INTRODUCTION:Mechanical thrombectomy (MT) is highly effective for acute large-vessel occlusion stroke. Evidence on how systolic blood pressure (SBP) should be managed in the periprocedural period, especially before reperfusion, is limited. The aims of the present study were to clarify the associations between BP before reperfusion and infarct growth (IG) on diffusion-weighted imaging (DWI) in consecutive acute stroke patients treated with MT. METHODS:Consecutive acute ischemic stroke patients treated with emergent MT were retrospectively enrolled. IG was defined as the difference between 24-h and baseline DWI infarct volumes. The associations between SBP parameters before reperfusion (maximum, minimum, mean, coefficient of variation [CV], SBP drop indices [from SBP on arrival], and area below the arrival SBP) and IG were assessed using multivariable regression models. RESULTS:A total of 292 MT procedures in 287 patients (175 male [60%], median age 76 [IQR 68-83] years, median onset to DWI time 131 [80-326] min) were included in this study. Follow-up MRI was performed at a median of 22 [17-26] h. On multivariable analyses, minimum SBP (standardized β -0.143, 95% confidence interval: -0.254 to -0.032, p = 0.012, i.e., low minimum SBP was associated with higher IG) and CV of SBP (0.157, 0.053-0.260, p = 0.003) were independently associated with IG. CONCLUSION:In MT-treated acute ischemic stroke, lower minimum SBP and greater SBP variability before reperfusion were associated with larger early IG, supporting the avoidance of hypotension and excessive SBP fluctuations during hyperacute management before and during MT.

OBJECTIVE:Procedure-related subarachnoid hemorrhage (SAH) is a recognized complication of mechanical thrombectomy for M2 middle cerebral artery occlusion, but whether the first-line device strategy influences its occurrence remains unclear. This study was performed to determine whether a stent retriever (SR)-first strategy, compared with a contact aspiration (CA)-first strategy, is independently associated with procedure-related SAH. METHODS:In this single-center retrospective study, 180 consecutive patients who underwent mechanical thrombectomy for isolated M2 occlusion were classified according to the first-line device strategy. Procedure-related SAH was assessed on postprocedural imaging. Associations were examined by multivariable logistic regression adjusted for age, admission National Institutes of Health Stroke Scale score, diffusion-weighted imaging Alberta Stroke Program Early CT Score, occluded vessel diameter, M1-M2 angle, and number of passes. Inverse probability of treatment weighting, doubly robust estimation, and multiple imputation by chained equations (m = 20) were performed as sensitivity analyses. RESULTS:Procedure-related SAH occurred in 52 patients (29%), and symptomatic intracranial hemorrhage occurred in 8 patients (4.4%). An SR-first strategy was independently associated with procedure-related SAH (adjusted odds ratio, 4.24; 95% confidence interval, 1.13-16.00; P = 0.003), as were a smaller occluded vessel diameter and a greater number of passes. The association was preserved across all sensitivity analyses (adjusted odds ratio, 4.74; 95% confidence interval, 2.00-11.27). Older age, higher admission National Institutes of Health Stroke Scale score, lower diffusion-weighted imaging Alberta Stroke Program Early CT Score, and longer onset-to-puncture time were independently associated with poor 90-day functional outcome. CONCLUSION:In mechanical thrombectomy for M2 occlusion, an SR-first strategy was independently associated with procedure-related SAH. A contact aspiration-first strategy may be preferable as the initial approach, particularly in small-caliber or acutely angulated M2 branches.

