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Zoetmulder R, Konduri PR, Obdeijn IV, Gavves E, Išgum I, Majoie CB, Dippel DW, Roos YB, Goyal M, Mitchell PJ, Campbell BCV, Lopes DK, Reimann G, Jovin TG, Saver JL, Muir KW, White P, Bracard S, Chen B, Brown S, Schonewille WJ, van der Hoeven E, Puetz V, Marquering HA. Automated Final Lesion Segmentation in Posterior Circulation Acute Ischemic Stroke Using Deep Learning. Diagnostics (Basel) 2021; 11:1621. [PMID: 34573963 PMCID: PMC8466415 DOI: 10.3390/diagnostics11091621] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Revised: 08/25/2021] [Accepted: 08/30/2021] [Indexed: 11/17/2022] Open
Abstract
Final lesion volume (FLV) is a surrogate outcome measure in anterior circulation stroke (ACS). In posterior circulation stroke (PCS), this relation is plausibly understudied due to a lack of methods that automatically quantify FLV. The applicability of deep learning approaches to PCS is limited due to its lower incidence compared to ACS. We evaluated strategies to develop a convolutional neural network (CNN) for PCS lesion segmentation by using image data from both ACS and PCS patients. We included follow-up non-contrast computed tomography scans of 1018 patients with ACS and 107 patients with PCS. To assess whether an ACS lesion segmentation generalizes to PCS, a CNN was trained on ACS data (ACS-CNN). Second, to evaluate the performance of only including PCS patients, a CNN was trained on PCS data. Third, to evaluate the performance when combining the datasets, a CNN was trained on both datasets. Finally, to evaluate the performance of transfer learning, the ACS-CNN was fine-tuned using PCS patients. The transfer learning strategy outperformed the other strategies in volume agreement with an intra-class correlation of 0.88 (95% CI: 0.83-0.92) vs. 0.55 to 0.83 and a lesion detection rate of 87% vs. 41-77 for the other strategies. Hence, transfer learning improved the FLV quantification and detection rate of PCS lesions compared to the other strategies.
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Tolhuisen ML, Ernst M, Boers AMM, Brown S, Beenen LFM, Guillemin F, Roos YBWEM, Saver JL, van Oostenbrugge R, Demchuck AM, van Zwam W, Jovin TG, Berkhemer OA, Muir KW, Bracard S, Campbell BCV, van der Lugt A, White P, Hill MD, Dippel DWJ, Mitchell PJ, Goyal M, Caan MWA, Marquering HA, Majoie CBLM. Value of infarct location in the prediction of functional outcome in patients with an anterior large vessel occlusion: results from the HERMES study. Neuroradiology 2021; 64:521-530. [PMID: 34476512 PMCID: PMC8850210 DOI: 10.1007/s00234-021-02784-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 08/01/2021] [Indexed: 11/22/2022]
Abstract
Purpose Follow-up infarct volume (FIV) is moderately associated with functional outcome. We hypothesized that accounting for infarct location would strengthen the association of FIV with functional outcome. Methods We included 252 patients from the HERMES collaboration with follow-up diffusion weighted imaging. Patients received endovascular treatment combined with best medical management (n = 52%) versus best medical management alone (n = 48%). FIV was quantified in low, moderate and high modified Rankin Scale (mRS)-relevant regions. We used binary logistic regression to study the relation between the total, high, moderate or low mRS-relevant FIVs and favorable outcome (mRS < 2) after 90 days. The strength of association was evaluated using the c-statistic. Results Small lesions only occupied high mRS-relevant brain regions. Lesions additionally occupied lower mRS-relevant brain regions if FIV expanded. Higher FIV was associated with a higher risk of unfavorable outcome, as were volumes of tissue with low, moderate and high mRS relevance. In multivariable modeling, only the volume of high mRS-relevant infarct was significantly associated with favorable outcome. The c-statistic was highest (0.76) for the models that included high mRS-relevant FIV or the combination of high, moderate and low mRS-relevant FIV but was not significantly different from the model that included only total FIV (0.75). Conclusion This study confirms the association of FIV and unfavorable functional outcome but showed no strengthened association if lesion location was taken into account.
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Ng FC, Yassi N, Sharma G, Brown SB, Goyal M, Majoie CBLM, Jovin TG, Hill MD, Muir KW, Saver JL, Guillemin F, Demchuk AM, Menon BK, San Roman L, Liebeskind DS, White P, Dippel DWJ, Davalos A, Bracard S, Mitchell PJ, Wald MJ, Davis SM, Sheth KN, Kimberly WT, Campbell BCV. Cerebral Edema in Patients With Large Hemispheric Infarct Undergoing Reperfusion Treatment: A HERMES Meta-Analysis. Stroke 2021; 52:3450-3458. [PMID: 34384229 DOI: 10.1161/strokeaha.120.033246] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Whether reperfusion into infarcted tissue exacerbates cerebral edema has treatment implications in patients presenting with extensive irreversible injury. We investigated the effects of endovascular thrombectomy and reperfusion on cerebral edema in patients presenting with radiological evidence of large hemispheric infarction at baseline. METHODS In a systematic review and individual patient-level meta-analysis of 7 randomized controlled trials comparing thrombectomy versus medical therapy in anterior circulation ischemic stroke published between January 1, 2010, and May 31, 2017 (Highly Effective Reperfusion Using Multiple Endovascular Devices collaboration), we analyzed the association between thrombectomy and reperfusion with maximal midline shift (MLS) on follow-up imaging as a measure of the space-occupying effect of cerebral edema in patients with large hemispheric infarction on pretreatment imaging, defined as diffusion-magnetic resonance imaging or computed tomography (CT)-perfusion ischemic core 80 to 300 mL or noncontrast CT-Alberta Stroke Program Early CT Score ≤5. Risk of bias was assessed using the Cochrane tool. RESULTS Among 1764 patients, 177 presented with large hemispheric infarction. Thrombectomy and reperfusion were associated with functional improvement (thrombectomy common odds ratio =2.30 [95% CI, 1.32-4.00]; reperfusion common odds ratio =4.73 [95% CI, 1.66-13.52]) but not MLS (thrombectomy β=-0.27 [95% CI, -1.52 to 0.98]; reperfusion β=-0.78 [95% CI, -3.07 to 1.50]) when adjusting for age, National Institutes of Health Stroke Score, glucose, and time-to-follow-up imaging. In an exploratory analysis of patients presenting with core volume >130 mL or CT-Alberta Stroke Program Early CT Score ≤3 (n=76), thrombectomy was associated with greater MLS after adjusting for age and National Institutes of Health Stroke Score (β=2.76 [95% CI, 0.33-5.20]) but not functional improvement (odds ratio, 1.71 [95% CI, 0.24-12.08]). CONCLUSIONS In patients presenting with large hemispheric infarction, thrombectomy and reperfusion were not associated with MLS, except in the subgroup with very large core volume (>130 mL) in whom thrombectomy was associated with increased MLS due to space-occupying ischemic edema. Mitigating cerebral edema-mediated secondary injury in patients with very large infarcts may further improve outcomes after reperfusion therapies.
