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Jadhav AP, Ribo M, Grandhi R, Linares G, Aghaebrahim A, Jovin TG, Jankowitz BT. Transcervical access in acute ischemic stroke. J Neurointerv Surg 2013; 6:652-7. [PMID: 24203916 DOI: 10.1136/neurintsurg-2013-010971] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
BACKGROUND Large vessel occlusive disease portends a poor prognosis unless recanalization is rapidly achieved. Endovascular treatment is typically performed via a transfemoral approach, but catheterization of the occluded vessel can be problematic in cases of extensive vessel tortuosity. METHODS A retrospective review of a prospectively maintained database identified 7 patients who underwent acute endovascular reperfusion therapy via transcervical approach. RESULTS We identified 7 patients. Admission NIHSS ranged from 8-27 and recanalization occurred between 7-49 min of carotid access. Prior to carotid access, 20-90 min were spent attempting target vessel catheterization via the transfemoral approach. All occlusions were in the left MCA. In 87.5% of patient, TICI2b/3 recanalization was achieved. Neck hematoma formation occurred in one case requiring elective intubation. At 2 months followup, all patients had survived with mRS 0-4 except for one patient who had a large infarct despite recanalization. CONCLUSIONS Transcervical access for acute ischemic stroke leads to rapid and high quality recanalization. Future studies will focus on improved hemostasis and early identification of patients who would benefit the most from direct carotid access for acute stroke.
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Affiliation(s)
- Ashutosh P Jadhav
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Marc Ribo
- Unitat d'Ictus, Neurologia, Hospital Vall d'Hebron Barcelona, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Ramesh Grandhi
- Department of Neurosurgery, UPMC Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Guillermo Linares
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Amin Aghaebrahim
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Tudor G Jovin
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Brian T Jankowitz
- Department of Neurosurgery, UPMC Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
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Campbell BCV, Mitchell PJ, Yan B, Parsons MW, Christensen S, Churilov L, Dowling RJ, Dewey H, Brooks M, Miteff F, Levi C, Krause M, Harrington TJ, Faulder KC, Steinfort BS, Kleinig T, Scroop R, Chryssidis S, Barber A, Hope A, Moriarty M, McGuinness B, Wong AA, Coulthard A, Wijeratne T, Lee A, Jannes J, Leyden J, Phan TG, Chong W, Holt ME, Chandra RV, Bladin CF, Badve M, Rice H, de Villiers L, Ma H, Desmond PM, Donnan GA, Davis SM. A Multicenter, Randomized, Controlled Study to Investigate Extending the Time for Thrombolysis in Emergency Neurological Deficits with Intra-Arterial Therapy (EXTEND-IA). Int J Stroke 2013; 9:126-32. [DOI: 10.1111/ijs.12206] [Citation(s) in RCA: 121] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background and Hypothesis Thrombolysis with tissue plasminogen activator is proven to reduce disability when given within 4.5 h of ischemic stroke onset. However, tissue plasminogen activator only succeeds in recanalizing large vessel arterial occlusion in a minority of patients. We hypothesized that anterior circulation ischemic stroke patients, selected with ‘dual target’ vessel occlusion and evidence of salvageable brain using computed tomography or magnetic resonance imaging ‘mismatch’ within 4.5 h of onset, would have improved reperfusion and early neurological improvement when treated with intra-arterial clot retrieval after intravenous tissue plasminogen activator compared with intravenous tissue plasminogen activator alone. Study Design EXTEND-IA is an investigator-initiated, phase II, multicenter prospective, randomized, open-label, blinded-endpoint study. Ischemic stroke patients receiving standard 0.9 mg/kg intravenous tissue plasminogen activator within 4.5 h of stroke onset who have good prestroke functional status (modified Rankin Scale <2, no upper age limit) will undergo multimodal computed tomography or magnetic resonance imaging. Patients who also meet dual target imaging criteria: vessel occlusion (internal carotid or middle cerebral artery) and mismatch (perfusion lesion: ischemic core mismatch ratio >1.2, absolute mismatch >10 ml, ischemic core volume <70 ml) will be randomized to either clot retrieval with the Solitaire FR device after full dose intravenous tissue plasminogen activator, or tissue plasminogen activator alone. Study Outcomes The coprimary outcome measure will be reperfusion at 24 h and favorable clinical response (reduction in National Institutes of Health Stroke Scale by ≥8 points or reaching 0–1) at day 3. Secondary outcomes include modified Rankin Scale at day 90, death, and symptomatic intracranial hemorrhage.
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Affiliation(s)
- Bruce C. V. Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Peter J. Mitchell
- Department of Radiology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Mark W. Parsons
- Priority Research Centre for Brain and Mental Health Research, John Hunter Hospital, University of Newcastle, Newcastle, New South Wales, Australia
| | - Søren Christensen
- Department of Radiology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Leonid Churilov
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
| | - Richard J. Dowling
- Department of Radiology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Helen Dewey
- Austin Health, Austin Hospital, Heidelberg, Victoria, Australia
| | - Mark Brooks
- Austin Health, Austin Hospital, Heidelberg, Victoria, Australia
| | - Ferdinand Miteff
- Priority Research Centre for Brain and Mental Health Research, John Hunter Hospital, University of Newcastle, Newcastle, New South Wales, Australia
- Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | - Christopher Levi
- Priority Research Centre for Brain and Mental Health Research, John Hunter Hospital, University of Newcastle, Newcastle, New South Wales, Australia
| | - Martin Krause
- Royal North Shore Hospital, St Leonards, New South Wales, Australia
| | | | | | | | - Timothy Kleinig
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Rebecca Scroop
- Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | | | - Alan Barber
- Auckland Hospital, University of Auckland, Auckland, New Zealand
| | - Ayton Hope
- Auckland Hospital, University of Auckland, Auckland, New Zealand
| | - Maurice Moriarty
- Auckland Hospital, University of Auckland, Auckland, New Zealand
| | - Ben McGuinness
- Auckland Hospital, University of Auckland, Auckland, New Zealand
| | - Andrew A. Wong
- Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia
| | - Alan Coulthard
- Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia
| | | | - Andrew Lee
- Flinders Medical Centre, Adelaide, South Australia, Australia
| | - Jim Jannes
- Queen Elizabeth Hospital, Adelaide, South Australia, Australia
| | - James Leyden
- Lyell McEwin Hospital, Adelaide, South Australia, Australia
| | - Thanh G. Phan
- Monash Medical Centre, Monash University, Clayton, Victoria, Australia
| | - Winston Chong
- Monash Medical Centre, Monash University, Clayton, Victoria, Australia
| | - Michael E. Holt
- Monash Medical Centre, Monash University, Clayton, Victoria, Australia
| | - Ronil V. Chandra
- Monash Medical Centre, Monash University, Clayton, Victoria, Australia
| | | | - Monica Badve
- Gold Coast University Hospital, Southport, Queensland, Australia
| | - Henry Rice
- Gold Coast University Hospital, Southport, Queensland, Australia
| | | | - Henry Ma
- Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
- Monash Medical Centre, Monash University, Clayton, Victoria, Australia
| | - Patricia M. Desmond
- Department of Radiology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Geoffrey A. Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Stephen M. Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
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1253
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Liggins JTP, Yoo AJ, Mishra NK, Wheeler HM, Straka M, Leslie-Mazwi TM, Chaudhry ZA, Kemp S, Mlynash M, Bammer R, Albers GW, Lansberg MG. A score based on age and DWI volume predicts poor outcome following endovascular treatment for acute ischemic stroke. Int J Stroke 2013; 10:705-9. [PMID: 24207136 DOI: 10.1111/ijs.12207] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2013] [Accepted: 08/30/2013] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND AIMS The Houston Intra-Arterial Therapy score predicts poor functional outcome following endovascular treatment for acute ischemic stroke based on clinical variables. The present study sought to (a) create a predictive scoring system that included a neuroimaging variable and (b) determine if the scoring systems predict the clinical response to reperfusion. METHODS Separate datasets were used to derive (n = 110 from the Diffusion and Perfusion Imaging Evaluation for Understanding Stroke Evolution 2 study) and validate (n = 125 from Massachusetts General Hospital) scoring systems that predict poor functional outcome, defined as a modified Rankin Scale score of 4-6 at 90 days. RESULTS Age (P < 0·001; β = 0·087) and diffusion-weighted imaging volume (P = 0·023; β = 0·025) were the independent predictors of poor functional outcome. The Stanford Age and Diffusion-Weighted Imaging score was created based on the patient's age (0-3 points) and diffusion-weighted imaging lesion volume (0-1 points). The percentage of patients with a poor functional outcome increased significantly with the number of points on the Stanford Age and Diffusion-Weighted Imaging score (P < 0·01 for trend). The area under the receiver operating characteristic curve for the Stanford Age and Diffusion-Weighted Imaging score was 0·82 in the derivation dataset. In the validation cohort, the area under the receiver operating characteristic curve was 0·69 for the Stanford Age and Diffusion-Weighted Imaging score and 0·66 for the Houston Intra-Arterial Therapy score (P = 0·45 for the difference). Reperfusion, but not the interactions between the prediction scores and reperfusion, were predictors of outcome (P > 0·5). CONCLUSIONS The Stanford Age and Diffusion-Weighted Imaging and Houston Intra-Arterial Therapy scores can be used to predict poor functional outcome following endovascular therapy with good accuracy. However, these scores do not predict the clinical response to reperfusion. This limits their utility as tools to select patients for acute stroke interventions.
