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Aoki J, Suzuki K, Sakamoto Y, Matsumaru Y, Takeuchi M, Morimoto M, Kanazawa R, Takayama Y, Kamiya Y, Shigeta K, Okubo S, Hayakawa M, Ishii N, Koguchi Y, Takigawa T, Inoue M, Naito H, Ota T, Hirano T, Kato N, Ueda T, Iguchi Y, Akaji K, Tsuruta W, Miki K, Fujimoto S, Higashida T, Iwasaki M, Kanamaru T, Saito T, Katano T, Kutsuna A, Nishiyama Y, Otsuka T, Kimura K. Ultra-early rt-PA administration should improve patient outcome on mechanical thrombectomy: Post hoc analysis of SKIP. J Neurol Sci 2023; 453:120772. [PMID: 37651883 DOI: 10.1016/j.jns.2023.120772] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Revised: 08/06/2023] [Accepted: 08/19/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND To investigate whether ultra-early recombinant tissue-plasminogen activator (rt-PA) administration can improve patient outcomes on mechanical thrombectomy (MT) in patients with large vessel occlusion (LVO). METHODS Participants comprised rt-PA-eligible 204 patients with internal carotid artery or middle cerebral artery occlusion in the SKIP trial, who were randomly assigned to receive mechanical thrombectomy alone or combined intravenous thrombolysis (rt-PA: alteplase at 0.6 mg/kg) plus mechanical thrombectomy. We assessed associations between onset-to-puncture time and onset-to-rt-PA administration time and frequency of favorable outcome at 90 days and any intracerebral hemorrhage (ICH) at 36 h after onset. RESULTS As a cut-off onset-to-puncture time for favorable outcome, receiver operating characteristic curves defined 2.5 h (57% sensitivity, 62% specificity). For onset-to-puncture times ≤2.5 h and > 2.5 h, frequencies of favorable outcomes were 72% and 63% (p = 0.402) in patients with rt-PA therapy and 44% and 58% (p = 0.212) in patients without rt-PA therapy, respectively. In terms of onset-to-rt-PA administration time, frequencies of favorable outcomes among patients with ultra-early rt-PA administration at ≤100, >100 min after onset, and without rt-PA therapy with onset-to-puncture time ≤ 2.5 h, and with and without rt-PA therapy with onset-to-puncture time > 2.5 h were 84% and 64%, 63%, and 44% and 58%, respectively (p = 0.025). Frequencies of any ICH among those patients were 37% and 32%, 32%, and 63% and 40%, respectively (p = 0.006). CONCLUSION Ultra-early rt-PA administration should improve patient outcomes on mechanical thrombectomy among patients with LVO. Relatively late rt-PA administration might increase the frequency of any ICH.
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Affiliation(s)
- Junya Aoki
- Department of Neurology, Nippon Medical School, Tokyo, Japan.
| | - Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Yuki Sakamoto
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Yuji Matsumaru
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | | | - Masafumi Morimoto
- Department of Neurosurgery, Yokohama Shintoshi Neurosurgery Hospital, Kanagawa, Japan
| | | | - Yohei Takayama
- Department of Neurology, Akiyama Neurosurgical Hospital, Kanagawa, Japan
| | - Yuki Kamiya
- Department of Cerebrovascular Medicine, NTT Medical Center Tokyo, Tokyo, Japan
| | - Keigo Shigeta
- Department of Neurosurgery, National Hospital Organization Disaster Medical Center, Tokyo, Japan
| | - Seiji Okubo
- Department of Cerebrovascular Medicine, NTT Medical Center Tokyo, Tokyo, Japan
| | - Mikito Hayakawa
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Norihiro Ishii
- Department of Neurosurgery, New Tokyo Hospital, Chiba, Japan
| | - Yorio Koguchi
- Department of Neurology and Neurosurgery, Chiba Emergency Medical Center, Chiba, Japan
| | - Tomoji Takigawa
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Masato Inoue
- Department of Neurosurgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hiromichi Naito
- Department of Neurosurgery, Funabashi Municipal Medical Center, Chiba, Japan
| | - Takahiro Ota
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Tokyo, Japan
| | - Noriyuki Kato
- Department of Neurosurgery, Mito Medical Center, Ibaraki, Japan
| | - Toshihiro Ueda
- Department of Strokology, Stroke Center, St. Marianna University Toyoko Hospital, Kanagawa, Japan
| | - Yasuyuki Iguchi
- Department of Neurology, the Jikei University School of Medicine, Tokyo, Japan
| | - Kazunori Akaji
- Department of Neurosurgery, Mihara Memorial Hospital, Gunma, Japan
| | - Wataro Tsuruta
- Department of Endovascular Neurosurgery, Toranomon Hospital, Tokyo, Japan
| | - Kazunori Miki
- Department of Endovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shigeru Fujimoto
- Division of Neurology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | | | - Mitsuhiro Iwasaki
- Department of Neurosurgery, Yokohama Shintoshi Neurosurgery Hospital, Kanagawa, Japan
| | - Takuya Kanamaru
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Tomonari Saito
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Takehiro Katano
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Akihito Kutsuna
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | | | - Toshiaki Otsuka
- Department of Hygiene and Public Health, Nippon Medical School, Tokyo, Japan
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
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Wang M, Dai Z, Zhang X, Xu X, Sun Y, Gong F, Qin B, Wang J, Liu B, Tang H, Li T, Zhang J, Wang J, Chen W, Ma L, Han Z, Liu D. The metabolic score for insulin resistance as a predictor of clinical outcome in stroke patients treated by intravenous thrombolysis. Neurol Sci 2023; 44:3587-3594. [PMID: 37202593 DOI: 10.1007/s10072-023-06848-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2023] [Accepted: 05/08/2023] [Indexed: 05/20/2023]
Abstract
BACKGROUND AND PURPOSE Insulin resistance is associated with clinical outcomes among patients with ischemic stroke. We aimed to investigate the association between metabolic score for insulin resistance (METS-IR) and clinical outcomes in stroke patients treated by intravenous thrombolysis (IVT). METHODS We recruited participants treated with IVT from a prospective registry including 3 stroke centers. Poor outcome was defined as a modified Rankin scale score ≥ 3 points at 90 days after the index stroke. We performed logistic regression models to investigate the association between METS-IR and the risk of poor outcome. We used the receiver operative characteristic to assess the discriminative ability and the restricted cubic spline to explore the relationship between METS-IR and the poor outcome. RESULTS This study enrolled a total of 1074 patients (median age, 68; 63.8% male). Three hundred sixty (33.5%) patients had poor outcome after IVT. METS-IR was associated with the risk of the poor outcome with the increase of confounding factors in models (odds ratio [OR], 1.078; 95% confidence interval [CI], 1.058-1.099; P < 0.001). The area under the curve for METS-IR for predicting the poor outcome was 0.790 (95% CI, 0.761-0.819). The restricted cubic spline revealed an increasing and non-linear association between METS-IR and the poor outcome (P for non-linearity < 0.001). CONCLUSION Our study found that METS-IR was associated with an increased risk of poor outcome after IVT. Further studies are warranted to investigate the efficacy of anti-diabetic agents regarding IR on clinical outcomes after IVT.
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Affiliation(s)
- Mingzhe Wang
- Department of Neurology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, No. 528 Zhang-Heng Road, Pu-Dong New Area, Shanghai, 201203, China
| | - Zheng Dai
- Department of Neurology, The Affiliated Wuxi People's Hospital of Nanjing Medical University, Wuxi People's Hospital, Wuxi Medical Center, Nanjing Medical University, Wuxi, Jiangsu Province, 214023, China
| | - Xiaohao Zhang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, 210000, Jiangsu, China
| | - Xiaochen Xu
- Department of Neurology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, No. 528 Zhang-Heng Road, Pu-Dong New Area, Shanghai, 201203, China
| | - Yan Sun
- Department of Neurology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, No. 528 Zhang-Heng Road, Pu-Dong New Area, Shanghai, 201203, China
| | - Fan Gong
- Department of Neurology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, No. 528 Zhang-Heng Road, Pu-Dong New Area, Shanghai, 201203, China
| | - Baofeng Qin
- Department of Neurology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, No. 528 Zhang-Heng Road, Pu-Dong New Area, Shanghai, 201203, China
| | - Jun Wang
- Department of Neurology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, No. 528 Zhang-Heng Road, Pu-Dong New Area, Shanghai, 201203, China
| | - Bin Liu
- Department of Neurology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, No. 528 Zhang-Heng Road, Pu-Dong New Area, Shanghai, 201203, China
| | - Haiyan Tang
- Department of Neurology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, No. 528 Zhang-Heng Road, Pu-Dong New Area, Shanghai, 201203, China
| | - Tingting Li
- Department of Neurology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, No. 528 Zhang-Heng Road, Pu-Dong New Area, Shanghai, 201203, China
| | - Jinsi Zhang
- Department of Neurology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, No. 528 Zhang-Heng Road, Pu-Dong New Area, Shanghai, 201203, China
| | - Jiecheng Wang
- Department of Encephalopathy, Qinghai Provincial Hospital of Traditional Chinese Medicine, Xining, 810000, Qinghai Province, China
| | - Wenjie Chen
- Department of Neurology, Nanping People's Hospital Affiliated to Fujian University of Traditional Chinese Medicine, Nanping, 353000, Fujian Province, China
| | - Ling Ma
- Department of Encephalopathy, Qinghai Provincial Hospital of Traditional Chinese Medicine, Xining, 810000, Qinghai Province, China
| | - Zhenxiang Han
- Department of Neurology and Rehabilitation, Seventh People's Hospital of Shanghai University of TCM, 200137, No 358 Datong Road, Shanghai, 200137, China.
| | - Dezhi Liu
- Department of Neurology, Shuguang Hospital Affiliated to Shanghai University of Traditional Chinese Medicine, No. 528 Zhang-Heng Road, Pu-Dong New Area, Shanghai, 201203, China.
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Checkouri T, Gerschenfeld G, Seners P, Yger M, Ben Hassen W, Chausson N, Olindo S, Caroff J, Marnat G, Clarençon F, Baron JC, Turc G, Alamowitch S. Early Recanalization Among Patients Undergoing Bridging Therapy With Tenecteplase or Alteplase. Stroke 2023; 54:2491-2499. [PMID: 37622385 DOI: 10.1161/strokeaha.123.042691] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Accepted: 07/25/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND Intravenous thrombolysis (IVT) with alteplase or tenecteplase before mechanical thrombectomy is the recommended treatment for large-vessel occlusion acute ischemic stroke. There are divergent data on whether these agents differ in terms of early recanalization (ER) rates before mechanical thrombectomy, and little data on their potential differences stratified by ER predictors such as IVT to ER evaluation (IVT-to-EReval) time, occlusion site and thrombus length. METHODS We retrospectively compared the likelihood of ER after IVT with tenecteplase or alteplase in anterior circulation large-vessel occlusion acute ischemic stroke patients from the PREDICT-RECANAL (alteplase) and Tenecteplase Treatment in Ischemic Stroke (tenecteplase) French multicenter registries. ER was defined as a modified Thrombolysis in Cerebral Infarction score 2b-3 on the first angiographic run, or noninvasive vascular imaging in patients with early neurological improvement. Analyses were based on propensity score overlap weighting (leading to exact balance in patient history, stroke characteristics, and initial management between groups) and confirmed with adjusted logistic regression (sensitivity analysis). A stratified analysis based on pre-established ER predictors (IVT-to-EReval time, occlusion site, and thrombus length) was conducted. RESULTS Overall, 1865 patients were included. ER occurred in 156/787 (19.8%) and 199/1078 (18.5%) patients treated with tenecteplase or alteplase, respectively (odds ratio, 1.09 [95% CI, 0.83-1.44]; P=0.52). A differential effect of tenecteplase versus alteplase on the probability of ER according to thrombus length was observed (Pinteraction=0.003), with tenecteplase being associated with higher odds of ER in thrombi >10 mm (odds ratio, 2.43 [95% CI, 1.02-5.81]; P=0.04). There was no differential effect of tenecteplase versus alteplase on the likelihood of ER according to the IVT-to-EReval time (Pinteraction=0.40) or occlusion site (Pinteraction=0.80). CONCLUSIONS Both thrombolytics achieved ER in one-fifth of patients with large-vessel occlusion acute ischemic stroke without significant interaction with IVT-to-EReval time and occlusion site. Compared with alteplase, tenecteplase was associated with a 2-fold higher likelihood of ER in larger thrombi.
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Affiliation(s)
- Thomas Checkouri
- AP-HP, Service des Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Hôpital Saint-Antoine, Sorbonne Université, Paris, France (T.C., G.G., M.Y., S.A.)
- STARE team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France (T.C., G.G., M.Y., S.A.)
| | - Gaspard Gerschenfeld
- AP-HP, Service des Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Hôpital Saint-Antoine, Sorbonne Université, Paris, France (T.C., G.G., M.Y., S.A.)
- STARE team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France (T.C., G.G., M.Y., S.A.)
| | - Pierre Seners
- Service de Neurologie, GHU Paris Psychiatrie et Neurosciences, France (P.S.)
- Université de Paris, INSERM U1266, FHU Neurovasc, France (P.S., W.B.H., N.C., J.-C.B., G.T.)
- Service de Neurologie, Hôpital Fondation Rothschild, Paris, France (P.S.)
| | - Marion Yger
- AP-HP, Service des Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Hôpital Saint-Antoine, Sorbonne Université, Paris, France (T.C., G.G., M.Y., S.A.)
- STARE team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France (T.C., G.G., M.Y., S.A.)
| | - Wagih Ben Hassen
- Université de Paris, INSERM U1266, FHU Neurovasc, France (P.S., W.B.H., N.C., J.-C.B., G.T.)
- Service de Neuroradiologie, GHU Paris Psychiatrie et Neurosciences, France (W.B.H.)
| | - Nicolas Chausson
- Université de Paris, INSERM U1266, FHU Neurovasc, France (P.S., W.B.H., N.C., J.-C.B., G.T.)
- Service de Neurologie, Unité Neuro-vasculaire, Hôpital Sud Francilien, Corbeil-Essonnes (N.C.)
| | | | - Jildaz Caroff
- AP-HP, Service de Neuroradiologie interventionnelle (NEURI), Hôpital Bicêtre, Université Paris-Saclay, Le Kremlin-Bicêtre, France (J.C.)
| | - Gaultier Marnat
- Service de Neuroradiologie diagnostique et interventionnelle (G.M.), France
- CHU de Bordeaux, France (G.M.)
| | - Frédéric Clarençon
- AP-HP, Service de Neuroradiologie, Hôpital Pitié-Salpêtrière, Sorbonne Université, Paris, France (F.C.)
| | - Jean-Claude Baron
- Université de Paris, INSERM U1266, FHU Neurovasc, France (P.S., W.B.H., N.C., J.-C.B., G.T.)
| | - Guillaume Turc
- Université de Paris, INSERM U1266, FHU Neurovasc, France (P.S., W.B.H., N.C., J.-C.B., G.T.)
| | - Sonia Alamowitch
- AP-HP, Service des Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Hôpital Saint-Antoine, Sorbonne Université, Paris, France (T.C., G.G., M.Y., S.A.)
- STARE team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France (T.C., G.G., M.Y., S.A.)
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Rodriguez-Calienes A, Galecio-Castillo M, Farooqui M, Hassan AE, Jumaa MA, Divani AA, Ribo M, Abraham M, Petersen NH, Fifi J, Guerrero WR, Malik AM, Siegler JE, Nguyen TN, Yoo AJ, Linares G, Janjua N, Quispe-Orozco D, Tekle WG, Alhajala H, Ikram A, Rizzo F, Qureshi A, Begunova L, Matsouka S, Vigilante N, Salazar-Marioni S, Abdalkader M, Gordon W, Soomro J, Turabova C, Vivanco-Suarez J, Mokin M, Yavagal DR, Jovin T, Sheth S, Ortega-Gutierrez S. Safety Outcomes of Mechanical Thrombectomy Versus Combined Thrombectomy and Intravenous Thrombolysis in Tandem Lesions. Stroke 2023; 54:2522-2533. [PMID: 37602387 PMCID: PMC10599264 DOI: 10.1161/strokeaha.123.042966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Revised: 06/19/2023] [Accepted: 07/11/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND We aimed to describe the safety and efficacy of mechanical thrombectomy (MT) with or without intravenous thrombolysis (IVT) for patients with tandem lesions and whether using intraprocedural antiplatelet therapy influences MT's safety with IVT treatment. METHODS This is a subanalysis of a pooled, multicenter cohort of patients with acute anterior circulation tandem lesions treated with MT from 16 stroke centers between January 2015 and December 2020. Primary outcomes included symptomatic intracranial hemorrhage (sICH) and parenchymal hematoma type 2. Additional outcomes included hemorrhagic transformation, successful reperfusion (modified Thrombolysis in Cerebral Infarction score 2b-3), complete reperfusion (modified Thrombolysis in Cerebral Infarction score 3), favorable functional outcome (90-day modified Rankin Scale score 0-2), excellent functional outcome (90-day modified Rankin Scale score 0-1), in-hospital mortality, and 90-day mortality. RESULTS Of 691 patients, 512 were included (218 underwent IVT+MT and 294 MT alone). There was no difference in the risk of sICH (adjusted odds ratio [aOR], 1.22 [95% CI, 0.60-2.51]; P=0.583), parenchymal hematoma type 2 (aOR, 0.99 [95% CI, 0.47-2.08]; P=0.985), and hemorrhagic transformation (aOR, 0.95 [95% CI, 0.62-1.46]; P=0.817) between the IVT+MT and MT alone groups after adjusting for confounders. Administration of IVT was associated with an increased risk of sICH in patients who received intravenous antiplatelet therapy (aOR, 3.04 [95% CI, 0.99-9.37]; P=0.05). The IVT+MT group had higher odds of a 90-day modified Rankin Scale score 0 to 2 (aOR, 1.72 [95% CI, 1.01-2.91]; P=0.04). The odds of successful reperfusion, complete reperfusion, 90-day modified Rankin Scale score 0 to 1, in-hospital mortality, or 90-day mortality did not differ between the IVT+MT versus MT alone groups. CONCLUSIONS Our study showed that the combination of IVT with MT for tandem lesions did not increase the overall risk of sICH, parenchymal hematoma type 2, or overall hemorrhagic transformation independently of the cervical revascularization technique used. However, intraprocedural intravenous antiplatelet therapy during acute stent implantation might be associated with an increased risk of sICH in patients who received IVT before MT. Importantly, IVT+MT treatment was associated with a higher rate of favorable functional outcomes at 90 days.
