Research Appraisals
Evidence-based critical appraisals of the latest medical research, systematically evaluated using Oxford CEBM methodology.
Showing 8 appraisals
Translational stroke research
Quantitative Cerebrovascular Analysis for Improved Prediction of Post-Stroke Complications
Endovascular thrombectomy (EVT) has transformed the treatment of acute ischemic stroke (AIS). However, a substantial proportion of AIS patients experience poor outcomes despite successful recanalization, often due to severe neurological deterioration or life-threatening complications. Early identification of these high-risk patients remains a major unmet need. In this study, we developed and validated machine-learning (ML) models that integrate automated quantitative brain arterial morphology and collateral grading with demographic, clinical, laboratory, and imaging variables to predict major post-EVT complications and early neurological outcomes. Using a prospectively collected database of 727 AIS patients that underwent EVT, we developed ML models to incorporate patient-specific vascular morphometry with conventional clinical, laboratory, and imaging data to predict emergence of early neurological deterioration (END), symptomatic intracranial hemorrhage (sICH), malignant brain edema (MBE) requiring surgical decompression, and neurogenic respiratory failure and dysphagia requiring tracheostomy/gastrostomy (TC/PEG). Our analysis of morphological features, including increased tortuosity and reduced vessel diameter, showed strong associations with complications. Morphology-informed (MI) models consistently outperformed baseline-clinical (BC) models for patients with END (AUROC 0.81 for MI model vs. 0.73 for BC), sICH (AUROC 0.68 MI vs. 0.56 BC model), MBE (AUROC 0.67 MI model vs. 0.56 BC), or patients who underwent TC/PEG (AUROC 0.66MI vs. 0.58 BC model). Statistical testing confirmed significant AUROC improvements for END, sICH and mRS (p < 0.05), Finally, patient-specific calibrated probability profiles enabled individualized, multidimensional risk stratification, revealing distinct complication-specific risk patterns across patients. These findings demonstrate that cerebrovascular structure-an often overlooked yet physiologically fundamental determinant of ischemic injury and reperfusion dynamics-provides significant predictive information that is not captured by standard clinical or visual imaging assessments. Automated vascular segmentation and collateral grading techniques enable rapid and objective integration of cerebrovascular metrics into prognostic models, offering a scalable tool for precision risk stratification, supporting earlier intervention, targeted monitoring, and improved post-EVT management.
9 July 2026
Read appraisal →Annals of medicine
Endovascular thrombectomy versus best medical therapy for acute vertebrobasilar artery occlusion in patients with low NIHSS scores: a meta-analysis
OBJECTIVE: The efficacy of endovascular thrombectomy (EVT) for acute vertebrobasilar artery occlusion (VBAO) presenting with mild symptoms (National Institutes of Health Stroke Scale [NIHSS] score ≤10) remains uncertain. This meta-analysis aimed to compare the effectiveness and safety of EVT versus best medical therapy (BMT) in this population. METHODS: We systematically searched PubMed, Embase, and the Cochrane Central Register of Controlled Trials from inception to September 2025 for comparative studies. The primary outcome was 90-day excellent functional outcome (modified Rankin Scale [mRS] score 0-1). Secondary outcomes included functional independence (mRS 0-2), symptomatic intracranial hemorrhage (sICH), and all-cause mortality. Pooled odds ratios (OR) with 95% confidence intervals (CI) were calculated using a random-effects model. RESULTS: Seven observational studies involving 3,107 patients were included. In unadjusted analyses, EVT was associated with a higher rate of excellent functional outcome (OR 2.17; 95% CI 1.58-2.96) but not with functional independence (OR 1.58; 95% CI 0.90-2.77). After adjustment for confounders, EVT was associated with higher rate of excellent functional outcome (OR 2.86; 95% CI 1.89-4.31) and functional independence (OR 1.91; 95% CI 1.01-3.62). Safety outcomes including sICH and mortality did not differ significantly between groups. CONCLUSION: In patients with acute VBAO and mild symptoms, EVT may be associated with superior functional outcomes compared to BMT alone, without a significant increase in procedural risks. These findings suggest a potential role for EVT in selected patients with low NIHSS scores and underscore the need for confirmation in randomized trials.
