• Acute ischemic stroke
• Endovascular treatment
• Large vessel occlusion

• 82371294 National Natural Science Foundation of China
• 82301651 National Natural Science Foundation of China
• 2022YFC2502400 National Key R&D Program of China
• 2022YFC2502403 National Key R&D Program of China

• clinical outcomes
• endovascular thrombectomy
• intravenous thrombolysis
• ischemic stroke
• large core infarctions

• Humans
• Male
• Female
• Thrombectomy/methods
• Thrombectomy/adverse effects
• Prospective Studies
• Aged
• Endovascular Procedures/methods
• Middle Aged
• Thrombolytic Therapy/methods
• Treatment Outcome
• Aged, 80 and over
• China
• Intracranial Hemorrhages/epidemiology
• Intracranial Hemorrhages/etiology

• Humans
• Male
• Female
• Aged
• White Matter/diagnostic imaging
• White Matter/pathology
• Ischemic Stroke/diagnostic imaging
• Ischemic Stroke/pathology
• Magnetic Resonance Imaging
• Middle Aged
• Severity of Illness Index
• Prognosis
• Aged, 80 and over
• Treatment Outcome

• NRF- 2021R1A6A1A03038865 National Priority Research Center Program Grant
• NRF- 2020R1A2C3008295 Basic Science Research Program Grant
• KMDF_PR_20200901_0098 Multi-ministry Grant for Medical Device Development of National Research Foundation, funded by Korean government.

• acute ischemic stroke
• anterior circulation
• collateral status
• large vessel occlusion
• relative cerebral blood flow

• Humans
• Male
• Female
• Aged
• Cerebrovascular Circulation/physiology
• Collateral Circulation
• Retrospective Studies
• Middle Aged
• Ischemic Stroke/physiopathology
• Ischemic Stroke/diagnostic imaging
• Aged, 80 and over
• Perfusion Imaging/methods
• Computed Tomography Angiography
• Cerebral Angiography/methods

• Endovascular treatment
• Stroke
• Thrombectomy
• Thrombolysis

• Humans
• Ischemic Stroke/etiology
• Brain Ischemia/drug therapy
• Thrombectomy/adverse effects
• Endovascular Procedures/adverse effects
• Stroke/drug therapy
• Stroke/etiology
• Treatment Outcome

• ischemic stroke
• large hemisphere infarction
• malignant cerebral edema
• nomogram
• stroke

• CT perfusion
• acute ischemic stroke
• atherosclerosis
• mechanical thrombectomy

• Humans
• Stroke/diagnostic imaging
• Stroke/therapy
• Ischemic Stroke/diagnostic imaging
• Ischemic Stroke/therapy
• Retrospective Studies
• Thrombectomy/methods
• Brain Ischemia/diagnostic imaging
• Brain Ischemia/therapy
• Endovascular Procedures/methods
• Treatment Outcome

• Balloon angioplasty
• Endovascular thrombectomy
• Middle cerebral artery occlusion
• Stenting

Randomized clinical trials and large stroke registries have demonstrated a time-dependent benefit of endovascular treatment (EVT) in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO). The aim of this study was to investigate whether this could be applied to different stroke subtypes in a real-world single-center cohort.

Consecutive ischemic stroke patients with LVOs presenting within 24 h after symptom onset were prospectively registered and retrospectively assessed. Baseline multimodal imaging was conducted before EVT. Independent predictors of functional independence [90-day modified Rankin scale (mRS), 0–2] and any incidence of intracranial hemorrhage (ICH) were explored using a stepwise logistic regression model in the entire cohort and in stroke subtypes.

From 2015 to 2020, 140 eligible patients received EVT, of whom 59 (42%) were classified as large artery atherosclerosis (LAA)-related. Time from last known normal to groin puncture was identified as an independent predictor for functional independence in patients of cardioembolic (CE) subtype [odds ratio (OR) 0.90 per 10 min; 95% CI 0.82–0.98; P = 0.013] but not in the LAA subtype and the whole cohort. Groin puncture within 6 h after the time of last known normal was associated with a lower risk of any ICH in the whole cohort (OR 0.36, 95% CI 0.17–0.75, P = 0.007). Sensitivity analysis of patients with complete imaging profiles also confirmed the above findings. Besides, compared with patients of the CE subtype, the LAA subtype had a smaller baseline ischemic core volume, a better collateral status, a slower core growth rate, and a numerically smaller final infarct volume.

