Background: The optimal anticoagulation strategy for patients with intracerebral hemorrhage (ICH) and atrial fibrillation (AF) remains uncertain. Although direct oral anticoagulants (DOACs) have largely replaced warfarin as first-line therapy for stroke prevention in AF—due to their lower risk of intracranial bleeding and fewer drug–food interactions—their safety and efficacy in patients with both AF and recent ICH remain poorly defined. This study aimed to compare the rates of ischemic and hemorrhagic stroke between patients receiving DOACs versus warfarin following an ICH. Methods: We conducted a retrospective cohort study using the COSMOS EPIC database, identifying adult patients admitted with ICH and have AF diagnosis. Patients were included if they had a documented anticoagulation prescription within 180 days of discharge after the index ICH admission. Diagnoses were identified using ICD-10 codes. Patients were stratified into two groups based on anticoagulant type: DOAC or warfarin. Baseline demographic and clinical characteristics, including comorbidities, were compared. The primary outcomes were recurrent hemorrhagic stroke (ICH or subarachnoid hemorrhage) and ischemic stroke after anticoagulation initiation. Kaplan–Meier survival curves were generated to estimate the cumulative incidence of each outcome, and differences were assessed using log-rank tests. Results: A total of 2,473 patients met inclusion criteria. Patients in the DOAC group were slightly older than those in the warfarin group (mean age 73 vs. 71 years, p = 0.02); other baseline characteristics and comorbidities were comparable. During follow-up, ischemic stroke occurred in 3.5% of DOAC-treated patients and 3.1% of warfarin-treated patients ( p = 0.70). Hemorrhagic stroke occurred in 7.4% and 6.1% of patients in the DOAC and warfarin groups, respectively ( p = 0.68). Kaplan–Meier analysis demonstrated no significant difference in the cumulative incidence of hemorrhagic stroke ( p = 0.60) or ischemic stroke ( p = 0.80) between groups. Conclusion: In this large retrospective cohort of patients with AF and ICH, DOAC and warfarin had comparable risk of recurrent hemorrhagic or ischemic strokes. Prospective studies are needed to guide anticoagulation decisions in this high-risk group.

Introduction: Pregnancy-related physiological changes may influence the risk of aneurysmal rupture, raising concerns for young patients with known unruptured cerebral aneurysms. This study aims to evaluate the relationship between pregnancy and the risk of subarachnoid hemorrhage (SAH) in young female patients. Methods: We conducted a retrospective study using the COSMOS EPIC database. Female patients aged 18–50 years with a diagnosis of unruptured cerebral aneurysm (ICD-10 M-code: I67.1) were included. Pregnancy was defined as the presence of any pregnancy-related ICD-10 code. The cohort was divided into two groups based on pregnancy status, and propensity score weighting (PSW) was applied to balance baseline characteristics. The association between pregnancy and SAH was evaluated using a Cox adjusted model. Results: A total of 35,346 patients were included, of whom 6,532 (18%) had a pregnancy-related ICD-10 code. Pregnant patients were younger (mean age 34.23 vs. 40.78 years; p = 0.001) and more likely to be Black (22.3% vs. 17%; p = 0.001). They were less likely to have diabetes, hyperlipidemia, or hypertension. After PSW, baseline characteristics were balanced between the groups. The incidence of SAH was similar (2.3% vs. 2.1%), with no statistically significant difference. Pregnancy was not associated with an increased risk of SAH in the Cox adjusted model (HR 1.11, 95% CI 0.91–1.34). Conclusion: In this large, retrospective cohort of young women with unruptured cerebral aneurysms, pregnancy was not associated with a significantly increased risk of SAH. These findings suggest that pregnancy may not independently elevate aneurysm rupture risk, though individualized risk assessment remains important.