18 May 2026
Read appraisal →Journal of neurointerventional surgery
Intravenous tenecteplase is associated with a higher incidence of thrombus movement before endovascular treatment for acute ischemic stroke: a secondary analysis of the AcT randomized controlled trial
BACKGROUND: Thrombus migration can occur in patients receiving IV thrombolysis for acute stroke. This study compared the effects of IV tenecteplase (0.25 mg/kg) versus alteplase (0.9 mg/kg) on thrombus movement in patients undergoing endovascular treatment (EVT) in the AcT trial. METHODS: Patients with intracranial occlusion on baseline CT angiography (CTA) who underwent EVT were included. Thrombus movement from baseline CTA to first angiographic EVT run was classified as no thrombus movement, thrombus extension (TE, movement to a proximal location on DSA compared with CTA), thrombus migration (TM, movement to a more distal location), or recanalization. Outcomes were 90-day modified Rankin Scale (mRS) score 0-2 and final extended Thrombolysis in Cerebral Infarction score 2b-3. Mixed-effects logistic regression was performed. RESULTS: Of the 1577 patients in the AcT trial, 496 patients with intracranial occlusions underwent EVT (median age 73 years, 50.8% female). No thrombus movement was seen in 398 patients (80.2%), TE in six (1.2%), TM in 77 (15.5%), and complete recanalization in 15 (3.0%). Tenecteplase recipients (n=252) had higher TM rates than alteplase recipients (19.4% vs 11.5%, adjusted OR (aOR) 1.83, 95% CI 1.10 to 3.07). TM did not impact final successful reperfusion (aOR 0.76, 95% CI 0.40 to 1.38) but was associated with increased odds of 90-day mRS 0-2 (aOR 1.77, 95% CI 1.05 to 3.06). Thrombolytic type did not affect the relationship between thrombus movement and study outcomes (P>0.05). CONCLUSION: IV tenecteplase is associated with higher thrombus migration rates before EVT compared with alteplase, which is linked to better functional outcomes. However, the type of thrombolytic agent did not affect final reperfusion and functional outcomes.
16 May 2026
Read appraisal →The New England journal of medicine
Endovascular Treatment of Medium-Vessel-Occlusion Strokes
BACKGROUND: Endovascular thrombectomy for acute ischemic stroke due to medium-vessel occlusion has had varying results across trials. Whether thrombectomy improves functional outcomes in patients with medium-vessel occlusion and moderate-to-severe deficits is unclear. METHODS: We conducted an open-label, randomized trial with blinded outcome assessment at 48 centers in China. Eligible patients were adults who presented within 24 hours after the onset of a moderate-to-severe stroke (National Institutes of Health Stroke Scale [NIHSS] score, ≥6; scale, 0 to 42, with higher scores indicating greater neurologic deficits) due to occlusion of a medium vessel. Patients were assigned in a 1:1 ratio to thrombectomy plus medical management (thrombectomy group) or medical management alone (control group). The primary outcome was functional disability as measured by the shift in the modified Rankin scale score (scale, 0 [no disability] to 6 [death]) at 90 days. Violation of the proportional-odds assumption precluded the use of shift in the modified Rankin scale score, so as prespecified, functional independence (modified Rankin scale score of 0, 1, or 2) at 90 days was used as the primary outcome. Safety outcomes were symptomatic intracranial hemorrhage and 90-day mortality. RESULTS: Among 280 patients in the thrombectomy group and 283 in the control group, the median age was 71 years, the median NIHSS score was 10 (range, 3 to 36), and 42.8% were women; 36.6% received intravenous thrombolysis. Functional independence at 90 days was seen in 58.6% of the patients in the thrombectomy group and in 46.6% of those in the control group (adjusted rate ratio, 1.24; 95% confidence interval, 1.07 to 1.44; P = 0.004). The incidence of symptomatic intracranial hemorrhage was 4.7% in the thrombectomy group and 2.2% in the control group; 90-day mortality was 11.1% and 10.2%, respectively. CONCLUSIONS: Among patients with acute ischemic stroke due to medium-vessel occlusion and moderate-to-severe deficits, thrombectomy led to a greater likelihood of functional independence than medical management alone but also to a higher risk of symptomatic intracranial hemorrhage. (Funded by the National Natural Science Foundation of China and the Noncommunicable Chronic Diseases-National Science and Technology Major Project; ORIENTAL-MeVO ClinicalTrials.gov number, NCT06146790.).
