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Nieboer KH. Rethinking the shoe: is CT perfusion the optimal screening tool for acute stroke patients? Eur Radiol 2024; 34:3059-3060. [PMID: 37851121 PMCID: PMC11126433 DOI: 10.1007/s00330-023-10336-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 08/10/2023] [Accepted: 08/18/2023] [Indexed: 10/19/2023]
Affiliation(s)
- Koenraad H Nieboer
- Department of Radiology and Medical Imaging, Vrije Universiteit Brussel (VUB), Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090, Brussels, Belgium.
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Bala F, Singh N, Ignacio K, Alhabli I, Ademola A, Alrohimi A, Khosravani H, Tkach A, Catanese L, Dowlatshahi D, Field T, Hunter G, Benali F, Horn M, Demchuk A, Hill M, Sajobi T, Buck B, Swartz R, Almekhlafi M, Menon BK. Tenecteplase Versus Alteplase in Medium Vessel Occlusion Ischemic Stroke: A Secondary Analysis of the Alteplase Compared to Tenecteplase Randomized Trial. J Stroke 2024; 26:280-289. [PMID: 38836275 PMCID: PMC11164589 DOI: 10.5853/jos.2023.03713] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 02/24/2024] [Accepted: 03/11/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND AND PURPOSE The safety and efficacy of tenecteplase in patients with ischemic stroke due to medium vessel occlusion (MeVO) are not well studied. We aimed to compare tenecteplase with alteplase in stroke due to MeVO. METHODS Patients with baseline M2-middle cerebral artery (MCA), M3/M4-MCA, P2/P3/P4-posterior cerebral artery (PCA), A2/A3/A4-anterior cerebral artery (ACA) occlusions from the Alteplase Compared to Tenecteplase (AcT) trial were included. Primary outcome was the proportion of 90-day modified Rankin Scale (mRS) 0-1. Secondary outcomes were 90-day mRS 0-2, ordinal mRS, mortality, quality of life measures (EuroQol 5-Dimension 5-Level, EuroQol visual analog scale), and symptomatic intracerebral hemorrhage (sICH). Initial and final successful reperfusion were reported in patients undergoing endovascular thrombectomy (EVT). RESULTS Among 1,558 patients with available baseline computed tomography angiography; 455 (29.2%) had MeVO of which 27.5% (125/455) were proximal M2; 16.3% (74/455) were distal M2; 35.2% (160/455) were M3/M4; 7.5% (34/455) were A2/A3/A4; and 13.6% (62/455) were P2/P3/P4 occlusions. EVT was performed in 87/455 (19.1%) patients. mRS 0-1 at 90 days was achieved in 37.9% in the tenecteplase versus 34.7% in the alteplase group (adjusted risk ratio [aRR] 1.07; 95% confidence interval [CI] 0.91-1.25). Rates of 90-day mRS 0-2, sICH, and mortality were similar in both groups. No statistical difference was noted in initial successful reperfusion rates (13.0% vs. 7.5%) among the 87 patients who underwent endovascular thrombectomy. However, final successful reperfusion was higher in the tenecteplase group (71.7% vs. 60.0%, aRR 1.29, 95% CI 1.04-1.61). CONCLUSION Intravenous tenecteplase had comparable safety, functional outcomes and quality of life compared to intravenous alteplase among patients with MeVO. Among those treated with EVT, tenecteplase was associated with higher successful reperfusion rates than alteplase.
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Affiliation(s)
- Fouzi Bala
- Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, Tours, France
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Nishita Singh
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Internal Medicine (Neurology Division), Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Katrina Ignacio
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Ibrahim Alhabli
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Ayoola Ademola
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Anas Alrohimi
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
- Department of Medicine (Neurology), King Saud University, Riyadh, Saudi Arabia
| | - Houman Khosravani
- Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, Canada
| | | | - Luciana Catanese
- Hamilton Health Sciences Centre and McMaster University, Hamilton, Canada
| | - Dariush Dowlatshahi
- Department of Medicine, University of Ottawa, and the Ottawa Heart Research Institute, Ottawa, Canada
| | - Thalia Field
- Vancouver Stroke Program and the Division of Neurology, University of British Columbia, Vancouver, Canada
| | - Gary Hunter
- University of Saskatchewan, Saskatoon, Canada
| | - Faysal Benali
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+ (MUMC+), Maastricht, The Netherlands
| | - MacKenzie Horn
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Andrew Demchuk
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Michael Hill
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Tolulope Sajobi
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Brian Buck
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada
| | - Richard Swartz
- Department of Medicine (Neurology), King Saud University, Riyadh, Saudi Arabia
| | - Mohammed Almekhlafi
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Bijoy K. Menon
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
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Nogueira RG, Doheim MF, Al-Bayati AR, Lee JS, Haussen DC, Mohammaden M, Lang M, Starr M, Rocha M, da Câmara CP, Gross BA, Bhatt NR. Distal Medium Vessel Occlusion Strokes: Understanding the Present and Paving the Way for a Better Future. J Stroke 2024; 26:190-202. [PMID: 38836268 PMCID: PMC11164590 DOI: 10.5853/jos.2023.02649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2023] [Revised: 02/02/2024] [Accepted: 02/06/2024] [Indexed: 06/06/2024] Open
Abstract
Distal medium vessel occlusions (DMVOs) are thought to cause as many as 25% to 40% of all acute ischemic strokes and may result in substantial disability amongst survivors. Although intravenous thrombolysis (IVT) is more effective for distal than proximal vessel occlusions, the overall efficacy of IVT remains limited in DMVO with less than 50% of patients achieving reperfusion and about 1/3 to 1/4 of the patients failing to achieve functional independence. Data regarding mechanical thrombectomy (MT) among these patients remains limited. The smaller, thinner, and more tortuous vessels involved in DMVO are presumably associated with higher procedural risks whereas a lower benefit might be expected given the smaller amount of tissue territory at risk. Recent advances in technology have shown promising results in endovascular treatment of DMVOs with room for future improvement. In this review, we discuss some of the key technical and clinical considerations in DMVO treatment including the anatomical and clinical terminology, diagnostic modalities, the role of IVT and MT, existing technology, and technical challenges as well as the contemporary evidence and future treatment directions.
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Affiliation(s)
- Raul G. Nogueira
- UPMC Stroke Institute, Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Mohamed F. Doheim
- UPMC Stroke Institute, Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alhamza R. Al-Bayati
- UPMC Stroke Institute, Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jin Soo Lee
- Department of Neurology, Ajou University Medical Center, Ajou University School of Medicine, Suwon, Korea
| | - Diogo C. Haussen
- Department of Neurology, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | - Mahmoud Mohammaden
- Department of Neurology, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael Lang
- UPMC Stroke Institute, Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Matthew Starr
- UPMC Stroke Institute, Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Marcelo Rocha
- UPMC Stroke Institute, Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Bradley A. Gross
- UPMC Stroke Institute, Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Nirav R. Bhatt
- UPMC Stroke Institute, Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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54
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Räty S, Nguyen TN, Nagel S, Strambo D, Michel P, Herweh C, Qureshi MM, Abdalkader M, Virtanen P, Olive-Gadea M, Ribo M, Psychogios M, Nguyen A, Kuramatsu JB, Haupenthal D, Köhrmann M, Deuschl C, Escolà JK, Demeestere J, Lemmens R, Vandewalle L, Yaghi S, Shu L, Puetz V, Kaiser DP, Kaesmacher J, Mujanovic A, Marterstoc DC, Engelhorn T, Berberich A, Klein P, Haussen DC, Mohammaden MH, Abdelhamid H, Fragata I, Cunha B, Romoli M, Hu W, Song J, Fifi JT, Matsoukas S, Sheth SA, Salazar-Marioni SA, Marto JP, Ramos JN, Miszczuk M, Riegler C, Poli S, Poli K, Jadhav AP, Desai S, Maus V, Kaeder M, Siddiqui AH, Monteiro A, Kokkonen T, Diana F, Masoud HE, Suryadareva N, Mokin M, Thanki S, Ylikotila P, Alpay K, Siegler JE, Linfante I, Dabus G, Yavaghal D, Saini V, Nolte CH, Siebert E, Möhlenbruch MA, Ringleb PA, Nogueira RG, Hanning U, Meyer L, Fischer U, Strbian D. Endovascular Thrombectomy Versus Intravenous Thrombolysis of Posterior Cerebral Artery Occlusion Stroke. J Stroke 2024; 26:290-299. [PMID: 38836276 PMCID: PMC11164587 DOI: 10.5853/jos.2024.00458] [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: 02/01/2024] [Revised: 04/04/2024] [Accepted: 04/17/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND AND PURPOSE Posterior cerebral artery occlusion (PCAo) can cause long-term disability, yet randomized controlled trials to guide optimal reperfusion strategy are lacking. We compared the outcomes of PCAo patients treated with endovascular thrombectomy (EVT) with or without intravenous thrombolysis (IVT) to patients treated with IVT alone. METHODS From the multicenter retrospective Posterior cerebraL ArTery Occlusion (PLATO) registry, we included patients with isolated PCAo treated with reperfusion therapy within 24 hours of onset between January 2015 and August 2022. The primary outcome was the distribution of the modified Rankin Scale (mRS) at 3 months. Other outcomes comprised 3-month excellent (mRS 0-1) and independent outcome (mRS 0-2), early neurological improvement (ENI), mortality, and symptomatic intracranial hemorrhage (sICH). The treatments were compared using inverse probability weighted regression adjustment. RESULTS Among 724 patients, 400 received EVT+/-IVT and 324 IVT alone (median age 74 years, 57.7% men). The median National Institutes of Health Stroke Scale score on admission was 7, and the occluded segment was P1 (43.9%), P2 (48.3%), P3-P4 (6.1%), bilateral (1.0%), or fetal posterior cerebral artery (0.7%). Compared to IVT alone, EVT+/-IVT was not associated with improved functional outcome (adjusted common odds ratio [OR] 1.07, 95% confidence interval [CI] 0.79-1.43). EVT increased the odds for ENI (adjusted OR [aOR] 1.49, 95% CI 1.05-2.12), sICH (aOR 2.87, 95% CI 1.23-6.72), and mortality (aOR 1.77, 95% CI 1.07-2.95). CONCLUSION Despite higher odds for early improvement, EVT+/-IVT did not affect functional outcome compared to IVT alone after PCAo. This may be driven by the increased risk of sICH and mortality after EVT.
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Affiliation(s)
- Silja Räty
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Thanh N. Nguyen
- Department of Radiology, Boston Medical Center, Boston, MA, USA
- Department of Neurology, Boston Medical Center, Boston, MA, USA
| | - Simon Nagel
- Department of Neurology, Klinikum Ludwigshafen, Ludwigshafen, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Davide Strambo
- Department of Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Patrik Michel
- Department of Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Christian Herweh
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | | | - Pekka Virtanen
- Department of Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Marta Olive-Gadea
- Department of Neurology, University Hospital Vall d’Hebron, Barcelona, Spain
| | - Marc Ribo
- Department of Neurology, University Hospital Vall d’Hebron, Barcelona, Spain
| | - Marios Psychogios
- Department of Neuroradiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Anh Nguyen
- Department of Neuroradiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | | | - David Haupenthal
- Department of Neurology, University of Erlangen, Erlangen, Germany
| | - Martin Köhrmann
- Department of Neurology, Universitätsklinikum Essen, Essen, Germany
| | | | | | | | | | | | - Shadi Yaghi
- Department of Neurology, Rhode Island Hospital, Providence, RI, USA
| | - Liqi Shu
- Department of Neurology, Rhode Island Hospital, Providence, RI, USA
| | - Volker Puetz
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Dresden Neurovascular Center, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Daniel P.O. Kaiser
- Dresden Neurovascular Center, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Institute of Neuroradiology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Adnan Mujanovic
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, University of Bern, Bern, Switzerland
| | | | - Tobias Engelhorn
- Department of Neuroradiology, University of Erlangen, Erlangen, Germany
| | - Anne Berberich
- Department of Neurology, Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - Piers Klein
- Department of Radiology, Boston Medical Center, Boston, MA, USA
| | - Diogo C. Haussen
- Department of Neurology, Grady Memorial Hospital, Atlanta, GA, USA
| | | | - Hend Abdelhamid
- Department of Neurology, Grady Memorial Hospital, Atlanta, GA, USA
| | - Isabel Fragata
- Department of Neuroradiology, Centro Hospitalar Universitario de Lisboa Central, Lisbon, Portugal
| | - Bruno Cunha
- Department of Neuroradiology, Centro Hospitalar Universitario de Lisboa Central, Lisbon, Portugal
| | - Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, Cesena, Italy
| | - Wei Hu
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Jianlon Song
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Johanna T. Fifi
- Department of Neurosurgery, Mount Sinai Hospital, New York, NY, USA
| | | | - Sunil A. Sheth
- Department of Neurology, UT Health McGovern Medical School, Houston, TX, USA
| | | | - João Pedro Marto
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - João Nuno Ramos
- Department of Neuroradiology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Milena Miszczuk
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, and Berlin Institute of Health (BIH), Freie Universität Berlin and Humboldt-Universität, Berlin, Germany
| | - Christoph Riegler
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, and Berlin Institute of Health (BIH), Freie Universität Berlin and Humboldt-Universität, Berlin, Germany
| | - Sven Poli
- Hertie-Institute for Clinical Brain Research, Tübingen University, Tübingen, Germany
| | - Khouloud Poli
- Hertie-Institute for Clinical Brain Research, Tübingen University, Tübingen, Germany
| | - Ashutosh P. Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Shashvat Desai
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Volker Maus
- Department of Radiology, Neuroradiology and Nuclear Medicine, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Maximilian Kaeder
- Department of Radiology, Neuroradiology and Nuclear Medicine, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | | | - Andre Monteiro
- Department of Neurosurgery, University of Buffalo, Buffalo, NY, USA
| | - Tatu Kokkonen
- Department of Radiology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Francesco Diana
- Department of Interventional Neuroradiology, University Hospital Vall d’Hebron, Barcelona, Spain
| | - Hesham E. Masoud
- Department of Neurology, New York Upstate Medical University, Syracuse, NY, USA
| | - Neil Suryadareva
- Department of Neurology, New York Upstate Medical University, Syracuse, NY, USA
| | - Maxim Mokin
- Department of Neurosurgery, University of South Florida, Tampa, FL, USA
| | - Shail Thanki
- Department of Neurosurgery, University of South Florida, Tampa, FL, USA
| | - Pauli Ylikotila
- Department of Neurology, Turku University Hospital and University of Turku, Turku, Finland
| | - Kemal Alpay
- Department of Radiology, Turku University Hospital and University of Turku, Turku, Finland
| | - James E. Siegler
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | | | | | - Dileep Yavaghal
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Vasu Saini
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Christian H. Nolte
- Department of Neurology with Experimental Neurology, Charité - Universitätsmedizin Berlin, and Berlin Institute of Health (BIH), Freie Universität Berlin and Humboldt-Universität, Berlin, Germany
| | - Eberhart Siebert
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, and Berlin Institute of Health (BIH), Freie Universität Berlin and Humboldt-Universität, Berlin, Germany
| | | | - Peter A. Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Raul G. Nogueira
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Uta Hanning
- 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
| | - Urs Fischer
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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55
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Radu RA, Costalat V, Romoli M, Musmar B, Siegler JE, Ghozy S, Khalife J, Salim H, Shaikh H, Adeeb N, Cuellar-Saenz HH, Thomas AJ, Kadirvel R, Abdalkader M, Klein P, Nguyen TN, Heit JJ, Regenhardt RW, Bernstock JD, Patel AB, Rabinov JD, Stapleton CJ, Cancelliere NM, Marotta TR, Mendes Pereira V, El Naamani K, Amllay A, Tjoumakaris SI, Jabbour P, Meyer L, Fiehler J, Faizy TD, Guerreiro H, Dusart A, Bellante F, Forestier G, Rouchaud A, Mounayer C, Kühn AL, Puri AS, Dyzmann C, Kan PT, Colasurdo M, Marnat G, Berge J, Barreau X, Sibon I, Nedelcu S, Henninger N, Ota T, Dofuku S, Yeo LLL, Tan BY, Gopinathan A, Martinez-Gutierrez JC, Salazar-Marioni S, Sheth S, Renieri L, Capirossi C, Mowla A, Chervak LM, Vagal A, Khandelwal P, Biswas A, Clarençon F, Elhorany M, Premat K, Valente I, Pedicelli A, Alexandre AM, Filipe JP, Varela R, Quintero-Consuegra M, Gonzalez NR, Ymd MA, Jesser J, Weyland C, Ter Schiphorst A, Yedavalli V, Harker P, Aziz Y, Gory B, Paul Stracke C, Hecker C, Killer-Oberpfalzer M, Griessenauer CJ, Hsieh CY, Liebeskind DS, Tancredi I, Fahed R, Lubicz B, Essibayi MA, Baker A, Altschul D, Scarcia L, Kalsoum E, Dmytriw AA, Guenego A. Outcomes with General Anesthesia Compared to Conscious Sedation for Endovascular Treatment of Medium Vessel Occlusions: Results of an International Multicentric Study. Clin Neuroradiol 2024:10.1007/s00062-024-01415-1. [PMID: 38687365 DOI: 10.1007/s00062-024-01415-1] [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: 02/24/2024] [Accepted: 04/14/2024] [Indexed: 05/02/2024]
Abstract
BACKGROUND Optimal anesthetic strategy for the endovascular treatment of stroke is still under debate. Despite scarce data concerning anesthetic management for medium and distal vessel occlusions (MeVOs) some centers empirically support a general anesthesia (GA) strategy in these patients. METHODS We conducted an international retrospective study of MeVO cases. A propensity score matching algorithm was used to mitigate potential differences across patients undergoing GA and conscious sedation (CS). Comparisons in clinical and safety outcomes were performed between the two study groups GA and CS. The favourable outcome was defined as a modified Rankin Scale (mRS) 0-2 at 90 days. Safety outcomes were 90-days mortality and symptomatic intracranial hemorrhage (sICH). Predictors of a favourable outcome and sICH were evaluated with backward logistic regression. RESULTS After propensity score matching 668 patients were included in the CS and 264 patients in the GA group. In the matched cohort, either strategy CS or GA resulted in similar rates of good functional outcomes (50.1% vs. 48.4%), and successful recanalization (89.4% vs. 90.2%). The GA group had higher rates of 90-day mortality (22.6% vs. 16.5%, p < 0.041) and sICH (4.2% vs. 0.9%, p = 0.001) compared to the CS group. Backward logistic regression did not identify GA vs CS as a predictor of good functional outcome (OR for GA vs CS = 0.95 (0.67-1.35)), but GA remained a significant predictor of sICH (OR = 5.32, 95% CI 1.92-14.72). CONCLUSION Anaesthetic strategy in MeVOs does not influence favorable outcomes or final successful recanalization rates, however, GA may be associated with an increased risk of sICH and mortality.
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Affiliation(s)
- Răzvan Alexandru Radu
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France.
