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Background A thrombus in the M1 segment of the middle cerebral artery (MCA) can occlude this main stem only or extend into the M1- M2 bifurcation. The occlusion pattern may affect endovascular treatment (EVT) success, as a bifurcated thrombus may be more prone to fragmentation during retrieval. Objective To investigate whether bifurcated thrombus patterns are associated with EVT procedural and clinical outcomes. Methods Occlusion patterns of MCA thrombi on CT angiography from MR CLEAN Registry patients were classified into three groups: main stem occlusion, bifurcation occlusion extending into one M2 branch, and bifurcation occlusion extending into both M2 branches. Procedural parameters, procedural outcomes (reperfusion grade and embolization to new territory), and clinical outcomes (24- 48 hour National Institutes of Health Stroke Scale [NIHSSFU] score, change in NIHSS scores between 24 and 48 hours and baseline Δ [NIHSS], and 90- day modified Rankin Scale [mRS] scores) were compared between occlusion patterns. Results We identified 1023 patients with an MCA occlusion of whom 370 (36%) had a main stem occlusion, 151 (15%) a single branch, and 502 (49%) a double branch bifurcation occlusion. There were no statistically significant differences in retrieval method, procedure time, number of retrieval attempts, reperfusion grade, and embolization to new territory between occlusion patterns. Patients with main stem occlusions had lower NIHSSFU scores than patients with single (7 vs 11, p=0.01) or double branch occlusions (7 vs 9, p=0.04). However, there were no statistically significant differences in Δ NIHSS or in 90- day mRS scores. Conclusions In our population, EVT procedural and long- term clinical outcomes were similar for MCA bifurcation occlusions and MCA main stem occlusions. [ABSTRACT FROM AUTHOR]

Aims and Background: We describe the initial results of the Syphontrack Super Distal Access (SDA) catheter (InNeuroco Inc., Sunrise, Fl, USA) used for endovascular treatment of patients with acute ischemic stroke of the anterior circulation.Methods: A retrospective review of prospectively collected data from June 2017 to May 2018 in Maastricht University Medical Center plus (MUMC +) with direct distal aspiration or a combination of distal aspiration with stent retriever thrombectomy was performed. Primary outcome measurements were accessibility and reperfusion grade (eTICI). Secondary outcome measurements were early neurologic recovery (a decrease of four or more points on the NIHSS), symptomatic intracranial hemorrhage (sICH) within 24 h and mRS score at 3 months.Results: The first 50 patients in whom the SDA catheter was used are included. Direct distal aspiration was performed in 33/50 (66%). In 29/33 (88%), distal position in contact with the clot was achieved of which 15 (52%) were successful (eTICI 2b or higher) after first attempt. Total successful reperfusion rate was 23/50 (46%) after first pass. Final successful reperfusion, after multiple attempts, was reached in 48/50 (96%). Early neurologic recovery was seen in 21/50 (42%), and functional independence (mRS score of 0-2) at 3 months was achieved in 17/50 (35%). sICH occurred in 4/50 (8%) within 24 h post-procedural.Conclusion: In our clinical practice, endovascular treatment of ischemic stroke with the SDA catheter had similar technical and clinical results as reported in the literature. [ABSTRACT FROM AUTHOR]

Objectives: Whereas highly cost-effective and cost-saving for patients with small infarcts, whether endovascular thrombectomy (EVT) remains cost-effective in patients with extensive ischemic injury is uncertain., Methods: We conducted a model-based cost-effectiveness analysis from the United States, Australian, and Spanish societal perspectives, using a 7-state Markov model, with each state defined by the modified Rankin Scale (mRS) score. Initial probabilities at 3 months were derived from the SELECT2 trial. All other model inputs, including transition probabilities, health care and non-health care costs, and utility weights, were sourced from published literature and government websites. Our analysis included extensive sensitivity and subgroup analyses., Results: EVT in patients with large ischemic stroke improved health outcomes and was associated with lower costs from a societal viewpoint. EVT was cost-effective with a mean between-group difference of 1.24 quality-adjusted life years (QALYs), and a cost-saving of $23,409 in the United States, $10,691 in Australia, and $30,036 in Spain, in addition to uncosted benefits in productivity for patients and carers. Subgroup analyses were directionally consistent with the overall population, notably with preserved cost-effectiveness in older patients (≥ 70 years) and those with more severe strokes (National Institutes of Health Stroke Scale [NIHSS] ≥ 20). Sensitivity analyses were largely consistent with the base-case results., Interpretation: EVT demonstrated cost-effectiveness in patients with large core across different settings in the United States, Australia, and Spain, including older patients and those with more severe strokes. These results further support adaptation of systems of care to accommodate the expansion of thrombectomy eligibility to patients with large cores and maximize EVT benefits. ANN NEUROL 2025;97:222-231., (© 2024 American Neurological Association.)

