1051
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1052
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Kim SK, Yoon W, Park MS, Heo TW, Baek BH, Lee YY. Outcomes Are Not Different between Patients with Intermediate and High DWI-ASPECTS after Stent-Retriever Embolectomy for Acute Anterior Circulation Stroke. AJNR Am J Neuroradiol 2016; 37:1080-5. [PMID: 26767711 DOI: 10.3174/ajnr.a4663] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Accepted: 11/23/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Questions remain as to what benefits embolectomy provides to patients presented with considerable early ischemic changes on baseline imaging studies. This study aimed to investigate the impact of the Alberta Stroke Program Early CT Score applied to DWI on treatment outcomes in patients with acute stroke undergoing stent-retriever embolectomy. MATERIALS AND METHODS We retrospectively analyzed the clinical and DWI data from 171 patients with acute anterior circulation stroke who were treated with stent-retriever embolectomy within 6 hours of symptom onset. DWI-ASPECTS scores were analyzed with the full scale or were dichotomized (4-6 versus 7-10). Patients with DWI-ASPECTS ≤3 were excluded from the study. Associations between outcome and clinical and radiologic factors were determined with a multivariate logistic regression analysis. A good outcome was defined as a modified Rankin Scale score of 0-2 at 3 months. RESULTS The median DWI-ASPECTS was 7 (interquartile range, 6-8). The rates of good outcome, symptomatic hemorrhage, and mortality were not different between high DWI-ASPECTS (scores of 7-10) and intermediate DWI-ASPECTS (scores of 4-6) groups. In patients with an intermediate DWI-ASPECTS, good outcome was achieved in 46.5% (20/43) of patients with successful revascularization, whereas no patients without successful revascularization had a good outcome (P = .016). In multivariate logistic regression analysis, independent predictors of good outcome were age and successful revascularization. CONCLUSIONS Our study suggested that there were no differences in outcomes between patients with a high DWI-ASPECTS and those with an intermediate DWI-ASPECTS who underwent stent-retriever embolectomy for acute anterior circulation stroke. Thus, patients with an intermediate DWI-ASPECTS otherwise eligible for endovascular therapy may not be excluded from stent-retriever embolectomy or stroke trials.
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Affiliation(s)
- S K Kim
- From the Departments of Radiology (S.K.K., W.Y., T.W.H., B.H.B., Y.Y.L.)
| | - W Yoon
- From the Departments of Radiology (S.K.K., W.Y., T.W.H., B.H.B., Y.Y.L.)
| | - M S Park
- Neurology (M.S.P.), Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - T W Heo
- From the Departments of Radiology (S.K.K., W.Y., T.W.H., B.H.B., Y.Y.L.)
| | - B H Baek
- From the Departments of Radiology (S.K.K., W.Y., T.W.H., B.H.B., Y.Y.L.)
| | - Y Y Lee
- From the Departments of Radiology (S.K.K., W.Y., T.W.H., B.H.B., Y.Y.L.)
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1053
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Yan S, Chen Q, Xu M, Sun J, Liebeskind DS, Lou M. Thrombus Length Estimation on Delayed Gadolinium-Enhanced T1. Stroke 2016; 47:756-61. [PMID: 26768206 DOI: 10.1161/strokeaha.115.011401] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Accepted: 11/18/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Previous studies revealed a close relationship between thrombus length and recanalization rate after intravenous thrombolysis (IVT). As a novel approach, we prospectively adjusted the order of sequence acquisition to obtain delayed gadolinium-enhanced T1 (dGE-T1) and thereby assess thrombus length on dGE-T1 to evaluate its predictive value for recanalization after IVT. METHODS We reviewed prospectively collected clinical and imaging data from acute ischemic stroke patients with middle cerebral artery occlusion who underwent multimodal magnetic resonance imaging before and 24 hours after IVT. Perfusion-weighted imaging was performed followed by conventional T1. We measured thrombus length on dGE-T1 and examined its association with middle cerebral artery recanalization. RESULTS Of the included 74 patients, the median age was 66 years and 28 (37.8%) were women. Thrombus length was 8.18±4.56 mm on dGE-T1, which was an acceptable predictor for no recanalization (odds ratio, 1.196; 95% confidence interval, 1.015-1.409; P=0.033), with a receiver-operator characteristic of 0.732 (95% confidence interval, 0.619-0.845; P=0.001). The optimal cut-off point was identified at 6.77 mm, which yielded a sensitivity of 77.8%, a specificity of 57.9%, and an odds ratio of 4.81 (95% confidence interval, 1.742-13.292; P=0.002). Moreover, no one achieved recanalization after IVT when length of thrombus exceeded 14 mm on dGE-T1. CONCLUSIONS The dGE-T1, obtained by simply adjusting scanning order in multimodal magnetic resonance imaging protocol, is a useful tool for thrombus length estimation and middle cerebral artery recanalization prediction after IVT.
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Affiliation(s)
- Shenqiang Yan
- From the Department of Neurology (S.Y., Q.C., M.X., M.L.) and Radiology (J.S.), The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China; and Department of Neurology, University of California-Los Angeles Stroke Center (D.S.L.)
| | - Qingmeng Chen
- From the Department of Neurology (S.Y., Q.C., M.X., M.L.) and Radiology (J.S.), The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China; and Department of Neurology, University of California-Los Angeles Stroke Center (D.S.L.)
| | - Mengjun Xu
- From the Department of Neurology (S.Y., Q.C., M.X., M.L.) and Radiology (J.S.), The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China; and Department of Neurology, University of California-Los Angeles Stroke Center (D.S.L.)
| | - Jianzhong Sun
- From the Department of Neurology (S.Y., Q.C., M.X., M.L.) and Radiology (J.S.), The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China; and Department of Neurology, University of California-Los Angeles Stroke Center (D.S.L.)
| | - David S Liebeskind
- From the Department of Neurology (S.Y., Q.C., M.X., M.L.) and Radiology (J.S.), The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China; and Department of Neurology, University of California-Los Angeles Stroke Center (D.S.L.)
| | - Min Lou
- From the Department of Neurology (S.Y., Q.C., M.X., M.L.) and Radiology (J.S.), The 2nd Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China; and Department of Neurology, University of California-Los Angeles Stroke Center (D.S.L.).
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1054
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Lyu J, Ma N, Liebeskind DS, Wang DJJ, Ma L, Xu Y, Wang T, Miao Z, Lou X. Arterial Spin Labeling Magnetic Resonance Imaging Estimation of Antegrade and Collateral Flow in Unilateral Middle Cerebral Artery Stenosis. Stroke 2016; 47:428-33. [PMID: 26732570 DOI: 10.1161/strokeaha.115.011057] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 11/30/2015] [Indexed: 01/04/2023]
Abstract
BACKGROUND AND PURPOSE Three-dimensional pseudocontinuous arterial spin labeling with multiple postlabeling delays has been used to assess cerebral blood flow (CBF). We used this modality to estimate antegrade and collateral flow in patients with unilateral middle cerebral artery stenosis. METHODS Consecutive patients with unilateral middle cerebral artery 50% to 99% stenosis at 2 centers underwent pseudocontinuous arterial spin labeling with a postlabeling delays of 1.5 and 2.5 s. Mean CBF of bilateral middle cerebral artery territory at the postlabeling delays 1.5 and 2.5 s was measured. Early-arriving flow proportion was defined as (CBF 1.5 s at lesion side/CBF 2.5 s at normal side)×100%. Late-arriving retrograde flow proportion was defined as ([CBF 2.5 s-CBF 1.5 s] at lesion side-[CBF 2.5 s-CBF 1.5 s] at normal side)/CBF 2.5 s at normal side×100%. Antegrade and collateral scales were evaluated in patients with conventional angiography. Spearman correlation coefficients were calculated between early-arriving flow and late-arriving retrograde flow proportions on arterial spin labeling and antegrade and collateral scales on conventional angiography, respectively. RESULTS Forty-one patients (46.0±12.0 years) were enrolled. The mean early-arriving flow proportion was 78.3±14.9%. The mean late-arriving retrograde flow proportion was 16.1±10.2%. In 21 patients with conventional angiography, Spearman correlation coefficient was 0.53 (95% confidence interval, 0.11-0.79) between antegrade grade and early-arriving flow proportion (P=0.01) and 0.81 (95% confidence interval, 0.56-0.92) between collateral grade and late-arriving retrograde flow proportion (P<0.0001). CONCLUSIONS Three-dimensional pseudocontinuous arterial spin labeling with 2 postlabeling delays may provide an empirical approach for estimating antegrade and collateral flow in patients with unilateral middle cerebral artery stenosis. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Unique identifier: NCT02479243.
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Affiliation(s)
- Jinhao Lyu
- From the Department of Radiology, Chinese PLA General Hospital, Beijing, China (J.L., L.M., Y.X., T.W., X.L.); Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China (N.M., Z.M.); and Department of Neurology, UCLA Stroke Center, Los Angeles (D.S.L., D.J.J.W.)
| | - Ning Ma
- From the Department of Radiology, Chinese PLA General Hospital, Beijing, China (J.L., L.M., Y.X., T.W., X.L.); Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China (N.M., Z.M.); and Department of Neurology, UCLA Stroke Center, Los Angeles (D.S.L., D.J.J.W.)
| | - David S Liebeskind
- From the Department of Radiology, Chinese PLA General Hospital, Beijing, China (J.L., L.M., Y.X., T.W., X.L.); Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China (N.M., Z.M.); and Department of Neurology, UCLA Stroke Center, Los Angeles (D.S.L., D.J.J.W.)
| | - Danny J J Wang
- From the Department of Radiology, Chinese PLA General Hospital, Beijing, China (J.L., L.M., Y.X., T.W., X.L.); Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China (N.M., Z.M.); and Department of Neurology, UCLA Stroke Center, Los Angeles (D.S.L., D.J.J.W.)
| | - Lin Ma
- From the Department of Radiology, Chinese PLA General Hospital, Beijing, China (J.L., L.M., Y.X., T.W., X.L.); Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China (N.M., Z.M.); and Department of Neurology, UCLA Stroke Center, Los Angeles (D.S.L., D.J.J.W.)
| | - Yang Xu
- From the Department of Radiology, Chinese PLA General Hospital, Beijing, China (J.L., L.M., Y.X., T.W., X.L.); Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China (N.M., Z.M.); and Department of Neurology, UCLA Stroke Center, Los Angeles (D.S.L., D.J.J.W.)
| | - Ting Wang
- From the Department of Radiology, Chinese PLA General Hospital, Beijing, China (J.L., L.M., Y.X., T.W., X.L.); Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China (N.M., Z.M.); and Department of Neurology, UCLA Stroke Center, Los Angeles (D.S.L., D.J.J.W.)
| | - Zhongrong Miao
- From the Department of Radiology, Chinese PLA General Hospital, Beijing, China (J.L., L.M., Y.X., T.W., X.L.); Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China (N.M., Z.M.); and Department of Neurology, UCLA Stroke Center, Los Angeles (D.S.L., D.J.J.W.).
| | - Xin Lou
- From the Department of Radiology, Chinese PLA General Hospital, Beijing, China (J.L., L.M., Y.X., T.W., X.L.); Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, China National Clinical Research Center for Neurological Diseases, Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China (N.M., Z.M.); and Department of Neurology, UCLA Stroke Center, Los Angeles (D.S.L., D.J.J.W.).
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1055
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Jahan R, Saver JL. Endovascular Treatment of Acute Ischemic Stroke. Stroke 2016. [DOI: 10.1016/b978-0-323-29544-4.00065-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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1056
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Wen WL, Fang YB, Yang PF, Zhang YW, Wu YN, Shen H, Ge JJ, Xu Y, Hong B, Huang QH, Liu JM. Parametric Digital Subtraction Angiography Imaging for the Objective Grading of Collateral Flow in Acute Middle Cerebral Artery Occlusion. World Neurosurg 2015; 88:119-125. [PMID: 26748176 DOI: 10.1016/j.wneu.2015.12.084] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2015] [Revised: 12/21/2015] [Accepted: 12/22/2015] [Indexed: 10/22/2022]
Abstract
PURPOSE To report the feasibility of parametric color-coded digital subtraction angiography (DSA) in complementing the traditional, subjective way of leptomeningeal collateral assessment in acute middle cerebral artery (MCA) occlusions. METHODS Thirty-three consecutive patients with acute MCA occlusion who received endovascular treatment were recruited for investigation. Eighteen of 33 consecutive patients were included. The target downstream territory (TDT) of MCA and reference point at terminal internal carotid artery of each patient was contoured by 5 raters independently on the basis of anteroposterior 2-dimensional DSA. Two parameters of relative maximum density of TDT (rDensitymax) and peak time interval (ΔPT) between reference and TDT were extracted by the use of parametric DSA analysis software. Interrater reliability was tested with intraclass correlation coefficients. Parameters with sufficient interrater reliability entered validity evaluation. Then, the correlation test with the American Society of Interventional and Therapeutic Neuroradiology collateral grading system and efficacy in predicting favorable clinical outcome was evaluated. RESULTS The intraclass correlation coefficient of rDensitymax and ΔPT were 0.983, 95% confidence interval 0.968-0.993 and 0.831, 95% confidence interval 0.705-0.923, respectively. The parameter rDensitymax showed a strong correlation with the American Society of Interventional and Therapeutic Neuroradiology collateral grading system score (r of Spearman correlation test = 0.869, P < 0.001) and mRS at 3 months (partial correlation coefficient = 0.616, P = 0.009), whereas ΔPT_average did not. A cut-off point of 0.224 in rDensitymax predicted a favorable clinical outcome with high sensitivity and specificity. CONCLUSIONS The relative maximum contrast density of MCA territory on 2-dimensional DSA measured by parametric imaging technique appears to be a simple and reliable metric for the assessment of leptomeningeal collaterals in cases of acute MCA occlusion.
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Affiliation(s)
- Wan-Ling Wen
- Department of Neurosurgery, Changhai Hospital, Shanghai, China
| | - Yi-Bin Fang
- Department of Neurosurgery, Changhai Hospital, Shanghai, China
| | - Peng-Fei Yang
- Department of Neurosurgery, Changhai Hospital, Shanghai, China
| | - Yong-Wei Zhang
- Department of Neurosurgery, Changhai Hospital, Shanghai, China
| | - Yi-Na Wu
- Department of Neurosurgery, Changhai Hospital, Shanghai, China
| | - Hui Shen
- Department of Neurosurgery, Changhai Hospital, Shanghai, China
| | - Jia-Jia Ge
- Department of Neurosurgery, Changhai Hospital, Shanghai, China
| | - Yi Xu
- Department of Neurosurgery, Changhai Hospital, Shanghai, China
| | - Bo Hong
- Department of Neurosurgery, Changhai Hospital, Shanghai, China
| | - Qing-Hai Huang
- Department of Neurosurgery, Changhai Hospital, Shanghai, China.
| | - Jian-Min Liu
- Department of Neurosurgery, Changhai Hospital, Shanghai, China.
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1057
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Yan S, Chen Q, Zhang X, Xu M, Han Q, Shao A, Liebeskind DS, Lou M. Extensive blooming artifact predicts no recanalization after intravenous thrombolysis. Eur J Neurol 2015; 23:737-43. [PMID: 26706832 DOI: 10.1111/ene.12930] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2015] [Accepted: 11/04/2015] [Indexed: 11/29/2022]
Affiliation(s)
- S. Yan
- Department of Neurology; School of Medicine; Second Affiliated Hospital of Zhejiang University; Hangzhou China
| | - Q. Chen
- Department of Neurology; School of Medicine; Second Affiliated Hospital of Zhejiang University; Hangzhou China
| | - X. Zhang
- Department of Neurology; School of Medicine; Second Affiliated Hospital of Zhejiang University; Hangzhou China
| | - M. Xu
- Department of Neurology; School of Medicine; Second Affiliated Hospital of Zhejiang University; Hangzhou China
| | - Q. Han
- Department of Neurology; School of Medicine; Second Affiliated Hospital of Zhejiang University; Hangzhou China
| | - A. Shao
- Department of Neurosurgery; School of Medicine; Second Affiliated Hospital of Zhejiang University; Hangzhou China
| | - D. S. Liebeskind
- University of California − Los Angeles Stroke Center; Los Angeles CA USA
| | - M. Lou
- Department of Neurology; School of Medicine; Second Affiliated Hospital of Zhejiang University; Hangzhou China
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1058
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Leng X, Fang H, Leung TWH, Mao C, Xu Y, Miao Z, Liu L, Wong KSL, Liebeskind DS. Impact of Collateral Status on Successful Revascularization in Endovascular Treatment: A Systematic Review and Meta-Analysis. Cerebrovasc Dis 2015; 41:27-34. [PMID: 26579719 DOI: 10.1159/000441803] [Citation(s) in RCA: 65] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2015] [Accepted: 10/17/2015] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Pre-treatment collateral status may be associated with the rates of successful revascularization in acute ischemic stroke patients receiving endovascular treatment (EVT). We conducted a systematic review and meta-analysis to synthesize relevant evidence currently available. METHODS Relevant full-text articles published in English since January 1, 2000, reporting associations between collateral status and successful reperfusion and/or recanalization in acute ischemic stroke patients receiving EVT in cohort or case-control studies, or randomized clinical trials, were retrieved through search of PubMed. Study selection, data extraction and study quality assessment were carried out by 2 investigators. Risk ratios (RR) were pooled for good vs. poor collaterals for the outcomes of successful reperfusion and recanalization, based on random-effects models. Subgroup analyses were conducted to explore for potential factors that might interfere with the effects of pre-treatment collateral status on reperfusion by EVT. RESULTS In total, 27 studies (2,366 subjects) were included in qualitative analysis, among which 24 studies (2,239 subjects) were quantitatively analyzed. Overall, good pre-treatment collaterals significantly increased the rate of both successful reperfusion (RR 1.28, 95% CI 1.17-1.40; p < 0.001) and recanalization (RR 1.23, 95% CI 1.06-1.42; p = 0.006), as compared with poor collaterals. Subgroup analyses revealed that the effects of collateral status on successful reperfusion by EVT might be different between populations with different ethnicities. CONCLUSIONS Good pre-treatment collaterals may enhance the rates of successful reperfusion and recanalization in EVT for acute ischemic stroke. This may partly explain the favorable effects of good pre-treatment collaterals on clinical outcomes of stroke patients receiving EVT. Thus, it would be valuable to assess the collateral status prior to EVT in acute ischemic stroke. But studies are needed to further verify if the positive effects of good collaterals on revascularization by EVT are restricted to certain subgroups of patients.
