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Zaidi SF, Castonguay AC, Zaidat OO, Mueller-Kronast N, Liebeskind DS, Salahuddin H, Jumaa MA. Intra-Arterial Thrombolysis after Unsuccessful Mechanical Thrombectomy in the STRATIS Registry. AJNR Am J Neuroradiol 2021; 42:708-712. [PMID: 33509921 DOI: 10.3174/ajnr.a6962] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Accepted: 10/21/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Recent data suggest that intra-arterial thrombolytics may be a safe rescue therapy for patients with acute ischemic stroke after unsuccessful mechanical thrombectomy; however, safety and efficacy remain unclear. Here, we evaluate the use of intra-arterial rtPA as a rescue therapy in the Systematic Evaluation of Patients Treated with Neurothrombectomy Devices for Acute Ischemic Stroke (STRATIS) registry. MATERIALS AND METHODS STRATIS was a prospective, multicenter, observational study of patients with acute ischemic stroke with large-vessel occlusions treated with the Solitaire stent retriever as the first-line therapy within 8 hours from symptom onset. Clinical and angiographic outcomes were compared in patients having rescue therapy treated with and without intra-arterial rtPA. Unsuccessful mechanical thrombectomy was defined as any use of rescue therapy. RESULTS A total of 212/984 (21.5%) patients received rescue therapy, of which 83 (39.2%) and 129 (60.8%) were in the no intra-arterial rtPA and intra-arterial rtPA groups, respectively. Most occlusions were M1, with 43.4% in the no intra-arterial rtPA group and 55.0% in the intra-arterial rtPA group (P = .12). The median intra-arterial rtPA dose was 4 mg (interquartile range = 2-12 mg). A trend toward higher rates of substantial reperfusion (modified TICI ≥ 2b) (84.7% versus 73.0%, P = .08), good functional outcome (59.2% versus 46.6%, P = .10), and lower rates of mortality (13.3% versus 23.3%, P = .08) was seen in the intra-arterial rtPA cohort. Rates of symptomatic intracranial hemorrhage did not differ (0% versus 1.6%, P = .54). CONCLUSIONS Use of intra-arterial rtPA as a rescue therapy after unsuccessful mechanical thrombectomy was not associated with an increased risk of symptomatic intracranial hemorrhage or mortality. Randomized clinical trials are needed to understand the safety and efficacy of intra-arterial thrombolysis as a rescue therapy after mechanical thrombectomy.
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Affiliation(s)
- S F Zaidi
- From the Department of Neurology (S.F.A., A.C.C., H.S., M.A.J.), University of Toledo, Toledo, Ohio
| | - A C Castonguay
- From the Department of Neurology (S.F.A., A.C.C., H.S., M.A.J.), University of Toledo, Toledo, Ohio
| | - O O Zaidat
- St. Vincent Mercy Hospital (O.O.Z.), Toledo, Ohio
- Department of Neurology (O.O.Z., D.S.L.), University of California Los Angeles, Los Angeles, California
| | | | - D S Liebeskind
- Department of Neurology (O.O.Z., D.S.L.), University of California Los Angeles, Los Angeles, California
| | - H Salahuddin
- From the Department of Neurology (S.F.A., A.C.C., H.S., M.A.J.), University of Toledo, Toledo, Ohio
| | - M A Jumaa
- From the Department of Neurology (S.F.A., A.C.C., H.S., M.A.J.), University of Toledo, Toledo, Ohio
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152
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Lee JS, Hwang YH, Sohn SI. Factors Contributing to an Efficacious Endovascular Treatment for Acute Ischemic Stroke in Asian Population. Neurointervention 2021; 16:91-110. [PMID: 33765729 PMCID: PMC8261106 DOI: 10.5469/neuroint.2020.00339] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2020] [Accepted: 02/19/2021] [Indexed: 12/13/2022] Open
Abstract
Although randomized control trials about endovascular treatment (EVT) of emergent large vessel occlusion (LVO) have demonstrated the success of mechanical thrombectomy as the choice of treatment, a wide range of caveats remain unaddressed. Asian patients were rarely included in the trials, thereby raising the question of whether the treatment could be generalized. In addition, there remains a concern on the feasibility of the method with respect to its application against intracranial atherosclerosis (ICAS)-related LVO, frequently observed in the Asian population. It is important to include evidence on ICAS LVO from Asian countries in the future for a comprehensive understanding of LVO etiology. Besides the issues with EVT, prognostic concerns in diabetes patients, acute kidney injury following EVT, neuroprotective management against reperfusion injury, and other peri-EVT issues should be considered in clinical practice. In the current article, we present an in-depth review of the literature that revises information pertaining to such concerns.
