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Faizy TD, Broocks G, Heit JJ, Kniep H, Flottmann F, Meyer L, Sporns P, Hanning U, Kaesmacher J, Deb-Chatterji M, Vollmuth P, Lansberg MG, Albers GW, Fischer U, Wintermark M, Thomalla G, Fiehler J, Winkelmeier L. Association Between Intravenous Thrombolysis and Clinical Outcomes Among Patients With Ischemic Stroke and Unsuccessful Mechanical Reperfusion. JAMA Netw Open 2023; 6:e2310213. [PMID: 37126350 PMCID: PMC10152307 DOI: 10.1001/jamanetworkopen.2023.10213] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
Importance Clinical evidence of the potential treatment benefit of intravenous thrombolysis preceding unsuccessful mechanical thrombectomy (MT) is scarce. Objective To determine whether intravenous thrombolysis (IVT) prior to unsuccessful MT improves functional outcomes in patients with acute ischemic stroke. Design, Setting, and Participants Patients were enrolled in this retrospective cohort study from the prospective, observational, multicenter German Stroke Registry-Endovascular Treatment between May 1, 2015, and December 31, 2021. This study compared IVT plus MT vs MT alone in patients with acute ischemic stroke due to anterior circulation large-vessel occlusion in whom mechanical reperfusion was unsuccessful. Unsuccessful mechanical reperfusion was defined as failed (final modified Thrombolysis in Cerebral Infarction grade of 0 or 1) or partial (grade 2a). Patients meeting the inclusion criteria were matched by treatment group using 1:1 propensity score matching. Interventions Mechanical thrombectomy with or without IVT. Main Outcomes and Measures Primary outcome was functional independence at 90 days, defined as a modified Rankin Scale score of 0 to 2. Safety outcomes were the occurrence of symptomatic intracranial hemorrhage and death. Results After matching, 746 patients were compared by treatment arms (median age, 78 [IQR, 68-84] years; 438 women [58.7%]). The proportion of patients who were functionally independent at 90 days was 68 of 373 (18.2%) in the IVT plus MT and 42 of 373 (11.3%) in the MT alone group (adjusted odds ratio [AOR], 2.63 [95% CI, 1.41-5.11]; P = .003). There was a shift toward better functional outcomes on the modified Rankin Scale favoring IVT plus MT (adjusted common OR, 1.98 [95% CI, 1.35-2.92]; P < .001). The treatment benefit of IVT was greater in patients with partial reperfusion compared with failed reperfusion. There was no difference in symptomatic intracranial hemorrhages between treatment groups (AOR, 0.71 [95% CI, 0.29-1.81]; P = .45), while the death rate was lower after IVT plus MT (AOR, 0.54 [95% CI, 0.34-0.86]; P = .01). Conclusions and Relevance These findings suggest that prior IVT was safe and improved functional outcomes at 90 days. Partial reperfusion was associated with a greater treatment benefit of IVT, indicating a positive interaction between IVT and MT. These results support current guidelines that all eligible patients with stroke should receive IVT before MT and add a new perspective to the debate on noninferiority of combined stroke treatment.
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Affiliation(s)
- Tobias D Faizy
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Helge Kniep
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Sporns
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Uta Hanning
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Philipp Vollmuth
- Department of Neuroradiology, University Medical Center Heidelberg, Heidelberg, Germany
| | - Maarten G Lansberg
- Department of Neurology and Neurological Science, Stanford University School of Medicine, Stanford, California
| | - Gregory W Albers
- Department of Neurology and Neurological Science, Stanford University School of Medicine, Stanford, California
| | - Urs Fischer
- Department of Neurology, University Medical Center Basel, Basel, Switzerland
| | - Max Wintermark
- Department of Neuroradiology, MD Anderson Cancer Center, Houston, Texas
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laurens Winkelmeier
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Weller JM, Dorn F, Meissner JN, Stösser S, Beckonert NM, Nordsiek J, Kindler C, Deb-Chatterji M, Petzold GC, Bode FJ. Endovascular thrombectomy in young patients with stroke. Int J Stroke 2023; 18:453-461. [PMID: 35912650 DOI: 10.1177/17474930221119602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Endovascular treatment (ET) is standard of care in patients with acute ischemic stroke due to large vessel occlusion, but data on ET in young patients remain limited. AIM We aim to compare outcomes for young stroke patients undergoing ET in a matched cohort. METHODS We analyzed patients from an observational multicenter cohort with acute ischemic stroke and ET, the German Stroke Registry-Endovascular Treatment trial. Baseline characteristics, procedural parameters, and functional outcome at 90 days were compared between young (<50 years) and older (⩾50 years) patients with and without nearest-neighbor 1:1 propensity score matching. RESULTS Out of 6628 acute ischemic stroke patients treated with ET, 363 (5.5%) were young. Young patients differed with regard to prognostic outcome characteristics. Specifically, National Institutes of Health Stroke Scale (NIHSS) at admission was lower (median 13, interquartile range (IQR) 8-17 vs. 15, IQR 9-19, p < 0.001), and prestroke dependence was less frequent (2.9% vs. 12.2%, p < 0.001) than in older patients. Compared to a matched cohort of older patients, ET was faster (time from groin puncture to flow restoration, 35 vs. 45 min, p < 0.001) and intracranial hemorrhage was less frequent in young patients (10.0% vs. 25.9%, p < 0.001). Good functional outcome (modified Rankin Scale (mRS) 0-2) at 3 months was achieved more frequently in young patients (71.6% vs. 44.1%, p < 0.001), and overall mortality was lower (6.7% vs. 25.4%, p < 0.001). Among previously employed young patients (n = 177), 37.9% returned to work at 3-month follow-up, while 74.1% of the remaining patients were still undergoing rehabilitation. CONCLUSION Young stroke patients undergoing ET have better outcomes compared to older patients, even when matched for prestroke condition, comorbidities, and stroke severity. Hence, more liberal guidelines to perform ET for younger patients may have to be established by future studies.
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Affiliation(s)
- Johannes M Weller
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Franziska Dorn
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Julius N Meissner
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Sebastian Stösser
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Niklas M Beckonert
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Julia Nordsiek
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Christine Kindler
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Gabor C Petzold
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Felix J Bode
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
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53
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Kanamoto T, Tateishi Y, Yamashita K, Furuta K, Torimura D, Tomita Y, Hirayama T, Shima T, Nagaoka A, Yoshimura S, Miyazaki T, Ideguchi R, Morikawa M, Morofuji Y, Horie N, Izumo T, Tsujino A. Impact of width of susceptibility vessel sign on recanalization following endovascular therapy. J Neurol Sci 2023; 446:120583. [PMID: 36827810 DOI: 10.1016/j.jns.2023.120583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 02/05/2023] [Accepted: 02/09/2023] [Indexed: 02/14/2023]
Abstract
BACKGROUND AND PURPOSE We aimed to investigate the relationship between arterial recanalization following endovascular therapy and the susceptibility vessel sign (SVS) length and width on susceptibility-weighted imaging. METHODS We retrospectively evaluated consecutive patients with anterior circulation ischemic stroke who underwent magnetic resonance imaging preceded endovascular therapy, and measured the SVS length and width. Successful recanalization was defined as expanded thrombolysis in cerebral infarction grade of 2b to 3. Logistic regression analysis was executed to determine the independent predictors of successful recanalization and first-pass reperfusion (FPR) after endovascular therapy. RESULTS Among 100 patients, successful recanalization and FPR were observed in 77 and 34 patients, respectively. The median SVS length and width were 10.3 mm (interquartile range, 6.8-14.1 mm) and 4.2 mm (interquartile range, 3.1-5.2 mm), respectively. In multivariate logistic regression analysis, SVS width was associated with successful recanalization (odds ratio, 1.88; 95% confidence interval, 1.14-3.07; p = 0.005) and FPR (odds ratio, 1.38; 95% confidence interval, 1.01-1.89; p = 0.039). The optimal cutoff value for the SVS width to predict successful recanalization and FPR were 4.2 mm and 4.0 mm, respectively. CONCLUSIONS Larger SVS width may predict successful recanalization and FPR following endovascular therapy.
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Affiliation(s)
- Tadashi Kanamoto
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Yohei Tateishi
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Kairi Yamashita
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Kanako Furuta
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Daishi Torimura
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Yuki Tomita
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Takuro Hirayama
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Tomoaki Shima
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Atsushi Nagaoka
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Shunsuke Yoshimura
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Teiichiro Miyazaki
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Reiko Ideguchi
- Department of Radiology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Minoru Morikawa
- Department of Radiology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Yoichi Morofuji
- Department of Neurosurgery, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Nobutaka Horie
- Department of Neurosurgery, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan; Department of Neurosurgery, Hiroshima University, Kasumi 1-2-3 Minami-ku, Hiroshima 734-8551, Japan
| | - Tsuyoshi Izumo
- Department of Neurosurgery, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Akira Tsujino
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
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54
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Stösser S, Bode FJ, Meissner JN, Weller JM, Kindler C, Sauer M, Paech D, Riegler C, Nolte CH, Pourian A, Röther J, Selo N, Ernemann U, Poli S, Eckert RM, Bohner G, Scherling K, Dorn F, Petzold GC. Outcome of Stroke Patients with Unknown Onset and Unknown Time Last Known Well Undergoing Endovascular Therapy. Clin Neuroradiol 2023; 33:107-112. [PMID: 35796854 PMCID: PMC10014703 DOI: 10.1007/s00062-022-01188-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2022] [Accepted: 06/13/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Endovascular treatment (ET) in patients with large vessel occlusion stroke (LVOS) with unknown onset or an extended time window can be safe and effective if patients are selected by defined clinical and imaging criteria; however, it is unclear if these criteria should also be applied to patients with unknown onset and unknown time last known well. In this study, we aimed to assess whether absent information on the time patients were last known to be well impacts outcome in patients with unknown onset LVOS. METHODS We analyzed patients who were enrolled in the German Stroke Registry-Endovascular Treatment between 2015 and 2019. Patients with unknown onset and unknown time last known well (LKWu) were compared to patients with known onset (KO) and to patients with unknown onset but known time last known well (LKWk) regarding clinical and imaging baseline characteristics and outcome. RESULTS Out of 5909 patients, 561 presented with LKWu (9.5%), 1849 with LKWk (31.3%) and 3499 with KO (59.2%). At 90 days, functional independency was less frequent in LKWu (27.0%) compared to KO (42.6%) and LKWk patients (31.8%). These differences were not significant after adjusting for confounders. A main confounder was the initial Alberta stroke program early CT score. CONCLUSION The LKWu patients had a similar outcome after ET as KO and LKWk patients after adjusting for confounders. Thus, ET should not be withheld if the time last known well is unknown. Instead, LKWu patients may be selected for ET using the same criteria as in LKWk patients.
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Affiliation(s)
- Sebastian Stösser
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
| | - Felix J Bode
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Julius N Meissner
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Johannes M Weller
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Christine Kindler
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Malte Sauer
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Daniel Paech
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Christoph Riegler
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Amitis Pourian
- Department of Neurology, Asklepios Hospital Hamburg Altona, Semmelweis University Campus Hamburg, Hamburg, Germany
| | - Joachim Röther
- Department of Neurology, Asklepios Hospital Hamburg Altona, Semmelweis University Campus Hamburg, Hamburg, Germany
| | - Nadja Selo
- Department of Neuroradiology, University Hospital Tübingen, Tübingen, Germany
| | - Ulrike Ernemann
- Department of Neuroradiology, University Hospital Tübingen, Tübingen, Germany
| | - Sven Poli
- Department of Neurology, University Hospital Tübingen, Tübingen, Germany
| | - Rosa Marie Eckert
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Georg Bohner
- Department of Neuroradiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Korbinian Scherling
- Department of Neuroradiology, Ludwig Maximilians University Munich, Campus Grosshadern, Munich, Germany
| | - Franziska Dorn
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Gabor C Petzold
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
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Kawano D, Fukuda K, Takeshita S, Fukumoto H, Horio Y, Ogata T, Higashi T, Inoue T, Abe H. Pooled blood volume measured by final flat-panel detector computed tomography predicts outcome after endovascular thrombectomy for acute ischemic stroke. World Neurosurg X 2023; 19:100178. [PMID: 37021291 PMCID: PMC10068609 DOI: 10.1016/j.wnsx.2023.100178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 02/27/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
Background Pooled blood volume (PBV), measured in real-time in the angiography room using an angiography system, correlates with cerebral blood volume (CBV). We examined the usefulness of PBV in endovascular thrombectomy (EVT) for acute ischemic stroke (AIS). Methods EVT for AIS in the anterior circulation (internal carotid artery (ICA) and middle cerebral artery (MCA)) was performed in 31 cases (13 males, 18 females, average age 75.7 years). PBV was acquired using a biplane flat-panel detector (FD) angiographic system. Then, we measured the average PBV value in the M1-6 regions similar to the Alberta Stroke Program Early CT score (ASPECTS) before and after EVT. We investigated factors associated with favorable outcome at 90 days after EVT. Results There were 13 patients (41.9%) in the good outcome group (mRS (modified Rankin Scale) ≦2) and 18 patients (58.1%) in the poor outcome group (mRS>2). In univariate analysis, NIHSS (National Institutes of Health Stroke Scale) (odds ratio [OR] 0.74, 95% CI 0.57-0.87, p < 0.0001) and post PBV value (odds ratio [OR] 1.13, 95% CI 1.03-1.29, p = 0.0086) were significantly associated with good outcome. The good outcome group had significantly higher post-thrombectomy PBV value (3.69 ± 0.32 ml/100 g versus 2.78 ± 0.93 ml/100 g, P = 0.002) compared to that of the poor outcome group. The relationship between pre-thrombectomy PBV value and outcome at 90 days was not significant. Conclusions Post-operative PBV value measured by FD-CT (computed tomography) correlated with 90-day outcome after EVT for AIS. FD-CT-PBV would be one of the good predictors of clinical outcome.
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Asdaghi N, Wang K, Gardener H, Jameson A, Rose DZ, Alkhachroum A, Gutierrez CM, Hao Y, Mueller-Kronast N, Sur NB, Dong C, Perue GG, LePain M, Koch S, Krementz N, Marulanda-Londoño E, Hanel R, Mehta B, Yavagal DR, Rundek T, Sacco RL, Romano JG. Impact of Time to Treatment on Endovascular Thrombectomy Outcomes in the Early Versus Late Treatment Time Windows. Stroke 2023; 54:733-742. [PMID: 36848428 PMCID: PMC9991076 DOI: 10.1161/strokeaha.122.040352] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 12/09/2022] [Indexed: 03/01/2023]
Abstract
BACKGROUND The impact of time to treatment on outcomes of endovascular thrombectomy (EVT) especially in patients presenting after 6 hours from symptom onset is not well characterized. We studied the differences in characteristics and treatment timelines of EVT-treated patients participating in the Florida Stroke Registry and aimed to characterize the extent to which time impacts EVT outcomes in the early and late time windows. METHODS Prospectively collected data from Get With the Guidelines-Stroke hospitals participating in the Florida Stroke Registry from January 2010 to April 2020 were reviewed. Participants were EVT patients with onset-to-puncture time (OTP) of ≤24 hours and categorized into early window treated (OTP ≤6 hours) and late window treated (OTP >6 and ≤24 hours). Association between OTP and favorable discharge outcomes (independent ambulation, discharge home and to acute rehabilitation facility) as well as symptomatic intracerebral hemorrhage and in-hospital mortality were examined using multilevel-multivariable analysis with generalized estimating equations. RESULTS Among 8002 EVT patients (50.9% women; median age [±SD], 71.5 [±14.5] years; 61.7% White, 17.5% Black, and 21% Hispanic), 34.2% were treated in the late time window. Among all EVT patients, 32.4% were discharged home, 23.5% to rehabilitation facility, 33.7% ambulated independently at discharge, 5.1% had symptomatic intracerebral hemorrhage, and 9.2% died. As compared with the early window, treatment in the late window was associated with lower odds of independent ambulation (odds ratio [OR], 0.78 [0.67-0.90]) and discharge home (OR, 0.71 [0.63-0.80]). For every 60-minute increase in OTP, the odds of independent ambulation reduced by 8% (OR, 0.92 [0.87-0.97]; P<0.001) and 1% (OR, 0.99 [0.97-1.02]; P=0.5) and the odds of discharged home reduced by 10% (OR, 0.90 [0.87-0.93]; P<0.001) and 2% (OR, 0.98 [0.97-1.00]; P=0.11) in the early and late windows, respectively. CONCLUSIONS In routine practice, just over one-third of EVT-treated patients independently ambulate at discharge and only half are discharged to home/rehabilitation facility. Increased time from symptom onset to treatment is significantly associated with lower chance of independent ambulation and ability to be discharged home after EVT in the early time window.
