Eloquence-based reperfusion scoring and its ability to predict post-thrombectomy disability and functional status

2021 ◽  
pp. 159101992110464
Author(s):  
Elliot Pressman ◽  
Victoria Sands ◽  
Gabriel Flores ◽  
Liwei Chen ◽  
Rahul Mhaskar ◽  
...  
Keyword(s):  
Frontal Lobe ◽  
Functional Outcomes ◽  
Visual Fields ◽  
Predictive Ability ◽  
Occipital Lobe ◽  
Cerebral Infarct ◽  
Modified Rankin Scale ◽  
Anterior Circulation ◽  
Endovascular Thrombectomy ◽  
Post Procedure

Background Angiographic reperfusion after endovascular thrombectomy in acute ischemic stroke is commonly graded using volume-based reperfusion scores such as the modified thrombolysis in cerebral infarct score. The location of non-reperfused regions is not included in modified thrombolysis in cerebral infarct score. We studied the predictive ability of an eloquence-based reperfusion score. Methods Consecutive cases of endovascular thrombectomy for anterior circulation strokes performed between January 2018 and April 2020 were included. Digital subtraction angiograms were reviewed by two blinded neurointerventionalist operators. Incomplete reperfusion was further classified by lobar regions lacking reperfusion to create various cohorts. Outcomes were graded four to seven days post-procedure with the National Institute of Health Stroke Scale (NIHSS) and 90 days post-procedure with the modified Rankin Scale. Results One hundred patients were identified. Via multivariate analysis, we found that frontal lobe non-reperfusion (mean difference (MD) = −1.60, p = 0.002) and occipital lobe non-reperfusion (MD = −1.68, p = 0.001) were associated with worse mental status improvement while left-sided stroke (MD = 2.02, p < 0.001) featured better improvement post-thrombectomy. Occipital lobe non-reperfusion (MD = −0.734, p = 0.009) was associated with the worse improvement of visual fields. The non-reperfusion of the frontal lobe was associated with a 1.732-worse NIHSS hemibody strength score (95% confidence interval (95%CI) = −3.39 to −0.072, p = 0.041). Worse improvement in NIHSS scores was found to be associated with frontal lobe non-reperfusion (MD = −5.34, 95%CI = −9.52 to −1.18, p = 0.013) and occipital lobe non-reperfusion (MD = −6.35, 95%CI = −10.4 to −2.31, p = 0.002). Odds of achieving modified Rankin Scale of 0–2 at 90 days were decreased with frontal lobe non-reperfusion (odds ratio (OR) = 0.279, 95%CI = 0.090–0.869, p = 0.028) and left laterality (OR = 0.376, 95%CI = 0.153–0.922, p = 0.033). Conclusions Eloquence-based reperfusion assessment is an important predictor for functional outcomes after thrombectomy.

Successful mechanical thrombectomy in acute ischemic stroke: revascularization grade and functional independence

2022 ◽  
pp. neurintsurg-2021-018436
Author(s):  
Sherief Ghozy ◽  
Salah Eddine Oussama Kacimi ◽  
Ahmed Y Azzam ◽  
Ramadan Abdelmoez Farahat ◽  
Abdelaziz Abdelaal ◽  
...  
Keyword(s):  
Systematic Review ◽  
Functional Outcomes ◽  
Mechanical Thrombectomy ◽  
Meta Analysis ◽  
Functional Independence ◽  
Complete Revascularization ◽  
Modified Rankin Scale ◽  
Technical Success ◽  
Endovascular Thrombectomy ◽  
Quantitative Synthesis

Most studies define the technical success of endovascular thrombectomy (EVT) as a Thrombolysis in Cerebral Infarction (TICI) revascularization grade of 2b or higher. However, growing evidence suggests that TICI 3 is the best angiographic predictor of improved functional outcomes. To assess the association between successful TICI revascularization grades and functional independence at 90 days, we performed a systematic review and network meta-analysis of thrombectomy studies that reported TICI scores and functional outcomes, measured by the modified Rankin Scale, using the semi-automated AutoLit software platform. Forty studies with 8691 patients were included in the quantitative synthesis. Across TICI, modified TICI (mTICI), and expanded TICI (eTICI), the highest rate of good functional outcomes was observed in patients with TICI 3 recanalization, followed by those with TICI 2c and TICI 2b recanalization, respectively. Rates of good functional outcomes were similar among patients with either TICI 2c or TICI 3 grades. On further sensitivity analysis of the eTICI scale, the rates of good functional outcomes were equivalent between eTICI 2b50 and eTICI 2b67 (OR 0.81, 95% CI 0.52 to 1.25). We conclude that near complete or complete revascularization (TICI 2c/3) is associated with higher rates of functional outcomes after EVT.

