BACKGROUND The optimal first‐line device choice for endovascular treatment (EVT) of cancer‐related stroke remains largely unknown. In this study, we evaluated the efficacy and safety of the EVT methods for treating cancer‐related stroke thrombi. METHODS We retrospectively analyzed 78 patients with cancer‐related stroke who underwent EVT between February 2011 and July 2024. Patients were compared based on the first‐line EVT technique (combined [ n = 29] versus stent retriever [SR] only [ n = 35] versus contact aspiration [CA, n = 14]) and the type of the SR (the dual‐layered stent retriever [Embotrap] [ n = 13], the single‐layered stent retriever (Trevo [ n = 16], and the Solitaire [ n = 35]) group. The primary efficacy end point was the first‐pass effect (achieving a modified Thrombolysis in Cerebral Infarction score of 2c or 3 after the first pass). The primary safety end point was the symptomatic intracranial hemorrhage rate. RESULTS The primary efficacy did not differ between the first‐line EVT techniques (first‐pass effect: combined 34.5% versus SR only 17.1% versus CA 35.7%; P = 0.2). Among the SR groups, the dual‐layered stent retriever group showed a higher rate of first‐pass effect compared with the single‐layered stent retriever (Trevo) and the single‐layered stent retriever (Solitaire) groups (53.8% versus 25.0% versus 14.3%, P = 0.023). The dual‐layered stent retriever group was independently associated with a higher rate of first pass effect (adjusted odds ratio, 11.0 [95% CI 1.4–126.0]; P = 0.031). The incidence of symptomatic intracranial hemorrhage after the procedure did not significantly differ between the groups. CONCLUSIONS In EVT for cancer‐related stroke, the dual‐layered stent retriever device demonstrated superior efficacy in higher rates of first‐pass effect without increasing the risk of symptomatic intracranial hemorrhage. These findings suggest that the dual‐layered SR may be preferred as the first‐line treatment option for EVT in cancer‐related stroke.

Background: The effects of blood pressure (BP) lowering in patients treated with intravenous tissue plasminogen activator (IV tPA) before endovascular thrombectomy (EVT) are unclear. Aims: This study aims to investigate whether intensive and conventional BP management affects outcomes differently, depending on IV tPA administration before EVT. Methods: In this subgroup analysis of the Outcome in Patients Treated with Intra-Arterial Thrombectomy–Optimal Blood Pressure Control (OPTIMAL-BP; ClinicalTrials.gov Identifier: NCT04205305) trial, patients were divided into groups based on IV tPA use before EVT. Clinical outcomes of intensive (systolic BP target < 140 mm Hg) or conventional BP management (systolic BP target 140–180 mm Hg) were compared among groups. The primary efficacy outcome was a favorable outcome at 3 months (modified Rankin Scale score of 0–2). Primary safety outcomes included symptomatic intracerebral hemorrhage (sICH) within 36 h and stroke-related death within 3 months. Results: Among the 302 patients, the IV tPA group included 98 (32.5%) and the non-IV tPA group comprised 204 subjects (67.5%). In the IV tPA group, intensive BP management significantly lowered the favorable outcome rate (intensive, 27.3% vs. conventional, 51.9%; adjusted odds ratio [aOR], 0.36; 95% confidence interval [CI], 0.13–0.93; p = 0.04). In the non-IV tPA group, the risk difference rate of favorable outcome was not significantly different between intensive and conventional BP management (44.1% vs. 55.9%; aOR, 0.62; 95% CI, 0.31–1.22; p = 0.17). Notably, the proportion of malignant cerebral edema within 36 h in the IV tPA group was significantly higher in the intensive management group (18.2%) than in the conventional management group (1.9%; aOR, 10.72; 95% CI, 1.24–92.29; p = 0.03). sICH and mortality rates were not significantly different between intensive and conventional BP management in either study groups. Conclusions: Intensive BP management worsens 3-month functional outcomes after successful EVT without reducing sICH among patients who received IV tPA before EVT, indicating that BP lowering in this population should be cautious.

