BACKGROUND:Direct transfer to angiography suite (DTAS) for patients with suspected stroke primarily admitted to an endovascular-capable centre could accelerate in-hospital workflow and improve outcome. We aimed to assess the safety and efficacy of DTAS for patients with acute severe neurological deficit highly suggestive of ischaemic stroke due to a large vessel occlusion (ASND-LVO). METHODS:We did an open-label, multicentre, randomised controlled trial in ten comprehensive stroke centres in France. We enrolled adult patients (age ≤85 years) with ASND-LVO (unilateral motor deficit with a score ≥5 plus a cortical symptom with a score ≥1 based on the National Institues of Health Stroke Scale) admitted within 5 h of symptom onset. Patients were randomly assigned (1:1) with a web-based system to DTAS or conventional pathway (ie, imaging followed by transfer to the angiography suite for endovascular treatment if eligible). The primary outcome was functional independence defined as a modified Rankin Scale score 0 to 2 at 90 days in the intention-to-treat population-ie, all randomly assigned patients in their originally assigned treatment groups, irrespective of diagnosis, imaging findings, or treatments received. Symptomatic intracranial haemorrhage and all-cause mortality at 90 days were the main safety outcomes. This study was registered on ClinicalTrials.gov (NCT03969511). FINDINGS:Between July 9, 2020, and April 18, 2023, 115 patients were randomly assigned to the DTAS group (n=57) or the conventional group (n=58). An interim analysis was done on Sept 27, 2023. The trial steering committee permanently stopped the trial on Dec 1, 2023, for safety reasons after unmasking and analysis of the data. In the intention-to-treat analysis, the risk of symptomatic intracranial haemorrhage was increased in the DTAS group compared with the conventional group (five [15%] of 34 vs zero [0%] of 42; adjusted odds ratio [OR] 11·0 [95% CI 1·28-1406]). All-cause mortality did not differ significantly between groups (ten [18%] of 56 vs six [11%] of 53; adjusted OR 1·65 [95% CI 0·52-5·55]). Functional independence was reached in 20 [36%] of 56 participants in the DTAS group vs 22 [42%] of 53 in the conventional group (adjusted OR 0·73 [95% CI 0·32-1·69]). INTERPRETATION:DTAS for patients with ASND-LVO was associated with an increased risk of symptomatic intracranial haemorrhage without evidence of a beneficial effect on functional outcome at 90 days. However, because the trial was stopped early for safety reasons, the small sample size limits the precision of the effect estimates on the primary outcome and all secondary and safety outcomes. Therefore, further clinical trials are required to firmly conclude on the safety and efficacy of DTAS for patients with suspected acute ischaemic stroke due to a large vessel occlusion. FUNDING:French Ministry of Health and Medtronic.

PURPOSE:The purpose of this study was to prospectively evaluate the contribution of intravoxel incoherent motion (IVIM) and diffusion kurtosis imaging (DKI) for predicting outcome after ischemic stroke. MATERIALS AND METHODS:Patients with acute ischemic stroke who underwent brain MRI at 3 Tesla, including a multi-b diffusion-weighted imaging sequence were prospectively included. Mean, maximum (max) and minimum (min) of diffusion parameters, including apparent diffusion coefficient (ADC), D, D*, f, f·D* and K were extracted from the infarct core and normal-appearing parenchyma. The primary endpoint was 3-month modified Rankin scale (mRS). Associations were tested by univariable ordinal logistic regression with false discovery rate correction. Model performance was assessed using area under the receiver operating characteristic curve (AUC) analysis and the ranked probability score. RESULTS:A total of 157 patients were included. There were 83 men and 74 women with a mean age of 70 ± 16 (standard deviation) years (range: 23-100 years). In univariable analyses, ADCmin in the infarct core was the strongest predictor of worse functional outcome at 3 months (OR, 0.37; P < 0.001). Within the infarct core, nine other parameters were significantly associated with mRS (one ADC, six IVIM and two DKI metrics). In the normal-appearing parenchyma, eight parameters (two ADC, four IVIM and two DKI metrics) were significantly associated with outcome. In multivariable analysis, the model combining ADCmin and Kmin in the core with ADCmax in the normal-appearing parenchyma provided the highest prognostic performance, with an AUC of 0.81 (95 % confidence interval [CI]: 0.77-0.86) compared to ADCmin alone (AUC, 0.75; 95 % CI: 0.67-0.82) (P < 0.0001). CONCLUSION:A combination of advanced diffusion MRI parameters could predict functional outcome in patients with ischemic stroke with higher precision than standard ADC alone.