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Affiliation(s)
- Negar Asdaghi
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL
| | - Kefeng Wang
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL
| | - Hannah Gardener
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL
| | - Angus Jameson
- University of South Florida Morsani College of Medicine, Tampa FL
| | - David Z Rose
- University of South Florida Morsani College of Medicine, Tampa FL
| | - Ayham Alkhachroum
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL
| | - Carolina M. Gutierrez
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL
| | - Ying Hao
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL
| | | | - Nicole B Sur
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL
| | - Chuanhui Dong
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL
| | - Gillian Gordon Perue
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL
| | - Marissa LePain
- Morton Plant Mease Hospitals, BayCare Health System West Region, FL
| | - Sebastian Koch
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL
| | - Nastajjia Krementz
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL
| | | | | | | | - Dileep R Yavagal
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL
| | - Tatjana Rundek
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL
| | - Ralph L. Sacco
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL
| | - Jose G. Romano
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL
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Start, Stop, Continue? The Benefit of Overlapping Intravenous Thrombolysis and Mechanical Thrombectomy : A Matched Case-control Analysis from the German Stroke Registry. Clin Neuroradiol 2023; 33:187-197. [PMID: 35881162 PMCID: PMC10014683 DOI: 10.1007/s00062-022-01200-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Accepted: 07/08/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Here we compare the procedural and clinical outcome of patients undergoing thrombectomy with running thrombolysis to matched controls with completed intravenous therapy and an only marginally overlapping activity. METHODS Patients from 25 sites in Germany were included, who presented with an acute ischemic stroke. Patients' baseline characteristics (including ASPECTS, NIHSS and mRS), grade of reperfusion, and functional outcome 24 h and at day 90 after intervention were extracted from the German Stroke Registry (n = 2566). In a case-control design we stepwise matched the groups due to age, sex and time to groin puncture and time to flow restoration. RESULTS In the initial cohort (overlap group n = 864, control group n = 1702) reperfusion status (median TICI in overlap group vs. control group: 3 vs. 2b), NIHSS after 24 h, early neurological improvement parameters, mRS at 24 h and at day 90 were significantly better in the overlap group (p < 0.001) with a similar risk of bleeding (2.9% vs. 2.4%) and death (18% vs. 22%). After adjustment mRS at day 90 still showed a trend for lower disability scores in the overlap group (3 IQR 1-5 vs. 3 IQR 1-6, p = 0.09). While comparable bleeding risk could be maintained (4% in both groups), there were significantly more deaths in the control group (18% vs. 30%, p = 0.006). CONCLUSION The presented results support the approach of continuing and completing a simultaneous administration of intravenous thrombolysis during mechanical thrombectomy procedures.
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Barow E, Probst AC, Pinnschmidt H, Heinze M, Jensen M, Rimmele DL, Flottmann F, Broocks G, Fiehler J, Gerloff C, Thomalla G. Effect of Comorbidity Burden and Polypharmacy on Poor Functional Outcome in Acute Ischemic Stroke. Clin Neuroradiol 2023; 33:147-154. [PMID: 35831611 PMCID: PMC10014774 DOI: 10.1007/s00062-022-01193-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2022] [Accepted: 06/22/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE Comorbidities and polypharmacy are risk factors for worse outcome in stroke. However, comorbidities and polypharmacy are mostly studied separately with various approaches to assess them. We aimed to analyze the impact of comorbidity burden and polypharmacy on functional outcome in acute ischemic stroke (AIS) patients undergoing mechanical thrombectomy (MT). METHODS Acute ischemic stroke patients with large vessel occlusion (LVO) treated with MT from a prospective observational study were analyzed. Relevant comorbidity burden was defined as a Charlson Comorbidity Index (CCI) score ≥ 2, polypharmacy as the intake of ≥ 5 medications at time of stroke onset. Favorable outcome was a score of 0-2 on the modified Rankin scale at 90 days after stroke. The effect of comorbidity burden and polypharmacy on favorable outcome was studied via multivariable regression analysis. RESULTS Of 903 patients enrolled, 703 AIS patients (mean age 73.4 years, 54.9% female) with anterior circulation LVO were included. A CCI ≥ 2 was present in 226 (32.1%) patients, polypharmacy in 315 (44.8%) patients. Favorable outcome was less frequently achieved in patients with a CCI ≥ 2 (47, 20.8% vs. 172, 36.1%, p < 0.001), and in patients with polypharmacy (69, 21.9% vs. 150, 38.7%, p < 0.001). In multivariable regression analysis including clinical covariates, a CCI ≥ 2 was associated with lower odds of favorable outcome (odds ratio, OR 0.52, 95% confidence interval, 95% CI 0.33-0.82, p = 0.005), while polypharmacy was not (OR 0.81, 95% CI 0.52-1.27, p = 0.362). CONCLUSION Relevant comorbidity burden and polypharmacy are common in AIS patients with LVO, with comorbidity burden being a risk factor for poor outcome.
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Affiliation(s)
- Ewgenia Barow
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Ann-Cathrin Probst
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Hans Pinnschmidt
- Institut für Medizinische Biometrie und Epidemiologie, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marlene Heinze
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Märit Jensen
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - David Leander Rimmele
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Fabian Flottmann
- 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
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Gerloff
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf- und Neurozentrum, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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59
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Ullberg T, von Euler M, Wassélius J, Wester P, Arnberg F. Survival and functional outcome following endovascular thrombectomy for anterior circulation acute ischemic stroke caused by large vessel occlusion in Sweden 2017-2019-a nationwide, prospective, observational study. Interv Neuroradiol 2023; 29:94-101. [PMID: 35044270 PMCID: PMC9893239 DOI: 10.1177/15910199211073019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Endovascular thrombectomy (EVT) is standard of care for anterior circulation acute ischemic stroke (AIS) caused by large vessel occlusion (LVO), but data on nationwide performance in routine healthcare are sparse. The study aims were to describe EVT patients with LVO AIS, analyze mortality and functional outcome, and compare results with randomized controlled trials (RCTs). METHODS Data from the Riksstroke and the Swedish Endovascular Treatment of Acute Stroke Registry (RSEVAS) on pre-stroke independent patients, with LVO AIS in 2017-2019, defined as occlusion of the intracranial internal carotid artery, or the M1 or M2 segments of the middle cerebral artery, and groin puncture <6 h of onset, were compared to aggregated HERMES collaboration RCT data. We assessed 90-day survival and function, defined by the modified Rankin Scale. Specific analyzes were stratified by occlusion location. RESULTS In all, 1011/2560 of RSEVAS patients matched RCT inclusion criteria. Compared with RCT data, patients were older (73 vs. 68), fewer received intravenous thrombolysis (63.1% vs. 83%), and M2 occlusions were more common (24.5% vs. 8%). 90-day survival in RSEVAS was 85.3%, 42.8% achieved good outcome and 5% had symptomatic intracerebral hemorrhage (sICH). Corresponding outcomes in RCT data were 84.7% survival, 46% good outcome, and 4.4% sICH. Functional outcome was most favorable following M2 occlusions. CONCLUSIONS EVT patients from our large real-world national dataset differed from RCT patients in several baseline factors including distribution of vascular occlusion site. However, the overall outcome of EVT in our Swedish cohort appeared to well match the pivotal trial findings.
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Affiliation(s)
- Teresa Ullberg
- Neurology, Department of Clinical Sciences Lund,
Lund University, Lund, Sweden,Neurology, Skåne University Hospital
Lund/Malmö, Lund, Sweden,Teresa Ullberg, Diagnostic radiology,
neuroradiology, Skåne University Hospital, Entrégatan 7, 222 41. Lund, Sweden.
| | - Mia von Euler
- School of Medicine, Örebro University, Örebro, Sweden
| | - Johan Wassélius
- Diagnostic Radiology, Department of Clinical Sciences Lund, Lund University, Lund, Sweden,Neuroradiology, Skåne University Hospital, Lund, Sweden
| | - Per Wester
- Department of Public Health and Clinical Science, Umeå University,
Umeå, Sweden,Department of Clinical Science, Karolinska Institute Danderyds
hospital, Stockholm, Sweden
| | - Fabian Arnberg
- Department of Clinical Neuroscience, Karolinska Institute,
Stockholm, Sweden,Department of Neuroradiology, Karolinska University
Hospital, Solna, Sweden
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60
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Feil K, Berndt MT, Wunderlich S, Maegerlein C, Bernkopf K, Zimmermann H, Herzberg M, Tiedt S, Küpper C, Wischmann J, Schönecker S, Dimitriadis K, Liebig T, Dieterich M, Zimmer C, Kellert L, Boeckh-Behrens T, Boeckh-Behrens T, Wunderlich S, Ludolph A, Henn KH, Reich A, Nikoubashman O, Wiesmann M, Ernemann U, Poli S, Nolte CH, Siebert E, Zweynert S, Bohner G, Solymosi L, Petzold G, Pfeilschifter W, Keil F, Röther J, Eckert B, Berrouschot J, Bormann A, Alegiani A, Fiehler J, Gerloff C, Thomalla G, Thonke S, Bangard C, Kraemer C, Dichgans M, Psychogios M, Liman J, Petersen M, Stögbauer F, Kraft P, Pham M, Braun M, Hamann GF, Roth C, Gröschel K, Uphaus T, Limmroth V. Endovascular thrombectomy for basilar artery occlusion stroke: Analysis of the German Stroke Registry-Endovascular Treatment. Eur J Neurol 2023; 30:1293-1302. [PMID: 36692229 DOI: 10.1111/ene.15694] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/05/2023] [Accepted: 01/09/2023] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND PURPOSE Acute ischemic stroke due to basilar artery occlusion (BAO) causes the most severe strokes and has a poor prognosis. Data regarding efficacy of endovascular thrombectomy in BAO are sparse. Therefore, in this study, we performed an analysis of the therapy of patients with BAO in routine clinical practice. METHODS Patients enrolled between June 2015 and December 2019 in the German Stroke Registry-Endovascular Treatment (GSR-ET) were analyzed. Primary outcomes were successful reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] score of 2b-3), substantial neurological improvement (≥8-point National Institute of Health Stroke Scale [NIHSS] score reduction from admission to discharge or NIHSS score at discharge ≤1), and good functional outcome at 3 months (modified Rankin Scale [mRS] score of 0-2). RESULTS Out of 6635 GSR-ET patients, 640 (9.6%) patients (age 72.2 ± 13.3, 43.3% female) experienced BAO (median [interquartile range] NIHSS score 17 [8, 27]). Successful reperfusion was achieved in 88.4%. Substantial neurological improvement at discharge was reached by 45.5%. At 3-month follow-up, good clinical outcome was observed in 31.1% of patients and the mortality rate was 39.2%. Analysis of mTICI3 versus mTICI2b groups showed considerable better outcome in those with mTICI3 (38.9% vs. 24.4%; p = 0.005). The strongest predictors of good functional outcome were intravenous thrombolysis (IVT) treatment (odds ratio [OR] 3.04, 95% confidence interval [CI] 1.76-5.23) and successful reperfusion (OR 4.92, 95% CI 1.15-21.11), while the effect of time between symptom onset and reperfusion seemed to be small. CONCLUSIONS Acute reperfusion strategies in BAO are common in daily practice and can achieve good rates of successful reperfusion, neurological improvement and good functional outcome. Our data suggest that, in addition to IVT treatment, successful and, in particular, complete reperfusion (mTICI3) strongly predicts good outcome, while time from symptom onset seemed to have a lower impact.
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Affiliation(s)
- Katharina Feil
- Department of Neurology, Ludwig Maximilians Universität (LMU), Munich, Germany.,Department of Neurology and Stroke, Eberhard-Karls University Tübingen/Universitätsklinikum Tübingen (UKT), Tübingen, Germany
| | - Maria Teresa Berndt
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Silke Wunderlich
- Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Kathleen Bernkopf
- Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | | | - Moriz Herzberg
- Institute of Neuroradiology, LMU, Munich, Germany.,Department of Radiology, University Hospital, Würzburg, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany
| | - Clemens Küpper
- Department of Neurology, Ludwig Maximilians Universität (LMU), Munich, Germany
| | - Johannes Wischmann
- Department of Neurology, Ludwig Maximilians Universität (LMU), Munich, Germany
| | - Sonja Schönecker
- Department of Neurology, Ludwig Maximilians Universität (LMU), Munich, Germany
| | - Konstantin Dimitriadis
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany
| | | | - Marianne Dieterich
- Department of Neurology, Ludwig Maximilians Universität (LMU), Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany.,German Center for Vertigo and Balance Disorders, LMU, Munich, Germany
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Lars Kellert
- Department of Neurology, Ludwig Maximilians Universität (LMU), Munich, Germany
| | - Tobias Boeckh-Behrens
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
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61
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Jalali N, Sadeghi Hokmabadi E, Ghoreishi A, Sariaslan P, Rafie S, Borhani-Haghighi A, Moghadam Ahmadi A, Azin H, Vakilian A, Khalili P, Farhoudi M. Outcome predictors in anterior and posterior ischemic strokes: a study based on the Iranian SITS registry. Sci Rep 2023; 13:1231. [PMID: 36681721 PMCID: PMC9867737 DOI: 10.1038/s41598-023-28465-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2022] [Accepted: 01/18/2023] [Indexed: 01/22/2023] Open
Abstract
Ischemic stroke is the major form of stroke with two separate vascular territories. Many risk factors are related to stroke outcomes in both territories. The present descriptive research was carried out on the basis of data obtained from the Safe Implementation of Treatments in Stroke (SITS) registry on Iranian intravenous thrombolysis ischemic stroke cases. Vascular territory involved in each case and three-month excellent outcome, functional independence, mortality rate, and brain hemorrhage occurrence were determined. Univariable and multivariable logistics regression analyses were utilized in order to investigate association of ischemic stroke outcomes with the vascular territory involved and other related factors. Among 1566 patients 95.4% was anterior circulation stroke patients and 4.6% was posterior circulation stroke cases. There is no significant association between vascular territory with mortality (OR of PCS vs ACS: 0.74, 95% CI 0.37-1.46), excellent functional outcome (OR 0.72, 95% CI 0.44-1.19), functional outcome (OR 0.86, 95% CI 0.52-1.42) and local hemorrhage (OR 0.98, 95% CI 0.30-3.21). Among major risk factors, age, diabetes, NIHSS score and admission duration, increased significantly odds of three-month mortality, excellent outcome, and functional independence in the multivariate analysis. The highest of odds was in NIHSS score with a dose-response association. The vascular territory was not an outcome predictor in ischemic strokes. The most important predictor was baseline NIHSS.
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Affiliation(s)
- Nazanin Jalali
- Department of Neurology, School of Medicine, Non-Communicable Diseases Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Elyar Sadeghi Hokmabadi
- Neurosciences Research Center, Neurology Department, Tabriz University of Medical Sciences, Tabriz, Iran
| | - Abdoreza Ghoreishi
- Stroke Research Group, Vali-E-Asr Hospital and Department of Neurology and Stroke Unit, School of Medicine, Zanjan University of Medical Sciences, Zanjan, Iran
| | - Payam Sariaslan
- Clinical Research Development Center, Imam Reza Hospital, Kermanshah University of Medical Sciences, Kermanshah, Iran
| | - Shahram Rafie
- Department of Neurology, School of Medicine, Ahvaz Jundishapur University of Medical Sciences, Ahvaz, Iran
| | | | - Amir Moghadam Ahmadi
- Department of Neurology, School of Medicine, Non-Communicable Diseases Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Hossein Azin
- Department of Neurology, School of Medicine, Non-Communicable Diseases Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Alireza Vakilian
- Department of Neurology, School of Medicine, Non-Communicable Diseases Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran.
| | - Parvin Khalili
- Department of Epidemiology, School of Public Health, Social Determinants of Health Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
| | - Mehdi Farhoudi
- Neurosciences Research Center, Neurology Department, Tabriz University of Medical Sciences, Tabriz, Iran
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62
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Broocks G, McDonough R, Bechstein M, Hanning U, Brekenfeld C, Flottmann F, Kniep H, Nawka MT, Deb-Chatterji M, Thomalla G, Sporns P, Yeo LL, Tan BY, Gopinathan A, Kastrup A, Politi M, Papanagiotou P, Kemmling A, Fiehler J, Meyer L. Benefit and risk of intravenous alteplase in patients with acute large vessel occlusion stroke and low ASPECTS. J Neurointerv Surg 2023; 15:8-13. [PMID: 35078927 DOI: 10.1136/neurintsurg-2021-017986] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 12/10/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND The benefit of best medical treatment including intravenous alteplase (IVT) before mechanical thrombectomy (MT) in patients with acute ischemic stroke and extensive early ischemic changes on baseline CT remains uncertain. The purpose of this study was to evaluate the benefit of IVT for patients with low ASPECTS (Alberta Stroke Programme Early CT Score) compared with patients with or without MT. METHODS This multicenter study pooled consecutive patients with anterior circulation acute stroke and ASPECTS≤5 to analyze the impact of IVT on functional outcome, and to compare bridging IVT with direct MT. Functional endpoints were the rates of good (modified Rankin Scale (mRS) score ≤2) and very poor (mRS ≥5) outcome at day 90. Safety endpoint was the occurrence of symptomatic intracranial hemorrhage (sICH). RESULTS 429 patients were included. 290 (68%) received IVT and 168 (39%) underwent MT. The rate of good functional outcome was 14.4% (95% CI 7.1% to 21.8%) for patients who received bridging IVT and 24.4% (95% CI 16.5% to 32.2%) for those who underwent direct MT. The rate of sICH was significantly higher in patients with bridging IVT compared with direct MT (17.8% vs 6.4%, p=0.004). In multivariable logistic regression analysis, IVT was significantly associated with very poor outcome (OR 2.22, 95% CI 1.05 to 4.73, p=0.04) and sICH (OR 3.44, 95% CI 1.18 to 10.07, p=0.02). Successful recanalization, age, and ASPECTS were associated with good functional outcome. CONCLUSIONS Bridging IVT in patients with low ASPECTS was associated with very poor functional outcome and an increased risk of sICH. The benefit of this treatment should therefore be carefully weighed in such scenarios. Further randomized controlled trials are required to validate our findings.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rosalie McDonough
- 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
| | - 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
| | - Fabian Flottmann
- 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
| | - Marie Teresa Nawka
- 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
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Sporns
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Diagnostic and Interventional Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Leonard Ll Yeo
- National University Health System and Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Benjamin Yq Tan
- National University Health System and Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Anil Gopinathan
- National University Health System and Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Andreas Kastrup
- Department of Neurology, Klinikum Bremen-Mitte gGmbH, Bremen, Germany
| | - Maria Politi
- Department of Neuroradiology, Klinikum Bremen-Mitte GmbH, Bremen, Germany
| | - Panagiotis Papanagiotou
- Department of Neuroradiology, Klinikum Bremen-Mitte GmbH, Bremen, Germany.,National and Kapodistrian University of Athens, Aretaiio Hospital, Athens, Greece
| | | | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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63
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Quandt F, Meißner N, Wölfer TA, Flottmann F, Deb-Chatterji M, Kellert L, Fiehler J, Goyal M, Saver JL, Gerloff C, Thomalla G, Tiedt S. RCT versus real-world cohorts: Differences in patient characteristics drive associations with outcome after EVT. Eur Stroke J 2022; 8:231-240. [PMID: 37021166 PMCID: PMC10069173 DOI: 10.1177/23969873221142642] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Accepted: 11/09/2022] [Indexed: 12/23/2022] Open
Abstract
Background: The selection of patients with large-vessel occlusion (LVO) stroke for endovascular treatment (EVT) depends on patient characteristics and procedural metrics. The relation of these variables to functional outcome after EVT has been assessed in numerous datasets from both randomized controlled trials (RCT) and real-world registries, but whether differences in their case mix modulate outcome prediction is unknown. Methods: We leveraged data from individual patients with anterior LVO stroke treated with EVT from completed RCTs from the Virtual International Stroke Trials Archive ( N = 479) and from the German Stroke Registry ( N = 4079). Cohorts were compared regarding (i) patient characteristics and procedural pre-EVT metrics, (ii) these variables’ relation to functional outcome, and (iii) the performance of derived outcome prediction models. Relation to outcome (functional dependence defined by a modified Rankin Scale score of 3–6 at 90 days) was analyzed by logistic regression models and a machine learning algorithm. Results: Ten out of 11 analyzed baseline variables differed between the RCT and real-world cohort: RCT patients were younger, had higher admission NIHSS scores, and received thrombolysis more often (all p < 0.0001). Largest differences at the level of individual outcome predictors were observed for age (RCT: adjusted odds ratio (aOR), 1.29 (95% CI, 1.10–1.53) vs real-world aOR, 1.65 (95% CI, 1.54–1.78) per 10-year increments, p < 0.001). Treatment with intravenous thrombolysis was not significantly associated with functional outcome in the RCT cohort (aOR, 1.64 (95 % CI, 0.91–3.00)), but in the real-world cohort (aOR, 0.81 (95% CI, 0.69–0.96); p for cohort heterogeneity = 0.056). Outcome prediction was more accurate when constructing and testing the model using real-world data compared to construction with RCT data and testing on real-world data (area under the curve, 0.82 (95% CI, 0.79–0.85) vs 0.79 (95% CI, 0.77–0.80), p = 0.004). Conclusions: RCT and real-world cohorts considerably differ in patient characteristics, individual outcome predictor strength, and overall outcome prediction model performance.