Background and Objectives: Understanding the mechanisms of thrombosis is crucial for the future advancement in treating ischemic stroke. While many researches on thrombogenesis have been conducted, there was a limited data on thrombus growth. In this study, we investigated whether the clot composition or clot characteristics differed by the clot size using microscopic analysis of ischemic clot. Methods: We obtained the clots from 238 ischemic stroke patients who received endovascular treatment between July 2017 and July 2023 at Severance Stroke Center. We quantitatively analysed the clot components identified using immunohistochemistry. The fractions of each component such as fibrin, red blood cells (RBC), and platelets were calculated as the percentage pixel density of the total clot area. Clot volume was semiautomatically measured on thin-section computed tomography performed at stroke presentation using software. We determined the association between clot volume and histopathologic composition, arrangement patterns, and clinical or radiological features. Results: Among the 238 patients, the median (interquartile) of clot volume was 47.0 mm 3 (range 23.8-79.8). As the clot volume increased, the proportion of RBC became larger (r = 0.307. P <0.001) and the proportion of platelet became smaller (r = -0.150, p=0.029). In terms of RBC patterns, purely aggregated RBC patterns, rather than RBC-fibrin mixture patterns, was positively associated with the clot volume. After adjusting for potential confounders including posterior circulation occlusion, serum hemoglobin levels, serum albumin levels, and the presence of active cancer (all p<0.05 in univariable analysis), clot volume was independently related with the proportion of RBC (ß 0.726, SE 0.302, p =0.017) or the presence of purely aggregated RBC pattern (ß 59.182, SE 11.684, p <0.001). Conclusions: As the clot volume increased, the proportion of RBCs increases, and areas of purely packed with RBCs become larger. These findings suggest that as the clot grows, RBC mainly involved the clot volume growth.

BACKGROUND: This study aimed to investigate whether net water uptake (NWU) is associated with 3-month catastrophic functional outcome (modified Rankin Scale score, 5–6) and to develop predictive models with preprocedural factors, including NWU, in patients with large infarcts who underwent endovascular thrombectomy. METHODS: This multicenter observational cohort study conducted in Korea included patients with anterior circulation stroke and an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of ≤5 receiving endovascular thrombectomy between 2015 and 2023. NWU, a quantitative imaging biomarker reflecting the degree of hypoattenuation on noncontrast computed tomography, was measured across the entire ASPECTS region (ASPECTS10-NWU), and its association with catastrophic functional outcome was assessed using a mixed-effects logistic regression model, adjusting for age, sex, prestroke modified Rankin Scale score, baseline National Institutes of Health Stroke Scale score, baseline ASPECTS, onset-to-baseline noncontrast computed tomography time, and intravenous tissue-type plasminogen activator, with hospital included as a random effect. Moreover, a predictive model has been developed with preprocedural factors that were significant covariates from the mixed-effects logistic regression analysis. RESULTS: A total of 255 patients were included (mean age, 71.0±12.6 years; 54.9% male). The median ASPECTS10-NWU was 3.0% (interquartile range, 1.9%–4.1%). Higher ASPECTS10-NWU was independently associated with catastrophic functional outcome (adjusted odds ratio, 1.70 [95% CI, 1.33–2.17]; P <0.001). The model integrating ASPECTS10-NWU with preprocedural variables suggested predicted catastrophic functional outcome probabilities; as ASPECTS10-NWU and baseline National Institutes of Health Stroke Scale score increased, the marginal probability of catastrophic functional outcome increased in all age (<80 and ≥80 years) and prestroke modified Rankin Scale score (0–1 and 2–4) groups, with the patients aged ≥80 years and with prestroke modified Rankin Scale score of 2 to 4 having higher outcome probability. CONCLUSIONS: Elevated ASPECTS10-NWU is strongly associated with catastrophic functional outcome in patients with large infarcts treated with endovascular thrombectomy. Integrating the ASPECTS10-NWU with clinical variables may provide patient-specific prognostication that may assist clinicians in decision-making for endovascular thrombectomy in large infarcts.

BACKGROUND: Several randomized clinical trials have indicated that intensive blood pressure (BP) lowering is associated with worse outcomes, leaving the optimal BP targets following endovascular thrombectomy (EVT) uncertain. AIMS: This study aimed to investigate the relationship between specific systolic BP (SBP) thresholds, time spent outside these thresholds, and clinical outcomes. METHODS: This post hoc analysis of the Outcome in Patients Treated With Intra-Arterial Thrombectomy-Optimal Blood Pressure Control (OPTIMAL-BP) trial, included patients with successful EVT randomized to intensive (<140 mmHg) or conventional (140-180 mmHg) BP management. We analyzed SBP parameters, including mean, maximum, and minimum SBP during study period, as well as excursions beyond predefined SBP thresholds (<90, <100, <110, >170, >180, and >190 mmHg), and the cumulative and continuous durations of these excursions. Associations with 3 month modified Rankin Scale (mRS) and symptomatic intracerebral hemorrhage (sICH) were assessed using multivariable logistic and ordinal regression models. RESULTS: A total of 302 patients (median 75 years; 180 [59.6%] men) were analyzed with 11,461 BP measurements recorded during the first 24 hours after EVT. Prolonged hypoperfusion (SBP below 100 mmHg for continuous duration) was associated with worse mRS score (adjusted OR [aOR] 1.21 per hour, 95% CI [1.02-1.45]; P = 0.030) and increased sICH risk (aOR 1.49 per hour, 95% CI [1.15-1.97]; P = 0.004). SBP surges above 190 mmHg were linked to mRS worsening (aOR 2.60, 95% CI [1.05-6.53]; P = 0.039), but upper threshold-related parameters were not significantly associated with sICH. CONCLUSION: Prolonged hypoperfusion below 100 mmHg and extreme surges above 190 mmHg, rather than specific SBP parameters, were associated with poor functional outcomes. These findings highlight the need for a threshold-based BP management approach post-EVT to minimize prolonged hypotension and excessive surges.