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Affiliation(s)
- Aaron Rodriguez-Calienes
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City
- Department of Neuroscience, Clinical Effectiveness and Public Health Research Group, Universidad Científica del Sur, Lima, Peru
| | | | - Mudassir Farooqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City
| | - Ameer E. Hassan
- Department of Neurology, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX
| | | | - Afshin A. Divani
- Department of Neurology, University of New Mexico Health Science Center, Albuquerque
| | - Marc Ribo
- Department of Neurology, Hospital Vall d’Hebron, Barcelona, Spain
| | - Michael Abraham
- Department of Neurology, University of Kansas Medical Center
| | - Nils H. Petersen
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Johanna Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York
| | - Waldo R. Guerrero
- Department of Neurology and Brain Repair, University of South Florida, Tampa
| | - Amer M. Malik
- Department of Neurology, University of Miami Miller School of Medicine, FL
| | - James E. Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ
- Cooper Medical School of Rowan University, Candem, NJ
| | | | | | | | - Nazli Janjua
- Asia Pacific Comprehensive Stroke Institute, Pomona Valley Hospital Medical Center, CA
| | - Darko Quispe-Orozco
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City
| | - Wondwossen G. Tekle
- Department of Neurology, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX
| | | | - Asad Ikram
- Department of Neurology, University of New Mexico Health Science Center, Albuquerque
| | - Federica Rizzo
- Department of Neurology, Hospital Vall d’Hebron, Barcelona, Spain
| | - Abid Qureshi
- Department of Neurology, University of Kansas Medical Center
| | - Liza Begunova
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Stavros Matsouka
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York
| | | | | | | | - Weston Gordon
- Department of Neurology, Saint Louis University, St. Louis, MO
| | | | - Charoskon Turabova
- Asia Pacific Comprehensive Stroke Institute, Pomona Valley Hospital Medical Center, CA
| | - Juan Vivanco-Suarez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City
| | - Maxim Mokin
- Department of Neurology and Brain Repair, University of South Florida, Tampa
| | - Dileep R. Yavagal
- Department of Neurology, University of Miami Miller School of Medicine, FL
| | - Tudor Jovin
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ
| | - Sunil Sheth
- Department of Neurology, UT Health McGovern Medical School, Houston, TX
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Neurosurgery & Radiology, University of Iowa Hospitals and Clinics, Iowa City
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Derraz I, Moulin S, Gory B, Kyheng M, Arquizan C, Costalat V, Lapergue B. Endovascular Thrombectomy Outcomes with and without Intravenous Thrombolysis for Large Ischemic Cores Identified with CT or MRI. Radiology 2023; 309:e230440. [PMID: 37847131 DOI: 10.1148/radiol.230440] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2023]
Abstract
Background Whether intravenous thrombolysis (IVT) prior to endovascular thrombectomy (EVT) provides additional benefits in patients with acute ischemic stroke (AIS) and a large infarct core (LIC) remains unclear. Purpose To examine whether treatment with IVT before EVT is beneficial in patients with LIC identified with CT or MRI (Alberta Stroke Program Early CT score 0-5). Materials and Methods This retrospective study included consecutive adult patients diagnosed with AIS due to large vessel occlusion (LVO) and LIC treated with EVT who were enrolled in the ETIS (Endovascular Treatment in Ischemic Stroke) Registry in France between January 2015 and January 2022. The primary outcome measure was a favorable outcome (modified Rankin Scale [mRS] score 0-3) at 90 days. Secondary outcomes included functional independence (mRS score 0-2) at 90 days, improvement in degree of disability (ordinal shift in mRS score toward a better outcome) at 90 days, early neurologic improvement at 24 hours, and successful reperfusion (modified Thrombolysis in Cerebral Infarction score of 2b or higher). Safety outcomes included symptomatic intracerebral hemorrhage within 24 hours and mortality at 90 days. Inverse probability of treatment weighting (IPTW)-adjusted analysis was used to assess the treatment effect of IVT adjusted for baseline variables. Results Of 1408 patients (mean age, 68.3 years ± 15.4 [SD]; 789 men), 654 (46.4%) were treated with IVT prior to EVT. In the IPTW-adjusted data set, IVT plus EVT was associated with a higher rate of favorable outcome at 90 days (odds ratio [OR], 1.24 [95% CI: 1.05, 1.46]; P = .01), functional independence at 90 days (OR, 1.47 [95% CI: 1.22, 1.77]; P < .001), improvement in degree of disability at 90 days (common OR, 1.30 [95% CI: 1.13, 1.49]; P < .001), early neurologic improvement (OR, 1.26 [95% CI: 1.07, 1.49]; P = .005), and successful reperfusion (OR, 1.43 [95% CI: 1.14, 1.79]; P = .002) than EVT alone. Rates of brain hemorrhage within 24 hours and mortality at 90 days were similar between groups. Conclusion In patients with AIS due to LVO with LIC identified with CT or MRI, treatment with IVT before EVT appeared to provide a clinical benefit over EVT alone. Clinical trial registration no. NCT03776877 © RSNA, 2023 Supplemental material is available for this article. See also the editorial by Kallmes and Rabinstein in this issue.
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Affiliation(s)
- Imad Derraz
- From the Departments of Neuroradiology (I.D., V.C.) and Neurology (C.A.), Hôpital Gui de Chauliac, Montpellier University Medical Center, 80 Avenue Augustin Fliche, Montpellier 34295, France; Department of Neurology, Reims University Hospital Center, Reims, France (S.M.); Department of Neuroradiology, Nancy University Hospital Center, Nancy, France (B.G.); Department of Biostatistics, University of Lille, Lille University Hospital Center, EA 2694-Public Health: Epidemiology and Quality of Care, Lille, France (M.K.); and Department of Neurology, University of Versailles Saint-Quentin-en-Yvelines, Foch Hospital, Suresnes, France (B.L.)
| | - Solène Moulin
- From the Departments of Neuroradiology (I.D., V.C.) and Neurology (C.A.), Hôpital Gui de Chauliac, Montpellier University Medical Center, 80 Avenue Augustin Fliche, Montpellier 34295, France; Department of Neurology, Reims University Hospital Center, Reims, France (S.M.); Department of Neuroradiology, Nancy University Hospital Center, Nancy, France (B.G.); Department of Biostatistics, University of Lille, Lille University Hospital Center, EA 2694-Public Health: Epidemiology and Quality of Care, Lille, France (M.K.); and Department of Neurology, University of Versailles Saint-Quentin-en-Yvelines, Foch Hospital, Suresnes, France (B.L.)
| | - Benjamin Gory
- From the Departments of Neuroradiology (I.D., V.C.) and Neurology (C.A.), Hôpital Gui de Chauliac, Montpellier University Medical Center, 80 Avenue Augustin Fliche, Montpellier 34295, France; Department of Neurology, Reims University Hospital Center, Reims, France (S.M.); Department of Neuroradiology, Nancy University Hospital Center, Nancy, France (B.G.); Department of Biostatistics, University of Lille, Lille University Hospital Center, EA 2694-Public Health: Epidemiology and Quality of Care, Lille, France (M.K.); and Department of Neurology, University of Versailles Saint-Quentin-en-Yvelines, Foch Hospital, Suresnes, France (B.L.)
| | - Maéva Kyheng
- From the Departments of Neuroradiology (I.D., V.C.) and Neurology (C.A.), Hôpital Gui de Chauliac, Montpellier University Medical Center, 80 Avenue Augustin Fliche, Montpellier 34295, France; Department of Neurology, Reims University Hospital Center, Reims, France (S.M.); Department of Neuroradiology, Nancy University Hospital Center, Nancy, France (B.G.); Department of Biostatistics, University of Lille, Lille University Hospital Center, EA 2694-Public Health: Epidemiology and Quality of Care, Lille, France (M.K.); and Department of Neurology, University of Versailles Saint-Quentin-en-Yvelines, Foch Hospital, Suresnes, France (B.L.)
| | - Caroline Arquizan
- From the Departments of Neuroradiology (I.D., V.C.) and Neurology (C.A.), Hôpital Gui de Chauliac, Montpellier University Medical Center, 80 Avenue Augustin Fliche, Montpellier 34295, France; Department of Neurology, Reims University Hospital Center, Reims, France (S.M.); Department of Neuroradiology, Nancy University Hospital Center, Nancy, France (B.G.); Department of Biostatistics, University of Lille, Lille University Hospital Center, EA 2694-Public Health: Epidemiology and Quality of Care, Lille, France (M.K.); and Department of Neurology, University of Versailles Saint-Quentin-en-Yvelines, Foch Hospital, Suresnes, France (B.L.)
| | - Vincent Costalat
- From the Departments of Neuroradiology (I.D., V.C.) and Neurology (C.A.), Hôpital Gui de Chauliac, Montpellier University Medical Center, 80 Avenue Augustin Fliche, Montpellier 34295, France; Department of Neurology, Reims University Hospital Center, Reims, France (S.M.); Department of Neuroradiology, Nancy University Hospital Center, Nancy, France (B.G.); Department of Biostatistics, University of Lille, Lille University Hospital Center, EA 2694-Public Health: Epidemiology and Quality of Care, Lille, France (M.K.); and Department of Neurology, University of Versailles Saint-Quentin-en-Yvelines, Foch Hospital, Suresnes, France (B.L.)
| | - Bertrand Lapergue
- From the Departments of Neuroradiology (I.D., V.C.) and Neurology (C.A.), Hôpital Gui de Chauliac, Montpellier University Medical Center, 80 Avenue Augustin Fliche, Montpellier 34295, France; Department of Neurology, Reims University Hospital Center, Reims, France (S.M.); Department of Neuroradiology, Nancy University Hospital Center, Nancy, France (B.G.); Department of Biostatistics, University of Lille, Lille University Hospital Center, EA 2694-Public Health: Epidemiology and Quality of Care, Lille, France (M.K.); and Department of Neurology, University of Versailles Saint-Quentin-en-Yvelines, Foch Hospital, Suresnes, France (B.L.)
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106
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Hu X, Zhou Y, Ospel J, Yao F, Liu Y, Wang H, Li B, Hui P, Yang P, Zhang Y, Zhang L, Li Z, Xing P, Shi H, Han H, Wang S, Fang Q, Liu J. Intracranial hemorrhage in large vessel occlusion patients receiving endovascular thrombectomy with or without intravenous alteplase: a secondary analysis of the DIRECT-MT trial. J Neurointerv Surg 2023; 15:977-982. [PMID: 36270789 PMCID: PMC10511977 DOI: 10.1136/jnis-2022-019021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 09/29/2022] [Indexed: 06/16/2023]
Abstract
BACKGROUND Alteplase before thrombectomy for patients with large vessel occlusion stroke raises concerns regarding an increased risk of intracranial hemorrhage (ICH), but the details of this relationship are not well understood. METHODS This was a secondary analysis of the DIRECT-MT trial. ICH and its subtypes were independently reviewed and classified according to the Heidelberg Bleeding Classification. The effects of alteplase before thrombectomy on ICH and ICH subtypes occurrence were evaluated using logistic regression. Clinical and imaging characteristics that may modify these effects were exploratorily tested. RESULTS Among 591 patients, any ICH occurred in 254 (43.0%), including hemorrhagic infarction type 1 in 12 (2.1%), hemorrhagic infarction type 2 in 127 (21.7%), parenchymal hematoma type 1 in 34 (5.8%), parenchymal hematoma type 2 in 50 (8.6%), and other hemorrhage types (3a-3c) in 24 (4.1%). Similar ICH frequencies were observed with combined alteplase and thrombectomy versus thrombectomy only (134/292 (45.9%) vs 120/299 (40.1%); OR 1.27, 95% CI 0.91 to 1.75, P=0.16), but patients treated with alteplase had a higher parenchymal hematoma rate (51/287 (17.8%) vs 33/297 (11.1%); OR 1.75, 95% CI 1.08 to 2.85, P=0.024). In the adjusted model, difference in parenchymal hematoma occurrence between groups remained significant (adjusted OR 1.71, 95% CI 1.00 to 2.92, P=0.049). Patients with history of diabetes (Pinteraction=0.048), hypertension (Pinteraction=0.02), antiplatelet therapy (Pinteraction=0.02), anticoagulation therapy (Pinteraction=0.04), and statin administration (Pinteraction=0.02) harbored a higher ICH rate when they received combination therapy. CONCLUSIONS Our data showed that in the DIRECT-MT trial, alteplase did not increase overall ICH for large vessel occlusion patients treated with thrombectomy, but it increased the parenchymal hematoma rate.
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Affiliation(s)
- Xiaowei Hu
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yu Zhou
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Johanna Ospel
- Department of Radiology, University Hospital Basel, Basel, Switzerland
| | - Feirong Yao
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Yizhi Liu
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Hui Wang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Bo Li
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Pinjing Hui
- Department of Stroke Center, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Pengfei Yang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Yongwei Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Lei Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Zifu Li
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Pengfei Xing
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Huaizhang Shi
- Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hongxing Han
- Department of Neurology, Linyi People's Hospital, Linyi, China
| | - Shouchun Wang
- Department of Neurology, The First Affiliated Hospital of Jilin University, Changchun, China
| | - Qi Fang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Jianmin Liu
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
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107
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Piscopo A, Zanaty M, Dlouhy K. Contemporary Methods for Detection and Intervention of Distal Medium and Small Vessel Occlusions. J Clin Med 2023; 12:6071. [PMID: 37763011 PMCID: PMC10531921 DOI: 10.3390/jcm12186071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/10/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
The efficacy of using mechanical thrombectomy for proximal large vessel occlusions has been demonstrated in multiple large-scale trials and has further raised the question of its potential utility for distal medium and small vessel occlusions (DMSVOs). Their longer, more tortuous course and smaller corresponding vascular territories render a significant challenge for detection and intervention. The aim of this study is to provide a comprehensive overview of the current imaging and endovascular intervention options for DMSVOs and review the current works in the literature. Compared with traditional computed tomography angiography (CTA) and CT perfusion, recent advances such as multiphase CTA and maps derived from the time-to-maximum parameter coupled with artificial intelligence have demonstrated increased sensitivity for the detection of DMSVOs. Furthermore, newer generations of mini stent retrievers and thromboaspiration devices have allowed for the access and navigation of smaller and more fragile distal arteries. Preliminary studies have suggested that mechanical thrombectomy using this newer generation of devices is both safe and feasible in distal medium-sized vessels, such as M2. However, endovascular intervention utilizing such contemporary methods and devices must be balanced at the discretion of operator experience and favorable vascular anatomy. Further large-scale multicenter clinical trials are warranted to elucidate the indications for as well as to strengthen the safety and efficacy of this approach.
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Affiliation(s)
| | - Mario Zanaty
- Department of Neurosurgery, University of Iowa Hospital and Clinics, Iowa City, IA 52242, USA; (A.P.); (K.D.)
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108
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Majoie CB, Cavalcante F, Gralla J, Yang P, Kaesmacher J, Treurniet KM, Kappelhof M, Yan B, Suzuki K, Zhang Y, Li F, Morimoto M, Zhang L, Miao Z, Rinkel LA, Huang J, Otsuka T, Wang S, Davis S, Cognard C, Hong B, Coutinho JM, Song J, Chen W, Emmer BJ, Eker O, Zhang L, Dobrocky T, Nguyen HT, Bush S, Peng Y, LeCouffe NE, Takeuchi M, Han H, Matsumaru Y, Strbian D, Lingsma HF, Nieboer D, Yang Q, Meinel T, Mitchell P, Kimura K, Zi W, Nogueira RG, Liu J, Roos YB, Fischer U. Value of intravenous thrombolysis in endovascular treatment for large-vessel anterior circulation stroke: individual participant data meta-analysis of six randomised trials. Lancet 2023; 402:965-974. [PMID: 37640037 DOI: 10.1016/s0140-6736(23)01142-x] [Citation(s) in RCA: 24] [Impact Index Per Article: 24.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Revised: 05/18/2023] [Accepted: 06/02/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND Intravenous thrombolysis is recommended before endovascular treatment, but its value has been questioned in patients who are admitted directly to centres capable of endovascular treatment. Existing randomised controlled trials have indicated non-inferiority of endovascular treatment alone or have been statistically inconclusive. We formed the Improving Reperfusion Strategies in Acute Ischaemic Stroke collaboration to assess non-inferiority of endovascular treatment alone versus intravenous thrombolysis plus endovascular treatment. METHODS We conducted a systematic review and individual participant data meta-analysis to establish non-inferiority of endovascular treatment alone versus intravenous thrombolysis plus endovascular treatment. We searched PubMed and MEDLINE with the terms "stroke", "endovascular treatment", "intravenous thrombolysis", and synonyms for articles published from database inception to March 9, 2023. We included randomised controlled trials on the topic of interest, without language restrictions. Authors of the identified trials agreed to take part, and individual participant data were provided by the principal investigators of the respective trials and collated centrally by the collaborators. Our primary outcome was the 90-day modified Rankin Scale (mRS) score. Non-inferiority of endovascular treatment alone was assessed using a lower boundary of 0·82 for the 95% CI around the adjusted common odds ratio (acOR) for shift towards improved outcome (analogous to 5% absolute difference in functional independence) with ordinal regression. We used mixed-effects models for all analyses. This study is registered with PROSPERO, CRD42023411986. FINDINGS We identified 1081 studies, and six studies (n=2313; 1153 participants randomly assigned to receive endovascular treatment alone and 1160 randomly assigned to receive intravenous thrombolysis and endovascular treatment) were eligible for analysis. The risk of bias of the included studies was low to moderate. Variability between studies was small, and mainly related to the choice and dose of the thrombolytic drug and country of execution. The median mRS score at 90 days was 3 (IQR 1-5) for participants who received endovascular treatment alone and 2 (1-4) for participants who received intravenous thrombolysis plus endovascular treatment (acOR 0·89, 95% CI 0·76-1·04). Any intracranial haemorrhage (0·82, 0·68-0·99) occurred less frequently with endovascular treatment alone than with intravenous thrombolysis plus endovascular treatment. Symptomatic intracranial haemorrhage and mortality rates did not differ significantly. INTERPRETATION We did not establish non-inferiority of endovascular treatment alone compared with intravenous thrombolysis plus endovascular treatment in patients presenting directly at endovascular treatment centres. Further research could focus on cost-effectiveness analysis and on individualised decisions when patient characteristics, medication shortages, or delays are expected to offset a potential benefit of administering intravenous thrombolysis before endovascular treatment. FUNDING Stryker and Amsterdam University Medical Centers, University of Amsterdam.
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Affiliation(s)
- Charles B Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands.
| | - Fabiano Cavalcante
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital of Bern, University of Bern, Bern, Switzerland
| | - Pengfei Yang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China; Oriental Pan-Vascular Devices Innovations College, University of Shanghai for Science and Technology, Shanghai, China
| | - Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital of Bern, University of Bern, Bern, Switzerland
| | - Kilian M Treurniet
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands; Department of Radiology, Haaglanden Medical Center, The Hague, Netherlands
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands
| | - Bernard Yan
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Yongwei Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Masafumi Morimoto
- Department of Neurosurgery, Yokohama Shintoshi Neurosurgery Hospital, Kanagawa, Japan
| | - Lei Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Leon A Rinkel
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands
| | - Jiacheng Huang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Toshiaki Otsuka
- Department of Hygiene and Public Health, Nippon Medical School, Tokyo, Japan
| | - Shouchun Wang
- Department of Neurology, First Affiliated Hospital of Jilin University, Changchun, China
| | - Stephen Davis
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Bo Hong
- Department of Neurovascular Intervention, Clinical Center of Neuroscience, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands
| | - Jiaxing Song
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Wenhuo Chen
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Bart J Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands
| | - Omer Eker
- Department of Neuroradiology, Hospices Civils de Lyon, Lyon, France
| | - Liyong Zhang
- Department of Neurosurgery, Liaocheng People's Hospital of Shandong First Medical University, Liaocheng, China
| | - Tomas Dobrocky
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital of Bern, University of Bern, Bern, Switzerland
| | | | - Steven Bush
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Ya Peng
- Department of Neurology, Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Natalie E LeCouffe
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands
| | | | - Hongxing Han
- Department of Neurology, Linyi People's Hospital of Qingdao University, Linyi, China
| | - Yuji Matsumaru
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Hester F Lingsma
- Department of Public Health, Erasmus Medical Center, Rotterdam, Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus Medical Center, Rotterdam, Netherlands
| | - Qingwu Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Thomas Meinel
- Department of Neurology, University Hospital of Bern, University of Bern, Stroke Research Center Bern, Bern, Switzerland
| | - Peter Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Raul G Nogueira
- UPMC Stroke Institute, Department of Neurology and Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jianmin Liu
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China; Oriental Pan-Vascular Devices Innovations College, University of Shanghai for Science and Technology, Shanghai, China
| | - Yvo B Roos
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, Netherlands
| | - Urs Fischer
- Department of Neurology, University Hospital of Bern, University of Bern, Stroke Research Center Bern, Bern, Switzerland; Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
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109
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Hankey GJ. Does thrombolysis add value to thrombectomy for acute ischaemic stroke? Lancet 2023; 402:938-939. [PMID: 37640036 DOI: 10.1016/s0140-6736(23)01202-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/07/2023] [Accepted: 06/09/2023] [Indexed: 08/31/2023]
Affiliation(s)
- Graeme J Hankey
- Perron Institute for Neurological and Translational Science, Perth, WA 6009, Australia; Medical School, The University of Western Australia, Perth, WA, Australia.