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Affiliation(s)
- John T P Liggins
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University Medical Center, Stanford, CA, USA
| | - Albert J Yoo
- Department of Radiology, Division of Interventional Neuroradiology, Massachusetts General Hospital, Boston, MA, USA
| | - Nishant K Mishra
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University Medical Center, Stanford, CA, USA
| | - Hayley M Wheeler
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University Medical Center, Stanford, CA, USA
| | - Matus Straka
- Department of Radiology, Lucas Magnetic Resonance Spectroscopy and Imaging Center, Stanford University Medical Center, Stanford, CA, USA
| | - Thabele M Leslie-Mazwi
- Department of Radiology, Division of Interventional Neuroradiology, Massachusetts General Hospital, Boston, MA, USA
| | - Zeshan A Chaudhry
- Department of Radiology, Division of Interventional Neuroradiology, Massachusetts General Hospital, Boston, MA, USA
| | - Stephanie Kemp
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University Medical Center, Stanford, CA, USA
| | - Michael Mlynash
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University Medical Center, Stanford, CA, USA
| | - Roland Bammer
- Department of Radiology, Lucas Magnetic Resonance Spectroscopy and Imaging Center, Stanford University Medical Center, Stanford, CA, USA
| | - Gregory W Albers
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University Medical Center, Stanford, CA, USA
| | - Maarten G Lansberg
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University Medical Center, Stanford, CA, USA
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Leslie-Mazwi TM, Chandra RV, Simonsen CZ, Yoo AJ. Elderly patients and intra-arterial stroke therapy. Expert Rev Cardiovasc Ther 2013; 11:1713-23. [PMID: 24195443 DOI: 10.1586/14779072.2013.839219] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Ischemic stroke disproportionately affects the elderly, particularly those over the age of 80 years. Rates of stroke are expected to increase over the next several decades due to increasing numbers of elderly individuals, making understanding stroke treatment in this population an imperative. The only proven acute stroke therapy is early reperfusion, accomplished through intravenous or intra-arterial means. Intra-arterial stroke therapy (IAT) offers higher recanalization rates than intravenous tissue plasminogen activator, but has yet to show clear superiority over intravenous tissue plasminogen activator alone. Existing data suggest that elderly stroke patients suffer worse outcomes following IAT, despite similar rates of recanalization and symptomatic intracranial hemorrhage. This article reviews the application of IAT in the elderly population and summarizes the available studies that investigate the response of elderly patients to IAT.
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Affiliation(s)
- Thabele M Leslie-Mazwi
- Neuroendovascular, Neurologic Critical Care, Massachusetts General Hospital, Boston, USA
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Osaki M, Miyashita F, Koga M, Fukuda M, Shigehatake Y, Nagatsuka K, Minematsu K, Toyoda K. Simple clinical predictors of stroke outcome based on National Institutes of Health Stroke Scale score during 1-h recombinant tissue-type plasminogen activator infusion. Eur J Neurol 2013; 21:411-8. [DOI: 10.1111/ene.12294] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2013] [Accepted: 09/23/2013] [Indexed: 11/30/2022]
Affiliation(s)
- M. Osaki
- Department of Cerebrovascular Medicine; National Cerebral and Cardiovascular Center; Osaka Japan
| | - F. Miyashita
- Department of Cerebrovascular Medicine; National Cerebral and Cardiovascular Center; Osaka Japan
| | - M. Koga
- Division of Stroke Care Unit; National Cerebral and Cardiovascular Center; Osaka Japan
| | - M. Fukuda
- Department of Cerebrovascular Medicine; National Cerebral and Cardiovascular Center; Osaka Japan
| | - Y. Shigehatake
- Department of Cerebrovascular Medicine; National Cerebral and Cardiovascular Center; Osaka Japan
| | - K. Nagatsuka
- Department of Neurology; National Cerebral and Cardiovascular Center; Osaka Japan
| | - K. Minematsu
- Department of Cerebrovascular Medicine; National Cerebral and Cardiovascular Center; Osaka Japan
| | - K. Toyoda
- Department of Cerebrovascular Medicine; National Cerebral and Cardiovascular Center; Osaka Japan
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Wintermark M, Sanelli P, Meltzer CC. Stroke imaging: diffusion, perfusion, but no more confusion! AJNR Am J Neuroradiol 2013; 34:2053. [PMID: 23907248 DOI: 10.3174/ajnr.a3691] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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1258
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Blacker D. Some thoughts on the future of stroke. FUTURE NEUROLOGY 2013. [DOI: 10.2217/fnl.13.48] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
David Blacker speaks to Simi Thankaraj, Assistant Commissioning Editor David Blacker was born in Bunbury, Western Australia, and studied medicine at the University of Western Australia (Perth, Australia), graduating in 1991. He undertook physician and neurology specialist training in Perth. He developed an interest in acute stroke therapies early in his career, and was involved with cases treated with intra-arterial techniques in the mid-1990s. Like many young Australian neurologists, he then undertook 2 years of fellowship training at the Mayo Clinic (MN, USA). There, Blacker was mentored by Professors Bob Brown and Eelco Wijdicks, and further developed interests in stroke and acute hospital-based neurology. His return to Australia in 2003 coincided with the approval of tissue plasminogen activator as a stroke therapy. He helped establish the acute stroke team at Sir Charles Gairdner Hospital (Perth, Australia), and has continued to work on the development of stroke services locally, and across the geoprahically enormous state of Western Australia ever since. In his role as a Clinical Associate Professor of Neurology at the University of Western Australia, he is actively involved in teaching, and has a wide range of research interests mainly in acute stroke, but also in neurorehabilitation. In this interview, he shares some thoughts on the future of stroke treatment and research.
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Affiliation(s)
- David Blacker
- Department of Neurology & Clinical Neurophysiology, Sir Charles Gairdner Hospital, Perth, Western Australia, Australia
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1259
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Lin C, Li N, Wang K, Zhao X, Li BQ, Sun L, Lin YX, Fan JM, Zhang M, Sun HC. Efficacy and safety of endovascular treatment versus intravenous thrombolysis for acute ischemic stroke: a meta-analysis of randomized controlled trials. PLoS One 2013; 8:e77849. [PMID: 24204995 PMCID: PMC3814965 DOI: 10.1371/journal.pone.0077849] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2013] [Accepted: 09/04/2013] [Indexed: 01/19/2023] Open
Abstract
Background and Purpose Although endovascular therapy (ET) is increasingly used in patients with moderate to severe acute ischemic stroke, its efficacy and safety remains controversial. We performed a meta-analysis aiming to compare the benefits and safety of endovascular treatment and intravenous thrombolysis in the treatment of acute ischemic stroke. Methods We systematically searched PubMed, Embase, Science direct and Springer unitil July, 2013. The primary outcomes included good outcome (mRS ≤ 2) and excellent outcome (mRS ≤ 1) at 90 days or at trial end point. Secondary outcomes were occurrence of symptomatic hemorrhage and all-cause mortality. Results Using a prespecified search strategy, 5 RCTs with 1106 patients comparing ET and intravenous thrombolysis (IVT) were included in the meta-analysis. ET and IVT were associated with similar good (43.06% vs 41.78%; OR=1.14; 95% CI, 0.77 to 1.69; P=0.52;) and excellent (30.43% vs 30.42%; OR=1.05; 95% CI, 0.80 to 1.38; P=0.72;) outcome. For additional end points, ET was not associated with increased occurrence of symptomatic hemorrhage (6.25% vs. 6.22%; OR=1.03; 95% CI, 0.62 to 1.69; P=0.91;), or all-cause mortality (18.45% vs. 17.35%; OR=1.00; 95% CI, 0.73 to 1.39; P=0.99;). Conclusions Formal meta-analysis indicates that there are similar safety outcomes and functional independence with endovascular therapy and intravenous thrombolysis for acute ischemic stroke.