BACKGROUND: Intravenous antihypertensives are frequently used to control blood pressure after successful endovascular thrombectomy (EVT), yet studies investigating the relationship between intravenous antihypertensive use and functional outcomes after successful EVT remain limited. METHODS: We conducted an exploratory secondary analysis of the OPTIMAL-BP trial (Outcome in Patients Treated With Intra-Arterial Thrombectomy–Optimal Blood Pressure Control), which compared intensive (systolic blood pressure <140 mm Hg) versus conventional blood pressure management (systolic blood pressure, 140–180 mm Hg) within the first 24 hours after successful recanalization across 19 stroke centers in South Korea between June 2020 and November 2022. Patients were classified according to the administration of intravenous antihypertensives within the initial 24 hours after enrollment. The primary efficacy outcome was functional independence (modified Rankin Scale score of 0–2) at 3 months. RESULTS: Of the 302 patients (median, 75 years; 180 [59.6%] men), 141 (46.7%) received intravenous antihypertensives within the first 24 hours after EVT. Among the 141 patients who received intravenous antihypertensives, 133 (94.3%) were treated with nicardipine, 10 (7.0%) received labetalol, and 2 (1.4%) were administered both drugs. Patients who received intravenous antihypertensives had significantly lower rates of functional independence at 3 months (adjusted odds ratio, 0.51 [95% CI, 0.27–0.95]; P =0.035) and excellent neurological recovery at 24 hours (adjusted odds ratio, 0.46 [95% CI, 0.22–0.94]; P =0.036), as well as higher stroke-related mortality rates (adjusted odds ratio, 4.21 [95% CI, 1.24–16.4]; P =0.027), compared with patients who did not receive intravenous antihypertensives. Symptomatic intracerebral hemorrhage was not significantly different between groups (adjusted odds ratio, 1.67 [95% CI, 0.68–4.19]; P =0.267). CONCLUSIONS: The use of intravenous antihypertensives within the first 24 hours after successful EVT was associated with worse functional outcomes at 3 months. This finding highlights the need for a cautious assessment of the risks and benefits of administering intravenous antihypertensives immediately after EVT. REGISTRATION: URL: https://www.clinicaltrials.gov ; Unique identifier: NCT04205305.

Abstract Introduction: While the efficacy of endovascular thrombectomy (EVT) in large core infarcts has been established, the influence of blood pressure (BP) management on functional outcomes based on infarct volume remains unclear. Patients and methods: We conducted a secondary analysis of the Outcome in Patients Treated With Intra-Arterial Thrombectomy–Optimal Blood Pressure Control (OPTIMAL-BP) trial, which compared intensive (systolic BP &lt; 140 mmHg) versus conventional (systolic BP 140–180 mmHg) BP management within the first 24 h following successful recanalization. Patients were grouped based on an infarct volume cut-off of 50 ml, assessed 24 h post-EVT. The primary efficacy outcome was functional independence (modified Rankin Scale of 0–2) at 3 months. Change of predicted probability for functional independence between BP managements, as infarct volume varied, was assessed. Results: Of the 300 patients, 222 (74.0%) were in the infarct volume ⩽50 ml group and 78 (26.0%) were in the infarct volume &gt;50 ml group. The conventional management was significantly associated with a higher rate of functional independence in the infarct volume ⩽50 ml group (adjusted odds ratio [AOR], 2.06 [95% CI, 1.12–3.86]). In the infarct volume &gt;50 ml group, the proportion of patients with functional independence was not significantly different between BP managements (AOR, 1.52 [95% CI, 0.46–5.04]). The interaction effect between the infarct volume groups and BP managements was not significant. As infarct volume increased, the difference in predicted probability of functional independence between BP managements decreased. Discussion and conclusions: Conventional BP management showed greater benefits for achieving functional independence at 3 months when infarct volumes were smaller. As infarct volume increased, the impact of BP management strategies on functional outcomes decreased. Registration: ClinicalTrials.gov (NCT04205305)