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Acute ischemic stroke affects men and women differently in many ways. In particular, women are oftentimes reported to experience a higher acute stroke severity than men. Here, we derived a low-dimensional representation of anatomical stroke lesions and designed a sex-aware Bayesian hierarchical modelling framework for a large-scale, well phenotyped stroke cohort. This framework was tailored to carefully estimate possible sex differences in lesion patterns explaining acute stroke severity (NIHSS) in 1,058 patients (39% female). Anatomical regions known to subserve motor and language functions emerged as relevant regions for both men and women. Female patients, however, presented a more widespread pattern of stroke severity-relevant lesions than male patients. Furthermore, particularly lesions in the posterior circulation of the left hemisphere underlay a higher stroke severity exclusively in women. These sex-sensitive lesion pattern effects could be discovered and subsequently robustly replicated in two large independent, multisite lesion datasets. The constellation of findings has several important conceptual and clinical implications: 1) suggesting sex-specific functional cerebral asymmetries, and 2) motivating a sex-stratified approach to management of acute ischemic stroke. To go beyond sex-averaged stroke research, future studies should explicitly test whether acute therapies administered on the basis of sex-specific cutoff volumes of salvageable tissue will lead to improved outcomes in women after acute ischemic stroke.

Background and PurposeTo explore the whole-brain dynamic functional network connectivity patterns in acute ischemic stroke (AIS) patients and their relation to stroke severity in the short and long term.MethodsWe investigated large-scale dynamic functional network connectivity of 41 AIS patients two to five days after symptom onset. Re-occurring dynamic connectivity configurations were obtained using a sliding window approach and k-means clustering. We evaluated differences in dynamic patterns between three NIHSS-stroke severity defined groups (mildly, moderately, and severely affected patients). Furthermore, we established correlation analyses between dynamic connectivity estimates and AIS severity as well as neurological recovery within the first 90 days after stroke (DNIHSS). Finally, we built Bayesian hierarchical models to predict acute ischemic stroke severity and examine the inter-relation of dynamic connectivity and clinical measures, with an emphasis on white matter hyperintensity lesion load.ResultsWe identified three distinct dynamic connectivity configurations in the early post-acute stroke phase. More severely affected patients (NIHSS 10–21) spent significantly more time in a highly segregated dynamic connectivity configuration that was characterized by particularly strong connectivity (three-level ANOVA: ppr = –0.68, pConclusionsOur findings demonstrate transiently increased segregation between multiple functional domains in case of severe AIS. Dynamic connectivity involving default mode network components significantly correlated with recovery in the first three months post-stroke.

Background and purpose The number of clot retrieval attempts required to achieve complete reperfusion by mechanical thrombectomy impacts functional outcome in acute ischaemic stroke (AIS). Complete reperfusion [expanded Treatment In Cerebral Infarction (eTICI) score = 3] at first pass (FP), is associated with the highest rates of favorable outcome compared to complete reperfusion by multiple passes. The aim of the present study was to investigate the relationship between FP complete reperfusion and infarct growth (IG). Methods Anterior AIS patients with baseline and 24-h diffusion-weighted magnetic resonance imaging were included from two prospective registries. IG was measured by voxel-based segmentation of initial and 24-h diffusion-weighted imaging lesions. IG and favorable 3-month modified Rankin Scale (mRS) score (≤ 2) were compared between patients in whom complete reperfusion (eTICI 3) was achieved with a single pass (FP group) and those for whom multiple passes were required (MP group), after matching for confounding factors. Mediation analysis was performed to examine the association between FP and 3-month mRS score, with IG as mediating variable. Results A total of 200 patients were included, of whom 118 (28.9%) had FP complete reperfusion. In case-control analysis, the FP group had lower IG than the MP group [8.7 (5.4-12.9) ml vs. 15.2 (11-22.6) ml, respectively; P = 0.03). Favorable outcome was higher in the FP population compared to a matched MP population (70.9% vs. 53.2%, respectively; P = 0.04). FP compete reperfusion (eTICI 3) was independently associated with favorable outcome in multivariable regression analysis [odds ratio 1.86, 95% confidence interval (CI) 1.01-4.39; P = 0.04]. The effect of complete reperfusion at FP on functional outcome was explained by limited IG in mediation analysis [indirect effect: -0.32 (95% CI -0.47 to -0.09)]. Conclusion Complete reperfusion at FP is independently associated with significant decrease in IG compared to complete reperfusion by multiple attempts, explaining better functional outcomes.

