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The Korean government implemented the pilot project for community care for older adults in June 2019. This study investigated the outcomes of the pilot project among Korean older adults by linking survey data from the pilot project with data of Korean National Health Insurance Service. The final sample included 17,801 pilot project participants and 68,145 in a matched comparison group. Pilot program participants experienced an increase of 4.8 days for length of home stay and a reduction of $956 (US) per participant relative to the matched comparison group. Pilot program participants with long-term care insurance who used home care services experienced an increase of 8.9 days for length of home stay and a reduction in $1,177 (US) in total costs, along with a reduction in the admission to long-term care facilities, compared to the matched comparison group. Patients discharged from hospitals indicated an increase of 35.2 days for length of home stay and a reduction of $6,947 (US) in total costs, but a 3.53 times increase in hospital readmissions relative to the matched comparison group. The pilot project for community care resulted in increased length of home stay and reduced total costs among older adults in Korea.

Objectives: This study aimed to evaluate the association between home-based primary care (HBPC) and postdischarge outcomes in Korean older adults., Design: HBPC was a service that provided medical care by visiting the homes of older adults with limited mobility. In this study, data from the National Health Insurance Service (NHIS) were used, and groups with and without HBPC services were matched 1:1 through propensity score matching. Cox proportional hazards model and linear regression analysis were performed to compare the HBPC group with the control group., Setting and Participants: Overall, 1580 older adults in Korea who used HBPC services after discharge from hospital and 1580 propensity score-matched older adults who did not use HBPC services were included., Methods: For 30-day readmission, hospitalizations, and admission to long-term care hospitals or facilities after discharge, this study used a Cox proportional hazards regression model. And linear regression analysis was performed considering that the dependent variable was a continuous variable to examine the average total medical costs after discharge from acute hospital., Results: Older adults who used HBPC services exhibited a lower risk of readmission for the same disease (risk reduction of 0.66, 95% CI 0.50, 0.87) and hospitalization (risk reduction of 0.58, 95% CI 0.46, 0.73) compared with those who did not use HBPC services. The annual average total medical cost was $4764 lower for older adults who used HBPC services than for those who did not (95% CI -6469.49, -3057.52). There was no significant difference in the risk of admission to long-term care hospitals or facilities., Conclusions and Implications: HBPC services had a positive effect on reducing 30-day readmission due to the same disease, hospitalization, and annual average total medical costs among older adults after discharge., Competing Interests: Disclosure The authors declare no conflicts of interest., (Copyright © 2024 Post-Acute and Long-Term Care Medical Association. Published by Elsevier Inc. All rights reserved.)

Background: The EXCELLENT registry aimed to evaluate the effectiveness of the EMBOTRAP Revascularization Device in an all-comer population in a real-world setting, with a focus on the composition of retrieved clots., Methods: EXCELLENT is a prospective, global registry of patients with acute ischemic stroke treated with EMBOTRAP as the first-line mechanical thrombectomy device conducted at 34 sites (25 sites contributing clot) from September 2018 to March 2021, utilizing core imaging and central histology laboratories blinded to clinical data, independent 90-day modified Rankin Scale assessment and Clinical Events Committee., Results: After screening 3799 patients, a total of 997 subjects (mean age, 70.0±14.2 years; 51.8% women; 19.7% non-White) were included. The first-pass modified Treatment in Cerebral Infarction (mTICI) ≥2b rate was 64.5% (623/966), first-pass mTICI ≥2c was 39.1% (378/966), and final mTICI ≥2b was 94.5% (931/985). A total of 427/912 (46.8%) patients achieved a 90-day modified Rankin Scale of 0 to 2 or ≤baseline. Embolization to a new territory occurred in 0.2% (2/984), and symptomatic intracranial hemorrhage at 24 hours in 1.6% (16/997). The 90-day mortality was 19.1% (175/918). Device- and/or procedure-related serious adverse events occurred in 5.9% (54/912) through 90 days. The mean RBC percentage of retrieved clots was 45.62±21.372. Among patients who achieved mTICI ≥2b with the first pass, 15.7% (52/331) and 9.7% (32/331), respectively, had RBC-poor (<25%) and RBC-rich (>75%) clots. Patients with no clot retrieved in any procedural pass had a lower percentage of hyperdense or susceptibility vessel sign on baseline imaging (58.9% versus 74.7%; P <0.001), pointing to a potential preprocedure indicator of challenging clot., Conclusions: The EXCELLENT registry informs real-world practices in mechanical thrombectomy and sheds light on the range of clots effectively retrieved by current technology. This is the first report of detailed patient characteristics where mechanical thrombectomy maneuvers failed to remove any clot material. Although the composition of nonretrievable clots cannot be assessed histologically, the results support the notion that no retrieval may be correlated with imaging findings suggesting clots lower in RBC., Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03685578., Competing Interests: Dr Nogueira: consulting for Anaconda, Medtronic, Cerenovus, Genentech, Viz-AI, Stryker, Prolong Pharmaceuticals, Perfuze, Biogen, Shanghai Wallaby, Brainomix, Hybernia, RapidPulse, Imperative Care, Corindus, NeuroVasc Technologies, Vesalio, Cerebrotech, Phenox, Astrocyte, Ceretrieve, Philips; grants from Stryker, Cerenovus; data safety monitoring for Synchron; ownership/investment interest in Ceretrieve, Corindus, Brainomix, Perfuze, Truvic, Viz-AI, Reist, Q’Apel, Vesalio, Cerebrotech, Viseon, Piraeus, Brain4Care, Quantanosis-AI. Dr Andersson: consulting for Neuravi, Anaconda, Johnson & Johnson (J&J), Rapid Medical; ownership/investment interest in Ceroflo. Dr Haussen: consulting for Brainomix, Vesalio, Stryker, Poseydon, Chiesi, Cerenovus; ownership/investment interest in Viz-AI; data safety monitoring for Jacobs Institute. Dr Yoo: consulting for Philips, Nicolab, ZOLL Circulation, Vesalio, Rapid Medical; grants and consulting for J&J, Medtronic, Penumbra; grants from Stryker, Genentech; ownership/investment interest in Gravity, Galaxy Therapeutics, Insera, Nicolab; data safety monitoring for NIH; employment with HCA Healthcare; other services for AHA. Dr Hanel: consulting for Balt, MicroVention, Medtronic, Rapid Medical, Stryker, Phenox, Cerenovus, Q’Apel; ownership/investment interest in Cerebrotech, Three Rivers Medical, NTI, Endostream, BlinkTBI, RisT, InNeuroCo, Corindus, eLum, Scientia. Dr Zaidat: consulting for J&J; patent holder. Dr Hacke: consulting for J&J. Dr Jovin: consulting for Contego Medical; grants from Medtronic, Stryker; employment with Cooper University Healthcare; data safety monitoring for Cerenovus; ownership/investment interest in Anaconda, StataDx, Galaxy, Basking, Freeox Biotech, Kandu, Viz-AI, Route92, Gravity. Dr Fiehler: consulting for Stryker, Cerenovus, Penumbra, MicroVention, Roche, Tonbridge, Phenox, TG Medical, Medtronic, Acandis; ownership/investment interest in Vastrax, Eppdata, Tegus; employment with Eppdata. Dr De Meyer: travel support from J&J. Dr Brinjikji: consulting for Cerenovus, MicroVention, Medtronic, Balt, Imperative Care, MIVI; ownership interest in Piraeus, Nested Knowledge, MIVI; research funding from Cerenovus, Brainomix, NIH. Dr Doyle: grants from SFI, Cerenovus. Dr Kallmes: grants from MIVI, Cerenovus, Balt, Vesalio, Stryker, MicroVention, Insera, Medtronic, Brainomix; ownership/investment interest in Superior Medical Experts, Conway Medical, Piraeus, Monarch Biosciences, Marblehead, Nested Knowledge; patent holder. Dr Liebeskind: consulting for Cerenovus, Medtronic, Genentech, Stryker, Rapid Medical. Dr Virmani: grants from Endotronix, L&J Bio, W.L. Gore, Recombinetics, Transverse Medical, Profusa, Lutonix, MicroVention, Envision, Neovasc, Cerus EndoVascular, MedAlliance, Interface Biologics, Biotronik, Mercator MedSystems, Spectrawave, Cook Medical, SoundPipe, Ossio, Bolt Medical, CardioMech, Olympus, Spartan Micro, Intact Vascular, Inc, Whiteswell, Vascudyne, Imperative Care, Biotyx Medical, SMT, Innovative Medical Devices, Cardiovascular Solutions, Dexcom, Emboline, Cooper Health, Children’s National, Concept Medical, Filterlex, eLum Technologies, Protembis, Boston Scientific, Polares, MDS, CeloNova, UCSF Foundation, Croivalve, Canon, Terumo, BD Biosciences, Limflow, Renata, Vetex, Recor, Mayo Clinic, CSI, Ohio Health, UPMC, Regencor, Vesper, Ripple Therapeutics, Polyvascular, Invatin, Innovative Cardiovascular Solutions, TruLeaf, Coramaze, ProKidney, 480 Biomedical, Transmural Systems, Intershunt Technologies, Pi-Cardia, Lyra Therapeutics, Sanofi, Phenox, Qool Therapeutics, Chansu Vascular Technologies, Nyra Medical, Surmodics, Microport, Leducq Foundation, OrbusNeich, Cardiac Implants, Rush University, Edwards Lifesciences, Cardionomic, Restore Medical, Medanex, CRL, Lahav, Pulse Biosciences, Jacobs Institute, Nova Vascular, Nephronyx, Maywell, Innovalve, Elucid Bioimaging, Medtronic, Biosensors International Group, ShockWave Medical, Cardiawave, NIH, Occlutech; consulting for Terumo, Recor Medical, Sino Medical, Medtronic, Cook, W.L. Gore, CSI, Surmodics, CeloNova, Edwards Lifesciences, BARD, Xeltis; other services for Xeltis, Medtronic; employment with CVPath Institute. Dr Kokoszka: employment with Cerenovus. Dr Inoa: consulting for Siemens, Viz-AI, Medtronic, Cerenovus, MicroVention, Penumbra; grants from Medtronic; employment with Semmes Murphey Clinic. Dr Humphries: consulting for Cerenovus. Dr Jabbour: consulting for Medtronic. Dr François: consulting for iVascular. Dr Levy: consulting for Guidepoint, GLG Consulting, Clarion, StimMed, Mosaic; other services for Penumbra, Medtronic, MicroVention; ownership/investment interest in Imperative Care, StimMed, Three Rivers Medical, NeXtGen Biologics, Q’Apel, Claret Medical, Rapid Medical. Dr Dashti: consulting for MicroVention, J&J, Cerenovus. Dr Schirmer: consulting for Balt, Medtronic, Stryker, Viz-AI, MicroVention; grants from Route92, MicroVention, Penumbra, Cerenovus, Balt, MIVI, Medtronic; employment with Geisinger; other services for Werfen, Cerenovus, NIH, Stryker, Neurotechnology Investors; ownership interest in Reist. Dr Hussain: consulting for J&J. Dr De Leacy: consulting for J&J, Imperative Care, Stryker; ownership/investment interest in Vastrax, Q’Apel, Spartan Micro, Synchron, Endostream. Dr Puri: consulting for J&J, MicroVention, Merit Medical, Stryker, Medtronic, Balt. Dr Chitale: grants, consulting, and data safety monitoring for Medtronic; grants from J&J. Dr Siddiqui: consulting for Cerebrotech, Boston Scientific, Rapid Medical, Cordis, W.L. Gore, Peijia Medical, Corindus, StimMed, J&J, Viz-AI, Silk Road Medical, Piraeus, Medtronic, Penumbra, Hyperfine Operations, Cerenovus, Endostream, Minnetronix Neuro, Stryker, Canon Medical Systems, Integra LifeSciences, Imperative Care, Apellis, Amnis Therapeutics, Vassol, IRRAS, Cardinal Health 200, Q’Apel, InspireMD, MicroVention, Serenity Medical; grants from Brain Aneurysm Foundation, NIH; other services for Rapid Medical, MicroVention, MIVI, Medical University of South Carolina, Penumbra, Cerenovus, InspireMD, Medtronic; ownership/investment interest in Willow Medtech, Cognition Medical, Whisper Medical, Spinnaker, Sim & Cure, Hyperion, BlinkTBI, Surgical, Inc, Radical Catheter Technologies, Imperative Care, Code Zero Medical, E8, Truvic, Tulavi, Bend IT, Neurolutions, Q’Apel, Endostream, Cerebrotech, Instylla, Collavidence Medical, Sense Diagnostics, Neurotechnology Investors, Peijia Medical, Synchron, Viseon, Borvo, E8, Galaxy Therapeutics, Piraeus, Adona Medical, NeuroRadial Technologies, NextGen Biologics, Viz-AI, Three Rivers Medical, StimMed, Serenity Medical, Cerevatech, Cvaid, Silk Road Medical, PerFlow Medical, InspireMD, VICIS, QAS.ai, SongBird, Launch NY, Neurovascular Diagnostics, Vastrax, Cognition Medical, Integra LifeSciences, Medtronic; employment with University at Buffalo Neurosurgery, Jacobs Institute; patent holder. The other authors report no conflicts.

