51
|
Broocks G, Minnerup J, McDonough R, Flottmann F, Kemmling A. Letter by Broocks et al Regarding Article, "Challenging the Ischemic Core Concept in Acute Ischemic Stroke Imaging". Stroke 2021; 52:e76-e77. [PMID: 33493065 DOI: 10.1161/strokeaha.120.032707] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (G.B., R.M., F.F.)
| | - Jens Minnerup
- Department of Neurology with Institute of Translational Neurology, University Hospital Münster, Germany (J.M.)
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (G.B., R.M., F.F.)
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (G.B., R.M., F.F.)
| | - Andre Kemmling
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Schleswig-Holstein, Lübeck (A.K.).,Department of Neuroradiology, Westpfalzklinikum-Kaiserslautern, Germany (A.K.)
| |
Collapse
|
52
|
Flottmann F, Brekenfeld C, Broocks G, Leischner H, McDonough R, Faizy TD, Deb-Chatterji M, Alegiani A, Thomalla G, Mpotsaris A, Nolte CH, Fiehler J, Maros ME. Good Clinical Outcome Decreases With Number of Retrieval Attempts in Stroke Thrombectomy: Beyond the First-Pass Effect. Stroke 2021; 52:482-490. [PMID: 33467875 PMCID: PMC7834657 DOI: 10.1161/strokeaha.120.029830] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose: Endovascular therapy is the standard of care in the treatment of acute ischemic stroke due to large-vessel occlusion. Often, more than one retrieval attempt is needed to achieve reperfusion. We aimed to quantify the influence of endovascular therapy on clinical outcome depending on the number of retrievals needed for successful reperfusion in a large multi-center cohort. Methods: For this observational cohort study, 2611 patients from the prospective German Stroke Registry included between June 2015 and April 2018 were analyzed. Patients who received endovascular therapy for acute anterior circulation stroke with known admission National Institutes of Health Stroke Scale score and Alberta Stroke Program Early CT Score, final Thrombolysis in Cerebral Infarction score, and number of retrievals were included. Successful reperfusion was defined as a Thrombolysis in Cerebral Infarction score of 2b or 3. The primary outcome was defined as functional independence (modified Rankin Scale score of 0–2) at day 90. Multivariate mixed-effects models were used to adjust for cluster effects of the participating centers and confounders. Results: The inclusion criteria were met by 1225 patients. The odds of good clinical outcome decreased with every retrieval attempt required for successful reperfusion: the first retrieval had the highest odds of good clinical outcome (adjusted odds ratio, 6.45 [95% CI, 4.0–10.4]), followed by the second attempt (adjusted odds ratio, 4.56 [95% CI, 2.7–7.7]), and finally the third (adjusted odds ratio, 3.16 [95% CI, 1.8–5.6]). Conclusions: Successful reperfusion within the first 3 retrieval attempts is associated with improved clinical outcome compared with patients without reperfusion. We conclude that at least 3 retrieval attempts should be performed in endovascular therapy of anterior circulation strokes. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03356392.
Collapse
Affiliation(s)
- Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology (F.F., C.B., G.B., H.L., R.M., T.D.F., J.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology (F.F., C.B., G.B., H.L., R.M., T.D.F., J.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology (F.F., C.B., G.B., H.L., R.M., T.D.F., J.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Hannes Leischner
- Department of Diagnostic and Interventional Neuroradiology (F.F., C.B., G.B., H.L., R.M., T.D.F., J.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology (F.F., C.B., G.B., H.L., R.M., T.D.F., J.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology (F.F., C.B., G.B., H.L., R.M., T.D.F., J.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Milani Deb-Chatterji
- Department of Neurology (M.D.-C., A.A., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Anna Alegiani
- Department of Neurology (M.D.-C., A.A., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Götz Thomalla
- Department of Neurology (M.D.-C., A.A., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Anastasios Mpotsaris
- University Clinic for Neuroradiology, Otto-von-Guericke-University Magdeburg, Germany (A.M.)
| | - Christian H Nolte
- Department of Neurology (C.H.N.), Charité-Universitätsmedizin Berlin, Germany.,Center for Stroke Research Berlin (C.H.N.), Charité-Universitätsmedizin Berlin, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology (F.F., C.B., G.B., H.L., R.M., T.D.F., J.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Máté E Maros
- Department of Neuroradiology (M.E.M.), Heidelberg University, Mannheim, Germany.,Department of Biomedical Informatics at the Center for Preventive Medicine and Digital Health (M.E.M.), Heidelberg University, Mannheim, Germany
| | | |
Collapse
|
53
|
Deb-Chatterji M, Schlemm E, Flottmann F, Meyer L, Alegiani A, Brekenfeld C, Fiehler J, Gerloff C, Thomalla G. Sex Differences in Outcome After Thrombectomy for Acute Ischemic Stroke are Explained by Confounding Factors. Clin Neuroradiol 2020; 31:1101-1109. [PMID: 33346850 PMCID: PMC8648700 DOI: 10.1007/s00062-020-00983-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 11/21/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE The aim of this study was to analyze sex differences in outcome after thrombectomy for acute ischemic stroke in clinical practice in a large prospective multicenter registry. METHODS Data of consecutive stroke patients treated with thrombectomy (June 2015-April 2018) derived from an industry-independent registry (German Stroke Registry-Endovascular Treatment) were prospectively analyzed. Multivariable binary logistic regression analyses were applied to determine whether sex is a predictor of functional independence outcome (defined as a modified Rankin scale [mRS] 0-2) 90 days after stroke. RESULTS In total, 2316 patients were included in the analysis, 1170 (50.5%) were female and 1146 (49.5%) were male. Women were older (median age 78 vs. 72 years; p < 0.001) and more frequently had a prestroke functional impairment defined by mRS >1 (24.8% vs. 14.1%; p < 0.001). In unadjusted analyses, independent outcome at 90 days was less frequent in women (33.2%) than men (40.6%; p < 0.001). Likewise, mortality was higher in women than in men (30.7% vs. 26.4%; p = 0.024). In adjusted regression analyses, however, sex was not associated with outcome. Lower age, a lower baseline National Institutes of Health Stroke Scale score, a higher Alberta Stroke Program Early CT score, prestroke functional independence, successful reperfusion, and concomitant intravenous thrombolysis therapy predicted independent outcome. CONCLUSION Women showed a worse functional outcome after thrombectomy for acute ischemic stroke in clinical practice; however, after adjustment for crucial confounders sex was not a predictor of outcome. The difference in outcome thus appears to result from differences in confounding factors such as age and prestroke functional status.
Collapse
Affiliation(s)
- Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Eckhard Schlemm
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Interventional Neuroradiology and Diagnostics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Interventional Neuroradiology and Diagnostics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Alegiani
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Interventional Neuroradiology and Diagnostics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Interventional Neuroradiology and Diagnostics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
54
|
Broocks G, Leischner H, Hanning U, Flottmann F, Faizy TD, Schön G, Sporns P, Thomalla G, Kamalian S, Lev MH, Fiehler J, Kemmling A. Lesion Age Imaging in Acute Stroke: Water Uptake in CT Versus DWI-FLAIR Mismatch. Ann Neurol 2020; 88:1144-1152. [PMID: 32939824 DOI: 10.1002/ana.25903] [Citation(s) in RCA: 40] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Revised: 09/14/2020] [Accepted: 09/14/2020] [Indexed: 11/11/2022]
Abstract
PURPOSE In acute ischemic stroke with unknown time of onset, magnetic resonance (MR)-based diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) estimates lesion age to guide intravenous thrombolysis. Computed tomography (CT)-based quantitative net water uptake (NWU) may be a potential alternative. The purpose of this study was to directly compare CT-based NWU to magnetic resonance imaging (MRI) at identifying patients with lesion age < 4.5 hours from symptom onset. METHODS Fifty patients with acute anterior circulation stroke were analyzed with both imaging modalities at admission between 0.5 and 8.0 hours after known symptom onset. DWI-FLAIR lesion mismatch was rated and NWU was measured in admission CT. An established NWU threshold (11.5%) was used to classify patients within and beyond 4.5 hours. Multiparametric MRI signal was compared with NWU using logistic regression analyses. The empirical distribution of NWU was analyzed in a consecutive cohort of patients with wake-up stroke. RESULTS The median time between CT and MRI was 35 minutes (interquartile range [IQR] = 24-50). The accuracy of DWI-FLAIR mismatch was 68.8% (95% confidence interval [CI] = 53.7-81.3%) with a sensitivity of 58% and specificity of 82%. The accuracy of NWU threshold was 86.0% (95% CI = 73.3-94.2%) with a sensitivity of 91% and specificity of 78%. The area under the curve (AUC) of multiparametric MRI signal to classify lesion age <4.5 hours was 0.86 (95% CI = 0.64-0.97), and the AUC of quantitative NWU was 0.91 (95% CI = 0.78-0.98). Among 87 patients with wake-up stroke, 46 patients (53%) showed low NWU (< 11.5%). CONCLUSION The predictive power of CT-based lesion water imaging to identify patients within the time window of thrombolysis was comparable to multiparametric DWI-FLAIR MRI. A significant proportion of patients with wake-up stroke exhibit low NWU and may therefore be potentially suitable for thrombolysis. ANN NEUROL 2020;88:1144-1152.
Collapse
Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hannes Leischner
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Radiology, Stanford University, Stanford, CA, USA
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Sporns
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Shahmir Kamalian
- Division of Neuroradiology, Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA
| | - Michael H Lev
- Division of Neuroradiology, Harvard Medical School and Massachusetts General Hospital, Boston, MA, USA
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andre Kemmling
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany.,Department of Neuroradiology, University of Schleswig-Holstein, Luebeck, Germany
| |
Collapse
|
55
|
Meyer L, Broocks G, Bechstein M, Flottmann F, Leischner H, Brekenfeld C, Schön G, Deb-Chatterji M, Alegiani A, Thomalla G, Fiehler J, Kniep H, Hanning U. Early clinical surrogates for outcome prediction after stroke thrombectomy in daily clinical practice. J Neurol Neurosurg Psychiatry 2020; 91:1055-1059. [PMID: 32934109 DOI: 10.1136/jnnp-2020-323742] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND PURPOSE To investigate early clinical surrogates for long-term independency of patients treated with thrombectomy for large vessel occlusion stroke in daily clinical routine. METHODS All patients with anterior circulation stroke enrolled in the German Stroke Registry-Endovascular Treatment from 07/2015 to 04/2018 were analysed. National Institute of Health Stroke Scale (NIHSS) on admission, NIHSS percentage change, NIHSS delta and NIHSS at 24 hours as well as existing binary definitions of early neurological improvement (ENI; improvement of 8 (major ENI)/10 (dramatic ENI) NIHSS points or reaching 0/1 were compared for predicting functional outcome at 90 days using the modified Rankin Scale (mRS). Excellent and favourable outcome were defined as 0-1 and 0-2, respectively. RESULTS Among 2262 endovasculary treated patients with acute ischaemic anterior circulation stroke, NIHSS at 24 hours had the highest discriminative ability to predict excellent (receiver operator characteristics (ROC)NIHSS 24 hours area under the curve (AUC) 0.86 (0.84-0.88)) and favourable long-term functional outcome (ROCNIHSS 24 hours AUC 0.86 (0.85-0.88)) in comparison to NIHSS percentage change (ROC% change AUC mRS ≤1: 0.81 (0.78-0.83) mRS ≤2: 0.81 (0.79-0.83)), NIHSS delta change (ROCΔ change AUC mRS ≤1: 0.74 (0.72-0.77), mRS ≤2: 0.77 (0.74-0.79)) and NIHSS admission (ROCAdm AUC mRS ≤1: 0.70 (0.68-0.73), mRS ≤2: 0.67 (0.68-0.71)). Advanced age was the only independent predictor (adjusted OR 1.05, 95% CI 1.03 to 1.07, p<0.001) for turning the outcome prognosis from favourable (mRS ≤2) to poor (mRS ≥4) at 90 days. CONCLUSION The NIHSS at 24 hours postintervention with a threshold of ≤8 points serves best as a surrogate for long-term functional outcome after thrombectomy for anterior circulation stroke in daily clinical practice. Only advanced age significantly decreases its predictive value.
Collapse
Affiliation(s)
- Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hannes Leischner
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Alegiani
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | |
Collapse
|
56
|
Deb-Chatterji M, Konnopka A, Flottmann F, Leischner H, Fiehler J, Gerloff C, Thomalla G. Patient-reported, health-related, quality of life after stroke thrombectomy in clinical practice. Neurology 2020; 95:e1724-e1732. [PMID: 32680947 DOI: 10.1212/wnl.0000000000010356] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2019] [Accepted: 04/06/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine patient-reported health-related quality of life (HRQOL) after stroke thrombectomy in clinical practice and to identify predictors of better HRQOL by analyzing data of 504 consecutive patients treated in a large university stroke center. METHODS All patients with stroke treated by thrombectomy (June 2015-October 2018) were prospectively enrolled in this observational study. At 90 days, functional outcome was assessed by the modified Rankin Scale (mRS) and patient-reported HRQOL was assessed by the EuroQol Group 5-Dimension (EQ-5D) self-report questionnaire, consisting of 5 health domains. The EQ-5D utility index (EQ-5D-I) score (-0.594 to 1.00, with higher values indicating better HRQOL) was calculated. Linear regression analysis was applied to identify predictors of better HRQOL (higher EQ-5D-I score). RESULTS Of 504 patients (median age 76 years, 51.8% female), the mean EQ-5D-I score was 0.39 (SD 0.44). The proportion of stroke survivors who reported complaints in the different domains decreased from 66% in Usual Activities to 57% in Mobility, 50.4% in Self-Care, 41.7% in Pain/Discomfort, and 40.8% Anxiety/Depression. Lower age, lower prestroke mRS score, lower baseline NIH Stroke Scale score, higher Alberta Stroke Program Early CT Score, concomitant thrombolysis therapy, and a successful recanalization were independent predictors of better HRQOL. CONCLUSIONS Patient-reported HRQOL provides a more comprehensive assessment of stroke outcome than the mRS score. Health domains involving motor function most frequently showed complaints in HRQOL after stroke thrombectomy, while a large proportion of patients did not report any complaints across the different health domains. Predictors of better HRQOL closely match the predictors of better functional outcome measured by the mRS in other thrombectomy studies.