BACKGROUND:The impact of stent retriever size on mechanical thrombectomy (MT) outcomes remains uncertain. We aim to clarify the influence of stent retriever size on MT outcomes by analyzing data from two national prospective registries. METHODS:A retrospective analysis was performed on data from the French and German MT registries including consecutive patients with anterior circulation large vessel occlusion who underwent Solitaire stent retriever MT with or without additional aspiration. Efficacy outcomes were successful reperfusion and complete reperfusion. Safety outcomes included any intracerebral hemorrhage (ICH) and symptomatic intracerebral hemorrhage (sICH). RESULTS:Complete reperfusion was lower in the 4×20 mm stent retriever group than in the 4×40 mm stent retriever group (47% vs 53%; OR 0.61, P=0.0039). Successful reperfusion did not differ between the 4×20 mm and 4×40 mm stent retriever groups (89% vs 93%; OR 0.69, P=0.25). There was no difference between the 6×30/6×40 mm and 4×20 mm stents, and there was no difference in functional outcomes between the groups. In terms of safety, any ICH was lower in the 4×20 mm group than in the 4×40 mm group (20% vs 36%; OR 0.60, P=0.0095). Symptomatic ICH was lower in the 4×20 mm group than in the 4×40 mm group (5% vs 10%; OR 0.58, P=0.086), but the difference did not reach statistical significance. Mortality was lower in the 4×20 mm than in the 6×40 mm group (26% vs 33%; OR 0.70, P=0.044). When compared according to occlusion location, the results were overall similar. CONCLUSION:This study suggests that longer and larger stent retrievers lead to a higher reperfusion rate but also a higher rate of hemorrhagic complications. Overall, the size of the stent did not affect functional outcomes.

BACKGROUND: Maternal stroke is an uncommon but serious complication of pregnancy. This study assessed the incidence, temporal trends, and outcomes of maternal stroke in the United States using the Cosmos Epic database. METHODS: We conducted a retrospective analysis of pregnancies resulting in births between January 1, 2016, and January 1, 2024, using the Cosmos Epic database, which includes deidentified electronic health records from >1800 US hospitals and 41 500 clinics. Maternal stroke was defined as any inpatient admission with a stroke diagnosis during pregnancy or within 6 weeks postpartum. The primary outcome was maternal stroke incidence; secondary outcomes included maternal mortality, delivery complications, and neonatal outcomes. Propensity score matching (1:1) was applied to adjust for confounding. RESULTS: Among 5 404 933 pregnancies, 2637 were complicated by stroke, yielding an incidence of 48.8 per 100 000 pregnancies. Ischemic stroke was most common (52.6%), followed by hemorrhagic stroke (40.7%). The overall rate remained stable though ischemic stroke showed an upward trend. Women with stroke were older and more likely to be Black, and had higher rates of hypertension, dyslipidemia, congenital heart disease, and eclampsia. In the matched cohort (n=1200 pairs), the stroke group had higher mortality (1.7% versus 0%), more delivery complications, lower birth weight, and longer neonatal hospital stays. Among 409 subsequent pregnancies, recurrent stroke occurred in 14.7% but with no maternal mortality and favorable neonatal outcomes. CONCLUSIONS: Maternal stroke, though rare, carries substantial risks. The increasing ischemic stroke trend warrants targeted prevention and multidisciplinary perinatal management.

BACKGROUND AND OBJECTIVES:Futile recanalization in endovascular thrombectomy (EVT) occurs when recanalization is achieved but patients nevertheless experience a poor functional outcome. Variables associated with futile recanalization after endovascular therapy in intracranial atherosclerosis-related large vessel occlusion have not been previously described. METHODS:This was a secondary analysis of Registry of Emergent Large Vessel Occlusion due to Intracranial Stenosis (RESCUE-ICAS), a multicenter prospective observational cohort study conducted at 25 EVT-capable centers in North America, Europe, and Asia. RESCUE-ICAS enrolled patients who underwent EVT, after which they had residual stenosis of 50% to 99% or intraprocedural reocclusion. This particular analysis focused on patients who had "futile recanalization" after endovascular therapy, that is modified Rankin Score 3 to 6 at 90-day follow-up despite successful revascularization at procedure end (modified thrombolysis in cerebral ischemia [mTICI] 2b-3). All Included patients in the study had baseline modified Rankin Scale 0 to 2, occlusion of the intracranial internal carotid artery or M1 segment, and successful recanalization (mTICI 2b-3) after endovascular therapy. RESULTS:In total, 325 patients (62.8% male, mean age: 66.2 years) met the inclusion criteria. On multivariable logistic regression analysis, several variables were independently associated with futile recanalization and poor outcome, including relatively old age, higher National Institutes of Health Stroke Scale, history of type 2 diabetes, and total number of revascularization attempts. On the other hand, complete angiographic recanalization (mTICI 3 vs mTICI 2b/c) and use of an intracranial stent were inversely associated with poor outcome and were independently protective against futile recanalization. CONCLUSION:Recanalization outcomes in intracranial atherosclerosis-related large vessel occlusion are inferior to thromboembolic large vessel occlusion. The broader RESCUE-ICAS cohort showed that stenting may augment end EVT thrombolysis in cerebral ischemia grading. In this analysis, which was restricted to patients experiencing good recanalization, stenting remained inversely associated with futile recanalization. Follow-up vessel imaging suggests this may be due to more durable vessel patency with stenting.