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Affiliation(s)
- Jin Soo Lee
- Department of Neurology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Yang-Ha Hwang
- Department of Neurology, Kyungpook National University Hospital, School of Medicine, Kyungpook National University, Daegu, Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University Dongsan Hospital, Kyemyung University School of Medicine, Daegu, Korea
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153
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Pulli B, Heit JJ, Wintermark M. Computed Tomography-Based Imaging Algorithms for Patient Selection in Acute Ischemic Stroke. Neuroimaging Clin N Am 2021; 31:235-250. [PMID: 33902877 DOI: 10.1016/j.nic.2020.12.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
Computed tomography remains the most widely used imaging modality for evaluating patients with acute ischemic stroke. Landmark trials have used computed tomography imaging to select patients for intravenous thrombolysis and endovascular treatment. This review summarizes the most important acute ischemic stroke trials, provides an outlook of ongoing studies, and proposes possible image algorithms for patient selection. Although evaluation with anatomic computed tomography imaging techniques is sufficient in early window patients, more advanced imaging techniques should be used beyond 6 hours from symptoms onset to quantify the ischemic core and evaluate for the salvageable penumbra.
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Affiliation(s)
- Benjamin Pulli
- Department of Radiology, Division of Neuroimaging and Neurointervention, Stanford Healthcare, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Jeremy J Heit
- Department of Radiology, Division of Neuroimaging and Neurointervention, Stanford Healthcare, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Max Wintermark
- Department of Radiology, Division of Neuroimaging and Neurointervention, Stanford Healthcare, 300 Pasteur Drive, Stanford, CA 94305, USA.
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154
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Krakauer JW, Kitago T, Goldsmith J, Ahmad O, Roy P, Stein J, Bishop L, Casey K, Valladares B, Harran MD, Cortés JC, Forrence A, Xu J, DeLuzio S, Held JP, Schwarz A, Steiner L, Widmer M, Jordan K, Ludwig D, Moore M, Barbera M, Vora I, Stockley R, Celnik P, Zeiler S, Branscheidt M, Kwakkel G, Luft AR. Comparing a Novel Neuroanimation Experience to Conventional Therapy for High-Dose Intensive Upper-Limb Training in Subacute Stroke: The SMARTS2 Randomized Trial. Neurorehabil Neural Repair 2021; 35:393-405. [PMID: 33745372 DOI: 10.1177/15459683211000730] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Evidence from animal studies suggests that greater reductions in poststroke motor impairment can be attained with significantly higher doses and intensities of therapy focused on movement quality. These studies also indicate a dose-timing interaction, with more pronounced effects if high-intensity therapy is delivered in the acute/subacute, rather than chronic, poststroke period. OBJECTIVE To compare 2 approaches of delivering high-intensity, high-dose upper-limb therapy in patients with subacute stroke: a novel exploratory neuroanimation therapy (NAT) and modified conventional occupational therapy (COT). METHODS A total of 24 patients were randomized to NAT or COT and underwent 30 sessions of 60 minutes time-on-task in addition to standard care. The primary outcome was the Fugl-Meyer Upper Extremity motor score (FM-UE). Secondary outcomes included Action Research Arm Test (ARAT), grip strength, Stroke Impact Scale hand domain, and upper-limb kinematics. Outcomes were assessed at baseline, and days 3, 90, and 180 posttraining. Both groups were compared to a matched historical cohort (HC), which received only 30 minutes of upper-limb therapy per day. RESULTS There were no significant between-group differences in FM-UE change or any of the secondary outcomes at any timepoint. Both high-dose groups showed greater recovery on the ARAT (7.3 ± 2.9 points; P = .011) but not the FM-UE (1.4 ± 2.6 points; P = .564) when compared with the HC. CONCLUSIONS Neuroanimation may offer a new, enjoyable, efficient, and scalable way to deliver high-dose and intensive upper-limb therapy.