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Affiliation(s)
- Xinyi Leng
- Department of Medicine and Therapeutics, Hong Kong Branch of The Chinese Cochrane Center (CM), Chinese University of Hong Kong, Hong Kong, SAR, China
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1059
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Ritzenthaler T, Lacalm A, Cho TH, Maucort-Boulch D, Klaerke Mikkelsen I, Ribe L, Østergaard L, Hjort N, Fiehler J, Pedraza S, Louis Tisserand G, Baron JC, Berthezene Y, Nighoghossian N. Sequential MR Assessment of the Susceptibility Vessel Sign and Arterial Occlusion in Acute Stroke. J Neuroimaging 2015; 26:355-9. [DOI: 10.1111/jon.12312] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2015] [Accepted: 09/23/2015] [Indexed: 11/28/2022] Open
Affiliation(s)
- Thomas Ritzenthaler
- Cerebrovascular Unit; Hôpital Neurologique Pierre Wertheimer; Hospices Civils de Lyon 69677 Bron Cedex France
- Université de Lyon CREATIS; CNRS UMR5220, INSERM U1044, INSA-Lyon, Université Lyon 1; Hospices Civils de Lyon France
| | - Audrey Lacalm
- Neuroradiology Department; Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon; 69677 Bron Cedex France
| | - Tae-Hee Cho
- Cerebrovascular Unit; Hôpital Neurologique Pierre Wertheimer; Hospices Civils de Lyon 69677 Bron Cedex France
- Université de Lyon CREATIS; CNRS UMR5220, INSERM U1044, INSA-Lyon, Université Lyon 1; Hospices Civils de Lyon France
| | - Delphine Maucort-Boulch
- Service de Biostatistiques; Hospices Civils de Lyon, Lyon 69003, France; CNRS UMR 5558, Equipe Biostatistique Santé; Pierre-Bénite, F-69310, France; Université Lyon I, Villeurbanne F-69100 France
| | - Irene Klaerke Mikkelsen
- Department of Clinical Medicine; Center of Functionally Integrative Neuroscience, Aarhus University; Aarhus Denmark
| | - Lars Ribe
- Department of Clinical Medicine; Center of Functionally Integrative Neuroscience, Aarhus University; Aarhus Denmark
| | - Leif Østergaard
- Department of Clinical Medicine; Center of Functionally Integrative Neuroscience, Aarhus University; Aarhus Denmark
| | - Niels Hjort
- Department of Clinical Medicine; Center of Functionally Integrative Neuroscience, Aarhus University; Aarhus Denmark
| | - Jens Fiehler
- Departments of Diagnostic and Interventional Neuroradiology; University Hospital Hamburg-Eppendorf; Hamburg Germany
| | - Salvador Pedraza
- Department of Radiology (IDI); Girona Biomedical Research Institute (IDIBGI), Hospital Universitari de Girona Dr Josep Trueta; Girona Spain
| | - Guy Louis Tisserand
- Neuroradiology Department; Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon; 69677 Bron Cedex France
| | | | - Yves Berthezene
- Neuroradiology Department; Hôpital Neurologique Pierre Wertheimer, Hospices Civils de Lyon; 69677 Bron Cedex France
- Université de Lyon CREATIS; CNRS UMR5220, INSERM U1044, INSA-Lyon, Université Lyon 1; Hospices Civils de Lyon France
| | - Norbert Nighoghossian
- Cerebrovascular Unit; Hôpital Neurologique Pierre Wertheimer; Hospices Civils de Lyon 69677 Bron Cedex France
- Université de Lyon CREATIS; CNRS UMR5220, INSERM U1044, INSA-Lyon, Université Lyon 1; Hospices Civils de Lyon France
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1060
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Gawlitza M, Friedrich B, Hobohm C, Schaudinn A, Schob S, Quäschling U, Hoffmann KT, Lobsien D. Distance to Thrombus in Acute Middle Cerebral Artery Occlusion Predicts Target Mismatch and Ischemic Penumbra. J Stroke Cerebrovasc Dis 2015; 25:298-305. [PMID: 26542822 DOI: 10.1016/j.jstrokecerebrovasdis.2015.09.032] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2015] [Revised: 09/11/2015] [Accepted: 09/26/2015] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND AND PURPOSE In patients with occlusion of the middle cerebral artery (MCA) treated by intravenous thrombolysis (IVT), the distance to thrombus (DT) has been proposed as a predictor of outcome. The purpose of the present study was to investigate how DT relates to dynamic susceptibility contrast perfusion metrics. METHODS Retrospective analysis was undertaken of patients who were diagnosed with acute MCA occlusion by magnetic resonance imaging and treated with IVT. Volumes of time-to-maximum (Tmax) perfusion deficits and diffusion-weighted imaging (DWI) lesions, diffusion-perfusion mismatch volumes, and the presence of target mismatch were determined. Correlations between the above stoke measures and DT were then calculated. RESULTS Fifty-five patients were included. DT showed significant inverse correlations with Tmax greater than 4, 6, 8, and 10 seconds, respectively, and mismatch volumes. Using the DT group median (14 mm) as a separator, significant intergroup differences were observed for Tmax greater than 4, 6, and 8 seconds, respectively, and for mismatch volumes. Grouping DT into quartiles showed significant intergroup differences regarding mismatch volumes and Tmax values greater than 4 and 6 seconds. Binary logistic regression identified DT (odds ratio [OR] = .89; 95% confidence interval [CI], .81-.99) and DWI lesion volumes (OR = .92; 95% CI, .86-.97) as independent predictors of target mismatch. A low DT predicted target mismatch with an area under the curve of .69. CONCLUSIONS DT correlates inversely with Tmax perfusion deficits and mismatch volumes and acts as an independent predictor of target mismatch.
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Affiliation(s)
- Matthias Gawlitza
- Department of Neuroradiology, University Hospital Leipzig, Leipzig, Germany.
| | - Benjamin Friedrich
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig, Germany
| | - Carsten Hobohm
- Department of Neurology, University Hospital Leipzig, Leipzig, Germany
| | - Alexander Schaudinn
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig, Germany
| | - Stefan Schob
- Department of Neuroradiology, University Hospital Leipzig, Leipzig, Germany
| | - Ulf Quäschling
- Department of Neuroradiology, University Hospital Leipzig, Leipzig, Germany
| | | | - Donald Lobsien
- Department of Neuroradiology, University Hospital Leipzig, Leipzig, Germany
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1061
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Hametner C, Stanarcevic P, Stampfl S, Rohde S, Veltkamp R, Bösel J. Noninvasive cerebral oximetry during endovascular therapy for acute ischemic stroke: an observational study. J Cereb Blood Flow Metab 2015; 35:1722-8. [PMID: 26243709 PMCID: PMC4635248 DOI: 10.1038/jcbfm.2015.181] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 06/18/2015] [Accepted: 06/22/2015] [Indexed: 01/20/2023]
Abstract
Implementing endovascular stroke care often impedes neurologic assessment in patients who need sedation or general anesthesia. Cerebral near-infrared spectroscopy (NIRS) may help physicians monitor cerebral tissue viability, but data in hyperacute stroke patients receiving endovascular treatment are sparse. In this observational study, the NIRS index regional oxygen saturation (rSO2) was measured noninvasively before, during, and after endovascular therapy via bilateral forehead NIRS optodes. During the study period, 63 patients were monitored with NIRS; 43 qualified for analysis. Before recanalization, 10 distinct rSO2 decreases occurred in 11 patients with respect to time to intubation. During recanalization, two kinds of unilateral rSO2 changes occurred in the affected hemisphere: small peaks throughout the treatment (n=14, 32.6%) and sustained increases immediately after recanalization (n=2, 4.7%). Lower area under the curve 10% below baseline was associated with better reperfusion status (thrombolysis in cerebral infarction ≥ 2b, P=0.009). At the end of the intervention, lower interhemispheric rSO2 difference predicted death within 90 days (P=0.037). After the intervention, higher rSO2 variability predicted poor outcome (modified Rankin scale > 3, P=0.032). Our findings suggest that bi-channel rSO2-NIRS has potential for guiding neuroanesthesia and predicting outcome. To better monitor local revascularization, an improved stroke-specific set-up in future studies is necessary.
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Affiliation(s)
| | - Predrag Stanarcevic
- Neurology Clinic, Clinical Centre of Serbia, University of Belgrade, Belgrade, Serbia
| | - Sibylle Stampfl
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Stefan Rohde
- Department of Radiology and Neuroradiology, Klinikum Dortmund, Dortmund, Germany
| | - Roland Veltkamp
- Department of Neurology/Stroke, Imperial College, London, UK
| | - Julian Bösel
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
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1062
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Lee JS, Hong JM, Lee KS, Suh HI, Choi JW, Kim SY. Primary stent retrieval for acute intracranial large artery occlusion due to atherosclerotic disease. J Stroke 2015; 18:96-101. [PMID: 26467196 PMCID: PMC4747073 DOI: 10.5853/jos.2015.01347] [Citation(s) in RCA: 88] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2015] [Revised: 08/28/2015] [Accepted: 09/07/2015] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND AND PURPOSE The goal of stent retriever-based thrombectomy is removal of embolic clots in patients with intracranial large artery occlusion. However, outcomes of stent retrieval may differ between acute arterial occlusions due to intracranial atherosclerotic disease (IAD) and those due to embolism. This case series describes the outcomes of stent retriever-based thrombectomy and rescue treatments in 9 patients with IAD-related occlusion. METHODS Among patients who underwent endovascular treatment for acute intracranial large artery occlusion, those in whom stent retrieval was attempted as first-line treatment were included in this review. IAD was defined as significant fixed focal stenosis at the occlusion site, which was evident on final angiographic assessment or observed during endovascular treatment. RESULTS Median number of stent retriever passes was 2 (range, 1-3), and temporary bypass was seen in all patients. Immediate partial recanalization (arterial occlusive lesion grade 2-3) was observed in 7 patients. Immediate modified thrombolysis in cerebral infarction grade 2b-3 was seen in 6 patients, but the lesions often required rescue treatment due to reocclusion or flow insufficiency. In terms of rescue treatments, angioplasty and intra-arterial tirofiban infusion seemed to be effective. CONCLUSIONS Our findings suggest that stent retrieval can effectively remove thrombi from stenotic lesions and achieve partial recanalization despite the tendency toward reocclusion in most patients with IAD-related occlusion. Further research into the use of rescue treatments, such as tirofiban infusion and angioplasty, is warranted.
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Affiliation(s)
- Jin Soo Lee
- Department of Neurology, School of Medicine, Ajou University Medical Center, Suwon, Korea
| | - Ji Man Hong
- Department of Neurology, School of Medicine, Ajou University Medical Center, Suwon, Korea
| | - Kyu Sun Lee
- Department of Neurology, School of Medicine, Ajou University Medical Center, Suwon, Korea
| | - Hong Il Suh
- Department of Neurology, School of Medicine, Ajou University Medical Center, Suwon, Korea
| | - Jin Wook Choi
- Department of Radiology, School of Medicine, Ajou University Medical Center, Suwon, Korea
| | - Sun Yong Kim
- Department of Radiology, School of Medicine, Ajou University Medical Center, Suwon, Korea
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1063
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Fanou EM, Knight J, Aviv RI, Hojjat SP, Symons SP, Zhang L, Wintermark M. Effect of Collaterals on Clinical Presentation, Baseline Imaging, Complications, and Outcome in Acute Stroke. AJNR Am J Neuroradiol 2015; 36:2285-91. [PMID: 26471754 DOI: 10.3174/ajnr.a4453] [Citation(s) in RCA: 74] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2015] [Accepted: 05/14/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Good CTA collaterals independently predict good outcome in acute ischemic stroke. Our aim was to evaluate the role of collateral circulation and its added benefit over CTP-derived total ischemic volume as a predictor of baseline NIHSS score, total ischemic volume, hemorrhagic transformation, final infarct size, and a modified Rankin Scale score >2. MATERIALS AND METHODS This was a retrospective study of 395 patients with stroke dichotomized by recanalization (recanalization positive/recanalization negative) and collateral status. Clot burden score was quantified on baseline CTA. Total ischemic volumes were derived from thresholded CTP maps. Final infarct size was assessed on follow-up CT/MRI. We performed uni-/multivariate analyses for each outcome, adjusting for rtPA status, using general linear (continuous variables) and logistic (binary variables) regression. Model comparison with collateral score and total ischemic volume was performed using the F or likelihood ratio test. RESULTS Collateral presence independently and inversely predicted all outcomes except hemorrhagic transformation in patients who were recanalization negative and mRS >2 in patients who were recanalization positive. The greatest collateral benefit occurred in patients who were recanalization negative, contributing 16.5% and 19.2% of the variability for final infarct size and mRS >2. The collateral score model is superior to the total ischemic volume for mRS >2 prediction, but a combination of total ischemic volume and collateral score is superior for mRS >2 and final infarct prediction (24% and 28% variability, respectively). In patients who were recanalization positive, a model including collateral score and total ischemic volume was superior to that of total ischemic volume for hemorrhagic transformation and final infarct prediction but was muted compared with patients who were recanalization negative (11.3% and 16.9% variability). CONCLUSIONS Collateral circulation is an independent predictor of all outcomes, but the magnitude of significance varies, greater in patients who were recanalization negative versus recanalization positive. Total ischemic volume assessment is complementary to collateral score in many cases.
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Affiliation(s)
- E M Fanou
- From the Division of Neuroradiology (E.M.F., J.K., R.I.A., S.-P.H., S.P.S., L.Z.), Department of Medical Imaging, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - J Knight
- From the Division of Neuroradiology (E.M.F., J.K., R.I.A., S.-P.H., S.P.S., L.Z.), Department of Medical Imaging, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - R I Aviv
- From the Division of Neuroradiology (E.M.F., J.K., R.I.A., S.-P.H., S.P.S., L.Z.), Department of Medical Imaging, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - S-P Hojjat
- From the Division of Neuroradiology (E.M.F., J.K., R.I.A., S.-P.H., S.P.S., L.Z.), Department of Medical Imaging, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - S P Symons
- From the Division of Neuroradiology (E.M.F., J.K., R.I.A., S.-P.H., S.P.S., L.Z.), Department of Medical Imaging, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - L Zhang
- From the Division of Neuroradiology (E.M.F., J.K., R.I.A., S.-P.H., S.P.S., L.Z.), Department of Medical Imaging, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, Ontario, Canada
| | - M Wintermark
- Division of Neuroradiology (M.W.), Department of Radiology, Stanford University, California
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1064
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Bang OY, Goyal M, Liebeskind DS. Collateral Circulation in Ischemic Stroke: Assessment Tools and Therapeutic Strategies. Stroke 2015; 46:3302-9. [PMID: 26451027 DOI: 10.1161/strokeaha.115.010508] [Citation(s) in RCA: 179] [Impact Index Per Article: 19.9] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/19/2015] [Accepted: 09/01/2015] [Indexed: 12/22/2022]
Affiliation(s)
- Oh Young Bang
- From the Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea (O.Y.B.); Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G.); and Neurovascular Imaging Research Core and Department of Neurology, Comprehensive Stroke Center, Geffen School of Medicine, University of California, Los Angeles (D.S.L.).
| | - Mayank Goyal
- From the Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea (O.Y.B.); Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G.); and Neurovascular Imaging Research Core and Department of Neurology, Comprehensive Stroke Center, Geffen School of Medicine, University of California, Los Angeles (D.S.L.)
| | - David S Liebeskind
- From the Department of Neurology, Samsung Medical Center, Sungkyunkwan University, Seoul, South Korea (O.Y.B.); Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada (M.G.); and Neurovascular Imaging Research Core and Department of Neurology, Comprehensive Stroke Center, Geffen School of Medicine, University of California, Los Angeles (D.S.L.)
