Background and Purpose— In ischemic stroke, body temperature is associated with functional outcome. However, the relationship between temperature and outcome may differ in the intraischemic and postischemic phases of stroke. We aimed to determine whether body temperature before or after endovascular thrombectomy (EVT) for large vessel occlusion stroke is associated with clinical outcomes. Methods— Consecutive EVT patients were identified from a prospective registry. Temperature measurements within 24 hours of admission were stratified into pre-EVT (preprocedural and intraprocedural) and post-EVT measurements, which served as surrogates for the intraischemic and postischemic phases of large vessel occlusion stroke, respectively. The primary outcome was functional independence, defined as a modified Rankin Scale score of 0, 1, or 2 at 3 months. Secondary outcomes included the ordinal shift of modified Rankin Scale scores at 3 months, symptomatic intracerebral hemorrhage, and mortality at 3 months. Results— Four hundred thirty-two participants were included (59% men, mean±SD age 65.6±15.7 years). Multivariable logistic regression demonstrated that higher median pre-EVT temperature (per 1°C increase) was an independent predictor of reduced functional independence (odds ratio [OR], 0.66 [95% CI, 0.46–0.94]; P =0.02), poorer modified Rankin Scale scores (common OR, 1.42 [95% CI, 1.08–1.85]; P =0.01), and increased mortality (OR, 1.65 [95% CI, 1.02–2.69]; P =0.04). Peak post-EVT temperature (per 1°C increase) was a significant predictor of elevated modified Rankin Scale scores (common OR, 1.39 [95% CI, 1.03–1.90]; P =0.03) and higher mortality (OR, 1.66 [95% CI, 1.04–2.67]; P =0.03). Conclusions— In patients with large vessel occlusion stroke treated with EVT, higher body temperatures during both the intraischemic and postischemic phases were associated with poorer clinical outcomes. Future research investigating the maintenance of normothermia or therapeutic hypothermia in patients needing to be transferred from primary to EVT-capable stroke centers could be considered.

Summary It is unknown whether systolic blood pressure augmentation during endovascular thrombectomy improves clinical outcomes. This pilot randomised controlled trial aimed to assess the feasibility of differential systolic blood pressure targeting during endovascular thrombectomy procedures for anterior circulation ischaemic stroke. Fifty‐one eligible patients fulfilling the national criteria for endovascular thrombectomy were randomly assigned to receive either standard or augmented systolic blood pressure management from the start of anaesthesia to recanalisation of the target vessel. Systolic blood pressure targets for the standard and augmented groups were 130–150 mmHg and 160–180 mmHg, respectively. The study achieved all feasibility targets, including a recruitment rate of 3.5 participants per week and median (IQR [range]) of mean systolic blood pressure separation between groups of 139 (135–143 [115–154]) vs. 167 (150–175 [113–188]) mmHg, p < 0.001. Data completeness was 99%. Independent functional recovery at 90 days (modified Rankin Scale 0, 1 or 2) was achieved in 30 (59%) patients, which is consistent with previously published data. There were no safety concerns with trial procedures. In conclusion, a large randomised controlled efficacy trial of standard vs. augmented systolic blood pressure management during endovascular thrombectomy is feasible.

ObjectiveTo evaluate the safety and efficacy of intra-arterial thrombolysis (IAT) as an adjunct to endovascular thrombectomy (EVT) in ischemic stroke, we performed a systematic review and meta-analysis of the literature.MethodsSearches were performed using MEDLINE, Embase, and Cochrane databases for studies that compared EVT with EVT with adjunctive IAT (EVT + IAT). Safety outcomes included symptomatic intracerebral hemorrhage and mortality at 3 months. Efficacy outcomes included successful reperfusion (Thrombolysis in Cerebral Infarction score of 2b–3) and functional independence, defined as a modified Rankin Scale score of 0–2 at 3 months.ResultsFive studies were identified that compared combined EVT + IAT (IA alteplase or urokinase) with EVT only and were included in the random-effects meta-analysis. There were 1693 EVT patients, including 269 patients treated with combined EVT + IAT and 1,424 patients receiving EVT only. Pooled analysis did not demonstrate any differences between EVT + IAT and EVT only in rates of symptomatic intracerebral hemorrhage (odds ratio [OR]: 0.61, 95% confidence interval [CI]: 0.20–1.85; p = 0.78), mortality (OR: 0.77, 95% CI: 0.54–1.10; p = 0.15), or successful reperfusion (OR: 1.05, 95% CI: 0.52–2.15; p = 0.89). There was a higher rate of functional independence in patients treated with EVT + IAT, although this was not statistically significant (OR: 1.34, 95% CI: 1.00–1.80; p = 0.053).ConclusionAdjunctive IAT appears to be safe. In specific situations, neurointerventionists may be justified in administering small doses of intra-arterial alteplase or urokinase as rescue therapy during EVT.

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atient 1 is a 42-year-old previously well man on no medications who presented to neurology clinic with 6 months of nonpositional chronic daily headache, hiccups, and behavior change. His wife reported impulsivity, disinhibition, and sexually inappropriate behavior. There was no family history of movement disorder or neurodegenerative disease. Six weeks prior to symptom onset, he had fallen 1 meter onto his back. Vital signs, bloodwork, and general examination were normal. He was disinhibited and inattentive and exhibited orofacial, tongue, and limb choreoathetosis, which worsened over 6 months of follow-up (video at Neurology.org/cp). MRI was consistent with brain sagging syndrome; basal ganglia were subtly deformed, but without signal disturbance (figure). CSF opening pressure was 18 cm H 2 O. A spinal CSF leak could not be located with conventional MRI, CT myelography, or radionuclide cisternography. Oral methylprednisolone, continuous epidural saline infusion, theophylline, and 2 lumbar epidural blood patches yielded no sustained improvement. Fat saturated MRI revealed a probable CSF leak at T4, but CT-guided T4 epidural blood patch was unsuccessful. He awaits surgical exploration. Patient 2 is a 64-year-old man with hyperlipidemia and previous C6/7 fusion who reported nine months of worsening dysarthria, dysphagia, hiccups, and orthostatic headaches. Examination revealed nasal speech. Gag reflex, tongue power, and other cranial nerves were normal. Choreoathetoid orofacial, tongue, and limb movements were evident (video). Imaging confirmed brain sagging and normal basal ganglia (figure). Lumbar puncture was not performed. Spinal MRI and CT myelography failed to detect a CSF leak. Two separate lumbar blood patches produced temporary improvement in speech and chorea, but this was not sustained.