Stroke, a major burden to society, can now be treated in increasingly larger numbers of patients. Intravenous thrombolysis and mechanical thrombectomy are both now standard of care with class I, level of evidence A. Various local, regional, and national challenges are present, preventing equality in access to care for many patients. France is a developed country with a centralized national health care system accessible for all citizens. This article discusses current challenges in the implementation of the delivery of stroke care and some solutions that are being evaluated by the medical community.

ObjectivesThe MRI-DRAGON score includes clinical and MRI parameters and demonstrates a high specificity in predicting 3 month outcome in patients with acute ischemic stroke (AIS) treated with intravenous tissue plasminogen activator (IV tPA). The aim of this study was to adapt this score to mechanical thrombectomy (MT) in a large multicenter cohort.MethodsConsecutive cases of AIS treated by MT between January 2015 and December 2017 from three stroke centers were reviewed (n=1077). We derived the MT-DRAGON score by keeping all variables of the MRI-DRAGON score (age, initial National Institutes of Health Stroke Scale score, glucose level, pre-stroke modified Rankin Scale (mRS) score, diffusion weighted imaging-Alberta Stroke Program Early CT score ≤5) and considering the following variables: time to groin puncture instead of onset to IV tPA time and occlusion site. Unfavorable 3 month outcome was defined as a mRS score >2. Score performance was evaluated by c statistics and an external validation was performed.ResultsAmong 679 included patients (derivation and validation cohorts, n=431 and 248, respectively), an unfavorable outcome was similar between the derivation (51.5%) and validation (58.1%, P=0.7) cohorts, and was significantly associated with all MT-DRAGON parameters in the multivariable analysis. The c statistics for unfavorable outcome prediction was 0.83 (95%CI 0.79 to 0.88) in the derivation and 0.8 (95%CI 0.75 to 0.86) in the validation cohort. All patients (n=55) with an MT-DRAGONscore ≥11 had an unfavorable outcome and 60/63 (95%) patients with an MT-DRAGON score ≤2 points had a favorable outcome.ConclusionThe MT-DRAGON score is a simple tool, combining admission clinical and radiological parameters that can reliably predict 3 month outcome after MT.

IntroductionTo determine the influence of white matter hyperintensity (WMH) burden on functional outcome, rate of symptomatic intracerebral hemorrhage (sICH), and procedural success in patients with acute ischemic stroke (AIS) treated by mechanical thrombectomy (MT) with current stentriever/aspiration devices.MethodsPatients with AIS due to large vessel occlusion (LVO) from the Thrombectomie des Artères Cérébrales (THRACE) trial and prospective cohorts from 2 academic comprehensive stroke centers treated with MT were pooled and retrospectively analyzed. WMH volumes were obtained by semiautomated planimetric segmentation and tested in association with the rate of favorable outcome (90-day functional independence), substantial recanalization after MT, and sICH.ResultsA total of 496 participants were included between 2015 and 2018 (50% female, mean age 68.1 ± 15.0 years). Overall, 434 (88%) patients presented with detectable WMH (mean ± SD 4.93 ± 7.7). Patients demonstrated increasingly worse outcomes with increasing WMH volumes (odds ratio [aOR]1.05 per 1-cm3 increase for unfavorable outcome, 95% confidence interval [CI] 1.01–1.06, p = 0.014). Fifty-seven percent of patients in the first quartile of WMH volume vs 28% in the fourth quartile demonstrated favorable outcome (p < 0.001). WMH severity was not associated with sICH rate (aOR 0.99, 95% CI 0.93–1.04, p = 0.66), nor did it influence recanalization success (aOR 0.99, 95% CI 0.96–1.02, p = 0.84).ConclusionOur study provides evidence that in patients with AIS due to LVO and high burden of WMH as assessed by pretreatment MRI, the safety and efficacy profiles of MT are similar to those in patients with lower WMH burden and confirms that they are at higher risk of unfavorable outcome. Because more than a quarter of patients in the highest WMH quartile experienced favorable 3 months outcome, WMH burden may not be a good argument to deny MT.ClinicalTrials.gov IdentifierNCT01062698.