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Affiliation(s)
- Fanny Quandt
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nina Meißner
- Institute for Stroke and Dementia Research, University Hospital, LMU Munich, Munich, Germany
| | - Teresa A Wölfer
- Institute for Stroke and Dementia Research, University Hospital, LMU Munich, Munich, 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
| | - Lars Kellert
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mayank Goyal
- Department of Radiology, University of Calgary, Foothills Medical Centre, Calgary, AB, Canada
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research, University Hospital, LMU Munich, Munich, Germany
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Lehnen NC, Paech D, Zülow S, Bode FJ, Petzold GC, Radbruch A, Dorn F. First Experience with the Nimbus Stentretriever. Clin Neuroradiol 2022; 33:491-497. [DOI: 10.1007/s00062-022-01237-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 10/31/2022] [Indexed: 12/03/2022]
Abstract
Abstract
Purpose
To share our first experience with the Nimbus stentretriever, a multizone device designed to assist neurointerventionalists in handling fibrin-rich clots in endovascular stroke treatment.
Methods
We retrospectively analyzed the data of patients who were treated with the Nimbus stentretriever at our high-volume stroke center between May 2021 and May 2022. We evaluated the number of passes before Nimbus was used, the number of passes with nimbus, as well as the recanalization success before and after Nimbus according to the modified treatment in cerebral ischemia (mTICI) scale. Also, patient characteristics, procedural times and clinical outcomes were documented.
Results
A total of 21 consecutive patients were included in the study. An mTICI 2b/3 could be achieved in 76.2% and mTICI 2c/3 could be achieved in 57.1%. The mean number of passes was 3.4 before the use of Nimbus, 2.2 with Nimbus, and 5.4 for all passes with and without Nimbus and 4 occlusions (19.0%) were successfully recanalized with direct aspiration after the use of Nimbus. We observed seven subarachnoid hemorrhages (33.3%) and two cases of vasospasm.
Conclusion
In our series, the use of Nimbus resulted in successful recanalization in half of the patients after otherwise unsuccessful thrombectomy maneuvers; therefore, it should be considered as a rescue option if the maneuver with conventional stent retrievers was unsuccessful.
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Farouki Y, Bonnet T, Mine B, Hulscher F, Wang M, Elens S, Vazquez Suarez J, Jodaitis L, Ligot N, Naeije G, Walker G, Lubicz B, Guenego A. First-Pass Effect Predicts Clinical Outcome and Infarct Growth After Thrombectomy for Distal Medium Vessel Occlusions. Neurosurgery 2022; 91:913-919. [PMID: 36250706 DOI: 10.1227/neu.0000000000002129] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 06/28/2022] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The first-pass effect in endovascular thrombectomy (EVT) has been associated with better clinical outcomes and decreased stroke progression in large vessel occlusion but has not been evaluated in distal, medium vessel occlusions (DMVOs). OBJECTIVE To assess the impact on clinical outcome and stroke progression of the modified first-pass effect (defined as a successful first-pass [modified Thrombolysis In Cerebral Infarction 2b/2c/3] revascularization) in patients who underwent EVT for a primary DMVOs. METHODS We collected data from consecutive patients who underwent EVT for a primary DMVO at a single large academic center. We compared the rate of good clinical outcome (modified Rankin Scale of 0-2 at 3 months) and stroke progression between patients who demonstrated modified first-pass effect (mFPE) vs those who did not (no-mFPE). RESULTS Between January 2018 and January 2021, we included 60 patients who underwent EVT for an acute ischemic stroke with a primary DMVO. Overall, mFPE was achieved in 32% (19/60) of EVTs. The mFPE was associated with a higher rate of good clinical outcome compared with no-mFPE (89% vs 46%, odds ratio = 16.04 [2.23-115.39], P = .006 in multivariate analysis). Final stroke volume was less among mFPE patients (6.9 mL [4.7-13.6] vs 23 mL [14.6-47], P = .001) as was stroke progression (6.8 mL [4-12.1] vs 17.8 mL [8.1-34.9], P = .016). The mFPE was still associated with higher rates of good clinical outcome when compared with patients reaching an modified Thrombolysis In Cerebral Infarction score ≥2b in more than 1 pass (89% vs 53%; odds ratio = 7.37 [1.43-38.08], P = .017). CONCLUSION The mFPE may be associated with better clinical outcomes and lower stroke progression in DMVO.
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Affiliation(s)
- Yousra Farouki
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Thomas Bonnet
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Benjamin Mine
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Franny Hulscher
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Maud Wang
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium.,Department of Radiology, Leuven University Hospital, Leuven, Belgium
| | - Stephanie Elens
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Juan Vazquez Suarez
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Lise Jodaitis
- Department of Neurology, Erasme University Hospital, Brussels, Belgium
| | - Noémie Ligot
- Department of Neurology, Erasme University Hospital, Brussels, Belgium
| | - Gilles Naeije
- Department of Neurology, Erasme University Hospital, Brussels, Belgium
| | - Gregory Walker
- Department of Medicine, Division of Neurology, Royal Columbian Hospital, New Westminster, University of British Columbia, British Columbia, Canada
| | - Boris Lubicz
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Adrien Guenego
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
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Ueda T, Hasegawa Y, Takeuchi M, Morimoto M, Tsuboi Y, Yamamoto R, Kaku S, Ayabe J, Akiyama T, Ishima D, Mori K, Kagami H, Ito H, Onodera H, Doi H, Tsumoto T, Hataoka S, Noda M, Tomura N, Masuo O, Yoshida Y, Kaga Y, Tatsuno K, Yoshie T, Takaishi S, Yamano Y. Primary results of mechanical thrombectomy for acute ischemic stroke: The K-NET registry in the Japanese metropolitan area. Int J Stroke 2022; 18:607-614. [PMID: 36305084 DOI: 10.1177/17474930221138014] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endovascular treatment (EVT) for acute large vessel occlusion has proven to be effective in randomized controlled trials. We conducted a prospective cohort study to evaluate the real-world efficacy of EVT in a metropolitan area with a large number of comprehensive stroke centers and to compare it with the results of other registries and randomized controlled trials (RCTs). METHODS We analyzed the Kanagawa Intravenous and Endovascular Treatment of Acute Ischemic Stroke registry, a prospective, multicenter observational study of patients treated by EVT and/or intravenous tissue-type plasminogen activator (tPA). Of the 2488 patients enrolled from January 2018 to June 2020, 1764 patients treated with EVT were included. The primary outcome was a good outcome, which was defined as a modified Rankin Scale (mRS) of 0-2 at 90 days. Secondary analysis included predicting a good outcome using multivariate logistic regression analysis. RESULTS The median age was 77 years, and the median National Institute of Health Stroke Scale (NIHSS) score was 18. Pretreatment mRS score 0-2 was 87%, and direct transport was 92%. The rate of occlusion in anterior circulation was 90.3%. Successful recanalization was observed in 88.7%. The median time from onset to recanalization was 193 min. Good outcomes at 90 days were 43.3% in anterior circulation and 41.9% in posterior circulation. Overall mortality was 12.6%. Significant predictors for a good outcome were as follows: age, male, direct transfer, NIHSS score, Alberta Stroke Program Early Computed Tomography Score, intravenous tPA, and successful recanalization. CONCLUSION EVT in routine clinical use in a metropolitan area showed comparable good outcomes and lower mortality compared to previous studies, despite the high proportion of patients with older age, pretreatment mRS score of >2, posterior circulation occlusion, and higher NIHSS. Those results may have been associated with more direct transport and faster onset-to-recanalization times.
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Affiliation(s)
- Toshihiro Ueda
- Department of Strokology and Neuroendovascular Therapy, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan
| | | | | | | | | | | | - Shogo Kaku
- Neurosurgical East Yokohama Hospital, Yokohama, Japan
| | | | | | | | | | | | - Hidemichi Ito
- St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hidetaka Onodera
- St. Marianna University Yokohama Seibu Hospital, Yokohama, Japan
| | - Hiroshi Doi
- Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | | | - Shunsuke Hataoka
- National Hospital Organization, Yokohama Medical Center, Yokohama, Japan
| | - Masayuki Noda
- Yokohama Shinmidori General Hospital, Yokohama, Japan
| | | | - Osamu Masuo
- Yokohama Municipal Citizen's Hospital, Yokohama, Japan
| | | | - Yasuyuki Kaga
- St. Marianna University School of Medicine, Kawasaki, Japan
| | - Kentaro Tatsuno
- Department of Strokology and Neuroendovascular Therapy, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan
| | - Tomohide Yoshie
- Department of Strokology and Neuroendovascular Therapy, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan
| | - Satoshi Takaishi
- Department of Strokology and Neuroendovascular Therapy, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan
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Deb-Chatterji M, Flottmann F, Meyer L, Brekenfeld C, Fiehler J, Gerloff C, Thomalla G, Fiehler J, Thomalla G, Alegiani A, Boeckh-Behrens, Wunderlich S, Ernemann U, Poli S, Siebert E, Nolte CH, Zweynert S, Bohner G, Ludolph A, Henn KH, Schäfer JH, Keil F, Röther J, Eckert B, Berrouschot J, Bormann A, Dorn F, Petzold G, Kraemer C, Leischner H, Trumm C, Tiedt S, Kellert L, Petersen M, Stögbauer F, Braun M, Hamann GF, Gröschel K, Uphaus T, Reich A, Nikoubashman O, Schellinger P, Borggrefe J, Hattingen J, Liman J, Ernst M. Side matters: differences in functional outcome and quality of life after thrombectomy in left and right hemispheric stroke. Neurol Res Pract 2022; 4:58. [PMID: 36411484 PMCID: PMC9677692 DOI: 10.1186/s42466-022-00223-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2022] [Accepted: 10/12/2022] [Indexed: 11/22/2022] Open
Abstract
BACKGROUND Patients with a left (LHS) or right hemispheric stroke (RHS) differ in terms of clinical symptoms due to lateralization of specific cortical functions. Studies on functional outcome after stroke and endovascular thrombectomy (EVT) comparing both hemispheres showed conflicting results so far. The impact of stroke laterality on patient-reported health-related quality of life (HRQoL) after EVT has not yet been adequately addressed and still remains unclear. METHODS Consecutive stroke thrombectomy patients, derived from a multi-center, prospective registry (German Stroke Registry) between June 2015 and December 2019, were included in this study. At 90 days, outcome after EVT was assessed by the modified Rankin scale (mRS) and HRQoL using the European QoL-five dimensions questionnaire utility-index (EQ-5D-I; higher values indicate better HRQoL) in patients with LHS and RHS. Adjusted regression analysis was applied to evaluate the influence of stroke laterality on outcome after EVT. RESULTS In total, 5683 patients were analyzed. Of these, 2953 patients (52.8%) had LHS and 2637 (47.2%) RHS. LHS patients had a higher baseline NIHSS (16 vs. 13, p < 0.001) and a higher ASPECTS (9 vs. 8, p < 0.001) compared to RHS patients. Among survivors, patients with LHS less frequently had a self-reported affected mobility (p = 0.037), suffered less often from pain (p = 0.04) and anxiety/depression (p = 0.032) three months after EVT. After adjusting for confounders (age, sex, baseline NIHSS), LHS was associated with a better HRQoL (ß coefficient 0.04, CI 95% 0.017-0.063; p = 0.001), and better functional outcome assessed by lower values on the mRS (ß coefficient - 0.109, CI 95% - 0.217-0.000; p = 0.049). CONCLUSIONS Ninety days after EVT, LHS patients have a better functional outcome and HRQoL. Patients with RHS should be actively assessed and treated for pain, anxiety and depression to improve their HRQoL after EVT.
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Affiliation(s)
- Milani Deb-Chatterji
- grid.13648.380000 0001 2180 3484Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Fabian Flottmann
- grid.13648.380000 0001 2180 3484Department of Neuroradiological Diagnostics and Intervention, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- grid.13648.380000 0001 2180 3484Department of Neuroradiological Diagnostics and Intervention, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- grid.13648.380000 0001 2180 3484Department of Neuroradiological Diagnostics and Intervention, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- grid.13648.380000 0001 2180 3484Department of Neuroradiological Diagnostics and Intervention, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| | - Christian Gerloff
- grid.13648.380000 0001 2180 3484Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
| | - Götz Thomalla
- grid.13648.380000 0001 2180 3484Department of Neurology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246 Hamburg, Germany
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Chen S, Spring KJ, Killingsworth MC, Calic Z, Beran RG, Bhaskar SMM. Association of Lesion Topography with Functional Outcomes in Acute Ischemic Stroke Patients Considered for, or Receiving, Reperfusion Therapy: A Meta-Analysis. Neurol Int 2022; 14:903-922. [PMID: 36412695 PMCID: PMC9680454 DOI: 10.3390/neurolint14040073] [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: 09/23/2022] [Revised: 10/31/2022] [Accepted: 11/02/2022] [Indexed: 11/09/2022] Open
Abstract
Background: The impact of lesion topography (LT), characterised by the Alberta Stroke Programme Early CT Score (ASPECTS), on outcomes after reperfusion therapy in acute ischemic stroke (AIS) is poorly elucidated. We investigated the prognostic accuracy of ASPECTS-based LT assessment and its association with clinical outcomes in AIS patients considered for reperfusion therapy or receiving intravenous thrombolysis (IVT), endovascular thrombectomy (EVT), or none or both. Methods: Studies were identified from PubMed with additional studies added from Google Scholar. The prevalence of individual ASPECTS regions will also be determined. The association of individual ASPECTS regions with the functional outcome at 90 days will be assessed using random-effects modelling for various cut-offs, such as 6, 7 and 8. The association of continuous ASPECTS with the functional outcome at 90 days will also be undertaken. Forest plots of odds ratios (ORs) will be generated. Results: A total of 25 studies have been included in the final analysis, encompassing 11,404 patients. Pooled estimates indicate that the highest prevalence rates were in cases involving the insula and lentiform nucleus. Subgroup analysis for ASPECTS < 6 (OR 6.10; 95% CI 2.50−14.90; p < 0.0001), ASPECTS < 7 (OR 4.58; 95% CI 1.18−17.86; p < 0.0001) and ASPECTS < 8 (OR 2.26; 95% CI 1.32−3.89; p < 0.0001) revealed a significant association with poor functional outcome at 90 days. Decreasing ASPECTS significantly increased the odds of poor functional outcomes at 90 days (SMD −1.15; 95% CI −1.77−−0.52; p < 0.0001). Conclusions: Our meta-analysis demonstrates that decreasing ASPECTS is significantly associated with poor functional outcomes. Individual ASPECTS regions associated with the highest odds of poor functional outcomes were identified. Future studies on the association of LT and clinical outcomes specific to EVT are required.
