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Background and Purpose: Two early basilar artery occlusion (BAO) randomized controlled trials (RCTs) did not establish the superiority of endovascular thrombectomy (EVT) over medical management. Yet many providers continued to recommend EVT. The goal of the present article is to compare physicians' diagnostic and management strategies of BAO among middle-income and high-income countries (MICs and HICs, respectively). Methods: We conducted an international survey from January to March 2022 regarding management strategies in acute BAO, to examine clinical and imaging parameters influencing clinician management of patients with BAO. We compared responses between physicians from HIC and MIC. Results: Among the 1245 respondents from 73 countries, 799 (64.2%) were from HIC, with the remaining 393 (31.6%) from MIC. Most respondents perceived that EVT was superior to medical management for acute BAO, but more so in respondents from HIC (98.0% vs. 94.2%, p < 0.01). MIC respondents were more likely to believe further RCTs were warranted (91.6% vs. 74.0%, p < 0.01) and were more likely to find it acceptable to enroll any patient who met a trial's criteria in the standard medical treatment arm (58.8% vs. 38.5%, p < 0.01). Conclusions: In an area where clinical equipoise was called into question despite the lack of RCT evidence, we found that respondents from MIC were more likely to express willingness to enroll patients with BAO in an RCT than their HIC counterparts. [ABSTRACT FROM AUTHOR]

Introduction Stroke is a leading cause of adult death and disability. Although acute ischemic stroke (AIS) in pregnancy is rare, it has devastating consequences on the life of the mother and fetus. Pregnancy was an exclusion criterion in endovascular thrombectomy (EVT) trials and so there are no evidence-based treatment recommendations in this subgroup. The objective of this study was to evaluate the safety and feasibility of mechanical thrombectomy in large vessel occlusion (LVO) stroke in pregnancy. Methods Patients with AIS due to LVO treated with EVT during pregnancy between 2000 and 2019 were identified at seven tertiary care centers. After IRB approval, retrospective analysis of prospectively maintained stroke/endovascular databases was performed. Results A total of seven subjects were identified. The average age was 33.2 years (range 25-38 years) and the average initial National Institutes of Health Stroke Scale (NIHSS) score at presentation was 15 (range 9-28). Three patients received IV tissue plasminogen activator. Techniques of EVT included stent retriever thrombectomy, stent retriever-assisted continuous aspiration, direct contact aspiration, and multimodal techniques including a rescue balloon mounted coronary stent placement. While one patient was noted to have petechial hemorrhage, no individuals developed parenchymal hematoma. Mean discharge NIHSS score was 1.7 (range 0-5). Conclusion EVT is a safe and effective treatment for acute stroke secondary to LVO in this series of pregnant patients. While EVT for acute stroke is standard of care in select patient populations, our study suggests that treatment should be considered in the gravid population. [ABSTRACT FROM AUTHOR]

Introduction The minimal stroke severity justifying endovascular intervention remains elusive; however, a significant proportion of patients presenting with large vessel occlusion (LVO) and mild symptoms subsequently decline and face poor outcomes. Objective To evaluate our experience with these patients by comparing best medical therapy with thrombectomy in an intention-to-treat analysis. Methods Analysis of prospectively collected data of all consecutive patients with National Institutes of Health Stroke Scale (NIHSS) score ≤5, LVO on CT angiography, and baseline modified Rankin Scale (mRS) score 0-2 from November 2014 to May 2016. After careful discussion with patients/family, a decision to pursue medical or interventional therapy was made. Deterioration (development of aphasia, neglect, and/or significant weakness) triggered reconsideration of thrombectomy. The primary outcome measure was NIHSS shift (discharge NIHSS score minus admission NIHSS score). Results Of the 32 patients qualifying for the study, 22 (69%) were primarily treated with medical therapy and 10 (31%) intervention. Baseline characteristics were comparable. Nine (41%) medically treated patients had subsequent deterioration requiring thrombectomy. Median time from arrival to deterioration was 5.2 hours (2.0-25.0). Successful reperfusion (modified Treatment in Cerebral Infarction 2b-3) was achieved in all 19 thrombectomy patients. The NIHSS shift significantly favored thrombectomy (-2.5 vs 0; p<0.01). The median NIHSS score at discharge was low with both thrombectomy (1 (0-3)) and medical therapy (2 (0.5-4.5)). 90-Day mRS 0-2 rates were 100% and 77%, respectively (p=0.15). Multivariable linear regression indicated that thrombectomy was independently associated with a beneficial NIHSS shift (unstandardized β -4.2 (95% CI -8.2 to -0.1); p=0.04). Conclusions Thrombectomy led to a shift towards a lower NIHSS in patients with LVO presenting with minimal stroke symptoms. Despite the overall perception that this condition is benign, nearly a quarter of patients primarily treated with medical therapy did not achieve independence at 90 days. [ABSTRACT FROM AUTHOR]