Managing atherosclerotic large vessel occlusion is procedurally challenging. Technical considerations remain heterogenous and further research is necessary. As such, first-line thrombectomy technique remains an active area of debate with respect to rate of recanalization, need for rescue stenting, and hemorrhagic complications. This is a pre-planned analysis of the prospective RESCUE-ICAS registry which included atherosclerotic large vessel occlusions treated with mechanical thrombectomy from 25 sites. Patients were dichotomized into two cohorts based on whether their first-line thrombectomy technique was with aspiration alone or a stentriever (SR). Primary procedural outcome was first-pass effect while primary safety outcome was mortality at 90 days. Propensity score matching and inverse probability weighted analysis were performed with respect to primary and secondary outcomes. Four-hundred-nineteen patients included in this analysis with 266 and 153 patients in the aspiration and stentriever cohorts, respectively. The cohort's mean age was 68 (SD±13) years, and the majority of patients were white (59%) and male (62%). There were no significant baseline demographic differences between cohorts; however, ICA occlusions were more common in the stentriever cohort (52% vs 31%), while MCA occlusions were more frequent in the aspiration cohort (35% vs 15%). In the unadjusted model, first pass effect was higher in stentriever versus aspiration (35.3% vs 23.7%, p = 0.01) with equivalent mortality rates (31% vs 26%, p = 0.31). Distal embolization rates were higher with aspiration (9.8% vs 3.9%, p = 0.03), yet aspiration was associated with lower procedural complications (6% vs 11%, p = 0.01). Propensity score matching demonstrated no significant differences in primary clinical efficacy and safety outcomes. In atherosclerotic large vessel occlusions, stentrievers more likely to achieve first-pass effect, lower rates of distal embolization and shorter procedural length compared to aspiration. However, no clinical outcome difference was appreciated while aspiration was associated with lower complication rates. ### Competing Interest Statement The authors have declared no competing interest. ### Funding Statement NA ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: The registry was approved by the institutional review board at the coordinating center at the Medical University of South Carolina. Institutional review board approval was also obtained from the local institutional review board at each participating center. Given the observational nature of the study, it was considered minimal risk, and informed consent was waived. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes Data will be made available upon submission and approval of requests to corresponding author.

BACKGROUND:Tenecteplase (TNK) has recently become a compelling alternative to alteplase. This study aims to compare the usage trends and outcomes of TNK versus alteplase in acute ischemic stroke. METHODS:We conducted retrospective analysis using the Cosmos Epic database to include ischemic stroke patients treated with intravenous thrombolysis between 1 and 1-2016 and 12-31-2023. The primary outcomes were 1) trend in the usage of alteplase vs. TNK and 2) home discharge. Secondary outcomes included 90-day mortality, in-hospital mortality, and rates of intracranial hemorrhage. RESULTS:The study included 71,150 patients (mean age, 67.46 years; 50.2 % male; mean NIH Stroke Scale score, 4.34; 73 % White). A total of 52591 patients (73 %) were treated with alteplase. Over the study period, the use of alteplase decreased, whereas TNK usage increased, surpassing alteplase by mid-2022. The rate of home discharge was higher in the TNK group (59.3 % vs. 58 %; P = .002), and TNK was associated with home discharge (odds ratio [OR], 1.17; 95 % CI, 1.12-1.22). There was no significant association between TNK and 90-day mortality. Intracranial hemorrhage was more common in the TNK group. In a sensitivity analysis restricted to patients who received endovascular therapy, TNK was associated with higher odds of home discharge, lower odds of in-hospital mortality, and higher odds of intracranial hemorrhage. CONCLUSION:Since 2022, the utilization of TNK for acute ischemic stroke in the US has increased significantly. TNK was associated with a higher likelihood of home discharge compared to alteplase. These findings support the use of TNK in clinical practice.