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Affiliation(s)
- Shuyue Chen
- Global Health Neurology Lab, Sydney, NSW 2000, Australia
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, NSW 2170, Australia
- UNSW Medicine and Health, University of New South Wales (UNSW), South West Sydney Clinical Campuses, Sydney, NSW 2170, Australia
| | - Kevin J. Spring
- UNSW Medicine and Health, University of New South Wales (UNSW), South West Sydney Clinical Campuses, Sydney, NSW 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW 2170, Australia
- Medical Oncology Group, Liverpool Clinical School, Ingham Institute for Applied Medical Research and Western Sydney University (WSU), Sydney, NSW 2751, Australia
- School of Medicine, Western Sydney University, Sydney, NSW 2000, Australia
| | - Murray C. Killingsworth
- UNSW Medicine and Health, University of New South Wales (UNSW), South West Sydney Clinical Campuses, Sydney, NSW 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW 2170, Australia
- School of Medicine, Western Sydney University, Sydney, NSW 2000, Australia
- Department of Anatomical Pathology, NSW Health Pathology, Correlative Microscopy Facility, Ingham Institute for Applied Medical Research and Western Sydney University (WSU), Liverpool, NSW 2170, Australia
| | - Zeljka Calic
- Global Health Neurology Lab, Sydney, NSW 2000, Australia
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, NSW 2170, Australia
- UNSW Medicine and Health, University of New South Wales (UNSW), South West Sydney Clinical Campuses, Sydney, NSW 2170, Australia
- Department of Neurology & Neurophysiology, Liverpool Hospital & South West Sydney Local Health District (SWSLHD), Sydney, NSW 2170, Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, Sydney, NSW 2170, Australia
| | - Roy G. Beran
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, NSW 2170, Australia
- UNSW Medicine and Health, University of New South Wales (UNSW), South West Sydney Clinical Campuses, Sydney, NSW 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW 2170, Australia
- School of Medicine, Western Sydney University, Sydney, NSW 2000, Australia
- Department of Neurology & Neurophysiology, Liverpool Hospital & South West Sydney Local Health District (SWSLHD), Sydney, NSW 2170, Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, Sydney, NSW 2170, Australia
- Griffith Health, School of Medicine and Dentistry, Griffith University, Southport, QLD 4215, Australia
| | - Sonu M. M. Bhaskar
- Global Health Neurology Lab, Sydney, NSW 2000, Australia
- Neurovascular Imaging Laboratory, Ingham Institute for Applied Medical Research, Clinical Sciences Stream, Sydney, NSW 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW 2170, Australia
- Department of Neurology & Neurophysiology, Liverpool Hospital & South West Sydney Local Health District (SWSLHD), Sydney, NSW 2170, Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, Sydney, NSW 2170, Australia
- Correspondence: ; Tel.: +61-(02)-873-89179; Fax: +61-(02)-873-83648
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Cabrera D, Eizadi Sharifabad M, Ranjbar JA, Telling ND, Harper AGS. Clot-targeted magnetic hyperthermia permeabilizes blood clots to make them more susceptible to thrombolysis. J Thromb Haemost 2022; 20:2556-2570. [PMID: 35950914 PMCID: PMC9826519 DOI: 10.1111/jth.15846] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2021] [Revised: 07/12/2022] [Accepted: 08/03/2022] [Indexed: 01/11/2023]
Abstract
BACKGROUND Thrombolysis is a frontline treatment for stroke, which involves the application of tissue plasminogen activator (tPA) to trigger endogenous clot-degradation pathways. However, it is only effective within 4.5 h of symptom onset because of clot contraction preventing tPA permeation into the clot. Magnetic hyperthermia (MH) mediated by tumor-targeted magnetic nanoparticles is used to treat cancer by using local heat generation to trigger apoptosis of cancer cells. OBJECTIVES To develop clot-targeting magnetic nanoparticles to deliver MH to the surface of human blood clots, and to assess whether this can improve the efficacy of thrombolysis of contracted blood clots. METHODS Clot-targeting magnetic nanoparticles were developed by functionalizing iron oxide nanoparticles with an antibody recognizing activated integrin αIIbβ3 (PAC-1). The magnetic properties of the PAC-1-tagged magnetic nanoparticles were characterized and optimized to deliver clot-targeted MH. RESULTS Clot-targeted MH increases the efficacy of tPA-mediated thrombolysis in contracted human blood clots, leading to a reduction in clot weight. MH increases the permeability of the clots to tPA, facilitating their breakdown. Scanning electron microscopy reveals that this effect is elicited through enhanced fibrin breakdown and triggering the disruption of red blood cells on the surface of the clot. Importantly, endothelial cells viability in a three-dimensional blood vessel model is unaffected by exposure to MH. CONCLUSIONS This study demonstrates that clot-targeted MH can enhance the thrombolysis of contracted human blood clots and can be safely applied to enhance the timeframe in which thrombolysis is effective.
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Affiliation(s)
- David Cabrera
- School of Pharmacy and BioengineeringGuy Hilton Research Centre, Keele UniversityStoke‐on‐TrentUK
| | - Maneea Eizadi Sharifabad
- School of Pharmacy and BioengineeringGuy Hilton Research Centre, Keele UniversityStoke‐on‐TrentUK
| | - Jacob A. Ranjbar
- School of Pharmacy and BioengineeringGuy Hilton Research Centre, Keele UniversityStoke‐on‐TrentUK
| | - Neil D. Telling
- School of Pharmacy and BioengineeringGuy Hilton Research Centre, Keele UniversityStoke‐on‐TrentUK
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Liu H, He Y, Zhou T, Zhu L, Zhao Y, Ding Y, He Y, Li T. Evaluation of using a double helical, closed-cell stent-retriever (Skyflow) for thrombectomy procedures in acute arterial occlusion: A preclinical study and a clinical trial. J Interv Med 2022; 5:190-195. [DOI: 10.1016/j.jimed.2022.09.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Revised: 08/30/2022] [Accepted: 09/05/2022] [Indexed: 11/29/2022] Open
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Nadkarni NA, Arias E, Fang R, Haynes ME, Zhang HF, Muller WA, Batra A, Sullivan DP. Platelet Endothelial Cell Adhesion Molecule (PECAM/CD31) Blockade Modulates Neutrophil Recruitment Patterns and Reduces Infarct Size in Experimental Ischemic Stroke. THE AMERICAN JOURNAL OF PATHOLOGY 2022; 192:1619-1632. [PMID: 35952762 PMCID: PMC9667712 DOI: 10.1016/j.ajpath.2022.07.008] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/22/2022] [Revised: 07/05/2022] [Accepted: 07/14/2022] [Indexed: 12/15/2022]
Abstract
The infiltration of polymorphonuclear leukocytes (PMNs) in ischemia-reperfusion injury (I/RI) has been implicated as a critical component of inflammatory damage following ischemic stroke. However, successful blockade of PMN transendothelial migration (TEM) in preclinical studies has not translated to meaningful clinical outcomes. To investigate this further, leukocyte infiltration patterns were quantified, and these patterns were modulated by blocking platelet endothelial cell adhesion molecule-1 (PECAM), a key regulator of TEM. LysM-eGFP mice and microscopy were used to visualize all myeloid leukocyte recruitment following ischemia/reperfusion. Visual examination showed heterogeneous leukocyte distribution across the infarct at both 24 and 72 hours after I/RI. A semiautomated process was designed to precisely map PMN position across brain sections. Treatment with PECAM function-blocking antibodies did not significantly affect total leukocyte recruitment but did alter their distribution, with more observed at the cortex at both early and later time points (24 hours: 89% PECAM blocked vs. 72% control; 72 hours: 69% PECAM blocked vs. 51% control). This correlated with a decrease in infarct volume. These findings suggest that TEM, in the setting of I/RI in the cerebrovasculature, occurs primarily at the cortical surface. The reduction of stroke size with PECAM blockade suggests that infiltrating PMNs may exacerbate I/RI and indicate the potential therapeutic benefit of regulating the timing and pattern of leukocyte infiltration after stroke.
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Affiliation(s)
- Neil A Nadkarni
- Department of Neurology, Northwestern University, Chicago, Illinois
| | - Erika Arias
- Department of Pathology, Northwestern University, Chicago, Illinois
| | - Raymond Fang
- Department of Biomedical Engineering, Northwestern University, Chicago, Illinois
| | - Maureen E Haynes
- Department of Pathology, Northwestern University, Chicago, Illinois
| | - Hao F Zhang
- Department of Biomedical Engineering, Northwestern University, Chicago, Illinois
| | - William A Muller
- Department of Pathology, Northwestern University, Chicago, Illinois
| | - Ayush Batra
- Department of Neurology, Northwestern University, Chicago, Illinois; Department of Pathology, Northwestern University, Chicago, Illinois
| | - David P Sullivan
- Department of Pathology, Northwestern University, Chicago, Illinois.
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Lu Q, Zhang H, Cao X, Fu J, Pan Y, Zheng X, Wang J, Geng D, Zhang J. Quantitative collateral score for the prediction of clinical outcomes in stroke patients: Better than visual grading. Front Neurosci 2022; 16:980135. [PMID: 36389251 PMCID: PMC9641373 DOI: 10.3389/fnins.2022.980135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 10/04/2022] [Indexed: 11/24/2022] Open
Abstract
Objectives To identify preoperative prognostic factors for acute ischemic stroke (AIS) patients receiving mechanical thrombectomy (MT) and compare the performance of quantitative collateral score (qCS) and visual collateral score (vCS) in outcome prediction. Methods Fifty-five patients with AIS receiving MT were retrospectively enrolled. qCS was defined as the percentage of the volume of collaterals of both hemispheres. Based on the dichotomous outcome assessed using a 90-day modified Rankin Scale (mRS), we compared qCS, vCS, age, sex, National Institute of Health stroke scale score, etiological subtype, platelet count, international normalized ratio, glucose levels, and low-density lipoprotein cholesterol (LDL-C) levels between favorable and unfavorable outcome groups. Logistic regression analysis was performed to determine the effect on the clinical outcome. The discriminatory power of qCS, vCS, and their combination with cofounders for determining favorable outcomes was tested with the area under the receiver-operating characteristic curve (AUC). Results vCS, qCS, LDL-C, and age could all predict clinical outcomes. qCS is superior over vCS in predicting favorable outcomes with a relatively higher AUC value (qCS vs. vCS: 0.81 vs. 0.74) and a higher sensitivity rate (qCS vs. vCS: 72.7% vs. 40.9%). The prediction power of qCS + LDL-C + age was best with an AUC value of 0.91, but the accuracy was just increased slightly compared to that of qCS alone. Conclusion Collateral scores, LDL-C and age were independent prognostic predictors for patients with AIS receiving MT; qCS was a better predictor than vCS. Furthermore, qCS + LDL-C + age offers a strong prognostic prediction power and qCS alone was another good choice for predicting clinical outcome.
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Affiliation(s)
- Qingqing Lu
- State Key Laboratory of Medical Neurobiology, Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
- Department of Radiology, Ningbo First Hospital, Ningbo, China
| | - Haiyan Zhang
- State Key Laboratory of Medical Neurobiology, Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Xin Cao
- State Key Laboratory of Medical Neurobiology, Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Junyan Fu
- State Key Laboratory of Medical Neurobiology, Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yuning Pan
- Department of Radiology, Ningbo First Hospital, Ningbo, China
| | - Xiaodong Zheng
- Department of Radiology, Ningbo First Hospital, Ningbo, China
| | - Jianhong Wang
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
- *Correspondence: Jianhong Wang,
| | - Daoying Geng
- State Key Laboratory of Medical Neurobiology, Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
- National Center for Neurological Disorders, Shanghai, China
- Daoying Geng,
| | - Jun Zhang
- State Key Laboratory of Medical Neurobiology, Department of Radiology, Huashan Hospital, Fudan University, Shanghai, China
- Center for Shanghai Intelligent Imaging for Critical Brain Diseases Engineering and Technology Research, Huashan Hospital, Fudan University, Shanghai, China
- Jun Zhang,
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Xu C, Jin T, Chen Z, Zhang Z, Zhang K, Mao H, Ye S, Geng Y, Shi Z. Increased blood pressure variability during general anaesthesia is associated with worse outcomes after mechanical thrombectomy: a prospective observational cohort study. BMJ Open 2022; 12:e059108. [PMID: 36198453 PMCID: PMC9535158 DOI: 10.1136/bmjopen-2021-059108] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
OBJECTIVES Optimal periprocedural blood pressure (BP) management during mechanical thrombectomy (MT) for acute ischaemic stroke is still controversial. The aim of this study was to investigate the association between intraprocedural BP variability (BPV) and outcomes in patients with large vessel occlusion (LVO) following MT with general anaesthesia. DESIGN A prospective observational cohort study. SETTING This study was conducted in a single tertiary hospital of Hangzhou in Zhejiang province. PARTICIPANTS A total of 141 patients with LVO treated with MT were finally included between January 2018 and September 2020. MAIN OUTCOME MEASURES Intraprocedural BP was recorded every 5 min throughout the procedure. BPV was measured as SD, coefficient of variation (CV), max-min (RANGE) and successive variation. Haemorrhagic transformation was assessed on 24-hour CT images according to European Cooperative Acute Stroke Study III trial. Poor functional outcome was defined as 90-day modified Rankin Scale score 3-6. Binary logistic regression analysis was used to investigate the association of BPV parameters with the incidence of parenchymal haemorrhage (PH) and poor functional outcome. RESULTS After controlling for age, female, history of smoking, hypertension and atrial fibrillation, baseline National Institutes of Health Stroke Scale, baseline systolic BP (SBP), baseline Alberta Stroke Program Early CT Score, bridging thrombolysis and times of retrieval attempts, the results demonstrated that intraprocedural SBPRANGE (OR 1.029; 95% CI 1.003 to 1.055; p=0.027), SBPSD (OR 1.135; 95% CI 1.023 to 1.259; p=0.017) and SBPCV (OR 1.189; 95% CI 1.053 to 1.342; p=0.005) were independently associated with poor functional outcome. However, the independent association between intraprocedural BPV and PH at 24 hours has not been established in this study. CONCLUSIONS Increased intraprocedural BPV was more likely to have poor functional outcome in patients with LVO following MT with general anaesthesia. This finding indicates that special precautions should be taken to minimise BP fluctuation during procedure.
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Affiliation(s)
- Chao Xu
- Department of Neurology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Tianyu Jin
- Department of Neurology, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Zhicai Chen
- Department of Neurology, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, Zhejiang, China
| | - Zheyu Zhang
- Department of Neurology, Zhejiang Chinese Medical University, Hangzhou, Zhejiang, China
| | - Kemeng Zhang
- Department of Neurology, Zhejiang University School of Medicine Second Affiliated Hospital, Hangzhou, Zhejiang, China
| | - Hui Mao
- Department of Anesthesiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Sasa Ye
- Department of Radiology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Yu Geng
- Department of Neurology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Zongjie Shi
- Department of Neurology, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
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Broocks G, Hanning U, Bechstein M, Elsayed S, Faizy TD, Brekenfeld C, Flottmann F, Kniep H, Deb-Chatterji M, Schön G, Thomalla G, Kemmling A, Fiehler J, Meyer L. Association of Thrombectomy With Functional Outcome for Patients With Ischemic Stroke Who Presented in the Extended Time Window With Extensive Signs of Infarction. JAMA Netw Open 2022; 5:e2235733. [PMID: 36239941 PMCID: PMC9568804 DOI: 10.1001/jamanetworkopen.2022.35733] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
IMPORTANCE Only limited data are available about a potential benefit associated with endovascular treatment (EVT) for patients with ischemic stroke presenting in the extended time window who also show signs of extensive infarction. OBJECTIVE To assess the association of recanalization after EVT with functional outcomes for patients with ischemic stroke presenting in the extended time window who also show signs of extensive infarction. DESIGN, SETTING, AND PARTICIPANTS This retrospective, multicenter cohort study included patients enrolled in the German Stroke Registry-Endovascular Treatment with an Alberta Stroke Program Early CT Score (ASPECTS) of 5 or less who presented between 6 and 24 hours after stroke onset and underwent computed tomography and subsequent EVT between July 1, 2015, and December 31, 2019. MAIN OUTCOMES AND MEASURES The primary end point was a modified Rankin Scale (mRS) score of 3 or less at day 90. The association between recanalization (defined as the occurrence of a modified Thrombolysis in Cerebral Infarction Scale score of 2b or 3) and outcome was assessed using logistic regression and inverse probability weighting analysis. INTERVENTION Endovascular treatment. RESULTS Of 5853 patients, 285 (5%; 146 men [51%]; median age, 73 years [IQR, 62-81 years]) met the inclusion criteria and were analyzed. Of these 285 patients, 79 (27.7%) had an mRS score of 3 or less at day 90. The rate of successful recanalization was 75% (215 of 285) and was independently associated with a higher probability of reaching an mRS score of 3 or less (adjusted odds ratio, 4.39; 95% CI, 1.79-10.72; P < .001). In inverse probability weighting analysis, a modified Thrombolysis in Cerebral Infarction Scale score of 2b or 3 was associated with a 19% increase (95% CI, 9%-29%; P < .001) in the probability for an mRS score of 3 or more. Multivariable logistic regression analysis suggested a significant treatment benefit associated with vessel recanalization in a time window of up to 17.6 hours and ASPECTS of 3 to 5. The rate of secondary symptomatic intracerebral hemorrhage was 6.3% (18 of 285). CONCLUSIONS AND RELEVANCE In this cohort study reflecting daily clinical practice, vessel recanalization for patients with a low ASPECTS and extended time window was associated with better functional outcomes in a time window up to 17.6 hours and ASPECTS of 3 to 5. The results of this study encourage current randomized clinical trials to enroll patients with a low ASPECTS, even within the extended time window.