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1065
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Yoon W, Kim SK, Heo TW, Baek BH, Lee YY, Kang HK. Predictors of Good Outcome After Stent-Retriever Thrombectomy in Acute Basilar Artery Occlusion. Stroke 2015; 46:2972-5. [DOI: 10.1161/strokeaha.115.010840] [Citation(s) in RCA: 78] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2015] [Accepted: 08/04/2015] [Indexed: 11/16/2022]
Affiliation(s)
- Woong Yoon
- From the Department of Radiology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, South Korea
| | - Seul Kee Kim
- From the Department of Radiology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, South Korea
| | - Tae Wook Heo
- From the Department of Radiology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, South Korea
| | - Byung Hyun Baek
- From the Department of Radiology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, South Korea
| | - Yun Young Lee
- From the Department of Radiology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, South Korea
| | - Heoung Keun Kang
- From the Department of Radiology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, South Korea
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1066
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Yan S, Liu K, Tong L, Yu Y, Zhang S, Lou M. Different risk factors for poor outcome between patients with positive and negative susceptibility vessel sign. J Neurointerv Surg 2015; 8:1001-5. [DOI: 10.1136/neurintsurg-2015-011999] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2015] [Accepted: 09/04/2015] [Indexed: 11/04/2022]
Abstract
PurposeThe absence of the susceptibility vessel sign (negative SVS) on gradient-recalled echo or susceptibility-weighted imaging (SWI) in thrombolytic therapy has not been well studied. Since positive and negative SVS may have different components, we aimed to investigate the difference in risk factors for clinical outcome between patients with positive and negative SVS.MethodsWe retrospectively examined clinical and imaging data from 85 consecutive patients with acute ischemic stroke with middle cerebral artery occlusion who underwent SWI before intravenous thrombolysis (IVT). We then examined the predictors of negative SVS and the risk factors for a poor outcome (defined as modified Rankin Scale score ≥3) 3 months after IVT in subgroup analysis.ResultsMultivariate regression analysis indicated that previous antiplatelet use (OR 0.076; 95% CI 0.007 to 0.847; p=0.036) and shorter time from onset to treatment (OR 1.051; 95% CI 1.003 to 1.102; p=0.037) were inversely associated with poor outcome in patients with negative SVS, while higher baseline National Institutes of Health Stroke Scale (NIHSS) score was associated with poor outcome in patients with positive SVS (OR 1.222; 95% CI 1.084 to 1.377; p=0.001).ConclusionsThe risk factors for clinical outcome after IVT in patients with negative SVS may differ from those with positive SVS.
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1067
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Liebeskind DS. Innovative Interventional and Imaging Registries: Precision Medicine in Cerebrovascular Disorders. INTERVENTIONAL NEUROLOGY 2015; 4:5-17. [PMID: 26600792 DOI: 10.1159/000438773] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
BACKGROUND Precision medicine in cerebrovascular disorders may be greatly advanced by the use of innovative interventional and imaging-intensive registries. Registries have remained subsidiary to randomized controlled trials, yet vast opportunities exist to leverage big data in stroke. SUMMARY This overview builds upon the rationale for innovative, imaging-intensive interventional registries as a pivotal step in realizing precision medicine for several cerebrovascular disorders. Such enhanced registries may serve as a model for expansion of our translational research pipeline to fully leverage the role of phase IV investigations. The scope and role of registries in precision medicine are considered, followed by a review on the history of stroke and interventional registries, data considerations, critiques or barriers to such initiatives, and the potential modernization of registry methods into efficient, searchable, imaging-intensive resources that simultaneously offer clinical, research and educational added value. KEY MESSAGES Recent advances in technology, informatics and endovascular stroke therapies converge to provide an exceptional opportunity for registries to catapult further progress. There is now a tremendous opportunity to deploy registries in acute stroke, intracranial atherosclerotic disease and carotid disease where other clinical trials leave questions unanswered. Unlike prior registries, imaging-intensive and modernized methods may leverage current technological capabilities around the world to efficiently address key objectives and provide added clinical, research and educational value.
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Affiliation(s)
- David S Liebeskind
- Neurovascular Imaging Research Core, University of California, Los Angeles, and Comprehensive Stroke Center and Department of Neurology, Geffen School of Medicine at the University of California, Los Angeles, Los Angeles, Calif., USA
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1068
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Jung C, Yoon W, Ahn SJ, Choi BS, Kim JH, Suh SH. The Revascularization Scales Dilemma: Is It Right to Apply the Treatment in Cerebral Ischemia Scale in Posterior Circulation Stroke? AJNR Am J Neuroradiol 2015; 37:285-9. [PMID: 26381554 DOI: 10.3174/ajnr.a4529] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 07/22/2015] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND PURPOSE Although various revascularization scales are used in the angiographic evaluation of acute ischemic stroke, observer reliability tests of these scales have been rarely performed for posterior circulation stroke. We aimed to evaluate inter- and intraobserver variability of 2 scales, the modified Treatment in Cerebral Ischemia and the Arterial Occlusive Lesion, in posterior circulation stroke. MATERIALS AND METHODS Three independent readers interpreted pre- and postthrombolytic angiographies of 62 patients with posterior circulation stroke by using the modified Treatment in Cerebral Ischemia and Arterial Occlusive Lesion scales. The κ statistic was used to measure observer agreement for both scales, and κ > 0.6 was considered substantial agreement. RESULTS For the Arterial Occlusive Lesion scale, inter- and intraobserver agreement was >0.6. While intraobserver agreement of the modified Treatment in Cerebral Ischemia scale was >0.6 except for 1 reader, interobserver agreement was lower in dichotomized and original scales. In 49 cases with solely basilar artery occlusion, inter- and intraobserver agreement of both scales was similar to that in all 62 patients with posterior circulation stroke. In 2 consecutive readings, there was a significant decrease in the proportion of mTICI 2a reads (22.58% in the first versus 13.44% in the second session, P < .03) and a reciprocal increase in the sum of proportions for modified Treatment in Cerebral Ischemia 2b and modified Treatment in Cerebral Ischemia 3 reads (62.37% in the first versus 72.58% in the second session, P < .046). CONCLUSIONS In angiographic assessment of posterior circulation stroke, inter- and intraobserver agreement for the Arterial Occlusive Lesion scale was reliable, while the modified Treatment in Cerebral Ischemia failed to achieve substantial interobserver agreement. The clinical impact of this result needs to be validated in future studies.
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Affiliation(s)
- C Jung
- From the Department of Radiology (C.J., B.S.C., J.H.K.), Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - W Yoon
- Department of Radiology (W.Y.), Chonnam National University Medical School, Gwangju, Korea
| | - S J Ahn
- Department of Radiology (S.J.A., S.H.S.), Gangnam Severance Hospital, Yonsei University, Seoul, Korea
| | - B S Choi
- From the Department of Radiology (C.J., B.S.C., J.H.K.), Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - J H Kim
- From the Department of Radiology (C.J., B.S.C., J.H.K.), Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam, Korea
| | - S H Suh
- Department of Radiology (S.J.A., S.H.S.), Gangnam Severance Hospital, Yonsei University, Seoul, Korea Severance Institute of Vascular and Metabolic Research (S.H.S.), Yonsei University College of Medicine, Seoul, Korea.
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1069
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Haussen DC, Rebello LC, Nogueira RG. Optimizating Clot Retrieval in Acute Stroke: The Push and Fluff Technique for Closed-Cell Stentrievers. Stroke 2015; 46:2838-42. [PMID: 26374483 DOI: 10.1161/strokeaha.115.010044] [Citation(s) in RCA: 61] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2015] [Accepted: 07/30/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We aimed to investigate the safety and efficacy of the Push and Fluff technique (PFT) as compared with the standard unsheathing technique for closed-cell stent retrievers in acute ischemic stroke. METHODS Acute ischemic stroke thrombectomy database was analyzed (September 2010 to January 2015) with the Trevo Retriever as a primary strategy. The PFT was compared with our internal standard unsheathing technique and with the Trevo Versus Merci Retrievers for Thrombectomy Revascularization of Large Vessel Occlusions in Acute Ischemic Stroke 2 (TREVO2) trial. Additionally, a silicon flow model was used to compare cell size/configuration, wall apposition/device diameter, and degree of foreshortening/device length across the 2 techniques. RESULTS One hundred fifty-one out of 662 patients qualified for the study. The PFT (n=71) was associated with higher rates of first-pass reperfusion (54% versus 35%, P=0.03; 54% versus 32.6%, P<0.01), lower number of passes (1.3±0.8 versus 1.8±1.0, P<0.01; 1.7±1.0 versus 2.4±1.6, P<0.01), and higher rates of modified treatment in cerebral ischemia-3 reperfusion (58% versus 40%, P=0.03; 58% versus 14%, P<0.01) as compared with the standard unsheathing technique (n=81) and the TREVO2 Trevo arm (n=88), respectively. No differences in hemorrhagic complications were observed across the groups. The in vitro model indicated that, compared with standard unsheathing technique, PFT resulted in improved wall apposition (device diameter, 75% larger) and cell size (mean area, 51% larger) at the cost of a mild degree of foreshortening (25% length reduction). CONCLUSIONS The PFT is safe and leads to optimization of wall apposition and cell size/configuration, resulting in higher chances of first-pass reperfusion, lower number of passes, and better rates of complete reperfusion.
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Affiliation(s)
- Diogo C Haussen
- From the Emory University School of Medicine/Marcus Stroke and Neuroscience Center-Grady Memorial Hospital, Atlanta, GA
| | - Leticia C Rebello
- From the Emory University School of Medicine/Marcus Stroke and Neuroscience Center-Grady Memorial Hospital, Atlanta, GA
| | - Raul G Nogueira
- From the Emory University School of Medicine/Marcus Stroke and Neuroscience Center-Grady Memorial Hospital, Atlanta, GA.
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1070
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Lobsien D, Gawlitza M, Schaudinn A, Schob S, Hobohm C, Fritzsch D, Quäschling U, Hoffmann KT, Friedrich B. Mechanical thrombectomy versus systemic thrombolysis in MCA stroke: a distance to thrombus-based outcome analysis. J Neurointerv Surg 2015; 8:878-82. [PMID: 26346459 DOI: 10.1136/neurintsurg-2015-011964] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2015] [Accepted: 08/15/2015] [Indexed: 01/29/2023]
Abstract
BACKGROUND Acute ischemic stroke due to occlusion of the middle cerebral artery (MCA) has a poor outcome. The distance to thrombus (DT) from the carotid T can predict the outcome after intravenous thrombolysis (IVT). With a DT <16 mm, fewer than 50% of patients treated with IVT have a favorable outcome. OBJECTIVE To compare stent retriever-based endovascular mechanical thrombectomy (MT) plus additional IVT (IVT-MT) with IVT alone. MATERIALS AND METHODS Patients with MCA occlusion proved by CT angiography with a DT <16 mm, treated with either IVT alone or with stent retriever-based endovascular IVT-MT, were included in this study. Changes in National Institutes of Health Stroke Scale (NIHSS), the 7-day NIHSS, and the 90-day modified Rankin Scale (mRS) scores were analyzed by treatment modality. RESULTS Of 621 patients, 87 fulfilled all inclusion criteria. Fifty-nine patients were treated with IVT and 28 with IVT-MT. Although patients treated with IVT-MT had had significantly more severe strokes than those treated with IVT alone (initial NIHSS 16 (7-18) vs 14 (5-22); p=0.032), both the short- and long-term outcomes were significantly better in this patient group (NIHSS improvement on day 7: 10.9±6.3 vs 6.7±6.7; p=0.008/90-day mRS: 2 (0.75-2.5) vs 4 (2-6); p=0.003). CONCLUSIONS In patients with an acute MCA occlusion and a DT <16 mm, IVT-MT leads to a significantly better outcome than in patients treated with IVT alone.
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Affiliation(s)
- Donald Lobsien
- Department of Neuroradiology, University Hospital Leipzig, Leipzig, Germany
| | - Matthias Gawlitza
- Department of Neuroradiology, University Hospital Leipzig, Leipzig, Germany
| | - Alexander Schaudinn
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig, Germany
| | - Stefan Schob
- Department of Neuroradiology, University Hospital Leipzig, Leipzig, Germany
| | - Carsten Hobohm
- Department of Neurology, University Hospital Leipzig, Leipzig, Germany
| | - Dominik Fritzsch
- Department of Neuroradiology, University Hospital Leipzig, Leipzig, Germany
| | - Ulf Quäschling
- Department of Neuroradiology, University Hospital Leipzig, Leipzig, Germany
| | | | - Benjamin Friedrich
- Department of Diagnostic and Interventional Radiology, University Hospital Leipzig, Leipzig, Germany
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1071
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Kim SK, Yoon W, Kim TS, Kim HS, Heo TW, Park MS. Histologic Analysis of Retrieved Clots in Acute Ischemic Stroke: Correlation with Stroke Etiology and Gradient-Echo MRI. AJNR Am J Neuroradiol 2015; 36:1756-62. [PMID: 26159515 PMCID: PMC7968760 DOI: 10.3174/ajnr.a4402] [Citation(s) in RCA: 151] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2014] [Accepted: 02/06/2015] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE It is unclear whether clot composition analysis is helpful to predict a stroke mechanism in acute large vessel occlusion. In addition, the relationship between early vessel signs on imaging studies and clot compositions has been poorly understood. The purpose of this study was to elucidate the relationship between clot composition and stroke etiology following mechanical thrombectomy and to investigate the effect of varied clot compositions on gradient-echo MR imaging of clots. MATERIALS AND METHODS Histopathologic analysis of retrieved clots from 37 patients with acute MCA occlusion was performed. Patients underwent gradient-echo imaging before endovascular therapy. Retrieved clots underwent semiquantitative proportion analysis to quantify red blood cells, fibrin, platelets, and white blood cells by area. Correlations between clot compositions and stroke subtypes and susceptibility vessel signs on gradient-echo imaging were assessed. RESULTS Stroke etiology was classified as cardioembolism in 22 patients (59.4%), large-artery atherosclerosis in 8 (21.6%), and undetermined in 7 (18.9%). The clots from cardioembolism had a significantly higher proportion of red blood cells (37.8% versus 16.9%, P = .031) and a lower proportion of fibrin (32.3% versus 48.5%, P = .044) compared with those from large-artery atherosclerosis. The proportion of red blood cells was significantly higher in clots with a susceptibility vessel sign than in those without it (48.0% versus 1.9%, P < .001), whereas the proportions of fibrin (26.4% versus 57.0%, P < .001) and platelets (22.6% versus 36.9%, P = .011) were significantly higher in clots without a susceptibility vessel sign than those with it. CONCLUSIONS The histologic composition of clots retrieved from cerebral arteries in patients with acute stroke differs between those with cardioembolism and large-artery atherosclerosis. In addition, a susceptibility vessel sign on gradient-echo imaging is strongly associated with a high proportion of red blood cells and a low proportion of fibrin and platelets in retrieved clots.
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Affiliation(s)
- S K Kim
- From the Departments of Radiology (S.K.K., W.Y., T.W.H.)
| | - W Yoon
- From the Departments of Radiology (S.K.K., W.Y., T.W.H.)
| | | | | | - T W Heo
- From the Departments of Radiology (S.K.K., W.Y., T.W.H.)
| | - M S Park
- Neurology (M.S.P.), Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Republic of Korea
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1072
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Klinger-Gratz PP, Schroth G, Gralla J, Jung S, Weisstanner C, Verma RK, Mordasini P, Kellner-Weldon F, Hsieh K, Heldner MR, Fischer U, Arnold M, Mattle HP, El-Koussy M. Protected stent retriever thrombectomy prevents iatrogenic emboli in new vascular territories. Neuroradiology 2015; 57:1045-54. [PMID: 26319999 PMCID: PMC4602059 DOI: 10.1007/s00234-015-1583-8] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2015] [Accepted: 08/19/2015] [Indexed: 01/19/2023]
Abstract
Introduction Diagnostic tools to show emboli reliably and protection techniques against embolization when employing stent retrievers are necessary to improve endovascular stroke therapy. The aim of the present study was to investigate iatrogenic emboli using susceptibility-weighted imaging (SWI) in an open series of patients who had been treated with stent retriever thrombectomy using emboli protection techniques. Methods Patients with anterior circulation stroke examined with MRI before and after stent retriever thrombectomy were assessed for iatrogenic embolic events. Thrombectomy was performed in flow arrest and under aspiration using a balloon-mounted guiding catheter, a distal access catheter, or both. Results In 13 of 57 patients (22.8 %) post-interventional SWI sequences detected 16 microemboli. Three of them were associated with small ischemic lesions on diffusion-weighted imaging (DWI). None of the microemboli were located in a new vascular territory, none showed clinical signs, and all 13 patients have been rated as Thrombolysis in Cerebral Infarction (TICI) 2b (n = 3) or 3 (n = 10). Retrospective reevaluation of the digital subtraction angiography (DSA) detected discrete flow stagnation nearby the iatrogenic microemboli in four patients with a positive persistent collateral sign in one. Conclusion Our study demonstrates two things: First, SWI seems to be more sensitive to detect emboli than DWI and DSA and, second, proximal or distal protected stent retriever thrombectomy seems to prevent iatrogenic embolization into new vascular territories during retraction of the thrombus, but not downstream during mobilization of the thrombus. Both techniques should be investigated and refined further.
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Affiliation(s)
- Pascal P Klinger-Gratz
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Freiburgstrasse 10, Bern University Hospital and University of Bern, 3010, Bern, Switzerland.,Department of Radiology, University of Basel, Basel, Switzerland
| | - Gerhard Schroth
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Freiburgstrasse 10, Bern University Hospital and University of Bern, 3010, Bern, Switzerland.