Faster groin puncture has a more pronounced effect on the functional outcome in patients of CE subtype than those of LAA subtype. Reducing time to groin puncture is of great importance in improving the prognosis of patients after EVT, especially those of CE subtype, and reducing the incidence of any ICH in all patients.

• National Natural Science Foundation of China
• Science and Technology Commission of Shanghai Municipality

We investigated the impact of stroke etiology on the endovascular treatment (EVT) procedure and clinical outcome of posterior circulation stroke (PCS) patients with EVT compared to anterior circulation stroke (ACS) patients.

We retrospectively analyzed ischemic stroke patients who underwent EVT between January 2012 and December 2020. Enrolled ACS and PCS patients were compared according to etiologies (intracranial arterial steno-occlusion [ICAS-O], artery-to-artery embolic occlusion [AT-O], and cardioembolic occlusion [CA-O]). EVT procedure and favorable clinical outcomes at 3 months (modified Rankin Scale 0–2) were compared between the ACS and PCS groups for each etiology.

We included 419 patients (ACS, 346; PCS, 73) including 88 ICAS-O (ACS, 67; PCS, 21), 66 AT-O (ACS, 50; PCS, 16), and 265 CA-O (ACS, 229; PCS, 36) patients in the study. The onset-to-recanalization time was longer in the PCS group than in the ACS group (median 628.0 minutes vs. 421.0 minutes, P=0.01). In CA-O patients, the door-to-puncture time was longer, whereas the puncture-to-recanalization time was shorter in the PCS group than in the ACS group. The proportions of successful recanalization and favorable clinical outcomes were similar between the ACS and PCS groups for all three etiologies. Low baseline National Institutes of Health Stroke Scale (NIHSS) scores and absence of intracerebral hemorrhage at follow-up imaging were associated with favorable clinical outcomes in both groups, whereas successful recanalization (odds ratio, 11.74; 95% confidence interval, 2.60 to 52.94; P=0.001) was only associated in the ACS group.

The proportions of successful recanalization and favorable clinical outcomes were similar among all three etiologies between PCS and ACS patients who underwent EVT. Initial baseline NIHSS score and absence of hemorrhagic transformation were related to favorable outcomes in the PCS and ACS groups, whereas successful recanalization was related to favorable outcomes only in the ACS group.

Collateral flow in acute ischemic stroke is known as a predictor of treatment outcome and long-term prognosis. However, factors determining the initial collateral flow remain unclear. We investigated factors related to collateral flow in patients with acute ischemic stroke caused by large vessel occlusion (AIS-LVO) and further analyzed the results according to stroke etiology.

This was a retrospective study using prospective stroke registry data from a single university hospital from October 2014 to May 2021. AIS-LVO with middle cerebral artery M1 occlusion identified by pre-treatment multiphasic computed tomography angiography was included. Collateral flow score was graded on a 6-point ordinal scale according to pial arterial filling.

A total of 74 patients [cardioembolism (CE): 57; large artery atherosclerosis (LAA): 17] was included. The mean age of all patients was 72.2 ± 11.7 years, and 37.8 % (n = 28) were men. Multivariate regression analysis showed that initial SBP [odds ratio (OR): 0.994; 95% confidence interval (CI): 0.990–0.998; p = 0.002] and stroke etiology (OR: 0.718; 95% CI: 0.548–0.940; p = 0.019) were independent factors of the collateral flow grade. Collateral flow grade was independently associated with initial SBP in the CE group (OR: 0.993; 95% CI: 0.989–0.998; p = 0.004) but not in the LAA group (OR: 0.992; 95% CI: 0.980–1.004; p = 0.218). Initial SBP was significantly correlated with NIHSS score in the CE group but not in the LAA group (r²= 0.091, p = 0.023; r² = 0.043, p = 0.426, respectively).

Elevated initial SBP was associated with poor cerebral collateral flow and more severe symptoms in the CE group, but not in the LAA group in patients with AIS-LVO. These findings suggest differential effects of initial SBP elevation on collateral flow by stroke subtypes.

• humans
• logistic models
• mediation analysis
• registries
• risk factors

Endovascular treatment’s (EVT) safety and efficacy have been proven in treating acute ischemic stroke (AIS) due to large vessel occlusion (LVO). However, limited data exist in different stroke subtypes. We aimed to investigate the differences in efficacy and safety of EVT for acute LVO according to different stroke subtypes.