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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
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sarah Elsayed
- 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
| | - Caspar Brekenfeld
- 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
| | - Helge Kniep
- 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
| | - Gerhard Schön
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - André Kemmling
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Weller JM, Dorn F, Meissner JN, Stösser S, Beckonert NM, Nordsiek J, Kindler C, Riegler C, Keil F, Petzold GC, Bode FJ. Antithrombotic treatment and outcome after endovascular treatment and acute carotid artery stenting in stroke patients with atrial fibrillation. Neurol Res Pract 2022; 4:42. [PMID: 36089621 PMCID: PMC9465921 DOI: 10.1186/s42466-022-00207-7] [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: 05/23/2022] [Accepted: 07/22/2022] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Oral anticoagulation (OAC) is the mainstay of secondary prevention in ischemic stroke patients with atrial fibrillation (AF). However, in AF patients with large vessel occlusion stroke treated by endovascular therapy (ET) and acute carotid artery stenting (CAS), the optimal antithrombotic medication remains unclear. METHODS This is a subgroup analysis of the German Stroke Registry-Endovascular Treatment (GSR-ET), a prospective multicenter cohort of patients with large vessel occlusion stroke undergoing ET. Patients with AF and CAS during ET were included. We analyzed baseline and periprocedural characteristics, antithrombotic strategies and functional outcome at 90 days. RESULTS Among 6635 patients in the registry, a total of 82 patients (1.2%, age 77.9 ± 8.0 years, 39% female) with AF and extracranial CAS during ET were included. Antithrombotic medication at admission, during ET, postprocedural and at discharge was highly variable and overall mortality in hospital (21%) and at 90 days (39%) was high. Among discharged patients (n = 65), most frequent antithrombotic regimes were dual antiplatelet therapy (DAPT, 37%), single APT + OAC (25%) and DAPT + OAC (20%). Comparing DAPT to single or dual APT + OAC, clinical characteristics at discharge were similar (median NIHSS 7.5 [interquartile range, 3-10.5] vs 7 [4-11], p = 0.73, mRS 4 [IQR 3-4] vs. 4 [IQR 3-5], p = 0.79), but 90-day mortality was higher without OAC (32 vs 4%, p = 0.02). CONCLUSIONS In AF patients who underwent ET and CAS, 90-day mortality was higher in patients not receiving OAC. REGISTRATION https://www. CLINICALTRIALS gov ; Unique identifier: NCT03356392.
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Affiliation(s)
- Johannes M Weller
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Franziska Dorn
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Julius N Meissner
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Sebastian Stösser
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Niklas M Beckonert
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Julia Nordsiek
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Christine Kindler
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Christoph Riegler
- Department of Neurology and Center for Stroke Research Berlin, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Fee Keil
- Division of Neuroradiology, University Hospital Frankfurt, Frankfurt, Germany
| | - Gabor C Petzold
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Felix J Bode
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
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76
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Tiedt S, Buchan AM, Dichgans M, Lizasoain I, Moro MA, Lo EH. The neurovascular unit and systemic biology in stroke - implications for translation and treatment. Nat Rev Neurol 2022; 18:597-612. [PMID: 36085420 DOI: 10.1038/s41582-022-00703-z] [Citation(s) in RCA: 30] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/22/2022] [Indexed: 12/24/2022]
Abstract
Ischaemic stroke is a leading cause of disability and death for which no acute treatments exist beyond recanalization. The development of novel therapies has been repeatedly hindered by translational failures that have changed the way we think about tissue damage after stroke. What was initially a neuron-centric view has been replaced with the concept of the neurovascular unit (NVU), which encompasses neuronal, glial and vascular compartments, and the biphasic nature of neural-glial-vascular signalling. However, it is now clear that the brain is not the private niche it was traditionally thought to be and that the NVU interacts bidirectionally with systemic biology, such as systemic metabolism, the peripheral immune system and the gut microbiota. Furthermore, these interactions are profoundly modified by internal and external factors, such as ageing, temperature and day-night cycles. In this Review, we propose an extension of the concept of the NVU to include its dynamic interactions with systemic biology. We anticipate that this integrated view will lead to the identification of novel mechanisms of stroke pathophysiology, potentially explain previous translational failures, and improve stroke care by identifying new biomarkers of and treatment targets in stroke.
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Affiliation(s)
- Steffen Tiedt
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA), . .,Institute for Stroke and Dementia Research (ISD), University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany.
| | - Alastair M Buchan
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA).,Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Martin Dichgans
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA).,Institute for Stroke and Dementia Research (ISD), University Hospital, Ludwig-Maximilians-Universität München, Munich, Germany.,German Center for Neurodegenerative Diseases (DZNE), Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany
| | - Ignacio Lizasoain
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA).,Department of Pharmacology and Toxicology, Complutense Medical School, Instituto de Investigación Hospital 12 de Octubre, Madrid, Spain
| | - Maria A Moro
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA).,Centro Nacional de Investigaciones Cardiovasculares, CNIC, Madrid, Spain
| | - Eng H Lo
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA), . .,Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA. .,Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
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77
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Stoll G, Schuhmann MK, Nieswandt B, Kollikowski AM, Pham M. An intravascular perspective on hyper-acute neutrophil, T-cell and platelet responses: Similarities between human and experimental stroke. J Cereb Blood Flow Metab 2022; 42:1561-1567. [PMID: 35676801 PMCID: PMC9441733 DOI: 10.1177/0271678x221105764] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In stroke patients, local sampling of pial blood within the occluded vasculature before recanalization by mechanical thrombectomy emerged as powerful tool enabling insights into ultra-early stroke pathophysiology. Thereby, a strong intravascular inflammatory response hallmarked by hyper-acute neutrophil recruitment, altered lymphocyte composition and platelet activation could be observed. These human findings mirror experimental stroke. Here, neutrophil and T-cell activation are driven by platelets involving engagement of platelet glycoprotein receptor (GP)Ib, GPVI and CD84 as well as α-granule release orchestrating infarct progression. Thus, targeting of early intravascular inflammation may evolve as a new therapeutic strategy to augment the effects of recanalization.
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Affiliation(s)
- Guido Stoll
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | | | - Bernhard Nieswandt
- Institute for Experimental Biomedicine and Rudolf-Virchow-Center, University of Würzburg, Würzburg, Germany
| | | | - Mirko Pham
- Department of Neuroradiology, University of Würzburg, Würzburg, Germany
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78
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Pan XH, Qiu K, Zhu FY, Shi HB, Liu S. Immediate postinterventional flat-panel CT: Differentiation of hemorrhagic transformation from contrast exudation of acute ischemic stroke patients after thrombectomy. Acta Radiol 2022; 64:1600-1607. [PMID: 36036263 DOI: 10.1177/02841851221122429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Flat-panel computed tomography (CT) is an available imaging modality immediately after endovascular thrombectomy without transferring patients to the CT room. PURPOSE To determine the accuracy of flat-panel CT scans in differentiating hemorrhagic transformation (HT) from contrast exudation after thrombectomy in patients with acute ischemic stroke (AIS). MATERIAL AND METHODS From January 2019 to December 2021, consecutive patients with AIS who received an immediate flat-panel CT scan and follow-up neuroimaging after thrombectomy were enrolled in our study. The receiver operating characteristic curve was adopted to assess the discriminating accuracy of characteristics of flat-panel CT for HT. RESULTS A total of 108 patients were enrolled in the study; 58 (53.7%) patients presented with hyperdense lesions on flat-panel CT. Patients with hyperdense lesions experienced a higher proportion of HT than patients without (58.7% vs. 10.0%; P < 0.001). Among all patients with hyperdensity on flat-panel CT, patients who experienced HT had higher average Hounsfield units (HUavg) (125 vs. 93; P = 0.001) and a higher proportion of mass effect (67.6 vs. 12.5; P < 0.001). The flat-panel CT differentiating HT from contrast exudation yielded a sensitivity of 87.2% and a negative predictive value of 90.0%. The area under the curve of HUavg, mass effect, and combination for differentiation of HT were 0.74, 0.78, and 0.83, respectively. CONCLUSION The hyperdensity on immediately post-thrombectomy flat-panel CT could differentiate HT from contrast exudation with an excellent negative predictive value. The ability of flat-panel CT in differentiating HT from contrast exudation was improved when combined with HUavg and mass effect.
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Affiliation(s)
- Xiao-Hu Pan
- Department of Neurology, Xuyi People's Hospital, Xuyi, PR China
| | - Kai Qiu
- Department of Interventional Radiology, 74734The First Affiliated Hospital with Nanjing Medical University, Nanjing, PR China
| | - Fa-Yong Zhu
- Department of Neurology, Xuyi People's Hospital, Xuyi, PR China
| | - Hai-Bin Shi
- Department of Interventional Radiology, 74734The First Affiliated Hospital with Nanjing Medical University, Nanjing, PR China
| | - Sheng Liu
- Department of Interventional Radiology, 74734The First Affiliated Hospital with Nanjing Medical University, Nanjing, PR China
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Li ZS, Zhong HL, Zhou TF, He YK, Li Q, Wang ZL, Zhu LF, Wen CM, Han JF, Li TX. Unequal Efficacy of Different Infarct Location in Predicting Futile Recanalization of Patients With Acute Ischemic Stroke. Front Neurol 2022; 13:928773. [PMID: 36090854 PMCID: PMC9462394 DOI: 10.3389/fneur.2022.928773] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
Objectives Endovascular thrombectomy (EVT) is a standard treatment for acute ischemic stroke (AIS) caused by large vessel occlusion, while futile recanalization is the main factor influencing the prognosis. The present study aimed to investigate the efficacy of different infarct sites in predicting futile recanalization of patients with AIS. Methods Data were obtained from two multicenter, prospective, randomized, and controlled trials, which were concurrently conducted in China. Cases achieving a successful recanalization and with complete data of preoperative Alberta Stroke Program Early CT score (ASPECTS) and 90-day follow-up were included. The ASPECTS subregions were used to mark different infarct locations in the two cerebral hemispheres. First, the distribution of each ASPECTS subregion in the left and right hemispheres and the whole brain was analyzed, respectively. Then, the regions associated with futile recanalization were initially assessed by a univariate model. Afterward, a multivariate logistic regression model was used to identify the efficacy of different infarct sites in predicting futile recanalization. Results A total of 336 patients were included in this study with a median age of 65 years (IQR: 51–74), of whom 210 (62.50%) patients were male, and 189 (56.25%) met the definition of futile recanalization. The correlation between each ASPECTS subregion and poor outcome was different when it was restricted to a specific cerebral hemisphere. Moreover, in the left hemisphere, the internal capsule region (OR: 1.42, 95%CI: 1.13–1.95, P = 0.03) and the M3 region (OR: 2.26, 95%CI: 1.36–3.52, P = 0.001), and in the right hemisphere, M6 region (OR: 2.24, 95%CI: 1.32–3.36, P = 0.001) showed significantly higher efficacy in predicting futile recanalization. Conclusion The efficacy of different infarct locations in predicting futile recanalization is different. Different preoperative patterns of the high-efficiency regions in the infarction core or penumbra can guide the thrombectomy decision-making.
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Affiliation(s)
- Zhao-shuo Li
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Hai-long Zhong
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Teng-fei Zhou
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Ying-kun He
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Qiang Li
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Zi-liang Wang
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Liang-fu Zhu
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Zhengzhou, China
| | - Chang-ming Wen
- Department of Neurology, Nanyang Central Hospital, Nanyang, China
| | - Jian-feng Han
- Department of Neurology, Xi'an Jiaotong University Medical College First Affiliated Hospital, Xi'an, China
| | - Tian-xiao Li
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Zhengzhou, China
- *Correspondence: Tian-xiao Li
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Schaefer JH, Kurka N, Keil F, Wagner M, Steinmetz H, Pfeilschifter W, Bohmann FO. Endovascular treatment for ischemic stroke with the drip-and-ship model—Insights from the German Stroke Registry. Front Neurol 2022; 13:973095. [PMID: 36081874 PMCID: PMC9445809 DOI: 10.3389/fneur.2022.973095] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2022] [Accepted: 07/22/2022] [Indexed: 11/21/2022] Open
Abstract
Background Endovascular therapy (EVT) in acute ischemic stroke has been widely established. Globally, stroke patients are transferred either directly to a thrombectomy center (DC) or a peripheral stroke unit with a “drip-and-ship” (DS) model. We aimed to determine differences between the DS and DC paradigms after EVT of acute stroke patients with large-vessel-occlusion (LVO) in the database of the German Stroke Registry (GSR). Methods We performed a retrospective analysis of GSR patients between June 2015 and December 2019 in 23 German centers. Primary outcome was an ordinal shift analysis of modified Rankin Scale (mRS) 90 days after index event. Secondary endpoints included time from symptom onset to recanalization and complications. Tertiary endpoint was the association of imaging strategies in DS admissions with outcome. Results 2,813 patients were included in the DS and 3,819 in the DC group. After propensity score matching mRS after 90 days was higher in DS than DC admissions (OR 1.26; 95%-CI 1.13–1.40). Time from symptom-onset to flow-restoration was shorter in DC than DS (median 199.0 vs. 298.0 min; p < 0.001). DS patients undergoing magnetic resonance imaging (MRI; n=183) before EVT had a lower 90-day mRS than without (n = 944) (OR 0.63; 95%-CI 0.45–0.88). ASPECTS assessed on MRI correlated with 90-day mRS (ρ = −0.326; p < 0.001). Conclusions Clinical outcome was worse for EVT-eligible patients in the DS setting, even though patients were in a better state of health prior to stroke. A potentially mutable factor was the time delay of 99 min from symptom-onset to successful recanalization. Performing MRI before thrombectomy was associated with good outcome and MRI-ASPECTS was negatively correlated with mRS after 90 days.
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Affiliation(s)
- Jan Hendrik Schaefer
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
- *Correspondence: Jan Hendrik Schaefer
| | - Natalia Kurka
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Fee Keil
- Department of Neuroradiology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Marlies Wagner
- Department of Neuroradiology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Helmuth Steinmetz
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
| | - Waltraud Pfeilschifter
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
- Department of Neurology, Klinikum Lüneburg, Lüneburg, Germany
| | - Ferdinand O. Bohmann
- Department of Neurology, University Hospital Frankfurt, Goethe-University, Frankfurt am Main, Germany
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81
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Middle Cerebral Artery M2 Thrombectomy: Safety and Technical Considerations in the German Stroke Registry (GSR). J Clin Med 2022; 11:jcm11154619. [PMID: 35956233 PMCID: PMC9369518 DOI: 10.3390/jcm11154619] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 08/05/2022] [Accepted: 08/05/2022] [Indexed: 11/16/2022] Open
Abstract
There is ongoing debate concerning the safety and efficacy of various mechanical thrombectomy (MT) approaches for M2 occlusions. We compared these for MT in M2 versus M1 occlusions. Subgroup analyses of different technical approaches within the M2 MT cohort were also performed. Patients were included from the German Stroke Registry (GSR), a multicenter registry of consecutive MT patients. Primary outcomes were reperfusion success events. Secondary outcomes were early clinical improvement (improvement in NIHSS score > 4) and independent survival at 90 days (mRS 0−2). Out of 3804 patients, 2689 presented with M1 (71%) and 1115 with isolated M2 occlusions (29%). The mean age was 76 (CI 65−82) and 77 (CI 66−83) years, respectively. Except for baseline NIHSS (15 (CI 10−18) vs. 11 (CI 6−16), p < 0.001) and ASPECTS (9 (CI 7−10) vs. 9 (CI 8−10, p < 0.001), baseline demographics were balanced. Apart from a more frequent use of dedicated small vessel stent retrievers (svSR) in M2 (17.4% vs. 3.0; p < 0.001), intraprocedural aspects were balanced. There was no difference in ICH at 24 h (11%; p = 1.0), adverse events (14.4% vs. 18.1%; p = 0.63), clinical improvement (62.5% vs. 61.4 %; p = 0.57), mortality (26.9% vs. 22.9%; p = 0.23). In M2 MT, conventional stent retriever (cSR) achieved higher rates of mTICI3 (54.0% vs. 37.7−42.0%; p < 0.001), requiring more MT-maneuvers (7, CI 2−8) vs. 2 (CI 2−7)/(CI 2−2); p < 0.001) and without impact on efficacy and outcome. Real-life MT in M2 can be performed with equal safety and efficacy as in M1 occlusions. Different recanalization techniques including the use of svSR did not result in significant differences regarding safety, efficacy and outcome.