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Affiliation(s)
- Chao Lin
- Department of Neurosurgery, Jinling Hospital, Nanjing University, Nanjing, China
| | - Nan Li
- Department of Urology, Gulou Hospital, Nanjing University, Nanjing, China
| | - Kang Wang
- Department of Neurosurgery, Jinling Hospital, Nanjing University, Nanjing, China
| | - Xin Zhao
- Department of Neurosurgery, Jinling Hospital, Nanjing University, Nanjing, China
| | - Bai-Qiang Li
- Department of Neurosurgery, Jinling Hospital, Nanjing University, Nanjing, China
| | - Lei Sun
- Department of Neurosurgery, Jinling Hospital, Nanjing University, Nanjing, China
| | - Yi-Xing Lin
- Department of Neurosurgery, Jinling Hospital, Nanjing University, Nanjing, China
| | - Jie-Mei Fan
- Department of Neurosurgery, Jinling Hospital, Nanjing University, Nanjing, China
| | - Miao Zhang
- Department of Urology, Gulou Hospital, Nanjing University, Nanjing, China
- * E-mail: (HCS); (MZ)
| | - Hai-Chen Sun
- Department of Neurosurgery, Jinling Hospital, Nanjing University, Nanjing, China
- * E-mail: (HCS); (MZ)
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1260
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Stampfl S, Ringleb PA, Möhlenbruch M, Hametner C, Herweh C, Pham M, Bösel J, Haehnel S, Bendszus M, Rohde S. Emergency cervical internal carotid artery stenting in combination with intracranial thrombectomy in acute stroke. AJNR Am J Neuroradiol 2013; 35:741-6. [PMID: 24157733 DOI: 10.3174/ajnr.a3763] [Citation(s) in RCA: 97] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
BACKGROUND AND PURPOSE In past years, thrombectomy has become a widely used procedure in interventional neuroradiology for the treatment of acute intracranial occlusions. However, in 10-20% of patients, there are additional occlusions or stenotic lesions of the ipsilateral cervical internal carotid artery. The purpose of this study was to evaluate the feasibility of emergency carotid artery stent placement in combination with intracranial thrombectomy and the clinical outcome of the treated patients. MATERIALS AND METHODS We analyzed clinical and angiographic data of patients who underwent emergency cervical ICA stent placement and intracranial thrombectomy with stent-retriever devices in our institution between November 2009 and July 2012. Recanalization was assessed according to the Thrombolysis in Cerebral-Infarction score. Clinical outcome was evaluated at discharge (NIHSS) and after 3 months (mRS). RESULTS Overall, 24 patients were treated. The mean age was 67.2 years; mean occlusion time, 230.2 minutes. On admission, the median NIHSS score was 18. In all patients, the Thrombolysis in Cerebral Infarction score was zero before the procedure. Stent implantation was feasible in all cases. In 15 patients (62.5%), a Thrombolysis in Cerebral Infarction score ≥ 2b could be achieved. Six patients (25%) improved ≥10 NIHSS points between admission and discharge. After 90 days, the median mRS score was 3.0. Seven patients (29.2%) had a good clinical outcome (mRS 0-2), and 4 patients (16.6%) died, 1 due to fatal intracranial hemorrhage. Overall, symptomatic intracranial hemorrhage occurred in 4 patients (16.6%). CONCLUSIONS Emergency ICA stent implantation was technically feasible in all patients, and the intracranial recanalization Thrombolysis in Cerebral Infarction score of ≥2b was reached in a high number of patients. Clinical outcome and mortality seem to be acceptable for a cohort with severe stroke. However, a high rate of symptomatic intracranial hemorrhage occurred in our study.
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Affiliation(s)
- S Stampfl
- From the Departments of Neuroradiology (S.S., M.M., C. Herweh, M.P., S.H., M.B., S.R.)
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Gascou G, Lobotesis K, Machi P, Maldonado I, Vendrell JF, Riquelme C, Eker O, Mercier G, Mourand I, Arquizan C, Bonafé A, Costalat V. Stent retrievers in acute ischemic stroke: complications and failures during the perioperative period. AJNR Am J Neuroradiol 2013; 35:734-40. [PMID: 24157734 DOI: 10.3174/ajnr.a3746] [Citation(s) in RCA: 139] [Impact Index Per Article: 12.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND PURPOSE Stent retriever-assisted thrombectomy promotes high recanalization rates in acute ischemic stroke. Nevertheless, complications and failures occur in more than 10% of procedures; hence, there is a need for further investigation. MATERIALS AND METHODS A total of 144 patients with ischemic stroke presenting with large-vessel occlusion were prospectively included. Patients were treated with stent retriever-assisted thrombectomy ± IV fibrinolysis. Baseline clinical and imaging characteristics were incorporated in univariate and multivariate analyses. Predictors of recanalization failure (TICI 0, 1, 2a), and of embolic and hemorrhagic complications were reported. The relationship between complication occurrence and periprocedural mortality rate was studied. RESULTS Median age was 69.5 years, and median NIHSS score was 18 at presentation. Fifty patients (34.7%) received stand-alone thrombectomy, and 94 (65.3%) received combined therapy. The procedural failure rate was 13.9%. Embolic complications were recorded in 12.5% and symptomatic intracranial hemorrhage in 7.6%. The overall rate of failure, complications, and/or death was 39.6%. The perioperative mortality rate was 18.4% in the overall cohort but was higher in cases of failure (45%; P = .003), embolic complications (38.9%; P = .0176), symptomatic intracranial hemorrhages (45.5%; P = .0236), and intracranial stenosis (50%; P = .0176). Concomitant fibrinolytic therapy did not influence the rate of recanalization or embolic complication, or the intracranial hemorrhage rate. Age was the only significant predictive factor of intracranial hemorrhage (P = .043). CONCLUSIONS The rate of perioperative mortality was significantly increased in cases of embolic and hemorrhagic complications, as well as in cases of failure and underlying intracranial stenoses. Adjunctive fibrinolytic therapy did not improve the recanalization rate or collateral embolic complication rate. The rate of symptomatic intracranial hemorrhage was not increased in cases of combined treatment.
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Affiliation(s)
- G Gascou
- From CHU Montpellier, Neuroradiology (G.G., P.M., I.M., J.F.V., C.R., O.E., A.B., V.C.)
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1262
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Eesa M, Burns PA, Almekhlafi MA, Menon BK, Wong JH, Mitha A, Morrish W, Demchuk AM, Goyal M. Mechanical thrombectomy with the Solitaire stent: is there a learning curve in achieving rapid recanalization times? J Neurointerv Surg 2013; 6:649-51. [PMID: 24151114 DOI: 10.1136/neurintsurg-2013-010906] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
METHODS In acute ischemic stroke, good outcome following successful recanalization is time dependent. In patients undergoing endovascular therapy at our institution, recanalization times with the Solitaire stent were retrospectively evaluated to assess for the presence of a learning curve in achieving rapid recanalization. METHODS We reviewed patients who presented to our stroke center and achieved successful recanalization with the Solitaire stent exclusively. Time intervals were calculated (CT to angiography arrival, angiography arrival to groin puncture, groin puncture to first deployment, and deployment to recanalization) from time stamped images and angiography records. Patients were divided into three sequential groups, with overall CT to recanalization time and subdivided time intervals compared. RESULTS 83 patients were treated with the Solitaire stent from May 2009 to February 2012. Recanalization (Thrombolyis in Cerebral Infarction score 2A) occurred in 75 (90.4%) patients. CT to recanalization demonstrated significant improvement over time, which was greatest between the first 25 and the most recent 25 cases (161-94 min; p<0.01). The maximal contribution to this was from improvements in first stent deployment to recanalization time (p=0.001 between the first and third groups), with modest contributions from moving patients from CT to the angiography suite faster (p=0.02 between the first and third groups) and from groin puncture to first stent deployment (p=0.02 between the first and third groups). CONCLUSIONS There is a learning curve involved in the efficient use of the Solitaire stent in endovascular acute stroke therapy. Along with improvements in patient transfer to angiography and improved efficiency with intracranial access, mastering this device contributed significantly towards reducing recanalization times.
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Affiliation(s)
- M Eesa
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - P A Burns
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - M A Almekhlafi
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada Department of Internal Medicine, King Abdulaziz University, Jeddah, Western, Saudi Arabia
| | - B K Menon
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - J H Wong
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - A Mitha
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - W Morrish
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - A M Demchuk
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - M Goyal
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
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Tansy AP, Liebeskind DS. The goldilocks dilemma in acute ischemic stroke. Front Neurol 2013; 4:164. [PMID: 24155740 PMCID: PMC3801149 DOI: 10.3389/fneur.2013.00164] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2013] [Accepted: 10/06/2013] [Indexed: 12/23/2022] Open
Abstract
Despite the advent of and exciting advances in novel endovascular therapies, t-PA remains the only proven treatment for acute ischemic stroke to date. Although a variety of reasons likely underlie why past trials of endovascular strategies have been unsuccessful, we address in this perspective piece one critical unknown for which a solution is undoubtedly necessary if future ones are to meet with success: determination and selection of patients that are “just right” for endovascular treatments, or the Goldilocks dilemma. Key clinical criteria highlighted in past trials may help provide a solution to this critical problem. However, for them to do so, we propose that they must be applied in service of a model that accounts for the nuanced, dynamic nature of acute ischemic stroke better than the prevailing “time is brain” model. We provide and examine three clinical cases to illustrate this proposal towards solving the Goldilocks dilemma and advancing treatment in acute ischemic stroke. Further, we address our field’s ongoing challenge and mission in the meantime to best care for the “not-so-right” patients, by far the majority of the affected stroke population.