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Affiliation(s)
| | - Tomoko Kitago
- Burke Neurological Institute, White Plains, NY, USA.,Weill Cornell Medicine, New York, NY, USA.,Columbia University, New York, NY, USA
| | - Jeff Goldsmith
- Columbia University Mailman School of Public Health, New York, NY, USA
| | - Omar Ahmad
- Johns Hopkins University, Baltimore, MD, USA
| | - Promit Roy
- Johns Hopkins University, Baltimore, MD, USA
| | - Joel Stein
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Lauri Bishop
- Columbia University Vagelos College of Physicians and Surgeons, New York, NY, USA
| | - Kelly Casey
- Johns Hopkins University, Baltimore, MD, USA
| | - Belen Valladares
- cereneo Center for Neurology and Rehabilitation, Vitznau, Switzerland.,University Hospital and University of Zurich, Switzerland
| | | | - Juan Camilo Cortés
- Johns Hopkins University, Baltimore, MD, USA.,Columbia University, New York, NY, USA
| | | | - Jing Xu
- Johns Hopkins University, Baltimore, MD, USA
| | | | - Jeremia P Held
- University Hospital and University of Zurich, Switzerland
| | - Anne Schwarz
- University Hospital and University of Zurich, Switzerland
| | - Levke Steiner
- University Hospital and University of Zurich, Switzerland
| | - Mario Widmer
- cereneo Center for Neurology and Rehabilitation, Vitznau, Switzerland
| | | | | | | | | | - Isha Vora
- Johns Hopkins University, Baltimore, MD, USA
| | | | | | | | | | - Gert Kwakkel
- Vrije Universiteit Amsterdam, Netherlands.,Amsterdam Rehabilitation Research Centre, Reade, Netherlands
| | - Andreas R Luft
- cereneo Center for Neurology and Rehabilitation, Vitznau, Switzerland.,University Hospital and University of Zurich, Switzerland
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155
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Nagaraja N, Kubilis PS, Hoh BL, Wilson CA, Khanna AY, Kelly AG. Trends of Acute Ischemic Stroke Reperfusion Therapies from 2012 to 2016 in the United States. World Neurosurg 2021; 150:e621-e630. [PMID: 33757890 DOI: 10.1016/j.wneu.2021.03.073] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2021] [Revised: 03/14/2021] [Accepted: 03/15/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND American Heart Association/American Stroke Association guidelines recommend endovascular stroke therapy (EST) with recombinant tissue plasminogen activator (rt-PA) for eligible patients in acute ischemic stroke (AIS). Using the National Inpatient Sample database, we evaluated trends in treatment with rt-PA and EST for AIS and their outcomes. METHODS This is a cross-sectional observational study of patients with AIS admitted in US hospitals from 2012 to 2016. Patients were grouped into those who received rt-PA alone, EST alone, and rtPA+EST. Survey statistical procedures were performed. Multivariable regression analysis with pairwise comparisons of each treatment group with no treatment group was performed for discharge outcomes. RESULTS The study included 2,290,520 patients with AIS with the mean age of 70.46 years. Treatment rates increased from 2012 to 2016 for rt-PA by 7% per year (5.86%-7.67%, odds ratio [OR] = 1.07, 95% confidence interval [CI]: 1.05-1.08) and EST by 38% per year (0.55%-1.75%, OR = 1.38, 95% CI: 1.31-1.45) but not rt-PA+EST (0.54%-0.57%, OR = 1.04, 95% CI: 0.99-1.08). The mean length of stay reduced from 2012 to 2016 for rt-PA (6.07-4.91 days, P < 0.0001) and rt-PA+EST (9.19-7.10 days, P = 0.0067) but not for EST (9.61-8.51 days, P = 0.5074). The odds of patients discharged home increased by 8%, 9%, and 15% among patients who received rt-PA alone, EST alone, and rt-PA+EST, respectively, compared with no treatment group. CONCLUSION The utilization of rt-PA alone and EST alone increased but that of rt-PA+EST remained unchanged from 2012 to 2016 in the National Inpatient Sample.