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Freiburgstrasse 10, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Simon Jung
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Freiburgstrasse 10, Bern University Hospital and University of Bern, 3010, Bern, Switzerland.,Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Christian Weisstanner
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Freiburgstrasse 10, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Rajeev K Verma
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Freiburgstrasse 10, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Pasquale Mordasini
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Freiburgstrasse 10, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Frauke Kellner-Weldon
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Freiburgstrasse 10, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Kety Hsieh
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Freiburgstrasse 10, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Heinrich P Mattle
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
| | - Marwan El-Koussy
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Freiburgstrasse 10, Bern University Hospital and University of Bern, 3010, Bern, Switzerland
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1073
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Kabbasch C, Mpotsaris A, Chang DH, Hiß S, Dorn F, Behme D, Onur O, Liebig T. Mechanical thrombectomy with the Trevo ProVue device in ischemic stroke patients: does improved visibility translate into a clinical benefit? J Neurointerv Surg 2015; 8:778-82. [PMID: 26276075 DOI: 10.1136/neurintsurg-2015-011861] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2015] [Accepted: 07/22/2015] [Indexed: 11/04/2022]
Abstract
PURPOSE To investigate the efficacy and safety of the Trevo ProVue (TPV) stent retriever in stroke patients with large artery occlusions, with particular attention to the full structural radiopacity of the TPV. MATERIALS AND METHODS Case files and images of TPV treatments were reviewed for clinical and technical outcome data, including revascularization rates, device and procedure related complications, and outcome at discharge and after 90 days. RESULTS 76 patients were treated with TPV. Mean National Institutes of Health Stroke Scale (NIHSS) score was 18 and 68% had additional intravenous thrombolysis. 63 occlusions were in the anterior circulation: 44 M1 (58%), 8 M2 (11%), 8 internal carotid artery-terminus (11%), 2 internal carotid artery- left (3%), 1 A2 (1%), and 13 vertebrobasilar (17%). 58 of 76 (76%) were solely treated with TPV; the remainder were treated with additional stent retrievers. Mean number of passes in TPV only cases was 2.2 (SD 1.2). In rescue cases, 3.2 (SD 2.2) passes were attempted with the TPV followed by 2.6 rescue device passes (SD 2). TPV related adverse events occurred in 4/76 cases (5%) and procedural events in 6/76 cases (8%). Mean procedural duration was 64 min (SD 42). Thrombolysis in Cerebral Infarction (TICI) 2b/3 recanalization was achieved in 69/76 patients (91%), including 50% TICI 3. Of 56 survivors (74%), 37 (49%) showed a favorable outcome at 90 days (Solitaire With the Intention for Thrombectomy trial criteria), statistically associated with age, baseline NIHSS, onset to revascularization time, and TICI 2b-3 reperfusion. TPV radiopacity allowed for visual feedback, changing the methodology of stent retriever use in 44/76 cases (58%). CONCLUSIONS Neurothrombectomy with TPV is feasible, effective, and safe. The recanalization rate compares favorably with reported data in the literature. Improved structural radiopacity may facilitate neurothrombectomy or influence the course of action during retrieval.
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Affiliation(s)
- Christoph Kabbasch
- Department of Radiology and Neuroradiology, University Hospital of Cologne, Cologne, Germany
| | - Anastasios Mpotsaris
- Department of Radiology and Neuroradiology, University Hospital of Cologne, Cologne, Germany
| | - De-Hua Chang
- Department of Radiology and Neuroradiology, University Hospital of Cologne, Cologne, Germany
| | - Sonja Hiß
- Department of Radiology and Neuroradiology, University Hospital of Cologne, Cologne, Germany
| | - Franziska Dorn
- Department of Radiology and Neuroradiology, University Hospital of Cologne, Cologne, Germany
| | - Daniel Behme
- Department of Neuroradiology, University Medical Center Goettingen, Goettingen, Germany
| | - Oezguer Onur
- Department of Neurology, University Hospital of Cologne, Cologne, Germany
| | - Thomas Liebig
- Department of Radiology and Neuroradiology, University Hospital of Cologne, Cologne, Germany
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1074
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Distance to thrombus on MR angiography predicts outcome of middle cerebral artery occlusion treated with IV thrombolysis. Neuroradiology 2015; 57:991-7. [DOI: 10.1007/s00234-015-1558-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Accepted: 07/01/2015] [Indexed: 10/23/2022]
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1075
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Yan S, Liu K, Cao J, Liebeskind DS, Lou M. "Sudden Drop" in Blood Pressure is Associated With Recanalization After Thrombolysis. Medicine (Baltimore) 2015. [PMID: 26222844 PMCID: PMC4554120 DOI: 10.1097/md.0000000000001132] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
We aim to investigate whether the phenomenon of "sudden drop" in blood pressure (BP) within the first 2 hours is associated with vessel recanalization.We retrospectively examined clinical and imaging data from a consecutive series of patients with stroke with large vessel occlusion treated with intravenous thrombolysis (IVT). BP was monitored every 15 minutes during the first 2 hours, then every 30 minutes for 6 hours, and then every hour for 16 hours.We observed the phenomenon of "sudden drop" in systolic BP (≥20 mm Hg) in 82 (50.9%) patients in the first 2 hours and vessel recanalization in 87 (54.0%) patients 24 hours after treatment. This phenomenon was independently associated with recanalization (odds ratio 2.100; 95% confidence interval: 1.085-4.062; P = 0.028) after adjusting for the history of atrial fibrillation, coronary heart disease, and hypertension.The phenomenon of "sudden drop" in systolic BP with 20 mm Hg or greater between 2 continuous measurements within the first 2 hours is associated with recanalization after IVT in patients with large vessel occlusion, especially for middle cerebral artery occlusion.
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Affiliation(s)
- Shenqiang Yan
- From the Department of Neurology (SY, KL, JC, ML), Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, China; and University of California-Los Angeles Stroke Center (DSL), Los Angeles, California
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1076
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Kim JM, Park KY, Lee WJ, Byun JS, Kim JK, Park MS, Ahn SW, Shin HW. The cortical contrast accumulation from brain computed tomography after endovascular treatment predicts symptomatic hemorrhage. Eur J Neurol 2015; 22:1453-8. [PMID: 26130213 DOI: 10.1111/ene.12764] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 05/07/2015] [Indexed: 11/27/2022]
Abstract
BACKGROUND AND PURPOSE The prognostic value of contrast accumulation from non-contrast brain computed tomography taken immediately after endovascular reperfusion treatment in acute ischaemic stroke patients to predict symptomatic hemorrhage was studied. METHODS Between July 2007 and August 2014, acute anterior circulation ischaemic stroke patients who were treated by intra-arterial thrombolysis or thrombectomy were included. Contrast accumulation was defined as a high attenuation area from non-contrast brain computed tomography immediately taken after endovascular reperfusion treatment, and patients were categorized into three groups according to the presence and location of contrast: (i) negative, (ii) cortical involvement and (iii) non-cortical involvement. The rates of symptomatic hemorrhage after 24 h and functional outcome at discharge were compared between patients with and without cortical involvement. RESULTS Of 64 patients who were treated by endovascular intervention, contrast accumulation was detected in 56, including 33 patients with cortical involvement and 23 patients without cortical involvement. The cortical involvement pattern was more frequently associated with symptomatic hemorrhage (13 vs. 1 patient, P = 0.003) and with grave outcome at discharge with modified Rankin Scale 5 or 6 (14 vs. 4, P = 0.048) than the non-cortical involvement group. Multivariate logistic regression analysis including initial collateral status and occlusion site disclosed that cortical involvement pattern independently predicted symptomatic hemorrhage after endovascular treatment (odds ratio 19.0, confidence interval 1.6-227.6, P = 0.020). CONCLUSION Our study provides evidence that the cortical involvement of contrast accumulation is associated with symptomatic hemorrhage after endovascular reperfusion treatment.
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Affiliation(s)
- J M Kim
- Department of Neurology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - K Y Park
- Department of Neurology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - W J Lee
- Department of Neuroradiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - J S Byun
- Department of Neuroradiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - J K Kim
- Department of Neuroradiology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - M S Park
- Department of Neurology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - S W Ahn
- Department of Neurology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
| | - H W Shin
- Department of Neurology, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea
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1077
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Powers WJ, Derdeyn CP, Biller J, Coffey CS, Hoh BL, Jauch EC, Johnston KC, Johnston SC, Khalessi AA, Kidwell CS, Meschia JF, Ovbiagele B, Yavagal DR. 2015 American Heart Association/American Stroke Association Focused Update of the 2013 Guidelines for the Early Management of Patients With Acute Ischemic Stroke Regarding Endovascular Treatment: A Guideline for Healthcare Professionals From the American Heart Association/American Stroke Association. Stroke 2015; 46:3020-35. [PMID: 26123479 DOI: 10.1161/str.0000000000000074] [Citation(s) in RCA: 1510] [Impact Index Per Article: 167.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE The aim of this guideline is to provide a focused update of the current recommendations for the endovascular treatment of acute ischemic stroke. When there is overlap, the recommendations made here supersede those of previous guidelines. METHODS This focused update analyzes results from 8 randomized, clinical trials of endovascular treatment and other relevant data published since 2013. It is not intended to be a complete literature review from the date of the previous guideline publication but rather to include pivotal new evidence that justifies changes in current recommendations. Members of the writing committee were appointed by the American Heart Association/American Stroke Association Stroke Council's Scientific Statement Oversight Committee and the American Heart Association/American Stroke Association Manuscript Oversight Committee. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Recommendations follow the American Heart Association/American Stroke Association methods of classifying the level of certainty of the treatment effect and the class of evidence. Prerelease review of the draft guideline was performed by 6 expert peer reviewers and by the members of the Stroke Council Scientific Statement Oversight Committee and Stroke Council Leadership Committee. RESULTS Evidence-based guidelines are presented for the selection of patients with acute ischemic stroke for endovascular treatment, for the endovascular procedure, and for systems of care to facilitate endovascular treatment. CONCLUSIONS Certain endovascular procedures have been demonstrated to provide clinical benefit in selected patients with acute ischemic stroke. Systems of care should be organized to facilitate the delivery of this care.
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1078
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Schellinger PD, Alexandrov AV, Barreto AD, Demchuk AM, Tsivgoulis G, Kohrmann M, Alleman J, Howard V, Howard G, Alexandrov AW, Brandt G, Molina CA. Combined Lysis of Thrombus with Ultrasound and Systemic Tissue Plasminogen Activator for Emergent Revascularization in Acute Ischemic Stroke (Clotbust-ER): Design and Methodology of a Multinational Phase 3 Trial. Int J Stroke 2015; 10:1141-8. [DOI: 10.1111/ijs.12536] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2015] [Accepted: 04/22/2015] [Indexed: 11/26/2022]
Abstract
Background We designed a Phase 3 clinical trial to determine the safety and efficacy of adding transcranial ultrasound using an operator-independent headframe to recombinant tissue-plasminogen-activator for the treatment of acute ischemic stroke. Methods Combined lysis of thrombus with ultrasound and systemic tissue-plasminogen-activator for emergent revascularization in acute ischemic stroke is a randomized, double-blind, placebo-controlled clinical trial that will enroll subjects with the following main inclusion criteria: less than 4·5 hours from symptom onset (three-hours in US and Canada), age 18–80 years, baseline National Institutes of Health Stroke Scale score ≥ 10, and premorbid modified-Rankin-score of 0–1, eligibility for full dose recombinant tissue-plasminogen-activator. Subjects will receive two-hours of 2-MHz pulsed wave transcranial ultrasound (target group) or sham ultrasound (control group). The projected sample size is approximately 824 subjects. Results The primary endpoint, based on intention-to-treat criteria of patients enrolled within three-hours of symptom onset is the comparison between target and control groups of modified-Rankin-score scores at day 90 poststroke assessed using the proportional odds method. The study will have two planned interim analyses after approximately one-third and two-thirds of subjects have reached the 90-day modified-Rankin-score evaluation. Safety outcomes are symptomatic intracranial hemorrhage within 24 h and an overall analysis of adverse events. Conclusions Since intravenous recombinant tissue-plasminogen-activator remains the only medical therapy to reverse ischemic stroke applicable in the emergency department, our trial will determine if the additional use of transcranial ultrasound improves functional outcomes in patients with severe acute ischemic stroke (NCT#01098981).
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Affiliation(s)
- Peter D. Schellinger
- Departments of Neurology and Geriatry, Johannes Wesling Medical Center, Minden, Germany
| | - Andrei V. Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Andrew D. Barreto
- Department of Neurology, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Andrew M. Demchuk
- Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Georgios Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
- Second Department of Neurology, ‘Attikon’ University Hospital, School of Medicine, University of Athens, Athens, Greece
| | - Martin Kohrmann
- Department of Neurology, University Hospital Erlangen, Erlangen, Germany
| | | | | | - George Howard
- University of Alabama at Birmingham, Birmingham, AL, UK
| | - Anne W. Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
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1079
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Saver JL, Goyal M, Bonafe A, Diener HC, Levy EI, Pereira VM, Albers GW, Cognard C, Cohen DJ, Hacke W, Jansen O, Jovin TG, Mattle HP, Nogueira RG, Siddiqui AH, Yavagal DR, Baxter BW, Devlin TG, Lopes DK, Reddy VK, du Mesnil de Rochemont R, Singer OC, Jahan R. Stent-retriever thrombectomy after intravenous t-PA vs. t-PA alone in stroke. N Engl J Med 2015; 372:2285-95. [PMID: 25882376 DOI: 10.1056/nejmoa1415061] [Citation(s) in RCA: 3573] [Impact Index Per Article: 397.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Among patients with acute ischemic stroke due to occlusions in the proximal anterior intracranial circulation, less than 40% regain functional independence when treated with intravenous tissue plasminogen activator (t-PA) alone. Thrombectomy with the use of a stent retriever, in addition to intravenous t-PA, increases reperfusion rates and may improve long-term functional outcome. METHODS We randomly assigned eligible patients with stroke who were receiving or had received intravenous t-PA to continue with t-PA alone (control group) or to undergo endovascular thrombectomy with the use of a stent retriever within 6 hours after symptom onset (intervention group). Patients had confirmed occlusions in the proximal anterior intracranial circulation and an absence of large ischemic-core lesions. The primary outcome was the severity of global disability at 90 days, as assessed by means of the modified Rankin scale (with scores ranging from 0 [no symptoms] to 6 [death]). RESULTS The study was stopped early because of efficacy. At 39 centers, 196 patients underwent randomization (98 patients in each group). In the intervention group, the median time from qualifying imaging to groin puncture was 57 minutes, and the rate of substantial reperfusion at the end of the procedure was 88%. Thrombectomy with the stent retriever plus intravenous t-PA reduced disability at 90 days over the entire range of scores on the modified Rankin scale (P<0.001). The rate of functional independence (modified Rankin scale score, 0 to 2) was higher in the intervention group than in the control group (60% vs. 35%, P<0.001). There were no significant between-group differences in 90-day mortality (9% vs. 12%, P=0.50) or symptomatic intracranial hemorrhage (0% vs. 3%, P=0.12). CONCLUSIONS In patients receiving intravenous t-PA for acute ischemic stroke due to occlusions in the proximal anterior intracranial circulation, thrombectomy with a stent retriever within 6 hours after onset improved functional outcomes at 90 days. (Funded by Covidien; SWIFT PRIME ClinicalTrials.gov number, NCT01657461.).
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1080
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Bendszus M, Thomalla G, Knauth M, Hacke W, Bonekamp S, Fiehler J. Thrombectomy in patients ineligible for iv tPA (THRILL). Int J Stroke 2015; 10:950-5. [PMID: 26044962 DOI: 10.1111/ijs.12527] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2014] [Accepted: 03/29/2015] [Indexed: 11/28/2022]
Abstract
RATIONALE A relevant proportion of patients with acute ischemic stroke are ineligible for intravenous thrombolysis with recombinant tissue plasminogen activator. Mechanical thrombectomy offers a treatment alternative for these patients; however, only few data are available on its safety and efficacy. AIMS AND/OR HYPOTHESIS The aim of this study was to compare safety and efficacy of stent retrievers as device class with best medical care alone in acute stroke patients with large intracranial vessel occlusion in the anterior circulation who are not eligible for intravenous thrombolysis with recombinant tissue plasminogen activator up to eight-hours of symptom onset. DESIGN 'Thrombectomy in patients ineligible for iv tPA' is a prospective, open-label, blinded end-point, binational (Germany and Austria), two-arm, randomized, controlled, post-market study. STUDY OUTCOME(S) Primary end-point is the modified Rankin Score shift analysis 90 days (±14) after stroke. Secondary end-points are excellent neurological outcomes (modified Rankin Score ≤ 1), good neurological outcomes (modified Rankin Score ≤ 2 or National Institutes of Health Stroke Scale improvement ≥ 10), difference between predicted infarct volume and actual core infarct volume (computed tomography or magnetic resonance imaging) at 30 (±6) h post-ictus, successful recanalization (thrombolysis in cerebral infarction score 2b or 3), functional health status 90 (±14) days after stroke (European Quality of Life-5 Dimensions) as well as common safety end-points (adverse event, serious adverse event, symptomatic intracranial haemorrhage at 30 (±6) h, death, or dependency). DISCUSSION Whether mechanical thrombectomy in patients with acute ischemic stroke who are not eligible for intravenous thrombolysis with recombinant tissue plasminogen activator improves clinical outcomes is unclear. 'Thrombectomy in patients ineligible for iv tPA' may change clinical practice by providing evidence of an effective and safe treatment for such patients.