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Kappelhof M, Tolhuisen ML, Treurniet KM, Dutra BG, Alves H, Zhang G, Brown S, Muir KW, Dávalos A, Roos YBWEM, Saver JL, Demchuk AM, Jovin TG, Bracard S, Campbell BCV, van der Lugt A, Guillemin F, White P, Hill MD, Dippel DWJ, Mitchell PJ, Goyal M, Marquering HA, Majoie CBLM. Endovascular Treatment Effect Diminishes With Increasing Thrombus Perviousness: Pooled Data From 7 Trials on Acute Ischemic Stroke. Stroke 2021; 52:3633-3641. [PMID: 34281377 PMCID: PMC8547583 DOI: 10.1161/strokeaha.120.033124] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose: Thrombus perviousness estimates residual flow along a thrombus in acute ischemic stroke, based on radiological images, and may influence the benefit of endovascular treatment for acute ischemic stroke. We aimed to investigate potential endovascular treatment (EVT) effect modification by thrombus perviousness. Methods: We included 443 patients with thin-slice imaging available, out of 1766 patients from the pooled HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke trials) data set of 7 randomized trials on EVT in the early window (most within 8 hours). Control arm patients (n=233) received intravenous alteplase if eligible (212/233; 91%). Intervention arm patients (n=210) received additional EVT (prior alteplase in 178/210; 85%). Perviousness was quantified by thrombus attenuation increase on admission computed tomography angiography compared with noncontrast computed tomography. Multivariable regression analyses were performed including multiplicative interaction terms between thrombus attenuation increase and treatment allocation. In case of significant interaction, subgroup analyses by treatment arm were performed. Our primary outcome was 90-day functional outcome (modified Rankin Scale score), resulting in an adjusted common odds ratio for a one-step shift towards improved outcome. Secondary outcomes were mortality, successful reperfusion (extended Thrombolysis in Cerebral Infarction score, 2B–3), and follow-up infarct volume (in mL). Results: Increased perviousness was associated with improved functional outcome. After adding a multiplicative term of thrombus attenuation increase and treatment allocation, model fit improved significantly (P=0.03), indicating interaction between perviousness and EVT benefit. Control arm patients showed significantly better outcomes with increased perviousness (adjusted common odds ratio, 1.2 [95% CI, 1.1–1.3]). In the EVT arm, no significant association was found (adjusted common odds ratio, 1.0 [95% CI, 0.9–1.1]), and perviousness was not significantly associated with successful reperfusion. Follow-up infarct volume (12% [95% CI, 7.0–17] per 5 Hounsfield units) and chance of mortality (adjusted odds ratio, 0.83 [95% CI, 0.70–0.97]) decreased with higher thrombus attenuation increase in the overall population, without significant treatment interaction. Conclusions: Our study suggests that the benefit of best medical care including alteplase, compared with additional EVT, increases in patients with more pervious thrombi.
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Venema E, Roozenbeek B, Mulder MJHL, Brown S, Majoie CBLM, Steyerberg EW, Demchuk AM, Muir KW, Dávalos A, Mitchell PJ, Bracard S, Berkhemer OA, Lycklama À Nijeholt GJ, van Oostenbrugge RJ, Roos YBWEM, van Zwam WH, van der Lugt A, Hill MD, White P, Campbell BCV, Guillemin F, Saver JL, Jovin TG, Goyal M, Dippel DWJ, Lingsma HF. Prediction of Outcome and Endovascular Treatment Benefit: Validation and Update of the MR PREDICTS Decision Tool. Stroke 2021; 52:2764-2772. [PMID: 34266308 PMCID: PMC8378416 DOI: 10.1161/strokeaha.120.032935] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose: Benefit of early endovascular treatment (EVT) for ischemic stroke varies considerably among patients. The MR PREDICTS decision tool, derived from MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands), predicts outcome and treatment benefit based on baseline characteristics. Our aim was to externally validate and update MR PREDICTS with data from international trials and daily clinical practice. Methods: We used individual patient data from 6 randomized controlled trials within the HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) collaboration to validate the original model. Then, we updated the model and performed a second validation with data from the observational MR CLEAN Registry. Primary outcome was functional independence (defined as modified Rankin Scale score 0–2) 3 months after stroke. Treatment benefit was defined as the difference between the probability of functional independence with and without EVT. Discriminative performance was evaluated using a concordance (C) statistic. Results: We included 1242 patients from HERMES (633 assigned to EVT, 609 assigned to control) and 3156 patients from the MR CLEAN Registry (all of whom underwent EVT within 6.5 hours). The C-statistic for functional independence was 0.74 (95% CI, 0.72–0.77) in HERMES and, after model updating, 0.80 (0.78–0.82) in the Registry. Median predicted treatment benefit of routinely treated patients (Registry) was 10.3% (interquartile range, 5.8%–14.4%). Patients with low (<1%) predicted treatment benefit (n=135/3156 [4.3%]) had low rates of functional independence, irrespective of reperfusion status, suggesting potential absence of treatment benefit. The updated model was made available online for clinicians and researchers at www.mrpredicts.com. Conclusions: Because of the substantial treatment effect and small potential harm of EVT, most patients arriving within 6 hours at an endovascular-capable center should be treated regardless of their clinical characteristics. MR PREDICTS can be used to support clinical judgement when there is uncertainty about the treatment indication, when resources are limited, or before a patient is to be transferred to an endovascular-capable center.
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Chandran M, Mitchell PJ, Amphansap T, Bhadada SK, Chadha M, Chan DC, Chung YS, Ebeling P, Gilchrist N, Habib Khan A, Halbout P, Hew FL, Lan HPT, Lau TC, Lee JK, Lekamwasam S, Lyubomirsky G, Mercado-Asis LB, Mithal A, Nguyen TV, Pandey D, Reid IR, Suzuki A, Chit TT, Tiu KL, Valleenukul T, Yung CK, Zhao YL. Publisher Correction to: Development of the Asia Pacific Consortium on Osteoporosis (APCO) framework: clinical standards of care for the screening, diagnosis, and management of osteoporosis in the Asia-Pacific region. Osteoporos Int 2021; 32:1277-1278. [PMID: 34043033 PMCID: PMC8192350 DOI: 10.1007/s00198-021-05953-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Chandran M, Mitchell PJ, Amphansap T, Bhadada SK, Chadha M, Chan DC, Chung YS, Ebeling P, Gilchrist N, Habib Khan A, Halbout P, Hew FL, Lan HPT, Lau TC, Lee JK, Lekamwasam S, Lyubomirsky G, Mercado-Asis LB, Mithal A, Nguyen TV, Pandey D, Reid IR, Suzuki A, Chit TT, Tiu KL, Valleenukul T, Yung CK, Zhao YL. Development of the Asia Pacific Consortium on Osteoporosis (APCO) Framework: clinical standards of care for the screening, diagnosis, and management of osteoporosis in the Asia-Pacific region. Osteoporos Int 2021; 32:1249-1275. [PMID: 33502559 PMCID: PMC8192320 DOI: 10.1007/s00198-020-05742-0] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2020] [Accepted: 11/11/2020] [Indexed: 01/07/2023]
Abstract
UNLABELLED Guidelines for doctors managing osteoporosis in the Asia-Pacific region vary widely. We compared 18 guidelines for similarities and differences in five key areas. We then used a structured consensus process to develop clinical standards of care for the diagnosis and management of osteoporosis and for improving the quality of care. PURPOSE Minimum clinical standards for assessment and management of osteoporosis are needed in the Asia-Pacific (AP) region to inform clinical practice guidelines (CPGs) and to improve osteoporosis care. We present the framework of these clinical standards and describe its development. METHODS We conducted a structured comparative analysis of existing CPGs in the AP region using a "5IQ" model (identification, investigation, information, intervention, integration, and quality). One-hundred data elements were extracted from each guideline. We then employed a four-round Delphi consensus process to structure the framework, identify key components of guidance, and develop clinical care standards. RESULTS Eighteen guidelines were included. The 5IQ analysis demonstrated marked heterogeneity, notably in guidance on risk factors, the use of biochemical markers, self-care information for patients, indications for osteoporosis treatment, use of fracture risk assessment tools, and protocols for monitoring treatment. There was minimal guidance on long-term management plans or on strategies and systems for clinical quality improvement. Twenty-nine APCO members participated in the Delphi process, resulting in consensus on 16 clinical standards, with levels of attainment defined for those on identification and investigation of fragility fractures, vertebral fracture assessment, and inclusion of quality metrics in guidelines. CONCLUSION The 5IQ analysis confirmed previous anecdotal observations of marked heterogeneity of osteoporosis clinical guidelines in the AP region. The Framework provides practical, clear, and feasible recommendations for osteoporosis care and can be adapted for use in other such vastly diverse regions. Implementation of the standards is expected to significantly lessen the global burden of osteoporosis.