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Affiliation(s)
- Nandakumar Nagaraja
- Department of Neurology, University of Florida College of Medicine, Gainesville, Florida, USA.
| | - Paul S Kubilis
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Brian L Hoh
- Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Christina A Wilson
- Department of Neurology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Anna Y Khanna
- Department of Neurology, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Adam G Kelly
- Department of Neurology, University of Florida College of Medicine, Gainesville, Florida, USA; Department of Neurology, University of Rochester Medical Center, Rochester, New York, USA
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156
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Mendelson SJ, Prabhakaran S. Diagnosis and Management of Transient Ischemic Attack and Acute Ischemic Stroke: A Review. JAMA 2021; 325:1088-1098. [PMID: 33724327 DOI: 10.1001/jama.2020.26867] [Citation(s) in RCA: 280] [Impact Index Per Article: 93.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
IMPORTANCE Stroke is the fifth leading cause of death and a leading cause of disability in the United States, affecting nearly 800 000 individuals annually. OBSERVATIONS Sudden neurologic dysfunction caused by focal brain ischemia with imaging evidence of acute infarction defines acute ischemic stroke (AIS), while an ischemic episode with neurologic deficits but without acute infarction defines transient ischemic attack (TIA). An estimated 7.5% to 17.4% of patients with TIA will have a stroke in the next 3 months. Patients presenting with nondisabling AIS or high-risk TIA (defined as a score ≥4 on the age, blood pressure, clinical symptoms, duration, diabetes [ABCD2] instrument; range, 0-7 [7 indicating worst stroke risk]), who do not have severe carotid stenosis or atrial fibrillation, should receive dual antiplatelet therapy with aspirin and clopidigrel within 24 hours of presentation. Subsequently, combined aspirin and clopidigrel for 3 weeks followed by single antiplatelet therapy reduces stroke risk from 7.8% to 5.2% (hazard ratio, 0.66 [95% CI, 0.56-0.77]). Patients with symptomatic carotid stenosis should receive carotid revascularization and single antiplatelet therapy, and those with atrial fibrillation should receive anticoagulation. In patients presenting with AIS and disabling deficits interfering with activities of daily living, intravenous alteplase improves the likelihood of minimal or no disability by 39% with intravenous recombinant tissue plasminogen activator (IV rtPA) vs 26% with placebo (odds ratio [OR], 1.6 [95% CI, 1.1-2.6]) when administered within 3 hours of presentation and by 35.3% with IV rtPA vs 30.1% with placebo (OR, 1.3 [95% CI, 1.1-1.5]) when administered within 3 to 4.5 hours of presentation. Patients with disabling AIS due to anterior circulation large-vessel occlusions are more likely to be functionally independent when treated with mechanical thrombectomy within 6 hours of presentation vs medical therapy alone (46.0% vs 26.5%; OR, 2.49 [95% CI, 1.76-3.53]) or when treated within 6 to 24 hours after symptom onset if they have a large ratio of ischemic to infarcted tissue on brain magnetic resonance diffusion or computed tomography perfusion imaging (modified Rankin Scale score 0-2: 53% vs 18%; OR, 4.92 [95% CI, 2.87-8.44]). CONCLUSIONS AND RELEVANCE Dual antiplatelet therapy initiated within 24 hours of symptom onset and continued for 3 weeks reduces stroke risk in select patients with high-risk TIA and minor stroke. For select patients with disabling AIS, thrombolysis within 4.5 hours and mechanical thrombectomy within 24 hours after symptom onset improves functional outcomes.
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Affiliation(s)
| | - Shyam Prabhakaran
- Department of Neurology, University of Chicago, Chicago, Illinois
- Pritzker School of Medicine, Department of Neurology, University of Chicago, Chicago, Illinois
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157
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Uyama A, Tsuto K, Matsumoto T, Takeuchi M. Effectiveness of Retrograde Angiography via the Contralateral Carotid Artery in Mechanical Thrombectomy for Carotid Non-T Occlusion by Dual Puncture Technique. JOURNAL OF NEUROENDOVASCULAR THERAPY 2021; 15:747-754. [PMID: 37502263 PMCID: PMC10371003 DOI: 10.5797/jnet.tn.2020-0184] [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: 10/14/2020] [Accepted: 01/20/2021] [Indexed: 07/29/2023]
Abstract
Objective We report the effectiveness of retrograde angiography via the contralateral carotid angiography using a dual puncture technique in mechanical thrombectomy (MT) for non-T occlusion in patients with acute internal carotid artery (ICA) occlusion not involving the ICA terminus. Case Presentation In the dual puncture technique, arterial puncture is performed at two sites: a balloon guiding catheter (BGC) is navigated to the ICA on the affected side and another catheter is navigated to the unaffected side. Thrombus retrieval is performed by manual aspiration through the BGC and MT using a stent retriever and/or aspiration device. Reperfusion is confirmed by retrograde angiography via the carotid artery on the unaffected side, with manual aspiration through the BGC on the affected side. Throughout the procedure, the BGC blocks the blood flow in the ICA on the affected side until reperfusion is confirmed. No distal embolization was occurred in our three patients treated using this technique. Conclusion Application of the dual puncture technique on MT is recommended for non-T occlusion to prevent distal embolization.