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Affiliation(s)
- Martin Bendszus
- Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf (UKE), Hamburg, Germany
| | - Michael Knauth
- Neuroradiology, University Medicine Goettingen, Goettingen, Germany
| | - Werner Hacke
- Neurology, Ruprecht-Karls-University of Heidelberg, Heidelberg, Germany
| | | | - Jens Fiehler
- Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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1081
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Liebeskind DS, Albers GW, Crawford K, Derdeyn CP, George MS, Palesch YY, Toga AW, Warach S, Zhao W, Brott TG, Sacco RL, Khatri P, Saver JL, Cramer SC, Wolf SL, Broderick JP, Wintermark M. Imaging in StrokeNet: Realizing the Potential of Big Data. Stroke 2015; 46:2000-6. [PMID: 26045600 DOI: 10.1161/strokeaha.115.009479] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2015] [Accepted: 05/13/2015] [Indexed: 01/07/2023]
Affiliation(s)
- David S Liebeskind
- From the Neurovascular Imaging Research Core (D.S.L.) and Department of Neurology, Comprehensive Stroke Center, Geffen School of Medicine (D.S.L., J.L.S.), University of California, Los Angeles; Departments of Neurology (G.W.A.) and Radiology (M.W.), Stanford University, Palo Alto, CA; Laboratory of Neuro Imaging, Institute for Neuroimaging and Informatics, Keck School of Medicine, University of Southern California, Los Angeles (K.C., A.W.T.); Departments of Neurology and Neurological Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (C.P.D.); Departments of Psychiatry, Radiology, and Neuroscience (M.S.G.) and Public Health Sciences (Y.Y.P., W.Z.), Medical University of South Carolina, Charleston; Ralph H Johnson VA Medical Center, Charleston, SC (M.S.G.); University of Texas Southwestern Medical Center, Austin (S.W.); Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.); Departments of Neurology, Public Health Sciences, Human Genetics, and Neurosurgery, Miller School of Medicine, University of Miami, FL (R.L.S.); Department of Neurology, University of Cincinnati, OH (P.K., J.P.B.); Department of Neurology, University of California, Irvine (S.C.C.); and Department of Rehabilitation Medicine, Emory University School of Medicine and Center for Visual and Cognitive Neurorehabilitation, Atlanta VA Medical Center, GA (S.L.W.).
| | - Gregory W Albers
- From the Neurovascular Imaging Research Core (D.S.L.) and Department of Neurology, Comprehensive Stroke Center, Geffen School of Medicine (D.S.L., J.L.S.), University of California, Los Angeles; Departments of Neurology (G.W.A.) and Radiology (M.W.), Stanford University, Palo Alto, CA; Laboratory of Neuro Imaging, Institute for Neuroimaging and Informatics, Keck School of Medicine, University of Southern California, Los Angeles (K.C., A.W.T.); Departments of Neurology and Neurological Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (C.P.D.); Departments of Psychiatry, Radiology, and Neuroscience (M.S.G.) and Public Health Sciences (Y.Y.P., W.Z.), Medical University of South Carolina, Charleston; Ralph H Johnson VA Medical Center, Charleston, SC (M.S.G.); University of Texas Southwestern Medical Center, Austin (S.W.); Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.); Departments of Neurology, Public Health Sciences, Human Genetics, and Neurosurgery, Miller School of Medicine, University of Miami, FL (R.L.S.); Department of Neurology, University of Cincinnati, OH (P.K., J.P.B.); Department of Neurology, University of California, Irvine (S.C.C.); and Department of Rehabilitation Medicine, Emory University School of Medicine and Center for Visual and Cognitive Neurorehabilitation, Atlanta VA Medical Center, GA (S.L.W.)
| | - Karen Crawford
- From the Neurovascular Imaging Research Core (D.S.L.) and Department of Neurology, Comprehensive Stroke Center, Geffen School of Medicine (D.S.L., J.L.S.), University of California, Los Angeles; Departments of Neurology (G.W.A.) and Radiology (M.W.), Stanford University, Palo Alto, CA; Laboratory of Neuro Imaging, Institute for Neuroimaging and Informatics, Keck School of Medicine, University of Southern California, Los Angeles (K.C., A.W.T.); Departments of Neurology and Neurological Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (C.P.D.); Departments of Psychiatry, Radiology, and Neuroscience (M.S.G.) and Public Health Sciences (Y.Y.P., W.Z.), Medical University of South Carolina, Charleston; Ralph H Johnson VA Medical Center, Charleston, SC (M.S.G.); University of Texas Southwestern Medical Center, Austin (S.W.); Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.); Departments of Neurology, Public Health Sciences, Human Genetics, and Neurosurgery, Miller School of Medicine, University of Miami, FL (R.L.S.); Department of Neurology, University of Cincinnati, OH (P.K., J.P.B.); Department of Neurology, University of California, Irvine (S.C.C.); and Department of Rehabilitation Medicine, Emory University School of Medicine and Center for Visual and Cognitive Neurorehabilitation, Atlanta VA Medical Center, GA (S.L.W.)
| | - Colin P Derdeyn
- From the Neurovascular Imaging Research Core (D.S.L.) and Department of Neurology, Comprehensive Stroke Center, Geffen School of Medicine (D.S.L., J.L.S.), University of California, Los Angeles; Departments of Neurology (G.W.A.) and Radiology (M.W.), Stanford University, Palo Alto, CA; Laboratory of Neuro Imaging, Institute for Neuroimaging and Informatics, Keck School of Medicine, University of Southern California, Los Angeles (K.C., A.W.T.); Departments of Neurology and Neurological Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (C.P.D.); Departments of Psychiatry, Radiology, and Neuroscience (M.S.G.) and Public Health Sciences (Y.Y.P., W.Z.), Medical University of South Carolina, Charleston; Ralph H Johnson VA Medical Center, Charleston, SC (M.S.G.); University of Texas Southwestern Medical Center, Austin (S.W.); Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.); Departments of Neurology, Public Health Sciences, Human Genetics, and Neurosurgery, Miller School of Medicine, University of Miami, FL (R.L.S.); Department of Neurology, University of Cincinnati, OH (P.K., J.P.B.); Department of Neurology, University of California, Irvine (S.C.C.); and Department of Rehabilitation Medicine, Emory University School of Medicine and Center for Visual and Cognitive Neurorehabilitation, Atlanta VA Medical Center, GA (S.L.W.)
| | - Mark S George
- From the Neurovascular Imaging Research Core (D.S.L.) and Department of Neurology, Comprehensive Stroke Center, Geffen School of Medicine (D.S.L., J.L.S.), University of California, Los Angeles; Departments of Neurology (G.W.A.) and Radiology (M.W.), Stanford University, Palo Alto, CA; Laboratory of Neuro Imaging, Institute for Neuroimaging and Informatics, Keck School of Medicine, University of Southern California, Los Angeles (K.C., A.W.T.); Departments of Neurology and Neurological Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (C.P.D.); Departments of Psychiatry, Radiology, and Neuroscience (M.S.G.) and Public Health Sciences (Y.Y.P., W.Z.), Medical University of South Carolina, Charleston; Ralph H Johnson VA Medical Center, Charleston, SC (M.S.G.); University of Texas Southwestern Medical Center, Austin (S.W.); Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.); Departments of Neurology, Public Health Sciences, Human Genetics, and Neurosurgery, Miller School of Medicine, University of Miami, FL (R.L.S.); Department of Neurology, University of Cincinnati, OH (P.K., J.P.B.); Department of Neurology, University of California, Irvine (S.C.C.); and Department of Rehabilitation Medicine, Emory University School of Medicine and Center for Visual and Cognitive Neurorehabilitation, Atlanta VA Medical Center, GA (S.L.W.)
| | - Yuko Y Palesch
- From the Neurovascular Imaging Research Core (D.S.L.) and Department of Neurology, Comprehensive Stroke Center, Geffen School of Medicine (D.S.L., J.L.S.), University of California, Los Angeles; Departments of Neurology (G.W.A.) and Radiology (M.W.), Stanford University, Palo Alto, CA; Laboratory of Neuro Imaging, Institute for Neuroimaging and Informatics, Keck School of Medicine, University of Southern California, Los Angeles (K.C., A.W.T.); Departments of Neurology and Neurological Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (C.P.D.); Departments of Psychiatry, Radiology, and Neuroscience (M.S.G.) and Public Health Sciences (Y.Y.P., W.Z.), Medical University of South Carolina, Charleston; Ralph H Johnson VA Medical Center, Charleston, SC (M.S.G.); University of Texas Southwestern Medical Center, Austin (S.W.); Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.); Departments of Neurology, Public Health Sciences, Human Genetics, and Neurosurgery, Miller School of Medicine, University of Miami, FL (R.L.S.); Department of Neurology, University of Cincinnati, OH (P.K., J.P.B.); Department of Neurology, University of California, Irvine (S.C.C.); and Department of Rehabilitation Medicine, Emory University School of Medicine and Center for Visual and Cognitive Neurorehabilitation, Atlanta VA Medical Center, GA (S.L.W.)
| | - Arthur W Toga
- From the Neurovascular Imaging Research Core (D.S.L.) and Department of Neurology, Comprehensive Stroke Center, Geffen School of Medicine (D.S.L., J.L.S.), University of California, Los Angeles; Departments of Neurology (G.W.A.) and Radiology (M.W.), Stanford University, Palo Alto, CA; Laboratory of Neuro Imaging, Institute for Neuroimaging and Informatics, Keck School of Medicine, University of Southern California, Los Angeles (K.C., A.W.T.); Departments of Neurology and Neurological Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (C.P.D.); Departments of Psychiatry, Radiology, and Neuroscience (M.S.G.) and Public Health Sciences (Y.Y.P., W.Z.), Medical University of South Carolina, Charleston; Ralph H Johnson VA Medical Center, Charleston, SC (M.S.G.); University of Texas Southwestern Medical Center, Austin (S.W.); Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.); Departments of Neurology, Public Health Sciences, Human Genetics, and Neurosurgery, Miller School of Medicine, University of Miami, FL (R.L.S.); Department of Neurology, University of Cincinnati, OH (P.K., J.P.B.); Department of Neurology, University of California, Irvine (S.C.C.); and Department of Rehabilitation Medicine, Emory University School of Medicine and Center for Visual and Cognitive Neurorehabilitation, Atlanta VA Medical Center, GA (S.L.W.)
| | - Steven Warach
- From the Neurovascular Imaging Research Core (D.S.L.) and Department of Neurology, Comprehensive Stroke Center, Geffen School of Medicine (D.S.L., J.L.S.), University of California, Los Angeles; Departments of Neurology (G.W.A.) and Radiology (M.W.), Stanford University, Palo Alto, CA; Laboratory of Neuro Imaging, Institute for Neuroimaging and Informatics, Keck School of Medicine, University of Southern California, Los Angeles (K.C., A.W.T.); Departments of Neurology and Neurological Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (C.P.D.); Departments of Psychiatry, Radiology, and Neuroscience (M.S.G.) and Public Health Sciences (Y.Y.P., W.Z.), Medical University of South Carolina, Charleston; Ralph H Johnson VA Medical Center, Charleston, SC (M.S.G.); University of Texas Southwestern Medical Center, Austin (S.W.); Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.); Departments of Neurology, Public Health Sciences, Human Genetics, and Neurosurgery, Miller School of Medicine, University of Miami, FL (R.L.S.); Department of Neurology, University of Cincinnati, OH (P.K., J.P.B.); Department of Neurology, University of California, Irvine (S.C.C.); and Department of Rehabilitation Medicine, Emory University School of Medicine and Center for Visual and Cognitive Neurorehabilitation, Atlanta VA Medical Center, GA (S.L.W.)
| | - Wenle Zhao
- From the Neurovascular Imaging Research Core (D.S.L.) and Department of Neurology, Comprehensive Stroke Center, Geffen School of Medicine (D.S.L., J.L.S.), University of California, Los Angeles; Departments of Neurology (G.W.A.) and Radiology (M.W.), Stanford University, Palo Alto, CA; Laboratory of Neuro Imaging, Institute for Neuroimaging and Informatics, Keck School of Medicine, University of Southern California, Los Angeles (K.C., A.W.T.); Departments of Neurology and Neurological Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (C.P.D.); Departments of Psychiatry, Radiology, and Neuroscience (M.S.G.) and Public Health Sciences (Y.Y.P., W.Z.), Medical University of South Carolina, Charleston; Ralph H Johnson VA Medical Center, Charleston, SC (M.S.G.); University of Texas Southwestern Medical Center, Austin (S.W.); Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.); Departments of Neurology, Public Health Sciences, Human Genetics, and Neurosurgery, Miller School of Medicine, University of Miami, FL (R.L.S.); Department of Neurology, University of Cincinnati, OH (P.K., J.P.B.); Department of Neurology, University of California, Irvine (S.C.C.); and Department of Rehabilitation Medicine, Emory University School of Medicine and Center for Visual and Cognitive Neurorehabilitation, Atlanta VA Medical Center, GA (S.L.W.)
| | - Thomas G Brott
- From the Neurovascular Imaging Research Core (D.S.L.) and Department of Neurology, Comprehensive Stroke Center, Geffen School of Medicine (D.S.L., J.L.S.), University of California, Los Angeles; Departments of Neurology (G.W.A.) and Radiology (M.W.), Stanford University, Palo Alto, CA; Laboratory of Neuro Imaging, Institute for Neuroimaging and Informatics, Keck School of Medicine, University of Southern California, Los Angeles (K.C., A.W.T.); Departments of Neurology and Neurological Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (C.P.D.); Departments of Psychiatry, Radiology, and Neuroscience (M.S.G.) and Public Health Sciences (Y.Y.P., W.Z.), Medical University of South Carolina, Charleston; Ralph H Johnson VA Medical Center, Charleston, SC (M.S.G.); University of Texas Southwestern Medical Center, Austin (S.W.); Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.); Departments of Neurology, Public Health Sciences, Human Genetics, and Neurosurgery, Miller School of Medicine, University of Miami, FL (R.L.S.); Department of Neurology, University of Cincinnati, OH (P.K., J.P.B.); Department of Neurology, University of California, Irvine (S.C.C.); and Department of Rehabilitation Medicine, Emory University School of Medicine and Center for Visual and Cognitive Neurorehabilitation, Atlanta VA Medical Center, GA (S.L.W.)
| | - Ralph L Sacco
- From the Neurovascular Imaging Research Core (D.S.L.) and Department of Neurology, Comprehensive Stroke Center, Geffen School of Medicine (D.S.L., J.L.S.), University of California, Los Angeles; Departments of Neurology (G.W.A.) and Radiology (M.W.), Stanford University, Palo Alto, CA; Laboratory of Neuro Imaging, Institute for Neuroimaging and Informatics, Keck School of Medicine, University of Southern California, Los Angeles (K.C., A.W.T.); Departments of Neurology and Neurological Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (C.P.D.); Departments of Psychiatry, Radiology, and Neuroscience (M.S.G.) and Public Health Sciences (Y.Y.P., W.Z.), Medical University of South Carolina, Charleston; Ralph H Johnson VA Medical Center, Charleston, SC (M.S.G.); University of Texas Southwestern Medical Center, Austin (S.W.); Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.); Departments of Neurology, Public Health Sciences, Human Genetics, and Neurosurgery, Miller School of Medicine, University of Miami, FL (R.L.S.); Department of Neurology, University of Cincinnati, OH (P.K., J.P.B.); Department of Neurology, University of California, Irvine (S.C.C.); and Department of Rehabilitation Medicine, Emory University School of Medicine and Center for Visual and Cognitive Neurorehabilitation, Atlanta VA Medical Center, GA (S.L.W.)
| | - Pooja Khatri
- From the Neurovascular Imaging Research Core (D.S.L.) and Department of Neurology, Comprehensive Stroke Center, Geffen School of Medicine (D.S.L., J.L.S.), University of California, Los Angeles; Departments of Neurology (G.W.A.) and Radiology (M.W.), Stanford University, Palo Alto, CA; Laboratory of Neuro Imaging, Institute for Neuroimaging and Informatics, Keck School of Medicine, University of Southern California, Los Angeles (K.C., A.W.T.); Departments of Neurology and Neurological Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (C.P.D.); Departments of Psychiatry, Radiology, and Neuroscience (M.S.G.) and Public Health Sciences (Y.Y.P., W.Z.), Medical University of South Carolina, Charleston; Ralph H Johnson VA Medical Center, Charleston, SC (M.S.G.); University of Texas Southwestern Medical Center, Austin (S.W.); Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.); Departments of Neurology, Public Health Sciences, Human Genetics, and Neurosurgery, Miller School of Medicine, University of Miami, FL (R.L.S.); Department of Neurology, University of Cincinnati, OH (P.K., J.P.B.); Department of Neurology, University of California, Irvine (S.C.C.); and Department of Rehabilitation Medicine, Emory University School of Medicine and Center for Visual and Cognitive Neurorehabilitation, Atlanta VA Medical Center, GA (S.L.W.)
| | - Jeffrey L Saver
- From the Neurovascular Imaging Research Core (D.S.L.) and Department of Neurology, Comprehensive Stroke Center, Geffen School of Medicine (D.S.L., J.L.S.), University of California, Los Angeles; Departments of Neurology (G.W.A.) and Radiology (M.W.), Stanford University, Palo Alto, CA; Laboratory of Neuro Imaging, Institute for Neuroimaging and Informatics, Keck School of Medicine, University of Southern California, Los Angeles (K.C., A.W.T.); Departments of Neurology and Neurological Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (C.P.D.); Departments of Psychiatry, Radiology, and Neuroscience (M.S.G.) and Public Health Sciences (Y.Y.P., W.Z.), Medical University of South Carolina, Charleston; Ralph H Johnson VA Medical Center, Charleston, SC (M.S.G.); University of Texas Southwestern Medical Center, Austin (S.W.); Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.); Departments of Neurology, Public Health Sciences, Human Genetics, and Neurosurgery, Miller School of Medicine, University of Miami, FL (R.L.S.); Department of Neurology, University of Cincinnati, OH (P.K., J.P.B.); Department of Neurology, University of California, Irvine (S.C.C.); and Department of Rehabilitation Medicine, Emory University School of Medicine and Center for Visual and Cognitive Neurorehabilitation, Atlanta VA Medical Center, GA (S.L.W.)