Collapse
Affiliation(s)
- Milani Deb-Chatterji
- From the Departments of Neurology (M.D.-C., C.G., G.T.), Health Economics (A.K.), and Interventional Neuroradiology and Diagnostics (F.F., H.L., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Alexander Konnopka
- From the Departments of Neurology (M.D.-C., C.G., G.T.), Health Economics (A.K.), and Interventional Neuroradiology and Diagnostics (F.F., H.L., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- From the Departments of Neurology (M.D.-C., C.G., G.T.), Health Economics (A.K.), and Interventional Neuroradiology and Diagnostics (F.F., H.L., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hannes Leischner
- From the Departments of Neurology (M.D.-C., C.G., G.T.), Health Economics (A.K.), and Interventional Neuroradiology and Diagnostics (F.F., H.L., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- From the Departments of Neurology (M.D.-C., C.G., G.T.), Health Economics (A.K.), and Interventional Neuroradiology and Diagnostics (F.F., H.L., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Gerloff
- From the Departments of Neurology (M.D.-C., C.G., G.T.), Health Economics (A.K.), and Interventional Neuroradiology and Diagnostics (F.F., H.L., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- From the Departments of Neurology (M.D.-C., C.G., G.T.), Health Economics (A.K.), and Interventional Neuroradiology and Diagnostics (F.F., H.L., J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
57
|
Nawka MT, Hanning U, Guerreiro H, Flottmann F, Van Horn N, Buhk JH, Fiehler J, Frölich AM. Feasibility of a customizable training environment for neurointerventional skills assessment. PLoS One 2020; 15:e0238952. [PMID: 32941466 PMCID: PMC7498089 DOI: 10.1371/journal.pone.0238952] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Accepted: 08/26/2020] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVE To meet increasing demands to train neuroendovascular techniques, we developed a dedicated simulator applying individualized three-dimensional intracranial aneurysm models ('HANNES'; Hamburg Anatomic Neurointerventional Endovascular Simulator). We hypothesized that HANNES provides a realistic and reproducible training environment to practice coil embolization and to exemplify disparities between neurointerventionalists, thus objectively benchmarking operators at different levels of experience. METHODS Six physicians with different degrees of neurointerventional procedural experience were recruited into a standardized training protocol comprising catheterization of two internal carotid artery (ICA) aneurysms and one basilar tip aneurysm, followed by introduction of one framing coil into each aneurysm and finally complete coil embolization of one determined ICA aneurysm. The level of difficulty increased with every aneurysm. Fluoroscopy was recorded and assessed for procedural characteristics and adverse events. RESULTS Physicians were divided into inexperienced and experienced operators, depending on their experience with microcatheter handling. Mean overall catheterization times increased with difficulty of the aneurysm model. Inexperienced operators showed longer catheterization times (median; IQR: 47; 30-84s) than experienced operators (21; 13-58s, p = 0.011) and became significantly faster during the course of the attempts (rho = -0.493, p = 0.009) than the experienced physicians (rho = -0.318, p = 0.106). Number of dangerous maneuvers throughout all attempts was significantly higher for inexperienced operators (median; IQR: 1.0; 0.0-1.5) as compared to experienced operators (0.0; 0.0-1.0, p = 0.014). CONCLUSION HANNES represents a modular neurointerventional training environment for practicing aneurysm coil embolization in vitro. Objective procedural metrics correlate with operator experience, suggesting that the system could be useful for assessing operator proficiency.
Collapse
Affiliation(s)
- Marie Teresa Nawka
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helena Guerreiro
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Noel Van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan-Hendrik Buhk
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Maximilian Frölich
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
58
|
Kyselyova AA, Fiehler J, Leischner H, Flottmann F, Buhk JH, Frölich AM. Vessel diameter and catheter-to-vessel ratio affect the success rate of clot aspiration. J Neurointerv Surg 2020; 13:605-608. [PMID: 32753556 DOI: 10.1136/neurintsurg-2020-016459] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2020] [Revised: 07/08/2020] [Accepted: 07/09/2020] [Indexed: 02/02/2023]
Abstract
BACKGROUND A direct aspiration first pass technique (ADAPT) is an efficient, safe, cost-effective, and fast thrombectomy technique. OBJECTIVE To evaluate anatomical and clot characteristics associated with success of the aspiration component as part of ADAPT. METHODS 106 cases of acute carotid-T, basilar, and middle cerebral artery occlusion undergoing endovascular treatment with ADAPT were retrospectively assessed for successful catheter-clot contact and successful primary aspiration, defined as a Thrombolysis in Cerebral Infarction score ≥2b after primary aspiration with 5F or 6F aspiration catheters. Patient age, National Institutes of Health Stroke Scale (NIHSS) score, time from symptom onset to groin puncture, time from groin puncture to revascularization, aortic arch type, access vessel tortuosity, vessel diameter at the proximal end of the thrombus, catheter-to-vessel ratio (CVR), clot density, length, and perviousness were determined. RESULTS Successful clot contact with the aspiration catheter was achieved in 76 cases (72%); these patients were younger (67.7±15.2 vs 73.7±11.4 years; p=0.05) and had less tortuous access vessels (1 vs 2 reverse curves; p=0.004) than those in whom clot contact failed. Successful primary aspiration occurred in 36 of these cases (47%) and was associated with significantly smaller vessel diameter at the proximal thrombus end (2.5±0.7 mm vs 3.1±1.3 mm; p=0.01) and higher CVR (CVR outer diameter: 0.85±0.2 vs 0.68±0.2; p=0.01 and CVR inner diameter: 0.72±0.2 vs 0.58±0.2; p<0.001). No significant differences were seen in aortic arch type, radiographic clot features, and NIHSS score. CONCLUSION With ADAPT, patient age and vessel tortuosity affect the ability to deliver the aspiration catheter and achieve clot contact, whereas vessel diameter and CVR at the aspiration site seem to affect the effectiveness of clot aspiration. Strategies aimed at improving catheter deliverability and increasing CVR may increase the efficacy of ADAPT.
Collapse
Affiliation(s)
- Anna Andriana Kyselyova
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hannes Leischner
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Hendrik Buhk
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Maximilian Frölich
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
59
|
Broocks G, Flottmann F, Schönfeld M, Bechstein M, Aye P, Kniep H, Faizy TD, McDonough R, Schön G, Deb-Chatterji M, Thomalla G, Sporns P, Fiehler J, Hanning U, Kemmling A, Meyer L. Incomplete or failed thrombectomy in acute stroke patients with Alberta Stroke Program Early Computed Tomography Score 0-5 - how harmful is trying? Eur J Neurol 2020; 27:2031-2035. [PMID: 32449311 DOI: 10.1111/ene.14358] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2020] [Accepted: 05/18/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND PURPOSE It is currently unknown whether mechanical thrombectomy (MT) for ischaemic stroke patients with low initial Alberta Stroke Program Early Computed Tomography Score (ASPECTS) is clinically beneficial or even harmful. The purpose of this study was to investigate whether failed or incomplete MT in acute large vessel occlusion stroke with an initial ASPECTS ≤ 5 is associated with worse clinical outcome compared to patients not undergoing MT. METHODS This observational cohort study included a consecutive sample of patients with anterior circulation stroke and initial ASPECTS ≤ 5 admitted between March 2015 and August 2019. Failed recanalization was defined as Thrombolysis in Cerebral Infarction (TICI) score 0-2a, and incomplete recanalization as TICI 2b. Clinical outcome was assessed using the modified Rankin Scale (mRS) at 90 days defining very poor clinical outcome as mRS > 4. RESULTS One hundred and seventy patients were included. Ninety-nine patients underwent MT and 71 patients received best medical treatment only. Clinical outcome after failed or incomplete MT (TICI 0-2b) was significantly better compared to patients with medical treatment only (median mRS 5, interquartile range 4-6 vs 5-6, P = 0.03). In multivariable logistic regression analysis, failed or incomplete MT (TICI 0-2b) showed a significantly reduced likelihood for very poor outcome (odds ratio 0.39, 95% confidence interval 0.19-0.83, P = 0.01). Failed MT (TICI 0-2a) was not associated with a worse outcome compared to best medical treatment. CONCLUSIONS Patients with failed or incomplete recanalization results (TICI 0-2b) showed a reduced likelihood for very poor outcome compared with those who did not receive MT. Evidence from randomized trials is needed to confirm that even failed or incomplete MT is not harmful in these patients.
Collapse
Affiliation(s)
- G Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - F Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - M Schönfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - M Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - P Aye
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - H Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - T D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Radiology, Stanford University, Stanford, CA, USA
| | - R McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - G Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - M Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - G Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - P Sporns
- Department of Neuroradiology, Universitätsspital Basel, Basel, Switzerland
| | - J Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - U Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - A Kemmling
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany.,Department of Neuroradiology, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - L Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
60
|
van Horn N, Kniep H, Leischner H, McDonough R, Deb-Chatterji M, Broocks G, Thomalla G, Brekenfeld C, Fiehler J, Hanning U, Flottmann F. Predictors of poor clinical outcome despite complete reperfusion in acute ischemic stroke patients. J Neurointerv Surg 2020; 13:14-18. [PMID: 32414889 DOI: 10.1136/neurintsurg-2020-015889] [Citation(s) in RCA: 59] [Impact Index Per Article: 14.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/07/2020] [Accepted: 04/07/2020] [Indexed: 02/07/2023]
Abstract
BACKGROUND In patients suffering from acute ischemic stroke from large vessel occlusion (LVO), mechanical thrombectomy (MT) often leads to successful reperfusion. Only approximately half of these patients have a favorable clinical outcome. Our aim was to determine the prognostic factors associated with poor clinical outcome following complete reperfusion. METHODS Patients treated with MT for LVO from a prospective single-center stroke registry between July 2015 and April 2019 were screened. Complete reperfusion was defined as Thrombolysis in Cerebral Infarction (TICI) grade 3. A modified Rankin scale at 90 days (mRS90) of 3-6 was defined as 'poor outcome'. A logistic regression analysis was performed with poor outcome as a dependent variable, and baseline clinical data, comorbidities, stroke severity, collateral status, and treatment information as independent variables. RESULTS 123 patients with complete reperfusion (TICI 3) were included in this study. Poor clinical outcome was observed in 67 (54.5%) of these patients. Multivariable logistic regression analysis identified greater age (adjusted OR 1.10, 95% CI 1.04 to 1.17; p=0.001), higher admission National Institutes of Health Stroke Scale (NIHSS) (OR 1.14, 95% CI 1.02 to 1.28; p=0.024), and lower Alberta Stroke Program Early CT Score (ASPECTS) (OR 0.6, 95% CI 0.4 to 0.84; p=0.007) as independent predictors of poor outcome. Poor outcome was independent of collateral score. CONCLUSION Poor clinical outcome is observed in a large proportion of acute ischemic stroke patients treated with MT, despite complete reperfusion. In this study, futile recanalization was shown to occur independently of collateral status, but was associated with increasing age and stroke severity.
Collapse
Affiliation(s)
- Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg, Hamburg, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg, Hamburg, Hamburg, Germany
| | - Hannes Leischner
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg, Hamburg, Hamburg, Germany
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg, Hamburg, Hamburg, Germany
| | | | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg, Hamburg, Hamburg, Germany
| | - Goetz Thomalla
- Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg, Hamburg, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg, Hamburg, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg, Hamburg, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg, Hamburg, Hamburg, Germany
| |
Collapse
|
61
|
Deb-Chatterji M, Pinnschmidt H, Flottmann F, Leischner H, Alegiani A, Brekenfeld C, Fiehler J, Gerloff C, Thomalla G. Stroke patients treated by thrombectomy in real life differ from cohorts of the clinical trials: a prospective observational study. BMC Neurol 2020; 20:81. [PMID: 32138684 PMCID: PMC7059360 DOI: 10.1186/s12883-020-01653-z] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Accepted: 02/24/2020] [Indexed: 11/18/2022] Open
Abstract
Background Randomized controlled trials (RCTs) demonstrated efficacy and safety of endovascular treatment (ET) in anterior circulation large vessel occlusions (LVO). We aimed at investigating how stroke patients treated by thrombectomy in clinical practice and their outcome compare to cohorts and results of thrombectomy trials. Methods In a prospective study, we consecutively included stroke patients treated by thrombectomy (2015–2017). Baseline characteristics, procedural and outcome data were analyzed. Outcome was assessed by modified Rankin Scale (mRS) at 90 days. Ordinal regression analysis was performed to identify predictors of outcome. Results Thrombectomy was applied in 264 patients (median 75 years, 49.6% female). Median baseline National Institutes of Health Stroke Scale (NIHSS) was 16, 58.0% received concomitant intravenous thrombolysis, 62.1% were referred from external hospitals. Median Alberta Stroke Program Early CT Score (ASPECTS) was 7. Successful recanalization (modified Thrombolysis in Cerebral Infarction Score, mTICI 2b/3) was achieved in 72.0%. Symptomatic intracranial hemorrhage (sICH) occurred in 4.5%. Independent outcome (mRS 0–2) was achieved in 26.2%, poor outcome (mRS 5–6) in 49.2%. Only 33.5% met the stringent enrolment criteria of previous RCTs. Lower age, baseline NIHSS, pre-stroke mRS, higher ASPECTS, and successful recanalization were independent predictors of favourable outcome. Conclusions The majority of stroke patients treated by ET in clinical practice would not have qualified for randomization in prior RCTs. Outcome in real-life patient cohorts is worse than in the highly selected cohorts from randomized trials, while rates of successful recanalization, sICH and outcome predictors are the same. Our findings support ET in broader patient populations than in the RCTs and may improve treatment decision in individual stroke patients with LVO in clinical practice.