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Cooley SR, Zhao H, Campbell BCV, Churilov L, Coote S, Easton D, Langenberg F, Stephenson M, Yan B, Desmond PM, Mitchell PJ, Parsons MW, Donnan GA, Davis SM, Yassi N. Mobile Stroke Units Facilitate Prehospital Management of Intracerebral Hemorrhage. Stroke 2021; 52:3163-3166. [PMID: 34187178 DOI: 10.1161/strokeaha.121.034592] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Mobile stroke units (MSUs) improve reperfusion therapy times in acute ischemic stroke (AIS). However, prehospital management options for intracerebral hemorrhage (ICH) are less established. We describe the initial Melbourne MSU experience in ICH. METHODS Consecutive patients with ICH and AIS treated by the Melbourne MSU were included. We describe demographics, proportions of patients receiving specific therapies, and bypass to comprehensive/neurosurgical centers. We also compare operational time metrics between patients with MSU-ICH and MSU-AIS. RESULTS During a 2-year period, the Melbourne MSU managed 49 patients with ICH, mean (SD) age 74 (12) years, median (interquartile range) National Institutes of Health Stroke Scale 17 (12-20). Intravenous antihypertensives were the commonest treatment provided (46.9%). Bypass of a primary center to a comprehensive center with neurosurgical expertise occurred in 32.7% of patients with MSU-ICH compared with 20.5% of patients with MSU-AIS. Compared with patients with MSU-AIS, patients with MSU-ICH had faster onset-to-emergency-call, and onset-to-scene-arrival times at the median and 75th percentiles. CONCLUSIONS MSUs can facilitate ultra-early ICH diagnosis, management, and triage.
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Almekhlafi MA, GOYAL MAYANK, Dippel DW, Majoie CB, Campbell B, Muir KW, Demchuk AM, Bracard S, guillemin F, Jovin TG, Mitchell PJ, White P, Hill MD, Brown S, Saver JL. Abstract 17: Time-Benefit Association is Magnified in Door-To-Puncture Window: Lose 1 Second, Lose 2.2 Hours of Healthy Life. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.17] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
The benefits of endovascular thrombectomy (EVT) are time dependent. Prior studies may have underestimated the magnitude of the time-benefit relation because time of onset (last known well ”LKW”) is imprecisely known, and analyses including late-arriving patients have under-representation of “fast-progressors.”
Methods:
Patient level data were pooled by the HERMES Investigators from all 7 RCTs of stent retriever thrombectomy devices (entirely or predominantly) versus medical therapy. Analysis was confined to early-treated patients (LKW-to-puncture≤4h). Exposures: last known well-to-door (LKWTD) time; door-to-puncture (DTP) time; door-to-reperfusion (DTR) time. Outcomes: stroke-related quality of life at 3m (utility-weighted modified Rankin Scale); years of healthy life lost [disability-adjusted life years (DALYs)].
Results:
Among the 781 EVT-treated patients, 406 (52.0%) were treated within 4h of LKW, with LKW-to-Door time median 188 minutes (IQR 151-215) and DTP time 105 minutes (IQR 76-135). Among the 295/372 (79.3%) with substantial reperfusion, DTR time was median 145 minutes (IQR 111-186). Care process delays were more strongly associated with worse clinical outcomes in the DTP and DTR epochs than the LKW-To-Door epoch (Table 1A), e.g., for each 10 minute delay, healthy life-years lost were: DTP 1.8 months vs LKW-to-Door 0.0 months, p < 0.0001. Considering granular time increments, the amount of healthy life-years lost associated with each 1 second of delay was: DTP 2.2 hours, DTR 2.1 hours.(Table 1B)
Conclusion:
Post-arrival care delays are strongly associated with worse EVT patient outcomes in the early post-arrival time period. With every 1 second of delay in EVT delivery, patients lose 2.2 hours of healthy life-years. Continuous quality improvement to minimize delays in DTP and DTR for endovascular thrombectomy is warranted.
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Sarraj A, Ribo M, Blasco J, Perez de la Ossa N, Chen M, Hassan AE, Wu TY, Cordato D, Kleinig TJ, Schaafsma JD, Blackburn S, Abraham MG, Gibson D, Wallace A, Pujara D, Shaker F, Moreno Negrete J, Beharry J, Cappelen-Smith C, Rodríguez-Esparragoza L, Olivé Gadea M, Requena M, Pereira V, Day AL, Sitton C, Martin-schild SB, Song S, Mitchell PJ, Parsons M, Grotta JC, Albers G. Abstract P473: Perfusion Imaging Identifies Patients With Mild Deficits Due to Large Vessel Occlusion Who May Benefit From Endovascular Thrombectomy: A Pooled International Cohort Study. Stroke 2021. [DOI: 10.1161/str.52.suppl_1.p473] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background:
Efficacy and safety of endovascular thrombectomy (EVT) in large vessel occlusion (LVO) patients with mild deficits is unclear.
Methods:
Pooled cohort of pts with mild deficits (NIHSS<6) due to (ICA, M1, M2) LVO from EXTEND IA TNK I & II RCTs and prospective data from 12 centers (US, AUS, NZ, Canada, Spain) from 1/2013 to 2/2020 was divided into medical management (MM) vs EVT. All pts had baseline CT, CTA, CTPRAPID software estimated ischemic core and mismatch. Pts stratified into with or without target profile (≥1cc core / mismatch ratio ≥ 1.8 / mismatch volume ≥ 15cc). Primary outcome- excellent (90 day mRS 0-1); Secondary- mRS shift, safety (sICH, neuro-worsening, mortality).