- Department of Clinical Neurosciences, "Carol Davila" University of Medicine and Pharmacy, Bucharest, Romania.
| | - Vincent Costalat
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Michele Romoli
- Neurology and Stroke Unit, Bufalini Hospital, AUSL Romagna, Cesena, Italy
| | - Basel Musmar
- Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Louisiana, LA, USA
| | - James E Siegler
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA
| | - Sherief Ghozy
- Departments of Neurological Surgery & Radiology, Mayo Clinic, Rochester, MN, USA
| | - Jane Khalife
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA
| | - Hamza Salim
- Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Louisiana, LA, USA
| | - Hamza Shaikh
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA
| | - Nimer Adeeb
- Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Louisiana, LA, USA
| | - Hugo H Cuellar-Saenz
- Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Louisiana, LA, USA
| | - Ajith J Thomas
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA
| | - Ramanathan Kadirvel
- Departments of Neurological Surgery & Radiology, Mayo Clinic, Rochester, MN, USA
| | - Mohamad Abdalkader
- Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA
| | - Piers Klein
- Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA
| | - Thanh N Nguyen
- Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA
| | - Jeremy J Heit
- Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, CA, USA
| | - Robert W Regenhardt
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Joshua D Bernstock
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA
- Department of Neurosurgery, Brigham and Women's Hospital, Boston, MA, USA
| | - Aman B Patel
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - James D Rabinov
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Christopher J Stapleton
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Nicole M Cancelliere
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Thomas R Marotta
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Vitor Mendes Pereira
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Kareem El Naamani
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Abdelaziz Amllay
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | | | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Lukas Meyer
- 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
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Radiology, Interventional Neuroradiology Section, University Medical Center Münster, Munster, Germany
| | - Helena Guerreiro
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anne Dusart
- Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium
| | - Flavio Bellante
- Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium
| | - Géraud Forestier
- University Hospital of Limoges, Neuroradiology Department, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252, Limoges, France
| | - Aymeric Rouchaud
- University Hospital of Limoges, Neuroradiology Department, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252, Limoges, France
| | - Charbel Mounayer
- University Hospital of Limoges, Neuroradiology Department, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252, Limoges, France
| | - Anna Luisa Kühn
- Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Ajit S Puri
- Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Christian Dyzmann
- Neuroradiology Department, Sana Kliniken, Lübeck GmbH, Lübeck, Germany
| | - Peter T Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Marco Colasurdo
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX, USA
- Department of Interventional Radiology, Oregon Health and Science University, 97239, Portland, OR, USA
| | - Gaultier Marnat
- Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France
| | - Jérôme Berge
- Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France
| | - Xavier Barreau
- Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France
| | - Igor Sibon
- Neurology Department, Bordeaux University Hospital, Bordeaux, France
| | - Simona Nedelcu
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Nils Henninger
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
- Department of Psychiatry, University of Massachusetts Chan Medical School, Worcester, MA, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA
| | - Takahiro Ota
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Shogo Dofuku
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Leonard L L Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Benjamin Yq Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | - Anil Gopinathan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Interventional Radiology, National University Hospital, Singapore, Singapore
| | | | | | - Sunil Sheth
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX, USA
| | - Leonardo Renieri
- Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy
| | - Carolina Capirossi
- Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy
| | - Ashkan Mowla
- Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), North State St, Suite 3300, 1200, Los Angeles, CA, USA
| | - Lina M Chervak
- Department of Neurology and Radiology, University of Cincinnati, Cincinnati, USA
| | - Achala Vagal
- Department of Neurology and Radiology, University of Cincinnati, Cincinnati, USA
| | - Priyank Khandelwal
- Department of Endovascular Neurosurgery and Neuroradiology NJMS, Newark, NJ, USA
| | - Arundhati Biswas
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Frédéric Clarençon
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
- Division of Interventional Radiology, National University Hospital, Singapore, Singapore
| | - Mahmoud Elhorany
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
- Neurology Department, Faculty of Medicine, Tanta University, Tanta, Egypt
- Division of Interventional Radiology, National University Hospital, Singapore, Singapore
| | - Kevin Premat
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
- Division of Interventional Radiology, National University Hospital, Singapore, Singapore
| | - Iacopo Valente
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A.Gemelli IRCCS Roma, Rome, Italy
| | - Alessandro Pedicelli
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A.Gemelli IRCCS Roma, Rome, Italy
| | - Andrea M Alexandre
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A.Gemelli IRCCS Roma, Rome, Italy
| | - João Pedro Filipe
- Department of Diagnostic and Interventional Neuroradiology, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Ricardo Varela
- Department of Neurology, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | | | - Nestor R Gonzalez
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, USA
| | - Markus A Ymd
- Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Jessica Jesser
- Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Charlotte Weyland
- Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Adrien Ter Schiphorst
- Department of Neurology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Vivek Yedavalli
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD, USA
| | - Pablo Harker
- Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Yasmin Aziz
- Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Benjamin Gory
- Department of Interventional Neuroradiology, Nancy University Hospital, Nancy, France
- INSERM U1254, IADI, Université de Lorraine, 54511, Vandoeuvre-les-Nancy, France
| | - Christian Paul Stracke
- Department of Radiology, Interventional Neuroradiology Section, University Medical Center Münster, Munster, Germany
| | - Constantin Hecker
- Departments of Neurology & Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Monika Killer-Oberpfalzer
- Departments of Neurology & Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Christoph J Griessenauer
- Departments of Neurology & Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Cheng-Yang Hsieh
- Neurology Department, Sin-Lau Hospital, Tainan, Taiwan, Province of China
| | - David S Liebeskind
- UCLA Stroke Center and Department of Neurology Department, UCLA, Los Angeles, California, USA
| | - Illario Tancredi
- Department of Medicine, Division of Neurology, The Ottawa Hospital, Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada
| | - Robert Fahed
- Department of Medicine, Division of Neurology, The Ottawa Hospital, Ottawa Hospital Research Institute and University of Ottawa, Ottawa, Ontario, Canada
| | - Boris Lubicz
- Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Muhammed Amir Essibayi
- Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Amanda Baker
- Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - David Altschul
- Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Luca Scarcia
- Department of Neuroradiology, Henri Mondor Hospital, Creteil, France
| | - Erwah Kalsoum
- Department of Neuroradiology, Henri Mondor Hospital, Creteil, France
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Adrien Guenego
- Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
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Li C, Zhang X, Ren Z, Wang J, Sun S, Fu J, Xu Y, Duan W. Design, Modeling, and Experimental Validation of an Active Microcatheter Driven by Shape Memory Effects. MICROMACHINES 2024; 15:603. [PMID: 38793176 PMCID: PMC11123389 DOI: 10.3390/mi15050603] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/02/2024] [Revised: 04/23/2024] [Accepted: 04/28/2024] [Indexed: 05/26/2024]
Abstract
Microcatheters capable of active guidance have been proven to be effective and efficient solutions to interventional surgeries for cardiovascular and cerebrovascular diseases. Herein, a novel microcatheter made of two biocompatible materials, shape memory alloy (SMA) and polyethylene (PE), is proposed. It consists of a reconfigurable distal actuator and a separate polyethylene catheter. The distal actuator is created via embedding U-shape SMA wires into the PE base, and its reconfigurability is mainly dominated by the shape memory effect (SME) of SMA wires, as well as the effect of thermal mismatch between the SMA and PE base. A mathematical model was established to predict the distal actuator's deformation, and the analytical solutions show great agreement with the finite element results. Structural optimization of such microcatheters was carried out using the verified analytical model, followed by fabrication of some typical prototypes. Experimental testing of their mechanical behaviors demonstrates the feasibility of the structural designs, and the reliability and accuracy of the mathematical model. The active microcatheter, together with the prediction model, will lay a solid foundation for rapid development and optimization of active navigation strategies for vascular interventions.
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Affiliation(s)
- Chengyang Li
- School of Mechanical Engineering, Shandong University, Jinan 250061, China; (C.L.); (X.Z.); (J.W.); (S.S.)
| | - Xu Zhang
- School of Mechanical Engineering, Shandong University, Jinan 250061, China; (C.L.); (X.Z.); (J.W.); (S.S.)
| | - Zhongjing Ren
- School of Mechanical Engineering, Shandong University, Jinan 250061, China; (C.L.); (X.Z.); (J.W.); (S.S.)
- Shenzhen Research Institute of Shandong University, Shenzhen 518057, China
- School of Electrical and Information Engineering, Lanzhou University of Technology, Lanzhou 730050, China
- Zhejiang Julihuang Sawing Machine Group Co., Ltd., Lishui 321404, China
| | - Jingkai Wang
- School of Mechanical Engineering, Shandong University, Jinan 250061, China; (C.L.); (X.Z.); (J.W.); (S.S.)
| | - Shouyu Sun
- School of Mechanical Engineering, Shandong University, Jinan 250061, China; (C.L.); (X.Z.); (J.W.); (S.S.)
- Shandong Ande Healthcare Apparatus Co., Ltd., Zibo 255086, China;
| | - Jian Fu
- Shandong Ande Healthcare Apparatus Co., Ltd., Zibo 255086, China;
| | - Yang Xu
- Department of Mechanical Engineering, Stevens Institute of Technology, Hoboken, NJ 07030, USA;
| | - Wu Duan
- Shenzhen Research Institute of Shandong University, Shenzhen 518057, China
- Department of Endocrinology, Qilu Hospital of Shandong University, Jinan 250012, China
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Kuwahara S, Uchida K, Sakai N, Yamagami H, Imamura H, Takeuchi M, Shirakawa M, Sakakibara F, Haraguchi K, Kimura N, Suzuki K, Yoshimura S. Technical and clinical outcomes of thrombectomy in patients with acute medium vessel occlusion and large vessel occlusion; sub-analyses of Japan Trevo registry. J Neurol Sci 2024; 459:122956. [PMID: 38498954 DOI: 10.1016/j.jns.2024.122956] [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: 11/27/2023] [Revised: 02/27/2024] [Accepted: 03/10/2024] [Indexed: 03/20/2024]
Abstract
BACKGROUND Little is known about endovascular therapy (EVT) for patients with medium vessel occlusion (MeVO) and more work is needed to establish its efficacy and to understand hemorrhagic complications. METHODS We analyzed the Japan Trevo Registry, which enrolled patients with acute stroke who underwent EVT using Trevo Retriever alone or in combination with an aspiration catheter. The primary outcome was effective reperfusion, and the secondary outcome was modified Rankin scale 0-2 at 90 days. Safety outcomes, including intracranial hemorrhage (ICH), were evaluated using a subgroup analyses focused on any ICH. RESULTS Among 1041 registered patients, 1025 patients were analyzed. 253 patients had MeVOs, and the majority (89.3%) had middle cerebral artery segment 2 (M2). The median National Institutes of Health Stroke Scale scores at admission were 15 and 19 for the MeVO and LVO groups (p < 0.0001). The primary outcome was 88.9% in MeVO vs. 91.8% in LVO group: adjusted odds ratio (aOR) [95% confidence interval (CI)] 0.60 [0.35-1.03], p = 0.07, and the secondary outcome was 43.2% vs. 42.2%, and the aOR [95%CI] was 0.70 [0.48-1.002], p = 0.051. However, the incidence of any ICH was more prominent in MeVO than in LVO group (35.7% vs. 28.8%, aOR [95%CI] 1.54 [1.10-2.15], p = 0.01). In subgroup analyses, the incidences of any ICH in MeVO group were generally higher than those in LVO group. CONCLUSIONS The effective reperfusion rate did not differ significantly between MeVO and LVO groups. Future development of devices and treatments for MeVO with fewer hemorrhagic complications is desirable.
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Affiliation(s)
- Shuntaro Kuwahara
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Kazutaka Uchida
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan.
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Hirotoshi Imamura
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan; Division of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | | | - Manabu Shirakawa
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | | | - Koichi Haraguchi
- Department of Neurosurgery, Hakodate Shintoshi Hospital, Hakodate, Japan
| | - Naoto Kimura
- Department of Neurosurgery, Iwate Prefectural Central Hospital, Morioka, Japan
| | - Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
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Grieb D, Greling B, Schulz K, Boxberg F, Melber K, Abu-Fares O, Lanfermann H, Schlunz-Hendann M, Meila D. Endovascular treatment of distal medium vessel occlusions using microcatheter aspiration thrombectomy. Interv Neuroradiol 2024; 30:234-241. [PMID: 36259323 PMCID: PMC11095358 DOI: 10.1177/15910199221133470] [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: 06/21/2022] [Accepted: 09/29/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND AND PURPOSE Recent studies suggest that endovascular treatment (EVT) in distal medium vessel occlusion (DMVO) stroke is beneficial even beyond middle cerebral artery (MCA) - M2 segment. However, data about aspiration thrombectomy of DMVOs is scarce since common state-of-the-art aspiration catheters are usually too large for small distal intracranial arteries. We report our initial experiences using the microcatheter aspiration thrombectomy (MAT) technique as frontline therapy for acute DMVOs in the MCA territory. METHODS We retrospectively analyzed all acute ischemic stroke (AIS) patients that underwent MAT of a primary or secondary DMVO in the M3 or M4 segment between January 2019 and October 2021. Recanalization rates, procedural safety and outcome data were recorded. RESULTS MAT of acute M3 and M4 occlusions was performed in 19 patients with AIS. Six had isolated DMVO strokes, 13 had secondary DMVOs during EVT of a proximal large vessel occlusion. Successful revascularization to DMVO TICI ≥ 2b was achieved in 58% (11/19) with a single pass in all of them. The median National Institutes of Health Strokes Scale (NIHSS) score at admission and discharge was 12 and 3, respectively. 68% (13/19) of the patients had a good clinical outcome at discharge (modified Rankin Scale 0-2). No symptomatic complications related to MAT occurred. CONCLUSIONS MAT of DMVOs in the MCA territory is technically feasible and effective. Compared to stent retriever-based thrombectomy in DMVOs the hemorrhagic complication rate appears notably lower. Further studies are needed to validate the benefit of mechanical thrombectomy in the distal intracranial vasculature.
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Affiliation(s)
- Dominik Grieb
- Department of Radiology and Neuroradiology, Sana Kliniken Duisburg, Duisburg, Germany
- Department of Diagnostic and Interventional Neuroradiology, Medical School Hannover, Hannover, Germany
| | - Björn Greling
- Department of Interventional Neuroradiology, Johanna-Étienne-Hospital, Neuss, Germany
| | - Katharina Schulz
- Department of Radiology and Neuroradiology, Sana Kliniken Duisburg, Duisburg, Germany
| | - Frederik Boxberg
- Department of Radiology and Neuroradiology, Sana Kliniken Duisburg, Duisburg, Germany
| | - Katharina Melber
- Department of Radiology and Neuroradiology, Sana Kliniken Duisburg, Duisburg, Germany
| | - Omar Abu-Fares
- Department of Diagnostic and Interventional Neuroradiology, Medical School Hannover, Hannover, Germany
| | - Heinrich Lanfermann
- Department of Diagnostic and Interventional Neuroradiology, Medical School Hannover, Hannover, Germany
| | | | - Dan Meila
- Department of Interventional Neuroradiology, Johanna-Étienne-Hospital, Neuss, Germany
- Department of Diagnostic and Interventional Radiology, Helios Klinikum Krefeld, Krefeld, Germany
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Koneru M, Hoseinyazdi M, Wang R, Ozkara BB, Hyson NZ, Marsh EB, Llinas RH, Urrutia VC, Leigh R, Gonzalez LF, Xu R, Caplan JM, Huang J, Lu H, Luna L, Wintermark M, Dmytriw AA, Guenego A, Albers GW, Heit JJ, Nael K, Hillis AE, Yedavalli VS. Pretreatment parameters associated with hemorrhagic transformation among successfully recanalized medium vessel occlusions. J Neurol 2024; 271:1901-1909. [PMID: 38099953 DOI: 10.1007/s00415-023-12149-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 11/26/2023] [Accepted: 12/03/2023] [Indexed: 03/28/2024]
Abstract
Although pretreatment radiographic biomarkers are well established for hemorrhagic transformation (HT) following successful mechanical thrombectomy (MT) in large vessel occlusion (LVO) strokes, they are yet to be explored for medium vessel occlusion (MeVO) acute ischemic strokes. We aim to investigate pretreatment imaging biomarkers representative of collateral status, namely the hypoperfusion intensity ratio (HIR) and cerebral blood volume (CBV) index, and their association with HT in successfully recanalized MeVOs. A prospectively collected registry of acute ischemic stroke patients with MeVOs successfully recanalized with MT between 2019 and 2023 was retrospectively reviewed. A multivariate logistic regression for HT of any subtype was derived by combining significant univariate predictors into a forward stepwise regression with minimization of Akaike information criterion. Of 60 MeVO patients successfully recanalized with MT, HT occurred in 28.3% of patients. Independent factors for HT included: diabetes mellitus history (p = 0.0005), CBV index (p = 0.0071), and proximal versus distal occlusion location (p = 0.0062). A multivariate model with these factors had strong diagnostic performance for predicting HT (area under curve [AUC] 0.93, p < 0.001). Lower CBV indexes, distal occlusion location, and diabetes history are significantly associated with HT in MeVOs successfully recanalized with MT. Of note, HIR was not found to be significantly associated with HT.
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Affiliation(s)
- Manisha Koneru
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Meisam Hoseinyazdi
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | - Richard Wang
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | | | - Nathan Z Hyson
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | | | - Rafael H Llinas
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | - Victor C Urrutia
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | - Richard Leigh
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | | | - Risheng Xu
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | - Justin M Caplan
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | - Judy Huang
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | - Hanzhang Lu
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | - Licia Luna
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | | | | | - Adrien Guenego
- Universite Libre De Bruxelles Hospital Erasme, Anderlecht, Belgium
| | | | - Jeremy J Heit
- Stanford University School of Medicine, Stanford, CA, USA
| | - Kambiz Nael
- David Geffen School of Medicine at UCLA, Los Angeles, CA, USA
| | - Argye E Hillis
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA
| | - Vivek S Yedavalli
- Johns Hopkins School of Medicine, Phipps B122-D, Baltimore, MD, 21287, USA.
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60
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Wang M, Henkes H, Ghozy S, Siegler JE, Shaikh H, Khalife J, Abdalkader M, Klein P, Nguyen TN, Heit JJ, Sweid A, Naamani KE, Regenhardt RW, Diestro JDB, Cancelliere NM, Amllay A, Meyer L, Dusart A, Bellante F, Forestier G, Rouchaud A, Saleme S, Mounayer C, Fiehler J, Kühn AL, Puri AS, Dyzmann C, Kan PT, Colasurdo M, Marnat G, Berge J, Barreau X, Sibon I, Nedelcu S, Henninger N, Weyland C, Marotta TR, Stapleton CJ, Rabinov JD, Ota T, Dofuku S, Yeo LL, Tan BYQ, Martinez-Gutierrez JC, Salazar-Marioni S, Sheth S, Renieri L, Capirossi C, Mowla A, Tjoumakaris SI, Jabbour P, Khandelwal P, Biswas A, Clarençon F, Elhorany M, Premat K, Valente I, Pedicelli A, Filipe JP, Varela R, Quintero-Consuegra M, Gonzalez NR, Möhlenbruch MA, Jesser J, Costalat V, Ter Schiphorst A, Yedavalli V, Harker P, Chervak LM, Aziz Y, Gory B, Stracke CP, Hecker C, Killer-Oberpfalzer M, Griessenauer CJ, Thomas AJ, Hsieh CY, Liebeskind DS, Radu RA, Alexandre AM, Tancredi I, Faizy TD, Patel AB, Pereira VM, Fahed R, Lubicz B, Dmytriw AA, Guenego A. Use of the pRESET LITE thrombectomy device in combined approach for medium vessel occlusions: A multicenter evaluation. Neuroradiology 2024; 66:631-641. [PMID: 38381145 DOI: 10.1007/s00234-024-03302-5] [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: 08/21/2023] [Accepted: 01/29/2024] [Indexed: 02/22/2024]
Abstract
PURPOSE Our purpose was to assess the efficacy and safety of the pRESET LITE stent retriever (Phenox, Bochum, Germany), designed for medium vessel occlusion (MeVO) in acute ischemic stroke (AIS) patients with a primary MeVO. METHODS We performed a retrospective analysis of the MAD MT Consortium, an integration of prospectively maintained databases at 37 academic institutions in Europe, North America, and Asia, of AIS patients who underwent mechanical thrombectomy with the pRESET LITE stent retriever for a primary MeVO. We subcategorized occlusions into proximal MeVOs (segments A1, M2, and P1) vs. distal MeVOs/DMVO (segments A2, M3-M4, and P2). We reviewed patient and procedural characteristics, as well as angiographic and clinical outcomes. RESULTS Between September 2016 and December 2021, 227 patients were included (50% female, median age 78 [65-84] years), of whom 161 (71%) suffered proximal MeVO and 66 (29%) distal MeVO. Using a combined approach in 96% of cases, successful reperfusion of the target vessel (mTICI 2b/2c/3) was attained in 85% of proximal MeVO and 97% of DMVO, with a median of 2 passes (IQR: 1-3) overall. Periprocedural complications rate was 7%. Control CT at day 1 post-MT revealed a hemorrhagic transformation in 63 (39%) patients with proximal MeVO and 24 (36%) patients with DMVO, with ECASS-PH type hemorrhagic transformations occurring in 3 (1%) patients. After 3 months, 58% of all MeVO and 63% of DMVO patients demonstrated a favorable outcome (mRS 0-2). CONCLUSION Mechanical thrombectomy using the pRESET LITE in a combined approach with an aspiration catheter appears effective for primary medium vessel occlusions across several centers and physicians.