Intravenous Thrombolysis Is Associated with Less Disabling Stroke and Lower Mortality in Multiple-Pass Endovascular Thrombectomy

2021 ◽  
pp. 1-6
Author(s):  
Christopher Blair ◽  
Leon Edwards ◽  
Cecilia Cappelen-Smith ◽  
Dennis Cordato ◽  
Andrew Cheung ◽  
...  
Keyword(s):  
Multivariate Analysis ◽  
Acute Ischaemic Stroke ◽  
Intravenous Thrombolysis ◽  
Additional Benefit ◽  
Modified Rankin Scale ◽  
Stroke Patients ◽  
Anterior Circulation ◽  
Endovascular Thrombectomy ◽  
Multiple Pass ◽  
First Pass

<b><i>Background and Purpose:</i></b> The benefit of bridging intravenous thrombolysis (IVT) in acute ischaemic stroke patients eligible for endovascular thrombectomy (EVT) is unclear. This may be particularly relevant where reperfusion is achieved with multiple thrombectomy passes. We aimed to determine the benefit of bridging IVT in first and multiple-pass patients undergoing EVT ≤6 h from stroke onset to groin puncture. <b><i>Methods:</i></b> We compared 90-day modified Rankin Scale (mRS) outcomes in 187 consecutive patients with large vessel occlusions (LVOs) of the anterior cerebral circulation who underwent EVT ≤6 h from symptom onset and who achieved modified thrombolysis in cerebral ischaemia (mTICI) 2c/3 reperfusion with the first pass to those patients who required multiple passes to achieve reperfusion. The effect of bridging IVT on outcomes was examined. <b><i>Results:</i></b> Significantly more first-pass patients had favourable (mRS 0–2) 90-day outcomes (68 vs. 42%, <i>p</i> = 0.001). Multivariate analysis showed an association between first-pass reperfusion and favourable outcomes (OR 2.25; 95% CI 1.08–4.68; <i>p</i> = 0.03). IVT provided no additional benefit in first-pass patients (OR 1.17; CI 0.42–3.20; <i>p</i> = 0.76); however, in multiple-pass patients, it reduced the risk of disabling stroke (mRS ≥4) (OR 0.30; CI 0.10–0.88; <i>p</i> = 0.02) and mortality (OR 0.07; CI 0.01–0.36; <i>p</i> = 0.002) at 90 days. <b><i>Conclusion:</i></b> Bridging IVT may benefit patients with anterior circulation stroke with LVO who qualify for EVT and who require multiple passes to achieve reperfusion.

Abstract TP28: Intravenous Thrombolysis is Associated With Better Functional Outcomes in Endovascular Thrombectomy Patients Requiring Multiple-Passes to Achieve Reperfusion

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Christopher Blair ◽  
Cecilia Cappelen-Smith ◽  
Dennis Cordato ◽  
Leon Edwards ◽  
Amer Mitchelle ◽  
...  
Keyword(s):  
Functional Outcomes ◽  
Intravenous Thrombolysis ◽  
Functional Independence ◽  
Independent Effect ◽  
Large Vessel Occlusion ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Multiple Pass ◽  
First Pass