Background: Challenges to revascularization of large vessel occlusions (LVOs) persist. Current stent retrievers have limited effectiveness for removing organized thrombi. The NeVa device is a novel stent retriever designed to capture organized thrombi within the scaffold during retrieval., Objective: To evaluate the safety and effectiveness of revascularization of acute LVOs with the NeVa device., Methods: Prospective, international, multicenter, single-arm, Investigational Device Exemption study to evaluate the performance of the NeVa device in recanalizing LVOs including internal carotid artery, M1/M2 middle cerebral artery, and vertebrobasilar arteries, within 8 hours of onset. Primary endpoint was rate of expanded Treatment in Cerebral Ischemia (eTICI) score 2b-3 within 3 NeVa passes, tested for non-inferiority against a performance goal of 72% with a -10% margin. Additional endpoints included first pass success and 90-day modified Rankin Scale (mRS) score 0-2. Primary composite safety endpoint was 90-day mortality and/or 24-hour symptomatic intracranial hemorrhage (sICH)., Results: From April 2021 to April 2022, 139 subjects were enrolled at 25 centers. Median National Institutes of Health Stroke Scale (NIHSS) score was 16 (IQR 12-20). In the primary analysis population (n=107), eTICI 2b-3 within 3 NeVa passes occurred in 90.7% (97/107; non-inferiority P<0.0001; post hoc superiority P<0.0001). First pass eTICI 2b-3 was observed in 73.8% (79/107), with first pass eTICI 2b67-3 in 69.2% (74/107) and eTICI 2c-3 in 48.6% (52/107). Median number of passes was 1 (IQR 1-2). Final eTICI 2b-3 rate was 99.1% (106/107); final eTICI 2b67-3 rate was 91.6% (98/107); final eTICI 2c-3 rate was 72.9% (78/107). Good outcome (90-day mRS score 0-2) was seen in 65.1% (69/106). Mortality was 9.4% (13/138) with sICH in 5.0% (7/139)., Conclusions: The NeVa device is highly effective and safe for revascularization of LVO strokes and demonstrates superior first pass success compared with a predicate performance goal., Trial Registration Number: NCT04514562., Competing Interests: Competing interests: AJY: consultant: Penumbra, Cerenovus, Vesalio, Zoll Circulation, Philips Neurovascular; individual stocks/stock options: Nicolab; ownership interest: Insera Therapeutics, Galaxy Therapeutics; research funding (principal investigator (PI) or named investigator): Medtronic, Cerenovus, Penumbra, Stryker, Genentech. LS: consultant: Balt, Medtronic, Microvention, Stryker; research funding (PI or named investigator): Philips. AH: consultant: Medtronic, Microvention, Stryker, Penumbra, Cerenovus, Genentech, GE Healthcare, Scientia, Balt, Viz.ai, Insera therapeutics, Proximie, NeuroVasc, NovaSignal, Vesalio, Rapid Medical, Imperative Care. AS: consultant: Microvention, Stryker, Vesalio. AHS: consultant: Amnis Therapeutics, Apellis Pharmaceuticals, Inc., Boston Scientific, Canon Medical Systems USA, Inc., Cardinal Health 200, LLC, Cerebrotech Medical Systems, Inc., Cerenovus, Cerevatech Medical, Inc; inidividual stocks/stock options: Adona Medical, Inc., Amnis Therapeutics, Bend IT Technologies, Ltd., BlinkTBI, Inc, Borvo Medical, Inc., Cerebrotech Medical Systems, Inc., Cerevatech Medical, Inc., Cognition Medical, Collavidence, I; other; Cerenovus EXCELLENT and ARISE II Trial; Medtronic SWIFT PRIME, VANTAGE, EMBOLISE and SWIFT DIRECT Trials; MicroVention FRED Trial; CONFIDENCE Study; MUSC POSITIVE Trial; Penumbra 3D Separator Trial, Research Funding (PI or named investigator); co-investigator for NIH - 1R01EB030092-01, Project Title: High speed angiography at 1000 frames per second; Mentor for Brain Aneurysm Foundation Carol W. Harvey Chair of Research, Sharon Epperson Chai. SG: Consultant; Stryker, Microvention, Medtronic. TRM: Advisor; Carpl AI. MTF: advisor; Cerenovus; research funding (PI or named investigator): Medtronic Neurovascular; researcher: Stryker Neurovascular, Cerenovus, Rapid Medical. DCH: consultant; Stryker Neurovascular, Cerenovus, Chiesi USA, Brainomix, Poseydon Medical; individual stocks/stock options: VizAI and Motif; other: Jacobs Institute/Medtronic, Vesalio., Frontiers in Neurology. MIC: advisor: Celt/Vasorum; consultant: Microvention, Medtronic, Imperative Care, Q'Apel; individual stocks/stock options: Imperative Care, Celt/Vasorum, Synchron, Endostream, Cerebrotech, Q'Apel, RIST, Three Rivers Medical, Neuolutions, Radical Medical, Tulavi, viseon, VMT, Vastrax, Serenity Medical. MF: consultant: Cerenovus, Balt, Jacobs Institute, Kai Medical, Oculus; research funding (PI or named investigator): Vesalio, Genentech, Siemens. MS: consultant: Vesalio., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Background: Recent trials confirmed the efficacy and safety of endovascular thrombectomy in patients with low Alberta Stroke Program Early Computed Tomography Score (ASPECTS); however, evidence in tandem lesions is limited. This study evaluates endovascular thrombectomy safety and efficacy in patients with acute large-vessel occlusion with tandem lesions, stratified by baseline ASPECTS., Methods and Results: We conducted a retrospective analysis of data from 16 centers. Inclusion criteria included the following: age ≥18 years, anterior circulation tandem lesions, endovascular thrombectomy <24 hours of symptom onset, and ≥70% internal carotid artery stenosis/occlusion. Patients were categorized into low (0-5) and high (6-10) ASPECTS. Inverse probability of treatment weighting matching was used to balance the groups. Primary outcomes included the following: 90-day modified Rankin Scale (mRS) score 0 to 2 and symptomatic intracranial hemorrhage. Secondary outcomes included the following: ordinal mRS, mRS 0 to 3, modified Thrombolysis in Cerebral Infarction ≥2b and 2c-3, petechial hemorrhage, parenchymal hematoma (1/2), early neurologic improvement, and mortality. Of 691 patients, 44 had ASPECTS 0 to 5 and 505 had ASPECTS 6 to 10. Patients with low ASPECTS had lower odds of 90-day mRS 0 to 2 (adjusted odds ratio [OR], 0.48; P =0.036) and higher odds of symptomatic intracranial hemorrhage (adjusted OR, 3.78; P =0.014). Additional significant differences were found in mRS shift, mRS 0 to 3, parenchymal hematoma 2, and mortality. In interaction analysis, the association between low ASPECTS and functional outcome persisted only in the internal carotid artery occlusion subgroup, with no significant interaction indicating no reason to suppose a difference between the effect of both subgroups., Conclusions: Endovascular thrombectomy in patients with tandem lesions with low ASPECTS is associated with reduced odds of functional recovery and increased symptomatic intracranial hemorrhage risk, when compared with patients with high ASPECTS. However, 30% of patients with low ASPECTS achieved 90-day functional independence, suggesting potential benefit for a nonnegligible proportion of patients.