Collapse
Affiliation(s)
- Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Hans Pinnschmidt
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Neuroradiological Diagnostics and Intervention, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hannes Leischner
- Department of Neuroradiological Diagnostics and Intervention, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Alegiani
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Neuroradiological Diagnostics and Intervention, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Neuroradiological Diagnostics and Intervention, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| |
Collapse
|
62
|
Broocks G, Hanning U, Flottmann F, Schönfeld M, Faizy TD, Sporns P, Baumgart M, Leischner H, Schön G, Minnerup J, Thomalla G, Fiehler J, Kemmling A. Clinical benefit of thrombectomy in stroke patients with low ASPECTS is mediated by oedema reduction. Brain 2020; 142:1399-1407. [PMID: 30859191 DOI: 10.1093/brain/awz057] [Citation(s) in RCA: 114] [Impact Index Per Article: 28.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2018] [Revised: 01/14/2019] [Accepted: 01/18/2019] [Indexed: 11/14/2022] Open
Abstract
The impact of endovascular vessel recanalization on patients with a low initial Alberta Stroke Program Early Computer Tomography Score (ASPECTS) is still uncertain. We hypothesized that vessel recanalization leads to an improvement in mortality and degree of disability by reducing brain oedema and malignant mass effect. In this multicentre observational study, patients with acute ischaemic stroke due to large vessel occlusion in the anterior circulation and an ASPECTS of ≤ 5 were analysed. Patients were assembled into two groups: successful vessel recanalization (thrombolysis in cerebral infarctions, TICI scale 2b/3) or persistent vessel occlusion (no endovascular procedure or TICI scale 0-2a). Observers were blinded to clinical data. Net water uptake within brain infarct, a quantitative biomarker based on CT densitometry, was used to quantify oedema in admission and follow-up CT and Δ-water uptake was calculated as difference between water uptake at both time points. Occurrence of malignant infarctions and secondary parenchymal haemorrhage was documented. Furthermore, modified Rankin scale score at 90 days was used for functional outcome. We included 117 patients admitted between March 2015 and August 2017 in three German stroke centres: 71 with persistent vessel occlusion and 46 with successful recanalization. The mean water uptake in the admission imaging was not different between both groups: 10.0% (±4.8) in patients with persistent vessel occlusion and 9.0% (±4.8) in patients with vessel recanalization (P = 0.4). After follow-up CT, the mean Δ-water uptake was 16.0% (±7.5) in patients with persistent vessel occlusion and 8.0% (±5.7) in patients with vessel recanalization (P < 0.001). Successful reperfusion was independently associated with a lowered Δ-water uptake of 8.0% (95% confidence interval, CI: -10.5 to -5.3%; P < 0.001) and lowered modifed Rankin scale score after 90 days of 1.5 (95% CI: -2.2 to -0.8; P < 0.001). The prevalence of malignant infarctions was 44.3% in patients with persistent vessel occlusion and 26.1% in patients with vessel recanalization. There was no significant difference for secondary haemorrhage in both groups (P = 0.7). In conclusion, successful recanalization in patients with low initial ASPECTS resulted in a significant reduction of oedema formation and was associated with a decreased prevalence of malignant infarctions and an improvement of clinical outcome.
Collapse
Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Schönfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias Djamsched Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Sporns
- Department of Clinical Radiology, University Hospital Münster, Münster, Germany
| | - Michael Baumgart
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hannes Leischner
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Minnerup
- Department of Neurology, University Hospital Münster, Münster, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andre Kemmling
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Neuroradiology, University Hospital Schleswig-Holstein, Luebeck, Germany.,Department of Neuroradiology, University Hospital Münster, Münster, Germany
| |
Collapse
|
63
|
Tiedt S, Herzberg M, Küpper C, Feil K, Kellert L, Dorn F, Liebig T, Alegiani A, Dichgans M, Wollenweber FA, Alber B, Bangard C, Berrouschot J, Bode F, Boeckh-Behrens T, Bohner G, Bormann A, Braun M, Eckert B, Fiehler J, Flottmann F, Gerloff C, Hamann G, Henn K, Kastrup A, Kraemer C, Krause L, Lehm M, Liman J, Lowens S, Mpotsaris A, Nolte C, Papanagiotou P, Petersen M, Petzold G, Pfeilschifter W, Psychogios M, Reich A, von Rennenberg R, Röther J, Schäfer J, Siebert E, Siedow A, Solymosi L, Thomalla G, Thonke S, Wagner M, Wunderlich S, Zweynert S. Stroke Etiology Modifies the Effect of Endovascular Treatment in Acute Stroke. Stroke 2020; 51:1014-1016. [DOI: 10.1161/strokeaha.119.028383] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Stroke etiology drives thrombus composition. We thus hypothesized that endovascular treatment shows different efficacy in cardioembolic versus noncardioembolic large-vessel occlusions (LVOs).
Methods—
Procedural characteristics, grade of reperfusion, and functional outcome at discharge and 90 days were compared between patients with cardioembolic versus noncardioembolic LVO from the GSR-ET (German Stroke Registry–Endovascular Treatment; n=2589). To determine associations with functional outcome, adjusted odds ratios and 95% CIs were calculated using ordinal multivariable logistic regression models adjusting for potential baseline confounder variables.
Results—
Endovascular treatment of cardioembolic LVO had a higher rate of successful reperfusion (85.6% versus 81.0%;
P
=0.002) and a higher rate of complete reperfusion after a single thrombectomy pass (45.7% versus 38.1%;
P
<0.001) compared with noncardioembolic LVO. Cardioembolic LVO was associated with better functional outcome at discharge (adjusted odds ratio, 1.61 [95% CI, 1.37–1.88]) and 90 days (adjusted odds ratio, 1.29 [95% CI, 1.09–1.53]). In mediation analysis, reperfusion explained 47% of the effect of etiology on functional outcome at discharge.
Conclusions—
These results provide evidence for higher efficacy of endovascular treatment in cardioembolic LVO compared with noncardioembolic LVO.
Collapse
Affiliation(s)
- Steffen Tiedt
- From the Institute for Stroke and Dementia Research (S.T., M.D., F.A.W.), University Hospital, LMU Munich, Germany
| | - Moriz Herzberg
- From the Institute for Stroke and Dementia Research (S.T., M.D., F.A.W.), University Hospital, LMU Munich, Germany
- Institute of Neuroradiology (M.H., F.D., T.L.), University Hospital, LMU Munich, Germany
| | - Clemens Küpper
- Department of Neurology (C.K., K.F., L.K., F.A.W.), University Hospital, LMU Munich, Germany
| | - Katharina Feil
- Department of Neurology (C.K., K.F., L.K., F.A.W.), University Hospital, LMU Munich, Germany
| | - Lars Kellert
- Department of Neurology (C.K., K.F., L.K., F.A.W.), University Hospital, LMU Munich, Germany
| | - Franziska Dorn
- Institute of Neuroradiology (M.H., F.D., T.L.), University Hospital, LMU Munich, Germany
| | - Thomas Liebig
- Institute of Neuroradiology (M.H., F.D., T.L.), University Hospital, LMU Munich, Germany
| | - Anna Alegiani
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany (A.A.)
| | | | - Frank A. Wollenweber
- From the Institute for Stroke and Dementia Research (S.T., M.D., F.A.W.), University Hospital, LMU Munich, Germany
- Department of Neurology (C.K., K.F., L.K., F.A.W.), University Hospital, LMU Munich, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
64
|
Deb-Chatterji M, Pinnschmidt H, Flottmann F, Leischner H, Broocks G, Alegiani A, Brekenfeld C, Fiehler J, Gerloff C, Thomalla G. Predictors of independent outcome of thrombectomy in stroke patients with large baseline infarcts in clinical practice: a multicenter analysis. J Neurointerv Surg 2020; 12:1064-1068. [DOI: 10.1136/neurintsurg-2019-015641] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2019] [Revised: 01/27/2020] [Accepted: 02/08/2020] [Indexed: 12/28/2022]
Abstract
ObjectiveTo analyze outcome and its predictors after endovascular treatment (ET) in stroke patients suffering from large vessel occlusion with large pre-treatment infarct cores defined by an Alberta Stroke Program Early CT Score (ASPECTS) <6.MethodsWe analyzed data from an industry-independent, multicenter, prospective registry (German Stroke Registry – Endovascular Treatment) which enrolled consecutive patients treated by ET (June 2015–April 2018) with different devices. Multivariate logistic regression analyses identified predictors of independent outcome (IO) defined as a modified Rankin Scale (mRS) 0–2, and mortality at 90 days in patients with ASPECTS <6.ResultsOf 1700 patients included in the analysis, 152 (8.9%) had a baseline ASPECTS <6. Of these, 33 patients (21.6%) achieved IO, and 68 (44.7%) were dead at 90 days. A lower age, lower baseline National Institutes of Health Stroke Scale (NIHSS) score, and successful recanalization (defined as modified Thrombolysis in Cerebral Infarction Score, mTICI 2b/3) were predictors of IO. Successful recanalization had the strongest association with IO (OR 7.0, 95% CI 1.8 to 26.8). Pre-treatment parameters predicting IO were age <70 years (sensitivity 0.79, specificity 0.69) and NIHSS <12 (0.57 and 0.94). A higher age, a pre-stroke mRS score >1, and failed recanalization were predictors of death.ConclusionsA substantial proportion of stroke patients with an ASPECTS <6 can achieve independence after thrombectomy, in particular, if they are younger, have only moderate baseline stroke symptoms, and no relevant pre-stroke disability. These results may encourage considering thrombectomy in low ASPECTS patients in clinical practice until randomized trials are available.
Collapse
|
65
|
Faizy TD, Thaler C, Broocks G, Flottmann F, Leischner H, Kniep H, Nawabi J, Schön G, Stellmann JP, Kemmling A, Reddy R, Heit JJ, Fiehler J, Kumar D, Hanning U. The Myelin Water Fraction Serves as a Marker for Age-Related Myelin Alterations in the Cerebral White Matter - A Multiparametric MRI Aging Study. Front Neurosci 2020; 14:136. [PMID: 32153358 PMCID: PMC7050496 DOI: 10.3389/fnins.2020.00136] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2019] [Accepted: 02/03/2020] [Indexed: 12/13/2022] Open
Abstract
Quantitative MRI modalities, such as diffusion tensor imaging (DTI) or magnetization transfer imaging (MTI) are sensitive to the neuronal effects of aging of the cerebral white matter (WM), but lack the specificity for myelin content. Myelin water imaging (MWI) is highly specific for myelin and may be more sensitive for the detection of changes in myelin content inside the cerebral WM microstructure. In this multiparametric imaging study, we evaluated the performance of myelin water fraction (MWF) estimates as a marker for myelin alterations during normal-aging. Multiparametric MRI data derived from DTI, MTI and a novel, recently-proposed MWF-map processing and reconstruction algorithm were acquired from 54 healthy subjects (aged 18-79 years) and region-based multivariate regression analysis was performed. MWFs significantly decreased with age in most WM regions (except corticospinal tract) and changes of MWFs were associated with changes of radial diffusivity, indicating either substantial alterations or preservation of myelin content in these regions. Decreases of fractional anisotropy and magnetization transfer ratio were associated with lower MWFs in commissural fiber tracts only. Mean diffusivity had no regional effects on MWF. We conclude that MWF estimates are sensitive for the assessment of age-related myelin alterations in the cerebral WM of normal-aging brains.