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Affiliation(s)
- Aaron P Tansy
- Department of Neurology, UCLA Stroke Center, University of California , Los Angeles, CA , USA
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1264
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Moreno A, Hernández-Fernández F. [IMSIII, SYNTHESIS, and MR-RESCUE studies: the end of endovascular treatment for stroke?]. RADIOLOGIA 2013; 56:2-6. [PMID: 24148839 DOI: 10.1016/j.rx.2013.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Revised: 08/19/2013] [Accepted: 08/23/2013] [Indexed: 11/25/2022]
Abstract
Last March, in a single issue New England Journal of Medicine published 3 studies that evaluated the efficacy of endovascular treatment for ischemic stroke, leading to a heated controversy between neurologists and interventional neuroradiologists. The negative results have resulted in numerous reviews pointing out serious methodological defects. In this article, we analyze the outcomes of thrombolytic treatment for stroke and discuss the strengths and weaknesses of the three above-mentioned studies. Despite the negative results, these studies can point the way for new trials that will justify this treatment modality that is backed up by scientific evidence.
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Affiliation(s)
- A Moreno
- Sección de Neurorradiología Diagnóstica y Terapéutica, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, España
| | - F Hernández-Fernández
- Servicio de Neurología, Complejo Hospitalario Universitario de Albacete, Albacete, España.
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Abstract
Major ischaemic stroke is a leading cause of morbidity and mortality in industrialized countries. For patients with acute stroke, fast and effective vessel recanalization is important for successful treatment. Neurothrombectomy--that is, angiographically performed mechanical thrombus removal from intracranial arteries--results in higher recanalization rates than with pharmaceutical thrombolysis alone, but the value of this treatment in terms of clinical outcome remains to be established. This article summarizes the history of intra-arterial stroke treatment, outlines the recent developments and the different techniques used, and discusses the results of current studies on neurothrombectomy. Owing to the high morphological and clinical variability of stroke, careful patient selection in future randomized controlled trials will be crucial for assessment of the true potential of neurothrombectomy.
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1266
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Jansen O, Macho JM, Killer-Oberpfalzer M, Liebeskind D, Wahlgren N. Neurothrombectomy for the treatment of acute ischemic stroke: results from the TREVO study. Cerebrovasc Dis 2013; 36:218-25. [PMID: 24135533 DOI: 10.1159/000353990] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2013] [Accepted: 06/20/2013] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Fast recanalization has been shown to be one of the most important factors for good clinical outcome in stroke patients with acute large vessel occlusion. While intravenous thrombolysis has been shown to be of limited effect in patients with large clot burden, intra-arterial neurothrombectomy offers a new and promising possibility to achieve high recanalization rates within a short time. The Trevo device is a stent-like retriever and was primarily designed to remove thrombus in patients experiencing an acute ischemic stroke. We report on the results of the TREVO Study, which was a prospective, multicenter study in acute stroke patients treated with the Trevo device. METHODS Patients were recruited in seven European centers under the control of an external monitor. Centers were selected because of their long experience with interventional stroke therapy especially with neurothrombectomy. We included adults aged 18-85 years with angiographically confirmed large vessel occlusion strokes and NIHSS scores of 8-30 and treatable within 8 h of symptom onset. The primary endpoint was revascularization, defined as at least TICI (thrombolysis in cerebral infarction) 2a. The revascularization scores were assessed by an independent core lab. Secondary endpoints were clinical outcome at 90 days (mRS 90), any device-related serious adverse events and the rate of symptomatic intracerebral hemorrhages. RESULTS 60 patients were enrolled. The overall recanalization rate (≥TICI 2a) was 91.7% and TICI 2b and 3 was achieved in 78.3%. At 90 days, 55% of the patients had a favorable neurological outcome (mRS 0-2) and 20% had died. Patients with successful recanalization (TICI 2a,b/3) had a good 90-day neurological outcome (mRS 0-2) in 60%, whereas no patient without recanalization had a mRS 90 <3. The overall rate of symptomatic intracerebral hemorrhage according to the SITS-MOST criteria was 5% (3/60). CONCLUSIONS The study suggest that the Trevo Stentriever™ is a safe and effective device, which may offer the possibility of a high reperfusion rate and a high rate of patients with good clinical outcome after acute ischemic stroke due to proximal arterial occlusion. Randomized trials comparing intravenous thrombolysis with neurothrombectomy are now urgently needed to evaluate this new approach of interventional stroke therapy.
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Affiliation(s)
- Olav Jansen
- Department of Neuroradiology, University Hospital Schleswig-Holstein Campus Kiel, Kiel, Germany
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Nogueira RG, Gupta R, Dávalos A. IMS-III and SYNTHESIS Expansion trials of endovascular therapy in acute ischemic stroke: how can we improve? Stroke 2013; 44:3272-4. [PMID: 24114453 DOI: 10.1161/strokeaha.113.002380] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Raul G Nogueira
- From the Departments of Neurology, Neurosurgery, and Radiology, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA (R.G.N., R.G.); and Department of Neurosciences, Hospital Universitari Germans Trias i Pujol, Universitat Autònoma de Barcelona, Badalona, Barcelona, Spain (A.D.)
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1268
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Pannell JS, Khalessi AA. Risk-stratification of ischemic stroke patients on the basis of anatomic criteria essential to the prevention of hospital-acquired conditions and performance along patient safety indicators. World Neurosurg 2013; 80:777-9. [PMID: 24103547 DOI: 10.1016/j.wneu.2013.09.050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2013] [Accepted: 09/30/2013] [Indexed: 10/26/2022]
Affiliation(s)
- J Scott Pannell
- Division of Neurological Surgery, University of California, San Diego, San Diego, California, USA
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1269
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Kamalian S, Morais LT, Pomerantz SR, Aceves M, Sit SP, Bose A, Hirsch JA, Lev MH, Yoo AJ. Clot length distribution and predictors in anterior circulation stroke: implications for intra-arterial therapy. Stroke 2013; 44:3553-6. [PMID: 24105699 DOI: 10.1161/strokeaha.113.003079] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Thin-section noncontrast computed tomography images can be used to measure hyperdense clot length in acute ischemic stroke. Clots≥8 mm have a very low probability of intravenous tissue-type plasminogen activator recanalization and hence may benefit from a bridging intra-arterial approach. To understand the prevalence of such clots, we sought to determine the distribution and predictors of clot lengths in consecutive anterior circulation proximal artery occlusions. METHODS Of 623 consecutive patients with acute ischemic stroke, 53 met inclusion criteria: presentation<8 hours from onset; intracranial internal carotid artery-terminus or proximal-middle cerebral artery occlusion; admission thin-slice noncontrast computed tomography (≤2.5 mm); and no intravenous tissue-type plasminogen activator pretreatment. For each patient, hyperdense clot length was measured and recorded along with additional relevant imaging and clinical data. RESULTS Mean age was 70 years, and mean time to computed tomography was 213 minutes. Median baseline National Institutes of Health Stroke Scale was 16.5. Occlusions were located in the internal carotid artery-terminus (34% [18 of 53]), middle cerebral artery M1 (49% [26 of 53]) and M2 segments (17% [9 of 53]). Hyperdense thrombus was visible in 96%, with mean and median clot lengths (mm) of 18.5 (±14.2) and 16.1 (7.6-25.2), respectively. Occlusion location was the strongest predictor of clot length (multivariate, P=0.02). Clot length was ≥8 mm in 94%, 73%, and 22% of internal carotid artery-terminus, M1, and M2 occlusions, respectively. CONCLUSIONS The majority of anterior circulation proximal occlusions are ≥8 mm long, helping to explain the low published rates of intravenous tissue-type plasminogen activator recanalization. Internal carotid artery-terminus occlusion is an excellent marker for clot length≥8 mm; vessel-imaging status alone may be sufficient. Thin-section noncontrast computed tomography seems useful for patients with middle cerebral artery occlusion because of the wide variability of clot lengths.
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Affiliation(s)
- Shervin Kamalian
- From the Department of Radiology, Massachusetts General Hospital and Harvard Medical School, Boston, MA (S.K., L.T.M., S.R.P., J.A.H., M.H.L., A.J.Y.); and Penumbra, Inc, Alameda, CA (M.A., S.P.S., A.B.)