BACKGROUND:Diffusion-weighted imaging (DWI) infarct volume and infarct growth are important imaging biomarkers in patients with acute ischemic stroke and treated with mechanical thrombectomy (MT), but manual measurement is time-consuming and resource-intensive. Deep learning (DL)-based automated segmentation may facilitate rapid and reliable assessment; however, its performance on hyperacute DWI and its prognostic value have not been fully validated. METHODS:We retrospectively analyzed consecutive patients with acute ischemic stroke treated with MT between September 2014 and December 2019 who underwent DWI on admission and at approximately 24 h. Infarct volumes were measured manually by stroke neurologists and automatically using a DL-based software. Agreement was assessed using Pearson's correlation, Bland-Altman analysis, and concordance correlation coefficient (CCC). Predictive abilities for good functional outcome at 3 months were compared between manual and automated measurements using C-statistics. RESULTS:A total of 371 patients (677 DWI scans) were included. Manual and automated infarct volumes showed very strong correlation (r = 0.94 for admission DWIs and 0.97 for follow-up DWIs) with minimal bias (-2.82 mL for admission and - 0.50 mL for follow-up). The CCC for manual-automated agreement was 0.935 for admission and 0.971 for follow-up, comparable to human inter- and intra-rater reliabilities. Agreement remained high across onset-to-imaging times. Predictive abilities for good outcome were similar between manual and automated admission DWI volume (C-statistics 0.867 vs. 0.861) and infarct growth (0.859 vs. 0.853). CONCLUSIONS:DL-based automated infarct volume measurement demonstrates substantial agreement with manual assessment and comparable prognostic performance, supporting its feasibility and reliability in hyperacute stroke management.

Background: Accurate assessment of baseline infarct volume and the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) on diffusion-weighted imaging (DWI) is crucial for treatment decision-making in candidates for mechanical thrombectomy (MT). However, evaluation of acute ischemic stroke lesions is affected by reader expertise, image quality, and interobserver variability. This study aimed to develop deep learning models for the automated assessment of infarct volume and ASPECTS on DWI in patients undergoing MT. Methods: We retrospectively analyzed patients with acute ischemic stroke due to large vessel occlusion who underwent emergent MT between September 2014 and December 2019. All input image masks were transferred to the SYNAPSE Creative Space, a cloud-based AI development platform (FUJIFILM Corporation). For semantic segmentation, acute DWI infarct volumes on 3D MRI were automatically segmented using a 3D U-Net model. For image classification, DWI-ASPECTS were automatically assessed using a convolutional neural network (CNN). The Dice score was calculated as (2 × overlapping area) / total area. Results: A total of 239 patients (152 male [64%], median age 75 years [IQR 67–81], median NIHSS score 15 [IQR 7–21], ICA: n=61, M1: n=95, M2: n=83) were included. The baseline median DWI infarct volume was 15.9 ml [IQR 7.4–75.1], and the median DWI-ASPECTS was 6 [IQR 4–8]. Of the dataset, 187 DWI-MRIs were used for training and 52 for internal validation. Automatic infarct segmentation on 3D DWI-MRI demonstrated good accuracy (mean Dice score: 0.76). CNN-based automatic assessment of DWI-ASPECTS achieved a mean Dice score of 0.83. Conclusion: We developed automated models for infarct volume estimation and ASPECTS assessment on DWI in patients undergoing MT. Our findings suggest that a two-step approach—segmentation followed by classification—is feasible and may support physicians in treatment decision-making for MT candidates.

INTRODUCTION:Post-stroke cognitive impairment is associated with increased mortality and healthcare costs. However, its characteristics in patients with large vessel occlusion after mechanical thrombectomy (MT) remain unclear. In this study, we aimed to evaluate the feasibility of administering the Montreal Cognitive Assessment (MoCA) in the acute phase after MT and examine its association with long-term cognitive outcomes. METHODS:We retrospectively analyzed patients with acute ischemic stroke (AIS) who underwent MT and completed MoCA within 5 days of admission, using data from a prospective registry. Patients were classified into acute MoCA feasible and non-feasible groups. Clinical characteristics and cognitive outcomes were compared between the groups, including MoCA and modified Rankin Scale (mRS) scores post-MT. RESULTS:In total, 161 patients were enrolled: 77 (median age, 73 years; 56 men) in the feasible group and 84 (median age, 77 years; 50 men) in the non-feasible group. Multivariate analysis showed that higher National Institute of Health Stroke Scale score on admission (odds ratio [OR] 1.09, 95% confidence interval [CI] 1.03-1.14; p < 0.01) and left-sided occlusion (OR 2.17, 95% CI 2.17-4.00, p = 0.01) were independently associated with MoCA feasibility. Among 51 patients assessed at 6 months, over 80% had persistent cognitive impairment. The chronic MoCA score in the feasible group was 24 and in the non-feasible group was 17. Both groups achieved a favorable functional outcome (mRS score ≤2). CONCLUSION:Over 80% of patients with AIS who underwent MT experienced chronic cognitive impairment, even among those with favorable functional outcomes.