INTRODUCTION:Haemorrhagic transformation (HT) seriously worsens functional outcome after endovascular therapy (EVT). Blood pressure (BP) variability may influence HT risk, but optimal monitoring strategies remain unclear. We aimed to determine whether continuous BP monitoring better identifies patients at risk of HT than standard intermittent measurements during the first 24 h post-EVT. PATIENTS AND METHODS:We conducted a single-centre prospective cohort study including adults with acute ischaemic stroke due to large-vessel occlusion treated with EVT. Non-invasive finger-cuff continuous BP and arm-cuff intermittent BP were recorded simultaneously for 24 h post-EVT. Haemorrhagic transformation on follow-up brain imaging at 24-36 h was the primary outcome. Blood pressure recordings were partitioned into three 8-h windows. Variability metrics (mean, maximum, range, SD, coefficient of variation and wavelet-based coefficient energies) were processed into logistic regression models adjusted for clinical covariates. Predictive performance was assessed using AUC-ROC. RESULTS:Among 455 enrolled patients, 199 contributed data to the first 8-h window, in which HT occurred in 58 (29%). Continuous BP variability features, particularly maximum, range and wavelet energies capturing < 32-min fluctuations, were significantly associated with HT, whereas no parameter from intermittent monitoring showed such an association. A multivariable model using continuous data yielded an AUC-ROC of 0.62 (95% CI, 0.54-0.71) vs 0.48 (95% CI, 0.37-0.58) for intermittent data. Associations were not observed in later windows. DISCUSSION AND CONCLUSION:Short-timescale BP variability captured by continuous monitoring in the first 8 h post-EVT is associated with increased HT risk, whereas intermittent monitoring fails to detect this signal and may miss opportunities for early risk stratification.

Importance:Evidence regarding efficacy and safety of thrombectomy in acute ischemic stroke (AIS) due to medium or distal vessel occlusions (MDVOs) is lacking. Objective:To evaluate the benefit of thrombectomy, in addition to medical treatment over medical treatment alone, in patients with an AIS related to a primary and isolated MDVO. Design, Setting, and Participants:Randomized clinical trial conducted at 22 stroke centers in France from November 2021 to April 2025, with planned enrollment of 488 patients. The trial has been stopped after the planned interim analysis on the recommendation of the data and safety monitoring board for futility and increased rate of symptomatic intracranial hemorrhage with thrombectomy. Eligible adult patients had an AIS due to a primary MDVO within 8 hours of symptom onset or within 24 hours of last seen well if no hyperintense signal was present on fluid-attenuated inversion recovery imaging. Intervention:Thrombectomy in addition to medical treatment (n = 123) or medical treatment alone (n = 121). Main Outcomes and Measures:The primary end point was a good clinical outcome at 3 months, defined as a modified Rankin Scale score of 0 to 2, assessed by an independent, blinded assessor. Secondary end points included mortality rate at 3 months and adverse and serious adverse events. Results:Of the 244 patients randomized (median age, 75 years [IQR, 67-81]; 56% male; median National Institutes of Health Stroke Scale score, 8 [IQR, 6-12]), 100 of the 123 patients in the thrombectomy group (81%) received thrombectomy and none of the 121 patients in the control group received thrombectomy; 217 (89%) completed follow-up. At 3 months, 72 of 116 patients (62%) in the thrombectomy group had a good clinical outcome vs 81 of 119 patients (68%) in the control group (odds ratio, 0.73 [95% CI, 0.40-1.31]; P = .29; adjusted absolute difference, -6.8% [95% CI, -19.4% to 5.7%]). The incidence of symptomatic intracranial hemorrhages was higher among the 100 patients who actually received thrombectomy than in those who did not (11% vs 3%, P = .008), as was incidence of subarachnoid hemorrhages (13% vs 2%, P < .001) and embolus migration (5% vs 1%, P = .04). Mortality rate did not significantly differ between the 2 groups (6% vs 8%; P = .49). Conclusions and Relevance:Thrombectomy did not lead to a higher rate of good clinical outcome at 3 months compared with medical treatment alone in patients with acute ischemic stroke related to an MDVO. Hemorrhagic complications were more frequent after thrombectomy. Trial Registration:ClinicalTrials.gov Identifier: NCT05030142.