A total of 1635 AIS patients with LVO undergoing EVT from a prospective cohort of the Endovascular Treatment Key Technique and Emergency Work Flow Improvement of Acute Ischemic Stroke (ANGEL-ACT) registry were classified into three types according to the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria. We compared the primary outcome: 90-day modified Rankin Scale (mRS) score, the secondary outcomes: 90-day mRS (0–1, 0–2, and 0–3), successful recanalization (mTICI 2b/3), and complete recanalization (mTICI 3), and the safety outcomes: death within 90 days, parenchymal hemorrhage (PH), and symptomatic intracranial hemorrhage (SICH) among the three subtypes of stroke patients. Then, multivariable logistic regression models adjusting for potential baseline-confounding variables to determine the associations between stroke subtypes and safety and efficacy endpoints were performed. Finally, we performed subgroup analyses to explore discrepancies in the relationships.

EVT of cardioembolic LVO (CE-LVO) had a higher rate of mTICI 3 (71.7% vs. 65.9% and 63.2%; P = 0.024) and a higher rate of PH (13.8% vs. 5.4% and 6.7%; P < 0.001) when compared to other stroke subtypes. Even multivariable analysis demonstrated that CE-LVO was associated with mTICI 3 [adjusted odds ratio (OR), 1.50 (95% CI 1.04–2.17)] and PH [adjusted OR, 1.97 (95% CI 1.09–3.55)]. However, the 90-day mRS distribution and 90-day mRS (0–1, 0–2, and 0–3) did not differ among the stroke subtypes, and nor did the SICH (P > 0.05).

Functional outcomes were similar among different stroke subtypes. Despite a higher rate of complete recanalization, there is an increased risk of parenchymal hemorrhage in CE-LVO.

Clinical trial registration number: NCT03370939.

• Efficacy
• Endovascular treatment
• Outcomes
• Safety
• TOAST classification

Background and Purpose: There is limited information on symptomatic intracranial hemorrhage (sICH) in stroke patients without thrombolysis. This study aimed to evaluate the risk factors of sICH and the association between sICH and the prognosis at 3 and 12 months in acute ischemic stroke patients without thrombolysis.

Methods: Data originated from the Chinese Acute Ischemic Stroke Treatment Outcome Registry. Univariate analysis and multivariate logistic regression were used to screen the risk factors of sICH. Multivariable logistic regression models were used to assess the association of sICH with poor outcome and all-cause mortality.

Results: Totally, 9,484 patients were included, of which 69 (0.73%) had sICH. Atrial fibrillation (odds ratio [OR], 3.682; 95% confidence interval [CI], 1.945–6.971; p < 0.001), history of tumors (OR, 2.956; 95% CI, 1.115–7.593; p = 0.024), and the National Institutes of Health Stroke Scale (NIHSS) score on admission ([6–15: OR, 2.344; 95% CI, 1.365–4.024; p = 0.002] [>15: OR, 4.731; 95% CI, 1.648–13.583; p = 0.004]) were independently associated with sICH. After adjustment of the confounders, patients with sICH had a higher risk of poor outcome (OR, 1.983; 95% CI, 1.117–3.521; p = 0.018) at 3 months and that of all-cause mortality at 3 (OR, 6.135; 95% CI, 2.328–16.169; p < 0.001) and 12 months (OR, 3.720; 95% CI, 1.513–9.148; p = 0.004).

Conclusion: sICH occurred in 0.73% of acute ischemic stroke patients without thrombolysis and was associated with a worse prognosis at 3 and 12 months. Atrial fibrillation, history of tumors, and NIHSS score at admission were independent risk factors of sICH.