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Kniep H, Bechstein M, Broocks G, Brekenfeld C, Flottmann F, van Horn N, Geest V, Faizy TD, Deb‐Chatterji M, Alegiani A, Thomalla G, Gellißen S, Fiehler J, Hanning U, Meyer L. Early Surrogates of Outcome after Thrombectomy in Posterior Circulation Stroke. Eur J Neurol 2022; 29:3296-3306. [DOI: 10.1111/ene.15519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/30/2022] [Accepted: 08/01/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Vincent Geest
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Tobias D. Faizy
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | | | - Anna Alegiani
- Department of Neurology, Asklepios Klinik Altona Hamburg Germany
| | - Götz Thomalla
- Department of Neurology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Susanne Gellißen
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
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83
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Shen JZ, Martin KD, Malla G, Lin C. Rural-urban differences in functional outcomes after acute stroke therapy within the stroke belt. Clin Neurol Neurosurg 2022; 219:107346. [DOI: 10.1016/j.clineuro.2022.107346] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Revised: 05/27/2022] [Accepted: 06/19/2022] [Indexed: 11/29/2022]
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Sprügel MI, Sembill JA, Kremer S, Gerner ST, Knott M, Hock S, Engelhorn T, Dörfler A, Huttner HB, Schwab S. Evaluation of Functional Recovery Following Thrombectomy in Patients With Large Vessel Occlusion and Prestroke Disability. JAMA Netw Open 2022; 5:e2227139. [PMID: 35972737 PMCID: PMC9382438 DOI: 10.1001/jamanetworkopen.2022.27139] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
IMPORTANCE It is uncertain whether thrombectomy is associated with benefits in patients with prestroke disability. OBJECTIVE To evaluate the use of thrombectomy for patients with large vessel occlusion and prestroke disability. DESIGN, SETTING, AND PARTICIPANTS This cohort study included patients with large vessel occlusion stroke and prestroke disability (modified Rankin Scale score, 3 or 4) admitted to a single tertiary care center between January 1, 2006, and June 30, 2019 (controls: 2006-2015; thrombectomy: 2015-2019). Follow-up was conducted at 90 days. Data analysis was performed from November 1 to December 31, 2021. EXPOSURES Use of thrombectomy vs no thrombectomy. MAIN OUTCOMES AND MEASURES The primary outcome was functional recovery at 90 days defined as clinical recovery to the functional status before stroke onset. Secondary outcomes included functional dependency, mortality, early neurologic improvement, and recanalization. RESULTS Among 205 patients (149 women [72.7%]; median age, 82 years [IQR, 75-87 years]), 102 individuals (49.8%) received thrombectomy and 103 (50.2%) were controls. Thrombectomy was significantly associated with functional recovery (thrombectomy, 20 [19.6%]; controls, 8 [7.8%]; adjusted difference, 9.4%; 95% CI, 2.2% to 16.7%; P = .005). Secondary outcomes showed differences in mortality, early neurologic improvement, and recanalization in favor of thrombectomy treatment. The rate of functional dependency did not differ significantly between the 2 groups (adjusted difference, 8.9%; 95% CI, -2.5% to 20.2%; P = .13). The rate of functional recovery after thrombectomy was 44.0% for patients with early neurologic improvement, 29.4% for patients with small infarct volume (<50 mL), and 7.0% for patients with neither of these parameters. CONCLUSIONS AND RELEVANCE Findings of this study suggest that selected patients with prestroke disability may benefit from thrombectomy. However, the thrombectomy-associated increase in functional recovery was small. Therefore, routine use of thrombectomy may not be beneficial among patients with a large ischemic core and infarct volumes less than 50 mL may be necessary to obtain functional recovery. Patients with higher chances of functional recovery are also at an increased risk of survival with substantial disability, indicating potential harms from the intervention; further studies are needed.
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Affiliation(s)
- Maximilian I. Sprügel
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Jochen A. Sembill
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Svenja Kremer
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Stefan T. Gerner
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Michael Knott
- Department of Neuroradiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Stefan Hock
- Department of Neuroradiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Tobias Engelhorn
- Department of Neuroradiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Arnd Dörfler
- Department of Neuroradiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Hagen B. Huttner
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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85
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Jang SH, Choi KH. Effects of atrial fibrillation on motor outcome in patients with cerebral infarction. Medicine (Baltimore) 2022; 101:e29549. [PMID: 35839007 PMCID: PMC11132401 DOI: 10.1097/md.0000000000029549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 04/21/2022] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Atrial fibrillation (AF) has been a leading cause of cerebral infarction, but the association with motor outcome after cerebral infarction remains unreported. In this study, we attempted to identify whether AF affects motor outcomes after cerebral infarction. METHODS Seventy-six patients with a first-incidence cerebral infarction and who completed 6 months of rehabilitation were recruited to this retrospective study. The patients were divided into two groups based on the presence of AF (AF and non-AF groups). The upper extremity motricity index, lower extremity motricity index (LMI), modified Brunnstrom classification, and functional ambulation category (FAC) were evaluated, and those results were obtained within the first day and after 6 months of onset. Clinical factors that could affect motor outcome after cerebral infarction were also obtained. RESULTS Compared with the non-AF group, the AF group had an upper extremity motricity index (47.15 ± 20.30 vs 58.66 ± 19.19; P = .032), LMI (53.42 ± 12.27 vs 65.58 ± 13.86; P = .001), and FAC scores (2.39 ± 0.93 vs 3.35 ± 0.93; P < .001) at 6 months after onset. Moreover, the AF group showed a lower FAC score gain than the non-AF group at 6 months after onset (2.33 ± 0.95 vs 3.28 ± 0.94; P < .001). Multivariate linear regression analyses showed that presence of AF had negative correlation with LMI gain (β = -0.197; P = .010) and FAC gain (β = -0.254; P = .011). CONCLUSION We observed that AF had a negative effect on the motor outcome of the affected leg and the recovery of gait function in patients with cerebral infarction.
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Affiliation(s)
- Sung Ho Jang
- Department of Physical Medicine and Rehabilitation, Yeungnam University Medical Center, Daegu, Republic of Korea
| | - Kyu Hwan Choi
- Department of Physical Medicine and Rehabilitation, Yeungnam University Medical Center, Daegu, Republic of Korea
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86
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Stösser S, Isakeit J, Bode FJ, Bode C, Petzold GC. Sepsis in Patients With Large Vessel Occlusion Stroke–Clinical Characteristics and Outcome. Front Neurol 2022; 13:902809. [PMID: 35903123 PMCID: PMC9315268 DOI: 10.3389/fneur.2022.902809] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Accepted: 06/23/2022] [Indexed: 11/13/2022] Open
Abstract
Background Infections are an important complication after stroke and negatively affect clinical outcome. While pneumonia and urinary tract infections are well recognized after stroke, the incidence and consequences of sepsis remain unclear. The aim of this study was to evaluate the frequency and characteristics of sepsis in patients undergoing endovascular therapy for large vessel occlusion stroke, and its association with clinical outcome. Methods We analyzed a cohort of patients who underwent endovascular therapy at a single center between 2016 and 2020. The diagnosis and timing of infections and Sequential Organ Failure Assessment scores were evaluated retrospectively to identify patients with sepsis. Patients with sepsis were compared to controls regarding clinical characteristics and outcome. Results Fifty-four of 406 patients (13.3%) were found to have sepsis. The median onset of sepsis was 2 days after admission. The majority of cases (85.2%) was caused by pneumonia. At 3 months, 72.5% of patients with sepsis were bedridden or dead compared to 25.7 and 42.7% of controls and patients with an infection without sepsis, respectively. The adjusted odds ratio (95% confidence interval) for a poor outcome was 5.4 (1.6–17.6) for patients with sepsis vs. controls, and 2.0 (0.8–5.2) for patients with sepsis vs. patients with an infection without sepsis. Conclusions Sepsis is a frequent complication after large vessel occlusion stroke, and may be associated with a poor clinical outcome. More studies are needed to determine specific risk factors and measures to early recognize and reduce the possibly negative impact of sepsis on outcome after stroke.
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Affiliation(s)
- Sebastian Stösser
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
- *Correspondence: Sebastian Stösser /0000-0002-1182-705X
| | - Julia Isakeit
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Felix J. Bode
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Christian Bode
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Gabor C. Petzold
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
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87
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Li X, Li C, Zhou J, Liu AF, Zhang YY, Zhang AP, Lai CC, Lv J, Jiang WJ. Predictors of ninety-day mortality following mechanical thrombectomy for acute large vessel occlusion stroke. Clin Neurol Neurosurg 2022; 221:107402. [DOI: 10.1016/j.clineuro.2022.107402] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2022] [Revised: 07/09/2022] [Accepted: 07/27/2022] [Indexed: 11/25/2022]
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88
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Zhong W, Chen Z, Yan S, Zhou Y, Zhang R, Luo Z, Yu J, Lou M. Multi-Mode Imaging Scale for Endovascular Therapy in Patients with Acute Ischemic Stroke (META). Brain Sci 2022; 12:brainsci12070821. [PMID: 35884628 PMCID: PMC9313044 DOI: 10.3390/brainsci12070821] [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: 05/24/2022] [Revised: 06/11/2022] [Accepted: 06/16/2022] [Indexed: 11/17/2022] Open
Abstract
Background: With the guidance of multi-mode imaging, the time window for endovascular thrombectomy (EVT) has been expanded to 24 h. However, poor clinical outcomes are still not uncommon. We aimed to develop a multi-mode imaging scale for endovascular therapy in patients with acute ischemic stroke (META) to predict the neurological outcome in patients receiving endovascular thrombectomy (EVT). Methods: We included consecutive acute ischemic stroke patients with occlusion of middle cerebral artery and/or internal carotid artery who underwent EVT. Poor outcome was defined as modified Rankin Scale (mRS) score of 3−6 at 3 months. A five-point META score was constructed based on clot burden score, multi-segment clot, the Alberta Stroke Program early computed tomography score of cerebral blood volume (CBV-ASPECTS), and collateral status. We evaluated the META score performance using area under the curve (AUC) calculations. Results: A total of 259 patients were included. A higher META score was independently correlated with poor outcomes at 3 months (odds ratio, 1.690, 95% CI, 1.340 to 2.132, p < 0.001) after adjusting for age, hypertension, baseline National Institutes of Health Stroke Scale (NIHSS) score, and baseline blood glucose. Patients with a META score ≥ 2 were less likely to benefit from EVT (mRS 3−6: 60.8% vs. 29.2%, p < 0.001). The META score predicted poor outcomes with an AUC of 0.714, higher than the Pittsburgh Response to Endovascular therapy (PRE) score, the totaled health risks in vascular events (THRIVE) score (AUC: 0.566, 0.706), and the single imaging marker in the scale. Conclusions: The novel META score could refine the predictive accuracy of prognosis after EVT, which might provide a promising avenue for future automatic imaging analysis to help decision making.
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Affiliation(s)
- Wansi Zhong
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou 310009, China; (W.Z.); (Z.C.); (S.Y.); (Y.Z.); (R.Z.); (Z.L.)
| | - Zhicai Chen
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou 310009, China; (W.Z.); (Z.C.); (S.Y.); (Y.Z.); (R.Z.); (Z.L.)
| | - Shenqiang Yan
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou 310009, China; (W.Z.); (Z.C.); (S.Y.); (Y.Z.); (R.Z.); (Z.L.)
| | - Ying Zhou
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou 310009, China; (W.Z.); (Z.C.); (S.Y.); (Y.Z.); (R.Z.); (Z.L.)
| | - Ruoxia Zhang
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou 310009, China; (W.Z.); (Z.C.); (S.Y.); (Y.Z.); (R.Z.); (Z.L.)
| | - Zhongyu Luo
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou 310009, China; (W.Z.); (Z.C.); (S.Y.); (Y.Z.); (R.Z.); (Z.L.)
| | - Jun Yu
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou 310009, China;
| | - Min Lou
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou 310009, China; (W.Z.); (Z.C.); (S.Y.); (Y.Z.); (R.Z.); (Z.L.)
- Correspondence: ; Tel.: +86-571-87784810; Fax: +86-571-87784850
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89
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Chen JH, Hong CT, Chung CC, Kuan YC, Chan L. Safety and efficacy of endovascular thrombectomy in acute ischemic stroke treated with anticoagulants: a systematic review and meta-analysis. Thromb J 2022; 20:35. [PMID: 35729578 PMCID: PMC9210791 DOI: 10.1186/s12959-022-00394-y] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2022] [Accepted: 06/12/2022] [Indexed: 11/24/2022] Open
Abstract
Background Endovascular thrombectomy (EVT) is an effective therapy in acute ischemic stroke (AIS) with large vessel occlusion, especially for those who are unsuitable for intravenous thrombolysis. However, the safety and efficacy of EVT in AIS patients who receiving oral anticoagulants (OACs) is unclear, especially for the risk of symptomatic intracranial hemorrhage (sICH). Methods Database of PubMed, Embase, and Cochrane Library were searched from Jan 1, 2000, through the final search date of Jun 2, 2021. Eligible studies for enrollment required outcomes reported for events of sICH, mortality, functional status, and successful reperfusion. Meta-analysis was conducted to compare the outcomes difference after EVT between AIS patients with or without OACs use. The primary safety outcome was sICH after EVT, and the primary efficacy outcome was functional status at 3 months. Results One thousand nine hundred forty studies were screened for eligibility and 15 of them were included in the meta-analysis. Compared the OACs group to control arm, vitamin K antagonists (VKAs) was associated with higher risk of sICH (OR 1.49, 95% CI 1.10–2.02) and mortality (OR 1.67, 95% CI 1.35–2.06). Poor functional outcomes were noted both in the VKAs and direct oral anticoagulants (DOACs) groups (OR 0.62, 95% CI 0.54–0.71 and OR 0.61, 95% CI 0.53–0.71, respectively). No differences in successful reperfusion were observed. Conclusions Comparing with DOACs, VKAs use was associated with a higher risk of sICH and mortality after EVT. Patients who did not receive OACs exhibited more favorable outcomes. The successful reperfusion did not differ between groups. However, results for mortality and functional outcomes have to be interpreted with caution since they are based on non-randomized data and unadjusted proportions. Supplementary Information The online version contains supplementary material available at 10.1186/s12959-022-00394-y.
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Affiliation(s)
- Jia-Hung Chen
- Department of Neurology, Shuang-Ho Hospital, Taipei Medical University, New Taipei City, Taiwan
| | - Chien-Tai Hong
- Department of Neurology, Shuang-Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Chen-Chih Chung
- Department of Neurology, Shuang-Ho Hospital, Taipei Medical University, New Taipei City, Taiwan.,Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Yi-Chun Kuan
- Department of Neurology, Shuang-Ho Hospital, Taipei Medical University, New Taipei City, Taiwan. .,Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
| | - Lung Chan
- Department of Neurology, Shuang-Ho Hospital, Taipei Medical University, New Taipei City, Taiwan. .,Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei, Taiwan.
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90
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Quandt F, Flottmann F, Madai VI, Alegiani A, Küpper C, Kellert L, Hilbert A, Frey D, Liebig T, Fiehler J, Goyal M, Saver JL, Gerloff C, Thomalla G, Tiedt S. Machine Learning-Based Identification of Target Groups for Thrombectomy in Acute Stroke. Transl Stroke Res 2022; 14:311-321. [PMID: 35670996 PMCID: PMC10159968 DOI: 10.1007/s12975-022-01040-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/19/2022] [Accepted: 05/22/2022] [Indexed: 11/29/2022]
Abstract
Whether endovascular thrombectomy (EVT) improves functional outcome in patients with large-vessel occlusion (LVO) stroke that do not comply with inclusion criteria of randomized controlled trials (RCTs) but that are considered for EVT in clinical practice is uncertain. We aimed to systematically identify patients with LVO stroke underrepresented in RCTs who might benefit from EVT. Following the premises that (i) patients without reperfusion after EVT represent a non-treated control group and (ii) the level of reperfusion affects outcome in patients with benefit from EVT but not in patients without treatment benefit, we systematically assessed the importance of reperfusion level on functional outcome prediction using machine learning in patients with LVO stroke treated with EVT in clinical practice (N = 5235, German-Stroke-Registry) and in patients treated with EVT or best medical management from RCTs (N = 1488, Virtual-International-Stroke-Trials-Archive). The importance of reperfusion level on outcome prediction in an RCT-like real-world cohort equaled the importance of EVT treatment allocation for outcome prediction in RCT data and was higher compared to an unselected real-world population. The importance of reperfusion level was magnified in patient groups underrepresented in RCTs, including patients with lower NIHSS scores (0-10), M2 occlusions, and lower ASPECTS (0-5 and 6-8). Reperfusion level was equally important in patients with vertebrobasilar as with anterior LVO stroke. The importance of reperfusion level for outcome prediction identifies patient target groups who likely benefit from EVT, including vertebrobasilar stroke patients and among patients underrepresented in RCT patients with low NIHSS scores, low ASPECTS, and M2 occlusions.
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Affiliation(s)
- Fanny Quandt
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Vince I Madai
- Charité Lab for Artificial Intelligence in Medicine-CLAIM, Charité - Universitätsmedizin Berlin, Berlin, Germany.,QUEST Center for Transforming Biomedical Research, Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Berlin, Germany.,School of Computing and Digital Technology, Faculty of Computing, Engineering and the Built Environment, Birmingham City University, Birmingham, UK
| | - Anna Alegiani
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Clemens Küpper
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Lars Kellert
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Adam Hilbert
- Charité Lab for Artificial Intelligence in Medicine-CLAIM, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Dietmar Frey
- Charité Lab for Artificial Intelligence in Medicine-CLAIM, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Liebig
- Institute of Neuroradiology, University Hospital, LMU Munich, Munich, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mayank Goyal
- Department of Radiology, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research, University Hospital, LMU Munich, Feodor-Lynen-Straße 17, 81377, Munich, Germany.
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91
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Keselman B, Berglund A, Ahmed N, Grannas D, von Euler M, Holmin S, Laska AC, Mathé JM, Sjöstrand C, Eriksson EE, Mazya MV. Analysis and modelling of mistriage in the Stockholm stroke triage system. Eur Stroke J 2022; 7:126-133. [PMID: 35647317 PMCID: PMC9134772 DOI: 10.1177/23969873221077845] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 01/13/2022] [Indexed: 01/03/2024] Open
Abstract
INTRODUCTION The Stockholm Stroke Triage System (SSTS) is a prehospital triage system for detection of patients eligible for endovascular thrombectomy (EVT). Assessment of hemiparesis combined with ambulance-hospital teleconsultation is used to route patients directly to the thrombectomy centre. Some patients are not identified and require secondary transport for EVT (undertriage) while others taken to the thrombectomy centre do not undergo EVT (overtriage). The aims of this study were to characterize mistriaged patients, model for and evaluate alternative triage algorithms. PATIENTS AND METHODS Patients with suspected stroke transported by priority 1 ground ambulance between October 2017 and October 2018 (n = 2905) were included. Three triage algorithms were modelled using prehospital data. Decision curve analysis was performed to calculate net benefit (correctly routing patients for EVT without increasing mistriage) of alternative models vs SSTS. RESULTS Undertriage for EVT occurred in n = 35/2582 (1.4%) and overtriage in n = 239/323 (74.0%). Compared to correct thrombectomy triages, undertriaged patients were younger and had lower median NIHSS (10 vs 18), despite 62.9% with an M1 occlusion. In overtriaged patients, 77.0% had a stroke diagnosis (29.7% haemorrhagic). Hemiparesis and FAST items face and speech were included in all models. Decision curve analysis showed highest net benefit for SSTS for EVT, but lower for large artery occlusion (LAO) stroke. DISCUSSION Undertriaged patients had lower NIHSS, likely due to better compensated proximal occlusions. SSTS was superior to other models for identifying EVT candidates, but lacked information allowing comparison to other prehospital scales. CONCLUSION Using prehospital data, alternative models did not outperform the SSTS in finding EVT candidates.