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Affiliation(s)
- Atsushi Uyama
- Department of Neurosurgery, Seisho Hospital, Odawara, Kanagawa, Japan
| | - Kazuma Tsuto
- Department of Neurosurgery, Seisho Hospital, Odawara, Kanagawa, Japan
| | - Takashi Matsumoto
- Department of Neurosurgery, Seisho Hospital, Odawara, Kanagawa, Japan
| | - Masataka Takeuchi
- Department of Neurosurgery, Seisho Hospital, Odawara, Kanagawa, Japan
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158
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YAMAGAMI H, HAYAKAWA M, INOUE M, IIHARA K, OGASAWARA K, TOYODA K, HASEGAWA Y, OHATA K, SHIOKAWA Y, NOZAKI K, EZURA M, IWAMA T. Guidelines for Mechanical Thrombectomy in Japan, the Fourth Edition, March 2020: A Guideline from the Japan Stroke Society, the Japan Neurosurgical Society, and the Japanese Society for Neuroendovascular Therapy. Neurol Med Chir (Tokyo) 2021. [PMID: 33583863 PMCID: PMC7966209 DOI: 10.2176/nmc.st.2020-0357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Hiroshi YAMAGAMI
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Osaka, Japan
,Corresponding author: Hiroshi Yamagami, MD, PhD Department of Stroke Neurology, National Hospital Organizat ion Osaka Nat ional Hospital, 2-1-14 Hoenzaka, Chuo-ku, Osaka 540-0006, Japan e-mail:;
| | - Mikito HAYAKAWA
- Division of Stroke Prevention and Treatment, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Manabu INOUE
- Division of Stroke Care Unit/Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Koji IIHARA
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kuniaki OGASAWARA
- Department of Neurosurgery, Iwate Medical University, Morioka, Iwate, Japan
| | - Kazunori TOYODA
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yasuhiro HASEGAWA
- Department of Neurology, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan
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Stroke Center and Department of Neurology, Shin-yurigaoka General Hospital, Kawasaki, Kanagawa, Japan
| | - Kenji OHATA
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Osaka, Japan
| | | | - Kazuhiko NOZAKI
- Department of Neurosurgery, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Masayuki EZURA
- Department of Neurosurgery, National Hospital Organization Sendai Medical Center, Sendai, Miyagi, Japan
| | - Toru IWAMA
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Gifu, Japan
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159
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Kleven RT, Karani KB, Hilvert N, Ford SM, Mercado-Shekhar KP, Racadio JM, Rao MB, Abruzzo TA, Holland CK. Accelerated sonothrombolysis with Definity in a xenographic porcine cerebral thromboembolism model. Sci Rep 2021; 11:3987. [PMID: 33597659 PMCID: PMC7889614 DOI: 10.1038/s41598-021-83442-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Accepted: 01/29/2021] [Indexed: 01/31/2023] Open
Abstract
Adjuvant ultrasound at 2 MHz with or without an ultrasound contrast agent improves the rate of thrombus resolution by recombinant tissue plasminogen activator (rt-PA) in laboratory and clinical studies. A sub-megahertz approach can further expand this therapy to a subset of patients with an insufficient temporal bone window, improving efficacy in unselected patient populations. The aim of this study was to determine if a clinical ultrasound contrast agent (UCA), Definity, and 220 kHz pulsed ultrasound accelerated rt-PA thrombolysis in a preclinical animal model of vascular occlusion. The effect of Definity and ultrasound on thrombus clearance was first investigated in vitro and subsequently tested in a xenographic porcine cerebral thromboembolism model in vivo. Two different microcatheter designs (end-hole, multi-side-hole) were used to infuse rt-PA and Definity at the proximal edge or directly into clots, respectively. Sonothrombolysis with Definity increased clot mass loss relative to saline or rt-PA alone in vitro, only when rt-PA was administered directly into clots via a multi-side-hole microcatheter. Combined treatment with rt-PA, Definity, and ultrasound in vivo increased the rate of reperfusion up to 45 min faster than clots treated with rt-PA or saline. In this porcine cerebral thromboembolism model employing retracted human clots, 220 kHz ultrasound, in conjunction with Definity increased the probability of early successful reperfusion with rt-PA.