BACKGROUND:We evaluated the clinical and safety outcomes of emergent carotid artery stenting (eCAS) plus endovascular thrombectomy (EVT) among patients with anterior tandem lesion (TL) and large ischemic core (LIC). METHODS:This retrospective study included consecutive stroke patients enrolled in the Endovascular Treatment in Ischemic Stroke Registry in France between January 2015 and June 2023. We compared the outcomes of carotid stenting vs no stenting in tandem lesion with pre-treatment LIC (Alberta Stroke Program Early CT Score (ASPECTS) 3-5) and stenting in tandem lesion vs thrombectomy alone for isolated intracranial occlusions with pre-treatment LIC. Primary outcome was a score of 0 to 3 on the modified Rankin scale (mRS) at 90 days. Multivariable mixed-effects logistic regression was performed. RESULTS:Among 218 tandem patients with LIC, 55 were treated with eCAS plus EVT. The eCAS group had higher odds of 90-day mRS 0-3 (adjusted Odds Ratio (aOR) 2.40, 95% confidence interval (CI) 1.10 to 5.21; p=0.027). There were no differences in the risk of any intracerebral hemorrhage (OR 1.41, 95% CI 0.69 to 2.86; p=0.346), parenchymal hematoma (aOR 1.216, 95% CI 0.49 to 3.02; p=0.675), symptomatic intracerebral hemorrhage (aOR 1.45, 95% CI 0.60 to 3.48; p=0.409), or 90-day mortality (aOR 0.74, 95% CI 0.33 to 1.68; p=0.472). eCAS was associated with a higher rate of carotid patency at day 1 (aOR 3.54, 95% CI 1.14 to 11.01; p=0.028). Safety outcomes were similar between EVT+eCAS group in TL-LIC and EVT alone group in isolated intracranial occlusions with LIC. CONCLUSION:eCAS appears to be a safe and effective strategy in patients with TL and LIC volume.

BACKGROUND:Patients presenting with cervical artery dissection (CAD) are at risk for subsequent ischemic events. We aimed to identify characteristics that are associated with increased risk of ischemic stroke after initial presentation of CAD and to evaluate the differential impact of anticoagulant versus antiplatelet therapy in these high-risk individuals. METHODS:This was a preplanned secondary analysis of the STOP-CAD study (Antithrombotic Treatment for Stroke Prevention in Cervical Artery Dissection), a multicenter international retrospective observational study (63 sites from 16 countries in North America, South America, Europe, Asia, and Africa) that included patients with CAD predominantly between January 2015 and June 2022. The primary outcome was subsequent ischemic stroke by day 180 after diagnosis. Clinical and imaging variables were compared between those with versus without subsequent ischemic stroke. Significant factors associated with subsequent stroke risk were identified using stepwise Cox regression. Associations between subsequent ischemic stroke risk and antithrombotic therapy type (anticoagulation versus antiplatelets) among patients with identified risk factors were explored using adjusted Cox regression. RESULTS:In all, 4023 patients (mean age was 47.4 years; 44.5% were women) were included. By day 180, subsequent ischemic stroke occurred in 5.3% of the cohort. In adjusted Cox regression, factors associated with increased risk of subsequent ischemic stroke were prior history of ischemic stroke (adjusted hazard ratio [aHR], 7.31 [95% CI, 1.61-33.13]; P=0.010), presentation within 7 days from first symptoms (aHR, 3.04 [95% CI, 1.04-8.91]; P=0.043), infarct on baseline imaging (aHR, 9.85 [95% CI, 3.65-26.58]; P<0.001), and occlusive dissection (aHR, 2.34 [95% CI, 1.03-5.34]; P=0.043). Only patients with occlusive dissection demonstrated a reduced risk of subsequent ischemic stroke when treated with anticoagulation versus antiplatelets (aHR, 0.36 [95% CI, 0.16-0.80]; P=0.01). CONCLUSIONS:In this post hoc analysis of the STOP-CAD study, several factors associated with subsequent ischemic stroke were identified among patients with CAD. Furthermore, we identified a potential benefit of anticoagulation in patients with CAD with occlusive dissection. These findings require validation by meta-analyses of prior studies to formulate optimal treatment strategies for specific high-risk CAD subgroups.

