Background Bridging treatment with intravenous thrombolysis (IVT) before endovascular thrombectomy (EVT) in acute ischemic stroke is applied under the assumption of benefits for patients with large vessel occlusion (LVO). However, the benefit of this additional step has not yet been proven. Purpose To compare procedural parameters (procedural time, number of attempts), complications, and clinical outcome in patients receiving EVT vs. patients with bridging treatment. Material and Methods In this prospective study all patients had acute anterior cerebral circulation occlusion and were treated with EVT. All patients were selected for treatment based on clinical criteria, multimodal computed tomography (CT) imaging. Eighty-four patients were treated with bridging IVT followed by EVT; 62 patients were treated with EVT only. Results Bridging therapy did not influence endovascular procedure time ( P = 0.71) or number of attempts needed ( P = 0.63). Bleeding from any site was more common in the bridging group (27, 32%) vs. the EVT group (12, 19%) ( P = 0.09). Functional independence modified Rankin Scale after 90 days was slightly higher in the bridging group (44%) vs. the EVT group (42%) ( P = 0.14). Mortality did not differ significantly at 90 days: 17% in the bridging group vs. 21% in EVT alone ( P = 0.57). Both treatment methods showed high recanalization rates: 94% in the bridging group and 89% for EVT alone. Conclusion Bridging treatment in LVO did not show benefits or elevated risks of complications in comparison to EVT only. The bridging group did not show significantly better neurological outcome or significant impact on procedural parameters vs. EVT alone.

Background: Although several studies have evaluated the change of cognitive performance after severe carotid artery stenosis, the results still remain elusive. The objective of this study was to assess changes in cognitive function, depressive symptoms and Health Related Quality of Life (HRQoL) after carotid stenosis revascularisation and Best Medical Treatment (BMT).Methods: Study involved 213 patients with ≥70% carotid stenosis who underwent assessment of cognitive function using Montreal Cognitive Assessment scale (MoCA), depressive symptoms - using Patient Health Questionnaire-9 (PHQ-9) and HRQoL - using Medical Outcome Survey Short Form version 2 (SF-36v2). The assessment was performed before and at 6 and 12 months follow-up periods in patients who had Carotid Endarterectomy (CEA), Carotid Artery Stenting (CAS) or received BMT only.Results: Improvement in the total MoCA scores was observed after 6 and 12 months (p<0.001, Kendall's W=0.28) in the CEA group. In the CAS group - after 12 months (p=0.01, Kendall's W=0.261) whereas in the BMT group - no significant changes (p=0.295, Kendall's W=0.081) were observed. Reduction of depressive symptoms was not found in any of the study groups. Comparing mean SF-36v2 scores in the CEA group, there was no significant difference in any of 10 subscales. Likewise in the CAS group - no significant difference in 9 of 10 subscales (p=0.028, η2=0.343) was observed. Three subscales worsened in the BMT group during the 1-year follow-up period.Conclusion: Patients with severe carotid stenosis who underwent revascularisation enhanced their cognitive performance without exerting significant change of depressive symptoms. Preoperative HRQoL may be maintained for at least one year in the CEA group.

Background:Carotid artery disease is not just a causal risk factor of ischemic stroke, but may predispose patients to depressive symptoms and low health related quality of life (HRQoL).Objectives:The objectives of the present study were to assess the association between severe carotid artery stenosis (CAS) and cognitive impairment, frequency of depressive symptoms and status of HRQoL.Methods:Cross - sectional study involved 55 patients with severe CAS and 54 patients with lower extremity peripheral artery disease (PAD). Cognitive impairment was assessed using Montreal Cognitive Assessment Scale (MoCA), depressive symptoms - PHQ-9 scale. HRQoL was measured using Medical Outcome Survey Short Form version 2 (SF-36v2).Results:Median MoCA score 24 [23;26] was significantly lower in patients with severe CAS than in patients with PAD - 26 [25-28],(p=0.005; effect size r=0.3). There was no statistically significant difference of median PHQ-9 scores the in CAS group (median PHQ-9 score 4.0 [5]) and in the PAD group (median PHQ-9 score 5.5 [7]), (p=0.08, effect size r=0.18). Mean SF-36v2 scores were similar in CAS and PAD groups except for bodily pain (p=0.001, Cohen's d value = 0.77) and vitality (p=0.02, Cohen's d value = 0.49).Conclusion:In summary, our findings indicate that severe CAS could play a role in cognitive decline. Further studies should be conducted using larger patient cohorts without ischemic brain lesions and with balanced vascular risk profiles to investigate impact of CAS on cognition. There was no association between severe CAS and depressive symptoms in the present study. As patients with severe CAS did not exhibit physical symptoms, HRQoL was better for those patients than for patients with lower extremity PAD.