Reperfusion therapy has profoundly transformed acute ischemic stroke (AIS) care. Initially, treatment decisions relied primarily on time from symptom onset. However, growing evidence has shown that the extent of irreversibly injured tissue and the presence of salvageable brain tissue determine the efficacy and safety of reperfusion therapy. This caused a paradigm shift from time-based selection toward tissue-based assessment, placing neuroimaging at the center of clinical decision-making. This narrative review traces the evolution of imaging-based stroke assessment in the reperfusion era. We review the development and clinical impact of the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) and diffusion-weighted imaging (DWI)-ASPECTS, which translated the pathophysiological concept of the ischemic core into a practical, reproducible, routine clinical tool. We discuss the emergence of imaging and clinical mismatch concepts, including perfusion-based ischemic core-penumbra mismatch, as well as clinical-diffusion, MRA-diffusion, and DWI-FLAIR mismatches, which address the limitations of strict time-based criteria and expand treatment opportunities, particularly in patients with unknown onset time. Finally, we examine the growing role of artificial intelligence (AI)-driven automated imaging platforms in acute stroke care, enabling rapid, standardized, and quantitative assessment of ischemic core, penumbra, and vascular pathology. These tools support clinical decision-making under severe time constraints and reduce inter-reader and inter-institutional variability. This iterative process of trial and refinement has shaped the current framework of tissue-based, data-driven stroke care. We discuss how integrating established imaging concepts with emerging AI technologies may further advance precision reperfusion therapy and improve equity and outcomes in AIS treatment.

Dyslipidemia is a major risk factor for atherosclerosis, and high low-density lipoprotein (LDL) cholesterol is closely associated with the onset of atherosclerotic cardiovascular disease (ASCVD), including coronary artery disease. Numerous large-scale clinical trials have demonstrated that LDL cholesterol-lowering therapy, primarily involving statins, reduces not only coronary events, but also stroke, and has been established as a cornerstone of cardiovascular prevention. However, ischemic stroke is a group of diseases comprising different pathologies, such as atherothrombotic stroke, cardioembolic stroke, and small-vessel disease; the involvement of dyslipidemia and the efficacy of lipid-lowering therapy vary significantly depending on the subtype. Therefore, the evidence established for coronary artery disease cannot necessarily be applied directly to stroke management, and establishing lipid management strategies tailored to each subtype has become a critical challenge in stroke management. Furthermore, in recent years, in addition to LDL cholesterol-lowering therapy, treatments targeting hypertriglyceridemia, lipoprotein(a) [Lp(a)], and residual inflammatory risk have advanced, and the development of new therapeutic agents-such as PCSK9 inhibitors, selective PPARα modulators, and ATP citrate lyase inhibitors-is progressing, thus raising expectations for their application in stroke prevention. This article provides an overview of domestic and international guidelines for dyslipidemia and summarizes the association between dyslipidemia and ischemic stroke from the perspectives of pathophysiology, pathological findings, and imaging and blood biomarker. In addition, it outlines the latest evidence from large-scale clinical trials, new lipid-lowering therapies, acute-phase lipid management, and interventions targeting residual risk, and discusses the current status and future prospects of lipid management tailored to specific stroke subtypes.