| | - Steven C Cramer
- From the Neurovascular Imaging Research Core (D.S.L.) and Department of Neurology, Comprehensive Stroke Center, Geffen School of Medicine (D.S.L., J.L.S.), University of California, Los Angeles; Departments of Neurology (G.W.A.) and Radiology (M.W.), Stanford University, Palo Alto, CA; Laboratory of Neuro Imaging, Institute for Neuroimaging and Informatics, Keck School of Medicine, University of Southern California, Los Angeles (K.C., A.W.T.); Departments of Neurology and Neurological Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (C.P.D.); Departments of Psychiatry, Radiology, and Neuroscience (M.S.G.) and Public Health Sciences (Y.Y.P., W.Z.), Medical University of South Carolina, Charleston; Ralph H Johnson VA Medical Center, Charleston, SC (M.S.G.); University of Texas Southwestern Medical Center, Austin (S.W.); Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.); Departments of Neurology, Public Health Sciences, Human Genetics, and Neurosurgery, Miller School of Medicine, University of Miami, FL (R.L.S.); Department of Neurology, University of Cincinnati, OH (P.K., J.P.B.); Department of Neurology, University of California, Irvine (S.C.C.); and Department of Rehabilitation Medicine, Emory University School of Medicine and Center for Visual and Cognitive Neurorehabilitation, Atlanta VA Medical Center, GA (S.L.W.)
| | - Steven L Wolf
- From the Neurovascular Imaging Research Core (D.S.L.) and Department of Neurology, Comprehensive Stroke Center, Geffen School of Medicine (D.S.L., J.L.S.), University of California, Los Angeles; Departments of Neurology (G.W.A.) and Radiology (M.W.), Stanford University, Palo Alto, CA; Laboratory of Neuro Imaging, Institute for Neuroimaging and Informatics, Keck School of Medicine, University of Southern California, Los Angeles (K.C., A.W.T.); Departments of Neurology and Neurological Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (C.P.D.); Departments of Psychiatry, Radiology, and Neuroscience (M.S.G.) and Public Health Sciences (Y.Y.P., W.Z.), Medical University of South Carolina, Charleston; Ralph H Johnson VA Medical Center, Charleston, SC (M.S.G.); University of Texas Southwestern Medical Center, Austin (S.W.); Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.); Departments of Neurology, Public Health Sciences, Human Genetics, and Neurosurgery, Miller School of Medicine, University of Miami, FL (R.L.S.); Department of Neurology, University of Cincinnati, OH (P.K., J.P.B.); Department of Neurology, University of California, Irvine (S.C.C.); and Department of Rehabilitation Medicine, Emory University School of Medicine and Center for Visual and Cognitive Neurorehabilitation, Atlanta VA Medical Center, GA (S.L.W.)
| | - Joseph P Broderick
- From the Neurovascular Imaging Research Core (D.S.L.) and Department of Neurology, Comprehensive Stroke Center, Geffen School of Medicine (D.S.L., J.L.S.), University of California, Los Angeles; Departments of Neurology (G.W.A.) and Radiology (M.W.), Stanford University, Palo Alto, CA; Laboratory of Neuro Imaging, Institute for Neuroimaging and Informatics, Keck School of Medicine, University of Southern California, Los Angeles (K.C., A.W.T.); Departments of Neurology and Neurological Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (C.P.D.); Departments of Psychiatry, Radiology, and Neuroscience (M.S.G.) and Public Health Sciences (Y.Y.P., W.Z.), Medical University of South Carolina, Charleston; Ralph H Johnson VA Medical Center, Charleston, SC (M.S.G.); University of Texas Southwestern Medical Center, Austin (S.W.); Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.); Departments of Neurology, Public Health Sciences, Human Genetics, and Neurosurgery, Miller School of Medicine, University of Miami, FL (R.L.S.); Department of Neurology, University of Cincinnati, OH (P.K., J.P.B.); Department of Neurology, University of California, Irvine (S.C.C.); and Department of Rehabilitation Medicine, Emory University School of Medicine and Center for Visual and Cognitive Neurorehabilitation, Atlanta VA Medical Center, GA (S.L.W.)
| | - Max Wintermark
- From the Neurovascular Imaging Research Core (D.S.L.) and Department of Neurology, Comprehensive Stroke Center, Geffen School of Medicine (D.S.L., J.L.S.), University of California, Los Angeles; Departments of Neurology (G.W.A.) and Radiology (M.W.), Stanford University, Palo Alto, CA; Laboratory of Neuro Imaging, Institute for Neuroimaging and Informatics, Keck School of Medicine, University of Southern California, Los Angeles (K.C., A.W.T.); Departments of Neurology and Neurological Surgery, Mallinckrodt Institute of Radiology, Washington University School of Medicine, St Louis, MO (C.P.D.); Departments of Psychiatry, Radiology, and Neuroscience (M.S.G.) and Public Health Sciences (Y.Y.P., W.Z.), Medical University of South Carolina, Charleston; Ralph H Johnson VA Medical Center, Charleston, SC (M.S.G.); University of Texas Southwestern Medical Center, Austin (S.W.); Department of Neurology, Mayo Clinic, Jacksonville, FL (T.G.B.); Departments of Neurology, Public Health Sciences, Human Genetics, and Neurosurgery, Miller School of Medicine, University of Miami, FL (R.L.S.); Department of Neurology, University of Cincinnati, OH (P.K., J.P.B.); Department of Neurology, University of California, Irvine (S.C.C.); and Department of Rehabilitation Medicine, Emory University School of Medicine and Center for Visual and Cognitive Neurorehabilitation, Atlanta VA Medical Center, GA (S.L.W.)
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1082
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Leker RR, Pikis S, Gomori JM, Cohen JE. Is Bridging Necessary? A Pilot Study of Bridging versus Primary Stentriever-Based Endovascular Reperfusion in Large Anterior Circulation Strokes. J Stroke Cerebrovasc Dis 2015; 24:1163-7. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.01.008] [Citation(s) in RCA: 53] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2014] [Revised: 12/07/2014] [Accepted: 01/04/2015] [Indexed: 11/26/2022] Open
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1083
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Liebeskind DS, Flint AC, Budzik RF, Xiang B, Smith WS, Duckwiler GR, Nogueira RG. Carotid I's, L's and T's: collaterals shape the outcome of intracranial carotid occlusion in acute ischemic stroke. J Neurointerv Surg 2015; 7:402-7. [PMID: 24789707 PMCID: PMC4216639 DOI: 10.1136/neurintsurg-2014-011231] [Citation(s) in RCA: 52] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2014] [Accepted: 04/13/2014] [Indexed: 12/21/2022]
Abstract
BACKGROUND Collaterals may affect revascularization, ischemic severity, and clinical outcomes in acute stroke owing to internal carotid artery (ICA) occlusion. OBJECTIVE To examine the hypothesis that morphology of occlusive thrombus and collateral flow patterns may influence the outcome of ICA occlusions after mechanical thrombectomy. METHODS Pooled analyses of ICA occlusions in the MERCI and Multi-MERCI trials employed central angiography review readings to categorize lesions as I, L, or T clots and functional lesions based on collateral flow patterns. Demographic variables, procedural details, and clinical outcomes were compared across ICA lesion types. RESULTS A total of 72 subjects (mean age 67 years (SD 16), 51% female, median National Institutes of Health Stroke Scale 20 (range 8-35)) were included, with 90-day modified Rankin score ≤2 in 28% and 51% mortality. Clots were categorized as an I lesion in 9/72 (12.5%), L lesion in 12/72 (16.7%), and T lesion in 51/72 (70.8%). Based on collateral flow patterns, cases were categorized as having a functional I lesion in 7/72 (9.7%), functional L in 38/72 (52.8%), and functional T in only 27/72 (37.5%). Multivariate analyses showed that a functional T lesion, with insufficient collateral flow to ipsilateral anterior cerebral arteries via the contralateral ICA, was a strong predictor of both revascularization success and subsequent clinical outcomes. CONCLUSIONS Collateral flow patterns distinguish the nature and impact of ICA occlusions on expected revascularization and subsequent clinical outcomes in acute ischemic stroke. The nomenclature of terminal ICA occlusions introduced here (carotid I's, L's, and T's) may enhance future endovascular trials targeting such proximal occlusions. TRIAL REGISTRATION NUMBER NCT00318071 (http://clinicaltrials.gov). MERCI was not registered because enrollment began before July 1, 2005.
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Affiliation(s)
- David S Liebeskind
- Department of Neurology, UCLA Stroke Center, Los Angeles, California, USA
| | | | | | - Bin Xiang
- Prospect Analytical, San Jose, California, USA
| | - Wade S Smith
- University of California San Francisco, San Francisco, California, USA
| | - Gary R Duckwiler
- Department of Neurology, UCLA Stroke Center, Los Angeles, California, USA
| | - Raul G Nogueira
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
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1084
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Mokin M, Ionita CN, Nagesh SVS, Rudin S, Levy EI, Siddiqui AH. Primary stentriever versus combined stentriever plus aspiration thrombectomy approaches: in vitro stroke model comparison. J Neurointerv Surg 2015; 7:453-7. [PMID: 24789594 PMCID: PMC4214918 DOI: 10.1136/neurintsurg-2014-011148] [Citation(s) in RCA: 60] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2014] [Accepted: 04/10/2014] [Indexed: 11/04/2022]
Abstract
BACKGROUND Artificial stroke models can be used for testing various thrombectomy devices. OBJECTIVE To determine the value of combined stentriever-aspiration thrombectomy compared with the stentriever-alone approach. METHODS We designed an in vitro model of the intracranial circulation with a focus on the middle cerebral artery (MCA) that closely resembles the human intracranial circulation. After introducing fresh clot in the MCA, we used conventional biplane angiography and microangiographic fluoroscopy to compare recanalization rates and occurrence of emboli in new, unaffected territory for thrombectomy approaches in which a stentriever (Solitaire flow restoration stentriever, Covidien) was used alone or in combination with continuous manual aspiration through a Navien catheter (Covidien). RESULTS In a total of 22 experiments (11 for each approach), successful clot delivery to the MCA was achieved in all cases. Successful angiographic recanalization (thrombolysis in cerebral infarction score of 2b-3) was achieved more frequently with the combined stentriever-aspiration approach than with the stentriever-alone approach (in 10 vs 4 experiments, p=0.023). Emboli in new territory occurred in three experiments with the stentriever-alone approach, and none were seen with the combined approach (p=0.21). CONCLUSIONS The combined stentriever-aspiration approach to thrombectomy leads to better angiographic recanalization rates than use of the stentriever alone. Further experiments are needed to test the value of balloon-guide catheters and aspiration performed using other types of catheters and modes of aspiration.
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Affiliation(s)
- Maxim Mokin
- Department of Neurosurgery, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Ciprian N Ionita
- Department of Neurosurgery, University at Buffalo, State University of New York, Buffalo, New York, USA
- Department of Biomedical Engineering, University at Buffalo, State University of New York, Buffalo, New York, USA
- Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Swetadri Vasan Setlur Nagesh
- Department of Biomedical Engineering, University at Buffalo, State University of New York, Buffalo, New York, USA
- Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York, USA
- Department of Electrical Engineering, University at Buffalo, State University of New York, Buffalo, New York, USA
- Department of Mechanical and Aerospace Engineering, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Stephen Rudin
- Department of Neurosurgery, University at Buffalo, State University of New York, Buffalo, New York, USA
- Department of Biomedical Engineering, University at Buffalo, State University of New York, Buffalo, New York, USA
- Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York, USA
- Department of Mechanical and Aerospace Engineering, University at Buffalo, State University of New York, Buffalo, New York, USA
- Department of Physiology and Biophysics, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Elad I Levy
- Department of Neurosurgery, University at Buffalo, State University of New York, Buffalo, New York, USA
- Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Department of Neurosurgery, University at Buffalo, State University of New York, Buffalo, New York, USA
- Toshiba Stroke and Vascular Research Center, University at Buffalo, State University of New York, Buffalo, New York, USA
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1085
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Tateishi Y, Wisco D, Aoki J, George P, Katzan I, Toth G, Hui F, Hussain MS, Uchino K. Large deep white matter lesions may predict futile recanalization in endovascular therapy for acute ischemic stroke. INTERVENTIONAL NEUROLOGY 2015; 3:48-55. [PMID: 25999992 DOI: 10.1159/000369835] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
OBJECTIVE This study investigated whether large ischemic lesions in the deep white matter (DWM) on pretreatment diffusion-weighted MRI (DWI) predict futile recanalization. METHODS Consecutive acute stroke patients with anterior circulation ischemia who underwent successful arterial recanalization with thrombolysis in cerebral infarction grade 2b or 3 were enrolled. A large DWI-DWM lesion was defined as a hyperintense lesion in the DWM on initial DWI, located mainly between the anterior and posterior horns of the lateral ventricle. The Alberta Stroke Program Early CT score on CT and DWI and stroke volume on initial DWI were recorded. Stroke severity was assessed using the National Institutes of Health Stroke Scale (NIHSS) score. Futile recanalization was defined as a 30-day modified Rankin scale score of 3-6 despite successful recanalization. Univariate and multivariate regression analyses were performed to identify predictors of futile recanalization. RESULTS In 35 of 46 patients (76%) with successful recanalization, futile recanalization was observed in 20 patients (57%). Patients with futile recanalization were older (median age 74 vs. 58 years; p = 0.053), had higher initial NIHSS scores (median 17 vs. 9; p = 0.042), and a higher prevalence of large DWI-DWM lesions (45 vs. 9%; p = 0.022). Logistic regression analysis showed that a large DWI-DWM lesion was an independent predictor of futile recanalization (OR 13.97; 95% CI 1.32-147.73; p = 0.028). CONCLUSION Patients with large preintervention DWI-DWM lesions may be poor candidates for endovascular therapy.
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Affiliation(s)
- Yohei Tateishi
- Cerebrovascular Center, Department of Neurology and Strokology, Nagasaki University Hospital, Nagasaki City, Tokyo, Japan ; Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Dolora Wisco
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Junya Aoki
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Pravin George
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Irene Katzan
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Gabor Toth
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Ferdinand Hui
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | | | - Ken Uchino
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
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1086
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Abstract
OPINION STATEMENT With the recent publication of multiple trials demonstrating the superiority of the endovascular treatment of patients presenting with stroke from large vessel occlusion (LVO) over medical management, the emergent care of these patients is entering a new era. This realization justifies an aggressive treatment approach with these stroke patients, given the poor natural history of the disease. In general, treatment should occur as quickly as is reasonably possible. Patients with NIHSS >8 should be considered, and if <6 h from onset imaging selection achieved with CT and CTA. Those with ASPECTS >5, LVO and intermediate or good collaterals should be treated emergently. For patients with clinical deficits presenting in later timeframes MRI should be used to define core infarct size and therefore treatment eligibility. MRI might also be considered for the workup of stroke patients in centers that can offer it rapidly. Recanalization should be attempted with a stentriever or using a direct aspiration technique, with the patient under conscious sedation rather than general anesthesia, if that is a safe option. Angiographically, the goal is reperfusion of mTICI 2b/3. Post-procedure, the patient should be admitted to an intensive care setting and assessed for inpatient rehabilitation placement as soon as stable. Continuous institutional process improvement ensures that optimization of treatment times and logistics is an ongoing endeavor. Finally, patient outcomes should be assessed at three months, most commonly using the modified Rankin score.
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1087
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Liebeskind DS, Jahan R, Nogueira RG, Jovin TG, Lutsep HL, Saver JL. Early arrival at the emergency department is associated with better collaterals, smaller established infarcts and better clinical outcomes with endovascular stroke therapy: SWIFT study. J Neurointerv Surg 2015; 8:553-8. [PMID: 25964375 DOI: 10.1136/neurintsurg-2015-011758] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2015] [Accepted: 04/23/2015] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND PURPOSE Increasing time from symptom onset to emergency department arrival may incur greater ischemic injury and decreased likelihood of good outcomes after acute stroke therapy. The impact of time may be assessed bythe extent of acute CT changes, status of collateral vessels, and clinical outcomes. METHODS The SOLITAIRE FR With the Intention For Thrombectomy (SWIFT) trial comparing two neurothrombectomy treatments was analyzed by time, Alberta Stroke Program Early CT Scores (ASPECTS), angiographic collaterals, and 90-day modified Rankin Scale outcomes. We determined the interaction of time with ASPECTS, collateral grade, reperfusion, and clinical outcomes, with established determinants of angiographic and clinical outcomes as covariates. RESULTS 137 patients (52% female) of mean age 67±12 years and median pretreatment NIH Stroke Scale score 18 (range 8-28) were enrolled. Median onset to door (OTD) time was 180 min (IQR 95-250). Presentation within 3 h of last known well was associated with absence of any prestroke disability and presence of atrial fibrillation but was unrelated to age, sex, other vascular risk factors, deficit severity, glucose level, or blood pressure. Worse collaterals were noted with longer OTD intervals: collateral grade 0-1 (n=32): mean 232±84 min; grade 2 (n=48): 164±99 min; grade 3 (n=35): 155±104 min; grade 4 (n=4): 54±16 min (p<0.001). Later presentation was associated with more extensive early infarct imaging changes (median ASPECTS 8 (IQR 7-9) >3 h vs 9 (IQR 8-10) <3 h, p=0.015). Multivariable analyses identified time >3 h as the only predictor of extensive infarct on imaging (ASPECTS ≤7), p=0.003. Earlier presentation was strongly associated with better 90-day modified Rankin Scale outcomes (p<0.001). CONCLUSIONS Time was a critical factor in successful clinical outcomes for neurothrombectomy in the SWIFT trial. Shorter times to presentation were associated with better collaterals, smaller established infarcts, and better clinical outcome after revascularization.