Background: A thrombus in the M1 segment of the middle cerebral artery (MCA) can occlude this main stem only or extend into the M1-M2 bifurcation. The occlusion pattern may affect endovascular treatment (EVT) success, as a bifurcated thrombus may be more prone to fragmentation during retrieval., Objective: To investigate whether bifurcated thrombus patterns are associated with EVT procedural and clinical outcomes., Methods: Occlusion patterns of MCA thrombi on CT angiography from MR CLEAN Registry patients were classified into three groups: main stem occlusion, bifurcation occlusion extending into one M2 branch, and bifurcation occlusion extending into both M2 branches. Procedural parameters, procedural outcomes (reperfusion grade and embolization to new territory), and clinical outcomes (24-48 hour National Institutes of Health Stroke Scale [NIHSS FU ] score, change in NIHSS scores between 24 and 48 hours and baseline ∆ [NIHSS], and 90-day modified Rankin Scale [mRS] scores) were compared between occlusion patterns., Results: We identified 1023 patients with an MCA occlusion of whom 370 (36%) had a main stem occlusion, 151 (15%) a single branch, and 502 (49%) a double branch bifurcation occlusion. There were no statistically significant differences in retrieval method, procedure time, number of retrieval attempts, reperfusion grade, and embolization to new territory between occlusion patterns. Patients with main stem occlusions had lower NIHSS FU scores than patients with single (7 vs 11, p=0.01) or double branch occlusions (7 vs 9, p=0.04). However, there were no statistically significant differences in ∆ NIHSS or in 90-day mRS scores., Conclusions: In our population, EVT procedural and long-term clinical outcomes were similar for MCA bifurcation occlusions and MCA main stem occlusions., Competing Interests: Competing interests: This project has received funding from the European Union’s Horizon 2020 research and innovation program under grant agreement No 777072 (INSIST project), and the AMC medical Research BV, Amsterdam UMC, location AMC, under project No 21937. The MR CLEAN registry is partially funded by unrestricted grants from the Applied Scientific Institute for Neuromodulation (Toegepast Wetenschappelijk Instituut voor Neuromodulatie), Erasmus Medical Center, Amsterdam University Medical Center and Maastricht University Medical Center. HAM reports co-founder and shareholder of Nicolab, a company that focuses on the use of artificial intelligence for medical image analysis. CBLMM reports grants from European Commission during the conduct of the study; grants from CVON/Dutch Heart Foundation, TWIN Foundation, and Stryker, outside the submitted work; and shareholder of Nicolab. IGHJ reports shareholder of Nicolab. DWJD and AvdL report unrestricted grants from Stryker, Penumbra, Medtronic, Cerenovus, Thrombolytic Science, LLC, Dutch Heart Foundation, Brain Foundation Netherlands, The Netherlands Organization for Health Research and Development, Health Holland Top Sector Life Sciences and Health, and Thrombolytic Science, LLC for research, paid to institution. BvdW received funds from Bayer and LivaNova for consultancy, paid to his institution, and grants from the Dutch Heart Foundation, the Horizon 2020 programme, and Stryker, paid to his institution, all outside the work submitted. The remaining authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest., (© Author(s) (or their employer(s)) 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Randomised controlled trials with perfusion selection have shown benefit of endovascular treatment (EVT) for ischaemic stroke between 6 and 24 hours after symptom onset or time last seen well. However, outcomes after EVT in these late window patients without perfusion imaging are largely unknown. We assessed their characteristics and outcomes in routine clinical practice., Methods: The Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands Registry, a prospective, multicentre study in the Netherlands, included patients with an anterior circulation occlusion who underwent EVT between 2014 and 2017. CT perfusion was no standard imaging modality. We used adjusted ordinal logistic regression analysis to compare patients treated