Importance: Recent large infarct thrombectomy trials used heterogeneous imaging modalities and time windows for patient selection. Noncontrast computed tomographic (CT) scan is the most common stroke imaging approach. It remains uncertain whether thrombectomy is effective for patients with large infarcts identified using noncontrast CT alone within 24 hours of stroke onset., Objective: To evaluate the effect of thrombectomy in patients with a large infarct on a noncontrast CT scan within 24 hours of onset., Design, Setting, and Participants: Open-label, blinded-end point, bayesian-adaptive randomized trial with interim analyses for early stopping (futility or success) or population enrichment, which was conducted at 47 US academic and community-based stroke thrombectomy centers. Three hundred patients presenting within 24 hours with anterior-circulation, large-vessel occlusion and large infarct on noncontrast CT scan, with Alberta Stroke Program Early CT Scores of 2 to 5, were randomized to undergo thrombectomy or usual care. Enrollment occurred July 16, 2019 to October 17, 2022; final follow-up, January 25, 2023., Intervention: The intervention patients (n = 152) underwent endovascular treatment using standard thrombectomy devices and usual medical care. Control patients (n = 148) underwent usual medical care alone., Main Outcomes and Measures: The primary efficacy end point was improvement in 90-day functional outcome measured using mean utility-weighted modified Rankin Scale (UW-mRS) scores (range, 0 [death or severe disability] to 10 [no symptoms]; minimum clinically important difference, 0.3). A bayesian model determined the posterior probability that the intervention would be superior to usual care; statistical significance was a 1-sided posterior probability of .975 or more. The primary adverse event end point was 90-day mortality; secondary adverse event end points included symptomatic intracranial hemorrhage and radiographic intracranial hemorrhage., Results: The trial enrolled 300 patients (152 intervention, 148 control; 138 females [46%]; median age, 67 years), without early stopping or enrichment; 297 patients completed the 90-day follow-up. The mean (SD) 90-day UW-mRS score was 2.93 (3.39) for the intervention group vs 2.27 (2.98) for the control group with an adjusted difference of 0.63 (95% credible interval [CrI], -0.09 to 1.34; posterior probability for superiority of thrombectomy, .96). The 90-day mortality was similar between groups: 35.3% (53 of 150) for the intervention group vs 33.3% (49 of 147) for the control group. Six of 151 patients (4.0%) in the intervention group and 2 of 149 (1.3%) in the control group experienced 24-hour symptomatic intracranial hemorrhage. Fourteen patients of 148 (9.5%) in the intervention group vs 4 of 146 (2.7%) in the control group experienced parenchymal hematoma type 1 hemorrhages; 14 (9.5%) in the intervention group vs 5 (3.4%) in the control group experienced parenchymal hematoma type 2 hemorrhages; and 24 (16.2%) in the intervention group vs 9 (6.2%) in the control group experienced subarachnoid hemorrhages., Conclusions and Relevance: Among patients with a large infarct on noncontrast CT within 24 hours, thrombectomy did not demonstrate improvement in functional outcomes. But the width of the credible interval around the effect estimate includes the possibility of both no important effect and a clinically relevant benefit, so the potential role of thrombectomy with this imaging approach and time window will likely require additional study., Trial Registration: ClinicalTrials.gov Identifier: NCT03805308.

Background: Intravenous thrombolysis is a standard treatment of acute ischemic stroke. The efficacy and safety of combining intravenous thrombolysis with argatroban (an anticoagulant agent) or eptifibatide (an antiplatelet agent) are unclear., Methods: We conducted a phase 3, three-group, adaptive, single-blind, randomized, controlled clinical trial at 57 sites in the United States. Patients with acute ischemic stroke who had received intravenous thrombolysis within 3 hours after symptom onset were assigned to receive intravenous argatroban, eptifibatide, or placebo within 75 minutes after the initiation of thrombolysis. The primary efficacy outcome, the utility-weighted 90-day modified Rankin scale score (range, 0 to 10, with higher scores reflecting better outcomes), was assessed by means of centralized adjudication. The primary safety outcome was symptomatic intracranial hemorrhage within 36 hours after randomization., Results: A total of 514 patients were assigned to receive argatroban (59 patients), eptifibatide (227 patients), or placebo (228 patients). All the patients received intravenous thrombolysis (70% received alteplase, and 30% received tenecteplase), and 225 patients (44%) underwent endovascular thrombectomy. At 90 days, the mean (±SD) utility-weighted modified Rankin scale scores were 5.2±3.7 with argatroban, 6.3±3.2 with eptifibatide, and 6.8±3.0 with placebo. The posterior probability that argatroban was better than placebo was 0.002 (posterior mean difference in utility-weighted modified Rankin scale score, -1.51±0.51) and that eptifibatide was better than placebo was 0.041 (posterior mean difference, -0.50±0.29). The incidence of symptomatic intracranial hemorrhage was similar in the three groups (4% with argatroban, 3% with eptifibatide, and 2% with placebo). Mortality at 90 days was higher in the argatroban group (24%) and the eptifibatide group (12%) than in the placebo group (8%)., Conclusions: In patients with acute ischemic stroke treated with intravenous thrombolysis within 3 hours after symptom onset, adjunctive treatment with intravenous argatroban or eptifibatide did not reduce poststroke disability and was associated with increased mortality. (Funded by the National Institute of Neurological Disorders and Stroke; MOST ClinicalTrials.gov number, NCT03735979.)., (Copyright © 2024 Massachusetts Medical Society.)

Background and Objectives: Current evidence suggests that acute carotid artery stenting (CAS) for cervical lesions is associated with better functional outcomes in patients with acute stroke with tandem lesions (TLs) treated with endovascular therapy (EVT). However, the underlying causal pathophysiologic mechanism of this relationship compared with a non-CAS strategy remains unclear. We aimed to determine whether, and to what degree, reperfusion mediates the relationship between acute CAS and functional outcome in patients with TLs., Methods: This subanalysis stems from a multicenter retrospective cohort study across 16 stroke centers from January 2015 to December 2020. Patients with anterior circulation TLs who underwent EVT were included. Successful reperfusion was defined as a modified Thrombolysis in Cerebral Infarction scale ≥2B by the local team at each participating center. Mediation analysis was conducted to examine the potential causal pathway in which the relationship between acute CAS and functional outcome (90-day modified Rankin Scale) is mediated by successful reperfusion., Results: A total of 570 patients were included, with a median age (interquartile range) of 68 (59-76), among whom 180 (31.6%) were female. Among these patients, 354 (62.1%) underwent acute CAS and 244 (47.4%) had a favorable functional outcome. The remaining 216 (37.9%) patients were in the non-CAS group. The CAS group had significantly higher rates of successful reperfusion (91.2% vs 85.1%; p = 0.025) and favorable functional outcomes (52% vs 29%; p = 0.003) compared with the non-CAS group. Successful reperfusion was a strong predictor of functional outcome (adjusted common odds ratio [acOR] 4.88; 95% CI 2.91-8.17; p < 0.001). Successful reperfusion partially mediated the relationship between acute CAS and functional outcome, as acute CAS remained significantly associated with functional outcome after adjustment for successful reperfusion (acOR 1.89; 95% CI 1.27-2.83; p = 0.002). Successful reperfusion explained 25% (95% CI 3%-67%) of the relationship between acute CAS and functional outcome., Discussion: In patients with TL undergoing EVT, successful reperfusion predicted favorable functional outcomes when CAS was performed compared with non-CAS. A considerable proportion (25%) of the treatment effect of acute CAS on functional outcome was found to be mediated by improvement of successful reperfusion rates.