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Affiliation(s)
- David S Liebeskind
- Neurovascular Imaging Research Core and the UCLA Stroke Center, Los Angeles, California, USA
| | - Reza Jahan
- UCLA Stroke Center, Los Angeles, California, USA
| | - Raul G Nogueira
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
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1088
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Haussen DC, Lima A, Nogueira RG. The Trevo XP 3×20 mm retriever (‘Baby Trevo’) for the treatment of distal intracranial occlusions. J Neurointerv Surg 2015; 8:295-9. [DOI: 10.1136/neurintsurg-2014-011613] [Citation(s) in RCA: 70] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2015] [Accepted: 04/13/2015] [Indexed: 11/04/2022]
Abstract
ObjectiveTo report our single-center initial experience using the Trevo XP ProVue Retriever 3×20 mm (‘Baby Trevo’) for distal intracranial occlusions.MethodsWe performed a retrospective review of our interventional database for consecutive patients who underwent treatment for acute ischemic stroke with the Baby Trevo device between February and December 2014.ResultsOf 134 patients treated during the study period, 8 underwent treatment with the Baby Trevo for distal occlusions. Their mean age was 51±20 years, 5 (62.5%) were male, mean baseline National Institutes of Health Stroke Scale was 19±5. The mean interval between the time the patient was last-known normal to groin puncture was 527±285 min, and the overall procedural length was 110±26 min. Intra-arterial tissue plasminogen activator was used in 5 (62.5%) cases. The device was used for a total of 10 branches: five middle cerebral artery (four superior M3 and one inferior M3), three anterior cerebral arteries (two pericallosal and one callosomarginal), and two posterior cerebral arteries (one P2 and one P3) occlusions. All patients achieved complete recanalization of the artery targeted by the Baby Trevo (arterial occlusive lesion 3). Good capillary reperfusion (TICI 2b–3) was noted in 6 (75%) cases. One pass was performed in 7 vessels and 2 passes in three branches. Vasospasm was noted in 5 (62.5%) of the vessels and fully responded to intra-arterial vasodilator infusion. Follow-up MRI revealed no infarct within the territory vascularized by the artery targeted by the Baby Trevo in 4 cases, partial infarct in 5, and complete infarct in 1. Two patients had parenchymal hematomas (one PH1 and one PH2). No vessel perforations, dissections, or subarachnoid hemorrhage were noted.ConclusionsOur initial data suggest that treatment of distal cerebrovascular occlusions with the Trevo XP 3×20 mm Retriever is feasible. Although this device emerges as a promising technology for small and tortuous distal intracranial vessels, larger studies are still necessary to establish its safety and clinical benefit.
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1089
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Haussen DC, Lima A, Frankel M, Anderson A, Belagaje S, Nahab F, Rangaraju S, Nogueira RG. Sulcal effacement with preserved gray-white junction: a sign of reversible ischemia. Stroke 2015; 46:1704-6. [PMID: 25931460 DOI: 10.1161/strokeaha.115.009304] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2015] [Accepted: 03/23/2015] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Sulcal effacement with preserved underlying gray-white matter junction (isolated sulcal effacement [ISE]) in acute ischemic stroke may not represent irreversible parenchymal injury. We aimed to evaluate the frequency and significance of ISE in patients with large vessel occlusion acute ischemic stroke. METHODS Consecutive acute ischemic stroke patients with middle cerebral artery M1 or internal carotid artery terminus occlusions who underwent computed tomography angiogram/perfusion followed by intra-arterial therapy were screened for ISE. RESULTS Out of the 568 patients who underwent intra-arterial therapy between March 2011 and September 2014, 108 fulfilled inclusion criteria. ISE was present in 8 (7.4%) patients (age 55.7±10.5 years, 6 female, baseline National Institutes of Health Stroke Scale 16.1±3.8, 5 middle cerebral artery-M1, and 3 internal carotid artery terminus occlusions). Computed tomography angiogram revealed engorged/dilated leptomeningeal vessels obliterating the sulci within the areas of effacement, whereas computed tomography perfusion indicated normal-to-increased cerebral blood volume and prolonged Tmax in all patients. Modified treatment in cerebral ischemia (mTICI) 2b-3 reperfusion was achieved in all patients. Follow-up imaging confirmed no infarct in the ISE area in all patients, and 5 (62%) had modified Rankin Scale 0 to 2 at 3 months. CONCLUSIONS Sulcal effacement with preserved gray-white delineation is occasionally visualized in patients with proximal occlusion strokes, relates to robust leptomeningeal collaterals, and indicates preserved underlying parenchyma. ISE should not be used to exclude patients from thrombectomy.
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Affiliation(s)
- Diogo C Haussen
- From the Department of Neurology, Emory University/Grady Memorial Hospital, Atlanta, GA
| | - Andrey Lima
- From the Department of Neurology, Emory University/Grady Memorial Hospital, Atlanta, GA
| | - Michael Frankel
- From the Department of Neurology, Emory University/Grady Memorial Hospital, Atlanta, GA
| | - Aaron Anderson
- From the Department of Neurology, Emory University/Grady Memorial Hospital, Atlanta, GA
| | - Samir Belagaje
- From the Department of Neurology, Emory University/Grady Memorial Hospital, Atlanta, GA
| | - Fadi Nahab
- From the Department of Neurology, Emory University/Grady Memorial Hospital, Atlanta, GA
| | - Srikant Rangaraju
- From the Department of Neurology, Emory University/Grady Memorial Hospital, Atlanta, GA
| | - Raul G Nogueira
- From the Department of Neurology, Emory University/Grady Memorial Hospital, Atlanta, GA.
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1090
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Horsch AD, Dankbaar JW, Niesten JM, van Seeters T, van der Schaaf IC, van der Graaf Y, Mali WPTM, Velthuis BK. Predictors of reperfusion in patients with acute ischemic stroke. AJNR Am J Neuroradiol 2015; 36:1056-62. [PMID: 25907522 DOI: 10.3174/ajnr.a4283] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2014] [Accepted: 12/11/2014] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND PURPOSE Ischemic stroke studies emphasize a difference between reperfusion and recanalization, but predictors of reperfusion have not been elucidated. The aim of this study was to evaluate the relationship between reperfusion and recanalization and identify predictors of reperfusion. MATERIALS AND METHODS From the Dutch Acute Stroke Study, 178 patients were selected with an MCA territory deficit on admission CTP and day 3 follow-up CTP and CTA. Reperfusion was evaluated on CTP, and recanalization on CTA, follow-up imaging. Reperfusion percentages were calculated in patients with and without recanalization. Patient admission and treatment characteristics and admission CT imaging parameters were collected. Their association with complete reperfusion was analyzed by using univariate and multivariate logistic regression. RESULTS Sixty percent of patients with complete recanalization showed complete reperfusion (relative risk, 2.60; 95% CI, 1.63-4.13). Approximately one-third of patients showed some discrepancy between recanalization and reperfusion status. Lower NIHSS score (OR, 1.06; 95% CI, 1.01-1.11), smaller infarct core size (OR, 3.11; 95% CI, 1.46-6.66; and OR, 2.40; 95% CI, 1.14-5.02), smaller total ischemic area (OR, 4.20; 95% CI, 1.91-9.22; and OR, 2.35; 95% CI, 1.12-4.91), lower clot burden (OR, 1.35; 95% CI, 1.14-1.58), distal thrombus location (OR, 3.02; 95% CI, 1.76-5.20), and good collateral score (OR, 2.84; 95% CI, 1.34-6.02) significantly increased the odds of complete reperfusion. In multivariate analysis, only total ischemic area (OR, 6.12; 95% CI, 2.69-13.93; and OR, 1.91; 95% CI, 0.91-4.02) was an independent predictor of complete reperfusion. CONCLUSIONS Recanalization and reperfusion are strongly associated but not always equivalent in ischemic stroke. A smaller total ischemic area is the only independent predictor of complete reperfusion.
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Affiliation(s)
- A D Horsch
- From the Department of Radiology (A.D.H., J.W.D., J.M.N., T.v.S., I.C.v.d.S., W.P.Th.M.M., B.K.V.), University Medical Center Utrecht, Utrecht, the Netherlands Department of Radiology (A.D.H.), Rijnstate Hospital, Arnhem, the Netherlands
| | - J W Dankbaar
- From the Department of Radiology (A.D.H., J.W.D., J.M.N., T.v.S., I.C.v.d.S., W.P.Th.M.M., B.K.V.), University Medical Center Utrecht, Utrecht, the Netherlands
| | - J M Niesten
- From the Department of Radiology (A.D.H., J.W.D., J.M.N., T.v.S., I.C.v.d.S., W.P.Th.M.M., B.K.V.), University Medical Center Utrecht, Utrecht, the Netherlands
| | - T van Seeters
- From the Department of Radiology (A.D.H., J.W.D., J.M.N., T.v.S., I.C.v.d.S., W.P.Th.M.M., B.K.V.), University Medical Center Utrecht, Utrecht, the Netherlands
| | - I C van der Schaaf
- From the Department of Radiology (A.D.H., J.W.D., J.M.N., T.v.S., I.C.v.d.S., W.P.Th.M.M., B.K.V.), University Medical Center Utrecht, Utrecht, the Netherlands
| | - Y van der Graaf
- Julius Center for Health Sciences and Primary Care (Y.v.d.G.), Utrecht, the Netherlands
| | - W P Th M Mali
- From the Department of Radiology (A.D.H., J.W.D., J.M.N., T.v.S., I.C.v.d.S., W.P.Th.M.M., B.K.V.), University Medical Center Utrecht, Utrecht, the Netherlands
| | - B K Velthuis
- From the Department of Radiology (A.D.H., J.W.D., J.M.N., T.v.S., I.C.v.d.S., W.P.Th.M.M., B.K.V.), University Medical Center Utrecht, Utrecht, the Netherlands
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1091
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Huang X, Cheripelli BK, Lloyd SM, Kalladka D, Moreton FC, Siddiqui A, Ford I, Muir KW. Alteplase versus tenecteplase for thrombolysis after ischaemic stroke (ATTEST): a phase 2, randomised, open-label, blinded endpoint study. Lancet Neurol 2015; 14:368-76. [PMID: 25726502 DOI: 10.1016/s1474-4422(15)70017-7] [Citation(s) in RCA: 204] [Impact Index Per Article: 22.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
BACKGROUND In most countries, alteplase given within 4·5 h of onset is the only approved medical treatment for acute ischaemic stroke. The newer thrombolytic drug tenecteplase has been investigated in one randomised trial up to 3 h after stroke and in another trial up to 6 h after stroke in patients selected by advanced neuroimaging. In the Alteplase-Tenecteplase Trial Evaluation for Stroke Thrombolysis (ATTEST), we aimed to assess the efficacy and safety of tenecteplase versus alteplase within 4·5 h of stroke onset in a population not selected on the basis of advanced neuroimaging, and to use imaging biomarkers to inform the design of a definitive phase 3 clinical trial. METHODS In this single-centre, phase 2, prospective, randomised, open-label, blinded end-point evaluation study, adults with supratentorial ischaemic stroke eligible for intravenous thrombolysis within 4·5 h of onset were recruited from The Institute of Neurological Sciences, Glasgow, Scotland. Patients were randomly assigned (1:1) to receive tenecteplase 0·25 mg/kg (maximum 25 mg) or alteplase 0·9 mg/kg (maximum 90 mg). Treatment allocation used a mixed randomisation and minimisation algorithm including age and National Institutes of Health Stroke Scale score, generated by an independent statistician. Patients were not informed of treatment allocation; treating clinicians were aware of allocation but those assessing the primary outcome were not. Imaging comprised baseline CT, CT perfusion, and CT angiography; and CT plus CT angiography at 24-48 h. The primary endpoint was percentage of penumbra salvaged (CT perfusion-defined penumbra volume at baseline minus CT infarct volume at 24-48 h). Analysis was per protocol. This study is registered with ClinicalTrials.gov, number NCT01472926. FINDINGS Between Jan 1, 2012, and Sept 7, 2013, 355 patients were screened, of whom 157 were eligible for intravenous thrombolysis, and 104 patients were enrolled. 52 were assigned to the alteplase group and 52 to tenecteplase. Of 71 patients (35 assigned tenecteplase and 36 assigned alteplase) contributing to the primary endpoint, no significant differences were noted for percentage of penumbral salvaged (68% [SD 28] for the tenecteplase group vs 68% [23] for the alteplase group; mean difference 1·3% [95% CI -9·6 to 12·1]; p=0·81). Neither incidence of symptomatic intracerebral haemorrhage (by SITS-MOST definition, 1/52 [2%] tenecteplase vs 2/51 [4%] alteplase, p=0·55; by ECASS II definition, 3/52 [6%] vs 4/51 [8%], p=0·59) nor total intracerebral haemorrhage events (8/52 [15%] vs 14/51 [29%], p=0·091) differed significantly. The incidence of serious adverse events did not differ between groups (32 in the tenecteplase group, three considered probably or definitely related to drug treatment; 16 in the alteplase group, five were considered drug-related). INTERPRETATION Neurological and radiological outcomes did not differ between the tenecteplase and alteplase groups. Evaluation of tenecteplase in larger trials of patients with acute stroke seems warranted. FUNDING The Stroke Association.
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Affiliation(s)
- Xuya Huang
- Institute of Neuroscience and Psychology, University of Glasgow, Southern General Hospital, Glasgow, Scotland, UK
| | - Bharath Kumar Cheripelli
- Institute of Neuroscience and Psychology, University of Glasgow, Southern General Hospital, Glasgow, Scotland, UK
| | - Suzanne M Lloyd
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, Scotland, UK
| | - Dheeraj Kalladka
- Institute of Neuroscience and Psychology, University of Glasgow, Southern General Hospital, Glasgow, Scotland, UK
| | - Fiona Catherine Moreton
- Institute of Neuroscience and Psychology, University of Glasgow, Southern General Hospital, Glasgow, Scotland, UK
| | - Aslam Siddiqui
- Department of Neuroradiology, Southern General Hospital, NHS Greater Glasgow and Clyde, Glasgow, Scotland, UK
| | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, Scotland, UK
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Southern General Hospital, Glasgow, Scotland, UK.
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1092
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Kim SK, Yoon W, Heo TW, Park MS, Kang HK. Negative Susceptibility Vessel Sign and Underlying Intracranial Atherosclerotic Stenosis in Acute Middle Cerebral Artery Occlusion. AJNR Am J Neuroradiol 2015; 36:1266-71. [PMID: 25814657 DOI: 10.3174/ajnr.a4280] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2014] [Accepted: 01/14/2015] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE The role of MR imaging in predicting underlying intracranial atherosclerotic stenosis before endovascular stroke therapy has not been studied. Our aim was to determine the diagnostic value of the negative susceptibility vessel sign on T2*-weighted gradient-echo MR imaging for predicting underlying intracranial atherosclerotic stenosis in patients with acute MCA occlusion. MATERIALS AND METHODS Ninety-one consecutive patients with acute stroke because of MCA occlusion underwent gradient-echo MR imaging and MRA before endovascular therapy. The negative susceptibility vessel sign was defined as an absence of a hypointense signal change within the occluded MCA on gradient-echo imaging. Underlying intracranial atherosclerotic stenosis was determined by conventional angiography. The sensitivity, specificity, predictive values, and accuracy of the negative susceptibility vessel sign for predicting the presence of underlying intracranial atherosclerotic stenosis were assessed. RESULTS The negative susceptibility vessel sign was identified in 42 (46.1%) of 91 patients, and 18 (19.8%) patients had an underlying intracranial atherosclerotic stenosis responsible for acute ischemic symptoms. The negative susceptibility vessel sign was more frequently observed in patients with intracranial atherosclerotic stenosis than in those without it (100% versus 32.9%, P < .001). In the prediction of an underlying intracranial atherosclerotic stenosis, the negative susceptibility vessel sign had 100% sensitivity, 67.1% specificity, 42.9% positive predictive value, 100% negative predictive value, and an accuracy of 73.6%. CONCLUSIONS The negative susceptibility vessel sign on gradient-echo MR imaging is a sensitive marker with a high negative predictive value for the presence of an underlying intracranial atherosclerotic stenosis in patients with acute ischemic stroke because of MCA occlusions. The susceptibility vessel sign can be used in decision-making when performing subsequent endovascular revascularization therapy in patients with acute MCA occlusions.
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Affiliation(s)
- S K Kim
- From the Departments of Radiology (S.K.K., W.Y., T.W.H., H.K.K.)
| | - W Yoon
- From the Departments of Radiology (S.K.K., W.Y., T.W.H., H.K.K.)
| | - T W Heo
- From the Departments of Radiology (S.K.K., W.Y., T.W.H., H.K.K.)
| | - M S Park
- Neurology (M.S.P.), Chonnam National University Medical School, Chonnam National University Hospital, Gwangju, Republic of Korea
| | - H K Kang
- From the Departments of Radiology (S.K.K., W.Y., T.W.H., H.K.K.)