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Endovascular Treatment in Two Cases of Bilateral Ischemic Stroke. Cardiovasc Intervent Radiol 2013; 37:829-34. [DOI: 10.1007/s00270-013-0746-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2013] [Accepted: 08/26/2013] [Indexed: 10/26/2022]
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Widimsky P, Coram R, Abou-Chebl A. Reperfusion therapy of acute ischaemic stroke and acute myocardial infarction: similarities and differences. Eur Heart J 2013; 35:147-55. [PMID: 24096325 PMCID: PMC3890694 DOI: 10.1093/eurheartj/eht409] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
The evolution of reperfusion therapy in acute myocardial infarction and acute ischaemic stroke has many similarities: thrombolysis is superior to placebo, intra-arterial thrombolysis is not superior to intravenous (i.v.), facilitated intervention is of questionable value, and direct mechanical recanalization without thrombolysis is proven (myocardial infarction) or promising (stroke) to be superior to thrombolysis-but only when started with no or minimal delay. However, there are also substantial differences. Direct catheter-based thrombectomy in acute ischaemic stroke is more difficult than primary angioplasty (in ST-elevation myocardial infarction [STEMI]) in many ways: complex pre-intervention diagnostic workup, shorter time window for clinically effective reperfusion, need for an emergent multidisciplinary approach from the first medical contact, vessel tortuosity, vessel fragility, no evidence available about dosage and combination of peri-procedural antithrombotic drugs, risk of intracranial bleeding, unclear respective roles of thrombolysis and mechanical intervention, lower number of suitable patients, and thus longer learning curves of the staff. Thus, starting acute stroke interventional programme requires a lot of learning, discipline, and humility. Randomized trials comparing different reperfusion strategies provided similar results in acute ischaemic stroke as in STEMI. Thus, it might be expected that also a future randomized trial comparing direct (primary) catheter-based thrombectomy vs. i.v. thrombolysis could show superiority of the mechanical intervention if it would be initiated without delay. Such randomized trial is needed to define the role of mechanical intervention alone in acute stroke treatment.
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Affiliation(s)
- Petr Widimsky
- Cardiocenter, Third Faculty of Medicine, Charles University Prague, Ruska 87, 100 00 Prague 10, Czech Republic
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1272
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Kwak JH, Zhao L, Kim JK, Park S, Lee DG, Shim JH, Lee DH, Kim JS, Suh DC. The outcome and efficacy of recanalization in patients with acute internal carotid artery occlusion. AJNR Am J Neuroradiol 2013; 35:747-53. [PMID: 24091441 DOI: 10.3174/ajnr.a3747] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND PURPOSE Acute occlusion of the ICA is often associated with poor outcomes and severe neurologic deficits. This study was conducted to evaluate outcome of the occluded ICA and efficacy of recanalization under protective flow arrest. MATERIALS AND METHODS Fifty consecutive patients who underwent endovascular treatment for acute ICA occlusion were identified from the prospectively collected data base. We assessed NIHSSo, occlusion type (cardioembolism vs atherosclerosis), occlusion level (supraclinoid-terminal, petrocavernous, or bulb-cervical), recanalization degree (TICI), and efficacy of recanalization (protective flow arrest vs nonprotection) leading to better outcome. RESULTS Successful recanalization (TICI ≥ 2) was obtained in 90% of patients and good recovery (mRS ≤ 2) in 60% of patients. Good outcome was related to National Institutes of Health Stroke Scale score on admission (P < .001), TICI (P < .007), occlusion type (P = .022), and occlusion level (P = .038). Poor initial patient status, less recanalization, cardioembolism, and supraclinoid-terminal occlusion were associated with poor prognosis. Application of protective flow arrest led to better outcome in the distal ICA segment than in the bulb-cervical segment. CONCLUSIONS In addition to the initial patient status and successful recanalization, the occlusion level or type of the occluded ICA could affect clinical outcome. In this study, treatment benefits of protective flow arrest were accentuated in patients with ICA occlusion above the bulb-cervical segment.
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Affiliation(s)
- J H Kwak
- From the Department of Radiology and Research Institute of Radiology (J.H.K., L.Z., S.P., D.-g.L., J.H.S., D.H.L., D.C.S.)
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Liebeskind DS, Cucchiara B. The quest to prove endovascular stroke therapy: searching for the "sweet spot" in patient selection. Mayo Clin Proc 2013; 88:1039-41. [PMID: 24079674 PMCID: PMC4159141 DOI: 10.1016/j.mayocp.2013.08.008] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2013] [Accepted: 08/23/2013] [Indexed: 01/21/2023]
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Eilaghi A, Brooks J, d'Esterre C, Zhang L, Swartz RH, Lee TY, Aviv RI. Reperfusion Is a Stronger Predictor of Good Clinical Outcome than Recanalization in Ischemic Stroke. Radiology 2013; 269:240-8. [PMID: 23716707 DOI: 10.1148/radiol.13122327] [Citation(s) in RCA: 73] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Armin Eilaghi
- Robarts Research Institute, University of Western Ontario, London, Ont, Canada; Department of Medical Imaging, Odette Cancer Centre, and Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, 2075 Bayview Ave, Toronto, ON, Canada M4N 3M5
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Singh B, Parsaik AK, Prokop LJ, Mittal MK. Endovascular therapy for acute ischemic stroke: a systematic review and meta-analysis. Mayo Clin Proc 2013; 88:1056-65. [PMID: 24079677 PMCID: PMC3883722 DOI: 10.1016/j.mayocp.2013.07.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2013] [Revised: 06/16/2013] [Accepted: 07/05/2013] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To consolidate the evidence from randomized trials for the use of endovascular therapy (ET) in patients with acute ischemic stroke. METHODS We searched major databases (MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, and Scopus) from their inception to February 12, 2013, for randomized trials evaluating the efficacy of ET compared with standard of care for acute ischemic stroke. Pooled absolute and relative risk estimates were synthesized by using a random-effects model. Heterogeneity was assessed by using Q statistic and I(2) statistic. Subset analysis was performed for patients with severe stroke (National Institutes of Health Stroke Scale score ≥20). The study was conducted from January 15, 2013 to April 30, 2013. RESULTS Of the 1252 retrieved articles, 5 randomized trials enrolling 1197 patients with acute ischemic stroke were included. Seven hundred eleven patients received ET, and 486 received intravenous (IV) tissue plasminogen activator. There was no significant improvement in any of the outcomes in patients receiving ET compared with those receiving IV thrombolysis. On subgroup analysis, ET was found to have better outcomes in patients with severe stroke (National Institutes of Health Stroke Scale score ≥20), showing a dose-response gradient and improving excellent, good, and fair outcomes by an additional 4%, 7%, and 13%, respectively, compared with IV thrombolysis. CONCLUSION Overall, ET is not superior to IV thrombolysis for acute ischemic strokes (level B recommendation). However, ET showed promise and improved outcomes in patients with severe strokes, but the evidence is limited due to sample size. There is a need for further trials evaluating the role of ET in this high-risk group.
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Higashida R, Alberts MJ, Alexander DN, Crocco TJ, Demaerschalk BM, Derdeyn CP, Goldstein LB, Jauch EC, Mayer SA, Meltzer NM, Peterson ED, Rosenwasser RH, Saver JL, Schwamm L, Summers D, Wechsler L, Wood JP. Interactions Within Stroke Systems of Care. Stroke 2013; 44:2961-84. [DOI: 10.1161/str.0b013e3182a6d2b2] [Citation(s) in RCA: 146] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
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1277
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Yoo HS, Kim YD, Lee HS, Song D, Song TJ, Kim BM, Kim DJ, Kim DI, Heo JH, Nam HS. Repeated thrombolytic therapy in patients with recurrent acute ischemic stroke. J Stroke 2013; 15:182-8. [PMID: 24396812 PMCID: PMC3859005 DOI: 10.5853/jos.2013.15.3.182] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2013] [Revised: 08/20/2013] [Accepted: 08/20/2013] [Indexed: 11/17/2022] Open
Abstract
Background and Purpose Widespread use of thrombolytic treatments, along with improved chances of survival after an initial ischemic stroke, increases the possibility of repeated thrombolysis. There are few reports, however, regarding repeated thrombolysis in patients who have suffered acute ischemic stroke. We explored the number and outcome of patients with repeated thrombolytic therapy in the era of multimodal thrombolytic treatments. Methods We investigated patients with acute ischemic stroke who had received thrombolytic treatments for a period of 10 years. Number of thrombolysis was determined in each patient. Recanalization was defined as Thrombolysis in Cerebral Infarction grading ≥2a. Symptomatic hemorrhagic transformation was defined as any increase in the National Institutes of Health Stroke Scale score that could be attributed to intracerebral hemorrhage. A good outcome was defined as a modified Rankin scale score ≤2. Results Of the 437 patients who received thrombolytic treatments, only 7 underwent repeated thrombolysis (1.6%). The median age at the time of repeated thrombolytic therapy was 71 years old; 4 of the patients were female. All patients had 1 or more potential sources of cardiac embolism. Recanalization was achieved in all patients, in both the first and the second thrombolysis. No symptomatic intracranial hemorrhage occurred after repeated thrombolytic treatments. Five patients (71.4%) showed good outcomes at 3 months. Conclusions Repeated thrombolysis for recurrent acute ischemic stroke appears to be safe and feasible. Among patients who experience recurrent acute ischemic stroke, thrombolytic therapy could be considered even if the patient has had previous thrombolytic treatments.