Background: Tandem lesions consist of cervical internal carotid artery (ICA) stenosis or occlusion, most commonly of atherosclerosis or dissection etiology, plus a large vessel occlusion. In this study, we compare outcomes in patients with atherosclerosis versus dissection of the cervical ICA., Methods: This multicenter retrospective cohort study includes data from tandem lesion patients who underwent endovascular treatment from 2015 to 2020. Atherosclerosis was defined as ICA stenosis/occlusion associated with a calcified lesion and dissection by the presence of a tapered or flame-shaped lesion and intramural hematoma. Primary outcome: 90-day functional independence (modified Rankin Scale score, 0-2); secondary outcomes: 90-day favorable shift in the modified Rankin Scale score, modified Thrombolysis in Cerebral Infarction score 2b-3, modified Thrombolysis in Cerebral Infarction score 2c-3, symptomatic intracranial hemorrhage, parenchymal hematoma type 2, petechial hemorrhage, distal embolization, early neurological improvement, and mortality. Analysis was performed with matching by inverse probability of treatment weighting., Results: We included 526 patients (68 [59-76] years; 31% females); 11.2% presented dissection and 88.8%, atherosclerosis. Patients with dissection were younger, had lower rates of hypertension, hyperlipidemia, diabetes, and smoking history. They also exhibited higher rates of ICA occlusion, multiple stents (>1), and lower rates of carotid self-expanding stents. After matching and adjusting for covariates, there were no differences in 90-day functional independence. The rate of successful recanalization was significantly lower in the dissection group (adjusted odds ratio, 0.38 [95% CI, 0.16-0.91]; P =0.031), which also had significantly higher rates of distal emboli (adjusted odds ratio, 2.53 [95% CI, 1.15-5.55]; P =0.021). There were no differences in other outcomes. Acute ICA stenting seemed to increase the effect of atherosclerosis in successful recanalization., Conclusions: This study reveals that among patients with acute stroke with tandem lesions, cervical ICA dissection is associated with higher rates of distal embolism and lower rates of successful recanalization than atherosclerotic lesions. Using techniques to minimize the risk of distal embolism may mitigate this contrast. Further prospective randomized trials are warranted to fully understand these associations., Competing Interests: Disclosures A.E. Hassan reports compensation from Penumbra, Inc, for consultant services; employment by Valley Baptist Medical Center; compensation from Cerenovus for consultant services; compensation from Medtronic for consultant services; compensation from viz AI for consultant services; compensation from MicroVention, Inc, for consultant services; compensation from Stryker Corporation for consultant services; and compensation from GE Healthcare for consultant services. Dr Divani reports employment by the University of New Mexico. Dr Abraham reports compensation from Penumbra, Inc, for consultant services; compensation from Stryker Corporation for consultant services; and compensation from Q’Apel for consultant services. Dr Fifi reports compensation from Cerenovus for consultant services; compensation from Mivi for data and safety monitoring services; employment by Mount Sinai Health System; compensation from MicroVention, Inc, for consultant services; compensation from Stryker Corporation for consultant services; grants from viz AI; stock holdings in Imperitive Care; compensation from Penumbra, Inc, for consultant services; and compensation from Medtronic for consultant services. Dr Siegler reports grants from Philips and viz AI. Dr Nguyen reports compensation from Brainomix for consultant services; compensation from Aruna for consultant services; and compensation from the American Stroke Association for other services. Dr Sheth reports compensation from viz AI for consultant services; compensation from Imperative Care, Inc, for consultant services; employment by UTHealth McGovern Medical School; compensation from Motif Neurosciences for other services; compensation from Penumbra, Inc, for consultant services; and grants from the National Institutes of Health. Dr Yoo reports compensation from Vesalio for consultant services; grants from Genentech USA, Inc, to other services; compensation from the National Institutes of Health for data and safety monitoring services; compensation from Rapid Medical, Ltd, for consultant services; stock holdings in Galaxy Therapeutics; compensation from Johnson & Johnson Medical Devices & Diagnostics Group-Latin America, L.L.C. for consultant services; compensation from ZOLL Circulation, Inc, for consultant services; grants from Medtronic to other services; employment by HCA Healthcare; grants from Johnson & Johnson Medical Devices & Diagnostics Group-Latin America, L.L.C. to other services; grants from Penumbra, Inc, to other services; stock holdings in Insera; compensation from Nicolab for consultant services; compensation from Penumbra, Inc, for consultant services; grants from Stryker to other services; stock options in Nicolab; compensation from Philips for consultant services; compensation from the American Heart Association for other services. Dr De Leacy reports compensation from Stryker Corporation for consultant services; stock holdings in endostream; stock holdings in Spartan Micro; stock holdings in Synchron; stock holdings in Q’Apel; compensation from Imperative Care, Inc, for consultant services; stock holdings in Vastrax; and compensation from Johnson & Johnson for consultant services. Dr Mokin reports stock holdings in QAS.AI; compensation from MicroVention, Inc, for consultant services; compensation from Balt USA, LLC for consultant services; stock holdings in Serenity Medical; stock holdings in Bendit Technology; compensation from Medtronic for consultant services; compensation from Johnson & Johnson Medical Devices & Diagnostics Group-Latin America, L.L.C. for consultant services; stock holdings in Borvo Medical; stock holdings in BrainQ; stock holdings in Quantanosis.AI; compensation from Rapid Pulse for consultant services; stock holdings in Sim&Cure; stock holdings in Synchrone; stock holdings in Radical Catheter Technologies; and stock holdings in Endostream. Dr Yavagal reports stock options in Rapid Medical; compensation from Stryker Corporation for consultant services; compensation from Johnson & Johnson Health Care Systems, Inc, for consultant services; stock holdings in Athersys; compensation from Poseydon for consultant services; compensation from Gravity Medical Technology for consultant services; compensation from Medtronic USA, Inc, for consultant services; compensation from Athersys for consultant services; compensation from Vascular Dynamics for consultant services; and stock options in Poseydon. Dr Ribo reports stock holdings in Methinks; stock holdings in Anaconda Biomed; compensation from Philips for consultant services; compensation from Stryker Corporation for consultant services; stock holdings in Nora; compensation from Cerenovus for consultant services; compensation from AptaTargets for consultant services; and compensation from Medtronic MiniMed, Inc, for consultant services. Dr Jovin reports employment by Cooper University Healthcare; stock options in Gravity; compensation from Johnson & Johnson Cerenovus for data and safety monitoring services; stock options in Anaconda; stock options in Route92; stock options in Galaxy; stock options in Methinks; stock options in viz AI; stock options in StataDx; stock options in Basking; compensation from Contego Medical, Inc, for consultant services; stock options in Freeox Biotech; stock options in Kandu; grants from Stryker Corporation; and grants from Medtronic USA, Inc. Dr Ortega-Gutierrez reports grants from MicroVention, Inc; grants from Siemens; grants from the National Institutes of Health; compensation from Medtronic for consultant services; compensation from Stryker for consultant services; compensation from MicroVention, Inc, for consultant services; grants from Methinks; grants from the National Institutes of Health; grants from Stryker; and employment by Carver College of Medicine–University of Iowa. The other authors report no conflicts.

Introduction: Since 2019, the Korean government has implemented a pilot project for integrated care to encourage healthy aging of older adults. This study investigated the changes in hospitalization rates among older adults who participated in the integrated care pilot project., Methods: Administrative survey data collected from 13 local governments and the National Health Insurance Database were used in present study. The participants comprised 17,801 older adults who participated in the pilot project between August 01, 2019 and April 30, 2022 and 68,145 matched controls. A propensity score matching method was employed to select the control group, and this study employed difference-in-differences (DID) approach to examine variations in the hospitalization rate., Results: The DID analysis revealed that the odds ratio for rates of hospitalization among older adults who participated in the pilot project was 0.88 (95% confidence interval [CI] 0.84, 0.91) in comparison to control group. In specifically, as compared to the control group, the odds ratio for hospitalization rates among the pilot project's discharged patients was 0.17 (95% CI 0.15, 0.20). Although not statistically significant, the odds ratio of older adults who utilized LTCI services was 0.93 (95% CI 0.83, 1.05), and the odds ratio of older adults who applied for LTCI but were rejected or were intensive social care was 1.09 (95% CI 0.95, 1.26) compared to the comparison group., Discussion: The findings imply that the discharged patient group had greater medical demands than the other types, and it can be claimed that this is the group that may anticipate greater efficacy while using health services. In addition, the integrated care services provided by the pilot project have the effect of reducing unnecessary hospitalization such as social hospitalization., Conclusion: Participants in the integrated care pilot project showed a lower hospitalization rate than the older adults who did not participate in the project but had similar characteristics. In particular, the admission rate of discharged patients showed a sharp decline., Competing Interests: The authors have no competing interests to declare., (Copyright: © 2024 The Author(s).)