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1093
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Campbell BCV, Mitchell PJ, Kleinig TJ, Dewey HM, Churilov L, Yassi N, Yan B, Dowling RJ, Parsons MW, Oxley TJ, Wu TY, Brooks M, Simpson MA, Miteff F, Levi CR, Krause M, Harrington TJ, Faulder KC, Steinfort BS, Priglinger M, Ang T, Scroop R, Barber PA, McGuinness B, Wijeratne T, Phan TG, Chong W, Chandra RV, Bladin CF, Badve M, Rice H, de Villiers L, Ma H, Desmond PM, Donnan GA, Davis SM. Endovascular therapy for ischemic stroke with perfusion-imaging selection. N Engl J Med 2015; 372:1009-18. [PMID: 25671797 DOI: 10.1056/nejmoa1414792] [Citation(s) in RCA: 4000] [Impact Index Per Article: 444.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Trials of endovascular therapy for ischemic stroke have produced variable results. We conducted this study to test whether more advanced imaging selection, recently developed devices, and earlier intervention improve outcomes. METHODS We randomly assigned patients with ischemic stroke who were receiving 0.9 mg of alteplase per kilogram of body weight less than 4.5 hours after the onset of ischemic stroke either to undergo endovascular thrombectomy with the Solitaire FR (Flow Restoration) stent retriever or to continue receiving alteplase alone. All the patients had occlusion of the internal carotid or middle cerebral artery and evidence of salvageable brain tissue and ischemic core of less than 70 ml on computed tomographic (CT) perfusion imaging. The coprimary outcomes were reperfusion at 24 hours and early neurologic improvement (≥8-point reduction on the National Institutes of Health Stroke Scale or a score of 0 or 1 at day 3). Secondary outcomes included the functional score on the modified Rankin scale at 90 days. RESULTS The trial was stopped early because of efficacy after 70 patients had undergone randomization (35 patients in each group). The percentage of ischemic territory that had undergone reperfusion at 24 hours was greater in the endovascular-therapy group than in the alteplase-only group (median, 100% vs. 37%; P<0.001). Endovascular therapy, initiated at a median of 210 minutes after the onset of stroke, increased early neurologic improvement at 3 days (80% vs. 37%, P=0.002) and improved the functional outcome at 90 days, with more patients achieving functional independence (score of 0 to 2 on the modified Rankin scale, 71% vs. 40%; P=0.01). There were no significant differences in rates of death or symptomatic intracerebral hemorrhage. CONCLUSIONS In patients with ischemic stroke with a proximal cerebral arterial occlusion and salvageable tissue on CT perfusion imaging, early thrombectomy with the Solitaire FR stent retriever, as compared with alteplase alone, improved reperfusion, early neurologic recovery, and functional outcome. (Funded by the Australian National Health and Medical Research Council and others; EXTEND-IA ClinicalTrials.gov number, NCT01492725, and Australian New Zealand Clinical Trials Registry number, ACTRN12611000969965.).
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1094
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Friedrich B, Gawlitza M, Schob S, Hobohm C, Raviolo M, Hoffmann KT, Lobsien D. Distance to Thrombus in Acute Middle Cerebral Artery Occlusion. Stroke 2015; 46:692-6. [DOI: 10.1161/strokeaha.114.008454] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Benjamin Friedrich
- From the Department of Interventional and Diagnostic Radiology (B.F., M.G., M.R.), Department of Neuroradiology (S.S., K.-T.H., D.L.), and Department of Neurology (C.H.), University Hospital Leipzig, Germany
| | - Matthias Gawlitza
- From the Department of Interventional and Diagnostic Radiology (B.F., M.G., M.R.), Department of Neuroradiology (S.S., K.-T.H., D.L.), and Department of Neurology (C.H.), University Hospital Leipzig, Germany
| | - Stefan Schob
- From the Department of Interventional and Diagnostic Radiology (B.F., M.G., M.R.), Department of Neuroradiology (S.S., K.-T.H., D.L.), and Department of Neurology (C.H.), University Hospital Leipzig, Germany
| | - Carsten Hobohm
- From the Department of Interventional and Diagnostic Radiology (B.F., M.G., M.R.), Department of Neuroradiology (S.S., K.-T.H., D.L.), and Department of Neurology (C.H.), University Hospital Leipzig, Germany
| | - Mariana Raviolo
- From the Department of Interventional and Diagnostic Radiology (B.F., M.G., M.R.), Department of Neuroradiology (S.S., K.-T.H., D.L.), and Department of Neurology (C.H.), University Hospital Leipzig, Germany
| | - Karl-Titus Hoffmann
- From the Department of Interventional and Diagnostic Radiology (B.F., M.G., M.R.), Department of Neuroradiology (S.S., K.-T.H., D.L.), and Department of Neurology (C.H.), University Hospital Leipzig, Germany
| | - Donald Lobsien
- From the Department of Interventional and Diagnostic Radiology (B.F., M.G., M.R.), Department of Neuroradiology (S.S., K.-T.H., D.L.), and Department of Neurology (C.H.), University Hospital Leipzig, Germany
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1095
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Mokin M, Levy EI. Guest editorial: endovascular treatment of acute ischemic stroke: what's next? Neurosurgery 2015; 76:235-8. [PMID: 25689388 DOI: 10.1227/neu.0000000000000647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Affiliation(s)
- Maxim Mokin
- *Department of Neurosurgery and ¶Department of Radiology, School of Medicine and Biomedical Sciences, and ‖Toshiba Stroke and Vascular Research Center, School of Medicine and Biomedical Sciences, University at Buffalo, State University of New York, Buffalo, New York ‡Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, New York §Departments of Neurology and Neurosurgery, University of South Florida College of Medicine, Tampa, Florida
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1096
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Mpotsaris A, Kowoll A, Weber W, Kabbasch C, Weber A, Behme D. Endovascular stroke therapy at nighttime and on weekends-as fast and effective as during normal business hours? JOURNAL OF VASCULAR AND INTERVENTIONAL NEUROLOGY 2015; 8:39-45. [PMID: 25825631 PMCID: PMC4367806] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
INTRODUCTION There is only limited data on the influence of the admission time (normal business hours versus nighttime and weekends) on procedural timings, revascularization efficacy, and outcome after mechanical thrombectomy. We investigated whether the admission time has an impact on the above-mentioned factors. METHODS Our neurointerventional database was screened for all mechanical thrombectomies in anterior circulation acute ischemic stroke between 07/13 and 06/14. Outcome measures were procedural timings and clinical and demographic data; we compared patients who were admitted at normal business hours (Monday to Friday 8:00-18:00) to those admitted at night or at the weekend. RESULTS 98 patients were identified. Of them, 52 (53%) were admitted during normal business hours, the remainder at night or at weekend. There was no statistically significant difference between the groups regarding the time from symptom-onset to admission, baseline National Institutes of Health Stroke Scale (NIHSS) or IVT-rate. There was a significant difference between groups for door-to-reperfusion timing, favoring patients admitted during normal business hours (146 versus 165 min, p = 0.02). Door-to-groin-puncture and groin-puncture-to-reperfusion time did not differ significantly. The rate of successful revascularizations (mTICI ≥ 2b) and the rate of favorable clinical outcome at discharge (mRS ≤ 2) did not differ between groups (77% versus 78% and 37% versus 35%, respectively). CONCLUSIONS There was a statistically significant prolongation of door-to-reperfusion timings for patients admitted during nighttime and weekends; it went along neither with a lower rate of successful revascularizations nor with a lower rate of favorable outcome in our series. ABBREVIATIONS AFatrial fibrillationAISacute ischemic strokeCTAcomputed tomography angiographyDMdiabetes mellitusENTembolization to new territoryEVTendovascular therapyHLPhyperlipoproteinemiaHTNhypertensionIQRinter-quartile rangeIVTintravenous thrombolysismRSmodified Rankin ScaleMTmechanical thrombectomyNIHSSNational Institutes of Health Stroke Scalen.s.not significantsICHsymptomatic intracranial hemorrhage.
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Affiliation(s)
- Anastasios Mpotsaris
- Klinikum Vest, Department of Radiology and Neuroradiology, Recklinghausen, Germany ; University of Cologne, University Medical Center, Department of Radiology and Neuroradiology, Cologne, Germany
| | - Annika Kowoll
- Ruhr-University-Bochum, University Medical Center Langendreer, Department of Radiology and Neuroradiology, Bochum, Germany ; Klinikum Vest, Department of Radiology and Neuroradiology, Recklinghausen, Germany
| | - Werner Weber
- Ruhr-University-Bochum, University Medical Center Langendreer, Department of Radiology and Neuroradiology, Bochum, Germany ; Klinikum Vest, Department of Radiology and Neuroradiology, Recklinghausen, Germany
| | - Christoph Kabbasch
- University of Cologne, University Medical Center, Department of Radiology and Neuroradiology, Cologne, Germany
| | - Anushe Weber
- Ruhr-University-Bochum, University Medical Center Langendreer, Department of Radiology and Neuroradiology, Bochum, Germany ; Klinikum Vest, Department of Radiology and Neuroradiology, Recklinghausen, Germany
| | - Daniel Behme
- Ruhr-University-Bochum, University Medical Center Langendreer, Department of Radiology and Neuroradiology, Bochum, Germany ; Klinikum Vest, Department of Radiology and Neuroradiology, Recklinghausen, Germany
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1098
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Singer OC, Berkefeld J, Nolte CH, Bohner G, Haring HP, Trenkler J, Gröschel K, Müller-Forell W, Niederkorn K, Deutschmann H, Neumann-Haefelin T, Hohmann C, Bussmeyer M, Mpotsaris A, Stoll A, Bormann A, Brenck J, Schlamann MU, Jander S, Turowski B, Petzold GC, Urbach H, Liebeskind DS. Mechanical recanalization in basilar artery occlusion: The ENDOSTROKE study. Ann Neurol 2015; 77:415-24. [DOI: 10.1002/ana.24336] [Citation(s) in RCA: 225] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 11/28/2014] [Accepted: 12/07/2014] [Indexed: 02/04/2023]
Affiliation(s)
| | | | | | - Georg Bohner
- Institute of Diagnostic and Interventional Radiology and Nuclear Medicine; Charité Hospital; Berlin Germany
| | | | | | - Klaus Gröschel
- Department of Neurology; Mainz University Hospital; Mainz Germany
| | | | - Kurt Niederkorn
- Department of Neurology; Division of Neuroradiology, Medical University of Graz; Graz Austria
| | - Hannes Deutschmann
- Department of Radiology; Division of Neuroradiology, Medical University of Graz; Graz Austria
| | | | - Carina Hohmann
- Departments of Neurology and Pharmacy; Fulda Hospital; Fulda Germany
| | | | - Anastasios Mpotsaris
- Institute of Radiology and Neuroradiology; Vest Hospital; Recklinghausen Germany
- Institute of Radiology; Division of Neuroradiology, Cologne University Hospital; Cologne Germany
| | - Anett Stoll
- Department of Neurology; Altenburger Land Hospital; Altenburg Germany
| | - Albrecht Bormann
- Institute of Radiology; Altenburger Land Hospital; Altenburg Germany
| | - Johannes Brenck
- Department of Neurology; Essen University Hospital; Essen Germany
| | - Marc U. Schlamann
- Institute of Diagnostic and Interventional Radiology and Neuroradiology; Essen University Hospital; Essen Germany
| | - Sebastian Jander
- Department of Neurology; Medical Faculty, Heinrich Heine University; Düsseldorf Germany
| | - Bernd Turowski
- Institute of Diagnostic and Interventional Radiology; Medical Faculty, Heinrich Heine University; Düsseldorf Germany
| | - Gabor C. Petzold
- German Center for Neurodegenerative Diseases and Department of Neurology; Bonn University Hospital; Bonn Germany
| | - Horst Urbach
- Department of Neuroradiology; Freiburg University Hospital; Freiburg Germany
| | - David S. Liebeskind
- UCLA Stroke Center and Department of Neurology; University of California, Los Angeles; Los Angeles CA
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1099
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Kowoll A, Weber A, Mpotsaris A, Behme D, Weber W. Direct aspiration first pass technique for the treatment of acute ischemic stroke: initial experience at a European stroke center. J Neurointerv Surg 2015; 8:230-4. [PMID: 25583533 DOI: 10.1136/neurintsurg-2014-011520] [Citation(s) in RCA: 80] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2014] [Accepted: 12/26/2014] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Over the past decade, endovascular techniques for the treatment of acute ischemic stroke have emerged significantly. However, revascularization rates are limited at approximately 80%, and mechanical thrombectomy procedures still last about 1 h. Therefore, we investigated the novel direct aspiration first pass technique for its efficacy and safety. METHODS Our neurointerventional database was screened for patients who received mechanical thrombectomy for acute ischemic stroke using the Penumbra 5MAX ACE aspiration catheter on an intention to treat basis between November 2013 and June 2014. Procedural data, including modified Thrombolysis in Cerebral Infarction (mTICI) score, procedural timings, and complications, as well as clinical data at admission and discharge, were analyzed. RESULTS 54 patients received mechanical thrombectomy using the 5MAX ACE. Median age was 69 (39-94) years (54% were men). Baseline National Institutes of Health Stroke Scale (NIHSS) score was 15 (2-27) and 44/54 (81%) patients received intravenous thrombolysis. Vessel occlusion sites were 91% anterior circulation and 9% posterior circulation. A successful revascularization result (mTICI ≥2b) was achieved in 93% of cases whereas direct aspiration alone was successful in 30/54 (56%) cases; among these, median time from groin puncture to revascularization was 30 min (9-113). Symptomatic intracranial hemorrhage occurred in 2/54 (4%) patients, and embolization to new territories in 3/54 (6%). Median NIHSS at discharge was 6 (0-24); 46% of patients were independent at discharge. CONCLUSIONS The direct aspiration first pass technique proofed to be fast, effective, and safe. Promising revascularization results can be achieved quickly in more than 50% of patients using this technique as the firstline option. Nevertheless, stent retrievers are still warranted in approximately 40% of cases to achieve a favorable revascularization result.
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Affiliation(s)
- Annika Kowoll
- Department of Radiology and Neuroradiology, University Medical Center Langendreer, Ruhr-University-Bochum, Bochum, Germany
| | - Anushe Weber
- Department of Radiology and Neuroradiology, University Medical Center Langendreer, Ruhr-University-Bochum, Bochum, Germany
| | - Anastasios Mpotsaris
- Department of Radiology and Neuroradiology, University Hospital of Cologne, University of Cologne, Cologne, Germany
| | - Daniel Behme
- Department of Neuroradiology, University Medical Center, Georg-August University Göttingen, Göttingen, Germany
| | - Werner Weber
- Department of Radiology and Neuroradiology, University Medical Center Langendreer, Ruhr-University-Bochum, Bochum, Germany
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1100
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Singer OC, Berkefeld J, Nolte CH, Bohner G, Reich A, Wiesmann M, Groeschel K, Boor S, Neumann-Haefelin T, Hofmann E, Stoll A, Bormann A, Liebeskind DS. Collateral vessels in proximal middle cerebral artery occlusion: the ENDOSTROKE study. Radiology 2015; 274:851-8. [PMID: 25559232 DOI: 10.1148/radiol.14140951] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To determine the impact of collateral vessel status on clinical and imaging outcomes in patients undergoing endovascular therapy (EVT) for proximal middle cerebral artery (MCA) occlusion. MATERIALS AND METHODS There were 160 patients with proximal MCA occlusion at six centers in this institutional review board-approved multicenter EVT registry. Angiograms were analyzed at a blinded core laboratory, and collateral vessel status was assessed by using the American Society of Interventional and Therapeutic Neuroradiology (ASITN)/Society of Interventional Radiology (SIR) collateral vessel grading system, while reperfusion was assessed by using the Thrombolysis in Cerebral Infarction (TICI) scale. Good outcome was defined as a modified Rankin Scale score of 0-2 at follow-up. Binary logistic regression analysis was performed by using parameters with P < .2 in univariate analysis. RESULTS Good clinical outcome was attained in 62 (39%) of the 160 patients, and TICI 2b-3 reperfusion was achieved in 94 (59%) patients. Nineteen patients had ASITN/SIR collateral vessel grades of 0 or 1, 63 patients had a grade of 2, and 78 patients had grades of 3 or 4. Better collateral vessels were associated with higher reperfusion rates (21%, 48%, and 77% for ASITN/SIR grades of 0 or 1, 2, and 3 or 4, respectively; P < .001), a higher proportion of infarcts smaller than one-third of the MCA territory (32%, 48%, and 69% for ASITN/SIR grades of 0 or 1, 2, and 3 or 4, respectively; P < .001), and a higher proportion of good clinical outcome (11%, 35%, and 49% for ASITN/SIR grades of 0 or 1, 2, and 3 or 4, respectively; P = .007). At multivariable analysis, collateral vessel status independently predicted reperfusion, final infarct size, and clinical outcome. Within an onset-to-treatment time (OTT) of 0-3 hours, collateral vessel status predicted final infarct size and reperfusion. Within an OTT of 3-6 hours, it additionally predicted clinical outcome, with 53% of patients with ASITN/SIR grades of 3 or 4 having a good outcome, as compared with 0% of patients with grades of 0 or 1 and 27% of patients with a grade of 2 (P = .008). CONCLUSION In this patient population, collateral vessel status independently predicted the pivotal outcome parameters of reperfusion, infarct size, and clinical outcome. These data underscore the utility of patient selection for EVT on the basis of collateral vessel status.
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Affiliation(s)
- Oliver C Singer
- From the Department of Neurology (O.C.S.) and Institute for Neuroradiology (J.B.), Goethe University, Schleusenweg 2-16, D-60528 Frankfurt/Main, Germany; Department of Neurology (C.H.N.) and Institute for Diagnostic and Interventional Radiology and Nuclear Medicine (G.B.), Charité Hospital, Berlin, Germany; Department of Neurology (A.R.) and Institute for Diagnostic and Interventional Neuroradiology (M.W.), University Hospital Aachen, Aachen, Germany; Department of Neurology (K.G.) and Institute for Neuroradiology (S.B.), University Hospital Mainz, Mainz, Germany; Department of Neurology (T.N.) and Institute for Diagnostic and Interventional Neuroradiology (E.H.), Klinikum Fulda, Fulda, Germany; Department of Neurology (A.S.) and Institute for Radiology (A.B.), Klinikum Altenburger Land, Altenburg, Germany; and UCLA Stroke Center and Department of Neurology, University of California-Los Angeles, Los Angeles, Calif (D.S.L.)
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