🧠🧠The clinical implications of this study are:

1. Thrombus composition could be an important factor underlying the variable efficacy of r-tPA in stroke patients. Knowing the composition of the occluding thrombus may help predict response to r-tPA and guide treatment decisions.
2. Imaging modalities like CT and MRI, which can identify RBC-rich thrombi, may be useful to predict r-tPA susceptibility. RBC-poor thrombi, not detectable by these methods, are likely to be r-tPA resistant.
3. For patients with r-tPA resistant thrombi (RBC-poor/platelet-rich), combining r-tPA with drugs targeting thrombus components like DNA (DNase-1) or VWF (diNAC) could be a promising approach to improve thrombolysis and recanalization rates.
4. A composition-tailored thrombolytic strategy, using r-tPA alone for RBC-rich thrombi and r-tPA + DNase-1/diNAC for RBC-poor thrombi, may expand the range of thrombi amenable to successful pharmacological lysis, especially benefiting patients currently failing r-tPA therapy.
5. If proven safe in terms of bleeding risk, a combination therapy targeting both fibrin and non-fibrin components could potentially be given to all patients, eliminating the need to determine thrombus composition beforehand.

"Given the methodological heterogeneity and distinct patient populations enrolled in the DISTAL and ESCAPE-MeVO trials, caution is warranted when attempting to synthesize or directly compare their findings. The disparate designs and inclusion criteria limit the cumulative interpretability of the results, necessitating independent evaluation of each study's conclusions. Furthermore, the following nuances necessitate careful consideration when interpreting each study's findings, as they may significantly influence the reader's understanding of the efficacy and safety of endovascular treatment for medium and distal vessel occlusions."🔴 Vessel Definition & Patient Population:DISTAL (Broader): Diluted EVT benefit due to inclusion of potentially less severe distal occlusions and exclusion of known EVT-responsive dominant M2s. Impact: Underestimation of EVT potential.ESCAPE-MeVO (Narrower): Targeted a more specific group, but chosen locations may have been less amenable to EVT or higher risk. Impact: Potential for negative result.Overall Impact: Differences may explain DISTAL's neutral result vs. ESCAPE-MeVO's harm signal.🔴 Time Window:DISTAL (Longer - 24h): Allowed more patients but increased irreversible damage and spontaneous recanalization. Impact: Diluted treatment effect.ESCAPE-MeVO (Shorter - 12h): Enriched for potentially responsive patients but may have missed others who could benefit. Impact: Potentially missed benefit, workflow negated any potential benefit.Imaging (ESCAPE-MeVO):🔴 Salvageable Tissue Required: Focused EVT on those with potential benefit, but specific criteria could have biased selection. Impact: Potential exclusion of treatable patients.🔴 Device Mandate (ESCAPE-MeVO):Solitaire X Only: Reduced procedural variability but limited operator choice and real-world applicability. Impact: Potential for suboptimal device selection, skewed real-world applicability.🔴 Mortality (ESCAPE-MeVO):Increased Mortality Signal: Serious concern suggesting potential harm in this specific context. Impact: Strong argument against routine EVT in this population.🔴 Workflow Times:🟢 Prolonged Times (Both, esp. ESCAPE-MeVO): Delays could negate EVT benefits due to irreversible damage. Impact: Undermined potential efficacy.🟢Spontaneous Recanalization (ESCAPE-MeVO):Recanalization Before EVT: Unnecessary EVT in some, diluting treatment effect and cumulating risk. Impact: Obscured potential benefit.

### Main Points🛜. Effectiveness: - High rate of adequate occlusion (88.7%). - 59.4% complete occlusion at last follow-up.🛜. Safety: - 17 complications in 12 patients (9.4%). - No intraoperative or periprocedural aneurysmal ruptures.🛜. Technique: - Single-stent L-stenting is effective and reduces the amount of metal used compared to dual-stent techniques.🛜. Comparison: - Favorable outcomes compared to other techniques like Y-stenting and new devices like the WEB device.🛜. Predictors: - Smaller aneurysm size and transcellular technique predict better outcomes. - Larger size and dome to neck ratio predict higher retreatment rates.### Clinical Implications ###✅**Treatment Choice:** - Single-stent L-stenting presents a viable alternative to dual-stent techniques, potentially reducing thromboembolic complications and procedural costs.✅ Patient Selection: - Patients with smaller aneurysms and those suitable for the transcellular technique may benefit most from L-stenting.✅ Procedure Planning: - Understanding predictors of success and retreatment can aid in better patient selection and pre-procedural planning.✅ Benchmarking: - This study provides a validated comparator for future studies on new devices and techniques for WNBAs, setting a benchmark for efficacy and safety.✅ Cost Considerations: - L-stenting could be more cost-effective due to the reduced use of stents and lower complication rates, though further studies are needed to confirm this.https://lnkd.in/dU984vPT