Background: Although CT perfusion (CTP) is often incorporated in acute stroke workflows, it remains largely unclear what the associated costs and health implications are in the long run of CTP-based patient selection for endovascular treatment (EVT) in patients presenting within 6 hours after symptom onset with a large vessel occlusion., Methods: Patients with a large vessel occlusion were included from a Dutch nationwide cohort (n=703) if CTP imaging was performed before EVT within 6 hours after stroke onset. Simulated cost and health effects during 5 and 10 years follow-up were compared between CTP based patient selection for EVT and providing EVT to all patients. Outcome measures were the net monetary benefit at a willingness-to-pay of €80 000 per quality-adjusted life year, incremental cost-effectiveness ratio), difference in costs from a healthcare payer perspective (ΔCosts) and quality-adjusted life years (ΔQALY) per 1000 patients for 1000 model iterations as outcomes., Results: Compared with treating all patients, CTP-based selection for EVT at the optimised ischaemic core volume (ICV≥110 mL) or core-penumbra mismatch ratio (MMR≤1.4) thresholds resulted in losses of health (median ΔQALYs for ICV≥110 mL: -3.3 (IQR: -5.9 to -1.1), for MMR≤1.4: 0.0 (IQR: -1.3 to 0.0)) with median ΔCosts for ICV≥110 mL of -€348 966 (IQR: -€712 406 to -€51 158) and for MMR≤1.4 of €266 513 (IQR: €229 403 to €380 110)) per 1000 patients. Sensitivity analyses did not yield any scenarios for CTP-based selection of patients for EVT that were cost-effective for improving health, including patients aged ≥80 years CONCLUSION: In EVT-eligible patients presenting within 6 hours after symptom onset, excluding patients based on CTP parameters was not cost-effective and could potentially harm patients., Competing Interests: Competing interests: BJE reports grants from LtC (ZonMW and TKI-PPP of Health Holland). WHvZ reports speaker fees from Cerenovus, NicoLab and Stryker, and consulting fees from Philips, all paid to Institution. DWJD report grants from the Dutch Heart Foundation, Brain Foundation Netherlands, ZON MW, Stryker, Medtronic, Cerenovus, Thrombolytic Science, received by the Erasmus University Medical Center outside this project. AJY reports Research grants from Medtronic, Cerenovus, Penumbra, Stryker, and Genentech. Consultant for Penumbra, Cerenovus, Nicolab, Philips, Vesalio, Zoll Circulation, and NIH/NINDS. CBM: grants from Healthcare Evaluation Netherlands, CVON/Dutch Heart Foundation, TWIN foundation and Stryker during the conduct of the study and from European Commission outside this project (all paid to institution) and is shareholder of Nicolab. All other contributors report no other conflicts of interest., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Objectives: CT perfusion (CTP) has been suggested to increase the rate of large vessel occlusion (LVO) detection in patients suspected of acute ischemic stroke (AIS) if used in addition to a standard diagnostic imaging regime of CT angiography (CTA) and non-contrast CT (NCCT). The aim of this study was to estimate the costs and health effects of additional CTP for endovascular treatment (EVT)-eligible occlusion detection using model-based analyses., Methods: In this Dutch, nationwide retrospective cohort study with model-based health economic evaluation, data from 701 EVT-treated patients with available CTP results were included (January 2018-March 2022; trialregister.nl:NL7974). We compared a cohort undergoing NCCT, CTA, and CTP (NCCT + CTA + CTP) with a generated counterfactual where NCCT and CTA (NCCT + CTA) was used for LVO detection. The NCCT + CTA strategy was simulated using diagnostic accuracy values and EVT effects from the literature. A Markov model was used to simulate 10-year follow-up. We adopted a healthcare payer perspective for costs in euros and health gains in quality-adjusted life years (QALYs). The primary outcome was the net monetary benefit (NMB) at a willingness to pay of €80,000; secondary outcomes were the difference between LVO detection strategies in QALYs (ΔQALY) and costs (ΔCosts) per LVO patient., Results: We included 701 patients (median age: 72, IQR: [62-81]) years). Per LVO patient, CTP-based occlusion detection resulted in cost savings (ΔCosts median: € - 2671, IQR: [€ - 4721; € - 731]), a health gain (ΔQALY median: 0.073, IQR: [0.044; 0.104]), and a positive NMB (median: €8436, IQR: [5565; 11,876]) per LVO patient., Conclusion: CTP-based screening of suspected stroke patients for an endovascular treatment eligible large vessel occlusion was cost-effective., Clinical Relevance Statement: Although CTP-based patient selection for endovascular treatment has been recently suggested to result in worse patient outcomes after ischemic stroke, an alternative CTP-based screening for endovascular treatable occlusions is cost-effective., Key Points: • Using CT perfusion to detect an endovascular treatment-eligible occlusions resulted in a health gain and cost savings during 10 years of follow-up. • Depending on the screening costs related to the number of patients needed to image with CT perfusion, cost savings could be considerable (median: € - 3857, IQR: [€ - 5907; € - 1916] per patient). • As the gain in quality adjusted life years was most affected by the sensitivity of CT perfusion-based occlusion detection, additional studies for the diagnostic accuracy of CT perfusion for occlusion detection are required., (© 2023. The Author(s).)

Introduction and Purpose: Basilar artery occlusion (BAO) is still one of the most devastating neurological conditions associated with high morbidity and mortality. In the present study, we aimed to assess the role of posterior circulation collaterals as predictors of outcome in the BASICS trial and to compare two grading systems (BATMAN score and PC-CS) in terms of prognostic value., Methods: We performed a sub-analysis of the BASICS trial. Baseline clinical and imaging variables were analyzed. For the imaging analysis, baseline CT and CTA were analyzed by a central core lab. Only those patients with good or moderate quality of baseline CTA and with confirmed BAO were included. Multivariable binary logistic regression analysis was used to test the independent association of clinical and imaging characteristics with a favorable outcome at 3 months (defined as a modified Rankin Score of ≤3). ROC curve analysis was used to assess and compare accuracy between the two collateral grading systems., Results: The mean age was 67.0 (±12.5) years, 196 (65.3%) patients were males and the median NIHSS was 21.5 (IQR 11-35). Median NCCT pc-ASPECTS was 10 (IQR10-10) and median collateral scores for BATMAN and PC-CS were 8 (IQR 7-9) and 7 (IQR 6-8) respectively. Collateral scores were associated with favorable outcome at 3 months for both BATMAN and PC-CS but only with a modest accuracy on ROC curve analysis (AUC 0.62, 95% CI [0.55-0.69] and 0.67, 95% CI [0.60-0.74] respectively). Age (OR 0.97, 95% CI [0.95-1.00]), NIHSS (OR 0.91, 95% CI [0.89-0.94]) and collateral score (PC-CS - OR 1.2495% CI [1.02-1.51]) were independently associated with clinical outcome., Conclusion: The two collateral grading systems presented modest prognostic accuracy. Only the PC-CS was independently associated with a favorable outcome at 3 months., Competing Interests: The 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. The author(s) declared that they were an editorial board member of Frontiers, at the time of submission. This had no impact on the peer review process and the final decision., (Copyright © 2024 Lima, Rocha, Silva, Puetz, Dippel, van den Wijngaard, Majoie, Yoo, van Zwam, de Lucena, Bandeira, Arndt, Barlinn, Gerber, Langezaal, Schonewille, Pontes Neto, Dias, Martins and Mont’Alverne.)

Background: Endovascular therapy (EVT) stands as an established and effective intervention for acute ischemic stroke in patients harboring tandem lesions (TLs). However, the optimal anesthetic strategy for EVT in TL patients remains unclear. This study aims to evaluate the impact of distinct anesthetic techniques on outcomes in acute ischemic stroke patients presenting with TLs., Methods: Patient-level data, encompassing cases from 16 diverse centers, were aggregated for individuals with anterior circulation TLs treated between January 2015 and December 2020. A stratification based on anesthetic technique was conducted to distinguish between general anesthesia (GA) and procedural sedation (PS). Multivariable logistic regression models were built to discern the association between anesthetic approach and outcomes, including the favorable functional outcome defined as 90-day modified Rankin Score (mRS) of 0-2, ordinal shift in mRS, symptomatic intracranial hemorrhage (sICH), any hemorrhage, successful recanalization (modified Thrombolysis In Cerebral Infarction (mTICI) score ≥2b), excellent recanalization (mTICI 3), first pass effect (FPE), early neurological improvement (ENI), door-to-groin and recanalization times, intrahospital mortality, and 90-day mortality., Results: Among 691 patients from 16 centers, 595 patients (GA 38.7%, PS 61.3%) were included in the final analysis. There were no significant differences noted in the door-to-groin time (80 (46-117.5) mins vs 54 (21-100), P=0.607) and groin to recanalization time (59 (39.5-85.5) mins vs 54 (38-81), P=0.836) among the groups. The odds of a favorable functional outcome (36.6% vs 52.6%; adjusted OR (aOR) 0.56, 95% CI 0.38 to 0.84, P=0.005) and a favorable shift in the 90-day mRS (aOR 0.71, 95% CI 0.51 to 0.99, P=0.041) were lower in the GA group. No differences were noted for sICH (3.9% vs 4.7%, P=0.38), successful recanalization (89.1% vs 86.5%, P=0.13), excellent recanalization (48.5% vs 50.3%, P=0.462), FPE (53.6% vs 63.4%, P=0.05), ENI (38.9% vs 38.8%, P=0.138), and 90-day mortality (20.3% vs 16.3%, P=0.525). An interaction was noted for favorable functional outcome between the type of anesthesia and the baseline Alberta Stroke Program Early CT Score (ASPECTS) (P=0.033), degree of internal carotid artery (ICA) stenosis (P<0.001), and ICA stenting (P<0.001), and intraparenchymal hematoma between the type of anesthesia and intravenous thrombolysis (P=0.019). In a subgroup analysis, PS showed better functional outcomes in patients with age ≤70 years, National Institutes of Health Stroke Scale (NIHSS) score <15, and acute ICA stenting., Conclusions: Our findings suggest that the preference for PS not only aligns with comparable procedural safety but is also associated with superior functional outcomes. These results prompt a re-evaluation of current anesthesia practices in EVT, urging clinicians to consider patient-specific characteristics when determining the optimal anesthetic strategy for this patient population., Competing Interests: Competing interests: SOG: research support from the NIH-NINDS (R01NS127114-01, RO3NS126804-01), Stryker (N/A), Medtronic(N/A), Microvention(N/A), Methinks(N/A), IschemiaView(N/A), Viz.ai(N/A), and Siemens(N/A); and consulting fees from Medtronic and Stryker Neurovascular. TN: advisory board for Idorsia, Brainomix. NP: research support from the NIH/NINDS (K23NS110980) and Liminal Sciences (N/A). TGJ: advisor and investor for Anaconda, Route92, Viz.AI, FreeOx, Blockade Medical, and Methinks; grant support from Medtronic (N/A) and from Stryker Neurovascular (N/A) in his capacity as principal investigator for DAWN and AURORA; he received personal fees in his role on the Data Safety Monitoring Board. The other co-authors do not report conflicts of interests., (© Author(s) (or their employer(s)) 2024. No commercial re-use. See rights and permissions. Published by BMJ.)