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Affiliation(s)
- Maud Wang
- Department of Radiology, Leuven University Hospitals, Leuven, Belgium.
| | - Hans Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, Stuttgart, Germany
| | - Sherief Ghozy
- Departments of Neurologic Surgery & Radiology, Mayo Clinic, Rochester, MN, USA
| | - James E Siegler
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA
| | - Hamza Shaikh
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA
| | - Jane Khalife
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA
| | - Mohamad Abdalkader
- Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA
| | - Piers Klein
- Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA
| | - Thanh N Nguyen
- Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA
| | - Jeremy J Heit
- Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, CA, USA
| | - Ahmad Sweid
- Departments of Neurologic Surgery & Radiology, Mayo Clinic, Rochester, MN, USA
| | - Kareem El Naamani
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Robert W Regenhardt
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Jose Danilo Bengzon Diestro
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Nicole M Cancelliere
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Abdelaziz Amllay
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anne Dusart
- Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium
| | - Flavio Bellante
- Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium
| | - Géraud Forestier
- Department of Neuroradiology, CHU Limoges Dupuytren, Université de Limoges, Limoges, France
| | - Aymeric Rouchaud
- Department of Neuroradiology, CHU Limoges Dupuytren, Université de Limoges, Limoges, France
| | - Suzana Saleme
- Department of Neuroradiology, CHU Limoges Dupuytren, Université de Limoges, Limoges, France
| | - Charbel Mounayer
- Department of Neuroradiology, CHU Limoges Dupuytren, Université de Limoges, Limoges, France
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Luisa Kühn
- Department of Radiology, University of Massachusetts Memorial Hospital, Worcester, MA, USA
| | - Ajit S Puri
- Department of Radiology, University of Massachusetts Memorial Hospital, Worcester, MA, USA
| | - Christian Dyzmann
- Department of Neuroradiology, Sana Kliniken, Lübeck GmbH, Lübeck, Germany
| | - Peter T Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Marco Colasurdo
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Gaultier Marnat
- Department of Interventional Neuroradiology, CHU Bordeaux, Bordeaux, France
| | - Jérôme Berge
- Department of Interventional Neuroradiology, CHU Bordeaux, Bordeaux, France
| | - Xavier Barreau
- Department of Interventional Neuroradiology, CHU Bordeaux, Bordeaux, France
| | - Igor Sibon
- Department of Neurology, CHU Bordeaux, Bordeaux, France
| | - Simona Nedelcu
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Nils Henninger
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
- Department of Psychiatry, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Charlotte Weyland
- Department of Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Thomas R Marotta
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Christopher J Stapleton
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - James D Rabinov
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Takahiro Ota
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Shogo Dofuku
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Leonard Ll Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Benjamin Y Q Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore, Singapore
| | | | | | - Sunil Sheth
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX, USA
| | - Leonardo Renieri
- Interventistica Neurovascolare, Ospedale Careggi Di Firenze, Florence, Italy
| | - Carolina Capirossi
- Interventistica Neurovascolare, Ospedale Careggi Di Firenze, Florence, Italy
| | - Ashkan Mowla
- Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), Los Angeles, CA, USA
| | | | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Priyank Khandelwal
- Department of Endovascular Neurosurgery and Neuroradiology NJMS, Newark, NJ, USA
| | - Arundhati Biswas
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Frédéric Clarençon
- Department of Neuroradiology, Pitié-Salpêtrière University Hospitals, Sorbonne University- Paris VI, Paris, France
| | - Mahmoud Elhorany
- Department of Neuroradiology, Pitié-Salpêtrière University Hospitals, Sorbonne University- Paris VI, Paris, France
- Department of Neurology, Faculty of Medicine, Tanta University, Tanta, Egypt
| | - Kevin Premat
- Department of Neuroradiology, Pitié-Salpêtrière University Hospitals, Sorbonne University- Paris VI, Paris, France
| | - Iacopo Valente
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alessandro Pedicelli
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - João Pedro Filipe
- Department of Diagnostic and Interventional Neuroradiology, Centro Hospitalar Universitário Do Porto, Porto, Portugal
| | - Ricardo Varela
- Department of Neurology, Centro Hospitalar Universitário Do Porto, Porto, Portugal
| | | | - Nestor R Gonzalez
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Markus A Möhlenbruch
- Sektion Vaskuläre Und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Jessica Jesser
- Sektion Vaskuläre Und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Vincent Costalat
- Department of Neuroradiology, Gui de Chauliac Hospital, CHU Montpellier, Montpellier, France
| | - Adrien Ter Schiphorst
- Department of Neurology, Gui de Chauliac Hospital, CHU Montpellier, Montpellier, France
| | - Vivek Yedavalli
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD, USA
| | - Pablo Harker
- Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Lina M Chervak
- Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Yasmin Aziz
- Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Benjamin Gory
- Department of Interventional Neuroradiology, CHU Nancy, Nancy, France
| | - Christian Paul Stracke
- Department of Radiology, Interventional Neuroradiology Section, University Medical Center Münster, Münster, Germany
| | - Constantin Hecker
- Departments of Neurology & Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Monika Killer-Oberpfalzer
- Departments of Neurology & Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Christoph J Griessenauer
- Departments of Neurology & Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Ajith J Thomas
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA
| | | | - David S Liebeskind
- Department of Neurology Department, UCLA Stroke Center, UCLA, Los Angeles, CA, USA
| | - Răzvan Alexandru Radu
- Department of Neuroradiology, Gui de Chauliac Hospital, CHU Montpellier, Montpellier, France
| | - Andrea M Alexandre
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Illario Tancredi
- Department of Radiology, Hôpital Civil Marie Curie, Charleroi, Belgium
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Aman B Patel
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Vitor Mendes Pereira
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Robert Fahed
- Department of Medicine, Division of Neurology, The Ottawa Hospital, Ottawa Hospital Research Institute and University of Ottawa, Ottawa, ON, Canada
| | - Boris Lubicz
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Adrien Guenego
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
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61
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Vos EM, Kappelhof M, den Hartog SJ, Coutinho JM, Emmer BJ, Roozenbeek B, van Zwam WH, van Oostenbrugge RJ, van der Worp HB, Uyttenboogaart M, van Es ACGM, Majoie CBLM, Dippel DWJ, Peeters-Scholte CMPCD, van den Wijngaard IR. Endovascular treatment of patients with stroke caused by anterior cerebral artery occlusions. Acta Neurol Belg 2024; 124:621-630. [PMID: 37828269 DOI: 10.1007/s13760-023-02395-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2023] [Accepted: 09/21/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND Occlusion of the anterior cerebral artery (ACA) is uncommon but may lead to significant disability. The benefit of endovascular treatment (EVT) for ACA occlusions remains uncertain. METHODS We included patients treated with EVT and compared patients with ACA occlusions with patients who had internal carotid artery (ICA) or proximal (M1/M2) middle cerebral artery (MCA) occlusions from the MR CLEAN Registry. Primary outcome was the modified Rankin Scale score (mRS). Secondary outcomes were functional independence (mRS 0-2), National Institutes of Health Stroke Scale (NIHSS) score, delta-NIHSS (baseline minus NIHSS score at 24-48 h), and successful recanalization (expanded thrombolysis in cerebral infarction (eTICI) score 2b-3). Safety outcomes were symptomatic intracranial hemorrhage (sICH), periprocedural complications, and mortality. RESULTS Of 5193 patients, 11 (0.2%) had primary ACA occlusions. Median NIHSS at baseline was lower in patients with ACA versus ICA/MCA occlusions (11, IQR 9-14; versus 15, IQR 11-19). Functional outcome did not differ from patients with ICA/MCA occlusions. Functional independence was 4/11 (36%) in patients with ACA versus 1949/4815 (41%) in ICA/MCA occlusions; median delta-NIHSS was - 1 (IQR - 7 to 2) and - 4 (IQR - 9 to 0), respectively. Successful recanalization was 4/9 (44%), versus 3083/4787 (64%) in ICA/MCA occlusions. Mortality was 3/11 (27%) versus 1263/4815 (26%). One patient with ACA occlusion had sICH; no other complications occurred. CONCLUSION In this cohort ACA occlusions were uncommon. Functional outcome did not differ between patients with ACA occlusions and ICA/MCA occlusions. Prospective research is needed to determine feasibility, safety, and outcomes of EVT for ACA occlusions.
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Affiliation(s)
- Erik M Vos
- Department of Neurology, Haaglanden Medical Center, The Hague, The Netherlands.
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Sanne J den Hartog
- Department of Neurology, Radiology and Nuclear Medicine, Erasmus Medical Center, Public Health, Rotterdam, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Bart J Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Radiology and Nuclear Medicine, Erasmus Medical Center, Public Health, Rotterdam, The Netherlands
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, School for Cardiovascular Diseases (CARIM), Maastricht UMC+, Maastricht, The Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, School for Cardiovascular Diseases (CARIM), School for Mental Health and Neuroscience, Maastricht UMC+, Maastricht, The Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, Department of Radiology, Medical Imaging Center, University Medical Center Groningen, Groningen, The Netherlands
| | - Adriaan C G M van Es
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
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62
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Arrarte Terreros N, Stolp J, Bruggeman AAE, Swijnenburg ISJ, Lopes RR, van Meenen LCC, Groot AED, Kappelhof M, Coutinho JM, Roos YBWEM, Emmer BJ, Beenen LFM, Dippel DWJ, van Zwam WH, van Bavel E, Marquering HA, Majoie CBLM. Thrombus Imaging Characteristics to Predict Early Recanalization in Anterior Circulation Large Vessel Occlusion Stroke. J Cardiovasc Dev Dis 2024; 11:107. [PMID: 38667725 PMCID: PMC11050543 DOI: 10.3390/jcdd11040107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 03/23/2024] [Accepted: 03/25/2024] [Indexed: 04/28/2024] Open
Abstract
The early management of transferred patients with a large vessel occlusion (LVO) stroke could be improved by identifying patients who are likely to recanalize early. We aim to predict early recanalization based on patient clinical and thrombus imaging characteristics. We included 81 transferred anterior-circulation LVO patients with an early recanalization, defined as the resolution of the LVO or the migration to a distal location not reachable with endovascular treatment upon repeated radiological imaging. We compared their clinical and imaging characteristics with all (322) transferred patients with a persistent LVO in the MR CLEAN Registry. We measured distance from carotid terminus to thrombus (DT), thrombus length, density, and perviousness on baseline CT images. We built logistic regression models to predict early recanalization. We validated the predictive ability by computing the median area-under-the-curve (AUC) of the receiver operating characteristics curve for 100 5-fold cross-validations. The administration of intravenous thrombolysis (IVT), longer transfer times, more distal occlusions, and shorter, pervious, less dense thrombi were characteristic of early recanalization. After backward elimination, IVT administration, DT and thrombus density remained in the multivariable model, with an AUC of 0.77 (IQR 0.72-0.83). Baseline thrombus imaging characteristics are valuable in predicting early recanalization and can potentially be used to optimize repeated imaging workflow.
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Affiliation(s)
- Nerea Arrarte Terreros
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (E.v.B.)
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Jeffrey Stolp
- Department of Neurology, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (J.S.)
| | - Agnetha A. E. Bruggeman
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Isabella S. J. Swijnenburg
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (E.v.B.)
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Ricardo R. Lopes
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (E.v.B.)
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Laura C. C. van Meenen
- Department of Neurology, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (J.S.)
| | - Adrien E. D. Groot
- Department of Neurology, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (J.S.)
| | - Manon Kappelhof
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (E.v.B.)
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Jonathan M. Coutinho
- Department of Neurology, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (J.S.)
| | - Yvo B. W. E. M. Roos
- Department of Neurology, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (J.S.)
| | - Bart J. Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Ludo F. M. Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | | | - Wim H. van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, 6229 HX Maastricht, The Netherlands;
| | - Ed van Bavel
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (E.v.B.)
| | - Henk A. Marquering
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (E.v.B.)
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Charles B. L. M. Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
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63
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Peng Q, Wang S, Han J, Huang C, Yu H, Li D, Qiu M, Cheng S, Wu C, Cai M, Fu S, Chen B, Wu X, Du S, Xu T. Thermal and Magnetic Dual-Responsive Catheter-Assisted Shape Memory Microrobots for Multistage Vascular Embolization. RESEARCH (WASHINGTON, D.C.) 2024; 7:0339. [PMID: 38550780 PMCID: PMC10976590 DOI: 10.34133/research.0339] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2023] [Accepted: 02/20/2024] [Indexed: 08/20/2024]
Abstract
Catheters navigating through complex vessels, such as sharp turns or multiple U-turns, remain challenging for vascular embolization. Here, we propose a novel multistage vascular embolization strategy for hard-to-reach vessels that releases untethered swimming shape-memory magnetic microrobots (SMMs) from the prior catheter to the vessel bifurcation. SMMs, made of organo-gel with magnetic particles, ensure biocompatibility, radiopacity, thrombosis, and fast thermal and magnetic responses. An SMM is initially a linear shape with a 0.5-mm diameter at 20 °C inserted in a catheter. It transforms into a predetermined helix within 2 s at 38 °C blood temperature after being pushed out of the catheter into the blood. SMMs enable agile swimming in confined and tortuous vessels and can swim upstream using helical propulsion with rotating magnetic fields. Moreover, we validated this multistage vascular embolization in living rabbits, completing 100-cm travel and renal artery embolization in 2 min. After 4 weeks, the SMMs maintained the embolic position, and the kidney volume decreased by 36%.
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Affiliation(s)
- Qianbi Peng
- Guangdong Provincial Key Lab of Robotics and Intelligent Systems, Shenzhen Institute of Advanced Technology,
Chinese Academy of Sciences, Shenzhen, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Shu Wang
- Guangdong Provincial Key Lab of Robotics and Intelligent Systems, Shenzhen Institute of Advanced Technology,
Chinese Academy of Sciences, Shenzhen, China
| | - Jianguo Han
- Department of Neurosurgery, South China Hospital, Medical School,
Shenzhen University, Shenzhen, China
| | - Chenyang Huang
- Guangdong Provincial Key Lab of Robotics and Intelligent Systems, Shenzhen Institute of Advanced Technology,
Chinese Academy of Sciences, Shenzhen, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Hengyuan Yu
- Guangdong Provincial Key Lab of Robotics and Intelligent Systems, Shenzhen Institute of Advanced Technology,
Chinese Academy of Sciences, Shenzhen, China
| | - Dong Li
- Guangdong Provincial Key Lab of Robotics and Intelligent Systems, Shenzhen Institute of Advanced Technology,
Chinese Academy of Sciences, Shenzhen, China
| | - Ming Qiu
- Department of Neurosurgery, South China Hospital, Medical School,
Shenzhen University, Shenzhen, China
| | - Si Cheng
- Department of Neurosurgery, South China Hospital, Medical School,
Shenzhen University, Shenzhen, China
| | - Chong Wu
- Department of Neurosurgery, South China Hospital, Medical School,
Shenzhen University, Shenzhen, China
| | - Mingxue Cai
- Guangdong Provincial Key Lab of Robotics and Intelligent Systems, Shenzhen Institute of Advanced Technology,
Chinese Academy of Sciences, Shenzhen, China
| | - Shixiong Fu
- Guangdong Provincial Key Lab of Robotics and Intelligent Systems, Shenzhen Institute of Advanced Technology,
Chinese Academy of Sciences, Shenzhen, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Binghan Chen
- Guangdong Provincial Key Lab of Robotics and Intelligent Systems, Shenzhen Institute of Advanced Technology,
Chinese Academy of Sciences, Shenzhen, China
- University of Chinese Academy of Sciences, Beijing, China
| | - Xinyu Wu
- Guangdong Provincial Key Lab of Robotics and Intelligent Systems, Shenzhen Institute of Advanced Technology,
Chinese Academy of Sciences, Shenzhen, China
| | - Shiwei Du
- Department of Neurosurgery, South China Hospital, Medical School,
Shenzhen University, Shenzhen, China
| | - Tiantian Xu
- Guangdong Provincial Key Lab of Robotics and Intelligent Systems, Shenzhen Institute of Advanced Technology,
Chinese Academy of Sciences, Shenzhen, China
- The Key Laboratory of Biomedical Imaging Science and System, Shenzhen Institute of Advanced Technology,
Chinese Academy of Sciences, Shenzhen, China
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64
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Clarençon F, Durand-Zaleski I, Premat K, Baptiste A, Chabert E, Ferrier A, Labeyrie MA, Reiner P, Spelle L, Denier C, Tuilier T, Hosseini H, Rodriguez-Régent C, Turc G, Fauché C, Lamy M, Lapergue B, Consoli A, Barbier C, Boulanger M, Bricout N, Henon H, Gory B, Richard S, Rouchaud A, Macian-Montoro F, Eker O, Cho TH, Soize S, Moulin S, Gentric JC, Timsit S, Darcourt J, Albucher JF, Janot K, Annan M, Pico F, Costalat V, Arquizan C, Marnat G, Sibon I, Pop R, Wolff V, Shotar E, Lenck S, Sourour NA, Radenne A, Alamowitch S, Dechartres A. Evaluation of mechanical thrombectomy in acute ischemic stroke related to a distal arterial occlusion: A randomized controlled trial. Int J Stroke 2024; 19:367-372. [PMID: 37740419 DOI: 10.1177/17474930231205213] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/24/2023]
Abstract
RATIONALE Mechanical thrombectomy (MT) associated with the best medical treatment (BMT) has recently shown efficacy for the management of acute ischemic stroke (AIS) secondary to a large vessel occlusion. However, evidence is lacking regarding the benefit of MT for more distal occlusions. AIM To evaluate the efficacy in terms of good clinical outcome at 3 months of MT associated with the BMT over the BMT alone in AIS related to a distal occlusion. METHODS The DISCOUNT trial is a multicenter open-label randomized controlled trial involving French University hospitals. Adult patients (⩾18 years) with an AIS involving the anterior or posterior circulation secondary to a distal vessel occlusion within 6 h of symptom onset or within 24 h if no hyperintense signal on fluid attenuation inversion recovery acquisition will be randomized 1:1 to receive either MT associated with the BMT (experimental group) or BMT alone (control group). The number of patients to be included is 488. STUDY OUTCOMES The primary outcome is the rate of good clinical outcome at 3 months defined as a modified Rankin scale (mRS) ⩽2 and evaluated by an independent assessor blinded to the intervention arm. Secondary outcomes include recanalization of the occluded vessel within 48 h, angiographic reperfusion in the experimental group, 3-month excellent clinical outcome (mRS ⩽ 1), all adverse events, and death. A cost utility analysis will estimate the incremental cost per quality-adjusted life year (QALY) gained. DISCUSSION If positive, this study will open new insights in the management of AISs. TRIAL REGISTRATION ClinicalTrials.gov: NCT05030142 registered on 1 September 2021.