Collapse
Affiliation(s)
- Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Thaler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hannes Leischner
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jawed Nawabi
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Institute of Applied Biometrics and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan-Patrick Stellmann
- Institute of Neuroimmunology and Multiple Sclerosis, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - André Kemmling
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Muenster, Münster, Germany
| | - Ravinder Reddy
- Department of Radiology, University of Pennsylvania, Philadelphia, PA, United States
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Palo Alto, CA, United States
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dushyant Kumar
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Radiology, University of Pennsylvania, Philadelphia, PA, United States
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
66
|
Meyer L, Alexandrou M, Flottmann F, Deb-Chatterji M, Abdullayev N, Maus V, Politi M, Bernkopf K, Roth C, Kastrup A, Hanning U, Brekenfeld C, Thomalla G, Gerloff C, Mpotsaris A, Papanagiotou P, Fiehler J, Leischner H. Endovascular Treatment of Very Elderly Patients Aged ≥90 With Acute Ischemic Stroke. J Am Heart Assoc 2020; 9:e014447. [PMID: 32089059 PMCID: PMC7335589 DOI: 10.1161/jaha.119.014447] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Patients aged ≥90 were excluded or under‐represented in past thrombectomy trials; thus, uncertainty remains whether treatment benefits can be expected regardless of age. This study investigates outcome and safety of thrombectomy in nonagenarians to improve decision making in a real‐world setting. Methods and Results All currently available data of patients aged ≥90 enrolled in the GSR‐ET (German Stroke Registry–Endovascular Treatment) were combined with a smaller cohort from 3 tertiary stroke centers. Baseline characteristics, procedural (Thrombolysis in Cerebral Infarction scale) and functional outcomes (modified Rankin Scale; mRS), as well as complications (symptomatic intracranial hemorrhage, serious adverse events; SAEs) were analyzed. Good functional outcome was defined as mRS ≤3 at 90‐days. 203 patients with anterior circulation stroke and prestroke mRS ≤3 were included. The rate of successful recanalization (Thrombolysis in Cerebral Infarction scale ≥2b) was 75.9% (154/203). Good functional outcome (mRS ≤3) was observed in 21.6% (41 of 193) at 90‐days. In‐hospital mortality was 27.1% (55 of 203) and increased significantly at 90 days to 48.9% (93 of 190; P<0.001). Symptomatic intracranial hemorrhage occurred in 3% (6 of 203) of patients. Logistic regression analysis identified Alberta Stroke Program Early CT Score (adjusted odds ratio, 1.93; 95% CI, 1.01–3.70; P=0.046) and initial National Institute of Health Stroke Scale (adjusted odds ratio, 0.85; 95% CI, 0.76–0.97; P=0.014) as independent predictors for good outcome. Patients with successful recanalization had a significant (P=0.001) shift of mRS distribution with higher rates of good functional outcomes (23.8% [34 of 143] versus 14.9% [7 of 47]) and lower mortality at 90‐days (46.8% [67 of 143] versus 55.3% [26 of 47]). Conclusions Despite high mortality and less frequent favorable outcome, our data suggest that thrombectomy is still effective and safe for nonagenarians. Decision making for thrombectomy in patients aged ≥90 should be based on a case‐by‐case basis with regard to initial National Institute of Health Stroke Scale and Alberta Stroke Program Early CT Score.
Collapse
Affiliation(s)
- Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Maria Alexandrou
- Department of Diagnostic and Interventional Neuroradiology Hospital Bremen-Mitte Bremen Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Milani Deb-Chatterji
- Department of Neurology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Nuran Abdullayev
- Department of Diagnostic and Interventional Radiology University Hospital of Cologne Germany
| | - Volker Maus
- Department of Radiology, Neuroradiology and Nuclear Medicine Ruhr University Bochum Knappschaftskrankenhaus Bochum Bochum Germany
| | - Maria Politi
- Department of Diagnostic and Interventional Neuroradiology Hospital Bremen-Mitte Bremen Germany
| | - Kathleen Bernkopf
- Clinic and Policlinic for Neurology Hospital of the Technical University Munich Munich Germany
| | - Christian Roth
- Department of Diagnostic and Interventional Neuroradiology Hospital Bremen-Mitte Bremen Germany
| | - Andreas Kastrup
- Department of Neurology Hospital Bremen-Mitte Bremen Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Götz Thomalla
- Department of Neurology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Christian Gerloff
- Department of Neurology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Anastasios Mpotsaris
- Department of Diagnostic and Interventional Neuroradiology University Hospital of Aachen Germany
| | - Panagiotis Papanagiotou
- Department of Diagnostic and Interventional Neuroradiology Hospital Bremen-Mitte Bremen Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Hannes Leischner
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | | |
Collapse
|
67
|
Flottmann F, Leischner H, Fiehler J, Thomalla G, Deb-Chatterji M, Maros M. Abstract WMP7: Clinical Outcome After Multiple Retrieval Attempts in Endovascular Treatment for Acute Ischemic Stroke. Stroke 2020. [DOI: 10.1161/str.51.suppl_1.wmp7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction:
Dedicated analyses scrutinizing the deteriorating benefit of multiple endovascular thrombectomy attempts are lacking. Here, we present insights into choosing the optimal number of retrieval attempts (RA) based on multicentric data of the German Stroke Registry (GSR).
Materials & Methods:
In this retrospective multicenter (n=17) study, 2611 patients of the GSR were included. In 1244 patients with complete datasets, clinical outcome was correlated with the number of retrieval attempts. The framework of generalized linear mixed-effects models was used, and the primary clinical outcome was modified Rankin scale (mRS) at 90 days <= 2. The main co-factor of interest was the number of successful RA while the model was also adjusted for confounders such as age, sex, admission NIHSS, ASPECTS, intravenous thrombolysis (IVT), type of anesthesia, time from groin puncture to final angiographic series, and reperfusion (thrombolysis in cerebral infarction [TICI]) score.
Results:
Age (ß=0.94, p<0.001), admission NIHSS (ß=0.89, p<0.001) and general anesthesia (ß=0.62, p=0.0063) showed significant negative-, while ASPECT-score (ß=1.19, p=8.6x10
-5
) and IVT (ß=1.34, p=0.044) showed positive association with mRS2 after adjusting for all covariates. Compared to the reference group of 0 successful RA, successful reperfusion after one RA showed the strongest trend (ß=3.14, p=0.096) toward functional independence. Similarly, the estimated effect of 2nd to 5th RAs stayed positive but non-significant. Six or more RAs had a negative effect (ß =0.55, p=0.45) on functional independence.
Conclusion:
There is decreasing clinical benefit of every retrieval attempt in EVT. However, successful reperfusion achieved after up to 5 retrieval attempts seems to be beneficial compared to failure of reperfusion.
Collapse
Affiliation(s)
| | | | - Jens Fiehler
- Neuroradiology, Univ Med Cntr Hamburg, Hamburg, Germany
| | | | | | - Matt Maros
- Univ Med Cntr Mannheim, Mannheim, Germany
| |
Collapse
|
68
|
Broocks G, Flottmann F, Hanning U, Schön G, Sporns P, Minnerup J, Fiehler J, Kemmling A. Impact of endovascular recanalization on quantitative lesion water uptake in ischemic anterior circulation strokes. J Cereb Blood Flow Metab 2020; 40:437-445. [PMID: 30628850 PMCID: PMC7370621 DOI: 10.1177/0271678x18823601] [Citation(s) in RCA: 36] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Studies evaluating the effect of reperfusion on ischemic edema in acute stroke described conflicting results. Net water uptake (NWU) per brain volume is a new quantitative imaging biomarker of space-occupying ischemic edema, which can be measured in computed tomography (CT). We sought to investigate the effects of vessel recanalization on the formation of ischemic brain edema using quantitative NWU. In this multicenter observational study, acute ischemic stroke patients with a large vessel occlusion (LVO) in the anterior circulation were consecutively screened. Patients with vessel recanalization (thrombolysis in cerebral infarction (TICI) 2 b or 3) versus persistent vessel occlusion (no thrombectomy, TICI 0-1) were compared. Lesion-NWU was quantified in multimodal admission CT and follow-up CT (FCT), and ΔNWU was calculated as difference. Of 194 included patients, 150 had successful endovascular recanalization and 44 persistent LVO. In FCT after treatment, the mean (standard deviation) ΔNWU was 15.8% (5.7) in patients with persistent LVO and 9.8% (5.8) with vessel recanalization (p < 0.001). In multivariate regression analysis, vessel recanalization was independently associated with a lowered ΔNWU by 6.3% compared to LVO (95% confidence interval: 3.7-9.0, p < 0.001). Successful vessel recanalization was associated with a significantly reduced formation of ischemic brain edema. Quantitative NWU may be used to compare the treatment effects in acute stroke.
Collapse
Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Sporns
- Department of Clinical Radiology, University Hospital Münster, Münster, Germany
| | - Jens Minnerup
- Department of Neurology, University Hospital Münster, Münster, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andre Kemmling
- Department of Clinical Radiology, University Hospital Münster, Münster, Germany
| |
Collapse
|
69
|
Flottmann F, Leischner H, Broocks G, Faizy TD, Aigner A, Deb-Chatterji M, Thomalla G, Krauel J, Issleib M, Fiehler J, Brekenfeld C. Emergency Conversion to General Anesthesia Is a Tolerable Risk in Patients Undergoing Mechanical Thrombectomy. AJNR Am J Neuroradiol 2020; 41:122-127. [PMID: 31806594 DOI: 10.3174/ajnr.a6321] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2019] [Accepted: 10/01/2019] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Mechanical thrombectomy for acute ischemic stroke is performed with the patient under local anesthesia, conscious sedation, or general anesthesia. According to recent trials, up to 16% of patients require emergency conversion to general anesthesia during mechanical thrombectomy. This study investigated the procedural and clinical outcomes after emergency conversion in comparison with local anesthesia, conscious sedation, and general anesthesia. MATERIALS AND METHODS This retrospective study included 254 patients undergoing mechanical thrombectomy for acute large-vessel occlusion. The procedure was started with the patient either under local anesthesia, conscious sedation, or general anesthesia. Emergency conversion was defined as induction of general anesthesia during mechanical thrombectomy. The primary outcomes were successful reperfusion (TICI 2b/3) and functional independence (mRS at 90 days, ≤2). RESULTS Twenty-five patients (9.8%) required emergency conversion to general anesthesia. The time from admission to flow restoration was increased under general anesthesia (median, 137 minutes) and emergency conversion (median, 138 minutes) compared with local anesthesia (median 110 minutes). After adjustment for confounders, emergency conversion to general anesthesia and primary general anesthesia had comparable chances of successful reperfusion (OR = 1.28; 95% CI, 0.31-5.25). Patients with emergency conversion had a tendency toward higher chances of functional independence (OR = 4.48; 95% CI, 0.49-40.86) compared with primary general anesthesia, but not compared with local anesthesia (OR = 0.86; 95% CI, 0.14-5.11) and conscious sedation (OR = 1.07; 95% CI, 0.17-6.53). CONCLUSIONS Patients with emergency conversion did not have lower chances of successful reperfusion or functional independence compared those with primary general anesthesia, and time to flow restoration was also similar. We found no evidence supporting the primary induction of general anesthesia in patients at risk for emergency conversion.
Collapse
Affiliation(s)
- F Flottmann
- From the Department of Diagnostic and Interventional Neuroradiology (F.F., H.L., G.B., T.D.F., J.F., C.B.)
| | - H Leischner
- From the Department of Diagnostic and Interventional Neuroradiology (F.F., H.L., G.B., T.D.F., J.F., C.B.)
| | - G Broocks
- From the Department of Diagnostic and Interventional Neuroradiology (F.F., H.L., G.B., T.D.F., J.F., C.B.)
| | - T D Faizy
- From the Department of Diagnostic and Interventional Neuroradiology (F.F., H.L., G.B., T.D.F., J.F., C.B.)
| | - A Aigner
- Institute of Medical Biometry and Epidemiology (A.A.)
- Institute of Public Health (A.A.), Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - G Thomalla
- Departments of Neurology (M.D.-C., G.T.)
| | - J Krauel
- Anaesthesiology (J.K., M.I.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - M Issleib
- Anaesthesiology (J.K., M.I.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - J Fiehler
- From the Department of Diagnostic and Interventional Neuroradiology (F.F., H.L., G.B., T.D.F., J.F., C.B.)
| | - C Brekenfeld
- From the Department of Diagnostic and Interventional Neuroradiology (F.F., H.L., G.B., T.D.F., J.F., C.B.)
| |
Collapse
|
70
|
Seker F, Fiehler J, Möhlenbruch MA, Heimann F, Flottmann F, Ringleb PA, Thomalla G, Steiner T, Kraemer C, Brekenfeld C, Bendszus M. Time Metrics to Endovascular Thrombectomy in 3 Triage Concepts. Stroke 2020; 51:335-337. [DOI: 10.1161/strokeaha.119.027050] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
NEUROSQUAD (Stroke Treatment: Quality and Efficacy in Different Referral Systems) is a prospective, observational, bi-center study comparing 3 triage pathways in endovascular stroke treatment: mothership (MS), drip and ship (DS) and transferring a neurointerventionalist to a remote hospital for thrombectomy (drive the doctor [DD]).
Methods—
Between February and October 2018, all stroke patients undergoing thrombectomy at 2 university hospitals and 2 associated remote hospitals were included. Primary outcome measures were time from onset to groin puncture and time from imaging to groin puncture. Secondary outcome measures were time from onset to imaging and time from onset to thrombolysis.
Results—
In total, 440 patients were included (mothership 32.3%, DS 55.9%, DD 11.8%). Median time from onset to groin puncture (168 minutes) and time from imaging to groin puncture (51 minutes) were the shortest in the mothership group. Time from onset to groin puncture (DD median 225 versus DS median 300 minutes;
P
=0.001) and time from imaging to groin puncture (DD median 118 versus DS median 172 minutes;
P
<0.001) were shorter in the DD group compared with DS. Time from onset to imaging was similar among mothership, DS, and DD (
P
=0.363). In patients receiving thrombolysis, time from onset to needle was similar among the groups (
P
=0.620).
Conclusions—
The NEUROSQUAD study adds evidence that DD may be a feasible alternative to DS, leading to shorter delay between symptom onset and groin puncture. Both are time-wise inferior compared with mothership, though.