Introducción y objetivos: El origen de los émbolos implicados en los episodios isquémicos relacionados con el foramen oval permeable (FOP) sigue estando poco documentado. El objetivo fue evaluar la enfermedad tromboembólica venosa (ETV) como posible fuente de episodios embólicos relacionados con el FOP.Métodos: Se sometió a los pacientes programados para el cierre del FOP como prevención secundaria de episodios embólicos arteriales relacionados con este a una evaluación sistemática del riesgo de ETV. Dicha evaluación incluyó: a) un cuestionario exhaustivo sobre antecedentes de ETV para identificar situaciones clínicas de alto riesgo en el momento del episodio embólico, y b) una resonancia magnética (RM) abdominopélvica con venografía para identificar enfermedades venosas abdominales o pélvicas.Resultados: Desde julio de 2020 hasta mayo de 2023, se incluyó prospectivamente a 366 pacientes consecutivos (edad media de 51 años [42-58], 42,9% mujeres). Un episodio previo de ETV, una situación de alto riesgo de ETV, un estado de hipercoagulabilidad o una anomalía venosa abdominal o pélvica en la RM estuvieron presentes en el 8,5% (IC95%, 6,0-11,8), el 22,7% (IC95%, 18,7-27,2), el 7,1% (IC95%, 4,9-10,2) y el 36,3% (IC95%, 31,6-41,4) de los pacientes, respectivamente, y el 58,5% (IC95%, 53,4-63,4) de ellos presentaron al menos 1 de estas condiciones. La RM identificó diversas anomalías venosas pélvicas no diagnosticadas previamente, con un 20,0% de varices pélvicas, un 9,8% de síndrome de May-Thurner/Cockett y un 7,4% de síndrome del cascanueces. Las anomalías en las imágenes fueron más frecuentes entre los pacientes más jóvenes (ORa = 1,02; IC95%, 1,00-1,04) y en mujeres (ORa = 1,94; IC95%, 1,25-3,02).Conclusiones: Un episodio previo de ETV, una situación de alto riesgo de ETV, un estado de hipercoagulabilidad o una anomalía venosa abdominal o pélvica en la RM pueden estar presentes en la mayoría de los pacientes con antecedentes de un episodio arterial relacionado con un FOP.

Abstract Background and aims Endovascular therapy (EVT) is not recommended for acute stroke due to posterior cerebral artery (PCA) occlusion. Perfusion imaging may identify patients who could benefit from EVT. Methods We conducted a multicenter international observational study of consecutive acute stroke patients with isolated PCA occlusion (P1/P2), admitted ≤ 6 hours from symptom onset and with baseline perfusion imaging. Patients received best medical management (BMM) alone or combined with EVT. The primary outcome was good functional outcome (GFO), defined as 3-month modified Rankin Scale score 0–2 or return to baseline mRS. Propensity-score with overlap weighting (PSOW) was used to balance baseline characteristics. Interaction between treatment strategy and perfusion mismatch volume was tested. Results Overall, 295 patients were included (69 BMM + EVT, 226 BMM alone). Median age was 74 years (IQR 64-83), median NIHSS was 6 (3-10), occlusion site was P1 in 21% and P2 in 79%, intravenous thrombolysis used in 70%. Median core volume was 1.5 mL (0-8) and mismatch volume was 15 mL (4-32). The distribution of baseline variables was similar across the 2 groups following PSOW. EVT was not associated with GFO (PSOW-OR 0.99, 95%CI 0.54–1.83; P = 0.97). The association between EVT and GFO was not modified by mismatch volume (Pinteraction = 0.42). Similar results were observed for mRS 0-1. Conclusions In this cohort of acute strokes with PCA occlusion, EVT was not associated with GFO compared to BMM alone. Perfusion mismatch volume did not modify this association and may not be useful to select good EVT candidates in this patient group. Conflict of interest Sabben: Nothing to disclose/Turc reports lecture fees from Guerbert France and consultant services for AI-Stroke and Neurologica/Obadia: Nothing to disclose/Charbonneau: Nothing to disclose/Strambo: Nothing to disclose/Heldner reports grants from SITEM Research Support Funds and Swiss National Science Foundation, Swiss Heart Foundation/Ong: Nothing to disclose/Ter Schiphorst: Nothing to disclose/Sibon: Nothing to disclose/Legris: Nothing to disclose/Carrera: Nothing to disclose/Mione: Nothing to disclose/Bagan-Triquenot: Nothing to disclose/Mazighi reports consulting fees from Acticor Biotech, Boerhinger/Seners speaker fees from Acticor Biotech and Boerhinger-Ingelheim.