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Affiliation(s)
- Frédéric Clarençon
- Sorbonne Université, GRC BioFast, APHP, Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Isabelle Durand-Zaleski
- Université de Paris, CRESS, INSERM, INRA, URCEco, AP-HP, Hôpital de l'Hôtel Dieu, Paris, France
| | - Kévin Premat
- APHP, Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Amandine Baptiste
- AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Unité de recherche clinique, Paris, France
| | - Emmanuel Chabert
- Department of Neuroradiology, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | - Anna Ferrier
- Department of Vascular Neurology, Clermont-Ferrand University Hospital, Clermont-Ferrand, France
| | | | - Peggy Reiner
- Department of Vascular Neurology, Lariboisière Hospital, Paris, France
| | - Laurent Spelle
- Department of Interventional Neuroradiology, Kremlin-Bicêtre Hospital, Kremlin-Bicêtre, France
| | - Christian Denier
- Department of Vascular Neurology, Kremlin-Bicêtre Hospital, Kremlin-Bicêtre, France
| | - Titien Tuilier
- Department of Neuroradiology, Henri-Mondor Hospital, Créteil, France
| | - Hassan Hosseini
- Department of Vascular Neurology, Henri-Mondor Hospital, Créteil, France
| | | | - Guillaume Turc
- Department of Vascular Neurology, Sainte-Anne Hospital, Paris, France
| | - Cédric Fauché
- Department of Neuroradiology, Poitiers University Hospital, Poitiers, France
| | - Matthias Lamy
- Department of Vascular Neurology, Poitiers University Hospital, Poitiers, France
| | | | - Arturo Consoli
- Department of Neuroradiology, Foch Hospital, Suresnes, France
| | - Charlotte Barbier
- Department of Neuroradiology, Caen University Hospital, Caen, France
| | - Marion Boulanger
- Department of Vascular Neurology, Caen University Hospital, Caen, France
| | - Nicolas Bricout
- Department of Neuroradiology, Lille University Hospital, Lille, France
| | - Hilde Henon
- Department of Vascular Neurology, Lille University Hospital, Lille, France
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, INSERM U1254, CHRU-Nancy, Université de Lorraine, Nancy, France
| | - Sébastien Richard
- Department of Neurology, INSERM U1116, Stroke Unit, CHRU-Nancy, Université de Lorraine, Nancy, France
| | - Aymeric Rouchaud
- Department of Interventional Neuroradiology, Limoges University Hospital, Limoges, France
| | | | - Omer Eker
- Department of Neuroradiology, Lyon University Hospital, Lyon, France
| | - Tae-Hee Cho
- Department of Vascular Neurology, Lyon University Hospital, Lyon, France
| | - Sébastien Soize
- Department of Neuroradiology, Reims University Hospital, Reims, France
| | - Solène Moulin
- Department of Vascular Neurology, Reims University Hospital, Reims, France
| | | | - Serge Timsit
- Department of Vascular Neurology, Brest University Hospital, Brest, France
| | - Jean Darcourt
- Department of Neuroradiology, Toulouse University Hospital, Toulouse, France
| | | | - Kévin Janot
- Department of Neuroradiology, Tours University Hospital, Tours, France
| | - Mariam Annan
- Department of Vascular Neurology, Tours University Hospital, Tours, France
| | - Fernando Pico
- Department of Vascular Neurology, Versailles Hospital, Versailles, France
| | - Vincent Costalat
- Department of Neuroradiology, Montpellier University Hospital, Montpellier, France
| | - Caroline Arquizan
- Department of Vascular Neurology, Montpellier University Hospital, Montpellier, France
| | - Gautier Marnat
- Department of Neuroradiology, Bordeaux University Hospital, Bordeaux, France
| | - Igor Sibon
- Department of Vascular Neurology, Bordeaux University Hospital, Bordeaux, France
| | - Raoul Pop
- Department of Neuroradiology, Strasbourg University Hospital, Strasbourg, France
| | - Valérie Wolff
- Department of Vascular Neurology, Strasbourg University Hospital, Strasbourg, France
| | - Eimad Shotar
- Sorbonne Université, GRC BioFast, APHP, Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Stéphanie Lenck
- Sorbonne Université, GRC BioFast, APHP, Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Nader-Antoine Sourour
- Sorbonne Université, GRC BioFast, APHP, Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - Anne Radenne
- AP-HP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Unité de recherche clinique, Paris, France
| | - Sonia Alamowitch
- Department of Vascular Neurology, Pitié-Salpêtrière Hospital, Paris, France
| | - Agnès Dechartres
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié-Salpêtrière, Département de Santé Publique, Paris, France
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65
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Hu H, Zhao Y, Liu X, Sun X, Nguyen TN, Chen H. Benefit of endovascular treatment for primary versus secondary medium vessel occlusion: A multi-center experience. CNS Neurosci Ther 2024; 30:e14687. [PMID: 38497517 PMCID: PMC10945881 DOI: 10.1111/cns.14687] [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: 12/29/2023] [Revised: 02/22/2024] [Accepted: 03/06/2024] [Indexed: 03/19/2024] Open
Abstract
AIMS This study aimed to compare the clinical outcomes and safety of endovascular treatment (EVT) in patients with primary versus secondary medium vessel occlusion (MeVO). METHODS From the endovascular treatment for acute ischemic stroke in the China registry, we collected consecutive patients with MeVO who received EVT. The primary endpoint was a good outcome, defined as a modified Rankin Scale (mRS) 0 to 2 at 90 days. RESULTS 154 patients were enrolled in the final analysis, including 74 primary MeVO and 80 secondary MeVO. A good outcome at 90 days was achieved in 42 (56.8%) patients with primary MeVO and 33 (41.3%) patients with secondary MeVO. There was a higher probability of good outcomes in patients with the primary vs secondary MeVO (adjusted odds ratio, 2.16; 95% confidence interval, 1.04 to 4.46; p = 0.04). There were no significant differences in secondary and safety outcomes between MeVO groups. In the multivariable analysis, baseline ASPECTS (p = 0.001), final modified thrombolysis in cerebral infarction score (p = 0.01), and any ICH (p = 0.03) were significantly associated with good outcomes in primary MeVO patients, while baseline National Institutes of Health Stroke Scale (p = 0.002), groin puncture to recanalization time (p = 0.02), and early neurological improvement (p < 0.001) were factors associated with good outcome in secondary MeVO patients. CONCLUSION In MeVO patients who received EVT, there was a higher likelihood of poor outcomes in patients with secondary versus primary MeVO.
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Affiliation(s)
- Hai‐Zhou Hu
- Department of NeurologyGeneral Hospital of Northern Theater CommandShenyangChina
- Department of Graduate SchoolChina Medical UniversityShenyangChina
| | - Yong‐Gang Zhao
- Department of NeurologyGeneral Hospital of Northern Theater CommandShenyangChina
| | - Xin Liu
- Department of NeurologyGeneral Hospital of Northern Theater CommandShenyangChina
| | - Xian‐Hui Sun
- Department of NeurologyGeneral Hospital of Northern Theater CommandShenyangChina
| | - Thanh N. Nguyen
- Neurology, RadiologyBoston Medical CenterBostonMassachusettsUSA
| | - Hui‐Sheng Chen
- Department of NeurologyGeneral Hospital of Northern Theater CommandShenyangChina
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Psychogios MN, Tsogkas I, Blackham K, Schulze-Zachau V, Rusche T, Ntoulias N, Brehm A, Fischer U, Sporns PB. The Quattro Technique for Medium Distal Vessel Occlusion Stroke. Clin Neuroradiol 2024; 34:257-262. [PMID: 37378841 DOI: 10.1007/s00062-023-01317-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 05/24/2023] [Indexed: 06/29/2023]
Affiliation(s)
| | - Ioannis Tsogkas
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Kristine Blackham
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
| | | | - Thilo Rusche
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Nikos Ntoulias
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Alex Brehm
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Peter B Sporns
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg-Eppendorf, Germany
- Department of Radiology and Neuroradiology, Stadtspital Zürich, Zürich, Switzerland
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67
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Ospel JM, Nguyen TN, Jadhav AP, Psychogios MN, Clarençon F, Yan B, Goyal M. Endovascular Treatment of Medium Vessel Occlusion Stroke. Stroke 2024; 55:769-778. [PMID: 38235587 DOI: 10.1161/strokeaha.123.036942] [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] [Indexed: 01/19/2024]
Abstract
Approximately one-third of acute ischemic strokes with an identifiable vessel occlusion are caused by medium vessel occlusion (MeVO), that is, nonlarge vessel occlusions that are potentially amenable to endovascular treatment (EVT). Management of patients with MeVO is challenging in many ways: detecting MeVOs can be challenging, particularly for inexperienced physicians, and in busy clinical routine, MeVOs, therefore, remain sometimes undiagnosed. While the clinical course of MeVO stroke with medical management, including intravenous thrombolysis, is by no means, benign, it is more favorable compared with large vessel occlusion. At the same time, EVT complication rates are higher, and thus, the marginal benefit of EVT beyond best medical management is expected to be smaller and more challenging to detect if it were present. Several randomized controlled trials are currently underway to investigate whether and to what degree patients with MeVO may benefit from EVT and will soon provide robust data for evidence-based MeVO EVT decision-making. In this review, we discuss different ways of defining MeVOs, strategies to optimize MeVO detection on imaging, and considerations for EVT decision-making in the setting of MeVO stroke. We discuss the technical challenges related to MeVO EVT and conclude with an overview of currently ongoing MeVO EVT trials.
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Affiliation(s)
- Johanna M Ospel
- Department of Diagnostic Imaging (J.M.O., M.G.), Foothills Medical Centre, University of Calgary, AB, Canada
- Department of Clinical Neurosciences (J.M.O., M.G.), Foothills Medical Centre, University of Calgary, AB, Canada
| | - Thanh N Nguyen
- Department of Neurology and Radiology, Boston Medical Center, Boston University School of Medicine, MA (T.N.N.)
| | - Ashutosh P Jadhav
- Department of Neurology, Barrow Neurological Institute, Phoenix, AZ (A.P.J.)
| | | | - Frédéric Clarençon
- Service de Neuroradiologie, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France (F.C.)
| | - Bernard Yan
- Melbourne Brain Centre, Royal Melbourne Hospital, Parkville, VIC, Australia (B.Y.)
| | - Mayank Goyal
- Department of Diagnostic Imaging (J.M.O., M.G.), Foothills Medical Centre, University of Calgary, AB, Canada
- Department of Clinical Neurosciences (J.M.O., M.G.), Foothills Medical Centre, University of Calgary, AB, Canada
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68
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Rizzo F, Romoli M, Simonetti L, Gentile M, Forlivesi S, Piccolo L, Naldi F, Paolucci M, Galluzzo S, Taglialatela F, Princiotta C, Migliaccio L, Petruzzellis M, Logroscino G, Zini A. Reperfusion strategies in stroke with medium-to-distal vessel occlusion: a prospective observational study. Neurol Sci 2024; 45:1129-1134. [PMID: 37798546 DOI: 10.1007/s10072-023-07089-w] [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: 05/08/2023] [Accepted: 09/24/2023] [Indexed: 10/07/2023]
Abstract
INTRODUCTION Medium vessel occlusion (MeVO) accounts for 30% of acute ischemic stroke cases. The risk/benefit profile of endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT) or the combination of the two (bridging therapy (BT)) is still unclear in MeVO. Here, we compare reperfusion strategies in MeVO for clinical and radiological outcomes. METHODS This prospective single center study enrolled consecutive patients with AIS due to primary MeVO undergoing IVT, EVT, or BT at a comprehensive stroke center. Primary outcome was good functional status, defined as modified Rankin Scale (mRS) 0-2 at 3-month follow-up. Additional outcomes included mortality, successful recanalization, defined as mTICI ≥ 2b, stroke severity at discharge, and symptomatic intracerebral hemorrhage (sICH) according to SITS-MOST criteria. Logistic regression was modeled to define independent predictors of the primary outcome. RESULTS Overall, 180 consecutive people were enrolled (IVT = 59, EVT = 38, BT = 83), mean age 75. BT emerged as independent predictor of primary outcome (OR = 2.76, 95% CI = 1.08-7.07) together with age (OR = 0.94, 95% CI = 0.9-0.97) and baseline NIHSS (OR = 0.88, 95% CI = 0.81-0.95). BT associated with a 20% relative increase in successful recanalization compared to EVT (74.4 vs 56.4%, p = 0.049). Rates of sICH (1.1%) and procedural complications (vasospasm 4.1%, SAH in 1.7%) were very low, with no difference across groups. DISCUSSION BT may carry a higher chance of good functional outcome compared to EVT/IVT only in people with AIS due to MeVO, with marginally higher rates of successful recanalization. Randomized trials are needed to define optimal treatment tailoring for MeVO.
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Affiliation(s)
- Federica Rizzo
- Stroke Unit, Vall d'Hebron Hospital and Vall d'Hebron Institut de Recerca, Barcelona, Spain
| | - Michele Romoli
- Neurology and Stroke Unit, Dept. of Neuroscience, Bufalini Hospital, AUSL Romagna, Cesena, Italy
| | - Luigi Simonetti
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, UO Neuroradiologia, Ospedale Maggiore, Bologna, Italy
| | - Mauro Gentile
- Department of Neurology and Stroke Center, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neurologia E Rete Stroke Metropolitana, Ospedale Maggiore, Largo Nigrisoli 2, 40133, Bologna, Italy
| | - Stefano Forlivesi
- Department of Neurology and Stroke Center, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neurologia E Rete Stroke Metropolitana, Ospedale Maggiore, Largo Nigrisoli 2, 40133, Bologna, Italy
| | - Laura Piccolo
- Department of Neurology and Stroke Center, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neurologia E Rete Stroke Metropolitana, Ospedale Maggiore, Largo Nigrisoli 2, 40133, Bologna, Italy
| | - Federica Naldi
- Department of Neurology and Stroke Center, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neurologia E Rete Stroke Metropolitana, Ospedale Maggiore, Largo Nigrisoli 2, 40133, Bologna, Italy
| | - Matteo Paolucci
- Department of Neurology and Stroke Center, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neurologia E Rete Stroke Metropolitana, Ospedale Maggiore, Largo Nigrisoli 2, 40133, Bologna, Italy
| | - Simone Galluzzo
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, UO Neuroradiologia, Ospedale Maggiore, Bologna, Italy
| | - Francesco Taglialatela
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, UO Neuroradiologia, Ospedale Maggiore, Bologna, Italy
| | - Ciro Princiotta
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, UO Neuroradiologia, Ospedale Maggiore, Bologna, Italy
| | - Ludovica Migliaccio
- Department of Neurology and Stroke Center, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neurologia E Rete Stroke Metropolitana, Ospedale Maggiore, Largo Nigrisoli 2, 40133, Bologna, Italy
| | - Marco Petruzzellis
- Department of Neurology and Stroke Unit, AOU Consorziale Policlinico, Bari, Italy
| | - Giancarlo Logroscino
- Department of Basic Medicine, Neuroscience, and Sense Organs, University of Bari 'Aldo Moro', Bari, Italy
| | - Andrea Zini
- Department of Neurology and Stroke Center, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neurologia E Rete Stroke Metropolitana, Ospedale Maggiore, Largo Nigrisoli 2, 40133, Bologna, Italy.
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Alkhiri A, Alamri AF, Alharbi AR, Almaghrabi AA, Alansari N, Niaz AA, Alghamdi BA, Sarraj A, Alhazzani A, Al-Ajlan FS. Endovascular therapy versus best medical management for isolated posterior cerebral artery occlusion: A systematic review and meta-analysis. Eur Stroke J 2024; 9:69-77. [PMID: 37752802 PMCID: PMC10916830 DOI: 10.1177/23969873231201715] [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: 07/31/2023] [Accepted: 08/31/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND AND PURPOSE Isolated posterior cerebral artery occlusions (iPCAO) were underrepresented in pivotal randomized clinical trial (RCTs) of endovascular thrombectomy (EVT) in ischemic stroke, and the benefit of EVT in this population is still indeterminate. We performed a systematic review and a meta-analysis to compare the safety and efficacy of EVT compared to best medical management (BMM) in patients with iPCAO. METHODS We searched Medline/PubMed, Embase, Web of Science, and the Cochrane databases up to May 2023 for eligible studies reporting outcomes of patients with iPCAO treated with EVT or BMM. We pooled odds ratios (ORs) with corresponding 95% confidence intervals (CI) using a random-effects model. RESULTS Seven studies involving 2560 patients were included. EVT was associated with significantly higher likelihood of early neurological improvement (OR, 2.31 [95% CI, 1.38-2.91]; p < 0.00001) and visual field normalization (OR, 3.08 [95% CI, 1.76-5.38]; p < 0.0001) compared to BMM. Rates of good functional outcomes (mRS 0-2) were comparable between the two arms (OR, 0.88 [95% CI, 0.70-1.10]; p = 0.26). Symptomatic intracranial hemorrhage (sICH) was comparable between the two groups (OR, 1.94 [95% CI, 0.96-3.93]; p = 0.07). Mortality was also similar between the two groups (OR, 1.36; [95% CI, 0.77-2.42]; p = 0.29). CONCLUSIONS In patients with iPCAO, EVT was associated with visual and early neurological improvement but with a strong trend toward increased sICH. Survival and functional outcomes may be slightly poorer. The role of EVT in iPCAO remains uncertain.
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Affiliation(s)
- Ahmed Alkhiri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Aser F Alamri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | | | - Ahmed A Almaghrabi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Nayef Alansari
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Abdulelah A Niaz
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Basil A Alghamdi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Amrou Sarraj
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Adel Alhazzani
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Fahad S Al-Ajlan
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
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70
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Meyer L, Stracke CP, Broocks G, Wallocha M, Elsharkawy M, Sporns PB, Piechowiak EI, Kaesmacher J, Maegerlein C, Hernandez Petzsche MR, Zimmermann H, Naziri W, Abdullayev N, Kabbasch C, Behme D, Thormann M, Maus V, Fischer S, Möhlenbruch MA, Weyland CS, Langner S, Ernst M, Jamous A, Meila D, Miszczuk M, Siebert E, Lowens S, Krause LU, Yeo LL, Tan BYQ, Gopinathan A, Gory B, Galvan Fernandez J, Schüller Arteaga M, Navia P, Raz E, Shapiro M, Arnberg F, Zeleňák K, Martínez-Galdámez M, Alexandrou M, Kastrup A, Papanagiotou P, Dorn F, Kemmling A, Psychogios MN, Andersson T, Chapot R, Fiehler J, Hanning U. Effect of anesthetic strategies on distal stroke thrombectomy in the anterior and posterior cerebral artery. J Neurointerv Surg 2024; 16:230-236. [PMID: 37142393 DOI: 10.1136/jnis-2023-020210] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/14/2023] [Indexed: 05/06/2023]
Abstract
BACKGROUND Numerous questions regarding procedural details of distal stroke thrombectomy remain unanswered. This study assesses the effect of anesthetic strategies on procedural, clinical and safety outcomes following thrombectomy for distal medium vessel occlusions (DMVOs). METHODS Patients with isolated DMVO stroke from the TOPMOST registry were analyzed with regard to anesthetic strategies (ie, conscious sedation (CS), local (LA) or general anesthesia (GA)). Occlusions were in the P2/P3 or A2-A4 segments of the posterior and anterior cerebral arteries (PCA and ACA), respectively. The primary endpoint was the rate of complete reperfusion (modified Thrombolysis in Cerebral Infarction score 3) and the secondary endpoint was the rate of modified Rankin Scale score 0-1. Safety endpoints were the occurrence of symptomatic intracranial hemorrhage and mortality. RESULTS Overall, 233 patients were included. The median age was 75 years (range 64-82), 50.6% (n=118) were female, and the baseline National Institutes of Health Stroke Scale score was 8 (IQR 4-12). DMVOs were in the PCA in 59.7% (n=139) and in the ACA in 40.3% (n=94). Thrombectomy was performed under LA±CS (51.1%, n=119) and GA (48.9%, n=114). Complete reperfusion was reached in 73.9% (n=88) and 71.9% (n=82) in the LA±CS and GA groups, respectively (P=0.729). In subgroup analysis, thrombectomy for ACA DMVO favored GA over LA±CS (aOR 3.07, 95% CI 1.24 to 7.57, P=0.015). Rates of secondary and safety outcomes were similar in the LA±CS and GA groups. CONCLUSION LA±CS compared with GA resulted in similar reperfusion rates after thrombectomy for DMVO stroke of the ACA and PCA. GA may facilitate achieving complete reperfusion in DMVO stroke of the ACA. Safety and functional long-term outcomes were comparable in both groups.