Results:
Of 371 pts, 189 (51%) had EVT. Time LKW to EVT center: EVT 165 (70- 416) vs MM 200 (72-564) min, p=0.35 were similar. EVT pts had larger perfusion lesions (51 cc (23-86) vs 30.1 (5, 65), p<0.001), higher NIHSS 4 (2-5) vs 3 (2-4), p=0.009), less IV tPA (30% vs 41%, p=0.044), more M1s (44% vs 29%, p<0.001). 93 pts (25%) had target profile, of whom 60% had EVT. Of 278 without target profile, 48% had EVT. Among all pts, excellent outcomes and mRS distribution were similar (EVT 63.5% vs MM 59.1%, aOR 1.55, 95%, p=0.16) and (adj cOR 1.44, p=0.16) Fig 1A. EVT had worse safety; sICH (6% vs 0%, p=0.002); neuro-worsening (19% vs 3%, p<0.001) and mortality (5% vs 1%, p=0.06). With target profile, EVT associated with more excellent outcomes (66% vs 49%, aOR 4.44, 95% CI 1.04-18.95, p=0.04), shift to better outcomes (adj cOR 2.9, 95% CI 1.03-7.91, p=0.04) Fig 1B. Safety was similar; sICH 2% vs 0%, p>0.99, neuro-worsening 17% vs 6%, p=0.30) and mortality 5% vs 3%, p>0.99). Without target profile, excellent outcomes were similar without a shift, Fig 1C. Safety was worse with EVT: sICH 8% vs 0%, p=0.001; neuro-worsening 20% vs 3%, p<0.001).
Conclusion:
EVT was not associated with improved outcomes in patients with mild deficits; safety was worse. However, EVT was safe and associated with improved outcomes in target profile patients.
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Cadilhac DA, Kim J, Tod EK, Morrison JL, Breen SJ, Jaques K, Grimley R, Jones B, Cloud GC, Kleinig T, Hillier S, Castley H, Lindley RI, Lannin NA, Middleton S, Yan B, Hill K, Clissold BB, Mitchell PJ, Anderson CS, Faux SG, Campbell BCV. COVID-19 Pandemic Impact on Care for Stroke in Australia: Emerging Evidence From the Australian Stroke Clinical Registry. Front Neurol 2021; 12:621495. [PMID: 33716925 PMCID: PMC7952624 DOI: 10.3389/fneur.2021.621495] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2020] [Accepted: 02/04/2021] [Indexed: 01/01/2023] Open
Abstract
We present information on acute stroke care for the first wave of the COVID-19 pandemic in Australia using data from the Australian Stroke Clinical Registry (AuSCR). The first case of COVID-19 in Australia was recorded in late January 2020 and national restrictions to control the virus commenced in March. To account for seasonal effects of stroke admissions, patient-level data from the registry from January to June 2020 were compared to the same period in 2019 (historical-control) from 61 public hospitals. We compared periods using descriptive statistics and performed interrupted time series analyses. Perceptions of stroke clinicians were obtained from 53/72 (74%) hospitals participating in the AuSCR (80% nurses) via a voluntary, electronic feedback survey. Survey data were summarized to provide contextual information for the registry-based analysis. Data from the registry covered locations that had 91% of Australian COVID-19 cases to the end of June 2020. For the historical-control period, 9,308 episodes of care were compared with the pandemic period (8,992 episodes). Patient characteristics were similar for each cohort (median age: 75 years; 56% male; ischemic stroke 69%). Treatment in stroke units decreased progressively during the pandemic period (control: 76% pandemic: 70%, p < 0.001). Clinical staff reported fewer resources available for stroke including 10% reporting reduced stroke unit beds. Several time-based metrics were unchanged whereas door-to-needle times were longer during the peak pandemic period (March-April, 2020; 82 min, control: 74 min, p = 0.012). Our data emphasize the need to maintain appropriate acute stroke care during times of national emergency such as pandemic management.
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Lim JC, Churilov L, Bivard A, Ma H, Dowling RJ, Campbell BCV, Parsons MW, Davis SM, Donnan GA, Mitchell PJ, Yan B. Does Intravenous Thrombolysis Within 4.5 to 9 Hours Increase Clot Migration Leading to Endovascular Inaccessibility? Stroke 2021; 52:1083-1086. [PMID: 33588590 DOI: 10.1161/strokeaha.120.030661] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Distal clot migration is a recognized event following intravenous thrombolysis (IVT) in the setting of acute ischemic stroke. Of note, clots that were initially retrievable by endovascular thrombectomy may migrate to a distal nonretrievable location and compromise clinical outcome. We investigated the incidence of clot migration leading to clot inaccessibility following IVT in the time window of 4.5 to 9 hours. METHODS We performed a retrospective analysis of the EXTEND trial (Extending the Time for Thrombolysis in Emergency Neurological Deficits) data. Baseline and 12- to 24-hour follow-up clot location was determined on computed tomography angiogram or magnetic resonance angiogram. The incidence of clot migration leading to a change from retrievable to nonretrievable location was identified and compared between the two treatment groups (IVT versus placebo). RESULTS Two hundred twenty patients were assessed. Clot migration from a retrievable to nonretrievable location occurred in 37 patients: 21 patients (19.3%) in the placebo group and 16 patients (14.4%) in the IVT group. No significant difference was identified in the incidence of clot migration leading to inaccessibility between groups (P=0.336). CONCLUSIONS Our results did not show increased clot migration leading to clot inaccessibility in patients treated with IVT.
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Alemseged F, Ng FC, Williams C, Puetz V, Boulouis G, Kleinig TJ, Rocco A, Wu TY, Shah D, Arba F, Kaiser D, Di Giuliano F, Morotti A, Sallustio F, Dewey HM, Bailey P, O'Brien B, Sharma G, Bush S, Dowling R, Diomedi M, Churilov L, Yan B, Parsons MW, Davis SM, Mitchell PJ, Yassi N, Campbell BCV. Tenecteplase vs Alteplase Before Endovascular Therapy in Basilar Artery Occlusion. Neurology 2021; 96:e1272-e1277. [PMID: 33408145 DOI: 10.1212/wnl.0000000000011520] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Accepted: 11/02/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To investigate the efficacy of tenecteplase (TNK), a genetically modified variant of alteplase with greater fibrin specificity and longer half-life than alteplase, prior to endovascular thrombectomy (EVT) in patients with basilar artery occlusion (BAO). METHODS To determine whether TNK is associated with better reperfusion rates than alteplase prior to EVT in BAO, clinical and procedural data of consecutive patients with BAO from the Basilar Artery Treatment and Management (BATMAN) registry and the Tenecteplase vs Alteplase before Endovascular Therapy for Ischemic Stroke (EXTEND-IA TNK) trial were retrospectively analyzed. Reperfusion >50% or absence of retrievable thrombus at the time of the initial angiogram was evaluated. RESULTS We included 110 patients with BAO treated with IV thrombolysis prior to EVT (mean age 69 [SD 14] years; median NIH Stroke Scale score 16 [interquartile range (IQR) 7-32]). Nineteen patients were thrombolysed with TNK (0.25 mg/kg or 0.40 mg/kg) and 91 with alteplase (0.9 mg/kg). Reperfusion >50% occurred in 26% (n = 5/19) of patients thrombolysed with TNK vs 7% (n = 6/91) thrombolysed with alteplase (risk ratio 4.0, 95% confidence interval 1.3-12; p = 0.02), despite shorter thrombolysis to arterial puncture time in the TNK-treated patients (48 [IQR 40-71] minutes) vs alteplase-treated patients (110 [IQR 51-185] minutes; p = 0.004). No difference in symptomatic intracranial hemorrhage was observed (0/19 [0%] TNK, 1/91 [1%] alteplase; p = 0.9). CONCLUSIONS TNK may be associated with an increased rate of reperfusion in comparison with alteplase before EVT in BAO. Randomized controlled trials to compare TNK with alteplase in patients with BAO are warranted. CLINICALTRIALSGOV IDENTIFIERS NCT02388061 and NCT03340493. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that TNK leads to higher reperfusion rates in comparison with alteplase prior to EVT in patients with BAO.