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110
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van den Berg SA, Uniken Venema SM, LeCouffe NE, Postma AA, Lycklama à Nijeholt GJ, Rinkel LA, Treurniet KM, Kappelhof M, Bruggeman AE, van Kranendonk KR, Majoie CBLM, Dippel DWJ, van der Worp HB, Coutinho JM, Nederkoorn PJ, Roos YBWEM. Admission blood pressure and clinical outcomes in patients with acute ischaemic stroke treated with intravenous alteplase and endovascular treatment versus endovascular treatment alone: A MR CLEAN-NO IV substudy. Eur Stroke J 2023; 8:647-654. [PMID: 37641554 PMCID: PMC10472956 DOI: 10.1177/23969873231173274] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2022] [Accepted: 04/04/2023] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION High systolic blood pressure (SBP) is associated with poor functional outcome. We analysed whether the association of SBP with outcomes after endovascular treatment (EVT) is modified by prior intravenous thrombolysis (IVT). PATIENTS AND METHODS This was a post-hoc analysis of MR CLEAN-NO IV, a randomised trial of IVT with alteplase followed by EVT versus EVT alone, within 4.5 h from stroke onset. SBP was recorded on hospital admission. The primary outcome was 90-day modified Rankin Scale (mRS) score and secondary outcomes included symptomatic intracranial haemorrhage (sICH) and successful reperfusion (eTICI 2b-3), analysed with (ordinal) logistic regression. Estimates were calculated per 10 mmHg change in SBP. We assessed whether IVT modified the associations of SBP with these outcomes using multiplicative interaction terms. RESULTS Of 539 randomised patients, 266 received IVT. The association of SBP with mRS score was J-shaped, with an inflection point at 150 mmHg. Using 150 mmHg as a reference point, SBPs higher than 150 mmHg were associated with poor functional outcome (acOR: 1.23, 95% CI: 1.09-1.38), but lower SBPs were not (acOR: 1.14, 95% CI: 0.99-1.30). Higher SBP was not associated with the risk of sICH (aOR: 1.09, 95% CI: 0.93-1.27) nor with the probability of successful reperfusion (aOR: 1.00, 95% CI: 0.91-1.10). Our main result was that we found no effect modification by IVT (p-values for interaction, mRS = 0.94; sICH = 0.26; successful reperfusion = 0.58). DISCUSSION AND CONCLUSION There was no effect modification of IVT with SBP for any of the clinical outcomes. Therefore, the level of SBP (if ⩽185/110 mmHg) should not guide IVT decisions in patients otherwise eligible for both IVT and EVT within the 4.5-h time window. TRIAL REGISTRATION ISRCTN80619088, https://www.isrctn.com/ISRCTN80619088.
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Affiliation(s)
- Sophie A van den Berg
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Simone M Uniken Venema
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Natalie E LeCouffe
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Alida A Postma
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
- School for Mental Health and Sciences, Maastricht University, Maastricht, The Netherlands
| | | | - Leon A Rinkel
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Kilian M Treurniet
- Department of Radiology, Haaglanden Medical Center, Den Haag, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Agnetha E Bruggeman
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Katinka R van Kranendonk
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Charles BLM Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Diederik WJ Dippel
- Department of Neurology, Erasmus MC – University Medical Center, Rotterdam, The Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
| | - Yvo BWEM Roos
- Department of Neurology, Amsterdam UMC Location University of Amsterdam, Amsterdam, The Netherlands
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111
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Bai X, Fu Z, Wang X, Song C, Xu X, Li L, Feng Y, Dmytriw AA, Regenhardt RW, Sun Z, Yang B, Jiao L. Clinical evidence comparing bridging and direct endovascular thrombectomy: progress and controversies. J Neurointerv Surg 2023; 15:881-885. [PMID: 36175017 DOI: 10.1136/jnis-2022-019362] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Accepted: 09/10/2022] [Indexed: 11/04/2022]
Abstract
Clinical evidence comparing bridging endovascular thrombectomy (bEVT) with intravenous thrombolysis and direct endovascular thrombectomy (dEVT) without thrombolysis for patients with acute ischemic stroke (AIS) presented directly to an EVT-capable center is overwhelming but inconsistent. This study aimed to analyze the progress and controversies in clinical evidence based on current meta-analyses. Three databases, including MEDLINE, EMBASE, and the Cochrane Library, were searched. Relevant data were extracted and reviewed from the pooled studies. The Assessment of Multiple Systematic Review (AMSTAR-2) was used for quality assessment. Twenty-five meta-analyses were finally included. There were 56% (14/25) from Asian countries, 20% (5/25) from North America, and 24% (6/25) from Europe. The majority (72%, 18/25) of evidence arose in a short period from 2020 to 2022 with the serial publication of four randomized controlled trials (RCTs). Among the 25 meta-analyses, 11 pooled at least three RCTs but there is substantial overlap among seven (five recruited the same four RCTs solely and two recruited the same three RCTs solely). Meanwhile, quality rating based on AMSTAR-2 showed 16 'high' rated studies (64%). For functional independence, 40% (10/25) of studies favored bEVT and 60% showed neutral results. For symptomatic intracerebral hemorrhage, most studies (82.6%, 19/23) showed no significant difference. Non-RCT studies contributed to evidence favoring bEVT. Current RCTs provide an update of clinical evidence comparing bEVT and dEVT. However, they simultaneously contribute to an unnecessary overlap among studies. Contemporary observational studies demonstrated different but possibly confounded evidence. Thus, this issue still requires more clinical evidence under standard procedures.
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Affiliation(s)
- Xuesong Bai
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute, Beijing, China
| | - Zhaolin Fu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute, Beijing, China
| | - Xue Wang
- Library Department, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chengyu Song
- Library Department, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Xin Xu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute, Beijing, China
| | - Long Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute, Beijing, China
| | - Yao Feng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute, Beijing, China
| | - Adam A Dmytriw
- Neurointerventional Program, Departments of Medical Imaging & Clinical Neurological Sciences, London Health Sciences Centre, Western University, London, Ontario, Canada
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Robert W Regenhardt
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Ziyi Sun
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute, Beijing, China
| | - Bin Yang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute, Beijing, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
- China International Neuroscience Institute, Beijing, China
- Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Beijing, China
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112
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Sanak D, Kocher M, Zapletalova J, Cihlar F, Czerny D, Cernik D, Duras P, Fiksa J, Husty J, Jurak L, Kovar M, Lacman J, Padr R, Prochazka P, Raupach J, Reiser M, Rohan V, Roubec M, Sova J, Sercl M, Skorna M, Simunek L, Snajdrova A, Sramek M, Tomek A. Endovascular treatment for acute ischemic stroke in patients with tandem lesion in the anterior circulation: analysis from the METRICS study. J Neurointerv Surg 2023; 15:e123-e128. [PMID: 36002287 DOI: 10.1136/jnis-2022-019176] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2022] [Accepted: 08/01/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Acute ischemic stroke (AIS) due to anterior circulation tandem lesion (TL) remains a technical and clinical challenge for endovascular treatment (EVT). Conflicting results from observational studies and missing evidence from the randomized trials led us to report a recent real-world multicenter clinical experience and evaluate possible predictors of good outcome after EVT. METHODS We analyzed all AIS patients with TL enrolled in the prospective national study METRICS (Mechanical Thrombectomy Quality Indicators Study in Czech Stroke Centers). A good 3-month clinical outcome was scored as 0-2 points in modified Rankin Scale (mRS), achieved recanalization using the Thrombolysis In Cerebral Infarction (TICI) scale and symptomatic intracerebral hemorrhage (sICH) according to the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (SITS-MOST) criteria. RESULTS Of 1178 patients enrolled in METRICS, 194 (19.2%) (59.8% males, mean age 68.7±11.5 years) were treated for TL. They did not differ in mRS 0-2 (48.7% vs 46.7%; p=0.616), mortality (17.3% vs 22.7%; p=0.103) and sICH (4.7% vs 5.1%; p=0.809) from those with single occlusion (SO). More TL patients with prior intravenous thrombolysis (IVT) reached TICI 3 (70.3% vs 50.8%; p=0.012) and mRS 0-2 (55.4% vs 34.4%; p=0.007) than those without IVT. No difference was found in the rate of sICH (6.2% vs 1.6%; p=0.276). Multivariate logistic regression analysis showed prior IVT as a predictor of mRS 0-2 after adjustment for potential confounders (OR 3.818, 95% CI 1.614 to 9.030, p=0.002). CONCLUSION Patients with TL did not differ from those with SO in outcomes after EVT. TL patients with prior IVT had more complete recanalization and mRS 0-2 and IVT was found to be a predictor of good outcome after EVT.
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Affiliation(s)
- Daniel Sanak
- Department of Neurology, Palacký University Faculty of Medicine and University Hospital Olomouc, Olomouc, Czech Republic
| | - Martin Kocher
- Department of Radiology, Palacký University Faculty of Medicine and University Hospital Olomouc, Olomouc, Czech Republic
| | - Jana Zapletalova
- Department of Biophysics and Statistics, Palacky University Olomouc, Olomouc, Czech Republic
| | - Filip Cihlar
- Department of Radiology, Masaryk Hospital in Usti nad Labem, Usti nad Labem, Czech Republic
| | - Daniel Czerny
- Department of Radiology, University Hospital Ostrava, Ostrava, Czech Republic
| | - David Cernik
- Department of Neurology, Krajska zdravotni as Masarykova nemocnice v Usti nad Labem oz, Usti nad Labem, Czech Republic
| | - Petr Duras
- Department of Radiology, University Hospital Plzen, Plzen, Czech Republic
| | - Jan Fiksa
- Department of Neurology, General University Hospital in Prague, Prague, Czech Republic
| | - Jakub Husty
- Department of Radiology and Nuclear Medicine, University Hospital Brno, Brno, Czech Republic
| | - Lubomir Jurak
- Department of Neurology, Regional Hospital Liberec, Liberec, Czech Republic
| | - Martin Kovar
- Department of Neurology, Na Homolce Hospital, Prague, Czech Republic
| | - Jiri Lacman
- Department of Radiology, Central Military Hospital Prague, Prague, Czech Republic
| | - Radek Padr
- Department of Radiology, University Hospital Motol Prague, Prague, Czech Republic
| | - Pavel Prochazka
- 2nd Department of Internal Medicine, General University Hospital in Prague, Prague, Czech Republic
| | - Jan Raupach
- Department of Radiology, Charles University Faculty of Medicine and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Martin Reiser
- Department of Neurology, Regional Hospital Ceske Budejovice, Ceske Budejovice, Czech Republic
| | - Vladimir Rohan
- Department of Neurology, Charles University Faculty of Medicine and University Hospital Plzen, Plzen, Czech Republic
| | - Martin Roubec
- Department of Neurology, University of Ostrava Faculty of Medicine and University Hospital Ostrava, Ostrava, Czech Republic
| | - Jindrich Sova
- Department of Radiology, Regional Hospital Ceske Budejovice, Ceske Budejovice, Czech Republic
| | - Miroslav Sercl
- Department of Radiology, Regional Hospital Liberec, Liberec, Czech Republic
| | - Miroslav Skorna
- Department of Neurology, Masaryk University Faculty of Medicine and University Hospital Brno, Brno, Czech Republic
| | - Libor Simunek
- Department of Neurology, Charles University Faculty of Medicine and University Hospital Hradec Kralove, Hradec Kralove, Czech Republic
| | - Alena Snajdrova
- Department of Radiology, Na Homolce Hospital Prague, Prague, Czech Republic
| | - Martin Sramek
- Department of Neurology, Central Military Hospital Prague, Prague, Czech Republic
| | - Ales Tomek
- Department of Neurology, Motol University Hospital, Praha, Praha, Czech Republic
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113
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Meinel TR, Kaesmacher J, Buetikofer L, Strbian D, Eker OF, Cognard C, Mordasini P, Deppeler S, Mendes Pereira V, Albucher JF, Darcourt J, Bourcier R, Guillon B, Papagiannaki C, Costentin G, Sibolt G, Räty S, Gory B, Richard S, Liman J, Ernst M, Boulanger M, Barbier C, Mechtouff L, Zhang L, Marnat G, Sibon I, Nikoubashman O, Reich A, Consoli A, Weisenburger D, Requena M, Garcia-Tornel A, Saleme S, Moulin S, Pagano P, Saliou G, Carrera E, Janot K, Boix M, Pop R, Della Schiava L, Luft A, Piotin M, Gentric JC, Pikula A, Pfeilschifter W, Arnold M, Siddiqui A, Froehler MT, Furlan AJ, Chapot R, Wiesmann M, Machi P, Diener HC, Kulcsar Z, Bonati L, Bassetti C, Escalard S, Liebeskind D, Saver JL, Fischer U, Gralla J. Time to treatment with bridging intravenous alteplase before endovascular treatment:subanalysis of the randomized controlled SWIFT-DIRECT trial. J Neurointerv Surg 2023; 15:e102-e110. [PMID: 35902234 DOI: 10.1136/jnis-2022-019207] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/13/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND We hypothesized that treatment delays might be an effect modifier regarding risks and benefits of intravenous thrombolysis (IVT) before mechanical thrombectomy (MT). METHODS We used the dataset of the SWIFT-DIRECT trial, which randomized 408 patients to IVT+MT or MT alone. Potential interactions between assignment to IVT+MT and expected time from onset-to-needle (OTN) as well as expected time from door-to-needle (DTN) were included in regression models. The primary outcome was functional independence (modified Rankin Scale (mRS) 0-2) at 3 months. Secondary outcomes included mRS shift, mortality, recanalization rates, and (symptomatic) intracranial hemorrhage at 24 hours. RESULTS We included 408 patients (IVT+MT 207, MT 201, median age 72 years (IQR 64-81), 209 (51.2%) female). The expected median OTN and DTN were 142 min and 54 min in the IVT+MT group and 129 min and 51 min in the MT alone group. Overall, there was no significant interaction between OTN and bridging IVT assignment regarding either the functional (adjusted OR (aOR) 0.76, 95% CI 0.45 to 1.30) and safety outcomes or the recanalization rates. Analysis of in-hospital delays showed no significant interaction between DTN and bridging IVT assignment regarding the dichotomized functional outcome (aOR 0.48, 95% CI 0.14 to 1.62), but the shift and mortality analyses suggested a greater benefit of IVT when in-hospital delays were short. CONCLUSIONS We found no evidence that the effect of bridging IVT on functional independence is modified by overall or in-hospital treatment delays. Considering its low power, this subgroup analysis could have missed a clinically important effect, and exploratory analysis of secondary clinical outcomes indicated a potentially favorable effect of IVT with shorter in-hospital delays. Heterogeneity of the IVT effect size before MT should be further analyzed in individual patient meta-analysis of comparable trials. TRIAL REGISTRATION NUMBER URL: https://www. CLINICALTRIALS gov ; Unique identifier: NCT03192332.
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Affiliation(s)
- Thomas R Meinel
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | | | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Omer Faruk Eker
- Department of Neuroradiology, Hospices Civils de Lyon, Lyon, France
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Pasquale Mordasini
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Sandro Deppeler
- Neuro Clinical Trial Unit, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Vitor Mendes Pereira
- Division of Neuroradiology and Division of Neurosurgery, Departments of Medical Imaging and Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Jean Darcourt
- Department of Neuroradiology, Hospices Civils de Lyon, Lyon, France
| | - Romain Bourcier
- Department of Diagnostic and Interventional Neuroradiology, Centre Hospitalier Universitaire de Nantes, Nantes Université, Nantes, France
| | - Benoit Guillon
- Department of Neurology, Centre Hospitalier Universitaire de Nantes, Nantes Université, Nantes, France
| | | | | | - Gerli Sibolt
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Silja Räty
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, CHRU-Nancy, Université de Lorraine, INSERM U1254, Nancy, France
| | - Sébastien Richard
- Department of Neurology, Stroke Unit, CHRU-Nancy, Université de Lorraine, INSERM U1116, Nancy, France
| | - Jan Liman
- Department of Neurology, Klinikum Nürnberg, Nürnberg, Germany
| | - Marielle Ernst
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Göttingen, Gottingen, Germany
| | - Marion Boulanger
- Deparment of Neurology, CHU Caen Normandie, University Caen Normandie, INSERM U1237, Caen, France
| | - Charlotte Barbier
- Department of Neuroradiology, CHU Caen Normandie, University Caen Normandie, INSERM U1237, Caen, France
| | - Laura Mechtouff
- Department of Vascular Neurology, Hospices Civils de Lyon, Lyon, France
| | - Liqun Zhang
- Department of Neurology, St George's University Hospital NHS Foundation Trust, London, UK
| | - Gaultier Marnat
- Department of Interventional and Diagnostic Neuroradiology, CHU Bordeaux, University of Bordeaux, Bordeaux, France
| | - Igor Sibon
- Stroke Unit, CHU Bordeaux, University of Bordeaux, Bordeaux, France
| | - Omid Nikoubashman
- Department of Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Arno Reich
- Department of Neurology, University Hospital RWTH Aachen, Aachen, Germany
| | - Arturo Consoli
- Department of Stroke and Diagnostic and Interventional Neuroradiology, Foch Hospital, Suresnes, France
| | - David Weisenburger
- Department of Stroke and Diagnostic and Interventional Neuroradiology, Foch Hospital, Suresnes, France
| | - Manuel Requena
- Stroke Unit, Department of Neurology, Hospital Vall d'Heborn, Barcelona, Spain
- Interventional Neuroradiology, Department of Radiology, Hospital Vall d'Heborn, Barcelona, Spain
| | | | - Suzana Saleme
- Department of Neuroradiology, CHU Limoges, Limoges, France
| | | | - Paolo Pagano
- Department of Neuroradiology, CHU Reims, Reims, France
| | - Guillaume Saliou
- Service of Interventional and Diagnostic Radiology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Emmanuel Carrera
- Department of Neurology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Kevin Janot
- Department of Diagnostic and Interventional Neuroradiology, Tours University Hospital, Tours, France
| | - Marti Boix
- Stroke Unit, Department of Neurosciences, University Hospital Germans Trias i Pujol, Barcelona, Spain
| | - Raoul Pop
- Department of Interventional Neuroradiology, Strasbourg University Hospitals, Strasbourg, France
| | | | - Andreas Luft
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
- Department of Neurology, Cereneo, Center for Neurology and Rehabilitation, Vitznau, Switzerland
| | - Michel Piotin
- Department of interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France
| | | | - Aleksandra Pikula
- Department of Neurology, University Health Network - Toronto Western Hospital - University of Toronto, Toronto, Ontario, Canada
| | | | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Adnan Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Michael T Froehler
- Vanderbilt Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anthony J Furlan
- School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - René Chapot
- Department of Intracranial Endovascular Therapy, Alfried-Krupp Krankenhaus, Essen, Germany
| | - Martin Wiesmann
- Department of Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Paolo Machi
- Department of Neuroradiology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Hans-Christoph Diener
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology (IMIBE), Essen, Germany
| | - Zsolt Kulcsar
- Department of Neuroradiology, University Hospital of Zurich, Zurich, Switzerland
| | - Leo Bonati
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Claudio Bassetti
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Simon Escalard
- Department of interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France
| | - David Liebeskind
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, UCLA, University of California, Los Angeles, California, USA
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, UCLA, University of California, Los Angeles, California, USA
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
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114
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Maïer B, Finitsis S, Mazighi M, Lapergue B, Marnat G, Sibon I, Richard S, Cognard C, Viguier A, Olivot JM, Gory B. Thrombectomy with or without Intravenous Thrombolytics in Basilar Artery Occlusion. Ann Neurol 2023; 94:596-604. [PMID: 37314741 DOI: 10.1002/ana.26720] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 06/01/2023] [Accepted: 06/08/2023] [Indexed: 06/15/2023]
Abstract
OBJECTIVE Two randomized trials demonstrated the benefit of endovascular therapy (EVT) in patients suffering from a stroke due to a basilar artery occlusion (BAO). However, intravenous thrombolytic (IVT) use before EVT was low in these trials, questioning the added value of this treatment in this setting. We sought to investigate the efficacy and safety of EVT alone compared to IVT + EVT in stroke patients with a BAO. METHODS We analyzed data from the Endovascular Treatment in Ischemic Stroke registry, a prospective, observational, multicenter study of acute ischemic stroke patients treated with EVT in 21 centers in France between 1 January 2015 and 31 December 2021. We included patients with BAO and/or intracranial vertebral artery occlusion and compared patients treated with EVT alone versus IVT + EVT after propensity score (PS) matching. Variables selected for the PS were pre-stroke mRS, dyslipidemia, diabetes, anticoagulation, admission mode, baseline NIHSS and ASPECTS, type of anesthesia, and time from symptom onset to puncture. Efficacy outcomes were good functional outcome (modified Rankin Scale [mRS] 0-3) and functional independence (mRS 0-2) at 90 days. Safety outcomes were symptomatic intracranial hemorrhages and all-cause mortality at 90 days. RESULTS Among 385 patients, 243 (134 EVT alone and 109 IVT + EVT) were included after PS matching. There was no difference between EVT alone and IVT + EVT regarding good functional outcome (adjusted odd ratio [aOR] labeling = 1.27, 95% confidence interval [CI], 0.68-2.37, p = 0.45) and functional independence (aOR = 1.50, 95% CI, 0.79-2.85, p = 0.21). Symptomatic intracranial hemorrhage and all-cause mortality were also similar between the two groups (aOR = 0.42, 95% CI, 0.10-1.79, p = 0.24 and aOR = 0.56, 95% CI, 0.29-1.10, p = 0.09, respectively). INTERPRETATION In this PS matching analysis, EVT alone seemed to lead to similar neurological recovery than IVT + EVT, with comparable safety profile. However, given our sample size and the observational nature of this study, further studies are needed to confirm these findings. ANN NEUROL 2023;94:596-604.
