy of tenecteplase prior to EVT in patients 4.5 to 24 hours after ischemic stroke onset due to proximal middle cerebral artery (MCA) occlusion. Design, Setting, and Participants Multicenter, phase 3, randomized, open-label, blinded end point, superiority trial conducted at 40 centers in China. Adult (>= 18 years) patients with acute ischemic stroke 4.5 to 24 hours after last known to be well due to MCA-M1 or proximal M2 occlusion with salvageable brain tissue (ischemic core volume <70 mL, mismatch ratio >= 1.8, and mismatch volume >= 15 mL) identified on computed tomography-perfusion or magnetic resonance-perfusion-diffusion imaging were enrolled from January 25, 2024, through July 21, 2025, and followed up for 90 days. Final follow-up occurred on October 14, 2025. Interventions Eligible patients were randomly assigned in a 1:1 ratio to receive intravenous tenecteplase (0.25 mg/kg; maximum dose, 25 mg) before EVT (n = 199) or EVT alone (n = 192). Main Outcomes and Measures The primary outcome was functional independence, defined as a score of 0 to 2 on the modified Rankin Scale (range, 0-6, with higher scores indicating greater disability) at 90 days. Adverse events outcomes included symptomatic intracranial hemorrhage and death. Results All of the 391 patients enrolled (median age, 68 years [IQR, 59-75]; 155 [39.6%] females) completed the trial. Functional independence at 90 days occurred in 88 patients (44.2%) in the tenecteplase before EVT group and 83 patients (43.2%) in the EVT alone group (adjusted relative rate, 1.01 [95% CI, 0.83-1.24]; P = .89; risk difference, 0.99% [95% CI, -8.84% to 10.83%]). Mortality within 90 days was 12.7% (25/197) in the tenecteplase before EVT group and 14.2% (27/190) in the EVT alone group. Symptomatic intracranial hemorrhage within 36 hours was 5.1% (10/197) and 2.6% (5/190), respectively. Conclusions and Relevance In patients presenting to EVT-capable centers 4.5 to 24 hours after stroke onset with proximal MCA occlusion, intravenous tenecteplase before EVT did not improve clinical outcomes vs EVT alone.

Background The impact of endovascular thrombectomy‐mediated reperfusion on malignant cerebral edema (MCE) in large‐core infarction remains unclear. We assessed the reperfusion–MCE relationship and MCE’s mediating role in poor outcomes. Methods This retrospective analysis used data from the national MAGIC (Prospective Multicenter Registry on Early Management of Acute Ischemic Stroke) registry (750 patients with large‐core infarction, 38 Chinese centers, 2021–2023). MCE was defined as a midline shift of ≥5 mm on follow‐up imaging within 72 hours after stroke onset. Recanalization was confirmed by computed tomography angiogram or magnetic resonance angiogram during hospitalization in the overall cohorts. Successful reperfusion was defined using the modified Treatment in Cerebral Ischemia classification 2b‐3 in the endovascular thrombectomy arm. Functional outcome was 90‐day modified Rankin scale score. Mediation analysis used reperfusion status as the independent variable and MCE as the mediator. Results Among 698 patients, (306 women [43.8%]; median age, 70 [interquartile range, 61–78] years; median, Alberta Stroke Program Early Computed Tomography] Scores, 4 [interquartile range, 2–5]), successful recanalization (adjusted odds ratio [aOR], 0.68 [95% CI, 0.47–0.99]; P=0.042) and reperfusion (aOR, 0.34 [95% CI, 0.18–0.67]; P=0.002) reduced MCE likelihood. MCE was partially responsible for worse modified Rankin Scale scores in patients without recanalization or reperfusion (MCE changed the logistic regression coefficients by 15.0% and 32.5%, respectively). Recanalization improved functional outcomes partly by mitigating MCE formation (indirect effect β=−0.10, 11.5% mediation proportion, P=0.028) in those with Alberta Stroke Program Early Computed Tomography Scores 3 to 5 but not in those with 0 to 2 (β=−0.26, P=0.140). Conclusions Successful reperfusion attenuates MCE formation and improves clinical outcomes in patients with large‐core infarction.