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Kuang H, Qiu W, Boers AM, Brown S, Muir K, Majoie CBLM, Dippel DWJ, White P, Epstein J, Mitchell PJ, Dávalos A, Bracard S, Campbell B, Saver JL, Jovin TG, Rubiera M, Khaw AV, Shankar JJ, Fainardi E, Hill MD, Demchuk AM, Goyal M, Menon BK. Computed Tomography Perfusion-Based Machine Learning Model Better Predicts Follow-Up Infarction in Patients With Acute Ischemic Stroke. Stroke 2020; 52:223-231. [PMID: 33280549 DOI: 10.1161/strokeaha.120.030092] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Prediction of infarct extent among patients with acute ischemic stroke using computed tomography perfusion is defined by predefined discrete computed tomography perfusion thresholds. Our objective is to develop a threshold-free computed tomography perfusion-based machine learning (ML) model to predict follow-up infarct in patients with acute ischemic stroke. METHODS Sixty-eight patients from the PRoveIT study (Measuring Collaterals With Multi-Phase CT Angiography in Patients With Ischemic Stroke) were used to derive a ML model using random forest to predict follow-up infarction voxel by voxel, and 137 patients from the HERMES study (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) were used to test the derived ML model. Average map, Tmax, cerebral blood flow, cerebral blood volume, and time variables including stroke onset-to-imaging and imaging-to-reperfusion time, were used as features to train the ML model. Spatial and volumetric agreement between the ML model predicted follow-up infarct and actual follow-up infarct were assessed. Relative cerebral blood flow <0.3 threshold using RAPID software and time-dependent Tmax thresholds were compared with the ML model. RESULTS In the test cohort (137 patients), median follow-up infarct volume predicted by the ML model was 30.9 mL (interquartile range, 16.4-54.3 mL), compared with a median 29.6 mL (interquartile range, 11.1-70.9 mL) of actual follow-up infarct volume. The Pearson correlation coefficient between 2 measurements was 0.80 (95% CI, 0.74-0.86, P<0.001) while the volumetric difference was -3.2 mL (interquartile range, -16.7 to 6.1 mL). Volumetric difference with the ML model was smaller versus the relative cerebral blood flow <0.3 threshold and the time-dependent Tmax threshold (P<0.001). CONCLUSIONS A ML using computed tomography perfusion data and time estimates follow-up infarction in patients with acute ischemic stroke better than current methods.
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Gao L, Moodie M, Mitchell PJ, Churilov L, Kleinig TJ, Yassi N, Yan B, Parsons MW, Donnan GA, Davis SM, Campbell BC. Cost-Effectiveness of Tenecteplase Before Thrombectomy for Ischemic Stroke. Stroke 2020; 51:3681-3689. [DOI: 10.1161/strokeaha.120.029666] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose:
Tenecteplase improved functional outcomes and reduced the requirement for endovascular thrombectomy in ischemic stroke patients with large vessel occlusion in the EXTEND-IA TNK randomized trial. We assessed the cost-effectiveness of tenecteplase versus alteplase in this trial.
Methods:
Post hoc within-trial economic analysis included costs of index emergency department and inpatient stroke hospitalization, rehabilitation/subacute care, and rehospitalization due to stroke within 90 days. Sources for cost included key study site complemented by published literature and government websites. Quality-adjusted life-years were estimated using utility scores derived from the modified Rankin Scale score at 90 days. Long-term modeled cost-effectiveness analysis used a Markov model with 7 health states corresponding to 7 modified Rankin Scale scores. Probabilistic sensitivity analyses were performed.
Results:
Within the 202 patients in the randomized controlled trial, total cost was nonsignificantly lower in the tenecteplase-treated patients (40 997 Australian dollars [AUD]) compared with alteplase-treated patients (46 188 AUD) for the first 90 days(
P
=0.125). Tenecteplase was the dominant treatment strategy in the short term, with similar cost (5412 AUD [95% CI, −13 348 to 2523];
P
=0.181) and higher benefits (0.099 quality-adjusted life-years [95% CI, 0.001–0.1967];
P
=0.048), with a 97.4% probability of being cost-effective. In the long-term, tenecteplase was associated with less additional lifetime cost (96 357 versus 106 304 AUD) and greater benefits (quality-adjusted life-years, 7.77 versus 6.48), and had a 100% probability of being cost-effective. Both deterministic sensitivity analysis and probabilistic sensitivity analyses yielded similar results.
Conclusions:
Both within-trial and long-term economic analyses showed that tenecteplase was highly likely to be cost-effective for patients with acute stroke before thrombectomy. Recommending the use of tenecteplase over alteplase could lead to a cost saving to the healthcare system both in the short and long term.
Registration:
URL:
https://www.clinicaltrials.gov
. Unique identifier: NCT02388061.
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Chandran M, Bhadada SK, Ebeling PR, Gilchrist NL, Khan AH, Halbout P, Lekamwasam S, Lyubomirsky G, Mitchell PJ, Nguyen TV, Tiu KL. IQ driving QI: the Asia Pacific Consortium on Osteoporosis (APCO): an innovative and collaborative initiative to improve osteoporosis care in the Asia Pacific. Osteoporos Int 2020; 31:2077-2081. [PMID: 32561953 PMCID: PMC7560927 DOI: 10.1007/s00198-020-05495-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2020] [Accepted: 06/04/2020] [Indexed: 01/30/2023]
Abstract
Asia Pacific Consortium on Osteoporosis (APCO) comprises of clinical experts from across the Asia Pacific region, uniting to develop solutions to problems facing osteoporosis management and care. The vision of APCO is to reduce the burden of osteoporosis and fragility fractures in the Asia Pacific region. INTRODUCTION The Asia Pacific (AP) region comprises 71 countries with vastly different healthcare systems. It is predicted that by 2050, more than half the world's hip fractures will occur in this region. The Asia Pacific Consortium on Osteoporosis (APCO) was set up in May 2019 with the vision of reducing the burden of osteoporosis and fragility fractures in the AP region. METHODS APCO has so far brought together 39 clinical experts from countries and regions across the AP to develop solutions to challenges facing osteoporosis management and fracture prevention in this highly populous region of the world. APCO aims to achieve its vision by engaging with relevant stakeholders including healthcare providers, policy makers and the public. The initial APCO project is to develop and implement a Framework of pan-AP minimum clinical standards for the screening, diagnosis and management of osteoporosis. RESULTS AND CONCLUSIONS The Framework will serve as a platform upon which new national clinical guidelines can be developed or existing guidelines be revised, in a standardised fashion. The Framework will also facilitate benchmarking for provision of quality of care. It is hoped that the principles underlying the formation and functioning of APCO can be adopted by other regions and that every health care facility and progressively every country in the world can follow our aspirational path and progress towards best practice.