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Affiliation(s)
- Benjamin Maïer
- Neurology Department, Hôpital Saint-Joseph, Paris, France
- Service de Recherche Clinique, Hôpital Fondation A. de Rothschild, Paris, France
- Université Paris-Cité, Paris, France
- Université Paris-Cité and Université Sorbonne Paris Nord, INSERM, LVTS, F-75018, Paris, France
| | - Stephanos Finitsis
- Aristotle University of Thessaloniki, Ahepa Hospital, Thessaoniki, Greece
| | - Mikael Mazighi
- Université Paris-Cité, Paris, France
- Université Paris-Cité and Université Sorbonne Paris Nord, INSERM, LVTS, F-75018, Paris, France
- Neurology Department, Hôpital Lariboisière, Paris, France
- Interventional Neuroradiology Department, Hôpital Fondation A. de Rothschild, Paris, France
| | - Bertrand Lapergue
- Department of Neurology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - Gaultier Marnat
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
| | - Igor Sibon
- Neurology Department, University Hospital of Bordeaux, Bordeaux, France
| | - Sebastien Richard
- Department of Neurology, Stroke Unit, CIC-P 1433, INSERM U1116, CHRU-Nancy, Nancy, France
| | | | - Alain Viguier
- Vascular Neurology Department, University Hospital of Toulouse, Toulouse, France
| | - Jean-Marc Olivot
- Vascular Neurology Department, University Hospital of Toulouse, Toulouse, France
| | - Benjamin Gory
- CHRU-Nancy, Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, Nancy, France
- INSERM 1254, IADI, Université de Lorraine, Nancy, France
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115
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Rinkel LA, Treurniet KM, Kappelhof M, LeCouffe NE, Bruggeman AAE, Nieboer D, van Zwam WH, Uyttenboogaart M, Dippel DWJ, Emmer BJ, Roos YBWEM, Majoie CBLM, Coutinho JM. Influence of time metrics on the treatment effect of intravenous alteplase prior to endovascular treatment in MR CLEAN-NO IV. J Neurointerv Surg 2023; 15:e54-e59. [PMID: 35831176 DOI: 10.1136/jnis-2022-018998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 06/15/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND We assessed whether the treatment effect of intravenous alteplase (IVT) prior to endovascular treatment (EVT) on functional outcome is modified by time metrics. METHODS We used data from all patients included in MR CLEAN-NO IV, a randomized trial of IVT followed by EVT versus EVT alone in patients who presented directly to EVT-capable hospitals. The primary outcome was the modified Rankin Scale score at 90 days. We used ordinal regression with a multiplicative interaction term to assess if the effect of IVT is modified by onset-to-randomization (OTR), onset-to-IV-needle (OTN), door-to-groin (DTG) or needle-to-groin (NTG) times. Secondary outcomes included successful reperfusion (extended Thrombolysis In Cerebral Infarction Scale 2b-3) and symptomatic intracranial hemorrhage (sICH). RESULTS In 539 included patients (266 allocated to IVT+EVT and 273 to EVT alone), median workflow times were OTR: 93 (IQR 71-145) min; OTN: 98 (IQR 75-156) min; DTG: 64 (IQR 51-78) min; and NTG: 28 (IQR 20-41) min. There was a significant association between worse outcomes and longer time intervals for all metrics except NTG. We found no interaction between any of the time metrics and IVT for the effect on functional outcome (p values for interaction: OTR=0.40, OTN=0.39, DTG=0.61, NTG=0.56). We also did not observe any significant interaction for successful reperfusion or sICH. CONCLUSION In MR CLEAN-NO IV, the effect of IVT prior to EVT was not modified by OTR, OTN, DTG or NTG times. Our results do not support the use of these metrics to guide IVT treatment decisions prior to EVT in comprehensive stroke centres. TRIAL REGISTRATION NUMBER ISRCTN80619088.
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Affiliation(s)
- Leon A Rinkel
- Department of Neurology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Kilian Maurizio Treurniet
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Natalie E LeCouffe
- Department of Neurology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Agnetha A E Bruggeman
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Wim H van Zwam
- Department of Radiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands
- Department of Radiology and Nuclear Medicine, University Medical Center Groningen, Groningen, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Bart J Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
| | - J M Coutinho
- Department of Neurology, Amsterdam UMC Location AMC, Amsterdam, The Netherlands
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116
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Chen H, Ahmad G, Colasurdo M, Yarbrough K, Schrier C, Phipps MS, Cronin CA, Mehndiratta P, Cole JW, Wozniak M, Miller TR, Gandhi D, Jindal G, Chaturvedi S. Mildly elevated INR is associated with worse outcomes following mechanical thrombectomy for acute ischemic stroke. J Neurointerv Surg 2023; 15:e117-e122. [PMID: 35961666 PMCID: PMC10593142 DOI: 10.1136/jnis-2022-019283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2022] [Accepted: 08/01/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Elevated International Normalized Ratio (INR) is a marker of coagulopathy, but its impact on outcomes following mechanical thrombectomy (MT) in patients with stroke is unclear. This study investigates the impact of mild INR elevations on clinical outcomes following MT. METHODS In this retrospective cohort study, consecutive patients with stroke treated with MT were identified from 2015 to 2020 at a Comprehensive Stroke Center. Demographic information, past medical history, INR, National Institutes of Health Stroke Scale score, use of tissue plasminogen activator, and last known normal to arteriotomy time were recorded. Outcome measures included modified Thrombolysis in Cerebral Infarction (mTICI) score, modified Rankin Scale (mRS) score at 90 days, and intracerebral hemorrhage (ICH). Patients were divided into two groups: normal INR (0.8-1.1) and mildly elevated INR (1.2-1.7). RESULTS A total of 489 patients were included for analysis, of which 349 had normal INR and 140 had mildly elevated INR. After multivariable adjustments, mildly elevated INR was associated with lower odds of excellent outcomes (mRS 0-1, OR 0.24, p=0.009), lower odds of functional independence (mRS 0-2, OR 0.38, p=0.038), and higher odds of 90-day mortality (OR 3.45, p=0.018). Elevated INR was not associated with a higher likelihood of ICH, and there were no differences in rates of HI1, HI2, PH1, or PH2 hemorrhagic transformations; however, elevated INR was associated with significantly higher odds of 90-day mortality in patients with ICH (OR 6.22, p=0.024). This effect size was larger than in patients without ICH (OR 3.38, p<0.001). CONCLUSION In patients with stroke treated with MT, mildly elevated INR is associated with worse clinical outcomes after recanalization and may worsen the mortality risk of hemorrhagic transformations.
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Affiliation(s)
- Huanwen Chen
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
- Department of Neurology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Ghasan Ahmad
- Department of Radiology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Marco Colasurdo
- Department of Radiology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Karen Yarbrough
- Department of Neurology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Chad Schrier
- Department of Neurology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Michael S Phipps
- Department of Neurology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Carolyn A Cronin
- Department of Neurology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Prachi Mehndiratta
- Department of Neurology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - John W Cole
- Department of Neurology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Marcella Wozniak
- Department of Neurology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Timothy R Miller
- Department of Radiology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Dheeraj Gandhi
- Department of Radiology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Gaurav Jindal
- Department of Radiology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Seemant Chaturvedi
- Department of Neurology, University of Maryland Medical Center, Baltimore, Maryland, USA
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Schlemm L, Siebert E, Kleine JF, Riegler C, Bode FJ, Petersens M, Schlemm E, Keil F, Tiedt S, Bohner G, Nolte CH. Decline of thrombolysis rates before endovascular therapy in patients with acute anterior circulation large vessel occlusion ischemic stroke: A multicenter analysis from the German Stroke Registry. Eur Stroke J 2023; 8:610-617. [PMID: 37243508 PMCID: PMC10472953 DOI: 10.1177/23969873231177774] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/07/2023] [Indexed: 05/29/2023] Open
Abstract
INTRODUCTION In recent years, the role of intravenous thrombolysis (IVT) before endovascular stroke treatment (EVT) has been discussed intensively. Whether the discussion was accompanied by changing rates of bridging IVT is unknown. METHODS Data were extracted from the prospectively maintained German Stroke Registry, including patients treated with EVT at one of 28 stroke centers in Germany between 2016 and 2021. Primary outcome parameters were the rate of bridging IVT (a) in the entire registry cohort and (b) in patients without formal contraindications to IVT (i.e. recent oral anticoagulants, time window ⩾4.5 h, extensive early ischemic changes) adjusted for demographic and clinical confounders. RESULTS 10,162 patients (52.8% women, median age 77 years, median National Institutes of Health Stroke Scale score 14) were analyzed. In the entire cohort, the rate of bridging IVT decreased from 63.8% in 2016 to 43.6% in 2021 (average absolute annual decrease 3.1%, 95% CI 2.4%-3.8%), while the proportion of patients with at least one formal contraindication increased by only 1.2% annually (95% CI 0.6%-1.9%). Among 5460 patients without record of formal contraindications, the rate of bridging IVT decreased from 75.5% in 2016 to 63.2% in 2021 and was significantly associated with admission date in a multivariable model (average absolute annual decrease 1.4%, 95% CI 0.6%-2.2%). Clinical factors associated with lower odds of bridging IVT included diabetes mellitus, carotid-T-occlusion, dual antiplatelet therapy, and direct admission to a thrombectomy center. CONCLUSION We observed a substantial decline in bridging IVT rates independent of demographic confounders and not explained by an increase in contraindications. This observation deserves further exploration in independent populations.
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Affiliation(s)
- Ludwig Schlemm
- Institute of Neuroradiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Department of Radiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Eberhard Siebert
- Institute of Neuroradiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Justus F Kleine
- Institute of Neuroradiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Riegler
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Felix J Bode
- Department of Neurology, Universitätsklinikum Bonn, Bonn, Germany
| | | | - Eckhard Schlemm
- Klinik und Poliklinik Für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Fee Keil
- Institute for Neuroradiology, University Hospital, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research, Klinikum der Universität München, Ludwig-Maximilians-Universität LMU, Munich, Germany
| | - Georg Bohner
- Institute of Neuroradiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany
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Sahoo A, Abdalkader M, Yamagami H, Huo X, Sun D, Jia B, Weyland CS, Diana F, Kaliaev A, Klein P, Bui J, Kasab SA, de Havenon A, Zaidat OO, Zi W, Yang Q, Michel P, Siegler JE, Yaghi S, Hu W, Nguyen TN. Endovascular Therapy for Acute Stroke: New Evidence and Indications. JOURNAL OF NEUROENDOVASCULAR THERAPY 2023; 17:232-242. [PMID: 38025253 PMCID: PMC10657733 DOI: 10.5797/jnet.ra.2023-0047] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 07/04/2023] [Accepted: 07/25/2023] [Indexed: 12/01/2023]
Abstract
Endovascular therapy (EVT) has revolutionized the treatment of acute ischemic stroke. In the past few years, endovascular treatment indications have expanded to include patients being treated in the extended window, with large ischemic core infarction, basilar artery occlusion (BAO) thrombectomy, as demonstrated by several randomized clinical trials. Intravenous thrombolysis (IVT) bridging to mechanical thrombectomy has also been studied via several randomized clinical trials, with the overall results indicating that IVT should not be skipped in patients who are candidates for both IVT and EVT. Simplification of neuroimaging protocols in the extended window to permit non-contrast CT, CTA collaterals have also expanded access to mechanical thrombectomy, particularly in regions across the world where access to advanced imaging may not be available. Ongoing study of areas to develop include rescue stenting in patients with failed thrombectomy, medium vessel occlusion thrombectomy, and carotid tandem occlusions. In this narrative review, we summarize recent trials and key data in the treatment of patients with large ischemic core infarct, simplification of neuroimaging protocols for the treatment of patients presenting in the late window, bridging thrombolysis, and BAO EVT evidence. We also summarize areas of ongoing study including medium and distal vessel occlusion.
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Affiliation(s)
- Anurag Sahoo
- Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Mohamad Abdalkader
- Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Hiroshi Yamagami
- Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Xiaochuan Huo
- Cerebrovascular Disease, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Dapeng Sun
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Baixue Jia
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | | | - Francesco Diana
- Interventional Neuroradiology, Vall d'Hebron University Hospital, Barcelona, Spain
- Vall d'Hebron Research Institute, Barcelona, Spain
| | - Artem Kaliaev
- Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Piers Klein
- Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Jenny Bui
- Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Sami Al Kasab
- Neurology and Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | | | | | - Wenjie Zi
- Neurology, Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Qingwu Yang
- Neurology, Xinqiao Hospital of Army Medical University, Chongqing, China
| | - Patrik Michel
- Neurosciences, Lausanne University Hospital, Lausanne, Switzerland
| | | | - Shadi Yaghi
- Neurology, Rhode Island Hospital, Brown University School of Medicine, Providence, RI, USA
| | - Wei Hu
- Neurology, The First Affiliated Hospital of University of Science and Technology of China, Hefei, China
| | - Thanh N Nguyen
- Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
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Patel J, Bhaskar SMM. Atrial Fibrillation and Reperfusion Therapy in Acute Ischaemic Stroke Patients: Prevalence and Outcomes-A Comprehensive Systematic Review and Meta-Analysis. Neurol Int 2023; 15:1014-1043. [PMID: 37755356 PMCID: PMC10537209 DOI: 10.3390/neurolint15030065] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Revised: 08/23/2023] [Accepted: 08/24/2023] [Indexed: 09/28/2023] Open
Abstract
Atrial fibrillation (AF) significantly contributes to acute ischaemic stroke (AIS), yet its precise influence on clinical outcomes post-intravenous thrombolysis (IVT) and post-endovascular thrombectomy (EVT) has remained elusive. Furthermore, the overall prevalence of AF in AIS patients undergoing reperfusion therapy has not been clearly determined. Employing random-effects meta-analyses, this research aimed to estimate the pooled prevalence of AF among AIS patients undergoing reperfusion therapy, while also examining the association between AF and clinical outcomes such as functional outcomes, symptomatic intracerebral haemorrhage (sICH) and mortality. Studies comparing AF and non-AF patient groups undergoing reperfusion therapy were identified and included following an extensive database search. Forty-nine studies (n = 66,887) were included. Among IVT patients, the prevalence of AF was 31% (Effect Size [ES] 0.31 [95%CI 0.28-0.35], p < 0.01), while in EVT patients, it reached 42% (ES 0.42 [95%CI 0.38-0.46], p < 0.01), and in bridging therapy (BT) patients, it stood at 36% (ES 0.36 [95%CI 0.28-0.43], p < 0.01). AF was associated with significantly lower odds of favourable 90-day functional outcomes post IVT (Odds Ratio [OR] 0.512 [95%CI 0.376-0.696], p < 0.001), but not post EVT (OR 0.826 [95%CI 0.651-1.049], p = 0.117). Our comprehensive meta-analysis highlights the varying prevalence of AF among different reperfusion therapies and its differential impact on patient outcomes. The highest pooled prevalence of AF was observed in EVT patients, followed by BT and IVT patients. Interestingly, our analysis revealed that AF was significantly associated with poorer clinical outcomes following IVT. Such an association was not observed following EVT.
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Affiliation(s)
- Jay Patel
- Global Health Neurology Lab., Sydney, NSW 2150, Australia
- South Western Sydney Clinical Campuses, University of New South Wales (UNSW) Medicine and Health, UNSW Sydney, Sydney, NSW 2170, Australia
- Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Sydney, NSW 2170, Australia
| | - Sonu M. M. Bhaskar
- Global Health Neurology Lab., Sydney, NSW 2150, Australia
- Neurovascular Imaging Laboratory, Clinical Sciences Stream, Ingham Institute for Applied Medical Research, Sydney, NSW 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW 2170, Australia
- Department of Neurology & Neurophysiology, Liverpool Hospital & South Western Sydney Local Health District (SWSLHD), Sydney, NSW 2170, Australia
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Deng Q, Zhang L, Liu Y, Zhou F, Yuan Z, Wang X, Gao J, Yang P, Zhang Y, Xing P, Li Z, Hong B, Han H, Shi H, Shi H, Liu J. Effect of Time Window on Endovascular Thrombectomy with or without Intravenous Thrombolysis in Acute Ischemic Stroke: Results from DIRECT-MT. Cerebrovasc Dis 2023; 53:176-183. [PMID: 37598670 DOI: 10.1159/000533231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 05/12/2023] [Indexed: 08/22/2023] Open
Abstract
INTRODUCTION Whether time window affects the intravenous thrombolysis (IVT) effect before endovascular thrombectomy (EVT) is uncertain. We aimed to investigate the effect of different time windows (0-3 h and >3-4.5 h from stroke onset to randomization) on clinical outcomes of EVT with or without IVT in a subgroup analysis of DIRECT-MT. METHODS The primary outcome was the 90-day modified Rankin Scale (mRS) according to time window. Logistic regression models were used to analyze the effect of different treatments (EVT with or without IVT) on outcomes within 0-3 h or >3-4.5 h. RESULTS Among 656 patients who were included in the analysis, 282 (43.0%) were randomized within >3-4.5 h after stroke onset (125 without IVT and 157 with IVT), and 374 (57.0%) were randomized within 0-3 h (202 without IVT and 172 with IVT). We noted no significant difference in the thrombectomy-alone effect between the time window subgroups according to 90-day ordinal mRS (adjusted common odds ratio [acOR] in patients within 0-3 h: 1.06 [95% CI: 0.73-1.52], acOR in patients within >3-4.5 h: 1.19 [95% CI: 0.78-1.82]) and 90-day functional independence. Thrombectomy alone resulted in an increased proportion of patients with 90-day mRS 0-3 treated within >3-4.5 h (62.90 vs. 48.72%) but not within 0-3 h (65.84 vs. 63.95%). However, there was no interaction effect regarding all outcomes after the Bonferroni correction. CONCLUSIONS Our results did not support thrombectomy-alone administration within 3-4.5 h in patients with acute ischemic stroke from large-vessel occlusion in the subgroup analysis of DIRECT-MT.