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Affiliation(s)
- Robert T Kleven
- Department of Biomedical Engineering, College of Engineering and Applied Sciences, University of Cincinnati, CVC 3921, 0586, 231 Albert Sabin Way, Cincinnati, OH, 45267-0586, USA.
| | - Kunal B Karani
- Department of Radiology and Medical Imaging, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Nicole Hilvert
- Department of Radiology and Medical Imaging, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Samantha M Ford
- Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati, Cincinnati, OH, USA
| | - Karla P Mercado-Shekhar
- Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati, Cincinnati, OH, USA
| | - John M Racadio
- Department of Radiology and Medical Imaging, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Marepalli B Rao
- Department of Biomedical Engineering, College of Engineering and Applied Sciences, University of Cincinnati, CVC 3921, 0586, 231 Albert Sabin Way, Cincinnati, OH, 45267-0586, USA
| | - Todd A Abruzzo
- Division of Radiology, Phoenix Children's Hospital, Phoenix, AZ, USA
- Department of Radiology, University of Arizona College of Medicine, Phoenix, AZ, USA
| | - Christy K Holland
- Department of Biomedical Engineering, College of Engineering and Applied Sciences, University of Cincinnati, CVC 3921, 0586, 231 Albert Sabin Way, Cincinnati, OH, 45267-0586, USA
- Department of Internal Medicine, Division of Cardiovascular Health and Disease, University of Cincinnati, Cincinnati, OH, USA
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160
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Zi W, Qiu Z, Wu D, Li F, Liu H, Liu W, Huang W, Shi Z, Bai Y, Liu Z, Wang L, Yang S, Pu J, Wen C, Wang S, Zhu Q, Chen W, Yin C, Lin M, Qi L, Zhong Y, Wang Z, Wu W, Chen H, Yao X, Xiong F, Zeng G, Zhou Z, Wu Z, Wan Y, Peng H, Li B, Hu X, Wen H, Zhong W, Wang L, Jin P, Guo F, Han J, Fu X, Ai Z, Tian X, Feng X, Sun B, Huang Z, Li W, Zhou P, Tu M, Sun X, Li H, He W, Qiu T, Yuan Z, Yue C, Yang J, Luo W, Gong Z, Shuai J, Nogueira RG, Yang Q. Assessment of Endovascular Treatment for Acute Basilar Artery Occlusion via a Nationwide Prospective Registry. JAMA Neurol 2021; 77:561-573. [PMID: 32080711 DOI: 10.1001/jamaneurol.2020.0156] [Citation(s) in RCA: 207] [Impact Index Per Article: 69.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Importance Several randomized clinical trials have recently established the safety and efficacy of endovascular treatment (EVT) of acute ischemic stroke in the anterior circulation. However, it remains uncertain whether patients with acute basilar artery occlusion (BAO) benefit from EVT. Objective To evaluate the association between EVT and clinical outcomes of patients with acute BAO. Design, Setting, and Participants This nonrandomized cohort study, the EVT for Acute Basilar Artery Occlusion Study (BASILAR) study, was a nationwide prospective registry of consecutive patients presenting with an acute, symptomatic, radiologically confirmed BAO to 47 comprehensive stroke centers across 15 provinces in China between January 2014 and May 2019. Patients with acute BAO within 24 hours of estimated occlusion time were divided into groups receiving standard medical treatment plus EVT or standard medical treatment alone. Main Outcomes and Measures The primary outcome was the improvement in modified Rankin Scale scores (range, 0 to 6 points, with higher scores indicating greater disability) at 90 days across the 2 groups assessed as a common odds ratio using ordinal logistic regression shift analysis, adjusted for prespecified prognostic factors. The secondary efficacy outcome was the rate of favorable functional outcomes defined as modified Rankin Scale scores of 3 or less (indicating an ability to walk unassisted) at 90 days. Safety outcomes included symptomatic intracerebral hemorrhage and 90-day mortality. Results A total of 1254 patients were assessed, and 829 patients (of whom 612 were men [73.8%]; median [interquartile] age, 65 [57-74] years) were recruited into the study. Of these, 647 were treated with standard medical treatment plus EVT and 182 with standard medical treatment alone. Ninety-day functional outcomes were substantially improved by EVT (adjusted common odds ratio, 3.08 [95% CI, 2.09-4.55]; P < .001). Moreover, EVT was associated with a significantly higher rate of 90-day modified Rankin Scale scores of 3 or less (adjusted odds ratio, 4.70 [95% CI, 2.53-8.75]; P < .001) and a lower rate of 90-day mortality (adjusted odds ratio, 2.93 [95% CI, 1.95-4.40]; P < .001) despite an increase in symptomatic intracerebral hemorrhage (45 of 636 patients [7.1%] vs 1 of 182 patients [0.5%]; P < .001). Conclusions and Relevance Among patients with acute BAO, EVT administered within 24 hours of estimated occlusion time is associated with better functional outcomes and reduced mortality.