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Langlois T, Goetze J, Bond T, Monk J, Abesamis RA, Asher J, Barrett N, Bernard ATF, Bouchet PJ, Birt MJ, Cappo M, Currey‐Randall LM, Driessen D, Fairclough DV, Fullwood LAF, Gibbons BA, Harasti D, Heupel MR, Hicks J, Holmes TH, Huveneers C, Ierodiaconou D, Jordan A, Knott NA, Lindfield S, Malcolm HA, McLean D, Meekan M, Miller D, Mitchell PJ, Newman SJ, Radford B, Rolim FA, Saunders BJ, Stowar M, Smith ANH, Travers MJ, Wakefield CB, Whitmarsh SK, Williams J, Harvey ES. A field and video annotation guide for baited remote underwater stereo‐video surveys of demersal fish assemblages. Methods Ecol Evol 2020. [DOI: 10.1111/2041-210x.13470] [Citation(s) in RCA: 68] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Kunz WG, Hunink MG, Almekhlafi MA, Menon BK, Saver JL, Dippel DWJ, Majoie CBLM, Jovin TG, Davalos A, Bracard S, Guillemin F, Campbell BCV, Mitchell PJ, White P, Muir KW, Brown S, Demchuk AM, Hill MD, Goyal M. Public health and cost consequences of time delays to thrombectomy for acute ischemic stroke. Neurology 2020; 95:e2465-e2475. [PMID: 32943483 DOI: 10.1212/wnl.0000000000010867] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 06/12/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine public health and cost consequences of time delays to endovascular thrombectomy (EVT) for patients, health care systems, and society, we estimated quality-adjusted life-years (QALYs) of EVT-treated patients and associated costs based on times to treatment. METHODS The Markov model analysis was performed from US health care and societal perspectives over a lifetime horizon. Contemporary data from 7 trials within the Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials (HERMES) collaboration served as data source. Aside from cumulative lifetime costs, we calculated the net monetary benefit (NMB) to determine the economic value of care. We used a contemporary willingness-to-pay threshold of $100,000 per QALY for NMB calculations. RESULTS Every 10 minutes of earlier treatment resulted in an average gain of 39 days (95% prediction interval 23-53 days) of disability-free life. Overall, the cumulative lifetime costs for patients with earlier or later treatment were similar. Patients with later treatment had higher morbidity-related costs but over a shorter time span due to their shorter life expectancy, resulting in similar lifetime costs as in patients with early treatment. Regarding the economic value of care, every 10 minutes of earlier treatment increased the NMB by $10,593 (95% prediction interval $5,549-$14,847) and by $10,915 (95% prediction interval $5,928-$15,356) taking health care and societal perspectives, respectively. CONCLUSIONS Any time delay to EVT reduces QALYs and decreases the economic value of care provided by this intervention. Health care policies to implement efficient prehospital triage and to accelerate in-hospital workflow are urgently needed.
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Kim J, Easton D, Zhao H, Coote S, Sookram G, Smith K, Stephenson M, Bernard S, W Parsons M, Yan B, M Desmond P, J Mitchell P, Cv Campbell B, Donnan GA, M Davis S, Cadilhac DA. Economic evaluation of the Melbourne Mobile Stroke Unit. Int J Stroke 2020; 16:466-475. [PMID: 32536328 DOI: 10.1177/1747493020929944] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The Melbourne Mobile Stroke Unit (MSU) is the first Australian service to provide prehospital acute stroke treatment, including thrombolysis and facilitated triage for endovascular thrombectomy. AIMS To estimate the cost-effectiveness of the MSU during the first full year of operation compared with standard ambulance and hospital stroke care pathways (standard care). METHODS The costs and benefits of the Melbourne MSU were estimated using an economic simulation model. Operational costs and service utilization data were obtained from the MSU financial and patient tracking reports. The health benefits were estimated as disability-adjusted life years (DALYs) avoided using local data on reperfusion therapy and estimates from the published literature on their effectiveness. Costs were presented in Australian dollars. The robustness of results was assessed using multivariable (model inputs varied simultaneously: 10,000 Monte Carlo iterations) and various one-way sensitivity analyses. RESULTS In 2018, the MSU was dispatched to 1244 patients during 200 days of operation. Overall, 167 patients were diagnosed with acute ischemic stroke, and 58 received thrombolysis, endovascular thrombectomy, or both. We estimated 27.94 DALYs avoided with earlier access to endovascular thrombectomy (95% confidence interval (CI) 15.30 to 35.93) and 16.90 DALYs avoided with improvements in access to thrombolysis (95% CI 9.05 to 24.68). The MSU was estimated to cost an additional $30,982 per DALY avoided (95% CI $21,142 to $47,517) compared to standard care. CONCLUSIONS There is evidence that the introduction of MSU is cost-effective when compared with standard care due to earlier provision of reperfusion therapies.
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Smaal JA, de Ridder IR, Heshmatollah A, van Zwam WH, Dippel D, Majoie CB, Brown S, Goyal M, Campbell B, Muir KW, Demchuck AM, Davalos A, Jovin TG, Mitchell PJ, White P, Saver JL, Hill MD, Roos YB, van der Lugt A, van Oostenbrugge RJ. Effect of atrial fibrillation on endovascular thrombectomy for acute ischemic stroke. A meta-analysis of individual patient data from six randomised trials: Results from the HERMES collaboration. Eur Stroke J 2020; 5:245-251. [PMID: 33072878 PMCID: PMC7538768 DOI: 10.1177/2396987320923447] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/03/2020] [Indexed: 12/22/2022] Open
Abstract
Background Atrial fibrillation is an important risk factor for ischemic stroke, and is
associated with an increased risk of poor outcome after ischemic stroke.
Endovascular thrombectomy is safe and effective in acute ischemic stroke
patients with large vessel occlusion of the anterior circulation. This
meta-analysis aims to investigate whether there is an interaction between
atrial fibrillation and treatment effect of endovascular thrombectomy, and
secondarily whether atrial fibrillation is associated with worse outcome in
patients with ischemic stroke due to large vessel occlusion. Methods Individual patient data were from six of the recent randomised clinical
trials (MR CLEAN, EXTEND-IA, REVASCAT, SWIFT PRIME, ESCAPE, PISTE) in which
endovascular thrombectomy plus standard care was compared to standard care
alone. Primary outcome measure was the shift on the modified Rankin scale
(mRS) at 90 days. Secondary outcomes were functional independence (mRS 0–2)
at 90 days, National Institutes of Health Stroke Scale score at 24 h,
symptomatic intracranial hemorrhage and mortality at 90 days. The primary
effect parameter was the adjusted common odds ratio, estimated with ordinal
logistic regression (shift analysis); treatment effect modification of
atrial fibrillation was assessed with a multiplicative interaction term. Results Among 1351 patients, 447 patients had atrial fibrillation, 224 of whom were
treated with endovascular thrombectomy. We found no interaction of atrial
fibrillation with treatment effect of endovascular thrombectomy for both
primary (p-value for interaction: 0.58) and secondary
outcomes. Regardless of treatment allocation, we found no difference in
primary outcome (mRS at 90 days: aOR 1.11 (95% CI 0.89–1.38) and secondary
outcomes between patients with and without atrial fibrillation. Conclusion We found no interaction of atrial fibrillation on treatment effect of
endovascular thrombectomy, and no difference in outcome between large vessel
occlusion stroke patients with and without atrial fibrillation.