🔔 Clinical Outcomes: Unfavorable Clinical Outcomes: Before PSM, unfavorable clinical outcomes (mRS scores 3-6) were 72.0% for SC and 66.2% for EC (P = .026). After PSM, these were 70.6% for SC and 63.3% for EC (P = .025). In-Hospital Mortality: Before PSM, in-hospital mortality was significantly higher for EC (16.1%) compared to SC (10.5%, P = .003). After PSM, the difference was not significant (EC: 12.7%, SC: 10.4%, P = .384). 🎤 Predictors of Unfavorable Outcomes: 🥁 Common Predictors: WFNS grade V, age older than 70 years, and Fisher CT grade 4 were predictors of unfavorable outcomes in both SC and EC groups. 🥁 SC-Specific Predictors: WFNS grade IV and Fisher CT grade 3 were associated with unfavorable outcomes only in the SC group. 🥁 EC-Specific Predictors: Ages in the 50s and 60s were associated with unfavorable outcomes only in the EC group. 🎤 Conclusion: EC was associated with significantly more favorable clinical outcomes than SC in patients with poor-grade aSAH, without significant differences in in-hospital mortality after PSM. The benefit of EC over SC might be particularly notable in patients with WFNS grade IV and Fisher CT grade 3. 📣 📣 Implications on Clinical Practice ✅ Treatment Strategy Shift: The findings suggest that EC may be preferred over SC for patients with poor-grade aSAH due to better clinical outcomes at discharge. This could lead to a shift in treatment protocols favoring EC, especially in high-risk cases. ✅ Patient Selection: Clinicians might consider WFNS grade IV and Fisher CT grade 3 as indicators for opting for EC over SC. Understanding the specific predictors of unfavorable outcomes can help tailor treatment plans to individual patient profiles, potentially improving overall outcomes. ✅ Age Considerations: With older age being a significant predictor of unfavorable outcomes, more careful consideration and possibly more aggressive management might be necessary for elderly patients undergoing either EC or SC. ✅ Resource Allocation: High-volume cerebrovascular centers equipped to perform both SC and EC may need to allocate more resources and training towards enhancing EC capabilities, given its demonstrated advantages. ✅ Guideline Revisions: The study’s results might influence revisions of existing guidelines from bodies such as the American Heart Association/American Stroke Association and European Stroke Organization to reflect the potential superiority of EC in poor-grade aSAH cases.

Clinical Implications: - Early switching to the combined technique after failed standalone stent retriever or aspiration passes may improve reperfusion rates.- Repeating the same standalone technique after failed passes may not improve reperfusion as much as early switching.- More data needed to confirm impact on clinical outcomes.

https://jnis.bmj.com/content/early/2024/04/04/jnis-2024-021545

The main points of the article "Effect of Intermittent Oro-Esophageal Tube Feeding in Bulbar Palsy After Ischemic Stroke: A Randomized Controlled Study" are: 1. The study compared the effects of intermittent oro-esophageal tube feeding (IOE) versus nasogastric tube feeding (NG) in patients with bulbar palsy after ischemic stroke who received routine treatment and swallowing rehabilitation training. 2. 148 patients were randomly divided into IOE (n=74) and NG (n=74) groups. 3. The primary outcome was nutritional status (body mass index, serum albumin, prealbumin). Secondary outcomes included swallowing function (Functional Oral Intake Scale, Penetration-Aspiration Scale), pneumonia, depression, and adverse events. 4. After treatment, the IOE group showed significantly better results compared to the NG group in terms of: - Nutritional status (body mass index, albumin, prealbumin) - Swallowing function (Functional Oral Intake Scale, Penetration-Aspiration Scale) - Lower incidence of stroke-associated pneumonia (4.05% vs 35.14%) - Lower incidence of depression (1.35% vs 59.46%) - Fewer adverse events (reflux, fever, throat discomfort) 5. The authors concluded that in patients with dysphagia and bulbar palsy after ischemic stroke receiving routine treatment and swallowing rehabilitation, IOE is safer and more conducive to improving nutritional status, swallowing function, pneumonia, and depression compared to NG. In summary, this randomized controlled study found intermittent oro-esophageal tube feeding to be superior to nasogastric tube feeding across multiple outcomes in stroke patients with bulbar palsy and dysphagia. https://lnkd.in/djPt7Kim

Main Points: - This cross-sectional MRI study looked at cerebral blood flow (CBF) in premenopausal, perimenopausal, and postmenopausal women compared to similar-aged men. - Premenopausal women had higher CBF in whole brain, gray matter, and white matter compared to the other groups. - Perimenopausal and postmenopausal women had more white matter hyperintensities (WMHs) than premenopausal women and men. - Multivariate regression analysis showed menopause status and the interaction of age and menopause status significantly affected CBF. - Premenopausal women showed slight CBF increases with age, while peri- and postmenopausal women showed CBF declines. Clinical Implications: - The findings suggest alterations in brain perfusion begin during perimenopause, possibly due to increased WMHs. - Monitoring brain perfusion changes in perimenopausal women could help identify those at higher cerebrovascular disease risk. - Strategies to maintain better brain perfusion during the menopausal transition may help reduce future cerebrovascular risk. - CBF could be a useful neuroimaging biomarker for cerebrovascular risk during menopause. - Longitudinal studies are needed to clarify how menopause-related CBF changes correlate to outcomes. Read more at hashtag#neurovascularnuggets https://lnkd.in/dRNp95kY