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Affiliation(s)
- Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Paul Stracke
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Interventional Neuroradiology, University Hospital Muenster, Muenster, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marta Wallocha
- Department of Endovascular Therapy, Alfred-Krupp Hospital, Essen, Germany
| | - Mohamed Elsharkawy
- Department of Interventional Neuroradiology, University Hospital Muenster, Muenster, Germany
| | - Peter B 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
| | - Eike I Piechowiak
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Moritz Roman Hernandez Petzsche
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany
| | - Hanna Zimmermann
- Institute of Neuroradiology, University Hospitals, Ludwig-Maximilians-Universität München, Munich, Germany
| | - Weis Naziri
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany
- Department of Neuroradiology, University Hospital Luebeck, Luebeck, Germany
| | - Nuran Abdullayev
- Department of Neuroradiology, University of Cologne, Cologne, Germany
| | | | - Daniel Behme
- Department of Neuroradiology, University Hospital Magdeburg, Magdeburg, Germany
| | - Maximilian Thormann
- Department of Neuroradiology, University Hospital Magdeburg, Magdeburg, Germany
| | - Volker Maus
- Department of Diagnostic Radiology and Interventional Neuroradiology and Nuclear Medicine, Universitätsklinikum Knappschaftskrankenhaus Bochum, Universitätsklinik der Ruhr-Universität Bochum, Bochum, Germany
| | - Sebastian Fischer
- Department of Diagnostic Radiology and Interventional Neuroradiology and Nuclear Medicine, Universitätsklinikum Knappschaftskrankenhaus Bochum, Universitätsklinik der Ruhr-Universität Bochum, Bochum, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Soenke Langner
- Institute for Diagnostic and Interventional Radiology, Pediatric and Neuroradiology, University Hospital Rostock, Rostock, Germany
| | - Marielle Ernst
- Department of Diagnostic and Interventional Neuroradiology, University Medical Centre Goettingen, Goettingen, Germany
| | - Ala Jamous
- Department of Diagnostic and Interventional Neuroradiology, University Medical Centre Goettingen, Goettingen, Germany
| | - Dan Meila
- Department of Interventional Neuroradiology, Johanna-Étienne-Hospital, Neuss, Germany
| | - Milena Miszczuk
- Institute of Neuroradiology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Eberhard Siebert
- Institute of Neuroradiology, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Stephan Lowens
- Department of Radiology, Klinikum Osnabrück, Osnabrück, Germany
| | - Lars Udo Krause
- Department of Neurology, Klinikum Osnabrück, Osnabrück, Germany
| | - Leonard Ll Yeo
- Division of Neurology, National University Health System, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Benjamin Y Q Tan
- Division of Neurology, National University Health System, Singapore
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Anil Gopinathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Interventional Radiology, Department of Diagnostic imaging, National University Health System, Singapore
| | - Benjamin Gory
- Université de Lorraine, CHRU-Nancy, Department of Diagnostic and Therapeutic Neuroradiology, F-54000 Nancy, France, Université de Lorraine, IADI, INSERM U1254, F-54000, Nancy, France
| | - Jorge Galvan Fernandez
- Department of Interventional Neuroradiology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Miguel Schüller Arteaga
- Department of Interventional Neuroradiology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Pedro Navia
- Department of Neuroradiology, Hospital Universitario La Paz, Madrid, Spain
| | - Eytan Raz
- Department of Radiology, New York Langone Medical Center, New York, New York, USA
| | - Maksim Shapiro
- Department of Radiology, New York Langone Medical Center, New York, New York, USA
| | - Fabian Arnberg
- Departments of Neuroradiology; Department of Clinical Neuroscience, Karolinska University Hospital; Karolinska Institutet, Stockholm, Sweden
| | - Kamil Zeleňák
- Department of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Martin, Slovakia
| | - Mario Martínez-Galdámez
- Department of Interventional Neuroradiology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Maria Alexandrou
- Diagnostic and Interventional Neuroradiology, Klinikum Bremen-Mitte gGmbH, Bremen, Germany
| | - Andreas Kastrup
- Department of Neurology, Hospital Bremen-Mitte, Bremen, Germany
| | - Panagiotis Papanagiotou
- Diagnostic and Interventional Neuroradiology, Klinikum Bremen-Mitte gGmbH, Bremen, Germany
- Department of Radiology, Areteion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Franziska Dorn
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - André Kemmling
- Department of Neuroradiology, University Hospital Marburg, Marburg, Germany
| | - Marios-Nikos Psychogios
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Tommy Andersson
- Departments of Neuroradiology; Department of Clinical Neuroscience, Karolinska University Hospital; Karolinska Institutet, Stockholm, Sweden
- Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
| | - René Chapot
- Department of Endovascular Therapy, Alfred-Krupp Hospital, Essen, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Salerno A, Michel P, Strambo D. Revascularization of arterial occlusions in posterior circulation acute ischemic stroke. Curr Opin Neurol 2024; 37:26-31. [PMID: 38085602 DOI: 10.1097/wco.0000000000001234] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2024]
Abstract
PURPOSE OF REVIEW This review highlights the latest advancements achieved in the revascularization of arterial occlusions associated with an acute ischemic stroke affecting the posterior circulation. It delves into the frequency and outcomes based on specific arterial segments and presents current evidence supporting revascularization treatments, including intravenous thrombolysis and endovascular thrombectomy. RECENT FINDINGS Comprehensive evidence for treatment across major arterial segments of the posterior circulation -- vertebral artery, basilar artery, posterior cerebral artery, cerebellar arteries, and multilevel posterior occlusions -- is provided. Additionally, the latest findings from randomized clinical trials on basilar artery occlusion are explored alongside results from extensive retrospective analyses of isolated vertebral and posterior cerebral artery occlusions. SUMMARY Current research supports the treatment decision in acute ischemic strokes of the posterior circulation using both intravenous thrombolysis and endovascular thrombectomy. This review also emphasizes existing knowledge gaps in the management of these strokes and advocates for more randomized clinical trials, notably concerning the posterior cerebral artery (currently ongoing), isolated vertebral artery, and multilevel posterior circulation occlusions.
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Affiliation(s)
- Alexander Salerno
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
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Ren Z, Sitti M. Design and build of small-scale magnetic soft-bodied robots with multimodal locomotion. Nat Protoc 2024; 19:441-486. [PMID: 38097687 DOI: 10.1038/s41596-023-00916-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 09/21/2023] [Indexed: 02/12/2024]
Abstract
Small-scale magnetic soft-bodied robots can be designed to operate based on different locomotion modes to navigate and function inside unstructured, confined and varying environments. These soft millirobots may be useful for medical applications where the robots are tasked with moving inside the human body. Here we cover the entire process of developing small-scale magnetic soft-bodied millirobots with multimodal locomotion capability, including robot design, material preparation, robot fabrication, locomotion control and locomotion optimization. We describe in detail the design, fabrication and control of a sheet-shaped soft millirobot with 12 different locomotion modes for traversing different terrains, an ephyra jellyfish-inspired soft millirobot that can manipulate objects in liquids through various swimming modes, a larval zebrafish-inspired soft millirobot that can adjust its body stiffness for efficient propulsion in different swimming speeds and a dual stimuli-responsive sheet-shaped soft millirobot that can switch its locomotion modes automatically by responding to changes in the environmental temperature. The procedure is aimed at users with basic expertise in soft robot development. The procedure requires from a few days to several weeks to complete, depending on the degree of characterization required.
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Affiliation(s)
- Ziyu Ren
- Physical Intelligence Department, Max Planck Institute for Intelligent Systems, Stuttgart, Germany
| | - Metin Sitti
- Physical Intelligence Department, Max Planck Institute for Intelligent Systems, Stuttgart, Germany.
- Institute for Biomedical Engineering, ETH Zurich, Zurich, Switzerland.
- School of Medicine and College of Engineering, Koç University, Istanbul, Turkey.
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Nome T, Enriquez B, Nome CG, Tennøe B, Lund CG, Skjelland M, Aamodt AH, Beyer M. Clinical outcome after thrombectomy in patients with MeVO stroke: importance of clinical and technical factors. J Neurol 2024; 271:877-886. [PMID: 37847291 PMCID: PMC10827971 DOI: 10.1007/s00415-023-12025-1] [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: 06/29/2023] [Revised: 09/23/2023] [Accepted: 09/25/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND AND AIMS Whereas high-level evidence has been proven for safety and efficacy of endovascular treatment (EVT) in large vessel occlusion (LVO) stroke, the evidence for EVT in medium vessel occlusion (MeVO) in both sexes and different age groupremains to be answered. The aim of this study was to evaluate the importance of clinical and technical parameters, focusing on sex, age and EVT procedural factors, on functional outcome in primary MeVO (pMeVO) strokes. METHODS 144 patients with pMeVO in the MCA territory from the Oslo Acute Reperfusion Stroke Study (OSCAR) were included. Clinical and radiological data were collected including 90-day mRS follow-up. RESULTS Successful reperfusion with modified thrombolysis in cerebral infarction (mTICI) ≥ 2b was achieved in 123 patients (84%). Good functional outcome (mRS ≤ 2) at 90-day follow-up was achieved in 84 patients (61.8%). Two or more passes with stent retriever was associated with increased risk of SAH, poor mTICI and poor functional outcome. In average, women had 62 min longer ictus to recanalization time compared to men. Age over 80 years was significantly associated with poor outcome and death. CONCLUSION In pMeVO patients, TICI score and number of passes with stent retriever were the main technical factors predicting mRS ≤ 2. Good clinical outcome occurred almost twice as often in patients under 80 years of age compared to patients over 80 years. Women with MeVO strokes had significant longer time from ictus to recanalization; however, this did not affect the clinical outcome.
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Affiliation(s)
- Terje Nome
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Brian Enriquez
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Cecilie G Nome
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
- Division of Anatomy, Department of Molecular Medicine, Institute of Basic Medical Sciences, GliaLab and Letten Centre, University of Oslo, Oslo, Norway
| | - Bjørn Tennøe
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Mona Skjelland
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Anne Hege Aamodt
- Department of Neurology, Oslo University Hospital, Oslo, Norway.
- Department of Neuromedicine and Movement Science, The Norwegian University of Science and Technology, Trondheim, Norway.
| | - Mona Beyer
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Brake A, Fry L, Heskett C, Alkiswani AR, LeBeau G, De Stefano F, Lei C, Le K, Rouse AG, Peterson J, Ebersole K. Endovascular thrombectomy for posterior cerebral artery strokes in the national inpatient sample (EaT PeCANpIeS) study. Interv Neuroradiol 2024:15910199231223535. [PMID: 38258468 DOI: 10.1177/15910199231223535] [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: 01/24/2024] Open
Abstract
BACKGROUND Posterior cerebral arteries with acute ischemic strokes (PCA-AISs) comprise around 2% of all acute ischemic strokes and may result in significant long-term deficits. Current guidance regarding endovascular thrombectomy (EVT) for PCA-AIS is insufficient as no published randomized trials exist. METHODS An analysis of the National Inpatient Sample database compared medical management versus EVT for PCA-AIS. Propensity score matching was applied to adjust for nonrandomization. RESULTS The study included 19,655 patients. Before matching, the EVT cohort had significantly higher National Institutes of Health Stroke Scale (NIHSS) (10.21 vs. 4.67, p < 0.001), had lower rates of favorable functional outcomes, functional independence, and higher rates of intracranial hemorrhage (ICH) and inpatient mortality. After matching, no differences in functional outcomes were identified, but revealed a higher proportion of ICH in the EVT group (17.45% vs. 8.98%, p < 0.001). However, NIHSS subgroup analysis identified improved functional outcomes associated with the EVT group who presented with an NIHSS between 10 and 19 both in terms of rates of favorable functional outcomes (35.56% vs. 12.09%, p < 0.001) and rates of functional independence (26.67% vs. 9.34%, p < 0.01). On further investigation, the clinical benefit, in the NIHSS 10-19 subgroup, was driven by patients receiving EVT in combination with intravenous thrombolysis (IVT). CONCLUSIONS This analysis shows that current national practices utilize EVT for more severe PCA strokes. Clinical benefit was only detected in patients with moderate stroke severity (NIHSS 10-19) who were treated with combined EVT and IVT. Further work is needed to investigate the features of PCA-AIS that might benefit from EVT the most.
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Affiliation(s)
- Aaron Brake
- The University of Kansas School of Medicine, Kansas City, Kansas, USA
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Lane Fry
- The University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Cody Heskett
- The University of Kansas School of Medicine, Kansas City, Kansas, USA
| | | | - Gabriel LeBeau
- The University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Frank De Stefano
- Department of Neurological Surgery, University of Kansas Health System, Kansas City, Kansas, USA
| | - Catherine Lei
- The University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Kevin Le
- The University of Kansas School of Medicine, Kansas City, Kansas, USA
| | - Adam G Rouse
- Department of Neurological Surgery, University of Kansas Health System, Kansas City, Kansas, USA
| | - Jeremy Peterson
- Department of Neurological Surgery, University of Kansas Health System, Kansas City, Kansas, USA
| | - Koji Ebersole
- Department of Neurological Surgery, University of Kansas Health System, Kansas City, Kansas, USA
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Bilgin C, Bolsegui ML, Ghozy S, Hassankhani A, Kobeissi H, Jabal MS, Gupta R, De Rubeis G, Kadirvel R, Brinjikji W, Saba L, Kallmes DF. Common design and data elements reported in active mechanical thrombectomy trials focusing on distal medium vessel occlusions and minor strokes: a systematic review. J Neurointerv Surg 2024:jnis-2023-021073. [PMID: 38212110 DOI: 10.1136/jnis-2023-021073] [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: 09/27/2023] [Accepted: 12/19/2023] [Indexed: 01/13/2024]
Abstract
BACKGROUND Distal medium vessel occlusions (DMVOs) and minor strokes represent emerging frontiers in mechanical thrombectomy (MT). Although several randomized clinical trials (RCTs) are underway, the design characteristics of these trials and the specific questions they aim to address have not been extensively explored. This current study sought to investigate the design and data elements reported in active prospective DMVO and minor stroke studies. METHODS The ClinicalTrials.gov database was searched for ongoing prospective studies assessing the role of MT in patients with DMVOs or minor strokes. The Nested Knowledge AutoLit platform was utilized to categorize reported outcomes and inclusion/exclusion criteria. Frequencies of reported data elements were extracted from study protocols. RESULTS A total of 10 (8 DMVO and 2 minor stroke) studies enrolling 3520 patients were included. All DMVO studies employ different criteria regarding target occlusion locations. Five DMVO studies use stent retrievers as the first-line thrombectomy technique (62.5%, 5/8), while three studies allow any MT techniques, generally at the operator's discretion. Four DMVO studies permit intravenous thrombolysis (IVT) utilization in both intervention and control arms (50%, 4/8). The DISTALS trial excludes patients receiving IVT, while the DUSK trial and Tigertriever registry only enroll patients who are ineligible for IVT or for whom IVT failed to achieve reperfusion. DMVO studies exhibit notable heterogeneity in symptom onset duration thresholds for inclusion (<6 hours: 2 studies; <12 hours: 2 studies; <24 hours: 3 studies). Minor stroke trials employ similar inclusion criteria and outcome measures except for symptom duration thresholds for inclusion (8 hours for ENDOLOW and 23 hours for MOSTE). CONCLUSIONS There is considerable heterogeneity among active DMVO trials regarding potential target DMVO locations and time thresholds for inclusion based on the last known well time. Furthermore, our review indicates that the utility of aspiration thrombectomy in DMVOs and the advantages of MT without IVT over IVT alone will remain largely unexplored even after completion of active DMVO trials.
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Affiliation(s)
- Cem Bilgin
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Marisabel L Bolsegui
- Department of Vascular and Interventional Radiology, The Johns Hopkins University, Baltimore, Maryland, USA
| | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Hassan Kobeissi
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Rishabh Gupta
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Ramanathan Kadirvel
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Luca Saba
- Department of Medical Imaging, Università degli Studi di Cagliari, Cagliari, Sardegna, Italy
| | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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Lee HG, Yi HJ, Shin DS, Kim BT. Comparison of 4 mm-sized and 3 mm-sized Stent Retrievers in Mechanical Thrombectomy for M2 Occlusion. Curr Neurovasc Res 2024; 21:157-165. [PMID: 38584536 DOI: 10.2174/0115672026303196240327053722] [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: 12/16/2023] [Revised: 01/18/2024] [Accepted: 12/22/2024] [Indexed: 04/09/2024]
Abstract
INTRODUCTION A stent retriever (SR) is widely used in mechanical thrombectomy (MT) for M2 segment occlusion. However, the suitable size of SR in M2 occlusion remains unclear. Therefore, we aimed to compare 4 mm-sized SR with 3 mm-sized SR in M2 occlusion. METHODS Patients who underwent MT with SR for M2 occlusion were dichotomized into 4×20 mm SR and 3×20 mm SR groups. Then, 1:1 propensity score matching was performed. The M2 segment was divided into proximal and distal segments according to the occlusion site. Subgroup analysis was then performed for each cohort. RESULTS A total of 111 patients were enrolled, with 4×20 mm SR and 3×20 mm SR applied in 72 (64.9%) and 39 (35.1%) cases, respectively. In propensity score matching, mean number of stent passages for reperfusion was significantly lower in the 4×20 mm SR group than in the 3×20 mm SR group (1.5 ± 0.8 vs. 2.1 ± 1.1; p = 0.004). First-pass reperfusion (FPR) was more highly achieved in the 4×20 mm SR group than in the 3×20 mm SR group (52.6% vs. 42.1%; p = 0.007). In both proximal and distal occlusion cohorts, the 4 mm SR group showed lower mean number of SR passage (p = 0.004 and p = 0.003, respectively) and higher FPR rate than the 3 mm SR group (p = 0.003 and p = 0.007, respectively). CONCLUSION In MT for M2 occlusion, 4×20 mm SR enables an effective procedure with lesser SR passage for reperfusion and a higher rate of FPR than 3×20 mm SR.
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Affiliation(s)
- Han Gyul Lee
- Department of Neurosurgery, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
| | - Ho Jun Yi
- Department of Neurosurgery, Soonchunhyang University Seoul Hospital, Seoul, Republic of Korea
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
- Department of Neurosurgery, St. Vincent's Hospital, The Catholic University of Korea, Suwon, Republic of Korea
| | - Dong-Seong Shin
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Bum-Tae Kim
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
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Cascio Rizzo A, Schwarz G, Cervo A, Giussani G, Ceresa C, Gatti A, De Angeli F, Motto C, Guccione A, Tortorella R, Granata G, Rollo C, Macera A, Piano M, Pero G, Agostoni EC. Safety and efficacy of endovascular thrombectomy for primary and secondary MeVO. J Stroke Cerebrovasc Dis 2024; 33:107492. [PMID: 37988832 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107492] [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: 06/15/2023] [Revised: 09/17/2023] [Accepted: 11/15/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Medium-vessel occlusions (MeVO) are emerging as a new target for endovascular treatment (EVT). Primary MeVO occur de novo, while secondary MeVO arise from large vessel occlusion (LVO) through clot migration or fragmentation - spontaneously, following intravenous thrombolysis or EVT. We aimed to evaluate efficacy and safety of EVT in primary and EVT-induced secondary MeVO. METHODS Retrospective single-center study on consecutive EVT-treated acute ischemic stroke, from 2019-to-2021. We considered: (1) exclusive-LVO, patients with LVO and - in case of residual distal occlusion - no rescue endovascular procedure; (2) primary MeVO: initial A2, A3, M2 non-dominant, M3, P2, P3 occlusions; (3) EVT-induced secondary MeVO, presenting LVO with subsequent (treated) EVT-induced MeVO. We compared (univariable/multivariable logistic regression) EVT efficacy (eTICI≥2b, 3-month modified Rankin Scale [mRS] 0-2) and safety (EVT-complications [vessel dissection, perforation, persistent-SAH], symptomatic ICH) in all MeVO versus exclusive-LVO, primary MeVO versus exclusive-LVO, EVT-induced secondary MeVO versus exclusive-LVO and EVT-induced secondary MeVO versus primary MeVO. RESULTS We included 335 patients: 221 (66.0 %) exclusive-LVO and 114 (34.0 %) MeVO (55 [48.2 %] primary, 59 [51.8 %] secondary). Compared to exclusive-LVO, primary MeVO had higher rates of EVT complications (aOR 3.77 [95%CI 1.58-9.00],p=0.003), lower rates of eTICI≥2b (aOR 0.32 [95%CI 0.12-0.88],p=0.027) and mRS 0-2 (aOR 0.28 [95%CI 0.13-0.63],p=0.002). EVT-induced secondary MeVO had no major differences in efficacy and safety outcomes compared to exclusive-LVO, but a better mRS 0-2 (aOR 8.00 [95%CI 2.12-30.17],p=0.002) compared to primary MeVO. CONCLUSIONS Primary and EVT-induced secondary MeVO showed different safety/efficacy EVT-related profiles. Dedicated randomized data are needed to identify the best acute reperfusion strategy in the two categories.
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Affiliation(s)
- Angelo Cascio Rizzo
- Department of Neurology and Stroke Unit - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
| | - Ghil Schwarz
- Department of Neurology and Stroke Unit - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Amedeo Cervo
- Department of Neuroradiology - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giuditta Giussani
- Department of Neurology and Stroke Unit - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Chiara Ceresa
- Department of Neurology and Stroke Unit - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Antonella Gatti
- Department of Neurology and Stroke Unit - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Fausto De Angeli
- Department of Neurology and Stroke Unit - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Cristina Motto
- Department of Neurology and Stroke Unit - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Angelo Guccione
- Department of Neurology and Stroke Unit - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Rachele Tortorella
- Department of Neurology and Stroke Unit - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giuseppe Granata
- Department of Neuroradiology - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Claudia Rollo
- Department of Neuroradiology - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Antonio Macera
- Department of Neuroradiology - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Mariangela Piano
- Department of Neuroradiology - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Guglielmo Pero
- Department of Neuroradiology - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Elio Clemente Agostoni
- Department of Neurology and Stroke Unit - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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Kim H, Ahn JH, Ko SM, Kim JW. Pre-navigation balloon technique: Distal emboli protection during stent retriever thrombectomy. Clin Neurol Neurosurg 2024; 236:108057. [PMID: 37995622 DOI: 10.1016/j.clineuro.2023.108057] [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: 06/21/2023] [Revised: 11/06/2023] [Accepted: 11/16/2023] [Indexed: 11/25/2023]
Abstract
OBJECTIVE During stent retriever thrombectomy, a balloon guide catheter reduces distal emboli and consequently improves clinical outcomes. Because balloons are usually used before stent retrieval, these can affect the thrombus including the distal emboli while performing microcatheter navigation. This study aimed to evaluate the usefulness and safety of the pre-navigation balloon technique during microcatheter and microwire navigation. METHODS Patients who underwent stent retriever thrombectomy secondary to an anterior circulation large-artery occlusion were retrospectively evaluated. The pre-navigation balloon technique was used, and the number of retrievals, procedure time, final recanalization, presence of distal emboli, first-pass effect (FPE), symptomatic intracranial hemorrhage including procedure-related complications, and clinical outcomes at 3 months were evaluated. RESULTS In total 123 patients were analyzed, and occurrence of distal emboli was lesser in the pre-navigation balloon than in the non-preballoon group (4.4% vs. 11.5%, p = 0.02). No statistical difference was found in successful recanalization, mortality, and procedure-related complications. Moreover, the pre-navigation balloon group had a higher FPE than the non-balloon group (37.8% vs. 20.5%, p = 0.004). Although no statistical difference was found in the pre-navigation balloon group, a trend toward a higher rate of good clinical outcomes was observed (mRS 0-2 at 3 months, 55.6% vs. 48.7%, p = 0.09). For ICA occlusion(n = 35), significant effects were seen in decreasing distal embolism (0(0%) vs 3(16%), p = 0.01), increasing FPE (8(50%) vs 6(32%), p = 0.003), and improving clinical outcomes (mRS 0-2 at 3 months, 9(56%) vs 7(37%), p = 0.03) in the pre-navigation balloon group. In the multivariate analysis, lesser distal embolism (0.91 [0.80-1.00], p = 0.02), higher successful recanalization (3.52 [1.11-7.03], p = 0.016), and higher FPE (3.17 [1.83-7.37], p = 0.001) secondary to the procedure was a predictor of favorable clinical outcomes. CONCLUSIONS The pre-navigation balloon technique significantly reduced occurrence of distal embolism and increased the FPE.
