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Background: Successful reperfusion is one of the strongest predictors of functional outcomes after mechanical thrombectomy (MT). Despite continuous advancements in MT technology and techniques, reperfusion failure still occurs in ≈15% to 30% of patients with large vessel occlusion strokes undergoing MT. We aim to evaluate the safety and efficacy of rescue intracranial stenting for large vessel occlusion stroke after failed MT. Methods: The SAINT (Stenting and Angioplasty in Neurothrombectomy) Study is a retrospective analysis of prospectively collected data from 14 comprehensive stroke centers through January 2015 to December 2020. Patients were included if they had anterior circulation large vessel occlusion stroke due to intracranial internal carotid artery and middle cerebral artery-M1/M2 segments and failed MT. The cohort was divided into 2 groups: rescue intracranial stenting and failed recanalization (modified Thrombolysis in Cerebral Ischemia score 0–1). Propensity score matching was used to balance the 2 groups. The primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale at 90 days. Secondary outcomes included functional independence (90-day modified Rankin Scale score 0–2). Safety measures included symptomatic intracranial hemorrhage and 90-day mortality. Results: A total of 499 patients were included in the analysis. Compared with the failed reperfusion group, rescue intracranial stenting had a favorable shift in the overall modified Rankin Scale score distribution (acOR, 2.31 [95% CI, 1.61–3.32]; P P P =0.04) at 90 days. Rates of symptomatic intracerebral hemorrhage were comparable across both groups (7.1% versus 10.2%; aOR, 0.99 [95% CI, 0.42–2.34]; P =0.98). The matched cohort analysis demonstrated similar results. Specifically, rescue intracranial stenting (n=107) had a favorable shift in the overall modified Rankin Scale score distribution (acOR, 3.74 [95% CI, 2.16–6.57]; P P P =0.03) at 90 days with similar rates of symptomatic intracerebral hemorrhage (7.5% versus 11.2%; aOR, 0.87 [95% CI, 0.31–2.42]; P =0.79) compared with patients who failed to reperfuse (n=107). There was no heterogeneity of treatment effect across the prespecified subgroups for improvement in functional outcomes. Conclusions: Acute intracranial stenting appears to be a safe and effective rescue strategy in patients with large vessel occlusion stroke who failed MT. Randomized multicenter trials are warranted.

Introduction: Chronic occlusion of the ICA (COICA) is an important cause of ischemic strokes. Evidence has showed that medical management (MM) alone is not sufficient for prevention of ischemic events. Carotid occlusion endovascular revascularization & stenting (COERS) is a promising technique, yet its safety and superiority to MM remain unclear. Objective: To pool and compare rates of safety and efficacy outcomes of COERS versus MM of COICA. Methods: We conducted a systematic search in Embase, Medline, and Web of Science for studies reporting short and long-term outcomes of symptomatic COICA patients who received MM and/or COERS. Main efficacy outcomes were successful recanalization and long-term recurrence of ischemic events. Safety outcomes for COERS were periprocedural ( Results: 11 studies contained data of COICA patients undergoing COERS, 3 studies of patients who received only MM, and 2 studies compared both arms; they provided data for 513 and 313 patients in the COERS and MM groups, respectively. The pooled recanalization rate after treatment with COERS was 75% (95% CI 0.67-0.82, PI 0.49-0.94, I 2 64%). Recurrence rates of ischemic events at long-term follow-up were 19% (95% CI 0.15-0.25, PI 0.11-0.32, I 2 25%) with MM, and 11% (95% CI 0.07-0.19, PI 0.02-0.42, I 2 2%) after COERS; comparison meta-analysis showed a similar non-significant trend (MM:24% vs. COERS:13%, OR 0.52, 95% CI 0.17-1.59, I 2 0%). The rate of periprocedural events in the COERS group were 2.3% (95% CI 0.012-0.045, I 2 0%) for stroke/TIA, and 2.1% (95% CI 0.011-0.038, I 2 0%) for any ICH. Conclusion: COERS is a feasible technique and a safe strategy for maximizing secondary stroke prevention for the treatment of symptomatic COICA. Still, further prospective trials to better define safety and efficacy boundaries are needed before starting a RCT.