INTRODUCTION:Acute ischaemic strokes (AIS) due to proximal anterior cerebral artery (ACA) occlusions are rare. Their clinical outcomes following medical management alone have been scarcely described. PATIENTS AND METHODS:We conducted a retrospective, multicentre, international study of consecutive AIS due to isolated proximal ACA occlusion (A1 or A2 segment) admitted within 6 h of symptom onset and treated with best medical management alone (ie, without endovascular therapy), across 23 centres in France and Switzerland. The primary outcome was poor functional outcome, defined as a mRS score > 2 at 3 months or failure to return to baseline mRS if the pre-stroke mRS was > 2. Associations between baseline clinical/radiological variables and outcome were evaluated in multivariable logistic regression analyses. Associations between outcome and key radiological follow-up variables such as recanalisation and haemorrhagic transformation were also analysed. RESULTS:Ninety-five patients were included in the study: median age was 76 (IQR, 66-87), baseline NIHSS score was 10 (IQR, 5-15) and occlusion site was A1 in 8 (8%) and A2 in 87 (92%). Intravenous thrombolysis was administered in 76 (80%) cases. Poor functional outcome was observed in 47 (49%) patients. Among baseline variables, older age (adjusted odds ratio [aOR] per 5-year increase = 1.25; 95% CI, 1.10-1.55; P = .028) and higher NIHSS score (aOR = 1.20, 95% CI, 1.07-1.34; P < .001) were independently associated with poor outcome. Lack of recanalisation at 24 h was also independently associated with poor outcome (aOR = 14.5, 95% CI, 1.1-188.7, P = .04). Poor outcome was higher in patients with than in those without haemorrhagic transformation (73% vs 42%, P = .03) in univariable analysis, but not in multivariable analysis adjusting for age and NIHSS score (aOR = 2.3, 95% CI, 0.5-11.5, P = .32). DISCUSSION AND CONCLUSION:Nearly half of AIS patients with isolated proximal ACA occlusion treated with medical management alone had poor 3-month functional outcomes. Older age, high NIHSS at admission and lack of recanalisation at 24 h were associated with poor outcome. These results underscore the need to investigate therapeutic strategies aimed at enhancing early arterial recanalisation to improve recovery in this population.

Importance Evidence regarding efficacy and safety of thrombectomy in acute ischemic stroke (AIS) due to medium or distal vessel occlusions (MDVOs) is lacking. Objective To evaluate the benefit of thrombectomy, in addition to medical treatment over medical treatment alone, in patients with an AIS related to a primary and isolated MDVO. Design, Setting, and Participants Randomized clinical trial conducted at 22 stroke centers in France from November 2021 to April 2025, with planned enrollment of 488 patients. The trial has been stopped after the planned interim analysis on the recommendation of the data and safety monitoring board for futility and increased rate of symptomatic intracranial hemorrhage with thrombectomy. Eligible adult patients had an AIS due to a primary MDVO within 8 hours of symptom onset or within 24 hours of last seen well if no hyperintense signal was present on fluid-attenuated inversion recovery imaging. Intervention Thrombectomy in addition to medical treatment (n = 123) or medical treatment alone (n = 121). Main Outcomes and Measures The primary end point was a good clinical outcome at 3 months, defined as a modified Rankin Scale score of 0 to 2, assessed by an independent, blinded assessor. Secondary end points included mortality rate at 3 months and adverse and serious adverse events. Results Of the 244 patients randomized (median age, 75 years [IQR, 67-81]; 56% male; median National Institutes of Health Stroke Scale score, 8 [IQR, 6-12]), 100 of the 123 patients in the thrombectomy group (81%) received thrombectomy and none of the 121 patients in the control group received thrombectomy; 217 (89%) completed follow-up. At 3 months, 72 of 116 patients (62%) in the thrombectomy group had a good clinical outcome vs 81 of 119 patients (68%) in the control group (odds ratio, 0.73 [95% CI, 0.40-1.31]; P = .29; adjusted absolute difference, −6.8% [95% CI, −19.4% to 5.7%]). The incidence of symptomatic intracranial hemorrhages was higher among the 100 patients who actually received thrombectomy than in those who did not (11% vs 3%, P = .008), as was incidence of subarachnoid hemorrhages (13% vs 2%, P < .001) and embolus migration (5% vs 1%, P = .04). Mortality rate did not significantly differ between the 2 groups (6% vs 8%; P = .49). Conclusions and Relevance Thrombectomy did not lead to a higher rate of good clinical outcome at 3 months compared with medical treatment alone in patients with acute ischemic stroke related to an MDVO. Hemorrhagic complications were more frequent after thrombectomy. Trial Registration ClinicalTrials.gov Identifier: NCT05030142

BACKGROUND:Early (≤ 28 days) supraventricular arrhythmia (SVA) is the most common complication that occurs after patent foramen ovale (PFO) closure, but little is known about the incidence and determinants of late (> 28 days) SVA. Our aim was to evaluate the determinants of late SVA after PFO closure. METHODS:Patients with percutaneous PFO closure and risk of SVA were proposed to receive an implantable loop recorder (ILR) device from 2019 to 2023. All rhythmic events recorded on ILR were adjudicated by cardiac electrophysiologists. Primary outcome was any late SVA, either new onset or recurrence, defined as SVA occurring > 28 days after PFO closure and lasting ≥ 30 seconds. Determinants were analyzed using a multivariable Cox proportional hazards model. RESULTS:Overall, 234 patients were included with a median duration of ILR rhythm monitoring of 21.6 (interquartile range, 15.5-30.6) months. An SVA after 28 days was recorded in 50 of 234 patients (2-year Kaplan-Meier estimate, 0.22 [0.16-0.27]), which were recurrent events in 29 of 50 (58.0%) cases and new-onset episodes in 21 of 50 (42.0%) cases. Incidence of new onset of SVA decreased significantly over time. In the multivariate analysis, determinants of late SVA were the early SVA burden (adjusted hazard ratio [aHR], 1.008; 95% confidence interval [CI], 1.003-1.013 per hour of SVA occurring in the first 28 days), male sex (aHR, 2.29; 95% CI, 1.19-4.42), and large left disc diameter (aHR, 2.50; 95% CI, 1.32-4.72). CONCLUSIONS:Determinants of late SVA after PFO closure were SVA burden during the first month, male sex and large left disc diameter.