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Affiliation(s)
- Hyunjung Kim
- Department of Radiology, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, South Korea
| | - Jhii-Hyun Ahn
- Department of Radiology, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, South Korea
| | - Sung Min Ko
- Department of Radiology, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, South Korea
| | - Jin Woo Kim
- Department of Radiology, Wonju Severance Christian Hospital, Yonsei University Wonju College of Medicine, Wonju, South Korea.
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Kwon Y, Yi HJ, Shin DS, Kim BT. Predictors of Emboli in Mechanical Thrombectomy for Anterior Circulation Stroke. Curr Neurovasc Res 2024; 21:131-138. [PMID: 38441020 DOI: 10.2174/0115672026298727240219110134] [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: 12/16/2023] [Revised: 01/18/2024] [Accepted: 01/22/2024] [Indexed: 03/06/2024]
Abstract
OBJECTIVE Emboli commonly occurs in mechanical thrombectomy (MT). The objective of this study was to analyze predicting factors of emboli after MT. METHODS Patients who underwent MT with successful reperfusion for anterior circulation occlusion were enrolled. Emboli included distal emboli at digital subtraction angiography (DSA) and unexpected embolic infarct on diffusion-weighted image (DWI) without distal emboli at DSA. Baseline characteristics, procedural details, angiographic outcomes, and clinical outcomes were reviewed. Multivariable analyses were performed to evaluate predictive factors for the occurrence of emboli. RESULTS Of 601 patients, 149 (24.8%) patients had distal emboli at DSA, and 169 (28.1%) patients had unexpected embolic infarction on DWI even without distal emboli at DSA. A total of 318 (52.9%) patients were enrolled in the embolic group, and 283 (47.1%) patients were assigned to the non-embolic group. In multivariate analysis, larger microcatheter (OR 1.26, 95% CI 1.12-1.94; p = 0.047), clot passage (OR 1.33, 95% CI 1.07-1.87; p = 0.041), use of balloon guide catheter (BGC) (OR 0.70, 95% CI 0.52-0.92; p = 0.014), early ballooning of BGC (OR 0.68, 95% CI 0.50-0.90; p = 0.009), and longer stent retriever (OR 0.72, 95% CI 0.54-0.90; p = 0.029) were associated with occurrence of emboli. CONCLUSION MT with only a stent retriever, use of a larger microcatheter, and clot passage might increase the risk of emboli. In contrast, contact aspiration thrombectomy, use of BGC, early ballooning of BGC, and use of longer stent retrievers could reduce the chance of emboli.
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Affiliation(s)
- Yongho Kwon
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Ho Jun Yi
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
- Department of Neurosurgery, Hangang Sacred Heart Hospital, Hallym University, Seoul, Korea
| | - Dong-Seong Shin
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Bum-Tae Kim
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
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Sousa JA, Sondermann A, Bernardo-Castro S, Varela R, Donato H, Sargento-Freitas J. CTA and CTP for Detecting Distal Medium Vessel Occlusions: A Systematic Review and Meta-analysis. AJNR Am J Neuroradiol 2023; 45:51-56. [PMID: 38164544 PMCID: PMC10756569 DOI: 10.3174/ajnr.a8080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Accepted: 10/31/2023] [Indexed: 01/03/2024]
Abstract
BACKGROUND The optimal imaging method for detecting distal medium vessel occlusions (DMVOs) remains undefined. PURPOSE The objective of this study is to compare the diagnostic performance of CTA with CTP in detecting DMVOs. DATA SOURCES We searched PubMed, EMBASE, Web of Science Core Collection, and Cochrane Central Register of Controlled Trials up to March 31, 2023 (PROSPERO: CRD42022344006). STUDY SELECTION A total of 12 studies reporting accuracy values of CTA and/or CTP were included, comprising 2607 patients with 479 cases (18.3%) of DMVOs. DATA ANALYSIS Pooled sensitivity and specificity of both imaging methods were compared using a random-effects model. Subgroup analyses were performed based on the technique used in CTA (multi or single-phase) and the subtype of DMVOs (M2-only vs. M2 and other DMVOs). We applied Quality Assessment of Diagnostic Accuracy (QUADAS-2) tool and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) quality assessment criteria. DATA SYNTHESIS CTA demonstrated significantly lower sensitivity compared to CTP in detecting DMVOs [0.74, 95%CI (0.63-0.82) vs. 0.89, 95% CI (0.82-0.93), P < 0.01]. When subgrouped into single-phase and multi-phase CTA, multi-phase CTA exhibited higher sensitivity for DMVO detection than single-phase CTA [0.91, 95%CI (0.85-0.94) vs. 0.64, 95%CI (0.56-0.71), P < .01], while reaching similar levels to CTP. The sensitivity of single-phase CTA substantially decreased when extending from M2 to other non-M2 DMVOs [0.74, 95%CI (0.63-0.83) vs. 0.61, 0.95%CI (0.53-0.68), P = .02]. LIMITATIONS We identified an overall high risk of bias and low quality of evidence, attributable to the design and reference standards of most studies. CONCLUSIONS Our findings highlight a significantly lower sensitivity of single-phase CTA compared to multi-phase CTA and CTP in diagnosing DMVOs.
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Affiliation(s)
- João André Sousa
- From the Neurology Department (J.A.S., S.B.-C., J.S.-F.), Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - Anton Sondermann
- Neurologeriatrie Department (A.S.), Christian-Albrechts-Universität zu Kiel, Kiel, Germany
| | - Sara Bernardo-Castro
- From the Neurology Department (J.A.S., S.B.-C., J.S.-F.), Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculdade de Medicina da Universidade de Coimbra (S.B.-C., J.S.-F.), Coimbra, Portugal
| | - Ricardo Varela
- Neurology Department (R.V.), Centro Hospitalar e Universitário de Santo António, Porto, Portugal
| | - Helena Donato
- Documentation and Scientific Information Service (H.D.), Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
| | - João Sargento-Freitas
- From the Neurology Department (J.A.S., S.B.-C., J.S.-F.), Centro Hospitalar e Universitário de Coimbra, Coimbra, Portugal
- Faculdade de Medicina da Universidade de Coimbra (S.B.-C., J.S.-F.), Coimbra, Portugal
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81
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Rodriguez-Calienes A, Vivanco-Suarez J, Sequeiros JM, Galecio-Castillo M, Zevallos CB, Farooqui M, Ortega-Gutierrez S. Mechanical thrombectomy for the treatment of primary and secondary distal medium-vessel occlusion stroke: systematic review and meta-analysis. J Neurointerv Surg 2023; 15:e460-e467. [PMID: 36797050 DOI: 10.1136/jnis-2022-019975] [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: 12/07/2022] [Accepted: 02/05/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND There is limited evidence on the indication and role of mechanical thrombectomy (MT) in patients with distal medium-vessel occlusions (DMVOs). The aim of this systematic review and meta-analysis was to evaluate all the evidence available on the efficacy and safety of MT techniques (stent retriever, aspiration) in primary and secondary DMVOs. METHODS Five databases were searched from inception to January 2023 for studies of MT in primary and secondary DMVOs. Outcomes of interest included favorable functional outcome (90-day modified Rankin scale (mRS) 0-2), successful reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 2b-3), symptomatic intracerebral hemorrhage (sICH), and 90-day mortality. Prespecified subgroup meta-analyses according to the specific MT technique and to the vascular territory (distal M2-M5, A2-A5, P2-P5) were also performed. RESULTS A total of 29 studies with 1262 patients were included. For primary DMVOs (n=971 patients), pooled rates of successful reperfusion, favorable outcome, 90-day mortality and sICH were 84% (95% confidence interval (CI) 76 to 90%), 64% (95% CI 54 to 72%), 12% (95% CI 8 to 18%), and 6% (95% CI 4 to 10%), respectively. For secondary DMVOs (n=291 patients), pooled rates of successful reperfusion, favorable outcome, 90-day mortality and sICH were 82% (95% CI 73 to 88%), 54% (95% CI 39 to 69%), 11% (95% CI 5 to 20%), and 3% (95% CI 1 to 9%), respectively. Subgroup analyses by MT technique and by vascular territory showed no differences in primary and secondary DMVOs. CONCLUSION Our findings suggest that MT using aspiration or stent retriever techniques appears to be effective and safe in primary and secondary DMVOs. However, given the level of evidence of our results, further confirmation in well-designed randomized controlled trials is needed.
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Affiliation(s)
- Aaron Rodriguez-Calienes
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
- Neuroscience, Clinical Effectiveness and Public Health Research Group, Universidad Cientifica del Sur, Lima, Peru
| | - Juan Vivanco-Suarez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Joel M Sequeiros
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | - Cynthia B Zevallos
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Mudassir Farooqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Santiago Ortega-Gutierrez
- Department of Neuroloy, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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82
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Loh EDW, Toh KZX, Kwok GYR, Teo YH, Teo YN, Goh C, Syn NL, Ho AFW, Sia CH, Sharma VK, Tan BY, Yeo LL. Endovascular therapy for acute ischemic stroke with distal medium vessel occlusion: a systematic review and meta-analysis. J Neurointerv Surg 2023; 15:e452-e459. [PMID: 36539273 DOI: 10.1136/jnis-2022-019717] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022]
Abstract
AIMS Endovascular therapy (EVT) for distal medium vessel occlusions (DMVOs) is a potential frontier of acute ischemic stroke (AIS) treatment, but its efficacy against best medical therapy (BMT) remains unknown. We performed a systematic review and meta-analysis evaluating the efficacy and safety of EVT versus BMT in primary DMVO. METHODS We systematically searched PubMed, Cochrane Library and Embase, from inception to August 14, 2022, for studies comparing EVT with BMT in DMVO-AIS. We adopted the Distal Thrombectomy Summit Group's definition of DMVO. Efficacy outcomes were functional independence (90-day modified Rankin Scale (mRS) 0-2) and excellent functional outcomes (90-day mRS 0-1). Safety outcomes were symptomatic intracranial hemorrhage (sICH) and 90-day mortality. RESULTS Fourteen observational and two randomized-controlled studies were included, with 1202 patients receiving EVT and 1267 receiving BMT. After trim-and-fill correction, EVT achieved significantly better odds of functional independence than BMT (adjusted OR 1.61, 95% CI 1.06 to 2.43). There were no significant differences in overall excellent functional outcomes (OR 1.23, 95% CI 0.88 to 1.71), sICH (OR 1.44, 95% CI 0.78 to 2.66), and mortality (OR 1.03, 95% CI 0.73 to 1.45). Stratified by EVT method, mechanical thrombectomy±intra-arterial thrombolysis achieved more excellent functional outcomes than BMT (OR 1.59, 95% CI 1.13 to 2.23). In mild strokes (National Institutes of Health Stroke Scale score <6), EVT caused significantly more sICH (OR 6.30, 95% CI 1.55 to 25.64). CONCLUSIONS EVT shows promising efficacy benefit over BMT for primary DMVO-AIS. Further randomized controlled trials are necessary to evaluate the efficacy and safety of EVT in DMVO-AIS.
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Affiliation(s)
- Enver De Wei Loh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Keith Zhi Xian Toh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Gabriel Yi Ren Kwok
- Institute of Health Sciences Education, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Yao Hao Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yao Neng Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Claire Goh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nicholas L Syn
- Department of Surgery, National University Health System, Singapore
| | - Andrew Fu-Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore
- Pre-hospital & Emergency Research Centre, Duke-National University of Singapore Medical School, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre, Singapore
| | - Vijay Kumar Sharma
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Benjamin Yq Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Leonard Ll Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
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83
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Kniep H, Meyer L, Broocks G, Faizy TD, Bechstein M, Brekenfeld C, Flottmann F, van Horn N, Geest V, Winkelmeier L, Alegiani A, Deb-Chatterji M, Hanning U, Thomalla G, Fiehler J, Gellissen S. Thrombectomy in M2 occlusion compared to M1 occlusion: treatment effects of Thrombolysis In Cerebral Infarction (TICI) 2b and TICI 3 recanalization on functional outcome. J Neurointerv Surg 2023; 15:e438-e445. [PMID: 36990689 PMCID: PMC10803999 DOI: 10.1136/jnis-2022-019898] [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: 11/20/2022] [Accepted: 02/14/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Emerging data suggest that mechanical thrombectomy (MT) might also be safe and efficient for medium and distal occlusions. This study aims to compare average treatment effects on functional outcome of different degrees of recanalization after MT in patients with M2 occlusion and M1 occlusion. METHODS All patients enrolled in the German Stroke Registry (GSR) between June 2015 and December 2021 were analyzed. Inclusion criteria were stroke with primary M1 occlusion or M2 occlusion, and availability of relevant clinical data. 4259 patients were included, thereof 1353 with M2 occlusion and 2906 with M1 occlusion. Treatment effects were analyzed using double-robust inverse-probability-weighted regression-adjustment (IPWRA) estimators to control for confounding covariates. Binarized endpoint metrics were defined as good outcome with modified Rankin Scale (mRS) ≤2 at 90 days, and linearized endpoint metrics were defined as mRS shift pre-stroke to 90 days. Effects were evaluated for near complete recanalization (Thrombolysis In Cerebral Infarction scale (TICI) 2b) and complete recanalization (TICI 3). RESULTS Treatment effect estimation for TICI ≥2b versus TICI <2b in M2 occlusions showed an increase in the probability of a good outcome from 27% to 47% with a number-needed-to-treat (NNT) of 5. For M1 occlusions the probability of a good outcome increased from 16% to 38% with NNT 4.5. TICI 3 versus TICI 2b increased the probability of a good outcome by 7 percentage points in M1 occlusions; for M2 occlusions the beneficial effect was not significant. CONCLUSIONS Results suggest that successful recanalization with TICI ≥2b versus TICI <2b after MT in M2 occlusions provides significant patient benefit with treatment effects comparable to M1 occlusions. The probability of functional independence increased by 20 percentage points (NNT 5) and stroke-related mRS increase was reduced by 0.9 mRS points. In contrast to M1 occlusions, complete recanalization TICI 3 versus TICI 2b had lower additional beneficial effect.
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Affiliation(s)
- Helge Kniep
- 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
| | - Gabriel Broocks
- 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
- Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Matthias Bechstein
- 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
| | - Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Vincent Geest
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laurens Winkelmeier
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Alegiani
- Department of Neurology, Asklepios Klinik Altona, Hamburg, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Goetz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Gellissen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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84
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Nedelcu S, Gulati A, Henninger N. Endovascular therapy versus medical management for mild strokes due to medium and distal vessel occlusions. Interv Neuroradiol 2023:15910199231216510. [PMID: 38105534 DOI: 10.1177/15910199231216510] [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: 12/19/2023] Open
Abstract
BACKGROUND Distal and medium vessel occlusion (DMVO) strokes account for up to 40% of all acute ischemic strokes, many of which have a low initial deficit severity. Increasingly, endovascular treatment (EVT) is considered for these patients. However, there is a paucity of data comparing potential safety and efficacy of EVT versus best medical management (BMT) in these patients, particularly when presenting with mild symptoms. METHODS We retrospectively analyzed consecutive DMVO patients with NIHSS ≤6 who presented between January 2018 and December 2021 within 24 h from last seen well. We compared early and late clinical outcomes, as well as safety outcomes using multivariable linear and logistic regression analyses to determine whether EVT was independently associated with the outcomes of interest. RESULTS We included 80 subjects that fulfilled our study criteria (n = 41 BMT and n = 39 EVT). On adjusted analyses, when comparing EVT and BMT groups, there was no statistical difference in the NIHSS at discharge (Coefficient = -0.6, 95%-CI = -3.45-2.26, p = 0.678) or in the modified Rankin scale (mRS) at discharge (Coefficient = 0.37, 95%-CI = -0.52-1.25, p = 0.408). Furthermore, there was no difference in the 3-month mRS defined as good (mRS 0-2) (OR = 0.56, 95%-CI = 0.17-1.83, p = 0.341) or excellent (mRS 0-1) (OR = 0.45, 95%-CI = 0.15-1.34, p = 0.152). Finally, there was no difference in the incidence of all-type parenchymal hemorrhage (OR = 0.9, 95%-CI = 0.22-3.62, p = 0.879). CONCLUSIONS We found that among DMVO patients with low admission NIHSS treatment with EVT versus BMT was associated with similar outcomes. Larger prospective studies are required to confirm these findings.
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Affiliation(s)
- Simona Nedelcu
- Department of Neuroradiology, UMass Chan Medical School, Worcester, MA, USA
| | - Akanksha Gulati
- Department of Neurology, UMass Chan Medical School, Worcester, MA, USA
| | - Nils Henninger
- Department of Neurology, UMass Chan Medical School, Worcester, MA, USA
- Department of Psychiatry, UMass Chan Medical School, Worcester, MA, USA
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85
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Pascarella R, Antonenko K, Boulouis G, De Boysson H, Giannini C, Heldner MR, Kargiotis O, Nguyen TN, Rice CM, Salvarani C, Schmidt-Pogoda A, Strbian D, Hussain S, Zedde M. European Stroke Organisation (ESO) guidelines on Primary Angiitis of the Central Nervous System (PACNS). Eur Stroke J 2023; 8:842-879. [PMID: 37903069 PMCID: PMC10683718 DOI: 10.1177/23969873231190431] [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: 05/18/2023] [Accepted: 07/11/2023] [Indexed: 11/01/2023] Open
Abstract
The European Stroke Organisation (ESO) guideline on Primary Angiitis of the Central Nervous System (PACNS), developed according to ESO standard operating procedures (SOP) and Grading of Recommendations, Assessment, Development and Evaluation (GRADE) methodology, was elaborated to assist clinicians in the diagnostic and treatment pathway of patients with PACNS in their decision making. A working group involving vascular neurologists, neuroradiologists, rheumatologists, a neuropathologist and a methodologist identified 17 relevant clinical questions; these were addressed according to the patient/population, intervention, comparison and outcomes (PICO) framework and systematic literature reviews were performed. Notably, each PICO was addressed with respect to large vessel (LV)-PACNS and small vessel (SV)-PACNS. Data to answer many questions were scarce or lacking and the quality of evidence was very low overall, so, for some PICOs, the recommendations reflect the ongoing uncertainty. When the absence of sufficient evidence precluded recommendations, Expert Consensus Statements were formulated. In some cases, this applied to interventions in the diagnosis and treatment of PACNS which are embedded widely in clinical practice, for example patterns of cerebrospinal fluid (CSF) and Magnetic Resonance Imaging (MRI) abnormalities. CSF analysis for hyperproteinorrachia and pleocytosis does not have evidence supporting their use as diagnostic tools. The working group recommended that caution is employed in the interpretation of non-invasive vascular imaging due to lack of validation and the different sensitivities in comparison with digital subtraction angiography (DSA) and histopathological analyses. Moreover, there is not a neuroimaging pattern specific for PACNS and neurovascular issues are largely underreported in PACNS patients. The group's recommendations on induction and maintenance of treatment and for primary or secondary prevention of vascular events also reflect uncertainty due to lack of evidence. Being uncertain the role and practical usefulness of current diagnostic criteria and being not comparable the main treatment strategies, it is suggested to have a multidisciplinary team approach in an expert center during both work up and management of patients with suspected PACNS. Highlighting the limitations of the currently accepted diagnostic criteria, we hope to facilitate the design of multicenter, prospective clinical studies and trials. A standardization of neuroimaging techniques and reporting to improve the level of evidence underpinning interventions employed in the diagnosis and management of PACNS. We anticipate that this guideline, the first comprehensive European guideline on PACNS management using GRADE methodology, will assist clinicians to choose the most effective management strategy for PACNS.
