Background: and Purpose In patients with ischemic stroke and isolated cervical internal carotid artery occlusion (c-ICA-O), endovascular therapy (EVT) can improve cerebral perfusion. To maintain vessel patency, EVT is frequently combined with carotid artery stenting (CAS). We assessed the efficacy and safety of emergent CAS during EVT for isolated c-ICA-O. Methods: This retrospective multinational cohort study (42 centers) included consecutive patients who underwent EVT for isolated c-ICA-O within 24 hours from the time last seen well. Patients who underwent emergent CAS were compared with those who did not. Co-primary outcomes were c-ICA vessel patency and symptomatic intracerebral hemorrhage (sICH) 24 hours post-EVT. Secondary outcomes included any intracerebral hemorrhage (ICH) at 24 hours and disability at 3 months (modified Rankin Scale [mRS] shift). Outcomes were adjusted using inverse probability of treatment weighting. Results: Of 317 patients (mean age, 68.6 years [standard deviation, 12.9]; median National Institutes of Health Stroke Scale 11 [interquartile range, 6–17]; 26.8% female), 219 (69.1%) underwent CAS, whereas 98 (30.9%) did not. At 24 hours, vessel patency was more common after CAS (83.5% vs. 40.7%; adjusted odds ratio [aOR], 9.45; 95% confidence interval [CI], 4.91–18.17); sICH rates did not differ (2.3% vs. 3.1%; aOR, 0.92; 95% CI, 0.18–4.73). Any ICH was more common after CAS (19.3% vs. 9.3%; aOR, 2.50; 95% CI, 1.12–5.60). CAS was not associated with mRS at 3 months (adjusted common odds ratio, 0.98; 95% CI, 0.62–1.56). Conclusions In patients undergoing EVT for isolated c-ICA-O, emergent CAS was technically effective and reasonably safe. More frequent vessel patency in patients who underwent CAS did not translate into improved functional outcome at 3 months.

Background: and Purpose This study aimed to investigate the effect of endovascular treatment (EVT, with or without intravenous thrombolysis [IVT]) versus IVT alone on outcomes in patients with acute ischemic stroke (AIS) and intracranial large vessel occlusion (LVO) attributable to cervical artery dissection (CeAD). Methods: This multinational cohort study was conducted based on prospectively collected data from the EVA-TRISP (EndoVAscular treatment and ThRombolysis for Ischemic Stroke Patients) collaboration. Consecutive patients (2015–2019) with AIS-LVO attributable to CeAD treated with EVT and/or IVT were included. Primary outcome measures were (1) favorable 3-month outcome (modified Rankin Scale score 0–2) and (2) complete recanalization (thrombolysis in cerebral infarction scale 2b/3). Odds ratios with 95% confidence intervals (OR [95% CI]) from logistic regression models were calculated (unadjusted, adjusted). Secondary analyses were performed in the patients with LVO in the anterior circulation (LVOant) including propensity score matching. Results: Among 290 patients, 222 (76.6%) had EVT and 68 (23.4%) IVT alone. EVT-treated patients had more severe strokes (National Institutes of Health Stroke Scale score, median [interquartile range]: 14 [10–19] vs. 4 [2–7], P<0.001). The frequency of favorable 3-month outcome did not differ significantly between both groups (EVT: 64.0% vs. IVT: 86.8%; ORadjusted 0.56 [0.24–1.32]). EVT was associated with higher rates of recanalization (80.5% vs. 40.7%; ORadjusted 8.85 [4.28–18.29]) compared to IVT. All secondary analyses showed higher recanalization rates in the EVT-group, which however never translated into better functional outcome rates compared to the IVT-group. Conclusion We observed no signal of superiority of EVT over IVT regarding functional outcome in CeAD-patients with AIS and LVO despite higher rates of complete recanalization with EVT. Whether pathophysiological CeAD-characteristics or their younger age might explain this observation deserves further research.

BACKGROUND AND PURPOSE: Standard operating procedures (SOP) incorporating plasma levels of rivaroxaban might be helpful in selecting patients with acute ischemic stroke taking rivaroxaban suitable for IVthrombolysis (IVT) or endovascular treatment (EVT). METHODS: This was a single-center explorative analysis using data from the Novel-Oral-Anticoagulants-in-Stroke-Patients-registry (clinicaltrials.gov:NCT02353585) including acute stroke patients taking rivaroxaban (September 2012 to November 2016). The SOP included recommendation, consideration, and avoidance of IVT if rivaroxaban plasma levels were < 20 ng/mL, 20‒100 ng/mL, and >100 ng/mL, respectively, measured with a calibrated anti-factor Xa assay. Patients with intracranial artery occlusion were recommended IVT+EVT or EVT alone if plasma levels were ≤100 ng/mL or >100 ng/mL, respectively. We evaluated the frequency of IVT/EVT, door-to-needle-time (DNT), and symptomatic intracranial or major extracranial hemorrhage. RESULTS: Among 114 acute stroke patients taking rivaroxaban, 68 were otherwise eligible for IVT/EVT of whom 63 had plasma levels measured (median age 81 years, median baseline National Institutes of Health Stroke Scale 6). Median rivaroxaban plasma level was 96 ng/mL (inter quartile range [IQR] 18‒259 ng/mL) and time since last intake 11 hours (IQR 4.5‒18.5 hours). Twenty-two patients (35%) received IVT/EVT (IVT n=15, IVT+EVT n=3, EVT n=4) based on SOP. Median DNT was 37 (IQR 30‒60) minutes. None of the 31 patients with plasma levels >100 ng/mL received IVT. Among 14 patients with plasma levels ≤100 ng/mL, the main reason to withhold IVT was minor stroke (n=10). No symptomatic intracranial or major extracranial bleeding occurred after treatment. CONCLUSIONS: Determination of rivaroxaban plasma levels enabled IVT or EVT in one-third of patients taking rivaroxaban who would otherwise be ineligible for acute treatment. The absence of major bleeding in our pilot series justifies future studies of this approach.
Arteries ; Hemorrhage ; Humans ; National Institutes of Health (U.S.) ; Plasma* ; Rivaroxaban* ; Stroke*