Collapse
Affiliation(s)
- Fatih Seker
- From the Department of Neuroradiology (F.S., M.A.M., F.H., M.B.), Heidelberg University Hospital, Germany
| | - Jens Fiehler
- Department of Neuroradiology (J.F., F.F., C.B.), University Hospital Hamburg-Eppendorf, Germany
| | - Markus A. Möhlenbruch
- From the Department of Neuroradiology (F.S., M.A.M., F.H., M.B.), Heidelberg University Hospital, Germany
| | - Friederike Heimann
- From the Department of Neuroradiology (F.S., M.A.M., F.H., M.B.), Heidelberg University Hospital, Germany
| | - Fabian Flottmann
- Department of Neuroradiology (J.F., F.F., C.B.), University Hospital Hamburg-Eppendorf, Germany
| | - Peter A. Ringleb
- Department of Neurology (P.A.R.), Heidelberg University Hospital, Germany
| | - Götz Thomalla
- Department of Neurology (G.T.), University Hospital Hamburg-Eppendorf, Germany
| | - Thorsten Steiner
- Department of Neurology, Klinikum Frankfurt Höchst, Germany (T.S.)
| | | | - Caspar Brekenfeld
- Department of Neuroradiology (J.F., F.F., C.B.), University Hospital Hamburg-Eppendorf, Germany
| | - Martin Bendszus
- From the Department of Neuroradiology (F.S., M.A.M., F.H., M.B.), Heidelberg University Hospital, Germany
| |
Collapse
|
71
|
Deb-Chatterji M, Flottmann F, Leischner H, Alegiani A, Brekenfeld C, Fiehler J, Gerloff C, Thomalla G. Recanalization is the Key for Better Outcome of Thrombectomy in Basilar Artery Occlusion. Clin Neuroradiol 2019; 30:769-775. [PMID: 31872288 DOI: 10.1007/s00062-019-00850-9] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Accepted: 10/25/2019] [Indexed: 10/25/2022]
Abstract
PURPOSE Patients with basilar artery occlusion (BAO) were excluded from previous randomized controlled trials (RCTs) of endovascular treatment (ET) for acute ischemic stroke, but are commonly treated in clinical practice. This study aimed at analyzing predictors of functional outcome of ET in patients with BAO to improve patient selection for ET. METHODS Consecutive patients with BAO who received ET over a 2-year time period were prospectively studied. Baseline characteristics, procedural and outcome data were evaluated. Outcome was assessed by the modified Rankin Scale (mRS) 90 days after stroke. Multivariate regression analyses were performed to identify predictors of outcome across the range of the mRS, of poor outcome (mRS 5-6) and independent outcome (mRS 0-2). RESULTS A total of 39 patients with BAO (median age: 75 years, 67% male) were included. Median baseline National Institutes of Health Stroke Scale (NIHSS) score was 24. Intravenous thrombolysis therapy (IVT) was administered in 56%. Successful recanalization assessed by a modified thrombolysis in cerebral infarction (TICI) score ≥2b was achieved in 82%. Independent outcome was observed in 30% of patients with successful recanalization, but in no patient with failed recanalization. Poor outcome was observed in 47% and 86%, respectively. Successful recanalization was associated with lower scores on the mRS at 90 days (p = 0.035), and failed recanalization was associated with an odds ratio of 13.6 for poor outcome (p = 0.036). CONCLUSION Reperfusion is the major predictor of functional outcome in BAO in clinical practice. Failed recanalization resulted in a 13-fold increase of the risk of poor outcome. Successful recanalization is crucial to achieve a better functional outcome in BAO.
Collapse
Affiliation(s)
- Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Fabian Flottmann
- Department of Neuroradiological Diagnostics and Intervention, University Medical Center Hamburg-Eppendorf, Martinistraße 52, Hamburg, Germany
| | - Hannes Leischner
- Department of Neuroradiological Diagnostics and Intervention, University Medical Center Hamburg-Eppendorf, Martinistraße 52, Hamburg, Germany
| | - Anna Alegiani
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Neuroradiological Diagnostics and Intervention, University Medical Center Hamburg-Eppendorf, Martinistraße 52, Hamburg, Germany
| | - Jens Fiehler
- Department of Neuroradiological Diagnostics and Intervention, University Medical Center Hamburg-Eppendorf, Martinistraße 52, Hamburg, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| |
Collapse
|
72
|
Broocks G, Kniep H, Schramm P, Hanning U, Flottmann F, Faizy T, Schönfeld M, Meyer L, Schön G, Aulmann L, Machner B, Royl G, Fiehler J, Kemmling A. Patients with low Alberta Stroke Program Early CT Score (ASPECTS) but good collaterals benefit from endovascular recanalization. J Neurointerv Surg 2019; 12:747-752. [DOI: 10.1136/neurintsurg-2019-015308] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Revised: 10/17/2019] [Accepted: 10/29/2019] [Indexed: 11/04/2022]
Abstract
BackgroundBenefit of thrombectomy in patients with a low initial Alberta Stroke Program Early CT Score (ASPECTS) is still uncertain. We hypothesized that, despite low ASPECTS, patients may benefit from endovascular recanalization if good collaterals are present.MethodsIschemic stroke patients with large vessel occlusion in the anterior circulation and an ASPECTS of ≤5 were analyzed. Collateral status (CS) was assessed using a 5-point-scoring system in CT angiography with poor CS defined as CS=0–1. Clinical outcome was determined using the modified Rankin Scale (mRS) score after 90 days. Edema formation was measured in admission and follow-up CT by net water uptake.Results27/100 (27%) patients exhibited a CS of 2–4. 50 patients underwent successful vessel recanalization and 50 patients had a persistent vessel occlusion. In multivariable logistic regression analysis, collateral status (OR 3.0; p=0.003) and vessel recanalization (OR 12.2; p=0.009) significantly increased the likelihood of a good outcome (mRS 0–3). A 1-point increase in CS was associated with 1.9% (95% CI 0.2% to 3.7%) lowered lesion water uptake in follow-up CT .ConclusionEndovascular recanalization in patients with ASPECTS of ≤5 but good collaterals was linked to improved clinical outcome and attenuated edema formation. Collateral status may serve as selection criterion for thrombectomy in low ASPECTS patients.
Collapse
|
73
|
Broocks G, Kemmling A, Aberle J, Kniep H, Bechstein M, Flottmann F, Leischner H, Faizy TD, Nawabi J, Schön G, Sporns P, Thomalla G, Fiehler J, Hanning U. Elevated blood glucose is associated with aggravated brain edema in acute stroke. J Neurol 2019; 267:440-448. [PMID: 31667625 DOI: 10.1007/s00415-019-09601-9] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2019] [Revised: 10/20/2019] [Accepted: 10/21/2019] [Indexed: 10/25/2022]
Abstract
BACKGROUND AND PURPOSE Clinical outcome after endovascular thrombectomy in patients with acute ischemic stroke still varies significantly. Higher blood glucose levels (BGL) have been associated with worse clinical outcome, but the pathophysiological causes are not yet understood. We hypothesized that higher levels of BGL are associated with more pronounced ischemic brain edema and worse clinical outcome mediated by cerebral collateral circulation. METHODS 178 acute ischemic stroke patients who underwent mechanical thrombectomy were included. Early ischemic brain edema was determined using quantitative lesion water uptake on initial computed tomography (CT) and collateral status was assessed with an established 5-point scoring system in CT-angiography. Good clinical outcome was defined as functional independence (modified Rankin Scale [mRS] score 0-2). Multivariable logistic regression analysis was performed to predict functional independence and linear regression analyses to investigate the impact of BGL and collateral status on water uptake. RESULTS The mean BGL at admission was significantly lower in patients with good outcome at 90 days (116.5 versus 138.5 mg/dl; p < 0.001) and early water uptake was lower (6.3% versus 9.6%; p < 0.001). The likelihood for good outcome declined with increasing BGL (odds ratio [OR] per 100 mg/dl BGL increase: 0.15; 95% CI 0.02-0.86; p = 0.039). Worse collaterals (1% water uptake per point, 95% CI 0.4-1.7%) and higher BGL (0.6% per 10 mg/dl BGL, 95% CI 0.3-0.8%) were significantly associated with increased water uptake. CONCLUSION Elevated admission BGL were associated with increased early brain edema and poor clinical outcome mediated by collateral status. Patients with higher BGL might be targeted by adjuvant anti-edematous treatment.
Collapse
Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
| | - Andre Kemmling
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany.,Faculty of Medicine Mannheim, University of Heidelberg, Heidelberg, Germany
| | - Jens Aberle
- Department of Endocrinology and Diabetology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Hannes Leischner
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Jawed Nawabi
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.,Department of Radiology, Charité University Medical Center, Berlin, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Sporns
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| |
Collapse
|
74
|
Nawabi J, Flottmann F, Kemmling A, Kniep H, Leischner H, Sporns P, Schön G, Hanning U, Thomalla G, Fiehler J, Broocks G. Elevated early lesion water uptake in acute stroke predicts poor outcome despite successful recanalization – When “tissue clock” and “time clock” are desynchronized. Int J Stroke 2019; 16:863-872. [DOI: 10.1177/1747493019884522] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background Ischemic water uptake in acute stroke is a reliable indicator of lesion age. Nevertheless, inter-individually varying edema progression has been observed and elevated water uptake has recently been described as predictor of malignant infarction. Aims We hypothesized that early-elevated lesion water uptake indicates accelerated “tissue clock” desynchronized with “time clock” and therefore predicts poor clinical outcome despite successful recanalization. Methods Acute middle cerebral artery stroke patients with multimodal admission-CT who received successful thrombectomy (TICI 2b/3) were analyzed. Net water uptake (NWU), a quantitative imaging biomarker of ischemic edema, was determined in admission-CT and tested as predictor of clinical outcome using modified Rankin Scale (mRS) after 90 days. A binary outcome was defined for mRS 0–4 and mRS 5–6. Results Seventy-two patients were included. The mean NWU (SD) in patients with mRS 0–4 was lower compared to patients with mRS 5–6 (5.0% vs. 12.1%; p < 0.001) with similar time from symptom onset to imaging (2.6 h vs. 2.4 h; p = 0.7). Based on receiver operating curve analysis, NWU above 10% identified patients with very poor outcome with high discriminative power (AUC 0.85), followed by Alberta Stroke Program Early CT Score (ASPECTS) (AUC: 0.72) and National Institutes of Health Stroke Scale (NIHSS) (AUC: 0.72). Conclusions Quantitative NWU may serve as an indicator of “tissue clock” and pronounced early brain edema with elevated NWU might suggest a desynchronized “tissue clock” with real “time clock” and therefore predict futile recanalization with poor clinical outcome.
Collapse
Affiliation(s)
- Jawed Nawabi
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andre Kemmling
- Department of Neuroradiology, University Hospital Münster, Münster, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hannes Leischner
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Sporns
- Department of Radiology, University Hospital Münster, Münster, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
75
|
Broocks G, Kemmling A, Aberle J, Kniep H, Bechstein M, Flottmann F, Leischner H, Faizy TD, Nawabi J, Schön G, Sporns P, Thomalla G, Fiehler J, Hanning U. Ischemic Lesion Water Uptake in Acute Stroke: Is Blood Glucose Related to Cause and Effect? J Stroke 2019; 21:347-349. [PMID: 31590479 PMCID: PMC6780013 DOI: 10.5853/jos.2019.01935] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2019] [Accepted: 08/12/2019] [Indexed: 12/03/2022] Open
Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andre Kemmling
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany.,Faculty of Medicine Mannheim, University of Heidelberg, Mannheim, Germany
| | - Jens Aberle
- Department of Endocrinology and Diabetology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hannes Leischner
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jawed Nawabi
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Sporns
- Department of Radiology, University Hospital Muenster, Muenster, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
76
|
Broocks G, Kniep H, Kemmling A, Flottmann F, Nawabi J, Elsayed S, Schön G, Thomalla G, Fiehler J, Hanning U. Effect of intravenous alteplase on ischaemic lesion water homeostasis. Eur J Neurol 2019; 27:376-383. [PMID: 31529738 DOI: 10.1111/ene.14088] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2019] [Accepted: 09/03/2019] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Intravenous (IV) lysis with alteplase is known to increase biomarkers of blood-brain barrier breakdown and has therefore been associated with secondary injuries such as hemorrhagic transformation. The impact of alteplase on brain edema formation, however, has not been investigated yet. The purpose was to examine the effects of IV alteplase on ischaemic lesion water homeostasis differentiated from final tissue infarct in patients with and without successful endovascular therapy (sET). METHODS In all, 232 middle cerebral artery stroke patients were analyzed. 147 patients received IV alteplase, of whom 106 patients received subsequent sET. Out of 85 patients without IV alteplase, 50 received sET. Ischaemic brain edema was quantified at admission and follow-up computed tomography using quantitative lesion net water uptake (NWU) and its difference was calculated (ΔNWU). The relationship of alteplase on ΔNWU and edema-corrected final infarct volume was analyzed using univariate and multivariate linear regression models. RESULTS The mean ΔNWU was 11.8% (SD 7.9) in patients with alteplase and 11.5% (SD 8.3) in patients without alteplase (P = 0.8). Alteplase was not associated with lowered ΔNWU whilst being associated with reduced edema-corrected tissue infarct volume [-27.4 ml, 95% confidence interval (CI) -49.4 to -5.4 ml; P = 0.02], adjusted for the Alberta Stroke Program Early Computed Tomography Score and recanalization status. In patients with sET, ΔNWU was 10.5% (95% CI 6.3%-10.5%) for patients with IV alteplase and 8.4% (95% CI 9.1%-12.0%) for patients without IV alteplase. CONCLUSION The application of IV alteplase did not significantly alter ischaemic lesion water homeostasis but was associated with reduced edema-corrected tissue infarct volume, which might be directly linked to improved functional outcome.