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Affiliation(s)
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Zhongming Qiu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China.,Department of Neurology, The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Deping Wu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Hansheng Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Wenhua Liu
- Department of Neurology, Wuhan No. 1 Hospital, Wuhan, China
| | - Wenguo Huang
- Department of Neurology, Chinese Medical Hospital of Maoming, Maoming, China
| | - Zhonghua Shi
- Department of Neurosurgery, The 904th Hospital of The People's Liberation Army, Wuxi, China
| | - Yongjie Bai
- Department of Neurology, The First Affiliated Hospital of Henan Science and Technology University, Luoyang, China
| | - Zhensheng Liu
- Department of Neurology, The First People's Hospital of Yangzhou, Yangzhou University, Yangzhou, China
| | - Li Wang
- Department of Neurology, The Third People's Hospital of Zigong, Zigong, China
| | - Shiquan Yang
- Department of Neurology, The 902th Hospital of The People's Liberation Army, Bengbu, China
| | - Jie Pu
- Department of Neurology, Hubei Province People's Hospital, Wuhan, China
| | - Changming Wen
- Department of Neurology, Nanyang Central Hospital, Nanyang, China
| | - Shouchun Wang
- Department of Neurology, The First Affiliated Hospital of Jilin University, Changchun, China
| | - Qiyi Zhu
- Department of Neurology, Linyi People's Hospital, Linyi, China
| | - Wenhuo Chen
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Congguo Yin
- Department of Neurology, The First People's Hospital of Hangzhou, Zhejiang University School of Medicine, Hangzhou, China
| | - Min Lin
- Department of Neurology, The 900th Hospital of The People's Liberation Army, Fuzhou, China
| | - Li Qi
- Department of Neurology, The 924th Hospital of The People's Liberation Army, Guilin, China
| | - Yaoyi Zhong
- Department of Neurology, The 909th Hospital of The People's Liberation Army, Zhangzhou, China
| | - Zhen Wang
- Department of Neurology, Changsha Central Hospital, Changsha, China
| | - Wenjun Wu
- Department of Neurology, Zhongshan People's Hospital, Zhongshan, China
| | - Huisheng Chen
- Department of Neurology, Northern Theater General Hospital of The People's Liberation Army, Shenyang, China
| | - Xiaoxi Yao
- Department of Neurology, The First People's Hospital of Chenzhou, Chenzhou, China
| | - Feng Xiong
- Department of Neurology, Zhuzhou Central Hospital, ZhuZhou, China
| | - Guoyong Zeng
- Department of Neurology, Ganzhou People's Hospital, Ganzhou, China
| | - Zhiming Zhou
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Zhilin Wu
- Department of Neurology, Yunfu People's Hospital, Yunfu, China
| | - Yue Wan
- Department of Neurology, Hubei Zhongshan Hospital, Wuhan, China
| | - Huiyuan Peng
- Department of Neurology, Chinese Medical Hospital of Zhongshan, Zhongshan, China
| | - Bing Li
- Department of Neurology, Yuhuangding Hospital, Qingdao University, Yantai, China
| | - Xinping Hu
- Department of Neurology, Jilin Central Hospital, Jilin, China
| | - Hongbin Wen
- Department of Neurology, Xiangyang Central Hospital, Hubei Arts and Science University, Xiangyang, China
| | - Wangtao Zhong
- Department of Neurology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Leyuan Wang
- Department of Neurology, Changle People's Hospital, Changle, China
| | - Ping Jin
- Department of Neurology, Lu'an Affiliated Hospital of Anhui Medical University, Lu'an, China
| | - Fuqiang Guo
- Department of Neurology, Sichuan Provincial People's Hospital, Chengdu, China
| | - Ju Han
- Department of Neurology, The First Affiliated Hospital of Shandong First Medical University, Jinan, China
| | - Xinmin Fu
- Department of Neurology, Xuzhou Central Hospital, Xuzhou, China
| | - Zhibing Ai
- Department of Neurology, Taihe Affiliated Hospital of Hubei Medical University, Shiyan, China
| | - Xiguang Tian
- Department of Neurology, The Chinese Armed Police Force Guangdong Armed Police Corps Hospital, Guangzhou, China
| | - Xiaoya Feng
- Department of Neurology, The Third Hospital of Shandong Province, Jinan, China
| | - Bo Sun
- Department of Neurology, The Affiliated Huai'an No.1 People's Hospital of Nanjing Medical University, Huai'an, China