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Affiliation(s)
- Rosario Pascarella
- Neuroradiology Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - Katherina Antonenko
- Department of Neurology, University Hospital and University of Bern, Bern, Switzerland
| | - Grégoire Boulouis
- Neuroradiology - Diagnostic and Interventional Neuroradiology, CIC-IT 1415, INSERM 1253 iBrain, Tours University Hospital, Centre Val de Loire Region, France
| | - Hubert De Boysson
- Service de Médecine Interne, CHU de Caen, Avenue de la Côte de Nacre, Caen, France; Université Caen Normandie, Caen, France
| | - Caterina Giannini
- Department of Laboratory Medicine and Pathology, Mayo Clinic, Rochester, MN, USA
| | - Mirjam R Heldner
- Department of Neurology, University Hospital and University of Bern, Bern, Switzerland
| | - Odysseas Kargiotis
- Stroke Unit, Metropolitan Hospital, Ethnarchou Makariou 9, Piraeus, Greece
| | - Thanh N Nguyen
- Neurology, Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Claire M Rice
- Neurology, Translational Health Sciences, Bristol Medical School, University of Bristol, Bristol, UK
- Department of Neurology, Southmead Hospital, North Bristol NHS Trust, Bristol, UK
| | - Carlo Salvarani
- Rheumatology, Rheumatology Unit, Azienda Ospedaliera-IRCCS di Reggio Emilia and Università di Modena e Reggio Emilia, Reggio Emilia, Italy
| | - Antje Schmidt-Pogoda
- Department of Neurology with Institute of Translational Neurology, Münster University Hospital, Albert-Schweitzer-Campus 1, Münster, Germany
| | - Daniel Strbian
- Department of Neurology, Helsinki University Central Hospital HUCH, Helsinki, Finland
| | | | - Marialuisa Zedde
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
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86
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Capirossi C, Laiso A, Renieri L, Capasso F, Limbucci N. Epidemiology, organization, diagnosis and treatment of acute ischemic stroke. Eur J Radiol Open 2023; 11:100527. [PMID: 37860148 PMCID: PMC10582298 DOI: 10.1016/j.ejro.2023.100527] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Revised: 09/25/2023] [Accepted: 09/30/2023] [Indexed: 10/21/2023] Open
Abstract
The management of acute ischemic stroke is changing. Over the period of 2010-2050, the number of incident strokes is expected to be more than double. Rapid access to mechanical thrombectomy for patients with large vessel occlusion is critically associated with their functional outcome. Moreover, patients with first pass effect had a better clinical outcome, lower mortality, and fewer procedural adverse events. We discuss some advances in acute ischemic stroke regarding the organization, the diagnosis and the treatment.
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Affiliation(s)
- Carolina Capirossi
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
| | - Antonio Laiso
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
| | - Leonardo Renieri
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
| | - Francesco Capasso
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
| | - Nicola Limbucci
- Interventional Neuroradiology Unit, University Hospital Careggi, Florence, Italy
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87
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Radu RA, Gascou G, Machi P, Capirossi C, Costalat V, Cagnazzo F. Current and future trends in acute ischemic stroke treatment: direct-to-angiography suite, middle vessel occlusion, large core, and minor strokes. Eur J Radiol Open 2023; 11:100536. [PMID: 37964786 PMCID: PMC10641156 DOI: 10.1016/j.ejro.2023.100536] [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: 05/28/2023] [Revised: 09/18/2023] [Accepted: 10/24/2023] [Indexed: 11/16/2023] Open
Abstract
Since the publication of the landmark thrombectomy trials in 2015, the field of endovascular therapy for ischemic stroke has been rapidly growing. The very low number needed to treat to provide functional benefits shown by the initial randomized trials has led clinicians and investigators to seek to translate the benefits of endovascular therapy to other patient subgroups. Even if the treatment effect is diminished, currently available data has provided sufficient information to extend endovascular therapy to large infarct core patients. Recently, published data have also shown that sophisticated imaging is not necessary for late time- window patients. As a result, further research into patient selection and the stroke pathway now focuses on dramatically reducing door-to-groin times and improving outcomes by circumventing classical imaging paradigms altogether and employing a direct-to-angio suite approach for selected large vessel occlusion patients in the early time window. While the results of this approach mainly concern patients with severe deficits, there are further struggles to provide evidence of the efficacy and safety of endovascular treatment in minor stroke and large vessel occlusion, as well as in patients with middle vessel occlusions. The current lack of good quality data regarding these patients provides significant challenges for accurately selecting potential candidates for endovascular treatment. However, current and future randomized trials will probably elucidate the efficacy of endovascular treatment in these patient populations.
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Affiliation(s)
- Răzvan Alexandru Radu
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
- Stroke Unit, Department of Neurology, University Emergency Hospital Bucharest, Bucharest, Romania
- Department of Clinical Neurosciences, “Carol Davila” University of Medicine and Pharmacy, Bucharest, Romania
| | - Gregory Gascou
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Paolo Machi
- Department of Neuroradiology, University of Geneva Medical Center, Switzerland
| | - Carolina Capirossi
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
- Department of Neurointerventional Radiology, Careggi Hospital, Florence, Italy
| | - Vincent Costalat
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Federico Cagnazzo
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
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88
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Wang M, Farouki Y, Hulscher F, Mine B, Bonnet T, Elens S, Suarez JV, Jodaitis L, Ligot N, Naeije G, Lubicz B, Guenego A. Severely Hypoperfused Brain Tissue Correlates with Final Infarct Volume Despite Recanalization in DMVO Stroke. J Belg Soc Radiol 2023; 107:90. [PMID: 38023296 PMCID: PMC10668880 DOI: 10.5334/jbsr.3269] [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] [Received: 07/11/2023] [Accepted: 10/30/2023] [Indexed: 12/01/2023] Open
Abstract
Objectives We sought to assess whether there were any parameter(s) on baseline computed-tomography-perfusion (CTP) strongly correlating with final-infarct-volume, and infarct volume progression after endovascular recanalization of acute ischemic stroke (AIS) with primary distal, medium vessel occlusion (DMVO). Materials and Methods We performed a retrospective analysis of consecutive AIS patients who were successfully recanalized by thrombectomy for DMVO. By comparing baseline CTP and follow-up MRI, we evaluated the correlation between baseline infarct and hypoperfusion volumes, and final infarct volume and infarct volume progression. We also examined their effect on good clinical outcome at 3 months (defined as an mRS score of 0 to 2). Results Between January 2018 and January 2021, 38 patients met the inclusion criteria (76% [29/38] female, median age 75 [66-86] years). Median final infarct volume and infarct volume progression were 8.4 mL [IQR: 5.2-44.4] and 7.2 mL [IQR: 4.3-29.1] respectively. TMax > 10 sec volume was strongly correlated with both (r = 0.831 and r = 0.771 respectively, p < 0.0001), as well as with good clinical outcome (-0.5, p = 0.001). A higher baseline TMax > 10 sec volume increased the probability of a higher final-infarct-volume (r2 = 0.690, coefficient = 0.83 [0.64-1.00], p < 0.0001), whereas it decreased the probability of good clinical outcome at 3 months (odds ratio = -0.67 [-1.17 to -0.18], p = 0.008). Conclusion TMax > 10 sec volume on baseline CTP correlates strongly with final infarct volume as well as with clinical outcome after mechanical thrombectomy for an AIS with DMVO.
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Affiliation(s)
- Maud Wang
- Department of Radiology, Leuven University Hospital, Leuven, Belgium
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Yousra Farouki
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Franny Hulscher
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Benjamin Mine
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Thomas Bonnet
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, 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
| | - Noemie Ligot
- Department of Neurology, Erasme University Hospital, Brussels, Belgium
| | - Gilles Naeije
- Department of Neurology, Erasme University Hospital, Brussels, Belgium
| | - 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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89
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Yao Z, Mao C, Ke Z, Xu Y. An explainable machine learning model for predicting the outcome of ischemic stroke after mechanical thrombectomy. J Neurointerv Surg 2023; 15:1136-1141. [PMID: 36446552 PMCID: PMC10579503 DOI: 10.1136/jnis-2022-019598] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 11/01/2022] [Indexed: 12/02/2022]
Abstract
BACKGROUND There is high variability in the clinical outcomes of patients with acute ischemic stroke (AIS) after mechanical thrombectomy (MT). METHODS 217 consecutive patients with anterior circulation large vessel occlusion who underwent MT between August 2018 and January 2022 were analysed. The primary outcome was functional independence defined as a modified Rankin Scale score of 0-2 at 3 months. In the derivation cohort (August 2018 to December 2020), 7 ensemble ML models were trained on 70% of patients and tested on the remaining 30%. The model's performance was further validated on the temporal validation cohort (January 2021 to January 2022). The SHapley Additive exPlanations (SHAP) framework was applied to interpret the prediction model. RESULTS Derivation analyses generated a 9-item score (PFCML-MT) comprising age, National Institutes of Health Stroke Scale score, collateral status, and postoperative laboratory indices (albumin-to-globulin ratio, estimated glomerular filtration rate, blood neutrophil count, C-reactive protein, albumin and serum glucose levels). The area under the curve was 0.87 for the test set and 0.84 for the temporal validation cohort. SHAP analysis further determined the thresholds for the top continuous features. This model has been translated into an online calculator that is freely available to the public (https://zhelvyao-123-60-sial5s.streamlitapp.com). CONCLUSIONS Using ML and readily available features, we developed an ML model that can potentially be used in clinical practice to generate real-time, accurate predictions of the outcome of patients with AIS treated with MT.
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Affiliation(s)
- Zhelv Yao
- Department of Neurology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
- Jiangsu Key Laboratory for Molecular Medicine, Nanjing University Medical School, Nanjing, China
- Nanjing Medicine Center For Neurological Diseases, Nanjing, China
| | - Chenglu Mao
- Department of Neurology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
- Jiangsu Key Laboratory for Molecular Medicine, Nanjing University Medical School, Nanjing, China
- Nanjing Medicine Center For Neurological Diseases, Nanjing, China
| | - Zhihong Ke
- Jiangsu Key Laboratory for Molecular Medicine, Nanjing University Medical School, Nanjing, China
- Nanjing Medicine Center For Neurological Diseases, Nanjing, China
- Department of Neurology, Nanjing Drum Tower Hospital, Clinical College of Nanjing Medical University, Nanjing, China
| | - Yun Xu
- Department of Neurology, Nanjing University Medical School Affiliated Nanjing Drum Tower Hospital, Nanjing, Jiangsu, China
- Jiangsu Key Laboratory for Molecular Medicine, Nanjing University Medical School, Nanjing, China
- Nanjing Medicine Center For Neurological Diseases, Nanjing, China
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90
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Keenan KJ, Smith WS, Jadhav AP, Haussen DC, Budzik RF, Bonafé A, Bhuva P, Yavagal DR, Ribò M, Cognard C, Hanel RA, Hassan AE, Sila CA, Saver JL, Liebeskind DS, Jovin TG, Nogueira RG. Large vessel occlusion prediction scale thresholds that are sensitive for DAWN Trial patients. Interv Neuroradiol 2023:15910199231203266. [PMID: 37915142 DOI: 10.1177/15910199231203266] [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: 11/03/2023] Open
Abstract
BACKGROUND Large vessel occlusion (LVO) prediction scales are used to triage prehospital suspected stroke patients with a high probability of LVO stroke to endovascular therapy centers. The sensitivities of these scales in the 6-to-24-h time window are unknown. Higher scale score thresholds are typically less sensitive and more specific. Knowing the highest scale score thresholds that remain sensitive could inform threshold selection for clinical use. Sensitivities may also vary between left and right-sided LVOs. METHODS LVO prediction scale scores were retrospectively calculated using the National Institutes of Health Stroke Scale (NIHSS) scores of patients enrolled in the DAWN Trial. All patients had last known well times between 6 and 24 h, NIHSS scores ≥ 10, intracranial internal carotid artery or proximal middle cerebral artery occlusions, and mismatches between their clinical severities and infarct core volumes. Scale thresholds with sensitivities ≥ 85% were identified, along with scores ≥ 5% more sensitive for left or right-sided LVOs. Specificities could not be calculated because all patients had LVOs. RESULTS A total of 201 out of 206 patients had the required NIHSS subitem scores. CPSS = 3, C-STAT ≥ 2, FAST-ED ≥ 4, G-FAST ≥ 3, RACE ≥ 5, and SAVE ≥ 3 were the highest thresholds that were still 85% sensitive for DAWN Trial LVO stroke patients. RACE ≥ 5 was the only typically used score threshold more sensitive for right-sided LVOs, though similar small differences were seen for other scales at higher thresholds. CONCLUSIONS Our findings likely represent the maximum sensitivities of the LVO prediction scales tested for ideal thrombectomy candidates in the 6-to-24-h time window because NIHSS scores were documented in hospitals during a clinical trial rather than in the prehospital setting. Patients with NIHSS scores < 10 or more distal LVOs would lower sensitivities further. Selecting even higher scale thresholds for LVO triage would lead to many missed LVO strokes.
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Affiliation(s)
- Kevin J Keenan
- Department of Neurology, University of California, Davis, Sacramento, CA, USA
| | - Wade S Smith
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Ashutosh P Jadhav
- Department of Neurology, Barrow Neurological Institute, Phoenix, AZ, USA
| | - Diogo C Haussen
- Department of Neurology and Radiology, Emory University School of Medicine at Grady Memorial Hospital, Atlanta, GA, USA
| | - Ronald F Budzik
- Department of Radiology, OhioHealth/Riverside Methodist Hospital, Columbus, OH, USA
| | - Alain Bonafé
- Department of Neuroradiology, University Hospital of Montpellier, Hop Gui de Chauliac, Montpellier, France
| | - Parita Bhuva
- Texas Stroke Institute at HCA North Texas, Plano, TX, USA
| | - Dileep R Yavagal
- Department of Neurology, University of Miami School of Medicine, Jackson Memorial Hospital, Miami, FL, USA
| | - Marc Ribò
- Vall d'Hebron University Hospital, Vall d'Hebron Research Institute, Barcelona, Spain
- Department of Neurology, Vall d'Hebron University Hospital, Stroke Unit, Barcelona, Spain
| | - Christophe Cognard
- Department of Neuroradiology, Hospital Purpan, Toulouse, Midi-Pyrénées, France
| | - Ricardo A Hanel
- Baptist Medical Center Jacksonville/Lyerly Neurosurgery, Jacksonville, FL, USA
| | - Ameer E Hassan
- Department of Neurology, Valley Baptist Medical Center - Harlingen, TX, USA
| | - Cathy A Sila
- University Hospitals Cleveland Medical Center, Cleveland, OH, USA
| | - Jeffrey L Saver
- Department of Neurology, University of California, Los Angeles, CA, USA
| | | | - Tudor G Jovin
- Cooper Hospital University Medical Center, Camden, NJ, USA
| | - Raul G Nogueira
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh, Pittsburgh, PA, USA
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91
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Yedavalli V, Hamam O, Mohseni A, Chen K, Wang R, Heo HY, Heit J, Marsh EB, Llinas R, Urrutia V, Xu R, Gonzalez F, Albers G, Hillis A, Nael K. Pretreatment brain CT perfusion thresholds for predicting final infarct volume in distal medium vessel occlusions. J Neuroimaging 2023; 33:968-975. [PMID: 37357133 DOI: 10.1111/jon.13142] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Revised: 06/12/2023] [Accepted: 06/15/2023] [Indexed: 06/27/2023] Open
Abstract
BACKGROUND AND PURPOSE Quantitative CT perfusion (CTP) thresholds for assessing the extent of ischemia in patients with acute ischemic stroke (AIS) have been established; relative cerebral blood flow (rCBF) <30% is typically used for estimating estimated ischemic core volume and Tmax (time to maximum) >6 seconds for critical hypoperfused volume in AIS patients with large vessel occlusion (LVO). In this study, we aimed to identify the optimal threshold values for patients presenting with AIS secondary to distal medium vessel occlusions (DMVOs). METHODS In this retrospective study, consecutive AIS patients with anterior circulation DMVO who underwent pretreatment CTP and follow-up MRI/CT were included. The CTP data were processed by RAPID (iSchemaView, Menlo Park, CA) to generate estimated ischemic core volumes using rCBF <20%, <30%, <34%, and <38% and critical hypoperfused volumes using Tmax (seconds) >4, >6, >8, and >10. Final infarct volumes (FIVs) were obtained from follow-up MRI/CT within 5 days of symptom onset. Diagnostic performance between CTP thresholds and FIV was assessed in the successfully and unsuccessfully recanalized groups. RESULTS Fifty-five patients met our inclusion criteria (32 female [58.2%], 68.0 ± 12.1 years old [mean ± SD]). Recanalization was attempted with intravenous tissue-type plasminogen activator and mechanical thrombectomy in 27.7% and 38.1% of patients, respectively. Twenty-five patients (45.4%) were successfully recanalized. In the successfully recanalized patients, no CTP threshold significantly outperformed what is used in LVO setting (rCBF < 30%). All rCBF CTP thresholds demonstrated fair diagnostic performances for predicting FIV. In unsuccessfully recanalized patients, all Tmax CTP thresholds strongly predicted FIV with relative superiority of Tmax >10 seconds (area under the receiver operating characteristic curve = .875, p = .001). CONCLUSION In AIS patients with DMVOs, longer Tmax delays than Tmax > 6 seconds, most notably, Tmax > 10 seconds, best predict FIV in unsuccessfully recanalized patients. No CTP threshold reliably predicts FIV in the successfully recanalized group nor significantly outperformed rCBF < 30%.
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Affiliation(s)
- Vivek Yedavalli
- Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Omar Hamam
- Department of Radiology, Massachusetts General Hospital, Cambridge, Massachusetts, USA
| | - Alireza Mohseni
- Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Kwan Chen
- Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Richard Wang
- Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Hye-Young Heo
- Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Jeremy Heit
- Department of Radiology, Division of Neuroimaging and Neurointervention, Stanford Neuroscience Health Center, Palo Alto, California, USA
| | | | - Raf Llinas
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Victor Urrutia
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Fernando Gonzalez
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Greg Albers
- Department of Radiology, Division of Neuroimaging and Neurointervention, Stanford Neuroscience Health Center, Palo Alto, California, USA
| | - Argye Hillis
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Kambiz Nael
- Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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92
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Kniep H, Meyer L, Broocks G, Bechstein M, Guerreiro H, Winkelmeier L, Brekenfeld C, Flottmann F, Deb-Chatterji M, Alegiani A, Hanning U, Thomalla G, Fiehler J, Gellißen S. Predictors of functional outcome after thrombectomy for M2 occlusions: a large scale experience from clinical practice. Sci Rep 2023; 13:18740. [PMID: 37907482 PMCID: PMC10618211 DOI: 10.1038/s41598-023-45232-x] [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: 02/18/2023] [Accepted: 10/17/2023] [Indexed: 11/02/2023] Open
Abstract
Mechanical thrombectomy (MT) for acute ischemic stroke with medium vessel occlusions is still a matter of debate. We sought to identify factors associated with clinical outcome after MT for M2-occlusions based on data from the German Stroke Registry-Endovascular Treatment (GSR-ET). All patients prospectively enrolled in the GSR-ET from 05/2015 to 12/2021 were analyzed (NCT03356392). Inclusion criteria were primary M2-occlusions and availability of relevant clinical data. Factors associated with excellent/good outcome (modified Rankin scale mRS 0-1/0-2), poor outcome/death (mRS 5-6) and mRS-increase pre-stroke to day 90 were determined in multivariable logistic regression. 1348 patients were included. 1128(84%) had successful recanalization, 595(44%) achieved good outcome, 402 (30%) had poor outcome. Successful recanalization (odds ratio [OR] 4.27 [95% confidence interval 3.12-5.91], p < 0.001), higher Alberta stroke program early CT score (OR 1.25 [1.18-1.32], p < 0.001) and i.v. thrombolysis (OR 1.28 [1.07-1.54], p < 0.01) increased probability of good outcome, while age (OR 0.95 [0.94-0.95], p < 0.001), higher pre-stroke-mRS (OR 0.36 [0.31-0.40], p < 0.001), higher baseline NIHSS (OR 0.89 [0.88-0.91], p < 0.001), diabetes (OR 0.52 [0.42-0.64], p < 0.001), higher number of passes (OR 0.75 [0.70-0.80], p < 0.001) and intracranial hemorrhage (OR 0.26 [0.14-0.46], p < 0.001) decreased the probability of good outcome. Additional predictors of mRS-increase pre-stroke to 90d were dissections, perforations (OR 1.59 [1.11-2.29], p < 0.05) and clot migration, embolization (OR 1.67 [1.21-2.30], p < 0.01). Corresponding to large-vessel-occlusions, younger age, low pre-stroke-mRS, low severity of acute clinical disability, i.v. thrombolysis and successful recanalization were associated with good outcome while diabetes and higher number of passes decreased probability of good outcome after MT in M2 occlusions. Treatment related complications increased probability of mRS increase pre-stroke to 90d.