Collapse
Affiliation(s)
- G Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - H Kniep
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - A Kemmling
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany.,Faculty of Medicine Mannheim, University of Heidelberg, Heidelberg, Germany
| | - F Flottmann
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - J Nawabi
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - S Elsayed
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - G Schön
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - G Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - J Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - U Hanning
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
77
|
Flottmann F, Leischner H, Broocks G, Nawabi J, Bernhardt M, Faizy TD, Deb-Chatterji M, Thomalla G, Fiehler J, Brekenfeld C. Recanalization Rate per Retrieval Attempt in Mechanical Thrombectomy for Acute Ischemic Stroke. Stroke 2019; 49:2523-2525. [PMID: 30355115 DOI: 10.1161/strokeaha.118.022737] [Citation(s) in RCA: 72] [Impact Index Per Article: 14.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Background and Purpose- In acute ischemic stroke, mechanical thrombectomy allows flow restoration in the majority of cases. In case of an unsuccessful retrieval, little is known about how many retrieval attempts should be performed before stopping the procedure. This study assessed the recanalization rate and clinical outcome per retrieval maneuver. Methods- In this analysis, 330 patients with acute large vessel occlusion treated exclusively with stentrieval devices were included. Successful recanalization was defined as Thrombolysis in Cerebral Infarction 2b-3, a good clinical outcome was defined as modified Rankin Scale at 90 days of ≤2. Results- The median number of retrieval attempts was 1 (interquartile range, 1-2, maximum 8). Recanalization rates per retrieval attempt were highest for the first retrieval (46.8%) and lowest for the fifth retrieval (22.7%). After 3 retrieval attempts, 67.9% of patients were successfully recanalized. Patients with 1 to 3 retrieval attempts had higher rates of good clinical outcome (28.9% versus 7.4%; P=0.018). The number of passes was an independent negative predictor of good clinical outcome (adjusted odds ratio, 0.65; 95% CI, 0.435-0.970; P=0.035). Conclusions- Two-thirds of occlusions were successfully recanalized with up to 3 retrieval attempts. Further attempts had good recanalization rates, but the rate of favorable clinical outcome did not improve.
Collapse
Affiliation(s)
- Fabian Flottmann
- From the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (F.F., H.L., G.B., J.N., M.B., T.D., J.F., C.B.), University Medical Center Hamburg-Eppendorf, Germany
| | - Hannes Leischner
- From the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (F.F., H.L., G.B., J.N., M.B., T.D., J.F., C.B.), University Medical Center Hamburg-Eppendorf, Germany
| | - Gabriel Broocks
- From the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (F.F., H.L., G.B., J.N., M.B., T.D., J.F., C.B.), University Medical Center Hamburg-Eppendorf, Germany
| | - Jawed Nawabi
- From the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (F.F., H.L., G.B., J.N., M.B., T.D., J.F., C.B.), University Medical Center Hamburg-Eppendorf, Germany
| | - Martina Bernhardt
- From the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (F.F., H.L., G.B., J.N., M.B., T.D., J.F., C.B.), University Medical Center Hamburg-Eppendorf, Germany
| | - Tobias Djamsched Faizy
- From the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (F.F., H.L., G.B., J.N., M.B., T.D., J.F., C.B.), University Medical Center Hamburg-Eppendorf, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany (M.D.-C., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany (M.D.-C., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Jens Fiehler
- From the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (F.F., H.L., G.B., J.N., M.B., T.D., J.F., C.B.), University Medical Center Hamburg-Eppendorf, Germany
| | - Caspar Brekenfeld
- From the Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (F.F., H.L., G.B., J.N., M.B., T.D., J.F., C.B.), University Medical Center Hamburg-Eppendorf, Germany
| |
Collapse
|
78
|
Wollenweber FA, Tiedt S, Alegiani A, Alber B, Bangard C, Berrouschot J, Bode FJ, Boeckh-Behrens T, Bohner G, Bormann A, Braun M, Dorn F, Eckert B, Flottmann F, Hamann GF, Henn KH, Herzberg M, Kastrup A, Kellert L, Kraemer C, Krause L, Lehm M, Liman J, Lowens S, Mpotsaris A, Papanagiotou P, Petersen M, Petzold GC, Pfeilschifter W, Psychogios MN, Reich A, von Rennenberg R, Röther J, Schäfer JH, Siebert E, Siedow A, Solymosi L, Thonke S, Wagner M, Wunderlich S, Zweynert S, Nolte CH, Gerloff C, Thomalla G, Dichgans M, Fiehler J. Functional Outcome Following Stroke Thrombectomy in Clinical Practice. Stroke 2019; 50:2500-2506. [DOI: 10.1161/strokeaha.119.026005] [Citation(s) in RCA: 121] [Impact Index Per Article: 24.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background and Purpose—
Endovascular treatment for large vessel occlusion in ischemic stroke has proven to be effective in large clinical trials. We aimed to provide real-world estimates of endovascular treatment reperfusion rates and functional outcome on a countrywide scale.
Methods—
Two thousand seven hundred ninety-four patients with large vessel occlusion were included into an investigator-initiated, industry-independent, prospective registry in 25 sites in Germany between June 2015 and April 2018. The primary outcome was the score on the modified Rankin Scale ranging from zero (no symptoms) to 6 (death) at 3 months. Secondary analyses included the prediction of a good outcome (modified Rankin Scale, 0–2). Dichotomized analyses of predictors were performed using logistic regression adjusted for potential confounders.
Results—
Median age was 75 years (interquartile range, 64–82); median National Institutes of Health Stroke Scale score was 15 (interquartile range, 10–19). Vessel occlusion was in the anterior circulation in 2265 patients (88%) and in the posterior circulation in 303 patients (12%). Intravenous alteplase before endovascular treatment was given in 1457 patients (56%). Successful reperfusion was achieved in 2143 subjects (83%). At 3 months, 854 patients (37%) showed a good outcome; mortality was 29%. There was no difference between anterior and posterior circulation occlusions (
P
=0.27). Significant predictors for a good outcome were younger age (odds ratio [OR], 1.06; 95% CI, 1.05–1.07), no interhospital transfer (OR, 1.39; 95% CI, 1.03–1.88), lower stroke severity (OR, 1.10; 95% CI, 1.08–1.13), smaller infarct size (OR, 1.26; 95% CI, 1.15–1.39), alteplase use (OR, 1.49; 95% CI, 1.08–2.06), and reperfusion success (OR, 1.69; 95% CI, 1.45–1.96).
Conclusions—
High rates of favorable outcome can be achieved on a countrywide scale by endovascular treatment. Mortality appears to be greater in the daily routine than otherwise reported by authors of large randomized trials. There were no outcome differences between the anterior and posterior circulation.
Clinical Trial Registration—
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT03356392.
Collapse
Affiliation(s)
- Frank A. Wollenweber
- From the Institute for Stroke and Dementia Research (F.A.W., S.T., M.D.), Klinikum der Universität München, Ludwig-Maximilians-Universität LMU, Munich, Germany
- Department of Neurology (F.A.W., L. Kellert), Klinikum der Universität München, Ludwig-Maximilians-Universität LMU, Munich, Germany
| | - Steffen Tiedt
- From the Institute for Stroke and Dementia Research (F.A.W., S.T., M.D.), Klinikum der Universität München, Ludwig-Maximilians-Universität LMU, Munich, Germany
| | - Anna Alegiani
- Department of Neurology (A.A., C.G., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Burkhard Alber
- Department of Neurology, Bezirkskrankenhaus Günzburg, Germany (B.A., G.F.H.)
| | - Christopher Bangard
- Department of Radiology, Institut für Diagnostische und Interventionelle Radiologie (C.B.), Klinikum Hanau, Germany
| | - Jörg Berrouschot
- Department of Neurology (J.B.), Klinikum Altenburger Land, Germany
| | - Felix J. Bode
- Department of Neurology (F.J.B., G.C.P.), University Hospital Bonn, Germany
| | - Tobias Boeckh-Behrens
- Department of Neuroradiology, Klinikum rechts der Isar Technical University Munich, Germany (T.B.-B., M.L.)
| | - Georg Bohner
- Department of Neuroradiology, Institute of Neuroradiology (G.B., E.S.), Charite Universitary Medicine Berlin, Germany
| | - Albrecht Bormann
- Department of Neuroradiology (A.B.), Klinikum Altenburger Land, Germany
| | - Michael Braun
- Department of Radiology, Sektion Neuroradiologie Klinik für Diagnostische und Interventionelle Radiologie, Universitätsklinikum Ulm, BKH-Günzburg, Germany (M.B.)
| | - Franziska Dorn
- Department of Neuroradiology (F.D., M.H.), Klinikum der Universität München, Ludwig-Maximilians-Universität LMU, Munich, Germany
| | - Bernd Eckert
- Department of Neuroradiology, Institut für Radiologie und Neuroradiologie, Asklepios Klinik Altona, Hamburg, Germany (B.E.)
| | - Fabian Flottmann
- Department of Neuroradiology (F.F., J.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Gerhard F. Hamann
- Department of Neurology, Bezirkskrankenhaus Günzburg, Germany (B.A., G.F.H.)
| | - Karl-Heinz Henn
- Department of Neurology, Sana Klinikum Offenbach, Germany (K.-H.H., A.S.)
| | - Moriz Herzberg
- Department of Neuroradiology (F.D., M.H.), Klinikum der Universität München, Ludwig-Maximilians-Universität LMU, Munich, Germany
| | - Andreas Kastrup
- Department of Neurology, Klinikum Bremen Mitte, Germany (A.K.)
| | - Lars Kellert
- Department of Neurology (F.A.W., L. Kellert), Klinikum der Universität München, Ludwig-Maximilians-Universität LMU, Munich, Germany
| | | | - Lars Krause
- Department of Neurology (L. Krause, M.P.), Klinikum Osnabrück, Germany
| | - Manuel Lehm
- Department of Neuroradiology, Klinikum rechts der Isar Technical University Munich, Germany (T.B.-B., M.L.)
| | - Jan Liman
- Department of Neurology (J.L.), University Medical Center Goettingen, Germany
| | - Stephan Lowens
- Department of Radiology (S.L.), Klinikum Osnabrück, Germany
| | | | - Panagiotis Papanagiotou
- Department of Neuroradiology, Clinic for Diagnostic and Interventional Neuroradiology, Hospitals, Bremen-Mitte, Germany (P.P.)
| | - Martina Petersen
- Department of Neurology (L. Krause, M.P.), Klinikum Osnabrück, Germany
| | - Gabor C. Petzold
- Department of Neurology (F.J.B., G.C.P.), University Hospital Bonn, Germany
- German Center for Neurodegenerative Diseases, Bonn, Germany (G.C.P., M.D.)
| | - Waltraud Pfeilschifter
- Department of Neurology, University Hospital Frankfurt, Frankfurt am Main, Germany (W.P., J.-H.S.)
| | - Marios-Nikos Psychogios
- Department of Neuroradiology (M.-N.P.), University Medical Center Goettingen, Germany
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Switzerland (M.-N.P.)
| | - Arno Reich
- Department of Neurology (A.R.), RWTH Aachen University, Germany
| | - Regina von Rennenberg
- Department of Neurology (R.v.R., S.Z., C.H.N.), Charite Universitary Medicine Berlin, Germany
| | - Joachim Röther
- Department of Neurology, Neurologische Abteilung, Asklepios Klinik Altona, Hamburg, Germany (J.R.)
| | - Jan-Hendrik Schäfer
- Department of Neurology, University Hospital Frankfurt, Frankfurt am Main, Germany (W.P., J.-H.S.)
| | - Eberhard Siebert
- Department of Neuroradiology, Institute of Neuroradiology (G.B., E.S.), Charite Universitary Medicine Berlin, Germany
| | - Andreas Siedow
- Department of Neurology, Sana Klinikum Offenbach, Germany (K.-H.H., A.S.)
| | - Laszlo Solymosi
- Department of Neuroradiology (L.S.), University Hospital Bonn, Germany
| | - Sven Thonke
- Department of Neurology (S.T.), Klinikum Hanau, Germany
| | - Marlies Wagner
- Department of Neuroradiology, Institute of Diagnostic and Interventional Neuroradiology, Frankfurt am Main, Germany (M.W.)
| | - Silke Wunderlich
- Department of Neurology, Clinic and Policlinic for Neurology, Hospital of the Technical University Munich, Germany (S.W.)
| | - Sarah Zweynert
- Department of Neurology (R.v.R., S.Z., C.H.N.), Charite Universitary Medicine Berlin, Germany
| | - Christian H. Nolte
- Department of Neurology (R.v.R., S.Z., C.H.N.), Charite Universitary Medicine Berlin, Germany
| | - Christian Gerloff
- Department of Neurology (A.A., C.G., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Götz Thomalla
- Department of Neurology (A.A., C.G., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Martin Dichgans
- From the Institute for Stroke and Dementia Research (F.A.W., S.T., M.D.), Klinikum der Universität München, Ludwig-Maximilians-Universität LMU, Munich, Germany
- German Center for Neurodegenerative Diseases, Bonn, Germany (G.C.P., M.D.)
| | - Jens Fiehler
- Department of Neuroradiology (F.F., J.F.), University Medical Center Hamburg-Eppendorf, Germany
| |
Collapse
|
79
|
Broocks G, Flottmann F, Scheibel A, Aigner A, Faizy TD, Hanning U, Leischner H, Broocks SI, Fiehler J, Gellissen S, Kemmling A. Quantitative Lesion Water Uptake in Acute Stroke Computed Tomography Is a Predictor of Malignant Infarction. Stroke 2019; 49:1906-1912. [PMID: 29976584 DOI: 10.1161/strokeaha.118.020507] [Citation(s) in RCA: 97] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Early selection of patients with acute middle cerebral artery infarction at risk for malignant edema is critical to initiate timely decompressive surgery. Net water uptake (NWU) per brain volume is a quantitative imaging biomarker of space-occupying ischemic edema which can be measured in computed tomography. We hypothesize that NWU in early infarct lesions can predict development of malignant edema. The aim was to compare NWU in acute brain infarct against other common predictors of malignant edema. Methods- After consecutive screening of single-center registry data, 153 patients with acute proximal middle cerebral artery occlusion fulfilled the inclusion criteria. A total of 29 (18.2%) patients developed malignant edema defined as end point in follow-up imaging leading to decompressive surgery and death as a direct implication of mass effect. Early infarct lesion volume and NWU were quantified in multimodal admission computed tomography; time from symptom onset to admission imaging was recorded. Results- Mean time from onset to admission imaging was equivalent between patients with and without malignant infarcts (mean±SD: 3.3±1.4 hours and 3.3±1.7 hours, respectively). Edematous tissue expansion by NWU within infarct lesions occurred across all patients in this cohort (NWU: 9.1%±6.8%; median, 7.9%; interquartile range, 8.8%; range, 0.1%-35.6%); 7.0% (±5.2) in nonmalignant and 18.0% (±5.7) in malignant infarcts. Based on univariate receiver operating characteristic curve analysis, NWU >12.7% or an edema rate >3.7% NWU/h identified malignant infarcts with high discriminative power (area under curve, 0.93±0.02). In multivariate binary logistic regression, the probability of malignant infarct was significantly associated with early infarct volume and NWU. Conclusions- Computed tomography-based quantitative NWU in early infarct lesions is an important surrogate marker for developing malignant edema. Besides volume of early infarct, the measurements of lesion water uptake may further support identifying patients at risk for malignant infarction.