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Affiliation(s)
- Han Soo Yoo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Hye Sun Lee
- Department of Biostatistics, Yonsei University College of Medicine, Seoul, Korea
| | - Dongbeom Song
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Tae Jin Song
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Byung Moon Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Joon Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Dong Ik Kim
- Department of Radiology, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Hoe Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul, Korea
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1278
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Johnston SC, Hauser SL. The dangers of clinical conviction: an "M&M" of endovascular therapies for stroke. Ann Neurol 2013; 73:A5-6. [PMID: 23868363 DOI: 10.1002/ana.23942] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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Janjua N, Qureshi AI, Zaidat OO. Systemization of advanced stroke care: the dollars and sense of comprehensive stroke centers. J Neurointerv Surg 2013; 6:162-5. [DOI: 10.1136/neurintsurg-2013-010938] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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1280
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Montaño A, Staff I, McCullough LD, Fortunato G. Community implementation of intravenous thrombolysis for acute ischemic stroke in the 3- to 4.5-hour window. Am J Emerg Med 2013; 31:1707-9. [PMID: 24060324 DOI: 10.1016/j.ajem.2013.08.032] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2013] [Accepted: 08/15/2013] [Indexed: 10/26/2022] Open
Abstract
BACKGROUND Intravenous (IV) tissue plasminogen activator (tPA) administration for ischemic stroke between 3 and 4.5 hours after onset was found to be safe and beneficial in the ECASS III trial. However, its use has remained controversial, and its benefit as applied in routine practice at community stroke centers is less well defined. METHODS This retrospective database study compared safety and clinical outcomes in 500 patients given IV tPA either from 0 to 3 or 3 to 4.5 hours after onset at a high-volume community center from January 2008 to October 2012. Additional independent variables included for univariate and multivariate analysis were age, sex, hypertension, diabetes mellitus, National Institutes of Health stroke scale on arrival. RESULTS There were no significant differences seen in rates of symptomatic intracranial hemorrhage (3.8% vs 5.8%, P > .05), in-hospital mortality, or Barthel index at 3 months between groups. In addition, tPA administration despite ECASS III contraindications did not appear to be an independent predictor of hemorrhage in the first 24 hours. DISCUSSION Our results show that the conclusions of the ECASS III trial can be applied to routine stroke treatment at a community center and that IV thrombolysis in the 3- to 4.5-hour window results in similar safety and efficacy functional outcome at 3 months compared with administration before 3 hours after onset.
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Affiliation(s)
- Arturo Montaño
- Department of Neurology, University of California, San Francisco, CA 94114, USA.
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1281
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Asif KS, Lazzaro MA, Zaidat O. Identifying delays to mechanical thrombectomy for acute stroke: onset to door and door to clot times. J Neurointerv Surg 2013; 6:505-10. [DOI: 10.1136/neurintsurg-2013-010792] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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1283
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Balami JS, Hadley G, Sutherland BA, Karbalai H, Buchan AM. The exact science of stroke thrombolysis and the quiet art of patient selection. ACTA ACUST UNITED AC 2013; 136:3528-53. [PMID: 24038074 DOI: 10.1093/brain/awt201] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
Abstract
The science of metric-based patient stratification for intravenous thrombolysis, revolutionized by the landmark National Institute of Neurological Disorders and Stroke trial, has transformed acute ischaemic stroke therapy. Recanalization of an occluded artery produces tissue reperfusion that unequivocally improves outcome and function in patients with acute ischaemic stroke. Recanalization can be achieved mainly through intravenous thrombolysis, but other methods such as intra-arterial thrombolysis or mechanical thrombectomy can also be employed. Strict guidelines preclude many patients from being treated by intravenous thrombolysis due to the associated risks. The quiet art of informed patient selection by careful assessment of patient baseline factors and brain imaging could increase the number of eligible patients receiving intravenous thrombolysis. Outside of the existing eligibility criteria, patients may fall into therapeutic 'grey areas' and should be evaluated on a case by case basis. Important factors to consider include time of onset, age, and baseline blood glucose, blood pressure, stroke severity (as measured by National Institutes of Health Stroke Scale) and computer tomography changes (as measured by Alberta Stroke Programme Early Computed Tomography Score). Patients with traditional contraindications such as wake-up stroke, malignancy or dementia may have the potential to receive benefit from intravenous thrombolysis if they have favourable predictors of outcome from both clinical and imaging criteria. A proportion of patients experience complications or do not respond to intravenous thrombolysis. In these patients, other endovascular therapies or a combination of both may be used to provide benefit. Although an evidence-based approach to intravenous thrombolysis for acute ischaemic stroke is pivotal, it is imperative to examine those who might benefit outside of protocol-driven practice.
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Affiliation(s)
- Joyce S Balami
- 1 Acute Stroke Programme, Department of Medicine and Clinical Geratology, Oxford University Hospitals NHS Trust, Oxford, UK
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1284
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[Anesthesia in the angiography suite : More than dancing in the dark]. Anaesthesist 2013; 62:687-91. [PMID: 24030857 DOI: 10.1007/s00101-013-2228-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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1285
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Affiliation(s)
- Michael Tymianski
- From the Toronto Western Hospital Research Institute, University Health Network, Toronto, ON, Canada; and Departments of Surgery and Physiology, University of Toronto, Toronto, ON, Canada
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1286
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Seiffge DJ, Karagiannis A, Strbian D, Gensicke H, Peters N, Bonati LH, Kotisaari K, Leppä M, Kejda-Scharler J, Tränka C, Ginsbach P, Tatlisumak T, Lyrer PA, Engelter ST. Simple variables predict miserable outcome after intravenous thrombolysis. Eur J Neurol 2013; 21:185-91. [PMID: 24010545 DOI: 10.1111/ene.12254] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2013] [Accepted: 07/26/2013] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE To test the predictability of miserable outcome amongst ischaemic stroke patients receiving intravenous thrombolysis (IVT) based on a simple variables model (SVM) and to compare the model's predictive performance with that of an existing score which includes imaging and laboratory parameters (DRAGON). METHODS The SVM consists of the parameters age, independence before stroke, normal Glasgow coma verbal score, able to lift arms and able to walk. In a derivation cohort (n = 1346) and a validation cohort (n = 638) of consecutive IVT-treated stroke patients, the probability estimated by SVM and the observed occurrence of miserable 3-month outcome (modified Rankin score 5-6) were compared. The performances of SVM and the DRAGON score were compared. The area under the receiver operating curve (AUC) (95% confidence interval, CI) and the bootstrapping approach were used to compare the predictive performance. RESULTS The AUCs to predict miserable outcome in the derivation cohort were 0.807 (95% CI 0.774-0.838) using the SVM and 0.822 (0.790-0.850) using the DRAGON score (P = 0.3). For the validation cohort, AUCs were 0.786 (0.742-0.829) for the SVM and 0.809 (0.774-0.845) for the DRAGON score (P = 0.23). Only one patient with an SVM probability of >70% for miserable outcome in either cohort had a good outcome whilst 83% had a miserable outcome. An online SVM calculator to estimate the probability of miserable outcome for individual patients is available under http://www.unispital-basel.ch/SVM-Tool. CONCLUSION The SVM was similar in accuracy to the DRAGON score for predicting miserable outcome after IVT. As these simple variables are available already at the pre-hospital stage, the SVM may facilitate and accelerate pre-hospital triage of patients at high risk for miserable outcome after IVT towards endovascular treatment.
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Affiliation(s)
- D J Seiffge
- Department of Neurology, University Hospital Basel, Basel, Switzerland
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1287
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González RG, Furie KL, Goldmacher GV, Smith WS, Kamalian S, Payabvash S, Harris GJ, Halpern EF, Koroshetz WJ, Camargo ECS, Dillon WP, Lev MH. Good outcome rate of 35% in IV-tPA-treated patients with computed tomography angiography confirmed severe anterior circulation occlusive stroke. Stroke 2013; 44:3109-13. [PMID: 24003051 DOI: 10.1161/strokeaha.113.001938] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND PURPOSE To determine the effect of intravenous tissue plasminogen activator (IV-tPA) on outcomes in patients with severe major anterior circulation ischemic stroke. METHODS Prospectively, 649 patients with acute stroke had admission National Institutes of Health stroke scale (NIHSS) scores, noncontrast computed tomography (CT), CT angiography (CTA), and 6-month outcome assessed using modified Rankin scale. IV-tPA treatment decisions were made before CTA, at the time of noncontrast CT scanning, as per routine clinical protocol. Severe symptoms were defined as NIHSS>10. Poor outcome was defined as modified Rankin scale >2. Major occlusions were identified on CTA. Univariate and multivariate stepwise-forward logistic regression analyses of the full cohort were performed. RESULTS Of 649 patients, 188 (29%) patients presented with NIHSS>10, and 64 out of 188 (34%) patients received IV-tPA. Admission NIHSS, large artery occlusion, and IV-tPA all independently predicted good outcomes; however, a significant interaction existed between IV-tPA and occlusion (P<0.001). Of the patients who presented with NIHSS>10 with anterior circulation occlusion, twice the percentage had good outcomes if they received IV-tPA (17 out of 49 patients, 35%) than if they did not (13 out of 77 patients, 17%; P=0.031). The number needed to treat was 7 (95% confidence interval, 3-60). CONCLUSIONS IV-tPA treatment resulted in significantly better outcomes in patients with severely symptomatic stroke with major anterior circulation occlusions. The 35% good outcome rate was similar to rates found in endovascular therapy trials. Vascular imaging may help in patient selection and stratification for trials of IV-thrombolytic and endovascular therapies.