Background and Importance: Neurointervention is a very competitive specialty in the United States due to the limited number of training spots and the larger pool of applicants. The training standards are continuously updated to ensure solid training experiences. Factors affecting candidate(s) selection have not been fully established yet. Our study aims to investigate the factors influencing the selection process., Methods: A 52-question survey was distributed to 93 program directors (PDs). The survey consisted of six categories: (a) Program characteristics, (b) Candidate demographics, (c) Educational credentials, (d) Personal traits, (e) Research and extracurricular activities, and (f) Overall final set of characteristics. The response rate was 59.1%. As per the programs' characteristics, neurosurgery was the most involved specialty in running the training programs (69%). Regarding demographics, the need for visa sponsorship held the greatest prominence with a mean score of 5.9 [standard deviation (SD) 2.9]. For the educational credentials, being a graduate from a neurosurgical residency and the institution where the candidate's residency training is/was scored the highest [5.4 (SD = 2.9), 5.4 (SD = 2.5), respectively]. Regarding the personal traits, assessment by faculty members achieved the highest score [8.9 (SD = 1)]. In terms of research/extracurricular activities, fluency in English had the highest score [7.2 (SD = 1.9)] followed by peer-reviewed/PubMed-indexed publications [6.4 (SD = 2.2)]., Conclusion: Our survey investigated the factors influencing the final decision when choosing the future neurointerventional trainee, including demographic, educational, research, and extracurricular activities, which might serve as valuable guidance for both applicants and programs to refine the selection process., Competing Interests: Declaration of conflicting interestsThe authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Background: The effectiveness of intravenous thrombolysis (IVT) before endovascular treatment (EVT) has been investigated in randomized trials and meta-analyses. These studies mainly concerned anterior circulation occlusions. We aimed to investigate clinical, technical, and safety outcomes of IVT before EVT in posterior circulation occlusions in a nationwide registry., Methods: Patients were included from the MR CLEAN Registry (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands), a nationwide, prospective, multicenter registry of patients with acute ischemic stroke due to a large intracranial vessel occlusion receiving EVT between 2014 and 2019. All patients with a posterior circulation occlusion were included. Primary outcome was a shift toward better functional outcome on the modified Rankin Scale at 90 days. Secondary outcomes were favorable functional outcome (modified Rankin Scale scores, 0-3), occurrence of symptomatic intracranial hemorrhages, successful reperfusion (extended Thrombolysis in Cerebral Ischemia ≥2B), first-attempt successful reperfusion, and mortality at 90 days. Regression analyses with adjustments based on univariable analyses and literature were applied., Results: A total of 248 patients were included, who received either IVT (n=125) or no IVT (n=123) before EVT. Results show no differences in a shift on the modified Rankin Scale (adjusted common odds ratio, 1.04 [95% CI, 0.61-1.76]). Although symptomatic intracranial hemorrhages occurred more often in the IVT group (4.8% versus 2.4%), regression analysis did not show a significant difference (adjusted odds ratio, 1.65 [95% CI, 0.33-8.35]). Successful reperfusion, favorable functional outcome, first-attempt successful reperfusion, and mortality did not differ between patients treated with and without IVT., Conclusions: We found no significant differences in clinical, technical, and safety outcomes between patients with a large vessel occlusion in the posterior circulation treated with or without IVT before EVT. Our results are in line with the literature on the anterior circulation., Competing Interests: Disclosures Dr Majoie reports grants from the Netherlands Cardiovascular Research Initiative, an initiative of the Dutch Heart Foundation, European Commission, Healthcare Evaluation Netherlands, Stichting Toegepast Wetenschappelijk Instituut voor Neuromodulatie Foundation, and Stryker (all paid to institution); and is a (minority interest) shareholder of Nicolab. Dr Emmer reports grants from leading the Change Healthcare Evaluation program, ZorgOnderzoek Nederland Medische Wetenschappen (ZonMw), Nico-Lab, and Top Consortia for Knowledge and Innovation- Public Private Partnership (TKI-PPP) Grant Topsector Lifesciences (all paid to institution); and participates as a representative of the European Union of Medical Specialists (UEMS) Neuroradiology Dutch, and as Board member of the Dutch Society of Radiology. Dr Vos reports compensation from Stryker Corporation for other services. Dr van Doormaal reports consulting fees from Stryker, Siemens, and Stryker (all paid to institution); participates in the advisory board of DX Medical solutions; and is shareholder of DX Medical Solutions. Dr Yoo reports grants from Medtronic, Cerenovus, Penumbra, Stryker, Genentech, and Johnson & Johnson Medical Devices & Diagnostics Group, Latin America LLC; holds stock options in Nico-Lab, Insera; and is a consultant for Vesalio, Cerenovus, Rapid Medical Ltd, Penumbra, Inc, Nico-Lab, ZOLL Circulation, Inc, and Philips, all outside the submitted work; compensation from American Heart Association for other services; compensation from National Institutes of Health for data and safety monitoring services. Dr van Zwam reports speaker fees from Stryker, Cerenovus, and Nicolab, and consulting fees from Philips (all paid to institution); participated in the advisory boards of WeTrust (Philips) and ANAIS ([Advanced Neurovascular Access in Combination With a Stent Retriever in Patients With Acute Ischemic Stroke]; Anaconda; all paid to institution); and participated in the advisory boards of InEcxtremis (CHU Montpellier, Montpellier, France) and DISTAL ([Endovascular Therapy Plus Best Medical Treatment (BMT) Versus BMT Alone for Medium Vessel Occlusion Stroke - a Pragmatic, International, Multicentre, Randomized Trial]; University Hospital Basel, Basel, Switzerland), studies for which no payments were received. The other authors report no conflicts.

Background: The Korean government implemented a pilot project for integrated care of older adults in August 2019. the pilot project of integrated care provided housekeeping support, nutrition support, movement assistance, home repair, consultations and education for healthy lifestyle, and some home-based primary care to older patients discharged from hospitals. This study investigated the outcomes of this project among older adults who participated in it after discharge from the hospital., Methods: This study combined the data from the pilot project survey with that from the National Health Insurance Service. The participants comprised 1,895 older adults who participated in the pilot project between August 01, 2019 and April 30, 2022. For comparison, 7,145 older adults who lived in regions where no pilot project were selected as the matched group using propensity score matching. The length of home stay, total expenses of national health insurance and long-term care insurance, emergency visits, and hospital readmission for the same disease were measured, till July 31, 2022. Statistical analysis was performed through difference-in-differences analysis using a generalized estimating equation and the Cox proportional hazards model., Results: The results indicated an increase of 35.2 days (95% confidence interval [CI] 30.7, 39.8) in length of home stay over an average observation period of 550.5 days and a reduction of 6,960 USD (95% CI: -7,924, -5,996) in total expenses for participants compared to the controls. The odds ratio of emergency visits of the pilot project participants was 0.56 (95% CI 0.48, 0.65) compared with the controls. The hazard ratio for hospital readmission for the same disease after hospital discharge was 3.53 (95% CI 2.98, 4.19) times higher in project participants than that in the controls., Conclusion: The pilot project for integrated care has resulted in an increased length of home stay and hospital readmission and reduced total expenses and emergency visits among older patients discharged from hospitals. The integrated care after discharge from hospitals can help older adults to continue living in the place where they lived, and improved collaboration between clinics and hospitals is required to prevent readmissions., (© 2024 The Author(s); Published by Kerman University of Medical Sciences This is an open-access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.)

Objective: The optimal technique for treating tandem lesions (TLs) with endovascular therapy is debatable. The authors evaluated the functional, safety, and procedural outcomes of different approaches in a multicenter study., Methods: Anterior circulation TL patients treated from January 2015 to December 2020 were divided on the basis of antegrade versus retrograde approach and included. The evaluated outcomes were favorable modified Rankin Scale (mRS) score (mRS score 0-2) at 3 months, ordinal shift in mRS score, successful recanalization, excellent recanalization, first-pass effect (FPE), time from groin puncture to successful recanalization, symptomatic intracranial hemorrhage (sICH), and 90-day mortality., Results: Among 691 patients treated at 16 centers, 286 patients (174 antegrade and 112 retrograde approach patients) with acute stenting were included in the final analysis. There were no significant differences in mRS score 0-2 at 90 days (52.2% vs 50.0%, adjusted odds ratio [aOR] 0.83, 95% CI 0.42-1.56, p = 0.54), favorable shift in 90-day mRS score (aOR 1.03, 95% CI 0.66-1.29, p = 0.11), sICH (4.0% vs 4.5%, aOR 0.64, 95% CI 0.24-1.51, p = 0.45), successful recanalization (89.4% vs 93%, aOR 0.49, 95% CI 0.19-1.28, p = 0.19), excellent recanalization (51.4% vs 58.9%, aOR 0.59, 95% CI 0.40-1.07, p = 0.09), FPE (58.3% vs 69.7%, aOR 0.62, 95% CI 0.44-1.15, p = 0.21), and mortality at 90 days (16.6% vs 14.0%, aOR 0.94, 95% CI 0.35-2.44, p = 0.81) between the groups. The median (interquartile range) groin puncture to recanalization time was significantly longer in the antegrade group (59 [43-90] minutes vs 49 [35-73] minutes, p = 0.036)., Conclusions: The retrograde approach was associated with faster recanalization times with a similar functional and safety profile when compared with the antegrade approach in patients with acute ischemic stroke with TL.

Risk of hemorrhage remains with antiplatelet medications required with carotid stenting during endovascular therapy (EVT) for tandem lesion (TLs). We evaluated the safety of antiplatelet regimens in EVT of TLs. This multicenter study included anterior circulation TL patients from 2015 to 2020, stratified by periprocedural EVT antiplatelet strategy: (1) no antiplatelets, (2) single oral, (3) dual oral, and (4) intravenous IV (in combination with single or dual oral). Primary outcome was symptomatic intracranial hemorrhage (sICH). Secondary outcomes were any hemorrhage, favorable functional status (mRS 0-2) at 90 days, successful reperfusion (mTICI score ≥ 2b), in-stent thrombosis, and mortality at 90 days. Of the total 691 patients, 595 were included in the final analysis. One hundred and nineteen (20%) received no antiplatelets, 134 (22.5%) received single oral, 152 (25.5%) dual oral, and 196 (31.9%) IV combination. No significant association was found for sICH (ref: no antiplatelet: 5.7%; single:4.2%; aOR 0.64, CI 0.20-2.06, p = 0.45, dual:1.9%; aOR 0.35, CI 0.09-1.43, p = 0.15, IV combination: 6.1%; aOR 1.05, CI 0.39-2.85, p = 0.92). No association was found for parenchymal or petechial hemorrhage. Odds of successful reperfusion were significantly higher with dual oral (aOR 5.85, CI 2.12-16.14, p = 0.001) and IV combination (aOR 2.35, CI 1.07-5.18, p = 0.035) compared with no antiplatelets. Odds of excellent reperfusion (mTICI 2c/3) were significantly higher for cangrelor (aOR 4.41; CI 1.2-16.28; p = 0.026). No differences were noted for mRS 0-2 at 90 days, in-stent thrombosis, and mortality rates. Administration of dual oral and IV (in combination with single or dual oral) antiplatelets during EVT was associated with significantly increased odds of successful reperfusion without an increased rate of symptomatic hemorrhage or mortality in patients with anterior circulation TLs., (© 2023. The Author(s), under exclusive licence to Springer Science+Business Media, LLC, part of Springer Nature.)