Objectives Cervical artery dissection (CeAD) accounts for 25% of ischemic strokes in young adults. This study evaluated the benefits and harms of intravenous thrombolysis (IVT) in patients presenting with spontaneous CeAD and acute ischemic stroke symptoms. Methods This analysis used data from the retrospective STOP-CAD study and included patients with spontaneous CeAD who presented within 1 day of acute ischemic stroke symptoms. Patients were dichotomized into those who received IVT and those managed without IVT. We assessed the association between IVT and 90-day functional independence (modified Rankin Scale scores 0-2) and the incidence of symptomatic intracranial hemorrhage (ICH, defined as ICH causing new or worsening neurologic symptoms within 72 hours after CeAD diagnosis). Results This study included 1,653 patients from the original STOP-CAD cohort of 4,023. The median age was 49 years, and 35.1% were women; 512 (31.0%) received IVT. IVT was associated with 90-day functional independence (adjusted odds ratio [aOR] = 1.67, 95% CI 1.23-2.28, p = 0.001), but not with symptomatic ICH (aOR = 1.52, 95% CI 0.79-2.92, p = 0.215). Discussion In patients with spontaneous CeAD and suspected ischemic stroke, IVT improved functional outcomes, without increasing symptomatic ICH risk. These findings support current guideline recommendations to consider thrombolysis for otherwise eligible patients with CeAD. Classification of Evidence This study provides Class III evidence that IVT significantly increases the probability of 90-day functional independence in patients with CeAD.

Background Recent clinical trials have demonstrated that patients with large vessel occlusion (LVO) and large infarction core may still benefit from mechanical thrombectomy (MT). In this study, we evaluate outcomes of MT in LVO patients presenting with extremely large infarction core Alberta Stroke Program Early CT Score (ASPECTS 0–2). Methods Data from the Stroke Thrombectomy and Aneurysm Registry (STAR) was interrogated. We identified thrombectomy patients presenting with an occlusion in the intracranial internal carotid artery (ICA) or M1 segment of the middle cerebral artery and extremely large infarction core (ASPECTS 0–2). A favorable outcome was defined by achieving a modified Rankin scale of 0–3 at 90 days post-MT. Successful recanalization was defined by achieving a modified Thrombolysis In Cerebral Ischemia (mTICI) score ≥2B. Results We identified 58 patients who presented with ASPECTS 0–2 and underwent MT. Median age was 74.0 (66.3–80.0) years, 30 (51.7%) were females, and 16 (27.6%) patients received intravenous tissue plasminogen activator. There was no difference regarding the location of the occlusion (p=0.57). Aspiration thrombectomy was performed in 34 (64.2%) patients and stent retriever was used in 8 (15.1%) patients. In patients presenting with ASPECTS 0-2 the mortality rate was 41.4%, 31% had mRS 0-3 at day 90, 66.67% ≥70 years of age had mRS of 5-6 at day 90. On multivariable analysis, age, National Institutes of Health Stroke Scale on admission, and successful recanalization (mTICI ≥2B) were independently associated with favorable outcomes. Conclusions This multicentered, retrospective cohort study suggests that MT may be beneficial in a select group of patients with ASPECTS 0–2.