BACKGROUND AND PURPOSE:The optimal timing for mobilizing patients during the acute phase of ischemic stroke remains unclear. Prior research has produced conflicting results, often neglecting the impact of upstream arterial stenosis on cerebral blood flow. This study aimed to determine whether early transition to a seated position in the acute phase of ischemic stroke influences intracranial hemodynamics, particularly in patients with significant carotid stenosis. METHODS:In a prospective, bi-centric, 1:1 case-control observational study (NCT04180826), we continuously and non-invasively monitored cerebral and systemic hemodynamics during the first authorized transition from supine to a sitting position in patients with ischemic stroke of the carotid territory. Cases were defined as those with homolateral carotid stenosis >50% by NASCET criteria. The primary outcome was a >10% reduction in mean flow velocity (MFV) in the homolateral middle cerebral artery (MCA). RESULTS:Of 42 screened patients, 36 were included (19 controls, 17 cases). A significant (>10%) MFV drop occurred in 9/17 cases (53%) versus 1/19 controls (5%; p = 0.012). Notably, cases with an MFV drop showed no compensatory systemic response (no rise in blood pressure or heart rate). Multivariate analysis revealed that a shorter time from stroke onset to sitting (coefficient = -2.793, p = 0.016) and being a case (coefficient = -6.283, p = 0.004) independently predicted an MFV decrease >10%. Additional factors associated with significant MFV decline in cases included the absence of a blood pressure increase after verticalization, lower hemoglobin (p = 0.007), and higher BNP levels (p = 0.024). CONCLUSIONS:Early sitting in the acute phase of ischemic stroke is more frequently associated with marked MFV reductions in patients with carotid stenosis, potentially due to impaired systemic hemodynamic adaptation. These findings underscore the importance of individualized mobilization strategies based on vascular and systemic factors.

INTRODUCTION AND OBJECTIVES:The origin of emboli involved in patent foramen ovale (PFO)-related ischemic events remains poorly documented. Our objective was to evaluate venous thromboembolic (VTE) disease as a potential source of PFO-related embolic events. METHODS:Patients scheduled for PFO closure for secondary prevention of PFO-related arterial embolic events underwent a systematic VTE risk evaluation. This included: a) a detailed questionnaire on past VTE history to identify clinical situations associated with a high risk of VTE at the time of the embolic event, and b) abdominopelvic magnetic resonance imaging (MRI) with venography to identify abdominal or pelvic venous disease. RESULTS:From July 2020 to May 2023, 366 consecutive patients (median age 51 [range, 42-58] years; 42.9% female) were prospectively included. A prior VTE event, a high-risk VTE situation, a hyperthrombotic state, or an abdominal or pelvic venous anomaly on MRI were present in 8.5% (95%CI, 6.0-11.8), 22.7% (95%CI, 18.7-27.2), 7.1% (95%CI, 4.9-10.2), and 36.3% (95%CI, 31.6-41.4) of patients, respectively. Overall, 58.5% (95%CI, 53.4-63.4) of patients had at least 1 of these conditions. MRI identified several previously undiagnosed pelvic venous anomalies, including pelvic varices in 20.0%, May-Thurner/Cockett in 9.8%, and nutcracker syndrome in 7.4%. Imaging abnormalities were more frequent among younger patients (aOR, 1.02; 95%CI, 1.00-1.04) and women (aOR, 1.94; 95%CI, 1.25-3.02). CONCLUSIONS:A prior VTE event, a high-risk VTE situation, a hyperthrombotic state, or an abdominal or pelvic venous anomaly may be present in most patients with a history of a PFO-related arterial event.