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Affiliation(s)
- Qiwen Deng
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China,
| | - Lei Zhang
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | - Yukai Liu
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Feng Zhou
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Zhenhua Yuan
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xixi Wang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Jie Gao
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Pengfei Yang
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | - Yongwei Zhang
- Department of Neurology, Naval Medical University Changhai Hospital, Shanghai, China
| | - Pengfei Xing
- Department of Neurology, Naval Medical University Changhai Hospital, Shanghai, China
| | - Zifu Li
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | - Bo Hong
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | - Hongxing Han
- Department of Neurology, Linyi People's Hospital of Qingdao University, Linyi, China
| | - Huaizhang Shi
- Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hongchao Shi
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Jianmin Liu
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
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Li K, Peng L, Xing Q, Zuo X, Huang W, Zhan L, Li H, Sun W, Zhong X, Zhu T, Pan G, Xu E. Transplantation of hESCs-Derived Neural Progenitor Cells Alleviates Secondary Damage of Thalamus After Focal Cerebral Infarction in Rats. Stem Cells Transl Med 2023; 12:553-568. [PMID: 37399126 PMCID: PMC10428088 DOI: 10.1093/stcltm/szad037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2022] [Accepted: 06/04/2023] [Indexed: 07/05/2023] Open
Abstract
Human embryonic stem cells-derived neural progenitor cells (hESCs-NPCs) transplantation holds great potential to treat stroke. We previously reported that delayed secondary degeneration occurs in the ventroposterior nucleus (VPN) of ipsilateral thalamus after distal branch of middle cerebral artery occlusion (dMCAO) in adult male Sprague-Dawley (SD) rats. In this study, we investigate whether hESCs-NPCs would benefit the neural recovery of the secondary damage in the VPN after focal cerebral infarction. Permanent dMCAO was performed with electrocoagulation. Rats were randomized into Sham, dMCAO groups with or without hESCs-NPCs treatment. HESCs-NPCs were engrafted into the peri-infarct regions of rats at 48 h after dMCAO. The transplanted hESCs-NPCs survive and partially differentiate into mature neurons after dMCAO. Notably, hESCs-NPCs transplantation attenuated secondary damage of ipsilateral VPN and improved neurological functions of rats after dMCAO. Moreover, hESCs-NPCs transplantation significantly enhanced the expression of BDNF and TrkB and their interaction in ipsilateral VPN after dMCAO, which was reversed by the knockdown of TrkB. Transplantated hESCs-NPCs reconstituted thalamocortical connection and promoted the formation of synapses in ipsilateral VPN post-dMCAO. These results suggest that hESCs-NPCs transplantation attenuates secondary damage of ipsilateral thalamus after cortical infarction, possibly through activating BDNF/TrkB pathway, enhancing thalamocortical projection, and promoting synaptic formation. It provides a promising therapeutic strategy for secondary degeneration in the ipsilateral thalamus post-dMCAO.
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Affiliation(s)
- Kongping Li
- Institute of Neurosciences and Department of Neurology of the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, People’s Republic of China
- CAS Key Laboratory of Regenerative Biology, Joint School of Life Sciences, The Affiliated Brain Hospital of Guangzhou Medical University, Guangzhou, Guangdong, People’s Republic of China
| | - Linhui Peng
- Institute of Neurosciences and Department of Neurology of the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, People’s Republic of China
| | - Qi Xing
- Department of Neurology, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, 190 Kaiyuan Avenue, Science Park, Guangdong, People’s Republic of China
| | - Xialin Zuo
- Institute of Neurosciences and Department of Neurology of the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, People’s Republic of China
| | - Wenhao Huang
- Department of Neurology, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, 190 Kaiyuan Avenue, Science Park, Guangdong, People’s Republic of China
| | - Lixuan Zhan
- Institute of Neurosciences and Department of Neurology of the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, People’s Republic of China
| | - Heying Li
- Department of Neurology, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, 190 Kaiyuan Avenue, Science Park, Guangdong, People’s Republic of China
| | - Weiwen Sun
- Institute of Neurosciences and Department of Neurology of the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, People’s Republic of China
| | - Xiaofen Zhong
- Department of Neurology, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, 190 Kaiyuan Avenue, Science Park, Guangdong, People’s Republic of China
| | - Tieshi Zhu
- Institute of Neurosciences and Department of Neurology of the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, People’s Republic of China
| | - Guangjin Pan
- Department of Neurology, Guangzhou Institutes of Biomedicine and Health, Chinese Academy of Sciences, 190 Kaiyuan Avenue, Science Park, Guangdong, People’s Republic of China
| | - En Xu
- Institute of Neurosciences and Department of Neurology of the Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, People’s Republic of China
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Liu C, Gu J, Yao Y. Longitudinal Change of Plasma Retinol-Binding Protein 4 and its Relation to Neurological-Function Recovery, Relapse, and Death in Acute Ischemic Stroke Patients. TOHOKU J EXP MED 2023; 260:293-300. [PMID: 37100600 DOI: 10.1620/tjem.2023.j036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/28/2023]
Abstract
Retinol-binding protein 4 (RBP4) promotes dyslipidemia, insulin resistance, inflammation, and atherosclerosis, etc. which may participate in the progression of acute ischemia stroke (AIS). This study aimed to evaluate the longitudinal change of RBP4 after disease onset and its correlation with prognosis in AIS patients. Plasma RBP4 was measured by enzyme-linked immunosorbent assays in 402 AIS patients at admission, one day (D1), 3 days (D3), 7 days (D7), and 30 days (D30) after admission; and in 100 healthy controls after enrollment. The neurological-function recovery was evaluated by the modified Rankin Scale (mRS) at 3 months (M3); disease relapse and death were also recorded during a median 20-month follow-up in AIS patients. Our study revealed that RBP4 was elevated in AIS patients compared with healthy controls. RBP4 was related to a history of diabetes mellitus, a history of cardiovascular disease, and elevated National Institutes of Health Stroke Scale score in AIS patients. Longitudinally, RBP4 was increased from admission to D1/D3, then reduced gradually to D30 in AIS patients. Notably, RBP4 at admission and D1 was elevated in AIS patients with mRS > 2 compared to those with mRS ≤ 2. Meanwhile, RBP4 at admission, D1, D3, D7, and D30 were all higher in AIS patients occurred relapse than those without; RBP4 at D3, D7, and D30 were also higher in AIS patients who died later than those who survived. In conclusion, plasma RBP4 originally elevates and continuously decreases during disease, which forecasts neurological-function recovery status, relapse, and death risk of AIS.
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Affiliation(s)
- Chao Liu
- Department of CT Diagnosis, Cangzhou Central Hospital
| | - Juxian Gu
- Department of Neurology, Cangzhou Central Hospital
| | - Yan Yao
- Department of Neurology, Cangzhou Central Hospital
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Raha O, Hall C, Malik A, D'Anna L, Lobotesis K, Kwan J, Banerjee S. Advances in mechanical thrombectomy for acute ischaemic stroke. BMJ MEDICINE 2023; 2:e000407. [PMID: 37577026 PMCID: PMC10414072 DOI: 10.1136/bmjmed-2022-000407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 05/25/2023] [Indexed: 08/15/2023]
Abstract
Mechanical thrombectomy is a ground breaking treatment for acute ischaemic stroke caused by occlusion of a large vessel. Its efficacy over intravenous thrombolysis has been proven in multiple trials with a lower number needed to treat than percutaneous coronary intervention for acute myocardial infarction. However, access to this key treatment modality remains limited with a considerable postcode lottery across the UK and many parts of the world. The evidence base for mechanical thrombectomy dates back to 2015. Since then, there have been important advances in establishing and widening the criteria for treatment. This narrative review aims to summarise the current evidence base and latest advances for physicians and academics with an interest in recanalisation treatments for acute ischaemic stroke.
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Affiliation(s)
- Oishik Raha
- Imperial Stroke Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Charles Hall
- Interventional Neuroradiology, Imperial College Healthcare NHS Trust, London, UK
| | - Abid Malik
- Imperial Stroke Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Lucio D'Anna
- Imperial Stroke Centre, Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
| | - Kyriakos Lobotesis
- Interventional Neuroradiology, Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
| | - Joseph Kwan
- Imperial Stroke Centre, Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
| | - Soma Banerjee
- Imperial Stroke Centre, Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
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Chen CH, Bala F, Najm M, Alhabli I, Singh N, Kashani N, McDonough RV, Horn M, Stang J, Demchuk AM, Menon BK, Hill MD, Almekhlafi MA. Effect of Needle-To-Puncture Time on Reperfusion Outcome in Acute Ischemic Stroke. Cerebrovasc Dis 2023; 53:168-175. [PMID: 37494909 DOI: 10.1159/000532118] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2023] [Accepted: 07/09/2023] [Indexed: 07/28/2023] Open
Abstract
INTRODUCTION The aim of the study was to investigate the impact of time interval between start of intravenous thrombolysis (IVT) to start of endovascular thrombectomy (EVT) on stroke outcomes. METHODS Data from the Quality Improvement and Clinical Research (QuICR) provincial stroke registry from Alberta, Canada, were used to identify stroke patients who received IVT and EVT from January 2015 to December 2019. We assessed the impact of the time interval between IVT bolus to EVT puncture (needle-to-puncture times [NPT]) on outcomes. Radiological outcomes included successful initial recanalization (revised Arterial Occlusive Lesion 2b-3), successful initial and final reperfusion (modified thrombolysis in cerebral infarction 2b-3). Clinical outcomes were 90-day modified Rankin Scale (mRS) and mortality. RESULTS Of the 680 patients, 233 patients (median age: 73, 41% females) received IVT + EVT. Median NPT was 38 min (IQR, 24-60). Arrival during working hours was independently associated with shorter NPT (p < 0.001). Successful initial recanalization and initial and final reperfusion were observed in 12%, 10%, and 83% of patients, respectively. NPT was not associated with initial successful recanalization (OR 0.97 for every 10-min increase of NPT, 95% CI: 0.91-1.04), initial successful reperfusion (OR 1.01, 95% CI: 0.96-1.07), or final successful reperfusion (OR: 1.03, 95% CI: 0.97-1.08). Every 10-min delay in NPT was associated with lower odds of functional independence at 90 days (mRS ≤2; OR: 0.93; 95% CI, 0.88-0.97). Patients with shorter NPT (≤38 min) had lower 90-day mRS scores (median 1 vs. 3; OR: 0.54 [0.31-0.91]) and had lower mortality (6.1% vs. 21.2%; OR, 0.23 [0.10-0.57]) than the longer NPT group. CONCLUSION Shorter NPT did not impact reperfusion outcomes but was associated with better clinical outcome.
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Affiliation(s)
- Chih-Hao Chen
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada,
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan,
| | - Fouzi Bala
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, Tours, France
| | - Mohamed Najm
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Ibrahim Alhabli
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Nishita Singh
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Department of Internal Medicine-Neurology Division, Health Sciences Center, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nima Kashani
- Department of Neurosurgery, Royal University Hospital, Saskatoon, Saskatchewan, Canada
| | - Rosalie V McDonough
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - MacKenzie Horn
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Jilian Stang
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Alberta Health Services, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brian Institute, University of Calgary, Calgary, Alberta, Canada
| | - Bijoy K Menon
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brian Institute, University of Calgary, Calgary, Alberta, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brian Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Mohammed A Almekhlafi
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brian Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
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Amaral S, Duloquin G, Béjot Y. Symptomatic Intracranial Hemorrhage after Ischemic Stroke Treated with Bridging Revascularization Therapy. Life (Basel) 2023; 13:1593. [PMID: 37511968 PMCID: PMC10381185 DOI: 10.3390/life13071593] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Revised: 07/12/2023] [Accepted: 07/13/2023] [Indexed: 07/30/2023] Open
Abstract
(1) Background: bridging revascularization therapy is now the standard of care in patients with ischemic stroke due to large vessel occlusion. This study aimed to determine the frequency of symptomatic intracranial hemorrhage (sICH) related to this treatment, and to assess contributing factors and patients' outcomes. (2) Methods: consecutive ischemic stroke patients treated with bridging therapy were prospectively enrolled. sICH (intracranial hemorrhage with an increase in NIHSS score of ≥4 points) was assessed on imaging at 24 h. The functional status of patients was measured at 6 months using the mRS score; (3) Results: 176 patients were included (mean age 68.7 ± 1.2 years, 52.3% women), among whom 15 (8.5%) had sICH. Patients with sICH had more frequent alcohol abuse (30.1% versus 9.7%, p = 0.023), prestroke use of dual antiplatelet therapy (14.3% versus 1.3%, p = 0.002), higher NIHSS scores at admission (median score 20.5 versus 15, p = 0.01), greater systolic blood pressure upon admission, more frequent vascular intracranial calcifications (p = 0.004), leukoaraiosis (p = 0.001), and intracranial atheroma (p = 0.02), and higher neutrophil-to-lymphocyte ratios (p = 0.02) and neutrophil-to-platelet ratios (p = 0.04). At 6-month follow-up, 9 (60%) patients with sICH died, versus 18% of patients without sICH (p < 0.001). Only 1 (7%) patient with sICH had a good functional outcome, defined as an mRS score of 0 to 2, versus 51% of patients without sICH. (4) Conclusions: one in twelve ischemic stroke patients treated with bridging therapy suffered sICH. Given the observed poor outcomes after sICH, further studies are required to better identify patients at risk to help clinicians in guiding therapeutic strategies.
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Affiliation(s)
- Simon Amaral
- Neurology Department, Dijon University Hospital, 21000 Dijon, France
- Dijon Stroke Registry, EA7460, University of Burgundy, 21078 Dijon, France
| | - Gauthier Duloquin
- Neurology Department, Dijon University Hospital, 21000 Dijon, France
- Dijon Stroke Registry, EA7460, University of Burgundy, 21078 Dijon, France
| | - Yannick Béjot
- Neurology Department, Dijon University Hospital, 21000 Dijon, France
- Dijon Stroke Registry, EA7460, University of Burgundy, 21078 Dijon, France
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126
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Man S, Solomon N, Grory BM, Alhanti B, Uchino K, Saver JL, Smith EE, Xian Y, Bhatt DL, Schwamm LH, Hussain MS, Fonarow GC. Shorter Door-to-Needle Times Are Associated With Better Outcomes After Intravenous Thrombolytic Therapy and Endovascular Thrombectomy for Acute Ischemic Stroke. Circulation 2023; 148:20-34. [PMID: 37199147 PMCID: PMC10356148 DOI: 10.1161/circulationaha.123.064053] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2023] [Accepted: 04/21/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Existing data and clinical trials could not determine whether faster intravenous thrombolytic therapy (IVT) translates into better long-term functional outcomes after acute ischemic stroke among those treated with endovascular thrombectomy (EVT). Patient-level national data can provide the required large population to study the associations between earlier IVT, versus later, with longitudinal functional outcomes and mortality in patients receiving IVT+EVT combined treatment. METHODS This cohort study included older US patients (age ≥65 years) who received IVT within 4.5 hours or EVT within 7 hours after acute ischemic stroke using the linked 2015 to 2018 Get With The Guidelines-Stroke and Medicare database (38 913 treated with IVT only and 3946 with IVT+EVT). Primary outcome was home time, a patient-prioritized functional outcome. Secondary outcomes included all-cause mortality in 1 year. Multivariate logistic regression and Cox proportional hazards models were used to evaluate the associations between door-to-needle (DTN) times and outcomes. RESULTS Among patients treated with IVT+EVT, after adjusting for patient and hospital factors, including onset-to-EVT times, each 15-minute increase in DTN times for IVT was associated with significantly higher odds of zero home time in a year (never discharged to home) (adjusted odds ratio, 1.12 [95% CI, 1.06-1.19]), less home time among those discharged to home (adjusted odds ratio, 0.93 per 1% of 365 days [95% CI, 0.89-0.98]), and higher all-cause mortality (adjusted hazard ratio, 1.07 [95% CI, 1.02-1.11]). These associations were also statistically significant among patients treated with IVT but at a modest degree (adjusted odds ratio, 1.04 for zero home time, 0.96 per 1% home time for those discharged to home, and adjusted hazard ratio 1.03 for mortality). In the secondary analysis where the IVT+EVT group was compared with 3704 patients treated with EVT only, shorter DTN times (≤60, 45, and 30 minutes) achieved incrementally more home time in a year, and more modified Rankin Scale 0 to 2 at discharge (22.3%, 23.4%, and 25.0%, respectively) versus EVT only (16.4%, P<0.001 for each). The benefit dissipated with DTN>60 minutes. CONCLUSIONS Among older patients with stroke treated with either IVT only or IVT+EVT, shorter DTN times are associated with better long-term functional outcomes and lower mortality. These findings support further efforts to accelerate thrombolytic administration in all eligible patients, including EVT candidates.
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Affiliation(s)
- Shumei Man
- Department of Neurology, Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Nicole Solomon
- Duke Clinical Research Institute, Duke University, Durham, NC
| | - Brian Mac Grory
- Department of Neurology, Duke University School of Medicine, Durham, NC
| | - Brooke Alhanti
- Duke Clinical Research Institute, Duke University, Durham, NC
| | - Ken Uchino
- Department of Neurology, Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Jeffrey L Saver
- Department of Neurology, University of California, Los Angeles, CA
| | - Eric E Smith
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Ying Xian
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai Health System, New York, NY
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, MA
| | - Muhammad Shazam Hussain
- Department of Neurology, Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH
| | - Gregg C Fonarow
- Division of Cardiology, University of California, Los Angeles, CA
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Bathla G, Ajmera P, Mehta PM, Benson JC, Derdeyn CP, Lanzino G, Agarwal A, Brinjikji W. Advances in Acute Ischemic Stroke Treatment: Current Status and Future Directions. AJNR Am J Neuroradiol 2023; 44:750-758. [PMID: 37202115 PMCID: PMC10337623 DOI: 10.3174/ajnr.a7872] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Accepted: 04/03/2023] [Indexed: 05/20/2023]
Abstract
The management of acute ischemic stroke has undergone a paradigm shift in the past decade. This has been spearheaded by the emergence of endovascular thrombectomy, along with advances in medical therapy, imaging, and other facets of stroke care. Herein, we present an updated review of the various stroke trials that have impacted and continue to transform stroke management. It is critical for the radiologist to stay abreast of the ongoing developments to provide meaningful input and remain a useful part of the stroke team.
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Affiliation(s)
- G Bathla
- From the Department of Radiology (G.B., P.M.M., J.C.B., G.L., W.B.), Mayo Clinic, Rochester, Minnesota
| | - P Ajmera
- Department of Radiology (P.A.), University College of Medical Sciences, Delhi, India
| | - P M Mehta
- From the Department of Radiology (G.B., P.M.M., J.C.B., G.L., W.B.), Mayo Clinic, Rochester, Minnesota
| | - J C Benson
- From the Department of Radiology (G.B., P.M.M., J.C.B., G.L., W.B.), Mayo Clinic, Rochester, Minnesota
| | - C P Derdeyn
- Department of Radiology (C.P.D.), University of Iowa Hospitals and Clinics, Iowa City, Iowa
| | - G Lanzino
- From the Department of Radiology (G.B., P.M.M., J.C.B., G.L., W.B.), Mayo Clinic, Rochester, Minnesota
| | - A Agarwal
- Department of Radiology (A.A.), Mayo Clinic, Jacksonville, Florida
| | - W Brinjikji
- From the Department of Radiology (G.B., P.M.M., J.C.B., G.L., W.B.), Mayo Clinic, Rochester, Minnesota
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128
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Liu W, Zhao J, Liu H, Li T, Zhou T, He Y, Zhu L, Ding Y, Hui FK, He Y. Safety and Efficacy of Direct Thrombectomy Versus Bridging Therapy in Patients with Acute Ischemic Stroke Eligible for Intravenous Thrombolysis: A Meta-Analysis of Randomized Controlled Trials. World Neurosurg 2023; 175:113-121.e3. [PMID: 37040841 DOI: 10.1016/j.wneu.2023.04.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 04/05/2023] [Indexed: 04/13/2023]
Abstract
OBJECTIVE In the present study, we conducted a meta-analysis of reported randomized controlled trials (RCTs) comparing the safety and efficacy of direct thrombectomy (DT) and bridging therapy (BT) for patients eligible for intravenous thrombolysis (IVT). METHODS A comprehensive search of PubMed, Cochrane Library, EMBASE, and Web of Science up to July 11, 2022 was performed. RCTs comparing DT and BT were included. The relative risk or rate difference and their 95% confidence intervals in a Mantel-Haenszel fixed effects model were used as the effect index of each outcome. The noninferior margin was specified as 80% for the relative risk or -10% for the rate difference. The primary outcome was the proportion of patients with a favorable functional outcome, defined as a modified Rankin scale (mRS) score of 0-2 or a return to baseline at 90 days. Additional efficacy and safety outcomes included successful recanalization at the end of thrombectomy, excellent clinical outcomes (defined as an mRS score of 0-1), death within 90 ± 14 days, symptomatic intracerebral hemorrhage, any type of intracerebral hemorrhage, and clot migration. RESULTS Six RCTs with 2334 patients were pooled for the meta-analysis. The results showed the noninferiority of DT for favorable functional outcomes, higher successful recanalization rates, and any intracerebral hemorrhage in the BT group, with no statistically significant differences for other outcomes. The risk of bias for all RCTs in our analysis was low. CONCLUSIONS DT achieved noninferiority to BT for favorable functional outcomes. Patient-level pooled analysis and subgroup analysis are needed to provide more information to distinguish which patients will benefit more from which therapy.
