Determinants Of Prognosis In Patients With Acute Anterior Circulation Large Vessel Occlusion Stroke After Thrombectomy Based On Etiologies

Part I Outcomes in Atherosclerosis versus Cardioembolic Cerebral Large Vessel Occlusion after ThrombectomyObjective: We aimed to investigate the outcomes in large vessel occlusion(LVO)patients undergoing endovascular treatment(EVT)based on different stroke etiologies,and further explore the determinant factors respectively.Methods: The data of patients who underwent EVT of LVO in anterior circulation from July 2015 to June 2022 in Yijishan hospital of Wanna Medical College has been retrospectively collected and analyzed.The causes of occlusion were classified into Large-artery atherosclerosis(LAA)and cardioembolism(CE)according to the Trial of ORG 10172 in Acute Stroke Treatment(TOAST)scale.The reperfusion grades were classified according to thrombolysis of cerebral infarction(TICI)scale and subdivided into successful recanalization(TICI 2b/3)and failed recanalization(TICI<2b).We compared the primary outcomes: 90-day modified Rankin Scale(m RS)score(0-1 defined as excellent prognosis,0-2 defined as good prognosis),the secondary outcomes: death within 90 days,parenchymal hemorrhage(PH),and symptomatic intracranial hemorrhage(SICH)among the LAA-LVO and CE-LVO patients.The multivariable models were performed to clarify the associations between two stroke subtypes and prognoses.Results: A total of 857 patients were collected from our center.Classified by TOASTscale,the number of CE-LVO was 537(62.7%),that of LAA-LVO 230(26.8%),while 33(3.9%)patients had ODC-LVO and 57(6.7%)patients had UND-LVO.According to exclusion and inclusion criteria,finally a total of 624 patients were enrolled into this retrospective study,among which 480(76.9%)patients had CE-LVO,and 144(23.1%)LAA-LVO.A total of 536(85.9%)patients had a successful reperfusion.Postoperative PH occurred in 80 patients(12.8%)and SICH in 45(7.2%).A total of 213(34.1%)patients had an excellent prognosis,while 296(47.4%)patients had a good prognosis and68(16.2%)died within 90 days.In regression models,we found no significant differences between the 90-day prognoses with stroke etiologies.However,the incidence of postoperative PH(OR = 3.378,95% CI: 1.281 to 10.907,P = 0.016)and SICH(OR = 5.8,95% CI: 1.335 to 25.192,P = 0.019)were significantly higher in CE group than in LAA.We further compared the determinant fators between groups with different prognoses.For patients with cardiogenic embolism,multivariable analysis showed that the good prognosis group were younger(OR = 0.948,95% CI: 0.923 to 0.975,P < 0.001),and had a higher rate of successful recanalization(OR = 2.862,95% CI: 1.3 to 6.3,P = 0.009),better collateral status(OR = 2.872,95% CI: 1.789 to 4.61,P < 0.001),higher ASPECT score(OR = 1.433,95% CI: 1.256 to 1.633,P < 0.001),lower NIHSS score(OR = 0.901,95% CI: 0.85 to 0.956,P=0.001)than the poor group.In contrast,for LAA patients,compared with patients who had 90 d poor prognosis,more patients achieving functional independence had better collateral status(OR = 3.451,95% CI: 1.242 to 9.586,P=0.017),lower baseline SBP level(OR = 0.982,95% CI: 0.965 to 0.998,P=0.032),lower NIHSS score(OR = 0.889,95% CI: 0.806 to 0.981,P=0.019)and shorter puncture-to-reperfusion time(OR = 0.985,95% CI: 0.973 to 0.998,P=0.021).Conclusion: In patients treated with EVT for acute large vessel occlusive stroke in the anterior circulation,CE patients had a higher incidence of postoperative PH and SICH than LAA patients,while no significant differences were found in 90-day prognoses or mortality.The 90 d prognosis of CE patients was significantly associated with age,admission NIHSS score,admission ASPECT score,collateral status and recanalization,whereas the 90 d prognosis of LAA patients was significantly associated with baseline SBP,admission NIHSS score,collateral status and puncture-to-reperfusion time.Part II Blood Pressure Parameters and Outcomes in Atherosclerosis versus Cardioembolism Cerebral Large Vessel Occlusion after Successful ThrombectomyObjective: We aimed to investigate the the association of outcomes with post-procedural BP parameters in large vessel occlusion(LVO)patients undergoing successful EVT based on different stroke etiologies.Methods: Patients with LVO in anterior circulation who underwent EVT and achieved successful recanalization have been retrospectively collected.The causes of occlusion were classified into large-artery atherosclerosis(LAA)and cardioembolism(CE)according to the Trial of ORG 10172 in Acute Stroke Treatment scale.24-hour BP and BPV measured as blood pressure reduction(r),standard deviation(SD),coefficient of variation(CV),successive variation(SV),average real variability(ARV)after EVT were collected for systolic blood pressure(SBP)and diastolic blood pressure(DBP).We defined favorable outcome as functional independence by 90-day modified Rankin Scale(m RS 0-2)and relatively poor outcome(m RS 3-6)as control.Results: Higher BPV parameters significantly resulted in 90 d functional dependence in CE-LVO patients(SBPSV OR: 1.083,95%CI =1.009-1.163;SBPARV OR: 1.121,95%CI =1.019-1.233;DBPSD OR: 1.124,95%CI = 1.007-1.1256;DBPCV OR: 1.078,95%CI =1.002-1.161).However,for LAA-LVO patients,no positive results correlated 90 d functional dependence with 24-hour BPV.Additionally,90 d functional dependence in CE patients with poor collaterals were significantly dependent on post-procedural BP/BPV(DBPmax OR: 1.044,95%CI = 1.002-1.087;DBPSD OR: 1.229,95%CI = 1.022-1.1.479;DBPCV OR: 1.143,95%CI = 1.009-1.295).Whereas to patients with good collaterals,there did not exist such a correlation.Conclusion: The 90 d prognosis of CE patients,especially those with poor collateral status,was significantly associated with 24 h BP/BPV after EVT.However,this association was not found in LAA patients.For CE patients with poor collateral status,the impact of DBP-related parameters on the prognosis needs to be equally appreciated with SBP depending on individualization.