Objective: Patients with cervical artery dissection (CAD) are at increased ischemic stroke risk. We aimed to identify characteristics that are associated with increased risk of ischemic stroke following initial presentation of CAD and to evaluate the differential impact of anticoagulant versus antiplatelet therapy in these high-risk individuals. Methods: This was a secondary analysis of the Antithrombotic Treatment for Stroke Prevention in Cervical Artery Dissection (STOP-CAD) study, a multicenter retrospective observational study. The primary outcome was subsequent ischemic stroke by day 180 after diagnosis. Patient characteristics were compared between those with vs. without subsequent ischemic stroke. Significant predictors were identified using stepwise Cox regression. Associations between subsequent ischemic stroke risk and antithrombotic therapy type in high-risk patients were explored using adjusted Cox regression. Results: 4,023 patients (mean age 47.4 years; 44.5% were women) were included. By day 180, 5.3% experienced a subsequent ischemic stroke. In adjusted Cox regression, factors associated with increased subsequent ischemic stroke risk were prior ischemic stroke (aHR 7.31, 95% CI 1.61-33.13, p=0.010), presentation within seven days from symptoms, (aHR 3.04, 95% CI 1.04-8.91, p=0.043), infarct on imaging (aHR 9.85, 95% CI 3.65-26.58, p<0.001), and occlusive dissection (aHR 2.34, 95% CI 1.03-5.34, p=0.043). Only patients with occlusive dissection had reduced subsequent ischemic stroke risk with anticoagulation versus antiplatelets (HR 0.37; 95% CI 0.15-0.89, p=0.03). Interpretation: This study identified several predictors of subsequent ischemic stroke among patients with CAD but only patients with occlusive dissection demonstrated a benefit from anticoagulation. These findings require validation by meta-analyses of prior studies. ### Competing Interest Statement CHN received funding from German Center for cardiovascular Research (DZHK) and German Center for neurodegenerative diseases (DZNE). CHN reports honoraria for lectures and/or speakers bureau from Abbott, Alexion, Astra Zeneca, BMS, Daiichi Sankyo, Novartis, Pfizer, Portola and Takeda. TNN reports advisory board for Brainomix, Aruna Bio; Associate Editor of Stroke. ### Funding Statement This study was not funded. ### Author Declarations I confirm all relevant ethical guidelines have been followed, and any necessary IRB and/or ethics committee approvals have been obtained. Yes The details of the IRB/oversight body that provided approval or exemption for the research described are given below: This analysis was conducted in accordance with the ethical guidelines of the original STOP-CAD study, which received Institutional Review Board (IRB) approval. As this is a secondary analysis of de-identified data, additional IRB approval was waived by the Lifespan IRB. Aggregate data will be shared upon reasonable request to the STOP-CAD principal investigator. I confirm that all necessary patient/participant consent has been obtained and the appropriate institutional forms have been archived, and that any patient/participant/sample identifiers included were not known to anyone (e.g., hospital staff, patients or participants themselves) outside the research group so cannot be used to identify individuals. Yes I understand that all clinical trials and any other prospective interventional studies must be registered with an ICMJE-approved registry, such as ClinicalTrials.gov. I confirm that any such study reported in the manuscript has been registered and the trial registration ID is provided (note: if posting a prospective study registered retrospectively, please provide a statement in the trial ID field explaining why the study was not registered in advance). Yes I have followed all appropriate research reporting guidelines, such as any relevant EQUATOR Network research reporting checklist(s) and other pertinent material, if applicable. Yes This analysis was conducted in accordance with the ethical guidelines of the original STOP-CAD study, which received Institutional Review Board (IRB) approval. As this is a secondary analysis of de-identified data, additional IRB approval was waived by the Lifespan IRB. Aggregate data will be shared upon reasonable request to the STOP-CAD principal investigator.

Introduction: Data on the association between blood pressure variability (BPV) after endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) and outcomes are limited. We sought to identify whether BPV within the first 24 hours post EVT was associated with key stroke outcomes.Methods: We combined individual patient-data from five studies among AIS-patients who underwent EVT, that provided individual BP measurements after the end of the procedure. BPV was estimated as either systolic-BP (SBP) standard deviation (SD) or coefficient of variation (CV) over 24 h post-EVT. We used a logistic mixed-effects model to estimate the association [expressed as adjusted odds ratios (aOR)] between tertiles of BPV and outcomes of 90-day mortality, 90-day death or disability [modified Rankin Scale-score (mRS) > 2], 90-day functional impairment (>= 1-point increase across all mRS-scores), and symptomatic intracranial hemorrhage (sICH), adjusting for age, sex, stroke severity, co-morbidities, pretreatment with intravenous thrombolysis, successful recanalization, and mean SBP and diastolic-BP levels within the first 24 hours post EVT.Results: There were 2640 AIS-patients included in the analysis. The highest tertile of SBP-SD was associated with higher 90-day mortality (aOR:1.44;95% CI:1.08-1.92), 90-day death or disability (aOR:1.49;95% CI:1.18-1.89), and 90-day functional impairment (adjusted common OR:1.42;95% CI:1.18-1.72), but not with sICH (aOR:1.22;95% CI:0.76-1.98). Similarly, the highest tertile of SBP-CV was associated with higher 90-day mortality (aOR:1.33;95% CI:1.01-1.74), 90-day death or disability (aOR:1.50;95% CI:1.19-1.89), and 90-day functional impairment (adjusted common OR:1.38;95% CI:1.15-1.65), but not with sICH (aOR:1.33;95% CI:0.83-2.14).Conclusions: BPV after EVT appears to be associated with higher mortality and disability, independently of mean BP levels within the first 24 h post EVT. BPV in the first 24 h may be a novel target to improve outcomes after EVT for AIS.