Introduction: In patients with anterior circulation stroke with large vessel occlusion (LVO), recent data suggest that successful reperfusion (mTICI≥2b) after a single device pass results in more favourable functional outcomes in comparison to patients requiring multiple passes. It is unclear if this effect represents an epiphenomenon or a true independent effect. Methods: A prospectively maintained database of EVT was interrogated for patients presenting with anterior circulation LVO with onset to groin puncture times of ≤ 6 hours from January 2016 to March 2019. Three-month functional outcomes were compared between first-pass reperfusion and multiple-pass reperfusion patients using logistic regression. Results: A total of 169 patients were identified (mean age 71 yrs, 44% female, median NIHSS 17, intravenous thrombolysis (IVT) in 47%). Successful reperfusion (mTICI≥2b) was achieved with the first-pass (FP) in 80 patients (47%) and multiple-passes (MP) in 89 patients (53%). First pass patients had better outcomes when compared to MP patients (mRS 0-2 71% vs 31%, p < 0.001). No difference in functional outcomes was seen between FP patients who received IVT and those that did not (mRS 0-2 68% vs 75%, p = 0.459). Multiple-pass patients who received IVT achieved higher rates of functional independence than those who did not (mRS 0-2 40% vs 27%, p = 0.035). Conclusion: Intravenous thrombolysis may improve functional recovery in EVT patients requiring multiple-passes to achieve reperfusion. Prospective studies should be considered.

Left ventricular systolic dysfunction is associated with poor functional outcomes after endovascular thrombectomy

2020 ◽  
pp. neurintsurg-2020-016216
Author(s):  
Benjamin Y Q Tan ◽  
Aloysius ST Leow ◽  
Tsong-Hai Lee ◽  
Vamsi Krishna Gontu ◽  
Tommy Andersson ◽  
...  
Keyword(s):  
Functional Outcomes ◽  
Left Ventricular Systolic Dysfunction ◽  
Systolic Dysfunction ◽  
Left Ventricular ◽  
Ventricular Systolic Dysfunction ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Global Cerebral Blood Flow ◽  
The Relationship

BackgroundEndovascular thrombectomy (ET) has transformed acute ischemic stroke (AIS) therapy in patients with large vessel occlusion (LVO). Left ventricular systolic dysfunction (LVSD) decreases global cerebral blood flow and predisposes to hypoperfusion. We evaluated the relationship between LVSD, as measured by LV ejection fraction (LVEF), and clinical outcomes in patients with anterior cerebral circulation LVO who underwent ET.MethodsThis multicenter retrospective cohort study examined anterior circulation LVO AIS patients from six international stroke centers. LVSD was measured by assessment of the echocardiographic LVEF using Simpson’s biplane method of discs according to international guidelines. LVSD was defined as LVEF <50%. The primary outcome was defined as a good functional outcome using a modified Rankin Scale (mRS) of 0–2 at 3 months.ResultsWe included 440 AIS patients with LVO who underwent ET. On multivariate analyses, pre-existing diabetes mellitus (OR 2.05, 95% CI 1.24 to 3.39;p=0.005), unsuccessful reperfusion (Treatment in Cerebral Infarction (TICI) grade 0-2a) status (OR 4.21, 95% CI 2.04 to 8.66; p<0.001) and LVSD (OR 2.08, 95% CI 1.18 to 3.68; p=0.011) were independent predictors of poor functional outcomes at 3 months. On ordinal (shift) analyses, LVSD was associated with an unfavorable shift in the mRS outcomes (OR 2.32, 95% CI 1.52 to 3.53; p<0.001) after adjusting for age and ischemic heart disease.ConclusionAnterior circulation LVO AIS patients with LVSD have poorer outcomes after ET, suggesting the need to consider cardiac factors for ET, the degree of monitoring and prognostication post-procedure.

scholarly journals Significant aortic stenosis associated with poorer functional outcomes in patients with acute ischaemic stroke undergoing endovascular therapy

2020 ◽  
Vol 26 (6) ◽  
pp. 793-799
Author(s):  
Nicholas JH Ngiam ◽  
Benjamin YQ Tan ◽  
Ching-Hui Sia ◽  
Bernard PL Chan ◽  
Gopinathan Anil ◽  
...  
Keyword(s):  
Aortic Stenosis ◽  
Ischaemic Stroke ◽  
Functional Outcome ◽  
Acute Ischaemic Stroke ◽  
Functional Outcomes ◽  
Modified Rankin Scale ◽  
Large Vessel Occlusion ◽  
Stroke Patients ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy

Background and aim Bi-directional feedback mechanisms exist between the heart and brain, which have been implicated in heart failure. We postulate that aortic stenosis may alter cerebral haemodynamics and influence functional outcomes after endovascular thrombectomy for acute ischaemic stroke. We compared clinical characteristics, echocardiographic profile and outcomes in patients with or without aortic stenosis that underwent endovascular thrombectomy for large vessel occlusion acute ischaemic stroke. Methods Consecutive acute ischaemic stroke patients with anterior and posterior circulation large vessel occlusion (internal carotid artery, middle cerebral artery and basilar artery) who underwent endovascular thrombectomy were studied. Patients were divided into those with significant aortic stenosis (aortic valve area <1.5 cm2) and without. Univariate and multivariate analyses were employed to compare and determine predictors of functional outcomes measured by modified Rankin scale at three months. Results We identified 26 (8.5%) patients with significant aortic stenosis. These patients were older (median age 76 (interquartile range 68–84) vs. 67 (interquartile range 56–75) years, p = 0.001), but similar in terms of medical comorbidities and echocardiographic profile. Rates of successful recanalisation (73.1% vs. 78.0%), symptomatic intracranial haemorrhage (7.7% and 7.9%) and mortality (11.5% vs. 12.6%) were similar. Significant aortic stenosis was independently associated with poorer functional outcome (modified Rankin scale >2) at three months (adjusted odds ratio 2.7, 95% confidence interval 1.1–7.5, p = 0.048), after adjusting for age, door-to-puncture times, stroke severity and rates of successful recanalisation. Conclusion In acute ischaemic stroke patients managed with endovascular thrombectomy, significant aortic stenosis is associated with poor functional outcome despite comparable recanalisation rates. Larger cohort studies are needed to explore this relationship further.

Internal cerebral vein asymmetry is an independent predictor of poor functional outcome in endovascular thrombectomy

2021 ◽  
pp. neurintsurg-2021-017684
Author(s):  
May Zin Myint ◽  
Leonard LL Yeo ◽  
Benjamin Y Q Tan ◽  
Ei Zune The ◽  
Mei Chin Lim ◽  
...  
Keyword(s):  
Functional Outcomes ◽  
Intravenous Thrombolysis ◽  
Contralateral Side ◽  
Cerebral Vein ◽  
Cerebral Veins ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Ct Angiogram ◽  
Venous Phase

BackgroundEndovascular thrombectomy (EVT) in large vessel occlusion (LVO) in anterior circulation acute ischaemic stroke (AIS) results in good functional outcomes in only approximately 60% of the patients. Internal cerebral veins (ICVs) are easily visible, with a consistent midline location, and are linked to stroke outcomes. We hypothesize that ICV asymmetry on multiphasic CT angiogram (mCTA) can be an adjunctive predictor for poor functional outcomes.MethodsWe studied consecutive AIS patients from 2017 to 2019 with anterior circulation LVO treated with EVT regardless of intravenous thrombolysis. Asymmetrical ICV was defined as the presence of hypodensity (less opacification) on the ipsilateral occlusion side as compared with the contralateral side. The primary outcome was modified Rankin Score (mRS) score at 3 months. Secondary outcomes were good recanalization (modified Thrombolysis In Cerebral Infarction (mTICI) 2b-3), symptomatic hemorrhage, and mortality.ResultsA total of 185 patients were included with a median age of 70 years (IQR 59–77); 87 patients (47%) were female. 82 patients (44.3%) achieved good functional outcomes (mRS 0–2) at 3 months. On multivariate analysis, National Institutes of Health Stroke Scale (NIHSS) (OR 1.076, 95% CI 1.015 to 1.140; p<0.013), poor collateral score (OR 0.285, 95% CI 0.162 to 0.501; p<0.001), asymmetrical ICV on the peak venous phase (OR 2.47, 95% CI 1.115 to 5.471; p<0.026), and late venous phase of the mCTA (OR 2.642, 95% CI 1.161 to 6.016; p<0.021) were independent risks factors of poor outcomes.ConclusionICV asymmetry is a novel radiological sign which is independently associated with poor functional outcomes in EVT, even after correction for collateral circulation. Further studies are needed to validate this finding.