15 May 2026
Read appraisal →Journal of medical systems
Prognostic Modeling Based on Post-Endovascular Thrombectomy Systolic Blood Pressure Trajectories Using Explainable Artificial Intelligence: A Secondary Analysis of the OPTIMAL-BP Trial
Blood pressure (BP) management following successful reperfusion after endovascular thrombectomy (EVT) is critical in achieving favorable clinical outcomes. Individualized BP management using predictive modeling by machine learning may further improve prediction of functional outcomes. This study was a retrospective analysis of data from the Outcome in Patients Treated with Intra-Arterial Thrombectomy-Optimal Blood Pressure Control (OPTIMAL-BP) trial, a randomized controlled trial comparing between intensive and conventional BP management during the 24 h after successful recanalization by EVT from June 18, 2020, to November 28, 2022. The trial was conducted across 19 centers in South Korea. Machine learning models were developed to predict functional independence (90-day modified Rankin Scale 0 to 2). Model performance was compared between clinical variables only and systolic blood pressure (SBP) metrics in addition to clinical variables. In addition, the Shapley additive explanations (SHAP) analysis was performed to provide model explanation and understand the importance of SBP metrics. A total of 288 patients (61.1% men, median age 75 years [interquartile range, 65-81]) were included. Among the six algorithms, the deep neural network model incorporating SBP metrics performed best on validation, achieving an area under the curve of 0.86 (95% confidence interval, 0.76-0.92) which was significantly better than the model using only clinical variables (area under the curve 0.80 [95% confidence interval, 0.69-0.88], P = .037). Among SBP metrics, SHAP analysis identified time rate of SBP and minimum SBP as important features, with time rate showing greater influence in the intensive group and minimum SBP in the conventional group. Integrating SBP metrics with clinical variables significantly improved machine learning performance in predicting functional outcomes after successful EVT. Explainable artificial intelligence (AI) identified time rate and minimum SBP as key predictors of outcome. Trial Registration Information: ClinicalTrials.gov (NCT04205305; registered December 17, 2019).
9 May 2026
Read appraisal →Journal of neurointerventional surgery
Systolic blood pressure within 24 hours after successful reperfusion correlates with outcomes in acute ischemic stroke: a secondary analysis of the EHCHANTED2/MT Trial
BACKGROUND: The optimal threshold or range for systolic blood pressure (SBP) control in patients with successful reperfusion after endovascular thrombectomy for acute ischemic stroke (AIS) remains undefined. This study investigated whether SBP within the first 24 hours after successful reperfusion correlates with functional outcomes in AIS. METHODS: In this secondary analysis of the ENCHANTED2/MT trial, patients were categorized into two groups (120-140 mm Hg and 140-180 mm Hg, respectively) based on achieved SBP within 24 hours after randomization. The primary outcome was the modified Rankin Scale (mRS) score at 90 days. Secondary outcomes included neurological deterioration at 7 days, major disability (mRS score of 3-5 at 90 days), hospitalization duration, and health-related quality of life assessed by the three-level EuroQoL 5-Dimension Self-Report Questionnaire (EQ-5D-3L) at 90 days. Safety outcomes included early neurological decline (END), 90-day mortality, symptomatic intracranial hemorrhage (sICH), and any intracranial hemorrhage (ICH). Treatment effects were expressed as ORs with 95% confidence intervals (CIs). RESULTS: A total of 611 patients (363 in the 120-140 mm Hg group and 248 in the 140-180 mm Hg group) were included. The mean (SD) age was 67 (12) years and 37.8% were female. After adjusting for confounders, the 120-140 mm Hg group was significantly associated with better functional outcomes (mRS: 2 (IQR 1-4) vs 2 (IQR 1-5); adjusted OR 1.54 (95% CI 1.10 to 2.17), P=0.013). Compared with the 140-180 mm Hg group, the 120-140 mm Hg group had lower rates of neurological deterioration at 7 days (adjusted OR 0.68 (95% CI 0.47 to 0.98), P=0.037) and 90-day mortality (47 (13.0%) vs 53 (21.4%); adjusted OR 0.48 (95% CI 0.27 to 0.86), P=0.013). There were no significant differences between groups in END, major disability at 90 days, hospitalization duration, EQ-5D-3L score, sICH, or ICH (all P>0.05). CONCLUSIONS: In patients with successful reperfusion after endovascular thrombectomy, an average SBP within 24 hours of 120-140 mm Hg was associated with a greater likelihood of functional independence compared with 140-180 mm Hg.