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Raza SA, Opie NL, Morokoff A, Sharma RP, Mitchell PJ, Oxley TJ. Endovascular Neuromodulation: Safety Profile and Future Directions. Front Neurol 2020; 11:351. [PMID: 32390937 PMCID: PMC7193719 DOI: 10.3389/fneur.2020.00351] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2019] [Accepted: 04/08/2020] [Indexed: 12/16/2022] Open
Abstract
Endovascular neuromodulation is an emerging technology that represents a synthesis between interventional neurology and neural engineering. The prototypical endovascular neural interface is the StentrodeTM, a stent-electrode array which can be implanted into the superior sagittal sinus via percutaneous catheter venography, and transmits signals through a transvenous lead to a receiver located subcutaneously in the chest. Whilst the StentrodeTM has been conceptually validated in ovine models, questions remain about the long term viability and safety of this device in human recipients. Although technical precedence for venous sinus stenting already exists in the setting of idiopathic intracranial hypertension, long term implantation of a lead within the intracranial veins has never been previously achieved. Contrastingly, transvenous leads have been successfully employed for decades in the setting of implantable cardiac pacemakers and defibrillators. In the current absence of human data on the StentrodeTM, the literature on these structurally comparable devices provides valuable lessons that can be translated to the setting of endovascular neuromodulation. This review will explore this literature in order to understand the potential risks of the StentrodeTM and define avenues where further research and development are necessary in order to optimize this device for human application.
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Campbell BCV, Mitchell PJ, Churilov L, Yassi N, Kleinig TJ, Dowling RJ, Yan B, Bush SJ, Thijs V, Scroop R, Simpson M, Brooks M, Asadi H, Wu TY, Shah DG, Wijeratne T, Zhao H, Alemseged F, Ng F, Bailey P, Rice H, de Villiers L, Dewey HM, Choi PMC, Brown H, Redmond K, Leggett D, Fink JN, Collecutt W, Kraemer T, Krause M, Cordato D, Field D, Ma H, O’Brien B, Clissold B, Miteff F, Clissold A, Cloud GC, Bolitho LE, Bonavia L, Bhattacharya A, Wright A, Mamun A, O’Rourke F, Worthington J, Wong AA, Levi CR, Bladin CF, Sharma G, Desmond PM, Parsons MW, Donnan GA, Davis SM. Effect of Intravenous Tenecteplase Dose on Cerebral Reperfusion Before Thrombectomy in Patients With Large Vessel Occlusion Ischemic Stroke: The EXTEND-IA TNK Part 2 Randomized Clinical Trial. JAMA 2020; 323:1257-1265. [PMID: 32078683 PMCID: PMC7139271 DOI: 10.1001/jama.2020.1511] [Citation(s) in RCA: 152] [Impact Index Per Article: 38.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Intravenous thrombolysis with tenecteplase improves reperfusion prior to endovascular thrombectomy for ischemic stroke compared with alteplase. OBJECTIVE To determine whether 0.40 mg/kg of tenecteplase safely improves reperfusion before endovascular thrombectomy vs 0.25 mg/kg of tenecteplase in patients with large vessel occlusion ischemic stroke. DESIGN, SETTING, AND PARTICIPANTS Randomized clinical trial at 27 hospitals in Australia and 1 in New Zealand using open-label treatment and blinded assessment of radiological and clinical outcomes. Patients were enrolled from December 2017 to July 2019 with follow-up until October 2019. Adult patients (N = 300) with ischemic stroke due to occlusion of the intracranial internal carotid, \basilar, or middle cerebral artery were included less than 4.5 hours after symptom onset using standard intravenous thrombolysis eligibility criteria. INTERVENTIONS Open-label tenecteplase at 0.40 mg/kg (maximum, 40 mg; n = 150) or 0.25 mg/kg (maximum, 25 mg; n = 150) given as a bolus before endovascular thrombectomy. MAIN OUTCOMES AND MEASURES The primary outcome was reperfusion of greater than 50% of the involved ischemic territory prior to thrombectomy, assessed by consensus of 2 blinded neuroradiologists. Prespecified secondary outcomes were level of disability at day 90 (modified Rankin Scale [mRS] score; range, 0-6); mRS score of 0 to 1 (freedom from disability) or no change from baseline at 90 days; mRS score of 0 to 2 (functional independence) or no change from baseline at 90 days; substantial neurological improvement at 3 days; symptomatic intracranial hemorrhage within 36 hours; and all-cause death. RESULTS All 300 patients who were randomized (mean age, 72.7 years; 141 [47%] women) completed the trial. The number of participants with greater than 50% reperfusion of the previously occluded vascular territory was 29 of 150 (19.3%) in the 0.40 mg/kg group vs 29 of 150 (19.3%) in the 0.25 mg/kg group (unadjusted risk difference, 0.0% [95% CI, -8.9% to -8.9%]; adjusted risk ratio, 1.03 [95% CI, 0.66-1.61]; P = .89). Among the 6 secondary outcomes, there were no significant differences in any of the 4 functional outcomes between the 0.40 mg/kg and 0.25 mg/kg groups nor in all-cause deaths (26 [17%] vs 22 [15%]; unadjusted risk difference, 2.7% [95% CI, -5.6% to 11.0%]) or symptomatic intracranial hemorrhage (7 [4.7%] vs 2 [1.3%]; unadjusted risk difference, 3.3% [95% CI, -0.5% to 7.2%]). CONCLUSIONS AND RELEVANCE Among patients with large vessel occlusion ischemic stroke, a dose of 0.40 mg/kg, compared with 0.25 mg/kg, of tenecteplase did not significantly improve cerebral reperfusion prior to endovascular thrombectomy. The findings suggest that the 0.40-mg/kg dose of tenecteplase does not confer an advantage over the 0.25-mg/kg dose in patients with large vessel occlusion ischemic stroke in whom endovascular thrombectomy is planned. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT03340493.
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Kunz WG, Almekhlafi MA, Menon BK, Saver JL, Hunink MG, Dippel DW, Majoie CB, Liebeskind DS, Jovin TG, Davalos A, Bracard S, Guillemin F, Campbell BC, Mitchell PJ, White P, Muir KW, Brown S, Demchuk AM, Hill MD, Goyal M. Public Health and Cost Benefits of Successful Reperfusion After Thrombectomy for Stroke. Stroke 2020; 51:899-907. [DOI: 10.1161/strokeaha.119.027874] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background and Purpose—
The benefit that endovascular thrombectomy offers to patients with stroke with large vessel occlusions depends strongly on reperfusion grade as defined by the expanded Thrombolysis in Cerebral Infarction (eTICI) scale. Our aim was to determine the lifetime health and cost consequences of the quality of reperfusion for patients, healthcare systems, and society.