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Affiliation(s)
- Wenbo Liu
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, China
| | - Jingge Zhao
- Clinical Research Center, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China
| | - Huan Liu
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, China
| | - Tianxiao Li
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, China
| | - Tengfei Zhou
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, China
| | - Yanyan He
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, China
| | - Liangfu Zhu
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, China
| | - Yonghong Ding
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ferdinand K Hui
- University of Hawaii, Queen's Medical Center, Honolulu, Hawaii, USA
| | - Yingkun He
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, China.
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Li L, Liu Y, Zheng Y, Zhu J, Wu D, Yan X, Li C, Wu M, Li W. Exploring the mechanisms under Zuogui Pill's treatment of ischemic stroke through network pharmacology and in vitro experimental verification. Front Pharmacol 2023; 14:1153478. [PMID: 37426810 PMCID: PMC10323140 DOI: 10.3389/fphar.2023.1153478] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 06/13/2023] [Indexed: 07/11/2023] Open
Abstract
Due to its high mortality, incidence and disability rates, ischemic stroke poses heavy economic burdens to families and society. Zuogui Pill (ZGP) is a classic Chinese medicine for tonifying the kidney, which is effective for the recovery of neurological function after ischemic stroke. However, Zuogui Pill has not been evaluated for its potential effects on ischemic strokes. Using network pharmacology, the research aimed to explore the mechanisms of Zuogui Pill on ischemic stroke, which were further validated in SH-SY5Y cells injured by oxygen and glucose deprivation/reperfusion (OGD/R). Network analysis of Zuogui Pill identified 86 active ingredients and 107 compound-related targets correlated with ischemic stroke. Additionally, 11 core active compounds were obtained, such as Quercetin, beta sitosterol, and stigmasterol. Most of the compounds have been proven to have pharmacological activities. Based on pathway enrichment studies, Zuogui Pill may exert neuroprotection through MAPK signaling, PI3K-Akt signaling and apoptosis, as well as enhance neurite outgrowth and axonal regeneration effect via mTOR signaling, p53 signaling and Wnt signaling pathways. In vitro experiment, the viability of ischemic neuron treated with Zuogui Pill was increased, and the ability of neurite outgrowth was significantly improved. Western blot assays shown that the pro-neurite outgrowth effect of Zuogui Pill on ischemic stroke may be relate to PTEN/mTOR signal pathway. The results of the study provided new insights into Zuogui Pill's molecular mechanism in treatment of ischemic stroke, as well as clinical references for its use.
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Affiliation(s)
- Li Li
- Department of Neurology, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
- The First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Yan Liu
- Department of Neurology, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
- The First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Yawei Zheng
- Department of Neurology, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
- The First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Jian Zhu
- Department of Endocrinology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Dan Wu
- Department of Neurology, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
- The First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Xiaohui Yan
- Department of Neurology, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
- The First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Changyin Li
- Department of Clinical Pharmacology, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
| | - Minghua Wu
- Department of Neurology, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
- The First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Wenlei Li
- Department of Neurology, Jiangsu Province Hospital of Chinese Medicine, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China
- The First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
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Morsi RZ, Zhang Y, Carrión-Penagos J, Desai H, Tannous E, Kothari S, Khamis AM, Darzi AJ, Tarabichi A, Bastin R, Hneiny L, Thind S, Coleman E, Brorson JR, Mendelson S, Mansour A, Prabhakaran S, Kass-Hout T. Endovascular thrombectomy with or without thrombolysis bridging in patients with acute ischaemic stroke: protocol for a systematic review, meta-analysis of randomised trials and cost-effectiveness analysis. BMJ Open 2023; 13:e064322. [PMID: 37308271 DOI: 10.1136/bmjopen-2022-064322] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2023] Open
Abstract
INTRODUCTION Current published guidelines and meta-analyses comparing endovascular thrombectomy (EVT) alone versus EVT with bridging intravenous thrombolysis (IVT) suggest that EVT alone is non-inferior to EVT with bridging thrombolysis in achieving favourable functional outcome. Because of this controversy, we aimed to systematically update the evidence and meta-analyse data from randomised trials comparing EVT alone versus EVT with bridging thrombolysis, and performed an economic evaluation comparing both strategies. METHODS AND ANALYSIS We will conduct a systematic review of randomised controlled trials comparing EVT with or without bridging thrombolysis in patients presenting with large vessel occlusions. We will identify eligible studies by systematically searching the following databases from inception without any language restrictions: MEDLINE (through Ovid), Embase and the Cochrane Library. The following criteria will be used to assess eligibility for inclusion: (1) adult patients ≥18 years old; (2) randomised patients to EVT alone or to EVT with IVT; and (3) measured outcomes, including functional outcomes, at least 90 days after randomisation. Pairs of reviewers will independently screen the identified articles, extract information and assess the risk of bias of eligible studies. We will use the Cochrane Risk-of-Bias tool to evaluate risk of bias. We will also use the Grading of Recommendations, Assessment, Development and Evaluation approach to assess the certainty in evidence for each outcome. We will then perform an economic evaluation based on the extracted data. ETHICS AND DISSEMINATION This systematic review will not require a research ethics approval because no confidential patient data will be used. We will disseminate our findings by publishing the results in a peer-reviewed journal and via presentation at conferences. PROSPERO REGISTRATION NUMBER CRD42022315608.
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Affiliation(s)
- Rami Z Morsi
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Yuan Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | | | - Harsh Desai
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Elie Tannous
- Department of Pathology, Albany Medical Center, Albany, New York, USA
| | - Sachin Kothari
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Assem M Khamis
- Wolfson Palliative Care Research Centre, Hull York Medical School, Hull, UK
| | - Andrea J Darzi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Ammar Tarabichi
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Reena Bastin
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Layal Hneiny
- Wegner Health Sciences Information Center, University of South Dakota, Sioux Falls, South Dakota, USA
| | - Sonam Thind
- Section of Neurosurgery, Department of Surgery, University of Chicago, Chicago, Illinois, USA
| | - Elisheva Coleman
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - James R Brorson
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Scott Mendelson
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Ali Mansour
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
| | - Tareq Kass-Hout
- Department of Neurology, University of Chicago, Chicago, Illinois, USA
- Section of Neurosurgery, Department of Surgery, University of Chicago, Chicago, Illinois, USA
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Liyis BGD, Surya SC, Tedyanto EH, Pramana NAK, Widyadharma IPE. Mechanical thrombectomy in M1 and M2 segments of middle cerebral arteries: A meta-analysis of prospective cohort studies. Clin Neurol Neurosurg 2023; 231:107823. [PMID: 37301003 DOI: 10.1016/j.clineuro.2023.107823] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Revised: 05/22/2023] [Accepted: 06/04/2023] [Indexed: 06/12/2023]
Abstract
BACKGROUND Recent studies indicate that endovascular therapy is superior to intravenous thrombolysis in treating M1 segment MCA occlusions, however, the effectiveness of mechanical thrombectomy in MI vs. M2 segment occlusions is unclear. METHODS The meta-analysis was conducted by searching databases from January 2016 to January 2023, without language constraints. The quality of the studies was assessed using the Newcastle-Ottawa Scale. Pooled data analysis of outcomes, pre-existing medical comorbidities, and baseline scores were performed. RESULTS Six prospective cohort studies with 6356 patients were included (4405 vs. 1638). Patients with M2 occlusion had a significantly lower mean baseline NIHSS at admission (MD: -2.14; 95 %CI: -3.48 to -0.81; p = 0.002). Conversely, patients with M1 occlusion had a lower ASPECTS at admission score (MD: 0.29; 95 %CI: 0.00-0.59; p = 0.05). No significant difference was found between segments in terms of pre-existing medical comorbidities (OR: 0.96; 95 %CI: 0.87-1.05; p = 0.36), mortality rate at 90 days (OR: 0.88; 95 %CI: 0.76-1.02; p = 0.10), and hemorrhage occurrence within 24-hours (OR: 1.06; 95 %CI: 0.89-1.25; p = 0.53). Patients with M2 occlusion were more likely to have good outcomes after therapy (OR: 1.18; 95 %CI: 1.05-1.32; p = 0.006). Successful recanalization rates were comparatively higher among patients with an M1 occlusion (OR: 0.79; 95 %CI: 0.68-0.92; p = 0.003). Functional outcomes at 90 days are better in M2 occlusion patients, while successful recanalization rates are higher in M1 occlusion patients. No significant differences were found in mortality rates or hemorrhage incidence. CONCLUSIONS These results suggest that mechanical thrombectomy is a safe and effective treatment for MCA occlusions in both M1 and M2 segments.
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Starikova N, Räty S, Strbian D, Kaiser DPO, Gerber JC, Huo X, Qiu Z, Chen HS, Kaesmacher J, Pallesen LP, Barlinn K, Sun D, Abdalkader M, Nguyen TN, Nagel S, Miao Z, Puetz V. Endovascular Thrombectomy for Anterior Circulation Large Vessel Occlusion Stroke: An Evolution of Trials. Semin Neurol 2023; 43:397-407. [PMID: 37549693 DOI: 10.1055/s-0043-1771454] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/09/2023]
Abstract
The last decade's progress in demonstrating the clinical benefit of endovascular thrombectomy (EVT) in patients with large vessel occlusion stroke has transformed the paradigm of care for these patients. This review presents the milestones in implementing EVT as standard of care, demonstrates the current state of evidence, provides guidance for identifying the candidate patient for EVT, and highlights unsolved and controversial issues. Ongoing trials investigate broadening of EVT indications for patients who present with large core infarction, adjunctive intra-arterial thrombolysis, medium vessel occlusion, low NIHSS, and tandem occlusion.
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Affiliation(s)
- Natalia Starikova
- Department of Neurology, University Clinic of Odessa National Medical University, Odessa, Ukraine
- TeleHealth Consulting Service, Medical Center "Expert Health," Odessa, Ukraine
| | - Silja Räty
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Finland
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Finland
| | - Daniel P O Kaiser
- Institute of Neuroradiology, University Clinics Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
- Dresden Neurovascular Center, University Clinics Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Johannes C Gerber
- Institute of Neuroradiology, University Clinics Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
- Dresden Neurovascular Center, University Clinics Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Xiaochuan Huo
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Zhongming Qiu
- Department of Neurology, The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, China
| | - Johannes Kaesmacher
- Interventional Neuroradiology, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lars-Peder Pallesen
- Dresden Neurovascular Center, University Clinics Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
- Department of Neurology, University Clinics Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Kristian Barlinn
- Dresden Neurovascular Center, University Clinics Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
- Department of Neurology, University Clinics Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Dapeng Sun
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Mohamad Abdalkader
- Department of Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Thanh N Nguyen
- Department of Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
- Department of Neurology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
- Department of Neurology, Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - Zhongrong Miao
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Volker Puetz
- Dresden Neurovascular Center, University Clinics Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
- Department of Neurology, University Clinics Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
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Zhang P, Li H, Wang J, Zhang F, Xiao L, Fang Y, Yan D, Xu G, Liu C, Huang Z, Gu M, Zhang H, Sun W. Sex differences in outcomes after endovascular treatment of patients with vertebrobasilar artery occlusion. Eur Stroke J 2023; 8:566-574. [PMID: 37231678 PMCID: PMC10334174 DOI: 10.1177/23969873221151142] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2022] [Accepted: 12/30/2022] [Indexed: 11/13/2023] Open
Abstract
BACKGROUND Current studies on the role of sex in the prognosis of acute vertebrobasilar artery occlusion (VBAO) are limited. We aimed to explore whether there are sex differences on outcomes in patients treated with endovascular therapy (EVT) for VBAO. METHODS Patients from December 2015 to December 2018 with acute VBAO within 24 h of the estimated occlusion time in 21 stroke centers in China were retrospectively analyzed. Baseline data between sexes were compared in the total population cohort and propensity score (PS)-matched cohort. Multivariate logistic regression and ordinal regression were used to analyze the association of sex with outcomes. Mixed-effects regression model was performed for changes in modified Rankin Scale (mRS) scores in men and women from 90 days to 1 year after discharge. RESULTS A total of 577 patients (28.4% women) were finally included. Multivariate logistic regression showed that women had a lower probability of favorable outcome (mRS score 0-3 at 90 days; OR 0.544; 95% CI 0.329-0.899) and functional independence (mRS score 0-2 at 90 days; OR 0.391; 95% CI 0.228-0.670) as well as a higher possibility of shifting to worse mRS (OR 1.484; 95% CI 1.020-2.158) than men. After PS matching, 391 patients (39.4% women) were analyzed, confirming the same results regarding favorable outcome (OR 0.580; 95% CI 0.344-0.977), functional independence (OR 0.394; 95% CI 0.218-0.712), and shift mRS (OR 1.504; 95% CI 1.023-2.210). However, the results of repeated ANOVA showed that men and women had a comparable functional recovery from 90 days to 1 year. CONCLUSIONS Stroke due to VBAO treated with EVT is associated with worse outcomes in women than in men. However, men and women showed similar long-term improvement trends.
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Affiliation(s)
- Pan Zhang
- Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Hao Li
- Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Jinjing Wang
- Department of Neurology, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Feng Zhang
- Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Lulu Xiao
- Department of Neurology, Affiliated Jinling Hospital, Medical School of Nanjing University, Nanjing, Jiangsu, China
| | - Yirong Fang
- Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Dingyi Yan
- Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Guoqiang Xu
- Department of Neurology, The First People’s Hospital of Yongkang, Yongkang, Zhejiang, China
| | - Chaolai Liu
- Department of Neurology, The First People’s Hospital of Jining, Jining, Shandong, China
| | - Zhixin Huang
- Department of Neurology, Guangdong Second Provincial General Hospital, Guangzhou, Guangdong, China
| | - Mengmeng Gu
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - Hanhong Zhang
- Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Wen Sun
- Stroke Center & Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
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Kraft AW, Awad A, Rosenthal JA, Dmytriw AA, Vranic JE, Bonkhoff AK, Bretzner M, Hirsch JA, Rabinov JD, Stapleton CJ, Schwamm LH, Rost NS, Leslie-Mazwi TM, Patel AB, Regenhardt RW. In a hub-and-spoke network, spoke-administered thrombolysis reduces mechanical thrombectomy procedure time and number of passes. Interv Neuroradiol 2023; 29:315-320. [PMID: 35317663 PMCID: PMC10369105 DOI: 10.1177/15910199221087498] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The utility of intravenous thrombolysis (IVT) prior to mechanical thrombectomy (MT) in large vessel occlusion stroke (LVO) is controversial. Some data suggest IVT increases MT technical difficulty. Within our hub-and-spoke telestroke network, we examined how spoke-administered IVT affected hub MT procedure time and pass number. METHODS Patients presenting to 25 spoke hospitals who were transferred to the hub and underwent MT from 2018 to 2020 were identified from a prospectively maintained database. MT procedure time, fluoroscopy time, and pass number were obtained from operative reports. RESULTS Of 107 patients, 48 received IVT at spokes. Baseline characteristics and NIHSS were similar. The last known well (LKW)-to-puncture time was shorter among IVT patients (4.3 ± 1.9 h vs. 10.5 ± 6.5 h, p < 0.0001). In patients that received IVT, mean MT procedure time was decreased by 18.8 min (50.5 ± 29.4 vs. 69.3 ± 46.7 min, p = 0.02) and mean fluoroscopy time was decreased by 11.3 min (21.7 ± 15.8 vs. 33.0 ± 30.9 min, p = 0.03). Furthermore, IVT-treated patients required fewer MT passes (median 1 pass [IQR 1.0, 1.80] vs. 2 passes [1.0, 2.3], p = 0.0002) and were more likely to achieve reperfusion in ≤2 passes (81.3% vs. 59.3%, p = 0.01). An increased proportion of IVT-treated patients achieved TICI 2b-3 reperfusion after MT (93.9% vs. 83.8%, p = 0.045). There were no associations between MT procedural characteristics and LKW-to-puncture time. CONCLUSION Within our network, hub MT following spoke-administered IVT was faster, required fewer passes, and achieved improved reperfusion. This suggests spoke-administered IVT does not impair MT, but instead may enhance it.
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Affiliation(s)
- Andrew W Kraft
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Amine Awad
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Joseph A Rosenthal
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Adam A Dmytriw
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Justin E Vranic
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Anna K Bonkhoff
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Martin Bretzner
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Joshua A Hirsch
- Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - James D Rabinov
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | | | - Lee H Schwamm
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Natalia S Rost
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | | | - Aman B Patel
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Robert W Regenhardt
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
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135
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Ringleb P, Bauer G, Purrucker J. [Intravenous thrombolysis of ischemic stroke-Current status]. DER NERVENARZT 2023:10.1007/s00115-023-01500-9. [PMID: 37249597 DOI: 10.1007/s00115-023-01500-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Accepted: 04/27/2023] [Indexed: 05/31/2023]
Abstract
Intravenous thrombolysis (IVT) treatment with alteplase (rtPA) is an essential part of the routine treatment of patients with ischemic stroke since its introduction in the late 1990s. Rapid treatment is of essential importance. For patients with an unclear time window, various mismatch concepts have been established to identify salvageable brain tissue prior to IVT. Numerous official contraindications for rtPA are not evidence-based; for example, current data from observational studies show that systemic thrombolytic treatment is possible even in patients receiving direct oral anticoagulant (DOAC) treatment. Tenecteplase (TNK) is an alternative thrombolytic agent with some pharmacologic advantages. The most recent guidelines indicate that TNK is particularly advantageous over rtPA in patients treated in combination with endovascular stroke therapy (EST). The combination of IVT and EST should primarily be performed in the 4.5‑h time window in patients without contraindications; in the later time window EST alone is conceivable if it can be performed without delay.
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Affiliation(s)
- Peter Ringleb
- Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland.
| | - Gregor Bauer
- Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland
| | - Jan Purrucker
- Neurologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland
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136
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Zheng M, Li L, Chen L, Li B, Feng C. Mechanical thrombectomy combined with intravenous thrombolysis for acute ischemic stroke: a systematic review and meta-analyses. Sci Rep 2023; 13:8597. [PMID: 37237159 DOI: 10.1038/s41598-023-35532-7] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 05/19/2023] [Indexed: 05/28/2023] Open
Abstract
To assess the clinical value of mechanical thrombectomy (MT) combined with intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) by comparing it with the MT alone. In this study, we conducted a comprehensive meta-analysis of both observational and randomized controlled studies (RCTs) to investigate various outcomes. Our search for relevant studies was conducted between January 2011 and June 2022 in four major databases: PubMed, Embase, WOS, and Cochrane Library. We collected data on several outcomes, including functional independence (FI; defined as modified Rankin Scale score of 0 to 2), excellent outcomes (mRS 0-1), successful recanalization (SR), symptomatic intracerebral hemorrhage (sICH), any intracerebral hemorrhage (aICH), and mortality at three months or discharge. The primary efficacy outcome and safety outcome were FI and sICH, respectively, whereas excellent outcomes and SR were considered secondary efficacy outcomes. Additionally, mortality and aICH were analyzed as secondary safety outcomes. We employed the Mantel-Haenszel fixed-effects model for RCTs when I2 < 50%, otherwise the random-effects model was utilized. For observational studies and subgroup analyses, we used the random-effects model to minimize potential bias. A total of 55 eligible studies (nine RCTs and 46 observational studies) were included. For RCTs, the MT + IVT group was superior in FI (OR: 1.27, 95% CI: 1.11-1.46), excellent outcomes (OR: 1.21, 95% CI: 1.03-1.43), SR (OR: 1.23, 95% CI: 1.05-1.45), mortality (OR: 0.72, 95% CI: 0.54-0.97) in crude analyses. In adjusted analyses, the MT + IVT group reduced the risk of mortality (OR: 0.65, 95% CI: 0.49-0.88). However, the difference in FI between the MT + IVT group and the MT alone group was not significant (OR: 1.17, 95% CI: 0.99-1.38, Fig. 3a). For observational studies, the results of FI (OR: 1.34, 95% CI: 1.16-1.33), excellent outcomes (OR: 1.30, 95% CI: 1.09-1.54), SR (OR: 1.23, 95% CI: 1.05-1.44), mortality (OR: 0.70, 95% CI: 0.64-0.77) in the MT + IVT group were better. Additionally, the MT + IVT group increased the risk of hemorrhagic transformation (HT) including sICH (OR: 1.16, 95% CI: 1.11-1.21) and aICH (OR: 1.24, 95% CI: 1.05-1.46) in crude analyses. In adjusted analyses, significant better outcomes were seen in the MT + IVT group on FI (OR: 1.36, 95% CI: 1.21-1.52), excellent outcomes (OR: 1.49, 95% CI: 1.26-1.75), and mortality (OR: 0.73, 95% CI: 0.56-0.94). The MT + IVT therapy did improve the prognosis for AIS patients and did not increase the risk of HT compared with MT alone therapy.