18 Apr 2026
Read appraisal →Neurology
Neurovascular Unit Dysfunction and Cerebral Small Vessel Disease in Parkinson Disease: A Systematic Review and a Meta Analysis
BACKGROUND AND OBJECTIVES: Parkinson disease (PD) pathogenesis remains incompletely understood; beyond nigrostriatal loss, nondopaminergic mechanisms including neurovascular unit dysfunction may contribute to disability. Cerebral small vessel disease (CSVD) burden reflects neurovascular dysfunction in the form of white matter hyperintensities (WMH), lacunes, cerebral microbleeds (CMB), and enlarged perivascular spaces (ePVS). In PD cohorts, CSVD burden correlates with worse motor and gait scores. The aim of the study was to explore whether patients with PD exhibit greater CSVD burden than healthy controls (HC). METHODS: We conducted a PRISMA-conformant systematic review and meta-analysis of studies including adults with idiopathic PD and a HC group that presented data comparing CSVD burden in these 2 groups. Six databases (MEDLINE, Embase, CINAHL Plus, CENTRAL, Scopus, and Web of Science) were searched on May 14 and 15, 2024. Two reviewers independently screened records, extracted data, and assessed risk of bias, with discrepancies resolved by consensus. Continuous outcomes were pooled as standardized mean differences (SMD); dichotomous outcomes as odds ratios (ORs). We evaluated small-study effects for pooled analyses with 10 or more studies using funnel plots and Egger regression test. RESULTS: We examined 13,403 records. Forty-six studies (45 cross-sectional) met inclusion criteria, totaling 3,817 PD and 2,593 HC (mean ages: 66.9 and 66.5, respectively). WMH volume (k = 21) was higher in PD (SMD 0.36, 95% CI 0.11-0.62). Visual ratings also indicated higher WMH in PD: global (k = 14) SMD 0.27 (95% CI 0.08-0.46); periventricular (k = 11) SMD 0.32 (95% CI 0.12-0.51); deep (k = 8) SMD 0.20 (95% CI 0.09-0.31). Differences in CMB (k = 6; OR 1.18, 95% CI 0.57-2.42) and lacunes (k = 4; OR 1.48, 95% CI 0.58-3.78) were not significant. ePVS results were heterogeneous but trended toward greater burden in PD, most notably in the midbrain (k = 3; SMD 1.80, 0.15-3.44). Overall evidence quality was rated as low, reflecting the observational nature of the included studies. DISCUSSION: Our analysis showed PD to be associated with greater WMH burden and increased midbrain ePVS. Pooled differences in CMB and lacunes were not significant. Substantial heterogeneity and cross-sectional designs limit certainty; standardized imaging and prospective cohorts are needed to define mechanisms and clinical implications.
10 Apr 2026
Read appraisal →AJNR. American journal of neuroradiology
Flow Diversion versus Coiling with or without Stenting for Unruptured Wide-Neck Intracranial Aneurysms: A Randomized Comparison
BACKGROUND AND PURPOSE: There are few randomized trials comparing coiling (with or without stent placement) and flow diversion (FD) for the treatment of wide-neck unruptured intracranial aneurysms. MATERIALS AND METHODS: EVIDENCE was an investigator-led randomized (1:1) trial conducted in 7 French university hospitals. Patients with 7 to 20-mm intradural unruptured intracranial aneurysms with a 4- to 10-mm neck and a "dome/neck" ratio of ≥1 were randomly allocated to coiling with or without adjunctive stent placement or FD alone. The composite primary efficacy outcome was "treatment failure," defined as initial failure to treat the aneurysm; aneurysm rupture or retreatment during follow-up; death or dependency (mRS> 2); or an angiographic residual aneurysm adjudicated by an independent core laboratory at 12 months. The primary hypothesis (revised for slow accrual) was that FD would decrease treatment failures from 35% to 10%, requiring 90 patients. Primary analyses were intent to treat. RESULTS: Among the 91 enrolled patients, four (two in each group) withdrew consent; 87 patients were included in the analysis: 43 in the FD group and 44 in the control group. Most patients had <10 mm (57/87; 65.5%) asymptomatic ophthalmic aneurysms (75/87, 86.2%). A poor primary outcome, ascertainable in 86 patients, was reached in 8/43 patients with FD (18.6%; 95% CI, 9.7%-32.6%) compared with 10/43 coiling patients (23.3%; 95 CI, 13.1%-37.7%) (RR = 0.80; 95% CI, 0.35-1.83; P = .60). Serious adverse events were similar. CONCLUSIONS: For patients with mostly unruptured, wide-neck ophthalmic aneurysms of <10 mm, FD was not superior to coiling with or without stent placement.
5 Apr 2026
Read appraisal →