Main Points - This was a multicenter randomized controlled trial comparing long-term (12 months) vs short-term (3 months) dual antiplatelet therapy (DAPT) with aspirin and clopidogrel after stent-assisted coil embolization (SACE) for cerebral aneurysms. - 142 patients were recruited and randomized. The primary outcome was ischemic stroke rate during 3-12 months after SACE. - There was no significant difference in ischemic stroke rates between the long-term and short-term DAPT groups (0 vs 2.1 per 100 person-years). - Rates of the secondary outcomes (death/any stroke, hemorrhagic events, death/stroke/hemorrhage, retreatment/stent issues) were also not significantly different between groups. - The trial was underpowered due to lower than expected enrollment and event rates. Implications for Clinical Practice - This trial did not find a statistically significant benefit of long-term over short-term DAPT after SACE, but was underpowered to definitively determine this. - The low ischemic event rates suggest DAPT for 3-6 months is likely sufficient for many patients after SACE with newer generation stents. However, longer DAPT may still benefit some high thromboembolic risk patients. - Platelet function testing to guide personalized DAPT duration decisions may be useful. Patients at high hemorrhagic risk may also benefit from shorter DAPT. - Large definitive randomized trials are still needed to determine optimal DAPT duration after SACE. In the meantime, decisions can be individualized based on thromboembolic vs hemorrhagic risk factors Read more at hashtag#neurovascularnuggets https://lnkd.in/dC9Wxhxt

🎁key points from the article - This was a randomized trial comparing stent-assisted coiling (SAC) versus coiling alone (CA) for unruptured intracranial aneurysms at high risk of recurrence (large, recurrent, or wide-neck aneurysms). - 205 patients were randomized, with 94 allocated to SAC and 111 to CA. The primary outcome was a composite of treatment failure, defined as initial failure, aneurysm rupture, retreatment, death/disability, or residual aneurysm at 12 months imaging. - The primary outcome occurred in 30.1% with SAC versus 27.3% with CA (relative risk 1.10, p=0.66). There was no significant difference in rates of 12-month morbidity/mortality or retreatment. - As-treated analysis showed lower residual aneurysm rates with SAC but higher complication rates compared to CA. - The study did not find evidence that SAC improves outcomes compared to CA in high-risk unruptured aneurysms. 💡Clinical Implications: - The results do not support routine use of SAC over CA in unruptured intracranial aneurysms, even those at higher recurrence risk. - SAC may increase procedural risks without improving clinical outcomes compared to CA. However, the study was underpowered for definitive safety conclusions. - Careful consideration of risks versus benefits is warranted before routinely using SAC instead of CA in eligible unruptured aneurysm patients. - Larger randomized trials could help clarify if subsets of aneurysms benefit from SAC over CA. Integrating future SAC studies into ongoing trials may be useful. In summary, this randomized trial did not find evidence to support superiority of SAC over CA for unruptured intracranial aneurysms prone to recurrence. The results argue against routine use of SAC in eligible patients, though larger studies are needed to guide optimal patient selection. Read more at https://lnkd.in/dwisZ3VA

🎁the key points from the article - The study retrospectively compared outcomes of endovascular therapy (EVT) achieving modified Thrombolysis in Cerebral Infarction (mTICI) grade 2b (incomplete reperfusion) versus grade 3 (complete reperfusion) in patients with large ischemic strokes. - In 226 patients with large anterior circulation strokes and baseline Alberta Stroke Program Early CT Score (ASPECTS) of 3-5, there was no significant difference in 90-day functional outcomes based on the modified Rankin Scale (mRS) between those with final mTICI 2b versus mTICI 3 reperfusion. - Rates of 90-day mortality and independent ambulation were also similar between mTICI 2b and mTICI 3 groups. - However, symptomatic intracranial hemorrhage (sICH) rates were lower with mTICI 3 compared to mTICI 2b reperfusion (4.5% vs 12.6%). - In subgroup analyses, mTICI 3 reperfusion did not provide added benefit over mTICI 2b reperfusion regardless of patient age, sex, baseline stroke severity, etc. - This suggests mTICI 2b may be an acceptable angiographic endpoint for EVT in large strokes, questioning the need for additional maneuvers to achieve full mTICI 3 reperfusion. 💡Clinical Implications: - The findings suggest interventionalists should carefully weigh risks/benefits of pursuing mTICI 3 if mTICI 2b reperfusion is achieved early in EVT for large ischemic strokes. - mTICI 2b may provide comparable outcomes to mTICI 3 in these patients, while reducing procedural risks such as sICH. - Intraprocedurally evaluating extent of persisting hypoperfusion versus established infarct on imaging could help determine whether to continue manipulating beyond mTICI 2b. - The results may help guide individualized decision making on optimal angiographic targets during EVT for large strokes. More data is needed to develop definitive recommendations. In summary, this study questions the clinical benefit of mandating mTICI 3 reperfusion in EVT for large anterior circulation strokes. It may support stopping at mTICI 2b in some patients to limit procedural risks based on individual characteristics. Read more at hashtag#neurovascularnuggets https://lnkd.in/diJUE4qy