Background and Purpose— Optimal management of the extracranial occlusive component remains controversial in patients with acute ischemic stroke by tandem occlusion treated with mechanical thrombectomy. We investigated the association between extracranial internal carotid artery (ICA) patency at day 1 and the clinical outcome after mechanical thrombectomy. Methods— Consecutive patients with acute ischemic stroke with tandem occlusion were identified from a hospital-based prospective registry from 2011 to 2017. Baseline characteristics, angiographic outcomes, and day 1 ICA patency assessed by MR angiography were analyzed with regard to their associations with 3-month modified Rankin Scale scores. Favorable outcome was defined as a modified Rankin Scale score of 0 to 2 at 3 months. Results— Of 594 patients with acute ischemic stroke treated with mechanical thrombectomy during the study period, 83 met inclusion criteria. Successful recanalization (modified Thrombolysis in Cerebral Infarction, 2b/3) was achieved in 61.5%. Extracranial ICA was patent in 37 of 83 patients (44.6%) at day 1, more frequently in those with prior intravenous thrombolysis ( P =0.035) or with cervical revascularization procedure (balloon angioplasty or stenting, P =0.034). Favorable 3-month functional outcome was more frequent in patients with patent extracranial ICA at day 1 (adjusted odds ratio, 4.72; 95% CI, 1.76–13.34; P =0.003) independent of intracranial recanalization success. Conclusions— Day 1 stable extracranial ICA patency is associated with better clinical outcome in patients with acute ischemic stroke with tandem occlusions. Randomized studies are needed.

Objective To study the safety and performance of real-world thrombectomy using the SOFIA Catheter in our comprehensive stroke center. Methods We conducted a cohort study from a prospective clinical registry of consecutive stroke patients treated by mechanical thrombectomy between March 2016 and September 2017. Baseline clinical and imaging characteristics, recanalization rates, complications, and clinical outcomes were analyzed. Results Among the 140 patients included, 54 were treated using aspiration first, 64 were treated using aspiration and stent-retriever straightaway, and 22 were treated with SOFIA as a rescue device. Successful recanalization (Modified Thrombolysis In Cerebral Infarction score 2b/3) was achieved in 82.1% patients and good outcomes in 34.3%. Symptomatic intracranial hemorrhage occurred in 7.1% and mortality in 25%. Conclusions In our single-center experience, thrombectomy using the SOFIA as an intermediate or aspiration catheter provided high recanalization rates under everyday conditions.

Introduction Cerebral white matter hyperintensity (WMH) on FLuid Attenuated Inversion Recovery (FLAIR) is linked to less favourable outcome in patients with acute ischemic stroke (AIS) but data on their relevance in patients with large vessel occlusion (LVO) treated with mechanical thrombectomy (MT) are sparse. In this post-hoc analysis of the MT arm of the THRACE trial and multicenter retrospective cohorts, we aimed to determine the influence of WMH burden on clinical outcome, rate of symptomatic intracranial hemorrhage (ICH) and procedural success in AIS patients treated by MT with current stentriever/aspiration devices. Patients and methods Patients from the MT arm of THRACE trial, and prospective cohorts from two academic comprehensive stroke centers were pooled and retrospectively analyzed. WMH volumes were obtained by semi-automated planimetric segmentation and tested in association with the rate of favourable outcome (mRS 0-2 at at 90 days), successful recanalization after MT (mTICI ≥ 2B), and symptomatic ICH. Results A total of 535 subjects met inclusion criteria between 2015 and 2018 (49 % female, mean age 68,0 years ± 15,0 Overall, 458 (85,6 %) patients presented with detectable WMH (median volume 5,7cc IQR [2,8–12,7]). Patients demonstrated increasingly worse outcomes with increasing WMH volumes), with 57 % of patients in the 1st quartile of WMH volume demonstrating favourable outcome vs. 27 % in the 4th (p Conclusion Our study provides evidence that patients with AIS due to LVO and severe WMH as assessed by pre-treatment MRI, are at higher risk for less favourable outcome following MT, despite similar rates of sICH and procedural success. Since 27 % of patients with severe WMH in our sample experienced favourable outcome at 3 months, severe WMH burden may not preclude MT.