Methods—
A Markov model estimated lifetime quality-adjusted life years (QALY) and lifetime costs of endovascular thrombectomy–treated patients with stroke based on eTICI grades. The analysis was performed over a lifetime horizon in a United States setting, adopting healthcare and societal perspectives. The reference case analysis was conducted for stroke at 65 years of age. National health and cost consequences of improved eTICI 2c/3 reperfusion rates were estimated. Input parameters were based on best available evidence.
Results—
Lifetime QALYs increased for every grade of improved reperfusion (median QALYs for eTICI 0/1: 2.62; eTICI 2a: 3.46; eTICI 2b: 5.42; eTICI 2c: 5.99; eTICI 3: 6.73). Achieving eTICI 3 over eTICI 2b reperfusion resulted on average in 1.31 incremental QALYs as well as healthcare and societal cost savings of $10 327 and $20 224 per patient. A 10% increase in the eTICI 2c/3 reperfusion rate of all annually endovascular thrombectomy–treated patients with stroke in the United States is estimated to yield additional 3656 QALYs and save $21.0 million and $36.8 million for the healthcare system and society, respectively.
Conclusions—
Improved reperfusion grants patients with stroke additional QALYs and leads to long-term cost savings. Procedural strategies to achieve complete reperfusion should be assessed for safety and feasibility, even when initial reperfusion seems to be adequate.
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Zhao H, Coote S, Easton D, Langenberg F, Stephenson M, Smith K, Bernard S, Cadilhac DA, Kim J, Bladin CF, Churilov L, Crompton DE, Dewey HM, Sanders LM, Wijeratne T, Cloud G, Brooks DM, Asadi H, Thijs V, Chandra RV, Ma H, Desmond PM, Dowling RJ, Mitchell PJ, Yassi N, Yan B, Campbell BC, Parsons MW, Donnan GA, Davis SM. Melbourne Mobile Stroke Unit and Reperfusion Therapy. Stroke 2020; 51:922-930. [DOI: 10.1161/strokeaha.119.027843] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Mobile stroke units (MSUs) are increasingly used worldwide to provide prehospital triage and treatment. The benefits of MSUs in giving earlier thrombolysis have been well established, but the impacts of MSUs on endovascular thrombectomy (EVT) and effect on disability avoidance are largely unknown. We aimed to determine the clinical impact and disability reduction for reperfusion therapies in the first operational year of the Melbourne MSU.
Methods—
Treatment time metrics for MSU patients receiving reperfusion therapy were compared with control patients presenting to metropolitan Melbourne stroke units via standard ambulance within MSU operating hours. The primary outcome was median time difference in first ambulance dispatch to treatment modeled using quantile regression analysis. Time savings were subsequently converted to disability-adjusted life years avoided using published estimates.
Results—
In the first 365-day operation of the Melbourne MSU, prehospital thrombolysis was administered to 100 patients (mean age, 73.8 years; 62% men). The median time savings per MSU patient, compared with the control cohort, was 26 minutes (
P
<0.001) for dispatch to hospital arrival and 15 minutes (
P
<0.001) for hospital arrival to thrombolysis. The calculated overall time saving from dispatch to thrombolysis was 42.5 minutes (95% CI, 36.0–49.0). In the same period, 41 MSU patients received EVT (mean age, 76 years; 61% men) with median dispatch-to-treatment time saving of 51 minutes ([95% CI, 30.1–71.9],
P
<0.001). This included a median time saving of 17 minutes ([95% CI, 7.6–26.4],
P
=0.001) for EVT hospital arrival to arterial puncture for MSU patients. Estimated median disability-adjusted life years saved through earlier provision of reperfusion therapies were 20.9 for thrombolysis and 24.6 for EVT.
Conclusions—
The Melbourne MSU substantially reduced time to reperfusion therapies, with the greatest estimated disability avoidance driven by the more powerful impact of earlier EVT. These findings highlight the benefits of prehospital notification and direct triage to EVT centers with facilitated workflow on arrival by the MSU.
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Bourcier R, Goyal M, Liebeskind DS, Muir KW, Desal H, Siddiqui AH, Dippel DWJ, Majoie CB, van Zwam WH, Jovin TG, Levy EI, Mitchell PJ, Berkhemer OA, Davis SM, Derraz I, Donnan GA, Demchuk AM, van Oostenbrugge RJ, Kelly M, Roos YB, Jahan R, van der Lugt A, Sprengers M, Velasco S, Lycklama À Nijeholt GJ, Ben Hassen W, Burns P, Brown S, Chabert E, Krings T, Choe H, Weimar C, Campbell BCV, Ford GA, Ribo M, White P, Cloud GC, San Roman L, Davalos A, Naggara O, Hill MD, Bracard S. Association of Time From Stroke Onset to Groin Puncture With Quality of Reperfusion After Mechanical Thrombectomy: A Meta-analysis of Individual Patient Data From 7 Randomized Clinical Trials. JAMA Neurol 2020; 76:405-411. [PMID: 30667465 DOI: 10.1001/jamaneurol.2018.4510] [Citation(s) in RCA: 112] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Importance Reperfusion is a key factor for clinical outcome in patients with acute ischemic stroke (AIS) treated with endovascular thrombectomy (EVT) for large-vessel intracranial occlusion. However, data are scarce on the association between the time from onset and reperfusion results. Objective To analyze the rate of reperfusion after EVT started at different intervals after symptom onset in patients with AIS. Design, Setting, and Participants We conducted a meta-analysis of individual patient data from 7 randomized trials of the Highly Effective Reperfusion Using Multiple Endovascular Devices (HERMES) group. This is a multicenter cohort study of the intervention arm of randomized clinical trials included in the HERMES group. Patients with anterior circulation AIS who underwent EVT for M1/M2 or intracranial carotid artery occlusion were included. Each trial enrolled patients according to its specific inclusion and exclusion criteria. Data on patients eligible but not enrolled (eg, refusals or exclusions) were not available. All analyses were performed by the HERMES biostatistical core laboratory using the pooled database. Data were analyzed between December 2010 and April 2015. Main Outcomes and Measures Successful reperfusion was defined as a modified thrombolysis in cerebral infarction score of 2b/3 at the end of the EVT procedure adjusted for age, occlusion location, pretreatment intravenous thrombolysis, and clot burden score and was analyzed in relation to different intervals (onset, emergency department arrival, imaging, and puncture) using mixed-methods logistic regression. Results Among the 728 included patients, with a mean (SD) age of 65.4 (13.5) years and of whom 345 were female (47.4%), decreases in rates of successful reperfusion defined as a thrombolysis in cerebral infarction score of 2b/3 were observed with increasing time from admission or first imaging to groin puncture. The magnitude of effect was a 22% relative reduction (odds ratio, 0.78; 95% CI, 0.64-0.95) per additional hour between admission and puncture and a 26% relative reduction (odds ratio, 0.74; 95% CI, 0.59-0.93) per additional hour between imaging and puncture. Conclusions and Relevance Because the probability of reperfusion declined significantly with time between hospital arrival and groin puncture, we provide additional arguments for minimizing the intervals after symptom onset in anterior circulation acute ischemic stroke.
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