BACKGROUND:We compared the effectiveness of direct oral anticoagulants (DOACs) and warfarin for resolving left atrial appendage (LAA) thrombus in patients with acute stroke with non-valvular atrial fibrillation (NVAF). METHODS:Among consecutive patients with acute stroke admitted to five major comprehensive stroke centers in Japan between January 2017 and December 2022, those with NVAF and LAA thrombus detected by transesophageal echocardiography (TEE) and underwent follow-up TEE were included. All patients received DOAC or warfarin treatment. We compared the clinical characteristics, changes in LAA thrombus size, resolution, recurrent stroke, and bleeding complications within 3 months of stroke onset. RESULTS:This study included 63 patients (DOAC group, 22; warfarin group, 41). Sex, age, and National Institutes of Health Stroke Scale scores on admission did not significantly differ between the groups. The initial LAA thrombus size was 0.83 cm2 and 0.88 cm2 in the DOAC and warfarin groups, respectively. On follow-up evaluation 10 days after initial TEE, LAA thrombus was completely resolved in 59 % and 34 % of patients in the DOAC and warfarin groups, respectively (P = 0.02). Multivariable analysis revealed DOAC treatment as an independent factor for LAA thrombus resolution (odds ratio, 3.21; 95 % confidence interval: 1.07-10.23, P = 0.04). Recurrent stroke occurred in one and three patients in the DOAC and warfarin groups, respectively. No intracerebral hemorrhage cases were observed in either group within 3 months of stroke onset. CONCLUSION:In patients with acute stroke with NVAF and LAA thrombus detected by TEE, DOACs may be more effective than warfarin in resolving LAA thrombus.

BACKGROUND:The optimal blood pressure control strategy after mechanical thrombectomy (MT) is not well understood, especially for patients with successful recanalization. We hypothesized that low systolic blood pressure (SBP) after MT is associated with infarct growth (IG), even in patients with successful recanalization. AIMS:The aim of the present study was to clarify the relationships between IG and SBP parameters in patients treated with MT. METHOD:Consecutive acute stroke patients who underwent emergent MT from September 2014 through December 2019 were retrospectively enrolled. Diffusion-weighted imaging (DWI) was performed on admission and approximately 24 h after the procedure. IG was calculated as the difference between infarct volume on 24-h DWI and initial DWI. SBP from recanalization to 24-h DWI was used. The associations between IG and SBP parameters, including maximum, minimum, and mean SBPs and coefficient of variation (CV) of SBPs, were evaluated with multiple regression analyses. RESULTS:A total of 377 MT cases (225 male (60%), median age = 76 (interquartile range (IQR) = 68-83) years, median National Institutes of Health Stroke Scale (NIHSS) score = 17 (10-23), median onset to initial DWI time = 131 (79-350) min) were enrolled in this study. Successful recanalization modified the association between SBP parameters and IG (p for interaction < 0.05). In cases with successful recanalization (n = 314), SBP was recorded 7007 times between recanalization and 24-h follow-up magnetic resonance imaging (MRI). Minimum SBP from recanalization to 24-h DWI (standardized coefficient = -0.144, 95% confidence interval (CI) -0.269 to -0.019, p = 0.024, i.e. low minimum SBP was associated with higher IG) and CV of SBP (0.122, 0.003 to 0.241, p = 0.045) were independently associated with IG, even after adjusting for various factors including age, sex, initial NIHSS score, baseline infarct volume, and symptomatic intracerebral hemorrhage. CONCLUSION:Minimum SBP and CV of SBP after recanalization were associated with IG in consecutive acute stroke patients who underwent successful MT. IG is a sensitive imaging marker for evaluating the effect of post-procedural SBP, and extremely low SBP after MT should be avoided to mitigate IG.

BACKGROUND:Constipation, a symptom of autonomic nervous system dysfunction affecting gastrointestinal motility, is common after acute ischemic stroke. The insular cortex is associated with autonomic symptoms, and damage to the left insula may result in constipation. We investigated the association between constipation and left-sided insular infarction in patients with acute stroke. METHODS:We retrospectively analyzed data from consecutive patients who received a diagnosis of acute infarction in the middle cerebral artery territory between January 2015 and December 2018. Constipation was defined as bowel movements less often than three times a week or a prescription for laxatives within 2 weeks of stroke onset. Clinical characteristics and factors associated with constipation were evaluated. RESULTS:Among 892 patients (mean age, 75 [66-82] years; male, 566 [63.5%]), 301 (32.8%) had constipation. Infarction involving the insula (57.7% vs. 25.1%) and left-sided infarction (62.5% vs. 46.4%) were more frequent in patients with constipation than in those without constipation. In multivariable analysis, infarction involving the insula (adjusted odds ratio [aOR], 2.30; 95% confidence interval [CI], 1.57-3.36; P<0.001), left-sided infarction (aOR, 1.93; 95% CI, 1.40-2.64; P<0.001), and baseline National Institutes of Health Stroke Score (aOR, 1.04; 95% CI, 1.01-1.06; P<0.001) were associated with constipation. The incidence of constipation was highest in cases of left-sided infarction with insular involvement (69.2%). CONCLUSIONS:Left-sided infarction, infarction involving the insular cortex, and baseline National Institutes of Health Stroke Score were identified as independent factors associated with constipation in patients with acute stroke.