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Affiliation(s)
- Meiling Zheng
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100010, People's Republic of China
| | - Li Li
- Department of Radiology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, Sichuan Province, People's Republic of China.
| | - Lizhou Chen
- Department of Radiology, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan Province, People's Republic of China.
| | - Bin Li
- Department of Geriatrics, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, People's Republic of China.
| | - Cuiling Feng
- Peking University People's Hospital, Beijing, 100000, People's Republic of China.
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137
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Lin L, Zhang H, Liu F, Chen C, Chen C, Bivard A, Parsons MW, Li G. Bridging Thrombolysis Before Endovascular Therapy in Stroke Patients With Faster Core Growth. Neurology 2023; 100:e2083-e2092. [PMID: 36963842 PMCID: PMC10186238 DOI: 10.1212/wnl.0000000000207154] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Accepted: 01/20/2023] [Indexed: 03/26/2023] Open
Abstract
BACKGROUND AND OBJECTIVES It is still uncertain that going direct to endovascular thrombectomy (EVT) leads to equivalent outcomes as bridging IV thrombolysis (IVT) in acute ischemic patients. This study aimed to explore whether the rate of ischemic core growth influenced the patient outcomes after bridging IVT vs direct EVT. METHODS This was a retrospective cohort study based on the International Stroke Perfusion Imaging Registry (INSPIRE). It selected acute ischemic stroke patients receiving perfusion CT within 4.5 hours of stroke onset. Patients who went direct to EVT were compared with those who received bridging treatment of IVT before EVT. Ischemic core growth rate was estimated by the acute ischemic core volume on perfusion CT divided by the time from stroke onset to perfusion CT, based on the assumption of a linear growth pattern of ischemic core. Core growth rate was stratified into fast (>15 mL/h) and slow (≤15 mL/h), based on its interaction with bridging IVT in predicting the primary outcome. The primary outcome was modified Rankin scale of 0-2 at 3 months. The secondary outcomes included successful thrombectomy reperfusion defined by modified Thrombolysis in Cerebral Infarction score of 2b-3 and time from groin puncture to reperfusion. RESULTS Of the 1,221 EVT patients in the INSPIRE, 323 patients were selected, of which 82 patients received direct EVT and 241 patients received bridging IVT. Bridging IVT was associated with a higher rate of good clinical outcome among patients with fast core growth (39% vs 7% for direct EVT, odds ratio [OR] 8.75 [1.96-39.1], p = 0.005), but the difference was not notable for patients with slow core growth (55% vs 55% for direct EVT, OR 1.00 [0.53-1.87], p = 0.989). In patients with fast core growth, the bridging and direct EVT patients showed no difference in the reperfusion rate (80% vs 76%, p = 0.616). However, patients who received bridging IVT were more likely to achieve reperfusion earlier (the median groin to reperfusion time of 63.0 vs 94.0 minutes, p = 0.005). DISCUSSION Patients with fast core growth were more likely to benefit from bridging IVT. This is likely because prior IVT facilitates clot removal and thus reduces time to reperfusion.
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Affiliation(s)
- Longting Lin
- From the South Western Clinical School (L.L., M.W.P.), Faculty of Medicine, University of New South Wales, Sydney; Faculty of Health (L.L., Chushuang Chen, M.W.P.), University of Newcastle, Australia; Shanghai East Hospital (H.Z., F.L., Chen Chen, G.L.), Tongji University, China; and Melbourne Brain Centre (A.B., M.W.P.), Royal Melbourne Hospital, University of Melbourne, Australia
| | - Hao Zhang
- From the South Western Clinical School (L.L., M.W.P.), Faculty of Medicine, University of New South Wales, Sydney; Faculty of Health (L.L., Chushuang Chen, M.W.P.), University of Newcastle, Australia; Shanghai East Hospital (H.Z., F.L., Chen Chen, G.L.), Tongji University, China; and Melbourne Brain Centre (A.B., M.W.P.), Royal Melbourne Hospital, University of Melbourne, Australia
| | - Feifeng Liu
- From the South Western Clinical School (L.L., M.W.P.), Faculty of Medicine, University of New South Wales, Sydney; Faculty of Health (L.L., Chushuang Chen, M.W.P.), University of Newcastle, Australia; Shanghai East Hospital (H.Z., F.L., Chen Chen, G.L.), Tongji University, China; and Melbourne Brain Centre (A.B., M.W.P.), Royal Melbourne Hospital, University of Melbourne, Australia
| | - Chen Chen
- From the South Western Clinical School (L.L., M.W.P.), Faculty of Medicine, University of New South Wales, Sydney; Faculty of Health (L.L., Chushuang Chen, M.W.P.), University of Newcastle, Australia; Shanghai East Hospital (H.Z., F.L., Chen Chen, G.L.), Tongji University, China; and Melbourne Brain Centre (A.B., M.W.P.), Royal Melbourne Hospital, University of Melbourne, Australia
| | - Chushuang Chen
- From the South Western Clinical School (L.L., M.W.P.), Faculty of Medicine, University of New South Wales, Sydney; Faculty of Health (L.L., Chushuang Chen, M.W.P.), University of Newcastle, Australia; Shanghai East Hospital (H.Z., F.L., Chen Chen, G.L.), Tongji University, China; and Melbourne Brain Centre (A.B., M.W.P.), Royal Melbourne Hospital, University of Melbourne, Australia
| | - Andrew Bivard
- From the South Western Clinical School (L.L., M.W.P.), Faculty of Medicine, University of New South Wales, Sydney; Faculty of Health (L.L., Chushuang Chen, M.W.P.), University of Newcastle, Australia; Shanghai East Hospital (H.Z., F.L., Chen Chen, G.L.), Tongji University, China; and Melbourne Brain Centre (A.B., M.W.P.), Royal Melbourne Hospital, University of Melbourne, Australia
| | - Mark W Parsons
- From the South Western Clinical School (L.L., M.W.P.), Faculty of Medicine, University of New South Wales, Sydney; Faculty of Health (L.L., Chushuang Chen, M.W.P.), University of Newcastle, Australia; Shanghai East Hospital (H.Z., F.L., Chen Chen, G.L.), Tongji University, China; and Melbourne Brain Centre (A.B., M.W.P.), Royal Melbourne Hospital, University of Melbourne, Australia.
| | - Gang Li
- From the South Western Clinical School (L.L., M.W.P.), Faculty of Medicine, University of New South Wales, Sydney; Faculty of Health (L.L., Chushuang Chen, M.W.P.), University of Newcastle, Australia; Shanghai East Hospital (H.Z., F.L., Chen Chen, G.L.), Tongji University, China; and Melbourne Brain Centre (A.B., M.W.P.), Royal Melbourne Hospital, University of Melbourne, Australia.
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138
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Faizy TD, Broocks G, Heit JJ, Kniep H, Flottmann F, Meyer L, Sporns P, Hanning U, Kaesmacher J, Deb-Chatterji M, Vollmuth P, Lansberg MG, Albers GW, Fischer U, Wintermark M, Thomalla G, Fiehler J, Winkelmeier L. Association Between Intravenous Thrombolysis and Clinical Outcomes Among Patients With Ischemic Stroke and Unsuccessful Mechanical Reperfusion. JAMA Netw Open 2023; 6:e2310213. [PMID: 37126350 PMCID: PMC10152307 DOI: 10.1001/jamanetworkopen.2023.10213] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
Importance Clinical evidence of the potential treatment benefit of intravenous thrombolysis preceding unsuccessful mechanical thrombectomy (MT) is scarce. Objective To determine whether intravenous thrombolysis (IVT) prior to unsuccessful MT improves functional outcomes in patients with acute ischemic stroke. Design, Setting, and Participants Patients were enrolled in this retrospective cohort study from the prospective, observational, multicenter German Stroke Registry-Endovascular Treatment between May 1, 2015, and December 31, 2021. This study compared IVT plus MT vs MT alone in patients with acute ischemic stroke due to anterior circulation large-vessel occlusion in whom mechanical reperfusion was unsuccessful. Unsuccessful mechanical reperfusion was defined as failed (final modified Thrombolysis in Cerebral Infarction grade of 0 or 1) or partial (grade 2a). Patients meeting the inclusion criteria were matched by treatment group using 1:1 propensity score matching. Interventions Mechanical thrombectomy with or without IVT. Main Outcomes and Measures Primary outcome was functional independence at 90 days, defined as a modified Rankin Scale score of 0 to 2. Safety outcomes were the occurrence of symptomatic intracranial hemorrhage and death. Results After matching, 746 patients were compared by treatment arms (median age, 78 [IQR, 68-84] years; 438 women [58.7%]). The proportion of patients who were functionally independent at 90 days was 68 of 373 (18.2%) in the IVT plus MT and 42 of 373 (11.3%) in the MT alone group (adjusted odds ratio [AOR], 2.63 [95% CI, 1.41-5.11]; P = .003). There was a shift toward better functional outcomes on the modified Rankin Scale favoring IVT plus MT (adjusted common OR, 1.98 [95% CI, 1.35-2.92]; P < .001). The treatment benefit of IVT was greater in patients with partial reperfusion compared with failed reperfusion. There was no difference in symptomatic intracranial hemorrhages between treatment groups (AOR, 0.71 [95% CI, 0.29-1.81]; P = .45), while the death rate was lower after IVT plus MT (AOR, 0.54 [95% CI, 0.34-0.86]; P = .01). Conclusions and Relevance These findings suggest that prior IVT was safe and improved functional outcomes at 90 days. Partial reperfusion was associated with a greater treatment benefit of IVT, indicating a positive interaction between IVT and MT. These results support current guidelines that all eligible patients with stroke should receive IVT before MT and add a new perspective to the debate on noninferiority of combined stroke treatment.
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Affiliation(s)
- Tobias D Faizy
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Helge Kniep
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Sporns
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Uta Hanning
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Philipp Vollmuth
- Department of Neuroradiology, University Medical Center Heidelberg, Heidelberg, Germany
| | - Maarten G Lansberg
- Department of Neurology and Neurological Science, Stanford University School of Medicine, Stanford, California
| | - Gregory W Albers
- Department of Neurology and Neurological Science, Stanford University School of Medicine, Stanford, California
| | - Urs Fischer
- Department of Neurology, University Medical Center Basel, Basel, Switzerland
| | - Max Wintermark
- Department of Neuroradiology, MD Anderson Cancer Center, Houston, Texas
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laurens Winkelmeier
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Ye Z, Zhou T, Zhang M, Zhou J, Xie F, Hill MD, Smith EE, Busse JW, Zhang Y, Liu Y, Wang X, Ma Z, An Z. Cost-effectiveness of endovascular thrombectomy with alteplase versus endovascular thrombectomy alone for acute ischemic stroke secondary to large vessel occlusion. CMAJ Open 2023; 11:E443-E450. [PMID: 37192770 DOI: 10.9778/cmajo.20220096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/18/2023] Open
Abstract
BACKGROUND Recent randomized trials have suggested that endovascular thrombectomy (EVT) alone may provide similar functional outcomes as the current standard of care, EVT combined with intravenous alteplase treatment, for acute ischemic stroke secondary to large vessel occlusion. We conducted an economic evaluation of these 2 therapeutic options. METHODS We constructed a decision analytic model with a hypothetical cohort of 1000 patients to assess the cost-effectiveness of EVT with intravenous alteplase treatment versus EVT alone for acute ischemic stroke secondary to large vessel occlusion from both the societal and public health care payer perspectives. We used studies and data published in 2009-2021 for model inputs, and acquired cost data for Canada and China, representing high- and middle-income countries, respectively. We calculated incremental cost-effectiveness ratios (ICERs) using a lifetime horizon and accounted for uncertainty using 1-way and probabilistic sensitivity analyses. All costs are reported in 2021 Canadian dollars. RESULTS In Canada, the difference in quality-adjusted life-years (QALYs) gained between EVT with alteplase and EVT alone was 0.10 from both the societal and health care payer perspectives. The difference in cost was $2847 from a societal perspective and $2767 from the payer perspective. In China, the difference in QALYs gained was 0.07 from both perspectives, and the difference in cost was $1550 from the societal perspective and $1607 from the payer perspective. One-way sensitivity analyses showed that the distributions of modified Rankin Scale scores at 90 days after stroke were the most influential factor on ICERs. For Canada, compared to EVT alone, the probability that EVT with alteplase would be cost-effective at a willingness-to-pay threshold of $50 000 per QALY gained was 58.7% from a societal perspective and 58.4% from a payer perspective. The corresponding values for at a willingness-to-pay threshold of $47 185 (3 times the Chinese gross domestic product per capita in 2021) were 65.2% and 67.4%. INTERPRETATION For patients with acute ischemic stroke due to large vessel occlusion eligible for immediate treatment with both EVT alone and EVT with intravenous alteplase treatment, it is uncertain whether EVT with alteplase is cost-effective compared to EVT alone in Canada and China.
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Affiliation(s)
- Zhikang Ye
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Ting Zhou
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Mengmeng Zhang
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Junwen Zhou
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Feng Xie
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Michael D Hill
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Eric E Smith
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Jason W Busse
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Yi Zhang
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Ying Liu
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Xin Wang
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Zhuo Ma
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont
| | - Zhuoling An
- Department of Pharmacy (Ye, Y. Zhang, Liu, Wang, Ma, An), Beijing Chaoyang Hospital, Capital Medical University, Beijing, China; School of International Pharmaceutical Business (T. Zhou), China Pharmaceutical University, Nanjing, China; The Michael G. DeGroote National Pain Centre (Ye, Busse), McMaster University, Hamilton, Ont.; Department of Health Research Methods, Evidence, and Impact (M. Zhang, Xie, Busse), McMaster University, Hamilton, Ont.; Health Economics Research Centre (J. Zhou), Nuffield Department of Population Health, University of Oxford, Oxford, UK; Department of Clinical Neurosciences and Hotchkiss Brain Institute (Hill), Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, and Department of Clinical Neurosciences and Calgary Stroke Program (Smith), University of Calgary, Calgary, Alta.; Department of Anesthesia (Busse), McMaster University; The Chronic Pain Centre of Excellence for Canadian Veterans (Busse), Hamilton, Ont.
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140
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Horvath LC, Bergmann F, Hosmann A, Greisenegger S, Kammerer K, Jilma B, Siller-Matula JM, Zeitlinger M, Gelbenegger G, Jorda A. Endovascular thrombectomy with or without intravenous thrombolysis in large-vessel ischemic stroke: A non-inferiority meta-analysis of 6 randomised controlled trials. Vascul Pharmacol 2023; 150:107177. [PMID: 37116733 DOI: 10.1016/j.vph.2023.107177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Revised: 04/23/2023] [Accepted: 04/25/2023] [Indexed: 04/30/2023]
Abstract
BACKGROUND It is unclear whether thrombectomy alone is non-inferior to thrombectomy with intravenous thrombolysis in patients with acute ischemic stroke due to large-vessel occlusion. PURPOSE To perform a comprehensive, trial-level data, non-inferiority meta-analysis of randomised controlled trials comparing endovascular thrombectomy with and without intravenous thrombolysis in patients with ischemic stroke due to large-vessel occlusion of anterior circulation. METHODS The prespecified primary efficacy outcome was functional independence, defined as a modified Rankin scale (mRS)score of 0 to 2 at 90 days. The two prespecified non-inferiority margins were risk differences of -10% and - 5%. The study was registered in PROSPERO (CRD42022361110) and conducted according to PRISMA guidelines. RESULTS Six trials were included in this analysis (DIRECT-MT, DEVT, SKIP, MR CLEAN-NO IV, DIRECT-SAFE and SWIFT DIRECT) comprising a total of 2334 patients. Functional independence at 90 days was achieved by 570 (49·0%) of 1164 patients in the thrombectomy alone group and 595 (50·9%) of 1170 patients in the thrombectomy with thrombolysis group (pooled risk difference - 0·02, [95% CI -0·06-0·02]). Combined thrombectomy and thrombolysis were associated with significantly higher rates of successful reperfusion (pooled risk ratio 0·96 [95% CI, 0·93-0·99], p = 0·006) but at the expense of a significantly increased risk of overall - but not symptomatic - intracranial haemorrhage (pooled risk ratio 0·87 [95% CI, 0·77-0·98], p = 0·02). CONCLUSIONS Compared with a combined treatment approach, thrombectomy alone was non-inferior at -10% non-inferiority margin, but not at a - 5% inferiority margin for functional independence. Current evidence cannot exclude clinically important differences between the two treatment approaches.
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Affiliation(s)
| | - Felix Bergmann
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria; Department of Plastic, Reconstructive and Aesthetic Surgery, Medical University of Vienna, Vienna, Austria
| | - Arthur Hosmann
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | | | - Kerstin Kammerer
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Bernd Jilma
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Jolanta M Siller-Matula
- Department of Medicine II, Division of Cardiology, Medical University of Vienna, Vienna, Austria; Department of Experimental and Clinical Pharmacology, Centre for Preclinical Research and Technology (CEPT), Medical University of Warsaw, Warsaw, Poland
| | - Markus Zeitlinger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Georg Gelbenegger
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria
| | - Anselm Jorda
- Department of Clinical Pharmacology, Medical University of Vienna, Vienna, Austria.
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141
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Tu WJ, Xu Y, Liu Y, Li J, Du J, Zhao J. Intravenous Thrombolysis or Medical Management for Minor Strokes. Thromb Haemost 2023. [PMID: 37037201 DOI: 10.1055/s-0043-1768150] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVE To evaluate the outcomes of acute ischemic stroke patients with minor deficits treated with either intravenous thrombolysis (IVT) or routine medical management (MM). METHODS The study included patients with acute ischemic stroke and National Institutes of Health Stroke Scale (NIHSS) scores of 5 or less who were treated with IVT within 4.5 hours from symptom onset and were classified as the IVT group. The MM group consisted of an equal number of patients with minor strokes, matched for sex, age, and severity, who did not receive thrombolysis. Data on patient information were collected for both groups. RESULTS A total of 26,236 patients were included in this study (13,208 in IVT and 13,208 in MM). Of these patients, 67.9% were men, and the mean age was 67.1 years (standard deviation: 10.9). At 3 months, the IVT group had a higher rate of stroke-independent outcome (Rankin Scale score of 0-2) compared with the MM group (IVT vs. MM: 91.6 vs. 88.6%, absolute difference: 2.5%, 95% confidence interval [CI]: 1.6-3.4%, p = 0.008; adjusted hazard ratio [HR]: 1.2, 95% CI: 1.1-1.4, p = 0.003). Furthermore, there was no significant difference in 3-month mortality rates between the IVT and MM groups (IVT vs. MM: 2.1 vs. 2.5%, absolute difference: -0.6%, 95% CI: -1.1 to 0.3%, p = 0.11; adjusted HR: 0.9, 95% CI: 0.8-1.2, p = 0.09). CONCLUSION Compared with MM, IVT does not reduce mortality in minor ischemic stroke but improves functional outcomes in minor stroke with an NIHSS score of 3 to 5.