Introduction La signification du rehaussement de la paroi des anevrismes intra-crâniens non rompus en IRM 3-Tesla demeure aujourd’hui incertaine. L’objectif de cette etude etait d’evaluer la prevalence du rehaussement de la paroi anevrismale dans une cohorte de patients presentant un anevrisme non rompu avant decision therapeutique. Methodes Nous avons inclus retrospectivement les patients consecutifs avec anevrisme intracrânien non rompu adresses dans notre service pour imagerie cerebrale complementaire avant decision therapeutique entre novembre 2015 et avril 2017. Les donnees cliniques et d’imagerie incluant des sequences d’IRM 3D-T1 Turbo Spin Echo apres injection de gadolinium ont ete collectees. Resultats Parmi les 68 patients (81 anevrismes) inclus, un rehaussement de la paroi anevrismale etait objective pour 31 (45,6 %) patients et 34 (42,0 %) anevrismes. La taille de l’anevrisme etait fortement associee au rehaussement de la paroi (Odds Ratio 2,60 ; IC 95 % : 1,61–4,19, p = 0,001). Une valeur seuil de 4,1 mm etait predictive d’un rehaussement de la paroi de l’anevrisme avec une sensibilite de 82,4 % et une specificite de 85,1 %. Il n’etait pas retrouve d’association entre les caracteristiques cliniques et le rehaussement anevrismal. Conclusion Notre etude suggere que la taille de l’anevrisme est un determinant majeur du rehaussement de la paroi pour les anevrismes intra-crâniens non rompus.

Objectif L’imagerie des caillots responsables d’AVC ischemiques est un potentiel biomarqueur pour la decision therapeutique, le diagnostic etiologique et le pronostic. L’IRM permet d’estimer la concentration en fer des tissus, a l’aide du QSM (quantitative susceptibility mapping) ou de la relaxivite R2*. Notre but etait de predire la concentration en globules rouges et en fer d’analogues experimentaux de caillots en IRM. Materiel et methode Vingt-deux analogues de caillots de concentrations croissantes en globules rouges (0 %, 20 %, 40 %, 60 %, 80 %, 99 %) ont ete analyses en IRM 7 teslas ex vivo avec une sequence 3D echo de gradient T2 multi-echo (voxel : 0,125 × 0,125 × 0,125 mm, nombre d’echos : 4, TR : 50ms, TE : 7 – 28ms) au cours de 4 sessions. Les cartes parametriques de susceptibilite magnetique et de R2* etaient calculees a l’aide de la toolbox MEDI (Cornell University). Au decours des acquisitions, la quantite de fer au sein de chaque caillot etait mesuree en photometrie d’absorption atomique electrothermique et la quantite de globules rouges par analyse histologique apres coloration MSB. Resultats Les valeurs de R2* etait correlees significativement a la concentration en fer (R2 = 0,2729 p = 0,022). Les valeurs de susceptibilite magnetique en QSM n’etaient pas correlees significativement avec la concentration en fer ou en globules rouges malgre une tendance observable. Cette absence de correlation est expliquee par un defaut de reproductibilite inter-sessions. Conclusion Les valeurs de R2* d’analogues de caillots sont correlees a leur concentration en fer. Une validation de ces resultats sur des caillots retires en thrombectomie mecanique est necessaire.