within versus beyond 6.5 hours after propensity score matching on age, prestroke modified Rankin Scale (mRS), National Institutes of Health Stroke Scale, Alberta Stroke Programme Early CT Score (ASPECTS), collateral status, location of occlusion and treatment with intravenous thrombolysis. Outcomes included 3-month mRS score, functional independence (defined as mRS 0-2), and death., Results: Of 3264 patients who underwent EVT, 106 (3.2%) were treated beyond 6.5 hours (median 8.5, IQR 6.9-10.6), of whom 93 (87.7%) had unknown time of stroke onset. CT perfusion was not performed in 87/106 (80.2%) late window patients. Late window patients were younger (mean 67 vs 70 years, p<0.04) and had slightly lower ASPECTS (median 8 vs 9, p<0.01), but better collateral status (collateral score 2-3: 68.3% vs 57.7%, p=0.03). No differences were observed in proportions of functional independence (43.3% vs 40.5%, p=0.57) or death (24.0% vs 28.9%, p=0.28). After matching, outcomes remained similar (adjusted common OR for 1 point improvement in mRS 1.04, 95% CI 0.56 to 1.93)., Conclusions: Without the use of CT perfusion selection criteria, EVT in the 6.5-24-hour time window was not associated with poorer outcome in selected patients with favourable clinical and CT/CT angiography characteristics. randomised controlled trials with lenient inclusion criteria are needed to identify more patients who can benefit from EVT in the late window., Competing Interests: Competing interests: Erasmus MC received funds from Stryker and Bracco Imaging by DWJD. MUMC received funds from Stryker and Codman for consultations by WHvZ. WHvZ and RJvO are principal investigators for the MR CLEAN-LATE trial. R-JBG and FAVP are coordinating researchers for MR CLEAN-LATE. CBLMM received funds from TWIN Foundation (related to this project, paid to institution) and from CVON/Dutch Heart Foundation, Stryker, European Commission, Health Evaluation Netherlands (unrelated; all paid to institution). YBWEMR, CBLMM and IGHJ are shareholders of Nico.lab, a company that focuses on the use of artificial intelligence for medical imaging analysis. RL reports institutional fees from Ischamaview for consultancy. The other authors had no conflicting interests., (© Author(s) (or their employer(s)) 2021. Re-use permitted under CC BY. Published by BMJ.)

Background and Purpose: Little is known about the combined effect of age and National Institutes of Health Stroke Scale (NIHSS) in endovascular treatment (EVT) for acute ischemic stroke due to large vessel occlusion, and it is not clear how the effects of baseline age and NIHSS on outcome compare to each other. The previously described Stroke Prognostication Using Age and NIHSS (SPAN) index adds up NIHSS and age to a 1:1 combined prognostic index. We added a weighting factor to the NIHSS/age SPAN index to compare the relative prognostic impact of NIHSS and age and assessed EVT effect based on weighted age and NIHSS., Methods: We performed adjusted logistic regression with good outcome (90-day modified Rankin Scale score 0–2) as primary outcome. From this model, the coefficients for NIHSS and age were obtained. The ratio between the NIHSS and age coefficients was calculated to determine a weighted SPAN index. We obtained adjusted effect size estimates for EVT in patient subgroups defined by weighted SPAN increments of 3, to evaluate potential changes in treatment effect., Results: We included 1750/1766 patients from the HERMES collaboration (Highly Effective Reperfusion Using Multiple Endovascular Devices) with available age and NIHSS data. Median NIHSS was 17 (interquartile range, 13–21), and median age was 68 (interquartile range, 57–76). Good outcome was achieved by 682/1743 (39%) patients. The NIHSS/age effect coefficient ratio was ([−0.0032]/[−0.111])=3.4, which was rounded to 3, resulting in a weighted SPAN index defined as ([3×NIHSS]+age). Cumulative EVT effect size estimates across weighted SPAN subgroups consistently favored EVT, with a number needed to treat ranging from 5.3 to 8.7., Conclusions: The impact on chance of good outcome of a 1-point increase in NIHSS roughly corresponded to a 3-year increase in patient age. EVT was beneficial across all weighted age/NIHSS subgroups.