Background The effect of multiple attempts on the outcome of endovascular treatment (EVT) of anterior circulation large ischemic core (LIC) stroke has not been fully explored. Methods We analyzed data from the Endovascular Treatment in Ischemic Stroke (ETIS) registry, a prospective, observational, multicenter study of acute ischemic stroke patients treated with EVT at 21 centers in France between January 1, 2015 and June 31, 2023. We included patients with proximal intracranial occlusion and LIC defined as Alberta Stroke Program Early CT Score (ASPECTS) of 0–5 up to 24 hours after last being seen well. We divided patients according to the number of passes with successful reperfusion (modified Thrombolysis In Cerebral Infarction (mTICI) ≥2b) into seven groups, according to the corresponding number of passes. We compared them to the group of patients with unsuccessful reperfusion. Results A total of 1235 patients with LIC constituted the study cohort. The rate of a modified Rankin Scale (mRS) score of 0 to 3 at 90 days was significantly higher for the one-pass successful recanalization category compared to no recanalization (48.1% vs 17.2%; adjusted OR (aOR) 7.99, 95% CI 4.30 to 14.8, P<0.001) and remained so even after six or more attempts (27.7% vs 17.2%; aOR 3.59, 95% CI 1.37 to 9.39, P=0.009). The rate of symptomatic intracranial hemorrhage was lower for successful recanalization up to two passes (11.1% vs 18.8%; aOR 0.36, 95% CI 0.18 to 0.69, P=0.002) without any significant differences for a higher number of passes. Conclusion In anterior circulation LIC patients, successful reperfusion, even after six passes, is associated with favorable clinical outcomes with no increased hemorrhagic risk when compared to unsuccessful reperfusion.

OBJECTIVE Identifying the optimal anesthetic technique for mechanical thrombectomy (MT) remains an unresolved issue. Prior research has not considered the influence of occlusion site when comparing general anesthesia (GA) with non-GA. This study evaluates the differential impacts of the anesthetic technique (GA vs non-GA) on outcomes according to the location of occlusion. METHODS This is a retrospective analysis of the ETIS (Endovascular Treatment in Ischemic Stroke) registry. Patients with anterior circulation large-vessel occlusion treated with MT were included. Patients were divided into groups according to the location of occlusion. Inverse propensity score weighting analysis was used. RESULTS Among 2783 patients included in the propensity score analysis, 669 (24%) received GA. In the total cohort, GA was not associated with favorable outcome, excellent outcome, successful reperfusion, or complete reperfusion. GA was associated with higher odds of parenchymal hemorrhage (OR 1.42, 95% 1.05–1.92) but not symptomatic intracranial hemorrhage. GA was associated with Alberta Stroke Program Early CT Score progression (OR 1.36, 95% CI 1.11–1.68). In the internal carotid artery occlusion group, GA was associated with higher odds of mortality (OR 1.94, 95% CI 1.15–3.27). In the M1 group, GA was associated with lower odds of complications (OR 0.41, 95% CI 0.19–0.92). In the M2 group, GA was associated with successful reperfusion (OR 2.79, 95% CI 1.02–7.64). In addition, the complication rate was lower with GA (2.7% vs 7%), although the association was not significant in adjusted analysis. CONCLUSIONS While GA and non-GA techniques did not differ significantly in functional outcomes, the influence of GA on angiographic and procedural safety outcomes was location dependent, underscoring the importance of a tailored anesthesia technique in MT procedures.