Background and Objectives: Oral anticoagulants are the hallmark of cardioembolic stroke prevention, but they are frequently underused, especially in elderly patients and patients with paroxysmal atrial fibrillation. In our paper, we analyzed the long-term outcome of severely disabled cardioembolic stroke survivors depending on the prescribed antithrombotic secondary prevention medication. Materials and Methods: In our study, we retrospectively collected data for ischemic stroke (IS) patients treated in P. Stradins Clinical University hospital, Riga, Latvia, from 2014 until 2017. Patients' clinical data were collected using local stroke registry, including patients' demographic data, vascular risk factors, clinical findings, and laboratory results. Severely disabled stroke survivors were followed up by phone at 30/90/180/365 days after discharge. Patients' functional outcomes were assessed using the adapted version of The Rankin Focused Assessment-Ambulation. The collected data were compared in 4 groups according to prescribed secondary prevention medication. Results: A total of 682 (91.42%) patients were followed up and included in data analysis. The median age of patients was 80 (IQR = 75-85) years. Of these patients, 231 (31%) were males and 515 (69%) were females. One-year probability of survival of patients not taking any preventive medication was 53% (IQR = 29-76), while in patients taking antiplatelet agents it was 57% (IQR = 37-78), 78% (IQR = 68-88) of patients on Vitamin K antagonists (VKA) and 81% (IQR = 72-90) in patients on direct oral anticoagulants (DOACs). One year after discharge 73 (31%) had mRS 0-2, 50 (20.9%), 29 (12.1%) were still severely disabled, and 87 (36.4%) had died. Conclusions: Anticoagulant use in secondary prevention predicts better functional outcome and higher survival rate in patients with severe cardioembolic stroke due to non-valvular atrial fibrillation (NVAF), therefore severe neurological deficit must not be a reason of restriction of anticoagulation.

BackgroundPerfusion computed tomography (CT) is a relatively new technique that allows fast evaluation of cerebral hemodynamics by providing perfusion maps and gives confirmation of perfusion deficits in ischemic areas. Some controversies exist regarding accuracy of quantitative detection of tissue viability: penumbra (tissue at risk) or core (necrosis).PurposeTo define brain tissue viability grade on the basis of the perfusion CT parameters in acute stroke patients.Material and MethodsA multimodal CT imaging protocol; unenhanced CT of the brain, CT angiography of head and neck blood vessels, followed by brain perfusion CT and 24 h follow-up brain CT was performed. Perfusion deficits were detected first visually, with subsequent manual quantitative and relative measurements in affected and contra-lateral hemisphere in 87 acute stroke patients.ResultsVisual perfusion deficit on perfusion CT images was found in 78 cases (38 women, 40 men; mean age, 30–84 years). Penumbra lesions (n = 49) and core lesions (n = 42) were detected by increased mean transit time (MTT) on perfusion CT maps in comparison to contra-lateral hemispheres. Cerebral blood volume (CBV) mean values in the penumbra group were increased in the penumbra group and decreased in the core group. Cerebral blood flow (CBF) values were decreased in penumbra and markedly decreased in core lesion.ConclusionPerfusion CT measurements are reliable in estimation of penumbra and core lesions in acute stroke patients, if relative threshold values are used. The most accurate parameter of hypoperfusion is increased MTT above 190%. Relative threshold values for irreversible lesion are CBF <30–40% and CBV <40% in comparison to contra-lateral hemisphere. Penumbra lesion is characterized by MTT increase and CBF decrease, while CBV shows variable values.