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Affiliation(s)
- Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Helena Guerreiro
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Laurens Winkelmeier
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Alegiani
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Neurology, Asklepios Klinik Altona, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Susanne Gellißen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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93
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Ash M, Dimisko L, Chalhoub RM, Howard BM, Cawley CM, Matouk C, Pabaney A, Spiotta AM, Jabbour P, Maier I, Wolfe SQ, Rai AT, Kim JT, Psychogios MN, Mascitelli JR, Starke RM, Shaban A, Yoshimura S, De Leacy R, Kan P, Fragata I, Polifka AJ, Arthur AS, Park MS, Crosa RJ, Williamson R, Dumont TM, Levitt MR, Al Kasab S, Tjoumakaris SI, Liman J, Saad H, Samaniego EA, Fargen KM, Grossberg JA, Alawieh A. Comprehensive analysis of the impact of procedure time and the 'golden hour' in subpopulations of stroke thrombectomy patients. J Neurointerv Surg 2023:jnis-2023-020792. [PMID: 37875342 DOI: 10.1136/jnis-2023-020792] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/19/2023] [Indexed: 10/26/2023]
Abstract
OBJECTIVE To evaluate the effect of procedure time on thrombectomy outcomes in different subpopulations of patients undergoing endovascular thrombectomy (EVT), given the recently expanded indications for EVT. METHODS This multicenter study included patients undergoing EVT for acute ischemic stroke at 35 centers globally. Procedure time was defined as time from groin puncture to successful recanalization (Thrombolysis in Cerebral Infarction score ≥2b) or abortion of procedure. Patients were stratified based on stroke location, use of IV tissue plasminogen activator (tPA), Alberta Stroke Program Early CT score, age group, and onset-to-groin time. Primary outcome was the 90-day modified Rankin Scale (mRS) score, with scores 0-2 designating good outcome. Secondary outcome was postprocedural symptomatic intracranial hemorrhage (sICH). Multivariate analyses were performed using generalized linear models to study the impact of procedure time on outcomes in each subpopulation. RESULTS Among 8961 patients included in the study, a longer procedure time was associated with higher odds of poor outcome (mRS score 3-6), with 10% increase in odds for each 10 min increment. When procedure time exceeded the 'golden hour', poor outcome was twice as likely. The golden hour effect was consistent in patients with anterior and posterior circulation strokes, proximal or distal occlusions, in patients with large core infarcts, with or without IV tPA treatment, and across age groups. Procedures exceeding 1 hour were associated with a 40% higher sICH rate. Posterior circulation strokes, delayed presentation, and old age were the variables most sensitive to procedure time. CONCLUSIONS In this work we demonstrate the universality of the golden hour effect, in which procedures lasting more than 1 hour are associated with worse clinical outcomes and higher rates of sICH across different subpopulations of patients undergoing EVT.
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Affiliation(s)
- Makenna Ash
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Laurie Dimisko
- Nell Hodgson Woodruff School of Nursing, Emory Healthcare, Atlanta, Georgia, USA
| | - Reda M Chalhoub
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Brian M Howard
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - C Michael Cawley
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Charles Matouk
- Department of Neurosurgery, Yale University, New Haven, Connecticut, USA
| | - Aqueel Pabaney
- Department of Neurosurgery, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ilko Maier
- Department of Neurology, University Medicine Goettingen, Goettingen, NS, Germany
| | - Stacey Q Wolfe
- Department of Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Ansaar T Rai
- Department of Interventional Neuroradiology, West Virginia University Rockefeller Neuroscience Institute, Morgantown, West Virginia, USA
| | - Joon-Tae Kim
- Department of Neurosurgery and Radiology, Chonnam National University, Gwangju, Jeollanam-do, Korea
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Justin R Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- University of Miami School of Medicine, Miami, Florida, USA
| | - Amir Shaban
- Department of Neurology, University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Reade De Leacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Isabel Fragata
- Department of Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Adam J Polifka
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Adam S Arthur
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Min S Park
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Roberto Javier Crosa
- Department of Endovascular Neurosurgery, Médica Uruguaya, Montevideo, Montevideo, Uruguay
| | - Richard Williamson
- Stroke and Cerebrovascular Center, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - Travis M Dumont
- Department of Surgery, Division of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Sami Al Kasab
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jan Liman
- Department of Neurology, University Medicine Goettingen, Goettingen, NS, Germany
| | - Hassan Saad
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Edgar A Samaniego
- Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Kyle M Fargen
- Department of Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Jonathan A Grossberg
- Department of Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ali Alawieh
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
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94
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Li X, Duan W, Du L, Chu D, Wang P, Yang Z, Qu X, Yang Z, Batinic-Haberle I, Spasojevic I, Warner DS, Crapo JD, Treggiari MM, Sheng H. Intracarotid Infusion of Redox-Active Manganese Porphyrin, MnTnBuOE-2-PyP 5+, following Reperfusion Improves Long-Term, 28-Day Post-Stroke Outcomes in Rats. Antioxidants (Basel) 2023; 12:1861. [PMID: 37891940 PMCID: PMC10603962 DOI: 10.3390/antiox12101861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/02/2023] [Accepted: 10/05/2023] [Indexed: 10/29/2023] Open
Abstract
Endovascular mechanical thrombectomy, combined with a tissue plasminogen activator (t-PA), is efficacious as a standard care for qualifying ischemic stroke patients. However, > 50% of thrombectomy patients still have poor outcomes. Manganese porphyrins, commonly known as mimics of superoxide dismutases, are potent redox-active catalytic compounds that decrease oxidative/nitrosative stress and in turn decrease inflammatory responses, mitigating therefore the secondary injury of the ischemic brain. This study investigates the effect of intracarotid MnTnBuOE-2-PyP5+ (BMX-001) administration on long-term, 28-day post-stroke recovery in a clinically relevant setting. The 90 min of transient middle cerebral artery occlusion was performed in young, aged, male, female, and spontaneous hypertension rats. All physiological parameters, including blood pressure, blood gas, glucose, and temperature, were well controlled during ischemia. Either BMX-001 or a vehicle solution was infused through the carotid artery immediately after the removal of filament, mimicking endovascular thrombectomy, and was followed by 7 days of subcutaneous injection. Neurologic deficits and infarct volume were assessed at 28 days in a blinded manner. The effects of BMX-001 on the carotid arterial wall and blood-brain barrier permeability and its interaction with t-PA were assessed in normal rats. There were no intra-group differences in physiological variables. BMX-001-treated stroke rats regained body weight earlier, performed better in behavioral tests, and had smaller brain infarct size compared to the vehicle-treated group. No vascular wall damage and blood-brain barrier permeability changes were detected after the BMX-001 infusion. There was no drug interaction between BMX-001 and t-PA. Intracarotid BMX-001 infusion was safe, and it significantly improved stroke outcomes in rats. These findings indicate that BMX-001 is a candidate drug as an adjunct treatment for thrombectomy procedure to further improve the neurologic outcomes of thrombectomy patients. This study warrants further clinical investigation of BMX-001 as a new stroke therapy.
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Affiliation(s)
- Xuan Li
- Multidisciplinary Neuroprotection Laboratories, Center of Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA; (X.L.); (W.D.); (L.D.); (D.C.); (P.W.); (Z.Y.); (X.Q.); (D.S.W.); (M.M.T.)
| | - Weina Duan
- Multidisciplinary Neuroprotection Laboratories, Center of Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA; (X.L.); (W.D.); (L.D.); (D.C.); (P.W.); (Z.Y.); (X.Q.); (D.S.W.); (M.M.T.)
| | - Li Du
- Multidisciplinary Neuroprotection Laboratories, Center of Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA; (X.L.); (W.D.); (L.D.); (D.C.); (P.W.); (Z.Y.); (X.Q.); (D.S.W.); (M.M.T.)
| | - Dongmei Chu
- Multidisciplinary Neuroprotection Laboratories, Center of Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA; (X.L.); (W.D.); (L.D.); (D.C.); (P.W.); (Z.Y.); (X.Q.); (D.S.W.); (M.M.T.)
| | - Peng Wang
- Multidisciplinary Neuroprotection Laboratories, Center of Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA; (X.L.); (W.D.); (L.D.); (D.C.); (P.W.); (Z.Y.); (X.Q.); (D.S.W.); (M.M.T.)
| | - Zhong Yang
- Multidisciplinary Neuroprotection Laboratories, Center of Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA; (X.L.); (W.D.); (L.D.); (D.C.); (P.W.); (Z.Y.); (X.Q.); (D.S.W.); (M.M.T.)
| | - Xingguang Qu
- Multidisciplinary Neuroprotection Laboratories, Center of Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA; (X.L.); (W.D.); (L.D.); (D.C.); (P.W.); (Z.Y.); (X.Q.); (D.S.W.); (M.M.T.)
| | - Zhenxing Yang
- Department of Neurosurgery, Duke University Medical Center, Durham, NC 27710, USA;
| | - Ines Batinic-Haberle
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA;
| | - Ivan Spasojevic
- Pharmacokinetics and Pharmacodynamics Core, Duke Cancer Institute, and Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA
| | - David S. Warner
- Multidisciplinary Neuroprotection Laboratories, Center of Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA; (X.L.); (W.D.); (L.D.); (D.C.); (P.W.); (Z.Y.); (X.Q.); (D.S.W.); (M.M.T.)
- Department of Neurosurgery, Duke University Medical Center, Durham, NC 27710, USA;
- Department of Neurobiology, Duke University Medical Center, Durham, NC 27710, USA
| | | | - Miriam M. Treggiari
- Multidisciplinary Neuroprotection Laboratories, Center of Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA; (X.L.); (W.D.); (L.D.); (D.C.); (P.W.); (Z.Y.); (X.Q.); (D.S.W.); (M.M.T.)
| | - Huaxin Sheng
- Multidisciplinary Neuroprotection Laboratories, Center of Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA; (X.L.); (W.D.); (L.D.); (D.C.); (P.W.); (Z.Y.); (X.Q.); (D.S.W.); (M.M.T.)
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95
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Russo R, Mistretta F, Molinaro S, Bergui M. 5F SOFIA intermediate catheter in the treatment of acute ischemic stroke: A retrospective observational study. Interv Neuroradiol 2023; 29:583-588. [PMID: 35929099 PMCID: PMC10549712 DOI: 10.1177/15910199221118145] [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: 06/10/2022] [Revised: 07/08/2022] [Accepted: 07/17/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND We herein report our experience with the 5F SOFIA (Soft Torqueable catheter Optimized for Intracranial Access) intermediate catheter for endovascular treatment of patients with acute ischemic stroke (AIS) both in distal middle vessel occlusions (DMVOs) and in large vessel occlusions (LVOs) with unfavorable anatomy. METHODS Records of forty-seven patients undergoing endovascular thrombectomy with 5F SOFIA between September 2020 and March 2022 were retrospectively reviewed. Patients' demographic data, clinical presentation, treatment details, and complications were recorded from the medical record. The primary outcomes were successful revascularization (modified treatment in cerebral ischemia, mTICI ≥2b) and good clinical outcome at 3 months (modified rankin scale, mRS 0-2). Secondary outcomes were complication rates and switch to alternative techniques. Our institutional review board approved this study. RESULTS Forty-seven patients with AIS treated with 5F SOFIA were examined. In eighteen (38%) cases the occlusion was located on a large vessel while in 29 (61.7%) on a distal-medium vessels. Median national institutes of health strokes scale (NIHSS) score was 16 at admission. Successful revascularization to mTICI 2b-3 was achieved in 14 of 18 patients (77.7%) with LVOs and in 24/29 cases with DMVOs (82.7%) respectively. mRS score 0-2 at three months (3 months-mRS 0-2) was 66.6% for LVOs and 68.9% in DMVOs respectively. Symptomatic intracranial hemorrhage (SICH) occurred in 2 (4.2%) patients. CONCLUSION 5F SOFIA intermediate catheter could be a safe and effective treatment for AIS and a viable alternative to 6 F conventional intermediate catheters in selected cases.
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Affiliation(s)
- Riccardo Russo
- Department of Neuroscience, Neuroradiological Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, Turin, Italy
| | - Francesco Mistretta
- Department of Neuroscience, Neuroradiological Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, Turin, Italy
| | - Stefano Molinaro
- Department of Neuroscience, Neuroradiological Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, Turin, Italy
| | - Mauro Bergui
- Department of Neuroscience, Neuroradiological Unit, University of Turin, Azienda Ospedaliera Città della Salute e della Scienza Hospital, Turin, Italy
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96
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Ren Z, Wangqin R, Demiraj F, Li W, Mokin M, Wang A, Miao Z, Wang Y, Burgin WS. Derivation and validation of a predictive scale to expedite endovascular intervention for acute stroke patients with an intervenable vessel occlusion. J Neurointerv Surg 2023:jnis-2023-020871. [PMID: 37734930 DOI: 10.1136/jnis-2023-020871] [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: 07/31/2023] [Accepted: 08/27/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Early endovascular intervention team mobilization may reduce reperfusion times and improve clinical outcomes for patients with acute ischemic stroke (AIS) with a possible intervenable vessel occlusion (IVO). In an emergency department or mobile stroke unit, incorporating rapidly available non-contrast CT (NCCT) information with examination findings may improve the accuracy of arterial occlusion prediction scales. For this purpose, we developed a rapid and straightforward IVO predictive instrument-the T3AM2PA1 scale. METHODS The T3AM2PA1 scale was retrospectively derived from our 'Get with the Guidelines' database. We included all patients with acute stroke alert between January 2017 and August 2018 with a National Institutes of Health Stroke Scale (NIHSS) score between 5 and 25 inclusive. Different pre-intervention variables were collected, including itemized NIHSS and NCCT information. The T3AM2PA1 scale was also compared with other commonly used scales and was validated in a separate sequential retrospective cohort of patients with a full range of NIHSS scores. RESULTS 574 eligible patients from 2115 acute stroke alerts were identified. The scale was established with five items (CT hyperdense sign, parenchymal hypodensity, lateralizing hemiparesis, gaze deviation, and language disturbance), with a total score of 9. To minimize unnecessary angiography, a cut-off of ≥5 for IVO detection yielded a sensitivity of 52%, a specificity of 90%, and a positive predictive value of 76%. CONCLUSIONS The T3AM2PA1 scale accurately predicts the presence of clinical IVO in patients with AIS. Adopting the T3AM2PA1 scale could reduce revascularization times, improve treatment outcomes, and potentially reduce disability.
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Affiliation(s)
- Zeguang Ren
- Department of Neurosurgery, the Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Runqi Wangqin
- Duke Clinical Research Institute, Duke Univeristy Medical Center, Durham, North Carolina, USA
| | - Francis Demiraj
- Department of Neurology, FAU Schmidt College of Medicine, Boca Raton, Florida, USA
| | - Weizhe Li
- Department of Neurology, Duke University, Durham, North Carolina, USA
| | - Maxim Mokin
- Department of Neurosurgery and Neurology, University of South Florida, Tampa, Florida, USA
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Zhongrong Miao
- Department of Neurological Intervention, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- China National Clinical Research Center for Neurological Diseases, Capital Medical University, Beijing, China
| | - W Scott Burgin
- Department of Neurology, University of South Florida, Tampa, Florida, USA
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97
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Piscopo A, Zanaty M, Dlouhy K. Contemporary Methods for Detection and Intervention of Distal Medium and Small Vessel Occlusions. J Clin Med 2023; 12:6071. [PMID: 37763011 PMCID: PMC10531921 DOI: 10.3390/jcm12186071] [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: 08/08/2023] [Revised: 09/10/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
The efficacy of using mechanical thrombectomy for proximal large vessel occlusions has been demonstrated in multiple large-scale trials and has further raised the question of its potential utility for distal medium and small vessel occlusions (DMSVOs). Their longer, more tortuous course and smaller corresponding vascular territories render a significant challenge for detection and intervention. The aim of this study is to provide a comprehensive overview of the current imaging and endovascular intervention options for DMSVOs and review the current works in the literature. Compared with traditional computed tomography angiography (CTA) and CT perfusion, recent advances such as multiphase CTA and maps derived from the time-to-maximum parameter coupled with artificial intelligence have demonstrated increased sensitivity for the detection of DMSVOs. Furthermore, newer generations of mini stent retrievers and thromboaspiration devices have allowed for the access and navigation of smaller and more fragile distal arteries. Preliminary studies have suggested that mechanical thrombectomy using this newer generation of devices is both safe and feasible in distal medium-sized vessels, such as M2. However, endovascular intervention utilizing such contemporary methods and devices must be balanced at the discretion of operator experience and favorable vascular anatomy. Further large-scale multicenter clinical trials are warranted to elucidate the indications for as well as to strengthen the safety and efficacy of this approach.
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Affiliation(s)
| | - Mario Zanaty
- Department of Neurosurgery, University of Iowa Hospital and Clinics, Iowa City, IA 52242, USA; (A.P.); (K.D.)
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98
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Amukotuwa SA, Bammer R. What the Stroke Team Needs to Know: CADt Software Must Only Be Used for Its Intended Purpose . . . and We Still Need the Radiologist. J Am Coll Radiol 2023; 20:819-820. [PMID: 37479072 DOI: 10.1016/j.jacr.2023.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2023] [Accepted: 07/08/2023] [Indexed: 07/23/2023]
Affiliation(s)
- Shalini A Amukotuwa
- Divisional Head for Neuroradiology and MSK and the Director of MRI, Diagnostic Imaging, Monash Health, Clayton, VIC, Australia, and Associate Professor, Department of Radiology and Radiological Sciences, Monash University, Clayton, VIC, Australia.
| | - Roland Bammer
- Diagnostic Imaging, Monash Health, Clayton, VIC, Australia; and Chair, Department of Radiology and Radiological Sciences, Monash University, Clayton, VIC, Australia
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99
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Kobeissi H, Bilgin C, Ghozy S, Kadirvel R, Kallmes DF, Brinjikji W. A review of acute ischemic stroke caused by distal, medium vessel occlusions. Interv Neuroradiol 2023:15910199231197616. [PMID: 37644821 DOI: 10.1177/15910199231197616] [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: 08/31/2023] Open
Abstract
Acute ischemic stroke (AIS) due to distal, medium vessel occlusion (DMVO) is increasingly recognized as the next frontier for mechanical thrombectomy. Distal, medium vessel occlusions are typically defined as an occlusion in the following arteries: anterior cerebral artery, M2-M4 segments of the middle cerebral artery, posterior cerebral artery, posterior inferior cerebellar artery, anterior inferior cerebellar artery, and superior cerebellar artery. It is estimated that 25-40% of all AIS is due to DMVO. Because of the large burden of DMVO, the frequency of literature published regarding these occlusions has greatly increased in recent years. Furthermore, treatment modalities have been created specifically for DMVOs. Due to the rapidly evolving literature on this topic, remaining up to date on DMVO definitions, anatomy, management, imaging, and clinical course is difficult. In this review article, we synthesized existing literature regarding the aforementioned topics and discussed future directions.
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Affiliation(s)
| | - Cem Bilgin
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Ramanathan Kadirvel
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
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100
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Amukotuwa SA, Bammer R. The Iodinated Contrast Crisis of 2022: A Near Miss or a Missed Opportunity? AJNR Am J Neuroradiol 2023; 44:908-909. [PMID: 37442594 PMCID: PMC10411830 DOI: 10.3174/ajnr.a7940] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/15/2023]
Affiliation(s)
- S A Amukotuwa
- Department of Diagnostic ImagingDepartment of RadiologyMonash University, Melbourne, Australia
| | - R Bammer
- Department of Diagnostic ImagingDepartment of RadiologyMonash University, Melbourne, Australia
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