Background and Purpose: Acute ischemic stroke (AIS) in the elderly encompasses approximately one-third of all AIS cases. Outcome data have been for the most part discouraging in this population. We aim to evaluate the outcomes in a large contemporary series of elderly patients treated with thrombectomy. Methods: Retrospective analysis of a single-center endovascular database for consecutive elderly ( ≥ 80 years) patients treated for anterior circulation large vessel occlusion AIS between September 2010 and April 2015. Univariate- and multivariate analyses were performed to identify the predictors of good clinical outcome (90-day modified Ranking Scale [mRS] ≤ 2). Receiver operating characteristic curves were used to calculate the optimal final infarct volume (FIV) threshold to predict good outcomes. Results: A total of 111 patients met our inclusion criteria (mean age 84.8 ± 4.2 years; National Institutes of Health Stroke Scale [NIHSS] score 19.1 ± 5.6; time from last-known normal to puncture, 349.6 ± 246.6 min; 33% male; 68% Alberta Stroke Program Early CT Score [ASPECTS] ≥ 8). The rates of successful reperfusion (modified treatment in cerebral ischemia ≥ 2b), symptomatic intracranial hemorrhage and 90- day mortality were 80%, 7% and 41%, respectively. The overall rate of good outcome was 29% (n = 32/111) but was 52% (n = 13/25) in patients with baseline mRS score of 0-2 who were selected based on CT perfusion and treated with stent retrievers. On multivariate analysis, only ASPECTS (OR 2.17; 95% CI 1.28-3.67.7; p = 0.004) and baseline NIHSS score (OR 0.87; 95% CI 0.77-0.97; p = 0.013) were independently associated with good outcome. A FIV ≤ 16 ml demonstrated the greatest accuracy for identifying good outcomes (sensitivity 75.0%, specificity 82.6%). Conclusions: Our results are encouraging demonstrating nearly one-third of elderly patients achieving full independence at 90 days. Contemporary treatment paradigms employing optimized patient selection and modern thrombectomy technology may result in even better outcomes. [ABSTRACT FROM AUTHOR]

Background: Ischemic strokes due to tandem occlusions (TOs) have poor outcomes if they have been treated with only medical interventions. Recent trials demonstrated the effectiveness of endovascular treatment of acute ischemic stroke due to intracranial occlusions; however, most studies excluded patients with TOs. Methods: Retrospective review of prospectively collected thrombectomy databases from 3 stroke centers between 2011 and 2015. Consecutive patients with tandem extracranial steno-occlusive carotid disease and intracranial occlusions who underwent emergent thrombectomy were selected. Angiographic and clinical outcomes were analyzed; baseline and procedural variables were included in univariate and multivariate analyses to define the independent predictors of good outcomes (90-day modified Rankin Scale ≤ 2). Results: A total of 100 patients met the study inclusion criteria. The mean age was 64.4 ± 12.5, baseline National Institutes of Health Stroke Scale (NIHSS) 17.6 ± 5.0, time from last known well to puncture 7.3 ± 5.8 h, and Alberta Stroke Program Early CT Score (ASPECTS) 7.5 ± 1.6. Forty percent received intravenous tissue plasminogen activator. Intracranial occlusion sites included: internal carotid artery thrombus, 31%; middle cerebral artery (MCA)-M1, 53%; MCA-M2, 10%; and anterior cerebral artery, 6%. Good outcome was achieved in 42% and successful reperfusion modified thrombolysis in cerebral infarction (mTICI ≥ 2B) in 88% of the cases, including complete (mTICI 3) reperfusion in 40%. Severe parenchymal hematoma (PH)-2 occurred in 6% of the patients and 90-day mortality was 20%. In the multivariate analysis, younger age (OR 0.93; 95% CI 0.88-0.98; p = 0.004), lower baseline NIHSS (OR 0.84; 95% CI 0.74-0.94; p = 0.003), higher ASPECTS (OR 1.50; 95% CI 1.02-2.19; p = 0.038), and mTICI 3 reperfusion (OR 3.56; 95% CI 1.18-10.76; p = 0.024) were independent predictors of good outcome at 90 days. Conclusions: Acute endovascular treatment of tandem anterior circulation occlusions yields good outcomes and has similar outcome predictors to isolated intracranial occlusions. Given their comparable clinical behavior, these patients should be included in future trials. [ABSTRACT FROM AUTHOR]