Background: Diffusion-weighted imaging (DWI) lesion volume and infarct growth are important imaging markers in acute ischemic stroke, but manual volume measurement is time-consuming and resource-intensive. Deep learning (DL)-based automated segmentation may facilitate rapid assessment; however, its performance on hyperacute DWI has not been sufficiently assessed. The aim was to evaluate the agreement between DL-based automated and manual infarct volume measurements and to compare their ability to predict clinical outcomes in patients treated with mechanical thrombectomy (MT). Method: Consecutive MT-treated patients (September 2014-December 2019) who underwent DWI at admission and at approximately 24 hours were retrospectively analyzed. Manual infarct volume was measured by stroke neurologists. Automated measurements were obtained using DL-based software. Agreement was assessed using Pearson?s correlation, Bland-Altman analysis, and intraclass correlation coefficients (ICC 2,1). Inter- and intra-rater reliabilities were evaluated in a randomly selected subgroup of 150 patients. Predictive ability for a good outcome at 3 months (modified Rankin Scale score 0?2 or stable/improved from premorbid status) was compared using C-statistics and DeLong's test. Results: A total of 371 patients (677 DWI scans) were included. Manual and automated measurements showed very strong correlation (r = 0.96) with minimal bias (?1.77 mL). The ICC for manual-automated agreement was 0.959 (95% CI, 0.952-0.965), comparable to inter- and intra-rater ICCs. Agreement remained high across onset-to-imaging times and lesion sizes. Predictive abilities for a good outcome were similar for manual and automated admission DWI volume (C-statistics 0.867 vs. 0.861) and infarct growth (0.859 vs. 0.853). Manual follow-up DWI volume showed slightly better predictive ability than automated measurement (0.880 vs. 0.866). Conclusion: DL-based automated infarct volume measurement shows excellent agreement with experienced clinicians, with predictive performance comparable to manual assessment. Automated DWI-based quantification is reliable and feasible for use in hyperacute stroke management. ### Competing Interest Statement The JLK Inc. provided the software to the authors as part of the Support Project for Establishing the K-Health AI Daegu Medical Ecosystem, supported by Daegu Technopark.

BACKGROUND:Details of in-hospital stroke are unknown. This study aimed to clarify the incidence rate and risk factors for in-hospital stroke among all inpatients. METHODS:This retrospective single-center study included consecutive patients admitted to our hospital. Patients aged <18 years, discharged within 24 h, and admitted to the neurology and neurosurgery departments were excluded. The incidence rate for in-hospital stroke was calculated, and patients were divided into stroke and control groups based on ischemic stroke occurrence, and the risk factors were assessed using multivariate analysis. RESULTS:Of the 83,990 enrolled patients, 101 (0.12%) developed stroke. The stroke group had a higher proportion of patients with older age (76 vs 69 years; P <.01), hypertension (49% vs 26%; P <.01), diabetes mellitus (34% vs 22%; P =.01), atrial fibrillation (25% vs 8%; P <.01), cardiovascular disease (20% vs 11%; P =.01), and emergency admission (68% vs 32%; P <.01) compared to the control group. The risk factors for in-hospital stroke were old age (odds ratio [OR], 1.03; P <.01), hypertension (OR, 1.57; P =.04), diabetes mellitus (OR, 1.61; P =.03), atrial fibrillation (OR, 2.43; P <.01), emergency admission (OR, 3.38; P <.01), and low serum albumin (OR, 0.66; P =.03). CONCLUSION:The incidence rate of in-hospital stroke was 0.12% and the independent risk factors were old age, history of hypertension, diabetes mellitus, atrial fibrillation, emergency admission, and low serum albumin.