BACKGROUND:Data on systolic blood pressure (SBP) trajectories in the first 24 hours after endovascular thrombectomy (EVT) in acute ischemic stroke are limited. We sought to identify these trajectories and their relationship to outcomes.METHODS:We combined individual-level data from 5 studies of patients with acute ischemic stroke who underwent EVT and had individual blood pressure values after the end of the procedure. We used group-based trajectory analysis to identify the number and shape of SBP trajectories post-EVT. We used mixed effects regression models to identify associations between trajectory groups and outcomes adjusting for potential confounders and reported the respective adjusted odds ratios (aORs) and common odds ratios.RESULTS:There were 2640 total patients with acute ischemic stroke included in the analysis. The most parsimonious model identified 4 distinct SBP trajectories, that is, general directional patterns after repeated SBP measurements: high, moderate-high, moderate, and low. Patients in the higher blood pressure trajectory groups were older, had a higher prevalence of vascular risk factors, presented with more severe stroke syndromes, and were less likely to achieve successful recanalization after the EVT. In the adjusted analyses, only patients in the high-SBP trajectory were found to have significantly higher odds of early neurological deterioration (aOR, 1.84 [95% CI, 1.20-2.82]), intracranial hemorrhage (aOR, 1.84 [95% CI, 1.31-2.59]), mortality (aOR, 1.75 [95% CI, 1.21-2.53), death or disability (aOR, 1.63 [95% CI, 1.15-2.31]), and worse functional outcomes (adjusted common odds ratio,1.92 [95% CI, 1.47-2.50]).CONCLUSIONS:Patients follow distinct SBP trajectories in the first 24 hours after an EVT. Persistently elevated SBP after the procedure is associated with unfavorable short-term and long-term outcomes.

BACKGROUND:Small, randomized trials of patients with cervical artery dissection showed conflicting results regarding optimal stroke prevention strategies. We aimed to compare outcomes in patients with cervical artery dissection treated with antiplatelets versus anticoagulation. METHODS:This is a multicenter observational retrospective international study (16 countries, 63 sites) that included patients with cervical artery dissection without major trauma. The exposure was antithrombotic treatment type (anticoagulation versus antiplatelets), and outcomes were subsequent ischemic stroke and major hemorrhage (intracranial or extracranial hemorrhage). We used adjusted Cox regression with inverse probability of treatment weighting to determine associations between anticoagulation and study outcomes within 30 and 180 days. The main analysis used an as-treated crossover approach and only included outcomes occurring with the above treatments. RESULTS:The study included 3636 patients (402 [11.1%] received exclusively anticoagulation and 2453 [67.5%] received exclusively antiplatelets). By day 180, there were 162 new ischemic strokes (4.4%) and 28 major hemorrhages (0.8%); 87.0% of ischemic strokes occurred by day 30. In adjusted Cox regression with inverse probability of treatment weighting, compared with antiplatelet therapy, anticoagulation was associated with a nonsignificantly lower risk of subsequent ischemic stroke by day 30 (adjusted hazard ratio [HR], 0.71 [95% CI, 0.45-1.12]; P=0.145) and by day 180 (adjusted HR, 0.80 [95% CI, 0.28-2.24]; P=0.670). Anticoagulation therapy was not associated with a higher risk of major hemorrhage by day 30 (adjusted HR, 1.39 [95% CI, 0.35-5.45]; P=0.637) but was by day 180 (adjusted HR, 5.56 [95% CI, 1.53-20.13]; P=0.009). In interaction analyses, patients with occlusive dissection had significantly lower ischemic stroke risk with anticoagulation (adjusted HR, 0.40 [95% CI, 0.18-0.88]; Pinteraction=0.009). CONCLUSIONS:Our study does not rule out the benefit of anticoagulation in reducing ischemic stroke risk, particularly in patients with occlusive dissection. If anticoagulation is chosen, it seems reasonable to switch to antiplatelet therapy before 180 days to lower the risk of major bleeding. Large prospective studies are needed to validate our findings.