Introduction: When mechanical thrombectomy (MT) fails to achieve successful recanalization, rescue stenting (RS) has proven to be a feasible rescue therapy. However, the available evidence remains underpowered to assess its safety and efficacy. Objective: To compare the safety and efficacy of RS versus routine medical treatment in patients who failed MT using an aggregated metanalysis. Methods: A systematic review was performed in Scopus, Embase, Medline, and Web of Science from inception to July 2022 for all studies that tested the safety and efficacy of RS after failed MT. Outcomes of interest included an mRS score of 0-2 at 90 days, successful recanalization (mTICI 2b-3) after RS, symptomatic intracranial hemorrhage (sICH), and all-cause mortality at 90 days. A random-effects meta-analysis was performed between the RS and medical treatment arm to calculate pooled odds ratios (OR) for each outcome. Statistical heterogeneity across studies was assessed with I 2 statistics. Results: In total 12 studies involved 1855 participants, 729 in the RS arm and 1126 in the medical treatment arm. The pooled results indicated that RS was associated with a higher proportion of patients with an mRS score of 0-2 at 90 days (RS: 41% vs. 21%; OR = 3.27; 95% CI 2.08 - 5.16; I 2 = 64%) and a decreased risk of mortality at 90 days (RS: 22.5% vs. 33.8%; OR = 0.47; 95% CI 0.32 - 0.69; I 2 = 45%), compared with medical treatment after failed MT. The pooled rate of successful recanalization after RS was 87% (95% CI 82 - 91; I 2 = 57%). The rate of sICH did not differ between groups (RS: 8.5% vs. 11.7%; OR = 0.85; 95% CI 0.59 - 1.20; I 2 = 7%) Conclusion: RS represents a promising strategy that for maximizing recovery in acute stroke patients after first line MT fails to achieve meaningful reperfusion. However, a randomized trial using a standardized approach/technique and independently adjudicated outcomes is needed to confirm this observation.

Introduction: Definitive evidence about the role and effectiveness of mechanical thrombectomy (MT) in patients with distal medium-vessel occlusions (DMVOs) is limited. Objective: To determine the efficacy and safety of MT for DMVOs. Methods: A systematic search was performed until May 2022 in Scopus, Embase, Medline, Web of Science, and Cochrane. An additional cohort of 33 patients from our institutional experience was also included. Primary efficacy and safety outcomes were successful reperfusion (mTICI 2b-3) and sICH, respectively. Additional outcomes were the rate of complete reperfusion (mTICI 3), 90-day excellent and favorable functional outcome (defined as an mRS of 0-1 and 0-2, respectively), and 90-day mortality. We conducted meta-analyses using random-effects models and assessed the certainty of evidence using the GRADE approach. Statistical heterogeneity across studies was assessed with I 2 statistics. Results: A total of 24 studies with 1046 patients were included in our analysis. Successful and complete reperfusion rates were 89.8% (95% CI 83.7-93.7%; I 2 =0%; moderate-certainty evidence) and 47.2% (95% CI 32.3-62.5%; I 2 =75%; very low-certainty evidence), respectively. Favorable and excellent functional outcome rates were 59.1% (95% CI 48.4-68.9%; I 2 =73%; moderate-certainty evidence) and 43% (95% CI 32.9-53.7%; I 2 =68%; low-certainty evidence), respectively. Mortality and sICH rates were 12.4% (95% CI 9.3-16.5%; I 2 =16%; high-certainty evidence) and 5.5% (95% CI 3.5-8.5%; I 2 =23%; moderate-certainty evidence), respectively. Conclusion: This systematic review with meta-analysis found that MT for DMVO provides rates of successful reperfusion and sICH comparable to the evidence from MT for LVO stroke and M2 occlusions. Given the level of evidence of our results, further confirmation on well-designed RCTs is needed.

Introduction: Infarct evolution is a highly dynamic process that varies among individuals. This study aimed to identify clinical and radiological features associated with an exponential infarct growth rate (IGR) pattern in stroke patients with large vessel occlusion (LVO). Methods: This is a retrospective cohort study of anterior LVO stroke patients who underwent mechanical thrombectomy (MT) and achieved complete recanalization (mTICI 2c-3). Infarct volumes were calculated at two time points, pre-MT: CT perfusion (CTP) using Rapid software to estimate the CBF Results: Of the 159 patients (median age 71 [6-82], 45% male, median NIHSS 14 [9-18]) included in the analysis, 91 (57%) patients had an exponential IGR pattern. These patients had higher CT ASPECTS (9[7-10] vs 8[7-9], p=0.038), higher glucose levels (126[114-150] vs 117[106-135], p=0.022), lower Tmax Conclusions: Parameters associated with exponential infarct growth might help to stratify the most time sensitive vulnerable LVO population in which newer therapeutic and triage strategies should be prioritized. Fig. Infarct Growth Rate Plots and Collateral Status . A shows IGR with an exponential pattern . B shows IGR with a non-exponential pattern.