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Affiliation(s)
- R Gilberto González
- From the Department of Radiology (R.G.G., K.L.F., G.V.G., S.K., S.P., G.J.H., E.F.H., E.C.S.C., M.H.L.), and Department of Radiology and Institute for Technology Assessment (E.F.H.), Massachusetts General Hospital and Harvard Medical School, Boston, MA; ICON Medical Imaging (Beacon Bioscience), North Wales, PA (G.V.G.); Department of Neurology (W.S.S.), and Department of Radiology (W.P.D.), University of California at San Francisco, CA; Department of Radiology, University of Minnesota, Minneapolis (S.P.); National Institutes of Neurological Disorders and Stroke, Bethesda, MD (W.J.K.); Department of Neurology, Boston University Medical Center, MA (E.C.S.C.); and Department of Neurology, Rhode Island Hospital and Warren Alpert Medical School, Brown University, Providence, RI (K.L.F.)
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Barreto AD, Pedroza C, Grotta JC. Adjunctive medical therapies for acute stroke thrombolysis: is there a CLEAR-ER choice? Stroke 2013; 44:2377-9. [PMID: 23887845 PMCID: PMC3845499 DOI: 10.1161/strokeaha.113.001830] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Andrew D. Barreto
- Department of Neurology, Stroke Program; University of Texas Health Science Center at Houston, Houston, Texas
| | - Claudia Pedroza
- Department of Pediatrics, Center for Clinical Research and Evidence-Based Medicine; University of Texas Health Science Center at Houston, Houston, Texas
| | - James C. Grotta
- Department of Neurology, Stroke Program; University of Texas Health Science Center at Houston, Houston, Texas
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1289
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Sacks D, Connors J(B, Black CM. Society of Interventional Radiology Position Statement on Endovascular Acute Ischemic Stroke Interventions. J Vasc Interv Radiol 2013; 24:1263-6. [DOI: 10.1016/j.jvir.2013.05.050] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2013] [Accepted: 05/22/2013] [Indexed: 10/26/2022] Open
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1290
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Zaidat OO, Yoo AJ, Khatri P, Tomsick TA, von Kummer R, Saver JL, Marks MP, Prabhakaran S, Kallmes DF, Fitzsimmons BFM, Mocco J, Wardlaw JM, Barnwell SL, Jovin TG, Linfante I, Siddiqui AH, Alexander MJ, Hirsch JA, Wintermark M, Albers G, Woo HH, Heck DV, Lev M, Aviv R, Hacke W, Warach S, Broderick J, Derdeyn CP, Furlan A, Nogueira RG, Yavagal DR, Goyal M, Demchuk AM, Bendszus M, Liebeskind DS. Recommendations on angiographic revascularization grading standards for acute ischemic stroke: a consensus statement. Stroke 2013; 44:2650-63. [PMID: 23920012 PMCID: PMC4160883 DOI: 10.1161/strokeaha.113.001972] [Citation(s) in RCA: 1156] [Impact Index Per Article: 105.1] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Osama O Zaidat
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, USA.
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1292
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Nakamura A, Ago T, Kamouchi M, Hata J, Matsuo R, Kuroda J, Kuwashiro T, Sugimori H, Kitazono T. Intensity of anticoagulation and clinical outcomes in acute cardioembolic stroke: the Fukuoka Stroke Registry. Stroke 2013; 44:3239-42. [PMID: 23963334 DOI: 10.1161/strokeaha.113.002523] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The relationship between the intensity of anticoagulation at the onset of acute cardioembolic stroke and clinical outcome after stroke is unclear. Here, we elucidated the relationship between prothrombin time-international normalized ratio (PT-INR) values on admission and clinical outcomes in patients with acute cardioembolic stroke. METHODS A total of 602 patients from the Fukuoka Stroke Registry in Japan who had been treated with warfarin but developed cardioembolic stroke were enrolled. The patients were classified into 3 groups according to their PT-INR values on admission: PT-INR <1.50, 411 patients; PT-INR 1.50 to 1.99, 146 patients; and PT-INR ≥2.00, 45 patients. The associations between PT-INR categories and severe neurological deficits (National Institutes of Health Stroke Scale ≥10) on admission and poor functional outcome (modified Rankin scale 4-6) at discharge were investigated using a logistic regression analysis. RESULTS Neurological deficits on admission were less severe, and functional outcome at discharge was more favorable as the PT-INR level on admission increased. The multivariate analysis revealed that severe neurological deficits were inversely associated with PT-INR on admission (PT-INR 1.50-1.99: odds ratio, 0.66; 95% confidence interval, 0.43-1.00; PT-INR ≥2.00: odds ratio, 0.41; 95% confidence interval, 0.20-0.83; compared with a reference group of PT-INR <1.50). Poor functional outcome was less likely in patients with PT-INR ≥2.00 (odds ratio, 0.20; 95% confidence interval, 0.06-0.55) after adjustment for confounders. CONCLUSIONS Prestroke PT-INR ≥2.0 is associated with favorable clinical outcomes after acute cardioembolic stroke.
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Affiliation(s)
- Asako Nakamura
- From the Department of Medicine and Clinical Sciences (A.N., T.A., J.H., R.M., J.K., T. Kuwashiro., H.S., T. Kitazono), Department of Health Care Administration and Management (M.K.), and Department of Environmental Medicine (J.H.), Graduate School of Medical Sciences, Kyushu University, Fukuoka, Japan; and Department of Nephrology, Hypertension, and Strokology (T.A., M.K., J.K., T. Kitazono), and Emergency and Critical Care Center (H.S.), Kyushu University Hospital, Kyushu University, Fukuoka, Japan
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1293
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Fiorella D, Turk A, Chaudry I, Turner R, Dunkin J, Roque C, Sarmiento M, Deuerling-Zheng Y, Denice CM, Baumeister M, Parker AT, Woo HH. A prospective, multicenter pilot study investigating the utility of flat detector derived parenchymal blood volume maps to estimate cerebral blood volume in stroke patients. J Neurointerv Surg 2013; 6:451-6. [PMID: 23943817 PMCID: PMC4112493 DOI: 10.1136/neurintsurg-2013-010840] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022]
Abstract
Purpose Newer flat panel angiographic detector (FD) systems have the capability to generate parenchymal blood volume (PBV) maps. The ability to generate these maps in the angiographic suite has the potential to markedly expedite the triage and treatment of patients with acute ischemic stroke. The present study compares FP-PBV maps with cerebral blood volume (CBV) maps derived using standard dynamic CT perfusion (CTP) in a population of patients with stroke. Methods 56 patients with cerebrovascular ischemic disease at two participating institutions prospectively underwent both standard dynamic CTP imaging followed by FD-PBV imaging (syngo Neuro PBV IR; Siemens, Erlangen, Germany) under a protocol approved by both institutional review boards. The feasibility of the FD system to generate PBV maps was assessed. The radiation doses for both studies were compared. The sensitivity and specificity of the PBV technique to detect (1) any blood volume deficit and (2) a blood volume deficit greater than one-third of a vascular territory, were defined using standard dynamic CTP CBV maps as the gold standard. Results Of the 56 patients imaged, PBV maps were technically adequate in 42 (75%). The 14 inadequate studies were not interpretable secondary to patient motion/positioning (n=4), an injection issue (n=2), or another reason (n=8). The average dose for FD-PBV was 219 mGy (median 208) versus 204 mGy (median 201) for CT-CBV. On CT-CBV maps 26 of 42 had a CBV deficit (61.9%) and 15 (35.7%) had a deficit that accounted for greater than one-third of a vascular territory. FD-PBV maps were 100% sensitive and 81.3% specific to detect any CBV deficit and 100% sensitive and 62.9% specific to detect any CBV deficit of greater than one-third of a territory. Conclusions PBV maps can be generated using FP systems. The average radiation dose is similar to a standard CTP examination. PBV maps have a high sensitivity for detecting CBV deficits defined by conventional CTP. PBV maps often overestimate the size of CBV deficits. We hypothesize that the FP protocol initiates PBV imaging prior to complete saturation of the blood volume in areas perfused via indirect pathways (ie, leptomeningeal collaterals), resulting in an overestimation of CBV deficits, particularly in the setting of large vessel occlusion.