Collapse
Affiliation(s)
- Gabriel Broocks
- From the Department of Diagnostic and Interventional Neuroradiology (G.B., F.F., A.S., T.D.F., U.H., H.L., J.F., S.G., A.K.)
| | - Fabian Flottmann
- From the Department of Diagnostic and Interventional Neuroradiology (G.B., F.F., A.S., T.D.F., U.H., H.L., J.F., S.G., A.K.)
| | - Alexandra Scheibel
- From the Department of Diagnostic and Interventional Neuroradiology (G.B., F.F., A.S., T.D.F., U.H., H.L., J.F., S.G., A.K.)
| | - Annette Aigner
- Institute of Medical Biometry and Epidemiology (A.A.), University Medical Center Hamburg-Eppendorf, Germany
| | - Tobias D Faizy
- From the Department of Diagnostic and Interventional Neuroradiology (G.B., F.F., A.S., T.D.F., U.H., H.L., J.F., S.G., A.K.)
| | - Uta Hanning
- From the Department of Diagnostic and Interventional Neuroradiology (G.B., F.F., A.S., T.D.F., U.H., H.L., J.F., S.G., A.K.)
| | - Hannes Leischner
- From the Department of Diagnostic and Interventional Neuroradiology (G.B., F.F., A.S., T.D.F., U.H., H.L., J.F., S.G., A.K.)
| | - Sabine I Broocks
- Department of Radiology, Friedrich-Ebert-Hospital Neumuenster, Germany (S.I.B.)
| | - Jens Fiehler
- From the Department of Diagnostic and Interventional Neuroradiology (G.B., F.F., A.S., T.D.F., U.H., H.L., J.F., S.G., A.K.)
| | - Susanne Gellissen
- From the Department of Diagnostic and Interventional Neuroradiology (G.B., F.F., A.S., T.D.F., U.H., H.L., J.F., S.G., A.K.)
| | - Andre Kemmling
- From the Department of Diagnostic and Interventional Neuroradiology (G.B., F.F., A.S., T.D.F., U.H., H.L., J.F., S.G., A.K.).,Department of Neuroradiology, University Hospital Schleswig-Holstein, Luebeck, Germany (A.K.).,Department of Radiology, University Hospital Muenster, Germany (A.K.)
| |
Collapse
|
80
|
Nawabi J, Kniep H, Schön G, Flottmann F, Leischner H, Kabiri R, Sporns P, Kemmling A, Thomalla G, Fiehler J, Broocks G, Hanning U. Hemorrhage After Endovascular Recanalization in Acute Stroke: Lesion Extent, Collaterals and Degree of Ischemic Water Uptake Mediate Tissue Vulnerability. Front Neurol 2019; 10:569. [PMID: 31214107 PMCID: PMC6558047 DOI: 10.3389/fneur.2019.00569] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Accepted: 05/15/2019] [Indexed: 11/17/2022] Open
Abstract
Background and Purpose: Intracranial hemorrhage (ICH) remains a major complication of endovascular treatment (ET) in acute stroke. The aim of this study was to identify clinical and imaging predictors for ICH in patients with acute ischemic stroke undergoing successful ET. Methods: We performed a retrospective analysis of patients with large vessel occlusion in the anterior circulation who underwent successful ET at our university medical center between 2015 and 2018. ICH was diagnosed on non-enhanced CT and a binary outcome was defined: ICH occurrence in the immediate post-interventional phase within 12–36 h (yes/no). The impacts of clinical, radiological, and interventional parameters on outcome were assessed in logistic regression models. Results: One hundred and seven patients fulfilled the inclusion criteria. 37 (34.6%) showed an ICH of which 7 (6.5%) patients were diagnosed as symptomatic and 30 (28.04%) as asymptomatic. Multivariable regression analyses identified a lower ASPECTS (adjusted odds ratio (OR) 1.95, 95%CI: 1.4–3.63, P = 0.037), low collateral score (adjusted OR 0.12, 95%CI: 0.03–0.49, P = 0.003) and high Net Water Uptake (NWU) (adjusted OR 1.56, 95%CI: 2.34–1.03, P = 0.007) as independent predictors of ICH after successful ET. Conclusions: CT-based quantitative NWU, ASPECTS, and collateral score mediate tissue vulnerability and are reliable independent predictors of a bleeding event after successful ET. This imaging-based prediction model might be useful for early stratification of patients at high risk of a bleeding event after ET, especially with low ASPECTS.
Collapse
Affiliation(s)
- Jawed Nawabi
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hannes Leischner
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Reza Kabiri
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Sporns
- Department of Radiology, University Hospital Münster, Münster, Germany
| | - André Kemmling
- Department of Radiology, University Hospital Münster, Münster, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
81
|
Meyer L, Alexandrou M, Leischner H, Flottmann F, Deb-Chatterji M, Abdullayev N, Maus V, Politi M, Roth C, Kastrup A, Thomalla G, Mpotsaris A, Fiehler J, Papanagiotou P. Mechanical thrombectomy in nonagenarians with acute ischemic stroke. J Neurointerv Surg 2019; 11:1091-1094. [DOI: 10.1136/neurintsurg-2019-014785] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2019] [Revised: 03/15/2019] [Accepted: 03/19/2019] [Indexed: 11/04/2022]
Abstract
BackgroundMechanical thrombectomy (MT) is a safe and effective therapy for ischemic stroke. Nevertheless, very elderly patients aged ≥90 years were either excluded or under-represented in previous trials. It remains uncertain whether MT is warranted for this population or whether there should be an upper age limit.MethodsWe retrospectively reviewed 79 patients with stroke aged ≥90 years from three neurointerventional centers who underwent MT between 2013 and 2017. Good functional outcome was defined as modified Rankin scale (mRS) ≤2 and assessed at 90-day follow-up. Successful recanalization was graded by Thrombolysis in Cerebral Infarction Scale (TICI) ≥2 b. Feasibility and safety assessments included unsuccessful recanalization attempts (TICI 0), time from groin puncture to recanalization, symptomatic intracranial hemorrhage (sICH), mortality, and intervention-related serious adverse events.ResultsOnly occlusions within the anterior circulation were included. Median time from groin puncture to recanalization was 39 min (IQR 25–57 min). The rate of successful recanalization (TICI ≥2 b) was 69.6% (55/79). Good functional outcome (mRS ≤2) at 90 days was observed in 16% (12/75) of patients. In-hospital mortality was 29.1% (23/79) and increased significantly at 90 days (46.7%, 35/75; p<0.001). sICH occurred in 5.1% (4/79) of patients. No independent predictor for good functional outcome (mRS ≤2) at 90 days was identified through logistic regression analysis.ConclusionMT in nonagenarians leads to high mortality rates and less frequently good functional outcome compared with younger patient cohorts in previous large randomized trials. However, MT appears to be safe and beneficial for a certain number of very elderly patients and therefore should generally not be withheld from nonagenarians.
Collapse
|
82
|
Faizy TD, Broocks G, Thaler C, Rauch G, Gebert P, Stürner KH, Flottmann F, Leischner H, Kniep HC, Stellmann JP, Heesen C, Fiehler J, Gellißen S, Hanning U. Development of Cortical Lesion Volumes on Double Inversion Recovery MRI in Patients With Relapse-Onset Multiple Sclerosis. Front Neurol 2019; 10:133. [PMID: 30873106 PMCID: PMC6401630 DOI: 10.3389/fneur.2019.00133] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2019] [Accepted: 02/01/2019] [Indexed: 11/30/2022] Open
Abstract
Background and Objective: In multiple sclerosis (MS) patients, Double Inversion Recovery (DIR) magnetic resonance imaging (MRI) can be used to detect cortical lesions (CL). While the quantity and distribution of CLs seems to be associated with patients' disease course, literature lacks frequent assessments of CL volumes (CL-V) in this context. We investigated the reliability of DIR for the longitudinal assessment of CL-V development with frequent follow-up MRIs and examined the course of CL-V progressions in relation to white-matter lesions (WML), contrast enhancing lesions (CEL) and clinical parameters in patients with Relapsing-Remitting Multiple Sclerosis (RRMS). Methods: In this post-hoc analysis, image- and clinical data of a subset of 24 subjects that were part of a phase IIa clinical trial on the “Safety, Tolerability and Mechanisms of Action of Boswellic Acids in Multiple Sclerosis (SABA)” (ClinicalTrials.gov, NCT01450124) were included. The study was divided in three phases (screening, treatment, study-end). All patients received 12 MRI follow-up-examinations (including DIR) during a 16-months period. CL-Vs were assessed for each patient on each follow-up MRI separately by two experienced neuroradiologists. Results of neurological screening tests, as well as other MRI parameters (WML number and volume and CELs) were included from the SABA investigation data. Results: Inter-rater agreement regarding CL-V assessment over time was good-to-excellent (κ = 0.89). Mean intraobserver variability was 1.1%. In all patients, a total number of 218 CLs was found. Total CL-Vs of all patients increased during the 4 months of baseline screening followed by a continuous and significant decrease from month 5 until study-end (p < 0.001, Kendall'W = 0.413). A positive association between WML volumes and CL-Vs was observed during baseline screening. Decreased CL-V were associated with lower EDSS and also with improvements of SDMT- and SCRIPPS scores. Conclusion: DIR MRI seems to be a reliable tool for the frequent assessment of CL-Vs. Overall CL-Vs decreased during the follow-up period and were associated with improvements of cognitive and disability status scores. Our results suggest the presence of short-term CL-V dynamics in RRMS patients and we presume that the laborious evaluation of lesion volumes may be worthwhile for future investigations. Clinical Trial Numbers:www.ClinicalTrials.gov, “The SABA trial”; number: NCT01450124
Collapse
Affiliation(s)
- Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Thaler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Geraldine Rauch
- Institute of Medical Biometry and Epidemiology, Charité Berlin-University Medical Center, Berlin, Germany
| | - Pimrapat Gebert
- Institute of Medical Biometry and Epidemiology, Charité Berlin-University Medical Center, Berlin, Germany
| | - Klarissa H Stürner
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Institute of Neuroimmunology and Multiple Sclerosis, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Neurology, Christian-Albrechts University of Kiel, Kiel, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hannes Leischner
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge C Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan-Patrick Stellmann
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Institute of Neuroimmunology and Multiple Sclerosis, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Heesen
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Institute of Neuroimmunology and Multiple Sclerosis, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Gellißen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
83
|
Broocks G, Rajput F, Hanning U, Faizy TD, Leischner H, Schön G, Gellißen S, Sporns P, Deb-Chatterji M, Thomalla G, Kemmling A, Fiehler J, Flottmann F. Highest Lesion Growth Rates in Patients With Hyperacute Stroke: When Time Is Brain Particularly Matters. Stroke 2019; 50:189-192. [PMID: 30580711 DOI: 10.1161/strokeaha.118.023457] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- The early growth of ischemic lesions has been described as being nonlinear, with lesion growth rates at their highest during the earliest period after stroke onset. We hypothesized that the time gap from imaging to revascularization results in higher lesion growth in patients with hyperacute presentation. Methods- Fifty-one patients with ischemic stroke with initial multimodal computed tomography (CT), follow-up CT after 24 hours, and successful endovascular recanalization were included and separated into 2 groups according to their median time from symptom onset to imaging (eg, hyperacute versus acute). The difference in Alberta Stroke Program Early CT Score (ASPECTS) between initial CT and follow-up CT was assessed, as well as volumetric lesion growth from early ischemic core in admission perfusion CT and total lesion volume in follow-up CT. Results- The median time from onset to imaging was 1.85 hours. There was no significant difference in admission ASPECTS (mean, 8.5 versus 8.2) or time from imaging to recanalization in both groups (median, 2.7 versus 2.4 hours; P=0.4). The mean (SD) lesion growth assessed by ASPECTS difference was 2.7 (2.3) in the hyperacute group and 1.6 (1.3) in the acute group (P=0.03). The mean (SD) volumetric difference in the hyperacute group was 26.6 mL (43.2 mL) and 17.2 mL (26.3 mL; P=0.36) in the acute group, respectively. For every passing hour after onset, ASPECTS lesion growth was reduced by 0.4. Conclusions- Patients in the hyperacute phase showed increased ASPECTS lesion growth from imaging to recanalization suggesting a particular benefit of faster recanalization times in this group of patients with stroke.