scholarly journals Predictors and Functional Outcomes of Fast, Intermediate, and Slow Progression Among Patients With Acute Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (8) ◽  
pp. 2553-2557 ◽  
Author(s):  
Woo-Keun Seo ◽  
David S. Liebeskind ◽  
Bryan Yoo ◽  
Latisha Sharma ◽  
Reza Jahan ◽  
...  
Keyword(s):  
Coronary Artery Disease ◽  
Ischemic Stroke ◽  
Coronary Artery ◽  
Functional Outcomes ◽  
Artery Occlusion ◽  
Large Artery ◽  
Anterior Circulation ◽  
Endovascular Thrombectomy ◽  
Ischemic Core ◽  
Artery Disease

Background and Purpose: We aimed to delineate the determinants of the initial speed of infarct progression and the association of speed of infarct progression (SIP) with procedural and functional outcomes. Methods: From a prospectively maintained stroke center registry, consecutive anterior circulation ischemic stroke patients with large artery occlusion, National Institutes of Health Stroke Scale score ≥4, and multimodal vessel, ischemic core, and tissue-at-risk imaging within 24 hours of onset were included. Initial SIP was calculated as ischemic core volume at first imaging divided by the time from stroke onset to imaging. Results: Among the 88 patients, SIP was median 2.2 cc/h (interquartile range, 0–8.7), ranging most widely within the first 6 hours after onset. Faster SIP was positively independently associated with a low collateral score (odds ratio [OR], 3.30 [95% CI, 1.25–10.49]) and arrival by emergency medical services (OR, 3.34 [95% CI, 1.06–10.49]) and negatively associated with prior ischemic stroke (OR, 0.12 [95% CI, 0.03–0.50]) and coronary artery disease (OR, 0.32 [95% CI, 0.10–1.00]). Among the 67 patients who underwent endovascular thrombectomy, slower SIP was associated with a shift to reduced levels of disability at discharge (OR, 3.26 [95% CI, 1.02–10.45]), increased substantial reperfusion by thrombectomy (OR, 8.30 [95% CI, 0.97–70.87]), and reduced radiological hemorrhagic transformation (OR, 0.34 [95% CI, 0.12–0.94]). Conclusions: Slower SIP is associated with a high collateral score, prior ischemic stroke, and coronary artery disease, supporting roles for both collateral robustness and ischemic preconditioning in fostering tissue resilience to ischemia. Among patients undergoing endovascular thrombectomy, the speed of infarct progression is a major determinant of clinical outcome.

Abstract WP13: Left Ventricular Systolic Dysfunction is Associated With Poor Functional Outcomes and Mortality After Endovascular Thrombectomy for Acute Ischemic Stroke

Stroke ◽  
2020 ◽  
Vol 51 (Suppl_1) ◽  
Author(s):  
Benjamin Y Tan ◽  
Aloysius ST Leow ◽  
Ching-Hui Sia ◽  
Sibi Sunny ◽  
Zhi-Xuan Ng ◽  
...  
Keyword(s):  
Functional Outcomes ◽  
Left Ventricular Systolic Dysfunction ◽  
Systolic Dysfunction ◽  
Management Strategies ◽  
Left Ventricular ◽  
Ventricular Systolic Dysfunction ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
American Society

Background: Endovascular thrombectomy (ET) has transformed acute ischaemic stroke (AIS) therapy in patients with large vessel occlusion (LVO). Left ventricular systolic dysfunction (LVSD) decreases global cerebral blood flow and predisposes to hypoperfusion. We evaluated the relationship between LVSD as measured by LVEF, and clinical outcomes in patients with anterior cerebral circulation LVO who undergo ET. Methods: This retrospective study examined patients from our AIS endovascular thrombectomy registry from 2013-2018. We included all consecutive patients who had anterior circulation LVO (ICA, M1, M2) who underwent ET, and had transthoracic two-dimensional echocardiography. LVSD was measured by assessment of the LVEF using Simpson’s biplane method of discs according to American Society of Echocardiography guidelines. LVSD was defined as a reduced LVEF of <50%. Primary outcome was defined as good functional outcome using a modified Rankin Scale (mRS) of 0-2 at 3-months. Results: Of 254 AIS patients with anterior circulation LVO, we included 229 patients with complete echocardiography assessment. On multivariate analyses, older age, diabetes mellitus, lower ASPECTS, unsuccessful recanalization, smaller LV outflow tract diameter and LVSD were significantly associated with poor functional outcomes (Table 1). On ordinal (shift) analyses, LVSD was associated with an unfavourable shift in the mRS outcomes (OR 3.09, 95% CI 1.68 - 5.69, p < 0.001) after adjusting for age and ischemic heart disease (Figure). Conclusion: Anterior circulation LVO AIS patients with LVSD have poorer outcomes after ET, suggesting the need to tailor peri-procedural management strategies.