Background and Purpose- The modified Rankin Scale (mRS) at 3 months is the most commonly used primary outcome measure in stroke treatment trials, but it lacks specificity and requires long-term follow-up interviews, which consume time and resources. An alternative may be the National Institutes of Health Stroke Scale (NIHSS), early after stroke. Our aim was to evaluate whether the NIHSS assessed within 1 week after treatment could serve as a primary outcome measure for trials of acute treatment for ischemic stroke. Methods- We used data from 2 randomized controlled trials of endovascular treatment for ischemic stroke: the positive MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands; N=500) and the neutral IMS (Interventional Management of Stroke) III trial (N=656). We used a causal mediation model, with linear and ordinal logistic regression adjusted for confounders, to evaluate the NIHSS 24 hours and 5 to 7 days after endovascular treatment as primary outcome measures (instead of the mRS at 3 months) in both trials. Patients who had died before the NIHSS was assessed received the maximum score of 42. NIHSS+1 was then log10-transformed. Results- In both trials, there was a significant correlation between the NIHSS at 24 hours and 5 to 7 days and the mRS. In MR CLEAN, we found a significant effect of endovascular treatment on the mRS and on the NIHSS at 24 hours and 5 to 7 days. After adjustment for NIHSS at 24 hours and 5 to 7 days, the effect of endovascular treatment on the mRS decreased from common odds ratio 1.68 (95% CI, 1.22-2.32) to respectively 1.36 (95% CI, 0.97-1.91) and 1.24 (95% CI, 0.87-1.79), indicating that treatment effect on the mRS is in large part mediated by the NIHSS. In the IMS III trial there was no treatment effect on the NIHSS at 24 hours and 5 to 7 days, corresponding with the absence of a treatment effect on the mRS. Conclusions- The NIHSS within 1 week satisfies the requirements for a surrogate end point and may be used as a primary outcome measure in trials of acute treatment for ischemic stroke, particularly in phase II(b) trials. This could reduce stroke-outcome assessment to its essentials (ie, neurological deficit), and reduce trial duration and costs. Whether and under which conditions it could be used in phase III trials requires a debate in the field with all parties. Clinical Trial Registration- URL: http://www.isrctn.com. Unique identifier: ISRCTN10888758; https://www.clinicaltrials.gov. Unique identifier: NCT00359424.

Objective  To improve the selection of patients with acute ischaemic stroke for intra-arterial treatment using a clinical decision tool to predict individual treatment benefit. Design  Multivariable regression modelling with data from two randomised controlled clinical trials. Setting  16 hospitals in the Netherlands (derivation cohort) and 58 hospitals in the United States, Canada, Australia, and Europe (validation cohort). Participants  500 patients from the Multicenter Randomised Clinical Trial of Endovascular Treatment for Acute Ischaemic Stroke in the Netherlands trial (derivation cohort) and 260 patients with intracranial occlusion from the Interventional Management of Stroke III trial (validation cohort). Main outcome measures  The primary outcome was the modified Rankin Scale (mRS) score at 90 days after stroke. We constructed an ordinal logistic regression model to predict outcome and treatment benefit, defined as the difference between the predicted probability of good functional outcome (mRS score 0-2) with and without intra-arterial treatment. Results  11 baseline clinical and radiological characteristics were included in the model. The externally validated C statistic was 0.69 (95% confidence interval 0.64 to 0.73) for the ordinal model and 0.73 (0.67 to 0.79) for the prediction of good functional outcome, indicating moderate discriminative ability. The mean predicted treatment benefit varied between patients in the combined derivation and validation cohort from -2.3% to 24.3%. There was benefit of intra-arterial treatment predicted for some individual patients from groups in which no treatment effect was found in previous subgroup analyses, such as those with no or poor collaterals. Conclusion  The proposed clinical decision tool combines multiple baseline clinical and radiological characteristics and shows large variations in treatment benefit between patients. The tool is clinically useful as it aids in distinguishing between individual patients who may experience benefit from intra-arterial treatment for acute ischaemic stroke and those who will not. Trial registration  clinicaltrials.gov NCT00359424 (IMS III) and isrctn.com ISRCTN10888758 (MR CLEAN)., Competing Interests: Competing interests: All authors have completed the ICMJE uniform disclosure form. JPB received study medication for intra-arterial tissue type plasminogen activator from Genentech and catheters were supplied by EKOS Corporation, Concentric Medical, and Cordis. His research is funded by the Department of Neurology and Rehabilitation Medicine. He is remunerated by Genentech for his role on the Steering Committee for A Study of the Efficacy and Safety of Activase (Alteplase) in Patients With Mild Stroke (PRISMS) trial. SDY is remunerated by Genentech for her statistical role in the PRISMS trial. PK is remunerated by Genentech for her role as lead principal investigator of the PRISMS trial and by Penumbra for her role as neurology principal investigator of the Assess the Penumbra System in the Treatment of Acute Stroke trial. She has also received royalties from UpToDate and consulted for Grand Rounds, St Jude Medical, and Biogen. BJE is remunerated for his role as CE mark reviewer by DEKRA and by Novartis for educational lectures. Erasmus MC received funds from Stryker for consultations by DWJD and AL and for training courses by BJE, and from Bracco Imaging for consultations by DWJD. The Academic Medical Centre received funds from Stryker for consultations by CBLMM and YBWEMR. Maastricht University Medical Centre received funds from Stryker and Codman for consultations by WHZ., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)