BACKGROUND AND AIMS:FLAIR vessel hyperintensities (FVH)-Alberta Stroke Program Early CT Score (ASPECTS) is an imaging marker but its clinical implications remain unclear. We estimated the correlation between FVH-ASPECTS and clinical outcomes in patients with wake-up stroke or unknown time of stroke onset. METHODS:The THrombolysis for Acute Wake-up and Unclear-onset Strokes with Alteplase at 0.6 mg/kg (THAWS) trial was a multicenter, randomized controlled trial conducted at 40 sites in Japan between 2014 and 2018. Patients with unknown stroke onset and diffusion-weighted imaging (DWI)-FLAIR mismatch were randomly assigned to receive either intravenous alteplase (0.6 mg/kg) or standard medical treatment. FVH-ASPECTS, a semiquantitative scoring system assessing FVH prominence in the seven cortical ASPECTS regions, was evaluated for its association with favorable outcomes (modified Rankin Scale 0-2 at 90 days). The optimal FVH-ASPECTS threshold was determined using receiver operating characteristic (ROC) analysis and its correlation with favorable outcomes was assessed. RESULTS:Among 131 patients (mean age, 76 ± 13 years; 42% women), 71 received alteplase and 60 did not. Median NIHSS score was 7 (interquartile range [IQR] 4-13), and median FVH-ASPECTS was 4 (IQR 2-4). ROC analysis identified FVH-ASPECTS 3 or more as predictive of favorable outcomes (sensitivity 80%, specificity 51%, area under the ROC curve [AUC] 0.717). A significant correlation was observed between FVH-ASPECTS 3 or more and favorable outcomes (adjusted odds ratio [OR] 4.50, 95% confidence interval [CI] 1.89-10.75; p < 0.001). CONCLUSION:FVH-ASPECTS could offer an indicator for achieving favorable clinical outcomes among stroke patients with unknown time of onset, with a threshold of 3 or more.

The therapeutic time window for endovascular therapy in acute stroke patients with large-vessel occlusion was extended to 24 hours from onset. Although a retrospective study showed the efficacy of endovascular therapy beyond 24 hours from the last known well, it remains unclear whether endovascular therapy is effective. Extending the time window of Endovascular therapy in the Triage of Late Presenting Strokes beyond 24 h (SKIP-EXTEND trial) aimed to clarify the efficacy of endovascular therapy compared to the best medical management. This is an investigator-initiated, multicenter, prospective, randomized, open-label, blinded end-point clinical trial. Eligibility criteria included adults and pre-stroke modified Rankin scale score <= 2 with internal carotid artery or M1 (horizontal or sphenoidal segment) occlusion beyond 24 to 72 hours of the last known well. The target enrollment is 260 patients, with 130 reeiving endovascular therapy and 130 receiving the best medical treatment. The primary outcome is the rate of favorable outcome defined as a modified Rankin scale score <= 2 at 90 days. The secondary outcomes are the ordinal logistic regression analysis of the modified Rankin scale score and the rate of recanalization at 48 hours. As safety outcomes, the rate of any and symptomatic intracranial hemorrhage at 24 hours and the rate of mortality at 90 days are assessed. This is the first randomized controlled trial to focus on the efficacy of endovascular therapy beyond 24 hours. Our results will not only benefit patients but also reduce healthcare costs. We believe that this novel study will be useful in clinical practice.