Background: The optimal anesthetic management for endovascular therapy (EVT) in patients with posterior circulation stroke remains unclear. Our objective was to investigate the impact of early intubation in patients enrolled in the BASICS trial (Basilar Artery International Cooperation Study)., Methods: BASICS was a multicenter, randomized, controlled trial that compared the efficacy of EVT compared with the best medical care alone in patients with basilar artery occlusion. In this post hoc analysis, early intubation within the first 24 hours of the estimated time of basilar artery occlusion was examined as an additional covariate using regression modeling. We estimated the adjusted relative risks (RRs) for favorable outcomes, defined as modified Rankin Scale scores of 0 to 3 at 90 days. An adjusted common odds ratio was estimated for a shift in the distribution of modified Rankin Scale scores at 90 days., Results: Of 300 patients in BASICS, 289 patients were eligible for analysis (151 in the EVT group and 138 in the best medical care group). compared with medical care alone, EVT was related to a higher risk of early intubation (RR, 1.29 [95% CI, 1.09-1.53]; P <0.01), and early intubation was negatively associated with favorable outcome (RR, 0.61 [95% CI, 0.45-0.84]; P =0.002). Whereas there was no overall treatment effect of EVT on favorable outcome (RR, 1.22 [95% CI, 0.95-1.55]; P =0.121), EVT was associated with favorable outcome (RR, 1.34 [95% CI, 1.05-1.71]; P =0.018) and a shift toward lower modified Rankin Scale scores (adjusted common odds ratio, 1.63 [95% CI, 1.04-2.57]; P =0.033) if adjusted for early intubation., Conclusions: In this post hoc analysis of the neutral BASICS trial, early intubation was linked to unfavorable outcomes, which might mitigate a potential benefit from EVT by indirect effects due to an increased risk of early intubation. This relationship may be considered when assessing the efficacy of EVT in patients with basilar artery occlusion in future trials., Competing Interests: Disclosures Dr van Zwam reports grants from Stryker Corporation; grants from Johnson and Johnson International; and compensation from Philips for data and safety monitoring services. Dr Roos reports stock holdings in Nicolab. Dr Yoo reports stock holdings in Insera; compensation from Johnson & Johnson Medical Devices & Diagnostics Group—Latin America, LLC, for consultant services; grants from Genentech USA, Inc to other; compensation from Vesalio for consultant services; compensation from American Heart Association for other services; compensation from ZOLL Circulation Inc for consultant services; compensation from Penumbra Inc for consultant services; stock options in Nicolab; employment by HCA Healthcare; compensation from Penumbra Inc for consultant services; grants from Penumbra Inc to other; grants from Johnson & Johnson Medical Devices & Diagnostics Group—Latin America, LLC, to other; grants from Stryker to other; compensation from National Institutes of Health for data and safety monitoring services; grants from Medtronic to other; compensation from Nicolab for consultant services; and compensation from Philips for consultant services. Dr Pontes-Neto reports compensation from Medtronic for other services; compensation from Bayer for other services; and compensation from Pfizer for other services. Dr Mazighi reports compensation from Acticor Biotech for consultant services and compensation from Boerhinger-Ingelheim for consultant services. Dr Audebert reports being the current president of the PREhospital Stroke Treatment Organization (PRESTO), compensation from Novo Nordisk for data monitoring committee services, grants from Deutsche Forschungsgemeinschaft, German Federal Ministry of Education and Research, Innovation Funds of the Joint Federal Committee (g-BA) and compensation from Bayer Healthcare, Pfizer for consultant services, grants from Pfizer, grants from BMS, grants from Boehringer Ingelheim and grants from Sanofi. Dr Michel reports grants from University of Lausanne to other; grants from Swiss Heart Foundation to other; and grants from Swiss National Science Foundation to other.

Background: We aimed to describe the safety and efficacy of mechanical thrombectomy (MT) with or without intravenous thrombolysis (IVT) for patients with tandem lesions and whether using intraprocedural antiplatelet therapy influences MT's safety with IVT treatment., Methods: This is a subanalysis of a pooled, multicenter cohort of patients with acute anterior circulation tandem lesions treated with MT from 16 stroke centers between January 2015 and December 2020. Primary outcomes included symptomatic intracranial hemorrhage (sICH) and parenchymal hematoma type 2. Additional outcomes included hemorrhagic transformation, successful reperfusion (modified Thrombolysis in Cerebral Infarction score 2b-3), complete reperfusion (modified Thrombolysis in Cerebral Infarction score 3), favorable functional outcome (90-day modified Rankin Scale score 0-2), excellent functional outcome (90-day modified Rankin Scale score 0-1), in-hospital mortality, and 90-day mortality., Results: Of 691 patients, 512 were included (218 underwent IVT+MT and 294 MT alone). There was no difference in the risk of sICH (adjusted odds ratio [aOR], 1.22 [95% CI, 0.60-2.51]; P =0.583), parenchymal hematoma type 2 (aOR, 0.99 [95% CI, 0.47-2.08]; P =0.985), and hemorrhagic transformation (aOR, 0.95 [95% CI, 0.62-1.46]; P =0.817) between the IVT+MT and MT alone groups after adjusting for confounders. Administration of IVT was associated with an increased risk of sICH in patients who received intravenous antiplatelet therapy (aOR, 3.04 [95% CI, 0.99-9.37]; P =0.05). The IVT+MT group had higher odds of a 90-day modified Rankin Scale score 0 to 2 (aOR, 1.72 [95% CI, 1.01-2.91]; P =0.04). The odds of successful reperfusion, complete reperfusion, 90-day modified Rankin Scale score 0 to 1, in-hospital mortality, or 90-day mortality did not differ between the IVT+MT versus MT alone groups., Conclusions: Our study showed that the combination of IVT with MT for tandem lesions did not increase the overall risk of sICH, parenchymal hematoma type 2, or overall hemorrhagic transformation independently of the cervical revascularization technique used. However, intraprocedural intravenous antiplatelet therapy during acute stent implantation might be associated with an increased risk of sICH in patients who received IVT before MT. Importantly, IVT+MT treatment was associated with a higher rate of favorable functional outcomes at 90 days., Competing Interests: Disclosures A.E. Hassan is a consultant/speaker at Medtronic, Microvention, Stryker, Penumbra, Cerenovus, Genentech, GE Healthcare, Scientia, Balt, vizai, Insera therapeutics, Proximie, NeuroVasc, NovaSignal, Vesalio, Rapid Medical, Imperative Care and Galaxy Therapeutics; principal investigator for COMPLETE study—Penumbra, LVO SYNCHRONISE—vizai, Millipede Stroke Trial—Perfuze, RESCUE—ICAD, Medtronic; steering committee/publication committee member for SELECT, DAWN, SELECT 2, EXPEDITE II, EMBOLISE, CLEAR, ENVI, DELPHI, DISTALS. Dr Divani performed fundings at the University of New Mexico Center for Brain Recovery and Repair Center of Biomedical Research Excellence through Grant Number (NIH P20GM109089, Pilot PI), W81XWH-17-2-0053 (PI), 1R21NS130423-01 (PI). Dr Ribo is consultant at aptaTargets, Anaconda Biomed, Philips, Medtronic, Cerenovus, Vesalio, and Rapid Pulse outside the submitted work. Dr Abraham is a consultant at Penumbra Inc, Qapel, Stryker Corporation. Dr Fifi is a consultant at Cerenovus, Stryker Corporation, Microvention Inc; received stock from Cerebrotech, Imperative Care, Sime&Cure; and received grants from viz AI. Data and Safety Monitoring: MIVI. Dr Yoo is a consultant for Johnson & Johnson Medical Devices & Diagnostics Group—Latin America, LLC, Nicolab, Penumbra Inc, Philips, Vesalio, ZOLL Circulation Inc; received grants from Genetech, USA Inc, Johnson & Johnson Medical Devices & Diagnostics Group—Latin America, LLC, Medtronic, Penumbra Inc, Stryker; Employment at HCA Healthcare; received stock from Insera, Nicolab; performed data and safety monitoring at National Institutes of Health. Dr Mokin is a consultant at Johnson & Johnson Medical Devices & Diagnostics Group—Latin America, LLC, Medtronic, MicroVention Inc, received stock from Bendit Technology, BrainQ, Serenity medical, Synchrone. Dr Yavagal is a consultant at Athersys, Gravity Medical Technology, Johnson & Johnson Health Care Systems Inc, Medtronic USA Inc, Poseydon, Stryker Corporation, Vascular Dynamics; received stock from Athersys, Poseydon, Rapid Medical. Dr Jovin is a consultant at Contego Medical Inc received stock from Anaconda, Freeox Biotech, Galaxy, Kandu, Methinks, Route92, vizai. Grant: Medtronicm, USA, Inc, Stryker Corporation; performed data and safety monitoring at Johnson & Johnson, Cerenovus. Dr Sheth is a consultant at vizAI, Penumbra, Imperative Care; received grants from NIH, vizAI; and took ownership for Motif Neuroscience (not related to this article). Dr Ortega-Gutierrez received grants from NIH-NINDS (R01NS127114-01, R03NS126804), Stryker, Medtronics, Microvention, Penumbra, IschemiaView, vizai, and Siemens; he is a consultant at Medtronic and Stryker Neurovascular. The other authors report no conflicts.