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Affiliation(s)
- Boris Keselman
- Department of Neurology, Karolinska University
Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Annika Berglund
- Department of Neurology, Karolinska University
Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Niaz Ahmed
- Department of Neurology, Karolinska University
Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - David Grannas
- Unit of Biostatistics, IMM, Karolinska
Institutet, Stockholm, Sweden
| | - Mia von Euler
- Department of Clinical Science and Education, Karolinska Institutet Stroke Research
Network at Södersjukhuset, Stockholm, Sweden
- School of Medicine, Örebro University, Örebro, Sweden
| | - Staffan Holmin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neuroradiology, Karolinska University
Hospital, Stockholm, Sweden
| | - Ann-Charlotte Laska
- Department of Clinical Sciences, Danderyd Hospital Karolinska
Institutet, Stockholm, Sweden
| | - Jan M. Mathé
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Capio St Göran’s
Hospital, Stockholm, Sweden
| | - Christina Sjöstrand
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Einar E. Eriksson
- Department of Neurology, Karolinska University
Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Michael V. Mazya
- Department of Neurology, Karolinska University
Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Feil K, Matusevicius M, Herzberg M, Tiedt S, Küpper C, Wischmann J, Schönecker S, Mengel A, Sartor‐Pfeiffer J, Berger K, Dimitriadis K, Liebig T, Dieterich M, Mazya M, Ahmed N, Kellert L. Minor stroke in large vessel occlusion: A matched analysis of patients from the German Stroke Registry-Endovascular Treatment (GSR-ET) and patients from the Safe Implementation of Treatments in Stroke-International Stroke Thrombolysis Register (SITS-ISTR). Eur J Neurol 2022; 29:1619-1629. [PMID: 35122371 PMCID: PMC9306813 DOI: 10.1111/ene.15272] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/27/2022] [Accepted: 01/31/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Reperfusion treatment in patients presenting with large vessel occlusion (LVO) and minor neurological deficits is still a matter of debate. We aimed to compare minor stroke patients treated with endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT) or IVT alone. METHODS Patients enrolled in the German Stroke Registry-Endovascular Treatment (GSR-ET) and the Safe Implementation of Treatments in Stroke-International Stroke Thrombolysis Registry (SITS-ISTR) between June 2015 and December 2019 were analyzed. Minor stroke was defined as National Institutes of Health Stroke Scale (NIHSS) score ≤5, and LVO as occlusion of the internal carotid, carotid-T, middle cerebral, basilar, vertebral or posterior cerebral arteries. GSR-ET and SITS-ISTR IVT-treated patients were matched in a 1:1 ratio using propensity-score (PS) matching. The primary outcome was good functional outcome at 3 months (modified Rankin Scale score 0-2). RESULTS A total of 272 GSR-ET patients treated with EVT and IVT (age 68.6 ± 14.0 years, 43.4% female, NIHSS score 4 [interquartile range 2-5]) were compared to 272 IVT-treated SITS-ISTR patients (age 69.4 ± 13.7, 43.4% female, NIHSS score 4 [2-5]). Good functional outcome was seen in 77.0% versus 82.9% (p = 0.119), mortality in 5.9% versus 7.9% (p = 0.413), and intracranial hemorrhage in 8.8% versus 12.5% (p = 0.308) of patients in the GSR-ET versus the SITS-ISTR IVT group, respectively. In a second PS-matched analysis, 624 GSR-ET patients (IVT rate 56.7%) and 624 SITS-ISTR patients (IVT rate 100%), good outcome was more often observed in the SITS-ISTR patients (68.2% vs. 80.9%; p < 0.001), and IVT independently predicted good outcome (odds ratio 2.16, 95% confidence interval 1.43-3.28). CONCLUSIONS Our study suggests similar effectiveness of IVT alone compared to EVT with or without IVT in minor stroke patients. There is an urgent need for randomized controlled trials on this topic.
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Affiliation(s)
- Katharina Feil
- Department of NeurologyLudwig‐Maximilians‐Universitaet (LMU) MunichMunichGermany,Department of Neurology and StrokeEberhard‐Karls University Tuebingen/Universitaetsklinikum Tuebingen (UKT)TuebingenGermany
| | - Marius Matusevicius
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden,Department of Research and EducationKarolinska University HospitalStockholmSweden
| | - Moriz Herzberg
- Institute of NeuroradiologyLMUMunichGermany,Department of RadiologyUniversity HospitalWuerzburgGermany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research (ISD)University HospitalLMU MunichMunichGermany
| | - Clemens Küpper
- Department of NeurologyLudwig‐Maximilians‐Universitaet (LMU) MunichMunichGermany
| | - Johannes Wischmann
- Department of NeurologyLudwig‐Maximilians‐Universitaet (LMU) MunichMunichGermany
| | - Sonja Schönecker
- Department of NeurologyLudwig‐Maximilians‐Universitaet (LMU) MunichMunichGermany
| | - Annerose Mengel
- Department of Neurology and StrokeEberhard‐Karls University Tuebingen/Universitaetsklinikum Tuebingen (UKT)TuebingenGermany
| | - Jennifer Sartor‐Pfeiffer
- Department of Neurology and StrokeEberhard‐Karls University Tuebingen/Universitaetsklinikum Tuebingen (UKT)TuebingenGermany
| | - Katharina Berger
- Department of Neurology and EpileptologyEberhard‐Karls University Tuebingen/Universitaetsklinikum Tuebingen (UKT)TuebingenGermany
| | - Konstantin Dimitriadis
- Institute for Stroke and Dementia Research (ISD)University HospitalLMU MunichMunichGermany
| | | | - Marianne Dieterich
- Department of NeurologyLudwig‐Maximilians‐Universitaet (LMU) MunichMunichGermany,Munich Cluster for Systems Neurology (SyNergy)MunichGermany,German Center for Vertigo and Balance DisordersLMUMunichGermany
| | - Michael Mazya
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden,Department of NeurologyKarolinska University HospitalStockholmSweden
| | - Niaz Ahmed
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden,Department of NeurologyKarolinska University HospitalStockholmSweden
| | - Lars Kellert
- Department of NeurologyLudwig‐Maximilians‐Universitaet (LMU) MunichMunichGermany
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93
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Liu J, He J, Zhang C. Clinical Significance and Value of Serum Homocysteine and Urine 11 Dehydrothromboxane B2 Combined with Transferrin-Specific Peptide in the Diagnosis of Cerebral Apoplexy. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2022; 2022:6130413. [PMID: 35620205 PMCID: PMC9129925 DOI: 10.1155/2022/6130413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2022] [Revised: 04/11/2022] [Accepted: 04/13/2022] [Indexed: 11/25/2022]
Abstract
Objective To explore the clinical significance and value of serum homocysteine (Hcy) and urine 11 dehydrothromboxane B2 (urine 11-DH-TXB2) combined with transferrin-specific peptide (TF-UP) in the diagnosis of stroke. Methods One hundred stroke patients treated from January 2019 to June 2021 were enrolled in our hospital as the study group. All the patients in the study group met the diagnostic criteria of stroke. The focus of stroke was confirmed by CT or MRI, and the first onset was less than 48 hours. One hundred healthy persons who went through physical examination in our hospital were enrolled as the control group. The comparison was taken to explore the clinical significance and value of Hcy and urine 11-DH-TXB2 combined with TF-UP in the diagnosis of stroke. Results There exhibited no significant difference in the history of smoking, drinking, and atrial fibrillation (P > 0.05). There were significant differences in systolic blood pressure, diastolic blood pressure, eGFR, history of hypertension, diabetes, and coronary heart disease (P < 0.05). In terms of the levels of Hcy, urine 11-DH-TXB2, and TF-UP, the levels of Hcy and urine 11-DH-TXB2 in the study group were higher compared to the control group, while the level of TF-UP in the study group was lower compared to the control group (P < 0.05). The results of logistic regression analysis indicated that there was a significant correlation between Hcy, urine 11-DH-TXB2, TF-UP, and stroke, and Hcy and urine 11-DH-TXB2 indicated positive correlation with stroke disease, while TF-UP level was negatively correlated with stroke disease (P < 0.05). The levels of Hcy, urine 11-DH-TXB2, and TF-UP were adopted as evaluation indexes to draw ROC curve. The results show that the area under the curve (AUC) of Hcy is 0.760 (95% CI 0.670~0.850). The best critical point was 3342.5 pg/mg Ucr, the sensitivity was 65.6%, and the specificity was 77.1%. The AUC of urine 11-DH-TXB2 was 0.773 (95% CI 0.685~0.861). The best critical point was 3354.44 pg/mg Ucr, the sensitivity was 71.2%, and the specificity was 78.3%. The AUC of TF-UP was 0.735 (95% CI 0.641~0.829). The best critical point was 3365.43 pg/mg Ucr, the sensitivity was 68.4%, and the specificity was 80.5%. If Hcy was detected in combination with other indexes, AUC increased to 0.749 when combined with urine 11-DH-TXB2, and AUC increased to 0.797 when combined with TF-UP. When the three are combined, the AUC can reach 0.836, the sensitivity is 79.1%, and the specificity is 80%. It shows that the combined detection of Hcy, urine 11-DH-TXB2, and TF-UP is of higher diagnostic value. The difference of data exhibited statistically significant (P < 0.05). Conclusion There is imbalance between Hcy, urine 11-DH-TXB2, and TF-UP in patients with acute stroke. High Hcy, urine 11-DH-TXB2, and low TF-UP are closely related to the occurrence of cerebral infarction. Hcy, urine 11-DH-TXB2, and TF-UP may be the risk factors of stroke and positively correlated with the degree of neurological impairment. Effective monitoring of Hcy and urine 11-DH-TXB2 combined with TF-UP levels and positive intervention measures may effectively prevent the occurrence and development of cerebral infarction, reduce Hcy and urine 11-DH-TXB2, or increase the level of TF-UP, which may provide new ideas for the treatment of cerebrovascular diseases.
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Affiliation(s)
- Junli Liu
- Laboratory Department, Union Jiangbei Hospital, 430100, China
| | - Juan He
- Laboratory Department, Hubei Cancer Hospital, Tongji Medical College, Huazhong University of Science and Technology, 430079, China
| | - Chang Zhang
- Hubei No. 3 People's Hospital of Jianghan University, Clinical Laboratory, 430033, China
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94
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Kniep H, Meyer L, Bechstein M, Broocks G, Guerreiro H, van Horn N, Brekenfeld C, Flottmann F, Deb-Chatterji M, Alegiani A, Thomalla G, Hanning U, Fiehler J, Gellißen S. How Much of the Thrombectomy Related Improvement in Functional Outcome Is Already Apparent at 24 Hours and at Hospital Discharge? Stroke 2022; 53:2828-2837. [PMID: 35549377 DOI: 10.1161/strokeaha.121.037888] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Early neurological status has been described as predictor of functional outcome in patients with anterior circulation stroke after mechanical thrombectomy. It remains unclear to what proportion the improvement of functional outcome at day 90 is already apparent at 24 hours and at hospital discharge and how later factors impact outcome. METHODS All patients enrolled in the German Stroke Registry (June 2015-December 2019) with anterior circulation stroke and availability of baseline data and neurological status were included. A mediation analysis was conducted to investigate the effect of successful recanalization (Thrombolysis in Cerebral Infarction scale score ≥2b) on good functional outcome (modified Rankin Scale score ≤2 at day 90) with mediation through neurological status (National Institutes of Health Stroke Scale [NIHSS] at 24 hours and at hospital discharge). RESULTS Three thousand fifty-seven patients fulfilled the inclusion criteria, thereof 2589 (85%) with successful recanalization and 1180 (39%) with good functional outcome. In a multivariate logistic regression analysis, probability of good outcome was significantly associated with age (odds ratio [95% CI], 0.95 [0.94-0.96]), prestroke modified Rankin Scale (0.48 [0.42-0.55]), admission-NIHSS (0.96 [0.94-0.98]), 24-hour NIHSS (0.83 [0.81-0.84]), diabetes (0.56 [0.43-0.72]), proximal middle cerebral artery occlusions (0.78 [0.62-0.97]), passes (0.88 [0.82-0.95]), Alberta Stroke Program Early CT Score (1.07 [1.00-1.14]), successful recanalization (2.39 [1.68-3.43]), intracerebral hemorrhage (0.51 [0.35-0.73]), and recurrent strokes (0.54 [0.32-0.92]). Mediation analysis showed a 20 percentage points (95% CI' 17-24 percentage points) increase of probability of good functional outcome after successful recanalization. Fifty-four percent (95% CI' 44%-66%) of the improvement in functional outcome was explained by 24-hour NIHSS and 75% (95% CI' 62%-90%) by NIHSS at hospital discharge. CONCLUSIONS Fifty-four percent of the improvement in functional outcome after successful recanalization is apparent in NIHSS at 24 hours, 75% in NIHSS at hospital discharge. Other unknown factors not apparent in NIHSS at the 2 time points investigated account for the remaining effect on long term outcome, suggesting, among others, clinical relevance of delayed neurological improvement and deterioration. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03356392.
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Affiliation(s)
- Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Helena Guerreiro
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany. (M.D.-C., A.A., G.T.)
| | - Anna Alegiani
- Department of Neurology, Asklepios Klinik Altona, Hamburg, Germany (A.A)
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany. (M.D.-C., A.A., G.T.)
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
| | - Susanne Gellißen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany. (H.K., L.M., M.B., G.B., H.G., N.v.H., C.B., F.F., U.H., J.F., S.G.)
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95
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Vogt ML, Kollikowski AM, Weidner F, Strinitz M, Feick J, Essig F, Neugebauer H, Haeusler KG, Pham M, Maerz A. Safety and Effectiveness of the New Generation APERIO® Hybrid Stent-retriever Device in Large Vessel Occlusion Stroke. Clin Neuroradiol 2022; 32:141-151. [PMID: 34936016 PMCID: PMC8894307 DOI: 10.1007/s00062-021-01122-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 11/05/2021] [Indexed: 11/28/2022]
Abstract
BACKGROUND It is unknown whether technological advancement of stent-retriever devices influences typical observational indicators of safety or effectiveness. METHODS Observational retrospective study of APERIO® (AP) vs. new generation APERIO® Hybrid (APH) (Acandis®, Pforzheim, Germany) stent-retriever device (01/2019-09/2020) for mechanical thrombectomy (MT) in large vessel occlusion (LVO) stroke. Primary effectiveness endpoint was successful recanalization eTICI (expanded Thrombolysis In Cerebral Ischemia) ≥ 2b67, primary safety endpoint was occurrence of hemorrhagic complications after MT. Secondary outcome measures were time from groin puncture to first pass and successful reperfusion, and the total number of passes needed to achieve the final recanalization result. RESULTS A total of 298 patients with LVO stroke who were treated by MT matched the inclusion criteria: 148 patients (49.7%) treated with AP vs. 150 patients (50.3%) treated with new generation APH. Successful recanalization was not statistically different between both groups: 75.7% for AP vs. 79.3% for APH; p = 0.450. Postinterventional hemorrhagic complications and particularly subarachnoid hemorrhage as the entity possibly associated with stent-retriever device type was significantly less frequent in the group treated with the APH: 29.7% for AP and 16.0% for APH; p = 0.005; however, rates of symptomatic hemorrhage with clinical deterioration and in domo mortality were not statistically different. Neither the median number of stent-retriever passages needed to achieve final recanalization, time from groin puncture to first pass, time from groin puncture to final recanalization nor the number of cases in which successful recanalization could only be achieved by using a different stent-retriever as bail-out device differed between both groups. CONCLUSION In the specific example of the APERIO® stent-retriever device, we observed that further technological developments of the new generation device were not associated with disadvantages with respect to typical observational indicators of safety or effectiveness.