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Affiliation(s)
- Wen-Jun Tu
- Institute of Radiation Medicine, Chinese Academy of Medical Sciences & Peking Union Medical College, Tianjin, 300192, People's Republic of China
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Yicheng Xu
- Department of Neurology, Aerospace Center Hospital and Peking University Aerospace School of Clinical Medicine, Beijing, People's Republic of China
| | - Yakun Liu
- Department of General Surgery, Beijing Children's Hospital, Capital Medical University, National Center for Children's Health, Beijing, People's Republic of China
| | - Jilai Li
- Department of Neurology, Aerospace Center Hospital and Peking University Aerospace School of Clinical Medicine, Beijing, People's Republic of China
| | - Jichen Du
- Department of Neurology, Aerospace Center Hospital and Peking University Aerospace School of Clinical Medicine, Beijing, People's Republic of China
| | - Jizong Zhao
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
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142
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Hoving JW, van Voorst H, Kappelhof M, Tolhuisen M, Treurniet KM, LeCouffe NE, Rinkel LA, Koopman MS, Cavalcante F, Konduri PR, van den Wijngaard IR, Ghariq E, Anton Meijer FJ, Coutinho JM, Marquering HA, Roos YBWEM, Emmer BJ, Majoie CBLM. Infarct Evolution in Patients with Anterior Circulation Large-Vessel Occlusion Randomized to IV Alteplase and Endovascular Treatment versus Endovascular Treatment Alone. AJNR Am J Neuroradiol 2023; 44:434-440. [PMID: 36958803 PMCID: PMC10084906 DOI: 10.3174/ajnr.a7826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2022] [Accepted: 01/31/2023] [Indexed: 03/25/2023]
Abstract
BACKGROUND AND PURPOSE Infarct evolution after endovascular treatment varies widely among patients with stroke and may be affected by baseline characteristics and procedural outcomes. Moreover, IV alteplase and endovascular treatment may influence the relationship of these factors to infarct evolution. We aimed to assess whether the infarct evolution between baseline and follow-up imaging was different for patients who received IVT and EVT versus EVT alone. MATERIALS AND METHODS We included patients from the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN)-NO IV trial with baseline CTP and follow-up imaging. Follow-up infarct volume was segmented on 24-hour or 1-week follow-up DWI or NCCT. Infarct evolution was defined as the follow-up lesion volume: CTP core volume. Substantial infarct growth was defined as an increase in follow-up infarct volume of >10 mL. We assessed whether infarct evolution was different for patients with IV alteplase and endovascular treatment versus endovascular treatment alone and evaluated the association of baseline characteristics and procedural outcomes with infarct evolution using multivariable regression. RESULTS From 228 patients with CTP results available, 145 patients had follow-up imaging and were included in our analysis. For patients with IV alteplase and endovascular treatment versus endovascular treatment alone, the baseline median CTP core volume was 17 (interquartile range = 4-35) mL versus 11 (interquartile range = 6-24) mL. The median follow-up infarct volume was 13 (interquartile range, 4-48) mL versus 17 (interquartile range = 4-50) mL. Collateral status and occlusion location were negatively associated with substantial infarct growth in patients with and without IV alteplase before endovascular treatment. CONCLUSIONS No statistically significant difference in infarct evolution was found in directly admitted patients who received IV alteplase and endovascular treatment within 4.5 hours of symptom onset versus patients who underwent endovascular treatment alone. Collateral status and occlusion location may be useful predictors of infarct evolution prognosis in patients eligible for IV alteplase who underwent endovascular treatment.
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Affiliation(s)
- J W Hoving
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
| | - H van Voorst
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
- Biomedical Engineering and Physics (H.v.V., M.T., F.C., P.R.K., H.A.M.)
| | - M Kappelhof
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
| | - M Tolhuisen
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
- Biomedical Engineering and Physics (H.v.V., M.T., F.C., P.R.K., H.A.M.)
| | - K M Treurniet
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
- Department of Radiology (K.M.T., I.R.v.d.W., E.G.), The Hague Medical Centers, The Hague, the Netherlands
| | - N E LeCouffe
- Neurology (N.E.L., L.A.R., J.M.C., Y.B.W.E.M.R.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - L A Rinkel
- Neurology (N.E.L., L.A.R., J.M.C., Y.B.W.E.M.R.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - M S Koopman
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
| | - F Cavalcante
- Biomedical Engineering and Physics (H.v.V., M.T., F.C., P.R.K., H.A.M.)
| | - P R Konduri
- Biomedical Engineering and Physics (H.v.V., M.T., F.C., P.R.K., H.A.M.)
| | - I R van den Wijngaard
- Department of Radiology (K.M.T., I.R.v.d.W., E.G.), The Hague Medical Centers, The Hague, the Netherlands
| | - E Ghariq
- Department of Radiology (K.M.T., I.R.v.d.W., E.G.), The Hague Medical Centers, The Hague, the Netherlands
| | - F J Anton Meijer
- Department of Radiology (F.J.A.M.), Radboud University Medical Center, Nijmegen, the Netherlands
| | - J M Coutinho
- Neurology (N.E.L., L.A.R., J.M.C., Y.B.W.E.M.R.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - H A Marquering
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
- Biomedical Engineering and Physics (H.v.V., M.T., F.C., P.R.K., H.A.M.)
| | - Y B W E M Roos
- Neurology (N.E.L., L.A.R., J.M.C., Y.B.W.E.M.R.), Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, the Netherlands
| | - B J Emmer
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
| | - C B L M Majoie
- From the Departments of Radiology and Nuclear Medicine (J.W.H., H.v.V., M.K., M.T., K.M.T., M.S.K., H.A.M., B.J.E., C.B.L.M.M.)
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Rajendram P, Ikram A, Fisher M. Combined Therapeutics: Future Opportunities for Co-therapy with Thrombectomy. Neurotherapeutics 2023; 20:693-704. [PMID: 36943636 PMCID: PMC10275848 DOI: 10.1007/s13311-023-01369-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 03/23/2023] Open
Abstract
Stroke is an urgent public health issue with millions of patients worldwide living with its devastating effects. The advent of thrombolysis and endovascular thrombectomy has transformed the hyperacute care of these patients. However, a significant proportion of patients receiving these therapies still goes on to have unfavorable outcomes and many more remain ineligible for these therapies based on our current guidelines. The future of stroke care will depend on an expansion of the scope of thrombolysis and endovascular thrombectomy to patients outside traditional time windows, more distal occlusions, and large vessel occlusions with mild clinical deficits, for whom clinical trial results have not proven therapeutic efficacy. Novel cytoprotective therapies targeting the ischemic cascade and reperfusion injury therapy, in combination with our existing treatment modalities, should be explored to further improve outcomes for these patients with acute ischemic stroke. In this review, we will review the current status of thrombolysis and thrombectomy, suggest additional data that is needed to enhance these therapies, and discuss how cytoprotection might be combined with thrombectomy.
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Affiliation(s)
- Phavalan Rajendram
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, Palmer Building Room 127, 330 Brookline Avenue, Boston, MA, 02215-5400, USA.
| | - Asad Ikram
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, Palmer Building Room 127, 330 Brookline Avenue, Boston, MA, 02215-5400, USA
| | - Marc Fisher
- Division of Stroke and Cerebrovascular Diseases, Department of Neurology, Harvard Medical School, Beth Israel Deaconess Medical Center, Palmer Building Room 127, 330 Brookline Avenue, Boston, MA, 02215-5400, USA
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144
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Ishfaq MF, Gulraiz S, Huang W, Lobanova I, Martin RH, French BR, Siddiq F, Gurkas E, Aytac E, Gomez CR, Qureshi AI. Endovascular Thrombectomy With or Without Intravenous Thrombolysis: A Meta-Analysis of Randomized Controlled Trials. Interv Neuroradiol 2023; 29:157-164. [PMID: 35450475 PMCID: PMC10152830 DOI: 10.1177/15910199221080232] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Revised: 01/23/2022] [Accepted: 01/27/2022] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND We performed this meta-analysis of randomized clinical trials to compare the outcomes in patients treated with endovascular thrombectomy who receive prior intravenous thrombolysis with those who do not receive such treatment. Recently, one randomized trial reported outcomes to address this issue, so timely update of meta-analysis is needed to determine the value of administering intravenous thrombolysis before endovascular thrombectomy. MATERIALS AND METHODS Four randomized clinical trials are included in our meta-analysis. We calculated pooled odds ratios and 95% CIs using random-effects models. The primary efficacy endpoint was a favorable outcome defined by a modified Rankin Scale score of 0 (no symptoms), 1 (no significant disability), or 2 (slight disability) at 90 days post-randomization. Secondary endpoints analyzed were any intracerebral hemorrhage, symptomatic intracerebral hemorrhage, and mortality. RESULTS Of the 1633 patients randomized, the proportion of patients who achieved a favorable outcome was similar between endovascular thrombectomy alone and combined approach with intravenous thrombolysis and endovascular thrombectomy (1631 patients analyzed; odds ratio 1.02; CI 0.84-1.25; p = 0.83). Risk of any intracerebral hemorrhage was significantly lower among those randomized to endovascular thrombectomy alone (1633 patients analyzed; odds ratio 0.75; CI 0.57-0.99; p = 0.04). Rates of symptomatic intracerebral hemorrhage (p = 0.36) and mortality (p = 0.62) were not significantly different between the two groups. CONCLUSIONS Compared with endovascular thrombectomy preceded by intravenous thrombolysis, endovascular thrombectomy resulted in similar rates of favorable outcome with a lower rate of intracerebral hemorrhage. A large phase 3 trial is required to conclusively demonstrate equivalency of both approaches to guide future practice.
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Affiliation(s)
- Muhammad F. Ishfaq
- Zeenat Qureshi Stroke Institute, St
Cloud, MN
- Department of Neurology, University of Missouri, MO, USA
| | | | - Wei Huang
- Zeenat Qureshi Stroke Institute, St
Cloud, MN
- Department of Neurology, University of Missouri, MO, USA
| | - Iryna Lobanova
- Zeenat Qureshi Stroke Institute, St
Cloud, MN
- Department of Neurology, University of Missouri, MO, USA
| | - Renee H. Martin
- Department of Public Health Sciences,
Medical University of South Carolina, SC, USA
| | | | - Farhan Siddiq
- Division of Neurosurgery, University of
Missouri, Columbia. MO
| | | | - Emrah Aytac
- Zeenat Qureshi Stroke Institute, St
Cloud, MN
| | | | - Adnan I. Qureshi
- Zeenat Qureshi Stroke Institute, St
Cloud, MN
- Department of Neurology, University of Missouri, MO, USA
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Pajor MJ, Adeoye OM. Evolving Stroke Systems of Care: Stroke Diagnosis and Treatment in the Post-Thrombectomy Era. Neurotherapeutics 2023; 20:655-663. [PMID: 36977818 PMCID: PMC10047478 DOI: 10.1007/s13311-023-01371-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/15/2023] [Indexed: 03/30/2023] Open
Abstract
Thrombectomy became the gold-standard treatment of acute ischemic stroke caused by large-vessel occlusions (LVO) in 2015 after five clinical trials published that year demonstrated significantly improved patient outcomes. In subsequent years, advances in stroke systems of care have centered around improving access to and expanding patient eligibility for thrombectomy. The prehospital and acute stroke treatment settings have had the greatest emphasis. Numerous prehospital stroke scales now provide emergency medical services with focused physical exams to identify LVOs, and many devices to non-invasively detect LVO are undergoing clinical testing. Mobile stroke units deployed throughout Western Europe and the USA also show promising results by bringing elements of acute stroke care directly to the patient. Numerous clinical trials since 2015 have aimed to increase candidates for thrombectomy by expanding indications and the eligibility time window. Further optimizations of thrombectomy treatment have focused on the role of thrombolytics and other adjunctive therapies that may promote neuroprotection and neurorecovery. While many of these approaches require further clinical investigation, the next decade shows significant potential for further advances in stroke care.
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Affiliation(s)
- Michael J. Pajor
- Department of Emergency Medicine, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8072, St. Louis, MO 63110 USA
| | - Opeolu M. Adeoye
- Department of Emergency Medicine, Washington University School of Medicine, 660 S. Euclid Ave, Campus Box 8072, St. Louis, MO 63110 USA
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146
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Roy D, Iancu D, Weill A, Raymond J. When enthusiasm defies science. Interv Neuroradiol 2023; 29:222-223. [PMID: 35175148 PMCID: PMC10152831 DOI: 10.1177/15910199221080874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Daniel Roy
- Service de Neuroradiologie
Interventionnelle, Département de Radiologie, Centre hospitalier de l’Université de Montréal
(CHUM), Montréal, Quebec, CANADA
| | - Daniela Iancu
- Service de Neuroradiologie
Interventionnelle, Département de Radiologie, Centre hospitalier de l’Université de Montréal
(CHUM), Montréal, Quebec, CANADA
| | - Alain Weill
- Service de Neuroradiologie
Interventionnelle, Département de Radiologie, Centre hospitalier de l’Université de Montréal
(CHUM), Montréal, Quebec, CANADA
| | - Jean Raymond
- Service de Neuroradiologie
Interventionnelle, Département de Radiologie, Centre hospitalier de l’Université de Montréal
(CHUM), Montréal, Quebec, CANADA
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147
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Grotta JC. Intravenous Thrombolysis for Acute Ischemic Stroke. Continuum (Minneap Minn) 2023; 29:425-442. [PMID: 37039403 DOI: 10.1212/con.0000000000001207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/12/2023]
Abstract
OBJECTIVE This article reviews the history of IV thrombolysis, its current indications and implementation, the duality of the "time is brain" versus "tissue clock" approaches, the impact of endovascular thrombectomy on IV thrombolysis, the emergence of tenecteplase, and future research directions. LATEST DEVELOPMENTS The growing use of factor Xa inhibitors has increasingly caused patients with stroke to be excluded from treatment with IV thrombolysis. Important geographic, socioeconomic, sex, race, and ethnic disparities have been identified in the implementation of IV thrombolysis and need to be overcome. IV thrombolysis substantially improves outcomes when provided within the first golden hour after stroke onset in patients treated in mobile stroke units, supporting the "time is brain" concept and encouraging the possible value of more widespread implementation of the mobile stroke unit approach. At the same time, other studies have shown that IV thrombolysis can be successful in patients whose "tissue clock" is still ticking up to 9 hours after stroke onset or in patients who awaken with their stroke, as demonstrated by favorable imaging profiles. These considerations, along with the emergence of endovascular thrombectomy, have fostered examination of our care systems, including the "drip and ship" versus direct to comprehensive or endovascular thrombectomy stroke center approaches, as well as the possibility of skipping IV thrombolysis in certain patients treated with endovascular thrombectomy. Data suggesting that tenecteplase is at least noninferior to alteplase, as well as its more convenient dosing, has led to its increased use. Ongoing studies are evaluating newer thrombolytics and adding antithrombotic therapy to IV thrombolysis. ESSENTIAL POINTS IV thrombolysis remains the most common acute stroke treatment. Advances in acting faster to treat stroke have increased its efficacy, and advances in imaging have expanded its use. However, implementing these advances and overcoming disparities in IV thrombolysis use remain major challenges.
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148
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Siddiqi AZ, Wadhwa A. Treatment of Acute Stroke: Current Practices and Future Horizons. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 49:56-65. [PMID: 36443221 DOI: 10.1016/j.carrev.2022.11.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 11/06/2022] [Accepted: 11/22/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE This review will discuss revascularization of acute ischemic stroke (AIS), discussing the concept of the ischemic penumbra and how thrombolysis and thrombectomy take advantage of it. SUMMARY The goal of AIS revascularization is to rescue the ischemic penumbra and the approach to has gone from a time-based to tissue-based approach. Patients must be carefully selected for thrombolysis, which traditionally was limited to those whose last known normal time (LKNT) was known and within 4.5 h. However, newer imaging techniques involving MRI and CT perfusion (CTP) can select patients for thrombolysis whose LKNT is unknown. Alteplase, or tPA, is still the agent of choice for thrombolysis in patients with AIS but tenecteplase (TNK) may be just as effective and more efficient to use. Endovascular thrombectomy (EVT) has shown considerable efficacy for treating large-vessel occlusions and using CTP, patients can be selected for hours after symptom-onset if viable tissue remains. Further research is underway to determine if EVT can be used for medium vessel occlusions and for basilar artery thromboses as well as to determine whether an "EVT-alone" strategy is superior to "tPA + EVT" strategy.
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Affiliation(s)
- A Zohaib Siddiqi
- University of Manitoba Max Rady College of Medicine, Winnipeg, Canada.
| | - Ankur Wadhwa
- University of Manitoba Max Rady College of Medicine, Winnipeg, Canada.
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149
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Molad J, Honig A. Current advances in endovascular treatment. Curr Opin Neurol 2023; 36:125-130. [PMID: 36762653 DOI: 10.1097/wco.0000000000001142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
PURPOSE OF REVIEW Endovascular thrombectomy (EVT) is the most beneficial reperfusion therapy for acute ischemic stroke. Currently, much effort is done to promote trials examining EVT efficacy and safety in various conditions not included in the main randomized controlled trials established the superiority of EVT. This review summarizes the current advances of EVT patients' selection and periprocedural management. RECENT FINDINGS Recent evidence points to beneficial effect of EVT among patients with relatively large ischemic core, premorbid independent nonagenarians and basilar artery occlusion, and suggest that intravenous thrombolysis bridging treatment is associated with better reperfusion rates. Ongoing trials currently examine EVT efficacy and safety in distal vessel occlusions and in large vessel occlusion with low NIHSS. Current evidence also support use of general anaesthesia and avoid postprocedural extremely low or high blood pressure as well as haemodynamic instability. SUMMARY The field of EVT is rapidly evolving. The results of recent trials have dramatically increased the indications for EVT, with many ongoing trials examining further indications.
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Affiliation(s)
- Jeremy Molad
- Department of Stroke & Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv
| | - Asaf Honig
- Department of Neurology, Soroka Medical Center, Beer-Sheva, Israel
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150
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Xue Y, Gu M, Chen C, Yao Y, Li Y, Weng G, Gu Y. Apolipoprotein E mimetic peptide COG1410 alleviates blood‑brain barrier injury in a rat model of ischemic stroke. Mol Med Rep 2023; 27:85. [PMID: 36866740 PMCID: PMC10018278 DOI: 10.3892/mmr.2023.12972] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Accepted: 02/15/2023] [Indexed: 03/04/2023] Open
Abstract
Blood‑brain barrier (BBB) damage is one of the main causes of poor outcomes and increased mortality rates following cerebral ischemia‑reperfusion injury. Apolipoprotein E (ApoE) and its mimetic peptide have been previously reported to exhibit potent neuroprotective properties in various central nervous system disease models. Therefore, the present study aimed to investigate the possible role of the ApoE mimetic peptide COG1410 in cerebral ischemia‑reperfusion injury and its potential underlying mechanism. Male SD rats were subjected to 2 h middle cerebral artery occlusion followed by 22 h reperfusion. Evans blue leakage and IgG extravasation assays results revealed that COG1410 treatment significantly reduced BBB permeability. In addition, in situ zymography and western blotting were used to prove that COG1410 was able to downregulate the activities of MMPs and upregulate the expression of occludin in the ischemic brain tissue samples. Subsequently, COG1410 was found to significantly reverse microglia activation while also suppressing inflammatory cytokine production, according to immunofluorescence signal of Iba‑1 and CD68 and protein expression of COX‑2. Consequently, this neuroprotective mechanism mediated by COG1410 was further tested using the BV2 cell line in vitro, which was exposed to oxygen glucose deprivation followed by reoxygenation. The mechanism of COG1410 was found to be mediated, as least partly, through the activation of triggering receptor expressed on myeloid cells 2. In conclusion, the data suggest that COG1410 can alleviate BBB injury and neuroinflammation following ischemic stroke.
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Affiliation(s)
- Yunwen Xue
- Clinical Research Center, Hainan Provincial Hospital of Traditional Chinese Medicine, Haikou, Hainan 570203, P.R. China
| | - Minhua Gu
- Clinical Research Center, Hainan Provincial Hospital of Traditional Chinese Medicine, Haikou, Hainan 570203, P.R. China
| | - Cuilan Chen
- Clinical Research Center, Hainan Provincial Hospital of Traditional Chinese Medicine, Haikou, Hainan 570203, P.R. China
| | - Yujian Yao
- Clinical Research Center, Hainan Provincial Hospital of Traditional Chinese Medicine, Haikou, Hainan 570203, P.R. China
| | - Yuzhen Li
- Clinical Research Center, Hainan Provincial Hospital of Traditional Chinese Medicine, Haikou, Hainan 570203, P.R. China
| | - Guohu Weng
- Hainan Clinical Research Center for Preventive Treatment of Diseases, Hainan Provincial Hospital of Traditional Chinese Medicine, Haikou, Hainan 570203, P.R. China
| | - Yong Gu
- Clinical Research Center, Hainan Provincial Hospital of Traditional Chinese Medicine, Haikou, Hainan 570203, P.R. China
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