Background: Studies during the COVID-19 pandemic have demonstrated an association between COVID-19 virus infection and the development of acute ischemic stroke, particularly large vessel occlusion (LVO). Studying the characteristics and immunohistochemistry of retrieved stroke emboli during mechanical thrombectomy for LVO may offer insights into the pathogenesis of LVO in COVID-19 patients. We examined retrieved COVID-19 emboli from the STRIP, EXCELLENT, and RESTORE registries and compared their characteristics to a control group., Methods: We identified COVID-positive LVO patients from the STRIP, RESTORE, and EXCELLENT studies who underwent mechanical thrombectomy. These patients were matched to a control group controlling for stroke etiology based on Trial of Org 10172 in Acute Stroke Treatment criteria. All clots were stained with Martius Scarlet Blue (MSB) along with immunohistochemistry for interleukin-6 (IL-6), C-reactive protein (CRP), von Willebrand factor (vWF), CD66b, fibrinogen, and citrullinated Histone H3. Clot composition was compared between groups., Results: Nineteen COVID-19-positive patients and 38 controls were included. COVID-19-positive patients had a significantly higher percentage of CRP and vWF. There was no difference in IL-6, fibrin, CD66b, or citrullinated Histone H3 between groups. Based on MSB staining, there was no statistically significant difference regarding the percentage of red blood cells, white blood cells, fibrin, and platelets., Conclusions: Our study found higher concentrations of CRP and vWF in retrieved clots of COVID-19-positive stroke patients compared to COVID-19-negative controls. These findings support the potential role of systemic inflammation as indicated by elevated CRP and endothelial injury as indicated by elevated vWF as precipitating factors in thrombus development in these patients.

Background: The proper imaging modality for use in the selection of patients for endovascular thrombectomy (EVT) presenting in the late window remains controversial, despite current guidelines advocating the use of advanced imaging in this population. We sought to understand if clinicians with different specialty training differ in their approach to patient selection for EVT in the late time window., Methods: We conducted an international survey of stroke and neurointerventional clinicians between January and May 2022 with questions focusing on imaging and treatment decisions of large vessel occlusion (LVO) patients presenting in the late window. Interventional neurologists, interventional neuroradiologists, and endovascular neurosurgeons were defined as interventionists whereas all other specialties were defined as non-interventionists. The non-interventionist group was defined by all other specialties of the respondents: stroke neurologist, neuroradiologist, emergency medicine physician, trainee (fellows and residents) and others., Results: Of 3000 invited to participate, 1506 (1027 non-interventionists, 478 interventionists, 1 declined to specify) physicians completed the study. Interventionist respondents were more likely to proceed directly to EVT (39.5% vs. 19.5%; p < 0.0001) compared to non-interventionist respondents in patients with favorable ASPECTS (Alberta Stroke Program Early CT Score). Despite no difference in access to advanced imaging, interventionists were more likely to prefer CT/CTA alone (34.8% vs. 21.0%) and less likely to prefer CT/CTA/CTP (39.1% vs. 52.4%) for patient selection (p < 0.0001). When faced with uncertainty, non-interventionists were more likely to follow clinical guidelines (45.1% vs. 30.2%) while interventionists were more likely to follow their assessment of evidence (38.7% vs. 27.0%) (p < 0.0001)., Conclusion: Interventionists were less likely to use advanced imaging techniques in selecting LVO patients presenting in the late window and more likely to base their decisions on their assessment of evidence rather than published guidelines. These results reflect gaps between interventionists and non-interventionists reliance on clinical guidelines, the limits of available evidence, and clinician belief in the utility of advanced imaging., (© 2023. The Author(s), under exclusive licence to Springer-Verlag GmbH Germany.)

Background and Purpose: Effect of endovascular therapy (EVT) in acute large vessel occlusion (LVO) patients with tandem lesions (TLs) within 6-24 hours after last known well (LKW) remains unclear. We evaluated the clinical and safety outcomes among TL-LVO patients treated within 6-24 hours., Methods: This multicenter cohort was divided into two groups, based on LKW to puncture time: early window (<6 hours), and late window (6-24 hours). Primary clinical and safety outcomes were 90-day functional independence measured by the modified Rankin Scale (mRS: 0-2) and symptomatic intracranial hemorrhage (sICH). Secondary outcomes were successful reperfusion (modified Thrombolysis in Cerebral Infarction score ≥2b), first-pass effect, early neurological improvement, ordinal mRS, and in-hospital and 90-day mortality., Results: Of 579 patients (median age 68, 32.1% females), 268 (46.3%) were treated in the late window and 311 (53.7%) in the early window. Late window group had lower median National Institutes of Health Stroke Scale score at admission, Alberta Stroke Program Early Computed Tomography Score, rates of intravenous thrombolysis, and higher rates for perfusion imaging. After adjusting for confounders, the odds of 90-day mRS 0-2 (47.7% vs. 45.0%, adjusted odds ratio [aOR] 0.71, 95% confidence interval [CI] 0.49-1.02), favorable shift in mRS (aOR 0.88, 95% CI 0.44-1.76), and sICH (3.7% vs. 5.2%, aOR 0.56, 95% CI 0.20-1.56) were similar in both groups. There was no difference in secondary outcomes. Increased time from LKW to puncture did not predicted the probability of 90-day mRS 0-2 (aOR 0.99, 95% CI 0.96-1.01, for each hour delay) among patients presenting <24 hours., Conclusion: EVT for acute TL-LVO treated within 6-24 hours after LKW was associated with similar rates of clinical and safety outcomes, compared to patients treated within 6 hours.

Background: While recent studies suggest a benefit of mechanical thrombectomy (MT) for the treatment of patients with isolated large vessel occlusions presenting after 24 hours from the last known well (LKW), the effect of MT for acute cervical tandem lesions (TLs) beyond 24 hours remains unknown. We aimed to evaluate the safety and effectiveness of MT beyond 24 hours of LKW in patients with TLs., Methods: We conducted a subanalysis study of patients with anterior circulation TL enrolled in a large, multicenter registry between January 2015 and December 2020. Patients were divided into 2 groups: MT beyond 24 hours versus MT 0-24-hour window. Outcomes of interest were functional independence (90-day modified Rankin scale 0-2), complete reperfusion (modified thrombolysis in cerebral infarction 3), delta NIH Stroke Scale (NIHSS), symptomatic intracranial hemorrhage (sICH), parenchymal hematoma 2 (PH2), in-hospital mortality, and 90-day mortality. Inverse probability of treatment weighting (IPTW) was used to balance the groups., Results: Overall, 589 participants were included, with 33 treated beyond 24 hours and 556 treated in the 0-24-hour window. After IPTW, we found no significant difference in the rates of achieving functional independence (odds ratio (OR)   = 0.51; 95% confidence interval (CI) 0.22-1.16; p  = 0.108), complete reperfusion (OR   = 1.35; 95% CI 0.60-3.05; p  = 0.464), sICH (OR   = 1.96; 95% CI 0.37-10.5; p  = 0.429), delta NIHSS (β   =   -3.61; 95% CI -8.11 to 0.87; p  = 0.114), PH2 (OR   = 1.46; 95% CI 0.29-7.27; p  = 0.642), in-hospital mortality (OR   = 1.74; 95% CI 0.52-5.86; p  = 0.370), or 90-day mortality (OR   = 1.37; 95% CI 0.49-3.83; p  = 0.544) across both time windows., Conclusions: Our results suggest that MT appears to benefit patients with TLs beyond 24 hours from LKW. Future prospective studies are warranted.

Background and Objectives: There is growing evidence for endovascular thrombectomy (EVT) in patients with large ischemic core infarct and large vessel occlusion (LVO). The objective of this study was to compare the efficacy and safety of EVT vs medical management (MM) using a systematic review and meta-analysis of observational studies and randomized controlled trials (RCTs)., Methods: We searched the PubMed, Embase, Cochrane Library, and Web of Science databases to obtain articles related to mechanical thrombectomy for large ischemic core from inception until February 10, 2023. The primary outcome was independent ambulation (modified Rankin Scale [mRS] 0-3). Effect sizes were computed as risk ratio (RR) with random-effect or fixed-effect models. The quality of articles was evaluated through the Cochrane risk assessment tool and the Newcastle-Ottawa Scale. This study was registered in PROSPERO (CRD42023396232)., Results: A total of 5,395 articles were obtained through the search and articles that did not meet the inclusion criteria were excluded by review of the title, abstract, and full text. Finally, 3 RCTs and 10 cohort studies met the inclusion criteria. The RCT analysis showed that EVT improved the 90-day functional outcomes of patients with large ischemic core with high-quality evidence, including independent ambulation (mRS 0-3: RR 1.78, 95% CI 1.28-2.48, p < 0.001) and functional independence (mRS 0-2: RR 2.59, 95% CI 1.89-3.57, p < 0.001), but without significantly increasing the risk of symptomatic intracranial hemorrhage (sICH: RR 1.83, 95% CI 0.95-3.55, p = 0.07) or early mortality (RR 0.95, 95% CI 0.78-1.16, p = 0.61). Analysis of the cohort studies showed that EVT improved functional outcomes of patients without an increase in the incidence in sICH., Discussion: This systematic review and meta-analysis indicates that in patients with LVO stroke with a large ischemic core, EVT was associated with improved functional outcomes over MM without increasing sICH risk. The results of ongoing RCTs may provide further insight in this patient population., (© 2023 American Academy of Neurology.)