BACKGROUND AND AIMS:The clinical evolution of acute ischemic stroke patients with isolated proximal posterior cerebral artery (PCA) occlusion treated with medical management alone has been poorly described. We aimed to determine the clinical and radiological factors associated with poor functional outcome in this population. METHODS:We conducted a multicenter international retrospective study of consecutive stroke patients with isolated occlusion of the first (P1) or second (P2) segment of PCA admitted within 6 h from symptoms onset in 26 stroke centers in France, Switzerland, and the United States, treated with the best medical management alone. Poor functional outcome was defined as a modified Rankin scale (mRS) ⩾2 at 3 months or no return to pre-stroke mRS. The associations between pretreatment variables and poor outcome were studied in univariable and then multivariable analyses, as well as the association between poor outcome and key follow-up radiological variables. RESULTS:Overall, 585 patients were included. The median age was 74 years (interquartile range (IQR) = 63-83), median National Institutes of Health Stroke Scale (NIHSS) was 6 (3-10), 80% received intravenous thrombolysis (IVT), and 22% and 78% had P1 and P2 occlusions, respectively. Poor outcome occurred in 56% of patients. In multivariable analysis focusing on pretreatment variables, age (adjusted odds ratio (OR) = 1.12 per 5-year increase [95% confidence interval (CI) = 1.05-1.20]; p = 0.001), NIHSS score (aOR = 1.12 per each point increase [1.08-1.18]; p < 0.001), infarct volume (aOR = 1.16 per 5 mL increase [1.07-1.25]; p < 0.001), and the lack of IVT use (aOR = 1.79 [1.10-2.94], p = 0.020) were independently associated with poor outcome. Regarding 24-h follow-up radiological variables, complete recanalization (defined as no clot in the vascular tree at or beyond the primary occlusive lesion, aOR = 0.37 [95% CI = 0.21-0.65], p < 0.001) and parenchymal hematoma occurrence (aOR = 2.37 [95% CI = 1.01-5.56], p = 0.048) were independently associated with poor 3-month outcome. CONCLUSIONS:Poor outcome occurred in more than half of medically treated PCA-related acute stroke patients. Facilitating IVT use may improve functional outcome. Therapeutic approaches aimed at enhancing recanalization and reducing hemorrhagic transformation need to be studied in clinical trials.

Background: Collateral circulation plays a key role in acute ischemic stroke. We sought to determine the association between the arterial collateral status, estimated by the Hypoperfusion Intensity Ratio (HIR) on perfusion MRI, and stroke etiology in anterior circulation large vessel occlusion (LVO). Methods: We retrospectively analyzed anterior circulation LVO acute stroke patients with a baseline perfusion MRI performed within 24 h from symptom onset. To avoid selection bias, patients were chosen from (1) the prospective registry of one comprehensive stroke center that included both thrombectomy-treated and untreated patients with systematic use of perfusion MRI and (2) one prospective thrombectomy study where perfusion MRI was acquired per protocol, but treatment decisions were made blinded to the results. Stroke etiology was evaluated according to the TOAST classification. HIR, defined as the proportion of time-to-maximum (T-max) > 6 s with T-max > 10 s volume, was measured on perfusion imaging. The relationship between stroke etiology (large artery atherosclerosis [LAA]) versus cardioembolism [CE]) and HIR was assessed by bivariate then multivariable binary logistic regression analyses. Results: Among the 310 included patients, stroke etiology was CE in 178 (57%) and LAA in 51 (16%). Patients with CE stroke etiology had higher HIR (0.43 vs 0.31, p < 0.001) than those with LAA etiology. Higher HIR, indicating worse collateral circulation, remained independently associated with CE etiology following adjustment for the main confounders (adjusted OR = 1.5 [95%CI 1.24-1.81] per 0.1-point increase, p < 0.001). Conclusion: CE etiology is associated with worse collateral circulation in LVO-related acute stroke patients.

Background: During the first wave of the coronavirus disease-2019 (COVID-19) pandemic, it was necessary to prepare for the possibility of triaging patients who could benefit from access to an intensive care unit (ICU). In our neuroscience institution, the challenge was to continue to manage usual neurological emergencies as well as the influx of COVID-19 patients. Methods: We report the experience of an ethical consulting unit to support care clinical decisions during the first wave of the pandemic (March 16 to April 30, 2020). Three objective evaluation criteria were defined: 2 of these criteria, patient’s factors and general disease severity (Simplified Acute Physiology Score II), were common to all patients, and the third was the specific severity of the disease (neurological for brain injury, respiratory for COVID-19). Given our scarce resources, we used a high probability of a 3-month modified Rankin Scale ≤3 as the criterion for further resuscitation and management. Results: A total of 295 patients were admitted during the first pandemic wave; 111 with COVID-19 and 184 with neurological emergencies. The ethical unit’s expertise was sought for 75 clinical situations in 56 patients (35 COVID-19 and 21 neurological). Decisions were as follows: 11% no limitation on care, 5% expectant care with reassessment (maximum therapy to assess possible progress pending decision), 67% partial limitation (no intensification of care or no transfer to ICU), and 17% limitation of curative care. At no time did a lack of availability of ICU beds require the ethical unit to advise against admission to the ICU. Conclusions: Our ethical consulting unit allowed for collegial ethical decision-making in line with international recommendations. This model could be easily transferred to other triage situations, provided it is adapted to the local context.