• atrial fibrillation
• ischemic stroke
• prognosis
• risk factors
• symptomatic intracranial hemorrhage
• tumor

• HIF-1α
• Polymorphisms
• Stroke outcome
• VEGFA
• VEGFR2

• Adult
• Aged
• Aged, 80 and over
• Cell Hypoxia/physiology
• Female
• Follow-Up Studies
• Genetic Predisposition to Disease/genetics
• Humans
• Intracranial Arteriosclerosis/genetics
• Intracranial Arteriosclerosis/metabolism
• Male
• Middle Aged
• Mutation, Missense/genetics
• Polymorphism, Single Nucleotide/genetics
• Predictive Value of Tests
• Signal Transduction/physiology
• Stroke/genetics
• Stroke/metabolism
• Treatment Outcome
• Vascular Endothelial Growth Factor A/genetics
• Vascular Endothelial Growth Factor A/metabolism
• Vascular Endothelial Growth Factor Receptor-2/genetics
• Vascular Endothelial Growth Factor Receptor-2/metabolism

• 81530038 National Natural Science Foundation of China
• 81571148 National Natural Science Foundation of China
• 81771285 National Natural Science Foundation of China
• 2016M592954 China Postdoctoral Science Foundation
• WK2019F08 Natural Science Foundation of Wannan Medical college

• functional status
• ischemic stroke
• logistic models
• registries
• reperfusion

• Aged
• Cerebrovascular Disorders/complications
• Cerebrovascular Disorders/surgery
• China
• Endovascular Procedures/methods
• Female
• Humans
• Ischemic Stroke/etiology
• Ischemic Stroke/surgery
• Male
• Middle Aged
• Registries
• Treatment Outcome

• Angioplasty
• Large vessel occlusion
• Reperfusion
• Thrombectomy
• Treatment outcome

• Brain Ischemia/diagnostic imaging
• Brain Ischemia/therapy
• Embolism
• Endovascular Procedures
• Humans
• Intracranial Arteriosclerosis
• Ischemic Stroke
• Propensity Score
• Treatment Outcome

• Atherosclerosis
• Cerebral infarction
• Endovascular
• Glycoprotein-IIb/IIIa inhibitor
• Intracranial
• Percutaneous transluminal angioplasty
• Stenting
• Thrombectomy

• acute ischemic stroke
• atherosclerosis
• endovascular therapy
• intracranial
• neuroimage

• Acute stroke
• Cerebrovascular disease
• Diffusion-weighted imaging
• Endovascular recanalization
• Endovascular treatment

• acute stroke
• cerebral blood volume
• perfusion-weighted magnetic resonance imaging
• salvianolic acid
• treatment

• Computed tomography
• Stroke
• Thrombectomy

• CT angiography
• arterial stenosis
• cerebrovascular diseases
• collateral circulation
• computational fluid dynamics
• stroke

• TOAST
• collateral circulation
• ischaemic stroke
• stroke subtype

Despite advances in imaging techniques and detailed examinations to determine the etiology of a stroke, the cause still remains undetermined in about one fourth of all ischemic strokes. The aim of this prospective study was to determine whether perfusion magnetic resonance imaging (MRI) can differentiate cardioembolic stroke from large artery atherosclerosis (LAA). We recruited 17 cardioembolic stroke and 22 LAA stroke patients, who were classified according to the Trial of Org 10172 in Acute Stroke Treatment and underwent perfusion MRI within 24 hours after the onset of stroke. The patients with cardioembolic stroke had more severe initial stroke severity and larger volumes of initial and final infarct compared to those with LAA stroke. Receiver operating characteristic curve analysis showed that the ratio of time to maximum of the residual curve (T_max) volume for a 2-, 3-, 4- or 5-s lag over T_max volume for a 8s lag all had excellent area under the curve values (> 0.9) to predict cardioembolic stroke. After adjusting for initial National Institute of Health Stroke Scale scores, a threshold of 3.73 for (T_max > 4s volume)/(T_max > 8s volume) had the highest odds ratio to predict cardioembolic stroke (p=0.012; odds ratio: 58.5; 95% confident interval: 2.5-1391.1), with 87.5% sensitivity and 94.4% specificity. In conclusion, perfusion MRI could be a reliable tool to identify cardioembolic stroke with its lower collateral. This is important as it could be used to reveal the exact mechanism and provide supportive evidence to classify a stroke.