Collapse
Affiliation(s)
- Gabriel Broocks
- From the Department of Diagnostic and Interventional Neuroradiology (G.B., F.R., U.H., T.D.F., H.L., S.G., J.F., F.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Furqan Rajput
- From the Department of Diagnostic and Interventional Neuroradiology (G.B., F.R., U.H., T.D.F., H.L., S.G., J.F., F.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Uta Hanning
- From the Department of Diagnostic and Interventional Neuroradiology (G.B., F.R., U.H., T.D.F., H.L., S.G., J.F., F.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Tobias Djamsched Faizy
- From the Department of Diagnostic and Interventional Neuroradiology (G.B., F.R., U.H., T.D.F., H.L., S.G., J.F., F.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Hannes Leischner
- From the Department of Diagnostic and Interventional Neuroradiology (G.B., F.R., U.H., T.D.F., H.L., S.G., J.F., F.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany
| | - Susanne Gellißen
- From the Department of Diagnostic and Interventional Neuroradiology (G.B., F.R., U.H., T.D.F., H.L., S.G., J.F., F.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Peter Sporns
- Department of Clinical Radiology, University Hospital Münster, Germany (P.S., A.K.)
| | - Milani Deb-Chatterji
- Department of Neurology (M.D.-C., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Götz Thomalla
- Department of Neurology (M.D.-C., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Andre Kemmling
- Department of Clinical Radiology, University Hospital Münster, Germany (P.S., A.K.)
| | - Jens Fiehler
- From the Department of Diagnostic and Interventional Neuroradiology (G.B., F.R., U.H., T.D.F., H.L., S.G., J.F., F.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Fabian Flottmann
- From the Department of Diagnostic and Interventional Neuroradiology (G.B., F.R., U.H., T.D.F., H.L., S.G., J.F., F.F.), University Medical Center Hamburg-Eppendorf, Germany
| |
Collapse
|
84
|
Leischner H, Flottmann F, Hanning U, Broocks G, Faizy TD, Deb-Chatterji M, Bernhardt M, Brekenfeld C, Buhk JH, Gellissen S, Thomalla G, Gerloff C, Fiehler J. Reasons for failed endovascular recanalization attempts in stroke patients. J Neurointerv Surg 2018; 11:439-442. [DOI: 10.1136/neurintsurg-2018-014060] [Citation(s) in RCA: 56] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Revised: 08/17/2018] [Accepted: 08/21/2018] [Indexed: 11/04/2022]
Abstract
PurposeMechanical thrombectomy (MT) is a highly effective therapy in patients with acute ischemic stroke due to large vessel occlusion (LVO). However, complete recanalization of the occluded vessel cannot be achieved in all patients, leading to poor clinical outcome. We analyzed the reasons for failed recanalization to help direct future improvements in therapy.Methods648 consecutive stroke patients with LVO and an MT attempt were retrospectively analyzed for none or minimal recanalization, assessed according to the Thrombolysis in Cerebral Infarction (TICI) score (0/1). Procedural parameters were evaluated in a standardized approach. Among other variables, number of retrieval attempts, devices, duration of the intervention, and rescue methods were analyzed.ResultsTICI 0/1 was observed in 72/648 patients (11%). In these patients, the thrombus could not be reached in 21% (n=15/72), was reached but not passed in 21% (n=15/72), and was reached and passed in 58% (n=42/72). Only a minor degree of initial recanalization was achieved in 19% (n=8/42) of patients with a reached occlusion during the course of the intervention. Furthermore, a higher number of passes with a single retriever device led to significant prolongation of the intervention. Therefore, major reasons for failed endovascular recanalization were difficult anatomical access and hard or resistant occlusions that might reflect hard thrombi or pre-existing atherosclerotic stenosis. Procedural complications such as dissection or perforation played a minor role.ConclusionIn stroke patients with failed MT attempts, approximately 60% of occlusions can be passed. In such cases, rescue therapy might be considered to improve recanalization and clinical outcome. Further development of access devices might help in the remaining cases where the microcatheter could not be manipulated to or through the occlusion.
Collapse
|
85
|
Faizy TD, Kumar D, Broocks G, Thaler C, Flottmann F, Leischner H, Kutzner D, Hewera S, Dotzauer D, Stellmann JP, Reddy R, Fiehler J, Sedlacik J, Gellißen S. Age-Related Measurements of the Myelin Water Fraction derived from 3D multi-echo GRASE reflect Myelin Content of the Cerebral White Matter. Sci Rep 2018; 8:14991. [PMID: 30301904 PMCID: PMC6177453 DOI: 10.1038/s41598-018-33112-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2017] [Accepted: 09/19/2018] [Indexed: 12/17/2022] Open
Abstract
Myelin Water Fraction (MWF) measurements derived from quantitative Myelin Water Imaging (MWI) may detect demyelinating changes of the cerebral white matter (WM) microstructure. Here, we investigated age-related alterations of the MWF in normal aging brains of healthy volunteers utilizing two fast and clinically feasible 3D gradient and spin echo (GRASE) MWI sequences with 3 mm and 5 mm isotropic voxel size. In 45 healthy subjects (age range: 18–79 years), distinct regions of interest (ROI) were defined in the cerebral WM including corticospinal tracts. For the 3 mm sequence, significant correlations of the mean MWF with age were found for most ROIs (r < −0.8 for WM ROIs; r = −0.55 for splenium of corpus callosum; r = −0.75 for genu of corpus callosum; p < 0.001 for all ROIs). Similar correlations with age were found for the ROIs of the 5 mm sequence. No significant correlations were found for the corticospinal tract and the occipital WM (p > 0.05). Mean MWF values obtained from the 3 mm and 5 mm sequences were strongly comparable. The applied 3D GRASE MWI sequences were found to be sensitive for age-dependent myelin changes of the cerebral WM microstructure. The reported MWF values might be of substantial use as reference for further investigations in patient studies.
Collapse
Affiliation(s)
- Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Dushyant Kumar
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Thaler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hannes Leischner
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel Kutzner
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Simon Hewera
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dominik Dotzauer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan-Patrick Stellmann
- Institute of Neuroimmunology und Multiple Sclerosis, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ravinder Reddy
- Department of Radiology, University of Pennsylvania, Philadelphia, USA
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Sedlacik
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Gellißen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
86
|
Gruber P, Zeller S, Garcia-Esperon C, Berberat J, Anon J, Diepers M, Nedeltchev K, Flottmann F, Fiehler J, Remonda L, Kahles T. Embolus Retriever with Interlinked Cages versus other stent retrievers in acute ischemic stroke: an observational comparative study. J Neurointerv Surg 2018; 10:e31. [DOI: 10.1136/neurintsurg-2018-013838] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Revised: 04/16/2018] [Accepted: 05/01/2018] [Indexed: 11/04/2022]
Abstract
Background and purposeGiven the promising performance of the new Embolus Retriever with Interlinked Cages (ERIC) in smaller case series, we sought to assess the efficacy and safety of mechanical thrombectomy (MT) with ERIC compared with other stent retrievers (SRs) in acute ischemic stroke due to large vessel occlusion (LVO).MethodsWe reviewed the databases of two comprehensive stroke centers in in Germany and Switzerland for MT due to LVO in the anterior circulation with either ERIC or another SR as a first device. Co-primary outcome was defined as successful recanalization (Thrombolysis in Cerebral Infarction 2b/3) after the first device and favorable outcome (modified Rankin Scale score 0–2) at 90 days' follow-up. Multiple logistic regression analysis was applied to adjust for potential confounders.Results183 consecutive patients with stroke were treated with either ERIC (49%) or a SR (51%) as the first device and successful recanalization was seen in 82% and 57%, respectively (P<0.001). Adding SR to futile ERIC recanalization or vice versa increased final recanalization rates (ERIC: 87%, SR: 79%). The use of ERIC as a first device resulted in favorable clinical outcome in 50% compared with 35% when a SR was used (P=0.038), an effect driven by age, stroke severity, presence of carotid-T-occlusion, and general anesthesia and not by the device deployed.ConclusionThe use of ERIC as a first device appeared to be associated with higher rates of successful recanalization and resulted in better functional outcome. However, favorable outcome was not attributable to ERIC. Most importantly, both device types complemented one another and improved final recanalization rates when used successively.
Collapse
|
87
|
Brekenfeld C, Goebell E, Schmidt H, Henningsen H, Kraemer C, Tebben J, Flottmann F, Thomalla G, Fiehler J. ‘Drip-and-drive’: shipping the neurointerventionalist to provide mechanical thrombectomy in primary stroke centers. J Neurointerv Surg 2018; 10:932-936. [DOI: 10.1136/neurintsurg-2017-013634] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2017] [Revised: 01/21/2018] [Accepted: 01/24/2018] [Indexed: 11/03/2022]
Abstract
BackgroundTo satisfy the increasing demand of mechanical thrombectomy (MT) for acute ischemic stroke treatment, new organizational concepts for patient care are required. This study evaluates time intervals of acute stroke management in two stroke care models, including one based on transportation of the interventionalist from a comprehensive stroke center (CSC) to treat patients in two primary stroke centers (PSC). We hypothesized that time intervals were not inferior for the ‘drip-and-drive’ concept compared with the traditional ‘drip-and-ship’ concept.MethodsPatients treated with MT at the PSC (‘drip-and-drive’, ‘D+D group’) were compared with patients transferred from PSC to CSC for MT (‘drip-and-ship’, ‘D+S group’) with regard to time delays. Time intervals assessed were: symptom onset to initial CT, to angiography, and to recanalization; time from initial CT to telephone call activation, to arrival, and to angiography; and time from telephone call activation to arrival and from arrival to angiography.Results42 patients were treated at the PSC after transfer of the interventionalist, and 32 patients were transferred to the CSC for MT. The groups did not differ with regard to median Onset–CT and CT–Phone times. Significant differences between the groups were found for the primary outcome measure CT–Arrival time (‘D+D group’: median 121 (IQR 108–134) min vs 181 (157–219) min for the ‘D+S group’; P<0.001). Time difference between the groups increased to more than 2 hours for median CT–Angio times (median 123 (IQR 93–147) min vs 252 (228–275) min; P<0.001).ConclusionTime intervals for the ‘D+D group’ were not inferior to those of the ‘D+S group’. Moreover, under certain conditions, the ‘drip-and-drive’ concept might even be superior.
Collapse
|
88
|
Kemmling A, Flottmann F, Forkert ND, Minnerup J, Heindel W, Thomalla G, Eckert B, Knauth M, Psychogios M, Langner S, Fiehler J. Multivariate dynamic prediction of ischemic infarction and tissue salvage as a function of time and degree of recanalization. J Cereb Blood Flow Metab 2015; 35:1397-405. [PMID: 26154867 PMCID: PMC4640330 DOI: 10.1038/jcbfm.2015.144] [Citation(s) in RCA: 51] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2015] [Revised: 04/01/2015] [Accepted: 04/02/2015] [Indexed: 01/19/2023]
Abstract
Benefit of endovascular recanalization beyond established treatment time windows likely exists in select stroke patients. However, there is currently no imaging model that predicts infarction adjusting for elapsed time between the pathologic snapshot of admission imaging until endovascular recanalization. We trained and cross validated a multivariate generalized linear model (GLM) that uses computer tomography perfusion and clinical data to quantify patient-specific dynamic change of tissue infarction depending on degree and time of recanalization. Multicenter data of 161 patients with proximal anterior circulation occlusion undergoing endovascular therapy were included. Multivariate voxelwise infarct probability was calculated within the GLM. The effect of increasing time to treatment and degree of recanalization on voxelwise infarction was calculated in each patient. Tissue benefit of successful relative to unsuccessful recanalization was shown up to 15 hours after onset in individual patients and decreased nonlinearly with time. On average, the relative reduction of infarct volume at the treatment interval of 5 hours was 53% and this salvage effect decreased by 5% units per hour to <5% after 10 additional hours to treatment. Treatment time-adjusted multivariate prediction of infarction by perfusion and clinical status may identify patients who benefit from extended time to recanalization therapy.
Collapse
Affiliation(s)
- André Kemmling
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Clinical Radiology, University of Muenster, Muenster, Germany.,Institute of Neuroradiology, University Medical Center Schleswig Holstein, Lübeck, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nils Daniel Forkert
- Department of Radiology and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Jens Minnerup
- Department of Neurology, University of Muenster, Muenster, Germany
| | - Walter Heindel
- Department of Clinical Radiology, University of Muenster, Muenster, Germany
| | - Goetz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernd Eckert
- Department of Neuroradiology, Asklepios Hospital Altona, Hamburg, Germany
| | - Michael Knauth
- Department of Neuroradiology, University of Medicine Goettingen, Goettingen, Germany
| | - Marios Psychogios
- Department of Neuroradiology, University of Medicine Goettingen, Goettingen, Germany
| | - Soenke Langner
- Institute of Diagnostic Radiology and Neuroradiology, University of Medicine Greifswald, Greifswald, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|