Introduction: Whether endovascular therapy (EVT) added on best medical management (BMM, including intravenous thrombolysis [IVT] if indicated), as compared to BMM alone, is beneficial in acute ischemic stroke (AIS) with isolated posterior cerebral artery occlusion is unknown. Methods: We conducted a multicenter international observational study of consecutive AIS patients admitted within 6hrs from last seen well in 26 stroke centers in France, Switzerland and USA with isolated proximal posterior cerebral artery strokes (P1 or P2 occlusions) and treated either with EVT+BMM or BMM alone. Propensity score with inverse probability of treatment weighting was used to account for baseline between-groups differences. The primary outcome was 3-month good functional outcome (modified Rankin score [mRS] 0-2). Secondary outcomes were excellent functional outcome (mRS 0-1) and symptomatic intracranial hemorrhage (sICH) at 24hrs. We searched for an interaction between treatment group and (1) occlusion site (P1 vs . P2), (2) NIHSS score (<10 vs. ≥10), and (3) IVT use. Results: Overall, 810 AIS patients were included (180 and 630 in the EVT+BMM and BMM alone groups, respectively). Median age was 74yo (IQR 63-83), 352 (44%) were female, median NIHSS was 6 (IQR 4-10), 594 (73%) received IVT, and occlusion site was P1 in 205 (25%) and P2 in 605 (75%) patients. Baseline clinical and radiological data were similar between the 2 groups following propensity-score weighting. EVT was not associated with good (adjusted OR=0.86; 95%CI: 0.67-1.09; P =0.21) or excellent (adjusted OR=1.10; 95%CI: 0.87-1.39; P =0.42) functional outcome but was associated with higher risk of sICH (OR=2.71; 95%CI: 1.41-5.21; P =0.003). No interaction was found between EVT effect and (1) NIHSS score, (2) occlusion site, or (3) IVT use for either outcome. Conclusion: In our population of AIS patients with isolated P1 or P2 occlusion, EVT was not associated with higher rates of good or excellent functional outcome as compared to BMM alone. However, EVT was associated with higher rates of sICH. Randomized trials are warranted.

In acute intracerebral hemorrhage (ICH), the prognostic value of the MRI spot sign on hematoma expansion (HE) and poor functional outcome is poorly known. We retrospectively included patients admitted over a 4-year period for an acute ICH in a single institution using MRI as the first-line imaging tool. The presence and number of MRI spot signs on contrast-enhanced T1-weighted imaging was evaluated by one neuroradiologist, blinded from outcomes. The primary outcome was HE, defined as > 6 mL or > 33% ICH volume growth from initial MRI to 24–48 h follow-up imaging; the secondary outcome was poor 3-month modified Rankin score (4–6). Overall, 147 patients were included, and 62% had a spot sign. Among the 130 patients with follow-up imaging, 24% experienced HE. HE occurred in 6%, 21% and 43% patients with 0, 1 and ≥ 2 spots, respectively (P < 0.001). The MRI spot sign was independently associated with HE (adjusted OR 6.15 [95% CI 1.60–23.65]; P = 0.008), with a dose-dependent effect. The negative and positive predictive values of the spot sign for HE were 0.94 and 0.35, respectively. Poor functional outcome occurred in 27%, 32% and 71% patients with 0, 1 and ≥ 2 spots, respectively (P < 0.001). In multivariable analysis, the presence of ≥ 2 spots was independently associated with poor functional outcome (adjusted OR 3.67 [95% CI 1.21–11.10]; P = 0.024). The MRI spot sign is an independent biomarker of HE, and the presence of ≥ 2 spots is independently associated with poor 3-month outcome. The lack of spot sign is highly predictive of a favorable evolution.

La topographie des infarctus cérébraux dans la maladie de CADASIL est généralement caractéristique. Nous rapportons un cas rare d'infarctus bilatéral des pédoncules cérébelleux moyens révélant une maladie de CADASIL. Une patiente de 45 ans, sans antécédent particulier, consulte pour une dysarthrie et instabilité d'installation brutale. L'examen initial retrouve une dysarthrie et une ataxie d'allure cérébelleuse prédominante à gauche. L'IRM met en évidence un hypersignal diffusion avec baisse de l'ADC des pédoncules cérébelleux moyens, associés à trois infarctus punctiformes supratentoriels et une leucopathie extensive bilatérale, symétrique s'étendant aux régions temporo-polaires et frontales, sans micro-saignement (Fig. 1). Les anomalies pédonculaires retrouvées évoquent, en premier lieu, une encéphalopathie métabolique, toxique ou inflammatoire. Une microangiopathie type CADASIL est toutefois évoquée devant la topographie de la leucopathie périventriculaire associée. Le bilan auto-immun, métabolique, toxique et inflammatoire revient négatif. Il n'existe aucune anomalie des troncs supra-aortiques ou des artères intracrâniennes, ni de cardiopathie emboligène. L'EEG montre un tracé réactif sans argument pour une encéphalopathie. Un traitement par acide acétylsalicylique est introduit. Une IRM de suivi à 2 mois montre l'évolution cavitaire des lésions bi-pédonculaires confirmant le mécanisme ischémique. Le bilan neuropsychologique réalisé au décours retrouve une atteinte des fonctions exécutives. L'étude génétique retrouve la présence de la mutation NOTCH 3. Il s'agit, à notre connaissance, du second cas rapporté d'infarctus bilatéral pédonculaire cérébelleux moyen chez un malade porteur de mutation NOTCH 3. Nous évoquons comme mécanisme une atteinte des petites artères dans le territoire des artères cérébelleuses antéro-inférieures. Devant la rareté de cette localisation ischémique, une étude génétique peut être utile chez les patients présentant une leucopathie vasculaire associée. La physiopathologie des infarctus bilatéraux des pédoncules cérébelleux moyens reste incertaine. La recherche d'une mutation NOTCH 3 peut être utile si ces infarctus sont associés à une leucopathie vasculaire étendue.