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Affiliation(s)
- David Fiorella
- Department of Neurosurgery, Stony Brook University Medical Center, Stony Brook, New York, USA
| | - Aquilla Turk
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Imran Chaudry
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Raymond Turner
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jared Dunkin
- Department of Neurosurgery, Stony Brook University Medical Center, Stony Brook, New York, USA
| | - Clemente Roque
- Department of Neurosurgery, Stony Brook University Medical Center, Stony Brook, New York, USA
| | | | | | - Christine M Denice
- Department of Neurosurgery, Stony Brook University Medical Center, Stony Brook, New York, USA
| | - Marlene Baumeister
- Department of Neurosurgery, Stony Brook University Medical Center, Stony Brook, New York, USA
| | - Adrian T Parker
- Medical University of South Carolina, Charleston, South Carolina, USA
| | - Henry H Woo
- Department of Neurosurgery, Stony Brook University Medical Center, Stony Brook, New York, USA
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Imaging recommendations for acute stroke and transient ischemic attack patients: a joint statement by the American Society of Neuroradiology, the American College of Radiology and the Society of NeuroInterventional Surgery. J Am Coll Radiol 2013; 10:828-32. [PMID: 23948676 DOI: 10.1016/j.jacr.2013.06.019] [Citation(s) in RCA: 64] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2013] [Accepted: 06/24/2013] [Indexed: 02/06/2023]
Abstract
In the article entitled "Imaging Recommendations for Acute Stroke and Transient Ischemic Attack Patients: A Joint Statement by the American Society of Neuroradiology, the American College of Radiology and the Society of NeuroInterventional Surgery", we are proposing a simple, pragmatic approach that will allow the reader to develop an optimal imaging algorithm for stroke patients at their institution.
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1295
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Nishiyama K, Tominaga N. [New and future treatments for neurological disorders--knowledge essential to daily clinics and future prospects. Topics: 3. Cerebrovascular disease; 1) Treatment for acute phase of stroke]. NIHON NAIKA GAKKAI ZASSHI. THE JOURNAL OF THE JAPANESE SOCIETY OF INTERNAL MEDICINE 2013; 102:1923-1929. [PMID: 24167849 DOI: 10.2169/naika.102.1923] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
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1296
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Mocco J, O'Kelly C, Arthur A, Meyers PM, Hirsch JA, Woo HH, Rasmussen PA, Albuquerque FC, Turk A, Tarr R, Fiorella D. Randomized clinical trials: the double edged sword. J Neurointerv Surg 2013; 5:387-90. [DOI: 10.1136/neurintsurg-2013-010882] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
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1297
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Sarraj A, Albright K, Barreto AD, Boehme AK, Sitton CW, Choi J, Lutzker SL, Sun CHJ, Bibars W, Nguyen CB, Mir O, Vahidy F, Wu TC, Lopez GA, Gonzales NR, Edgell R, Martin-Schild S, Hallevi H, Chen PR, Dannenbaum M, Saver JL, Liebeskind DS, Nogueira RG, Gupta R, Grotta JC, Savitz SI. Optimizing prediction scores for poor outcome after intra-arterial therapy in anterior circulation acute ischemic stroke. Stroke 2013; 44:3324-30. [PMID: 23929748 DOI: 10.1161/strokeaha.113.001050] [Citation(s) in RCA: 80] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND PURPOSE Intra-arterial therapy (IAT) promotes recanalization of large artery occlusions in acute ischemic stroke. Despite high recanalization rates, poor clinical outcomes are common. We attempted to optimize a score that combines clinical and imaging variables to more accurately predict poor outcome after IAT in anterior circulation occlusions. METHODS Patients with acute ischemic stroke undergoing IAT at University of Texas (UT) Houston for large artery occlusions (middle cerebral artery or internal carotid artery) were reviewed. Independent predictors of poor outcome (modified Rankin Scale, 4-6) were studied. External validation was performed on IAT-treated patients at Emory University. RESULTS A total of 163 patients were identified at UT Houston. Independent predictors of poor outcome (P≤0.2) were identified as score variables using sensitivity analysis and logistic regression. Houston Intra-Arterial Therapy 2 (HIAT2) score ranges 0 to 10: age (≤59=0, 60-79=2, ≥80 years=4), glucose (<150=0, ≥150=1), National Institute Health Stroke Scale (≤10=0, 11-20=1, ≥21=2), the Alberta Stroke Program Early CT Score (8-10=0, ≤7=3). Patients with HIAT2≥5 were more likely to have poor outcomes at discharge (odds ratio, 6.43; 95% confidence interval, 2.75-15.02; P<0.001). After adjusting for reperfusion (Thrombolysis in Cerebral Infarction score≥2b) and time from symptom onset to recanalization, HIAT2≥5 remained an independent predictor of poor outcome (odds ratio, 5.88; 95% confidence interval, 1.96-17.64; P=0.02). Results from the cohort of Emory (198 patients) were consistent; patients with HIAT2 score≥5 had 6× greater odds of poor outcome at discharge and at 90 days. HIAT2 outperformed other previously published predictive scores. CONCLUSIONS The HIAT2 score, which combines clinical and imaging variables, performed better than all previous scores in predicting poor outcome after IAT for anterior circulation large artery occlusions.
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Affiliation(s)
- Amrou Sarraj
- From the Department of Neurology, University of Texas, Houston (A.S., A.D.B., C.W.S., J.C., S.L.L., W.B., C.B.N., O.M., F.V., T.-C.W., G.A.L., N.R.G., R.E., P.R.C., M.D., J.C.G., S.I.S.); Department of Neurology, University of Alabama, Birmingham (K.A., A.K.B.); Department of Neurology, Tulane University, New Orleans, LA (S.M.-S.); Department of Neurology, Emory University, Atlanta, GA (C.-H.J.S., R.G.N., R.G.); Department of Neurology, Sourasky Medical Center, Tel Aviv, Israel (H.H.); and Department of Neurology, University of California, Los Angeles (J.L.S., D.S.L.)
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Yoo AJ, Simonsen CZ, Prabhakaran S, Chaudhry ZA, Issa MA, Fugate JE, Linfante I, Liebeskind DS, Khatri P, Jovin TG, Kallmes DF, Dabus G, Zaidat OO. Refining angiographic biomarkers of revascularization: improving outcome prediction after intra-arterial therapy. Stroke 2013; 44:2509-12. [PMID: 23920017 DOI: 10.1161/strokeaha.113.001990] [Citation(s) in RCA: 149] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
BACKGROUND AND PURPOSE Angiographic revascularization grading after intra-arterial stroke therapy is limited by poor standardization, making it unclear which scale is optimal for predicting outcome. Using recently standardized criteria, we sought to compare the prognostic performance of 2 commonly used reperfusion scales. METHODS Inclusion criteria for this multicenter retrospective study were acute ischemic stroke attributable to middle cerebral artery M1 occlusion, intra-arterial therapy, and 90-day modified Rankin scale score. Post-intra-arterial therapy reperfusion was graded using the Thrombolysis in Myocardial Infarction (TIMI) and Modified Thrombolysis in Cerebral Infarction (mTICI) scales. The scales were compared for prediction of clinical outcome using receiver-operating characteristic analysis. RESULTS Of 308 patients, mean age was 65 years, and median National Institutes of Health Stroke Scale score was 17. The mean time from stroke onset to groin puncture was 305 minutes. There was no difference in the time to treatment between patients grouped by final TIMI (ie, 0 versus 1 versus 2 versus 3) or mTICI grades (ie, 0 versus 1 versus 2a versus 2b versus 3). Good outcome (modified Rankin scale, 0-2) was achieved in 32.5% of patients, and mortality rate was 25.3% at 90 days. There was a 6.3% rate of parenchymal hematoma type 2. In receiver-operating characteristic analysis, mTICI was superior to TIMI for predicting 90-day modified Rankin scale 0 to 2 (c-statistic: 0.74 versus 0.68; P<0.0001). The optimal threshold for identifying a good outcome was mTICI 2b to 3 (sensitivity 78.0%; specificity 66.1%). CONCLUSIONS mTICI is superior to TIMI for predicting clinical outcome after intra-arterial therapy. mTICI 2b to 3 is the optimal biomarker for procedural success.
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Affiliation(s)
- Albert J Yoo
- Division of Interventional Neuroradiology, Massachusetts General Hospital, Boston, MA, USA.
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Matias-Guiu JA, Gil A, Serna-Candel C, Simal P, García-García AM, Egido JA, Matías-Guiu J, López-Ibor L. Endovascular Treatment of Distal Internal Carotid Artery Occlusions with Retrievable Stents. Eur Neurol 2013; 70:159-64. [DOI: 10.1159/000351352] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Accepted: 04/14/2013] [Indexed: 11/19/2022]
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1300
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Jayaraman MV. Reply: To PMID 23493893. AJNR Am J Neuroradiol 2013; 34:E99. [PMID: 24137636 DOI: 10.3174/ajnr.a3703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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