Various mechanisms underlie causative large artery occlusion (LAO) in patients with acute ischaemic stroke. Cardioembolic and atherosclerotic occlusions are the two most common types. The pathophysiological changes and responses to mechanical thrombectomy (MT) and antithrombotic treatments including thrombolysis, antiplatelet and anticoagulation therapy may vary among patients with different aetiological mechanisms of occlusion. Atherosclerotic occlusion is inclined to have relatively abundant collaterals and larger area of penumbra, hence a relatively wider time window for reperfusion therapy, while poor response to medical thrombolysis and MT. Severe residual stenosis and reocclusion occurred frequently after MT in atherosclerotic LAO. Angioplasty and stenting as rescue or the first-line therapy and more intensified antiplatelet therapy beyond related recommendations in the current guidelines are sometimes used in managing acute causative LAO because of poor recanalisation after recommended standard thrombolysis or MT therapy, which are usually based on individual experience. Standard protocol to establish emergent aetiological diagnosis of causative LAO and individualised aetiology-specific treatment strategy is needed.

• antiplatelet
• atherosclerosis
• cardioembolism
• large artery occlusion
• mechanical thromboectomy

• Anticoagulants/adverse effects
• Anticoagulants/therapeutic use
• Clinical Decision-Making
• Endovascular Procedures/adverse effects
• Humans
• Ischemic Stroke/diagnostic imaging
• Ischemic Stroke/etiology
• Ischemic Stroke/therapy
• Patient Selection
• Platelet Aggregation Inhibitors/adverse effects
• Platelet Aggregation Inhibitors/therapeutic use
• Recurrence
• Risk Assessment
• Risk Factors
• Thrombectomy/adverse effects
• Thrombolytic Therapy/adverse effects
• Treatment Outcome

• Hainan Provincial Committe of Health and Family Planning

• Collaterals
• endovascular therapy
• perfusion
• stroke

The purpose of this study was to analyze the outcomes and complications between stroke subtypes after intravenous thrombolysis. A total of 471 patients with acute ischemic stroke after intravenous thrombolysis from January 2007 to April 2014 were enrolled and classified according to the Trial of Org 10172 in Acute Stroke Treatment. A multivariate logistic regression model was used to evaluate the outcomes and complications among stroke subtypes after adjusting for baseline variables. Of the 471 patients, 117 (25.1 %) had large-artery atherosclerosis (LAA), 148 (31.8 %) had cardioembolism (CE), 82 (17.6 %) had small vessel disease (SVD), 119 (25.5 %) had undetermined etiology, and 5 (1.1 %) had other determined etiology. The patients with SVD had the mildest initial stroke severity and highest ratio of good and favorable outcomes, whereas those with CE had a higher rate of symptomatic intracranial hemorrhage (sICH) than those with SVD. After adjusting for confounding factors, the ratio of favorable outcome in the patients with SVD stroke was higher than in those with LAA. SVD was associated with a significantly lower rate of any hemorrhage compared to other stroke subtypes, whereas there were no differences in sICH or mortality between stroke subtypes. A lower initial National Institutes of Health Stroke Scale score was associated with good and favorable outcomes, and lower rates of sICH and mortality. The patients with SVD after intravenous thrombolysis had better outcomes and a lower rate of hemorrhage even after adjusting for confounding factors. Stroke severity was an independent factor associated with better functional outcomes, sICH and mortality.

• Acute ischemic stroke
• Intravenous thrombolysis
• Stroke subtype

• atrial fibrillation
• brain ischemia
• cerebrovascular disease
• magnetic resonance imaging
• stroke outcome

• Aged
• Aged, 80 and over
• Female
• Humans
• Male
• Middle Aged
• Administration, Intravenous
• Atrial Fibrillation/complications
• Atrial Fibrillation/pathology
• Atrial Fibrillation/physiopathology
• Brain/pathology
• Brain/physiopathology
• Brain Ischemia/complications
• Brain Ischemia/drug therapy
• Brain Ischemia/pathology
• Brain Ischemia/physiopathology
• Cerebrovascular Circulation/drug effects
• Cerebrovascular Circulation/physiology
• Double-Blind Method
• Fibrinolytic Agents/therapeutic use
• Magnetic Resonance Imaging
• Multimodal Imaging
• Prospective Studies
• Regional Blood Flow/drug effects
• Regional Blood Flow/physiology
• Stroke/complications
• Stroke/drug therapy
• Stroke/pathology
• Stroke/physiopathology
• Thrombolytic Therapy/methods
• Tissue Plasminogen Activator/therapeutic use
• Treatment Outcome

• R01 EB002711 NIBIB NIH HHS
• R01 NS39325 NINDS NIH HHS
• K24 NS044848 NINDS NIH HHS
• K23 NS051372 NINDS NIH HHS
• R01 NS039325 NINDS NIH HHS