ObjectivesTo determine the validity and reliability of a Latvian version of the National Institutes of Health Stroke Scale (LV-NIHSS) for evaluating Latvian stroke patients.MethodsThe adaption of the LV-NIHSS followed standard methods used for the adaption and validation of clinical assessment tools. The scale validity was tested by comparison with the Glasgow Coma Scale (GCS) and the modified Rankin scale (mRs). The reliability of the LV-NIHSS was evaluated by intra-rater and inter-rater agreement using intra-class correlation coefficient (ICC) analysis.ResultsA total of 296 stroke patients and 101 control subjects were evaluated. The mean age of the overall study population was 73.6 years (range, 37 – 94 years; 227 [57.2%] were female). The mean LV-NIHSS score of the patients with stroke was 8.4 ± 6.2. In terms of construct validity of the LV-NIHSS, it correlated with the GCS (r = −0.571) and mRs (r = 0.755). In terms of the reliability of the LV-NIHSS, the inter-rater agreement had an ICC of 0.99 and the intra-rater agreement had an ICC of 0.99.ConclusionThe adaption of LV-NIHSS was successful and the evaluation showed that the scale was valid and reliable for evaluating Latvian stroke patients.

Introduction: We assessed best available data on access and delivery of acute stroke unit (SU) care, intravenous thrombolysis (IVT) and endovascular treatment (EVT) in the European region in 2019 and 2020. Patients and methods: We compared national data per number of inhabitants and per 100 annual incident first-ever ischaemic strokes (AIIS) in 46 countries. Population estimates and ischaemic stroke incidence were based on United Nations data and the Global Burden of Disease Report 2019, respectively. Results: The estimated mean number of acute SUs in 2019 was 3.68 (95% CI: 2.90–4.45) per one million inhabitants (MIH) with 7/44 countries having less than one SU per one MIH. The estimated mean annual number of IVTs was 21.03 (95% CI: 15.63–26.43) per 100,000 and 17.14% (95% CI: 12.98–21.30) of the AIIS in 2019, with highest country rates at 79.19 and 52.66%, respectively, and 15 countries delivering less than 10 IVT per 100,000. The estimated mean annual number of EVTs in 2019 was 7.87 (95% CI: 5.96–9.77) per 100,000 and 6.91% (95% CI: 5.15–8.67) of AIIS, with 11 countries delivering less than 1.5 EVT per 100,000. Rates of SUs, IVT and EVT were stable in 2020. There was an increase in mean rates of SUs, IVT and EVT compared to similar data from 2016. Conclusion: Although there was an increase in reperfusion treatment rates in many countries between 2016 and 2019, this was halted in 2020. There are persistent major inequalities in acute stroke treatment in the European region. Tailored strategies directed to the most vulnerable regions should be prioritised.

Background and Objectives: The study aimed to investigate the efficacy of intravenous thrombolysis with Tenecteplase before thrombectomy for acute ischemic stroke (AIS) patients compared with previous results using Alteplase. Previous trials for Tenecteplase have indicated an increased incidence of vascular reperfusion. In April 2021, we started to primarily give Tenecteplase to patients eligible to undergo thrombectomy. Materials and Methods: In this retrospective observational single-center non-randomized study, we analyzed directly admitted patients with AIS who had occlusion of the internal carotid, middle cerebral, or basilar artery and who underwent thrombectomy, as well as the recanalization rate for these patients at the first angiographic assessment (mTICI score 2b–3), and complications. Results: We included 184 patients (demographic characteristics did not differ between Tenecteplase and Alteplase groups (mean age 68.4 vs. 73.0 years; female sex 53.3% vs. 51.1%, NIHSS 14 (IQR 4–26) vs. 15 (2–31). Forty-five patients received Tenecteplase and 139 Alteplase before endovascular treatment (EVT). Pre-EVT (endovascular treatment) recanalization was more likely to occur with Tenecteplase rather than Alteplase (22.2% vs. 8.6%, p = 0.02). Successful reperfusion (mTICI 2b–3) after EVT was achieved in 155 patients (42 (93.4%) vs. 113 (81.3), p = 0.07). Hemorrhagic imbibition occurred in 15 (33.3%) Tenecteplase-treated patients compared with 39 (28.1%) Alteplase-treated patients (p = 0.5). Patients treated with Tenecteplase had higher odds of excellent functional outcome than Alteplase-treated patients (Tenecteplase 48.6% vs. Alteplase 26.1%; OR 0.37 (95% CI 0.17–0.81), p = 0.01). Conclusions: Tenecteplase (25 mg/kg) could have superior clinical efficacy over Alteplase for AIS patients with large-vessel occlusion (LVO), administered before EVT. The improvement in reperfusion rate and the better excellent functional outcome could come without an increased safety concern.