Clinical and Neuroimaging Outcomes of Direct Thrombectomy vs Bridging Therapy in Large Vessel Occlusion: Analysis of the SELECT Cohort Study

Neurology ◽  
2021 ◽  
pp. 10.1212/WNL.0000000000012063
Author(s):  
Amrou Sarraj ◽  
James Grotta ◽  
Gregory W. Albers ◽  
Ameer E. Hassan ◽  
Spiros Blackburn ◽  
...  
Keyword(s):  
Functional Outcomes ◽  
Functional Independence ◽  
Stroke Severity ◽  
Large Vessel Occlusion ◽  
Bridging Therapy ◽  
Anterior Circulation ◽  
Vessel Occlusion ◽  
Endovascular Thrombectomy ◽  
Subgroup Analyses ◽  
Core Volume

Objective:To evaluate the comparative safety and efficacy of direct endovascular thrombectomy(dEVT) compared to bridging therapy(BT:IV-tPA+EVT) and assess if BT potential benefit relates to stroke severity, size and initial presentation to EVT vs. non-EVT center.Methods:In a prospective multicenter cohort-study of imaging selection for endovascular thrombectomy[SELECT], anterior-circulation large vessel occlusion (LVO) patients presenting to EVT-capable centers within 4.5hours from last-known-well were stratified into BT vs. dEVT. The primary outcome was 90-day functional independence[modified Rankin Scale(mRS)=0-2]. Secondary outcomes included a shift across 90-day mRS grades, mortality, symptomatic intracranial hemorrhage. We also performed subgroup-analyses according to initial presentation to EVT-capable center (direct versus transfer), stroke severity and baseline infarct core volume.Results:We identified 226 LVOs (54%:men, mean age:65.6±14.6years, median NIHSS-score: 17, 28% received dEVT). Median time from arrival to groin-puncture did not differ in BT-patients when presenting directly[dEVT:1.43 (IQR=1.13-1.90) hours vs. BT:1.58(IQR=1.27-2.02)hours,p=0.40] or transferred to EVT-capable centers[dEVT:1.17 (IQR: 0.90-1.48) hours vs. BT:1.27 (IQR: 0.97-1.87) hours,p=0.24]. BT was associated with higher odds of 90-day functional independence (57% vs. 44%,aOR=2.02,95%CI:1.01-4.03,p=0.046) and functional improvement (adjusted cOR=2.06,95%CI:1.18-3.60,p=0.011), and lower likelihood of 90-day mortality (11% vs. 23%,aOR: 0.20,95%CI:0.07-0.58,p=0.003). No differences in any other outcomes were detected. In subgroup-analyses, BT patients with baseline NIHSS-scores<15 had higher functional independence likelihood compared to dEVT (aOR=4.87,95%CI:1.56-15.18,p=0.006); this association was not evident for patients with NIHSS-scores≥15 (aOR=1.05,95%CI:0.40-2.74,p=0.92). Similarly, functional outcomes improvements with BT were detected in patients with core volume strata (Ischemic core <50cc: aOR: 2.10, 95% CI:1.02-4.33, p=0.044 vs ischemic core ≥50cc: aOR: 0.41,95% CI:0.01-16.02,p=0.64) and transfer status (transferred: aOR: 2.21,95% CI:0.93-9.65,p=0.29 vs direct to EVT center: aOR:1.84,95%CI:0.80-4.23,p=0.15).Conclusions:Bridging therapy appears to be associated with better clinical outcomes, especially with milder NIHSS-scores, smaller presentation core volumes and those who were “dripped and shipped”. We did not observe any potential benefit of bridging therapy in patients with more severe strokes.Classification of Evidence:This study provides Class III evidence that for patients with ischemic stroke from anterior-circulation LVO within 4.5 hours from last-known-well, bridging therapy compared to direct endovascular thrombectomy leads to better 90-day functional outcomes.

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