Background: We investigated the clinical effect of intravenous thrombolysis using a magnetic resonance imaging (MRI)-guided approach in cardioembolic stroke (CE) patients with unknown time of onset. Methods and Results: This subanalysis of the THAWS trial assessed the efficacy and safety of alteplase 0.6 mg/kg in CE patients with unknown time of onset and showing diffusion -weighted imaging-fluid-attenuated inversion recovery mismatch. Patients were classified as CE and non -CE using the SSS-TOAST classification system during the acute period. The efficacy outcome was a modified Rankin Scale score of 0-1 at 90 days. In all, 126 patients from the THAWS trial were included in this study, of whom 45 (35.7%) were diagnosed with CE. In the CE group, a favorable outcome was numerically more frequent in the alteplase than control group (52% vs. 35%; adjusted odds ratio [aOR] 2.25; 95% confidence interval [CI] 0.50-9.99). However, in the non -CE group, favorable outcomes were comparable between the alteplase and control groups (44% vs. 55%, respectively; aOR 0.39; 95% CI 0.12- 1.21). Treatment -by -cohort interaction for a favorable outcome was modestly significant between the CE and non -CE groups (P=0.069). In the CE group, no patients experienced symptomatic intracranial hemorrhage (ICH) or parenchymal hematoma Type II following thrombolysis. Conclusions: When an MRI-guided approach is used, CE patients with unknown time of onset appear to be suitable candidates for thrombolysis.

BACKGROUND:Infarct volume on diffusion-weighted imaging (DWI) is a promising imaging marker for clinical outcomes in patients with acute stroke treated with mechanical thrombectomy (MT), but its predictive value has not been well evaluated, especially in consecutive patients. The present study aimed to elucidate the relationship between infarct volume and its change and favorable functional outcomes in consecutive patients with acute stroke who underwent MT. METHOD:Of patients with consecutive acute stroke who underwent MT from September 2014 through December 2019, those who were pre-morbidly independent were enrolled. Infarct volume on DWI was measured at admission (DWIinitial) and 24 h after admission (DWI24h) with semi-automated imaging software. Infarct growth (IG) was calculated as the difference between DWI24h and DWIinitial. Factors associated with a favorable outcome (mRS score 0-2) 3 months after stroke onset were assessed by multivariable analyses. Model performance was evaluated with the C-statistic. RESULTS:A total of 251 patients (165 male [66 %], median age 75 [IQR 67-81] years, median NIHSS score 15 [7-21]) were enrolled in the present study. Multivariable logistic regression analysis showed that DWI24h (OR 0.74, 95 % CI 0.62-0.87 for every 10-mL increment) and IG (0.74, 0.62-0.88 for every 10-mL increment) were independently and negatively associated with a favorable outcome. These associations were observed in patients with diverse vessel occlusions. Adding DWI24h or IG to the conventional predictors of favorable outcomes improved predictive accuracy (p < 0.05). CONCLUSION:DWI infarct volume 24 h after admission and IG can be strong imaging predictors of favorable outcomes after MT.

BACKGROUND:Antithrombotic therapy (AT) should generally be avoided within 24 hours after recombinant tissue-plasminogen activator (rt-PA) treatment but should be considered in patients with large-artery atherosclerosis (LAA) who undergo concomitant emergent endovascular treatment (EVT). The aim of the present study was to assess the safety of AT within 24 hours after rt-PA treatment in patients with hyperacute ischemic stroke due to LAA who received concomitant EVT. METHODS:From January 2013 through July 2019, consecutive patients with acute ischemic cerebrovascular disease due to LAA who were admitted within 6 hours from symptom onset were recruited. The patients were classified into six groups based on the reperfusion treatment and early (within 24 hours) AT from rt-PA treatment. Safety outcomes were compared among the groups. RESULTS:A total of 155 patients (35 women [23%], median age 74 [IQR 66-79] years; NIHSS score 3 [1-10]) were included in the present study. Of these, 73 (47%) received no reperfusion therapy, 24 (15%) received rt-PA treatment and early AT, seven (6%) received rt-PA without early AT, 26 (17%) received EVT only, six (4%) received both rt-PA and EVT without early AT, and 19 (12%) received rt-PA and EVT with early AT. AT was administered a median of 3.9 (1.6-8.0) hours after rt-PA in patients with rt-PA+EVT with early AT. AT within 24 hours after rt-PA and EVT treatment did not increase hemorrhagic complications (p > 0.05 for all). CONCLUSION:In this retrospective analyses, early AT administration for patients with hyperacute stroke due to LAA treated with rt-PA plus EVT did not increase hemorrhagic events.