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Affiliation(s)
- Marius L Vogt
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Würzburg, Würzburg, Germany.
| | - Alexander M Kollikowski
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Würzburg, Würzburg, Germany
| | - Franziska Weidner
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Würzburg, Würzburg, Germany
| | - Marc Strinitz
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Würzburg, Würzburg, Germany
| | - Jörn Feick
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Würzburg, Würzburg, Germany
| | - Fabian Essig
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | - Hermann Neugebauer
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | | | - Mirko Pham
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Würzburg, Würzburg, Germany
| | - Alexander Maerz
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Würzburg, Würzburg, Germany
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96
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Compagne KCJ, Kappelhof M, Hinsenveld WH, Brouwer J, Goldhoorn RJB, Uyttenboogaart M, Bokkers RPH, Schonewille WJ, Martens JM, Hofmeijer J, van der Worp HB, Lo RTH, Keizer K, Yo LSF, Lycklama À Nijeholt GJ, den Hertog HM, Sturm EJC, Brouwers PJAM, van Walderveen MAA, Wermer MJH, de Bruijn SF, van Dijk LC, Boogaarts HD, van Dijk EJ, van Tuijl JH, Peluso JPP, de Kort PLM, van Hasselt BAAM, Fransen PS, Schreuder THCML, Heijboer RJJ, Jenniskens SFM, Sprengers MES, Ghariq E, van den Wijngaard IR, Roosendaal SD, Meijer AFJA, Beenen LFM, Postma AA, van den Berg R, Yoo AJ, van Doormaal PJ, van Proosdij MP, Krietemeijer MGM, Gerrits DG, Hammer S, Vos JA, Boiten J, Coutinho JM, Emmer BJ, van Es ACGM, Roozenbeek B, Roos YBWEM, van Zwam WH, van Oostenbrugge RJ, Majoie CBLM, Dippel DWJ, van der Lugt A. Improvements in Endovascular Treatment for Acute Ischemic Stroke: A Longitudinal Study in the MR CLEAN Registry. Stroke 2022; 53:1863-1872. [PMID: 35135323 PMCID: PMC9126265 DOI: 10.1161/strokeaha.121.034919] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We evaluated data from all patients in the Netherlands who underwent endovascular treatment for acute ischemic stroke in the past 3.5 years, to identify nationwide trends in time to treatment and procedural success, and assess their effect on clinical outcomes.
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Affiliation(s)
- Kars C J Compagne
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, the Netherlands. (K.C.J.C., P.J.v.D.).,Department of Neurology, Erasmus MC, University Medical Center' Rotterdam' the Netherlands. (K.C.J.C., B.R., D.W.J.D.)
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam' the Netherlands. (M.K., M.E.S.S., S.D.R., L.F.M.B., R.v.d.B., B.J.E., C.B.L.M.M.)
| | - Wouter H Hinsenveld
- Department of Radiology and Nuclear Medicine, School for Cardiovascular Diseases (CARIM), School for Mental Health and Sciences, Maastricht University Medical Center' the Netherlands. (A.A.P., W.H.v.Z.)
| | - Josje Brouwer
- Department of Neurology, Amsterdam UMC, University of Amsterdam' the Netherlands. (J.B., J.M.C., Y.B.W.E.M.R.)
| | - Robert-Jan B Goldhoorn
- Department of Neurology, School for Cardiovascular Diseases (CARIM), School for Mental Health and Sciences, Maastricht University Medical Center' the Netherlands. (W.H.H., R.-J.B.G., R.J.v.O.)
| | | | - Reinoud P H Bokkers
- Department of Radiology, University Medical Center Groningen' the Netherlands. (R.P.H.B.)
| | | | - Jasper M Martens
- Department of Radiology, Rijnstate Hospital' Arnhem' the Netherlands. (J.M.M.)
| | - Jeannette Hofmeijer
- Department of Neurology, Rijnstate Hospital' Arnhem' the Netherlands. (J.H.)
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht' the Netherlands. (H.B.v.d.W.)
| | - Rob T H Lo
- Department of Radiology, University Medical Center Utrecht' the Netherlands. (R.T.H.L.O.)
| | - Koos Keizer
- Department of Neurology, Catharina Hospital' Eindhoven' the Netherlands. (K.K.)
| | - Lonneke S F Yo
- Department of Radiology, Catharina Hospital' Eindhoven' the Netherlands. (L.S.F.Y., M.G.M.K.)
| | | | - Heleen M den Hertog
- Department of Neurology, Isala Klinieken' the Netherlands. (H.M.d.H., P.S.F.)
| | - Emiel J C Sturm
- Department of Radiology, Medical Spectrum Twente' the Netherlands. (E.J.C.S., D.G.G.)
| | - Paul J A M Brouwers
- Department of Neurology, Medical Spectrum Twente' the Netherlands. (P.J.A.M.B.)
| | | | - Marieke J H Wermer
- Department of Neurology, Leiden University Medical Center' the Netherlands. (M.J.H.W.)
| | | | - Lukas C van Dijk
- Department of Radiology, HAGA Hospital' the Netherlands. (L.C.v.D.)
| | - Hieronymus D Boogaarts
- Department of Neurosurgery, Radboud University Medical Center' the Netherlands. (H.D.B.)
| | - Ewout J van Dijk
- Department of Neurology, Radboud University Medical Center' the Netherlands. (E.J.v.D.)
| | | | - Jo P P Peluso
- Department of Radiology, Sint Elisabeth Hospital' the Netherlands. (J.P.P.)
| | - Paul L M de Kort
- Department of Neurology, Sint Elisabeth Hospital' the Netherlands. (P.L.M.d.K.)
| | | | - Puck S Fransen
- Department of Neurology, Isala Klinieken' the Netherlands. (H.M.d.H., P.S.F.)
| | | | | | - Sjoerd F M Jenniskens
- Department of Radiology, Radboud University Medical Center' the Netherlands. (S.F.M.J., A.F.J.A.M.)
| | - Marieke E S Sprengers
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam' the Netherlands. (M.K., M.E.S.S., S.D.R., L.F.M.B., R.v.d.B., B.J.E., C.B.L.M.M.)
| | - Elias Ghariq
- Department of Radiology, Haaglanden Medical Center' the Netherlands. (G.J.L.à.N., E.G.)
| | | | - Stefan D Roosendaal
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam' the Netherlands. (M.K., M.E.S.S., S.D.R., L.F.M.B., R.v.d.B., B.J.E., C.B.L.M.M.)
| | - Anton F J A Meijer
- Department of Radiology, Radboud University Medical Center' the Netherlands. (S.F.M.J., A.F.J.A.M.)
| | - Ludo F M Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam' the Netherlands. (M.K., M.E.S.S., S.D.R., L.F.M.B., R.v.d.B., B.J.E., C.B.L.M.M.)
| | - Alida A Postma
- Department of Radiology and Nuclear Medicine, School for Cardiovascular Diseases (CARIM), School for Mental Health and Sciences, Maastricht University Medical Center' the Netherlands. (A.A.P., W.H.v.Z.)
| | - René van den Berg
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam' the Netherlands. (M.K., M.E.S.S., S.D.R., L.F.M.B., R.v.d.B., B.J.E., C.B.L.M.M.)
| | - Albert J Yoo
- Department of Radiology, Texas Stroke Institute' Plano' TX (A.J.Y.)
| | - Pieter Jan van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, the Netherlands. (K.C.J.C., P.J.v.D.)
| | - Marc P van Proosdij
- Department of Radiology, Noordwest Ziekenhuisgroep' the Netherlands (M.P.v.P.)
| | - Menno G M Krietemeijer
- Department of Radiology, Catharina Hospital' Eindhoven' the Netherlands. (L.S.F.Y., M.G.M.K.)
| | - Dick G Gerrits
- Department of Radiology, Medical Spectrum Twente' the Netherlands. (E.J.C.S., D.G.G.)
| | | | - Jan Albert Vos
- Department of Radiology, Sint Antonius Hospital' the Netherlands. (J.A.V.)
| | - Jelis Boiten
- Department of Neurology, Haaglanden Medical Center' the Netherlands. (I.R.v.d.W., J.B.)
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, University of Amsterdam' the Netherlands. (J.B., J.M.C., Y.B.W.E.M.R.)
| | - Bart J Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam' the Netherlands. (M.K., M.E.S.S., S.D.R., L.F.M.B., R.v.d.B., B.J.E., C.B.L.M.M.)
| | - Ad C G M van Es
- Department of Radiology, Leiden University Medical Center' the Netherlands. (M.A.A.v.W., A.C.G.M.v.E.)
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC, University Medical Center' Rotterdam' the Netherlands. (K.C.J.C., B.R., D.W.J.D.)
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam' the Netherlands. (J.B., J.M.C., Y.B.W.E.M.R.)
| | - Wim H van Zwam
- Department of Neurology, School for Cardiovascular Diseases (CARIM), School for Mental Health and Sciences, Maastricht University Medical Center' the Netherlands. (W.H.H., R.-J.B.G., R.J.v.O.)
| | - Robert J van Oostenbrugge
- Department of Neurology, School for Cardiovascular Diseases (CARIM), School for Mental Health and Sciences, Maastricht University Medical Center' the Netherlands. (W.H.H., R.-J.B.G., R.J.v.O.)
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam' the Netherlands. (M.K., M.E.S.S., S.D.R., L.F.M.B., R.v.d.B., B.J.E., C.B.L.M.M.)
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC, University Medical Center' Rotterdam' the Netherlands. (K.C.J.C., B.R., D.W.J.D.)
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Correia M, Silva I, Gabriel D, Simrén J, Carneiro A, Ribeiro S, Dória HM, Varela R, Aires A, Minta K, Antunes R, Felgueiras R, Castro P, Blenow K, Magalhães R, Zetterberg H, Maia LF. Early plasma biomarker dynamic profiles are associated with acute ischemic stroke outcomes. Eur J Neurol 2022; 29:1630-1642. [DOI: 10.1111/ene.15273] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Accepted: 02/03/2022] [Indexed: 11/28/2022]
Affiliation(s)
- Manuel Correia
- Department of Neurology Centro Hospitalar Universitário do Porto Porto Portugal
- Instituto de Ciências Biomédicas Abel Salazar University of Porto Porto Portugal
| | - Isabel Silva
- Department of Neurology Centro Hospitalar Universitário do Porto Porto Portugal
- i3S ‐ Instituto de Investigação e Inovação em Saúde University of Porto, Porto, Portugal and IBMC ‐ Instituto de Biologia Molecular e Celular, University of Porto Porto Portugal
| | - Denis Gabriel
- Department of Neurology Centro Hospitalar Universitário do Porto Porto Portugal
| | - Joel Simrén
- Department of Psychiatry and Neurochemistry Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg 431 41 Mölndal Sweden
- Clinical Neurochemistry Laboratory Sahlgrenska University Hospital 431 80 Mölndal Sweden
| | - Angelo Carneiro
- Department of Neuroradiology Centro Hospitalar Universitário do Porto Porto Portugal
| | - Sara Ribeiro
- i3S ‐ Instituto de Investigação e Inovação em Saúde University of Porto, Porto, Portugal and Ipatimup ‐ Institute of Molecular Pathology and Immunology, University of Porto Porto Portugal
| | - Hugo Mota Dória
- Department of Neuroradiology Centro Hospitalar Universitário do Porto Porto Portugal
| | - Ricardo Varela
- Department of Neurology Centro Hospitalar Universitário do Porto Porto Portugal
| | - Ana Aires
- Department of Neurology Centro Hospitalar Universitário de São João Porto Portugal
| | - Karolina Minta
- Department of Psychiatry and Neurochemistry Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg 431 41 Mölndal Sweden
- Department of Neurodegenerative Disease University College London Institute of Neurology Queen Square London UK
| | - Rui Antunes
- Intensive Care Unit Centro Hospitalar Universitário do Porto Porto Portugal
| | - Rui Felgueiras
- Department of Neurology Centro Hospitalar Universitário do Porto Porto Portugal
| | - Pedro Castro
- Department of Neurology Centro Hospitalar Universitário de São João Porto Portugal
| | - Kaj Blenow
- Department of Psychiatry and Neurochemistry Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg 431 41 Mölndal Sweden
- Clinical Neurochemistry Laboratory Sahlgrenska University Hospital 431 80 Mölndal Sweden
| | - Rui Magalhães
- Population Studies Instituto de Ciências Biomédicas Abel Salazar University of Porto Porto Portugal
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry Institute of Neuroscience and Physiology Sahlgrenska Academy University of Gothenburg 431 41 Mölndal Sweden
- Clinical Neurochemistry Laboratory Sahlgrenska University Hospital 431 80 Mölndal Sweden
- Department of Neurodegenerative Disease University College London Institute of Neurology Queen Square London UK
- UK Dementia Research Institute at UCL London UK
- Hong Kong Center for Neurodegenerative Diseases Hong Kong China
| | - Luis F Maia
- Department of Neurology Centro Hospitalar Universitário do Porto Porto Portugal
- Instituto de Ciências Biomédicas Abel Salazar University of Porto Porto Portugal
- i3S ‐ Instituto de Investigação e Inovação em Saúde University of Porto, Porto, Portugal and IBMC ‐ Instituto de Biologia Molecular e Celular, University of Porto Porto Portugal
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98
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Fiehler J, Nawka MT, Meyer L. Persistent challenges in endovascular treatment decision-making for acute ischaemic stroke. Curr Opin Neurol 2022; 35:18-23. [PMID: 34812746 DOI: 10.1097/wco.0000000000001006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Although endovascular treatment (EVT) is the gold standard for treating acute stroke patients with large vessel occlusion (LVO), multiple challenges in decision-making for specific conditions persist. Recent evidence on a selection of patient subgroups will be discussed in this narrative review. RECENT FINDINGS Two randomized controlled trials (RCTs) have been published in EVT of basilar artery occlusion (BAO). Large single arm studies showed promising results in Patients with low Alberta stroke program early CT score (ASPECTS) and more distal vessel occlusions. Recent data confirm patients with low National Institutes of Health Stroke Scale (NIHSS) despite LVO to represent a heterogeneous and challenging patient group. SUMMARY The current evidence does not justify withholding EVT from BAO patients as none of the RCTs showed any signal of superiority of BMT alone vs. EVT. Patients with low ASPECTS, more distal vessel occlusions and patients with low NIHSS scores should be included into RCTs if possible. Without participation in a RCT, patients should be selected for EVT based on age, severity and type of neurological impairment, time since symptom onset, location of the ischaemic lesion and perhaps also results of advanced imaging.
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Affiliation(s)
- Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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99
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Sharobeam A, Yan B. Advanced imaging in acute ischemic stroke: an updated guide to the hub-and-spoke hospitals. Curr Opin Neurol 2022; 35:24-30. [PMID: 34845146 DOI: 10.1097/wco.0000000000001020] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW The purpose of this review is to summarize the role of the hub-and-spoke system in acute stroke care, highlight the role of advanced imaging and discuss emerging concepts and trials relevant to the hub-and-spoke model. RECENT FINDINGS The advent of advanced stroke multimodal imaging has provided increased treatment options for patients, particularly in rural and regional areas. When used in the hub-and-spoke model, advanced imaging can help facilitate and triage transfers, appropriately select patients for acute therapy and treat patients who may otherwise be ineligible based on traditional time metrics.Recent, ongoing trials in this area may lead to an even greater range of patients being eligible for acute reperfusion therapy, including mild strokes and patients with large core infarct volumes. SUMMARY Integration of advanced imaging into a hub-and-spoke system, when complemented with other systems including telemedicine, improves access to acute stroke care for patients in regional and rural areas.
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Affiliation(s)
- Angelos Sharobeam
- Melbourne Brain Centre, The Royal Melbourne Hospital, Parkville, Australia
- School of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville
- Victorian Stroke Telemedicine Service, Ambulance Victoria, Australia
| | - Bernard Yan
- Melbourne Brain Centre, The Royal Melbourne Hospital, Parkville, Australia
- School of Medicine, Dentistry and Health Sciences, The University of Melbourne, Parkville
- Neurointervention Service, The Royal Melbourne Hospital, Parkville, Australia
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Sommer P, Scharer S, Posekany A, Serles W, Marko M, Langer A, Fertl E, Sykora M, Lang W, Dafert S, Seiringer F, Kiechl S, Knoflach M, Greisenegger S. Thrombectomy in basilar artery occlusion. Int J Stroke 2022; 17:1006-1012. [PMID: 35083954 DOI: 10.1177/17474930211069859] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE The benefit of thrombectomy (TE) for acute ischemic stroke (AIS) in patients suffering basilar artery occlusion (BAO) is still unclear. Our aim was to analyze functional outcome after 3 months in BAO compared to anterior circulation large vessel occlusion (ACLVO) in a nationwide registry. METHODS Patients enrolled into the Austrian Endostroke Registry from 2013 to 2018 were analyzed. We used propensity score matching to control for imbalances and to compare patients with BAO and ACLVO. The primary outcome was favorable functional outcome after 3 months measured by the modified Rankin Scale (mRS) (0-2). Multivariate models were applied to estimate the effect of localization (BAO vs ACLVO). RESULTS In total, 2288 patients underwent TE for AIS with proximal vessel occlusion, of these 267 with BAO. Two hundred and sixty-four patients with BAO were matched to 264 patients with ACLVO. Baseline characteristics were well-balanced. The 90-day mortality did not significantly differ between patients with BAO and ACLVO. In a multivariate logistic regression model, we did not detect a significant difference in functional outcome between BAO and ACLVO (odds ratio for favorable outcome defined as mRS = 0-2: 1.19; 95% confidence interval (CI) = 0.78-1.81; p = 0.42). In patients with an onset-to-door-time ⩾270 min, TE of BAO was associated with poor functional outcome defined as mRS 3-6 (odds ratio (OR) = 3.97; 95% CI = 1.32-11.94; p = 0.01) as compared to ACLVO. CONCLUSION In this study, functional outcome did not differ after TE in patients with BAO and ACLVO overall; however, we detected an association of BAO with poor outcome in patients arriving late.
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Affiliation(s)
- Peter Sommer
- Department of Neurology, Klinik Landstrasse, Vienna, Austria
| | - Sebastian Scharer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | | | - Wolfgang Serles
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Martha Marko
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Agnes Langer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Elisabeth Fertl
- Department of Neurology, Klinik Landstrasse, Vienna, Austria
| | - Marek Sykora
- Department of Neurology, Krankenhaus Barmherzige Brüder, Vienna, Austria
| | - Wilfried Lang
- Department of Neurology, Krankenhaus Barmherzige Brüder, Vienna, Austria
| | - Sebastian Dafert
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Fiona Seiringer
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Stefan Kiechl
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Michael Knoflach
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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