Background The Safety and Efficacy of Intensive Blood Pressure Lowering after Successful Endovascular Therapy in Acute Ischaemic Stroke (BP TARGET) trial demonstrated no benefit from intensive systolic blood pressure (SBP) treatment after successful reperfusion with endovascular therapy. However, it remains unknown if the response to blood pressure treatment is modified by other factors. Objective To carry out a post hoc analysis of the BP TARGET trial data to determine if the response to blood pressure treatment is modified by factors such as age, history of hypertension, recanalization status, location of occlusion, diabetes, hyperglycemia, or pretreatment with intravenous thrombolysis. Methods This is a post hoc analysis of the BP TARGET trial. Patients were divided into groups based on age, diabetes, blood glucose, site of occlusion, history of hypertension, and pretreatment with intravenous thrombolysis. The primary outcome was any intraparenchymal hemorrhage. Results 318 patients were included. Diabetes modified the treatment effect on favorable functional outcome (P-heteogenity=0.041). There was a trend towards benefit from intensive SBP treatment in diabetic patients (OR=2.81; 95% CI 0.88 to 8.88; p=0.08) but not in non-diabetic patients (OR=0.75; 95% 0.45 to 126; p 0.28). Age, location of occlusion, admission SBP, pretreatment with intravenous thrombolysis, and history of hypertension did not modify the effect of intensive SBP treatment on any of the outcomes. Conclusion The effect of SBP lowering treatment was not modified by age, location of occlusion history of hypertension, intravenous thrombolysis, and admission SBP. Diabetes modified the effect of intensive SBP lowering treatment, and there was a trend towards benefit from intensive SBP treatment in diabetic patients. This finding is hypothesis generating and requires further validation.

Background and ObjectivesCOVID-19-related inflammation, endothelial dysfunction, and coagulopathy may increase the bleeding risk and lower the efficacy of revascularization treatments in patients with acute ischemic stroke (AIS). We aimed to evaluate the safety and outcomes of revascularization treatments in patients with AIS and COVID-19.MethodsThis was a retrospective multicenter cohort study of consecutive patients with AIS receiving intravenous thrombolysis (IVT) and/or endovascular treatment (EVT) between March 2020 and June 2021 tested for severe acute respiratory syndrome coronavirus 2 infection. With a doubly robust model combining propensity score weighting and multivariate regression, we studied the association of COVID-19 with intracranial bleeding complications and clinical outcomes. Subgroup analyses were performed according to treatment groups (IVT-only and EVT).ResultsOf a total of 15,128 included patients from 105 centers, 853 (5.6%) were diagnosed with COVID-19; of those, 5,848 (38.7%) patients received IVT-only and 9,280 (61.3%) EVT (with or without IVT). Patients with COVID-19 had a higher rate of symptomatic intracerebral hemorrhage (SICH) (adjusted OR 1.53; 95% CI 1.16-2.01), symptomatic subarachnoid hemorrhage (SSAH) (OR 1.80; 95% CI 1.20-2.69), SICH and/or SSAH combined (OR 1.56; 95% CI 1.23-1.99), 24-hour mortality (OR 2.47; 95% CI 1.58-3.86), and 3-month mortality (OR 1.88; 95% CI 1.52-2.33). Patients with COVID-19 also had an unfavorable shift in the distribution of the modified Rankin score at 3 months (OR 1.42; 95% CI 1.26-1.60).DiscussionPatients with AIS and COVID-19 showed higher rates of intracranial bleeding complications and worse clinical outcomes after revascularization treatments than contemporaneous non-COVID-19 patients receiving treatment. Current available data do not allow direct conclusions to be drawn on the effectiveness of revascularization treatments in patients with COVID-19 or to establish different treatment recommendations in this subgroup of patients with ischemic stroke. Our findings can be taken into consideration for treatment decisions, patient monitoring, and establishing prognosis.