| | - Zhizhi Huang
- Department of Neurology, Baise People's Hospital, Baise, China
| | - Wei Li
- Department of Neurology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Peiyang Zhou
- Department of Neurology, The First People's Hospital of Xiangyang, Hubei Medical University, Xiangyang, China
| | - Mingyi Tu
- Department of Neurology, Hubei Wuchang Hospital, Wuhan, China
| | - Xiangrong Sun
- Department of Neurology, Affiliated Hospital of North Sichuan Medical College, Nanchong, China
| | - Hua Li
- Department of Neurology, The 476th Hospital of The People's Liberation Army, Fuzhou, China
| | - Wencheng He
- Department of Neurology, Guiping People's Hospital, Guiping, China
| | - Tao Qiu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China.,Department of Neurology, The First People's Hospital of Zigong, Zigong, China
| | - Zhengzhou Yuan
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China.,Department of Neurology, Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Chengsong Yue
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jun Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Weidong Luo
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Zili Gong
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jie Shuai
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Raul Gomes Nogueira
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia
| | - Qingwu Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
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161
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Yamagami H, Hayakawa M, Inoue M, Iihara K, Ogasawara K, Toyoda K, Hasegawa Y, Ohata K, Shiokawa Y, Nozaki K, Ezura M, Iwama T. Guidelines for Mechanical Thrombectomy in Japan, the Fourth Edition, March 2020: A Guideline from the Japan Stroke Society, the Japan Neurosurgical Society, and the Japanese Society for Neuroendovascular Therapy. Neurol Med Chir (Tokyo) 2021; 61:163-192. [PMID: 33583863 DOI: 10.2176/nmc.nmc.st.2020-0357] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Osaka, Japan
| | - Mikito Hayakawa
- Division of Stroke Prevention and Treatment, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Manabu Inoue
- Division of Stroke Care Unit/Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Koji Iihara
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kuniaki Ogasawara
- Department of Neurosurgery, Iwate Medical University, Morioka, Iwate, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yasuhiro Hasegawa
- Department of Neurology, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan.,Stroke Center and Department of Neurology, Shin-yurigaoka General Hospital, Kawasaki, Kanagawa, Japan
| | - Kenji Ohata
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Osaka, Japan
| | | | - Kazuhiko Nozaki
- Department of Neurosurgery, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Masayuki Ezura
- Department of Neurosurgery, National Hospital Organization Sendai Medical Center, Sendai, Miyagi, Japan
| | - Toru Iwama
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Gifu, Japan
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162
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Ahmed N, Lees KR, von Kummer R, Holmin S, Escudero-Martinez I, Bottai M, Jansen O, Wahlgren N. The SITS Open Study: A Prospective, Open Label Blinded Evaluation Study of Thrombectomy in Clinical Practice. Stroke 2021; 52:792-801. [PMID: 33563015 DOI: 10.1161/strokeaha.120.031031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE We designed SITS (Safe Implementation of Treatment in Stroke) Open to determine benefit and safety of thrombectomy in clinical practice for large artery occlusion stroke, using selected stent retrievers plus standard care versus standard care alone. METHODS SITS Open was a prospective, open, blinded evaluation, international, multicenter, controlled, nonrandomized registry study. Centers lacking access to thrombectomy contributed controls. Primary end point was categorical shift in modified Rankin Scale score at 3 months in the per protocol (PP) population. Principal secondary outcomes were symptomatic intracranial hemorrhage, functional independency (modified Rankin Scale score 0-2) and death at 3 months. Patients independently evaluated by video-recorded modified Rankin Scale interviews blinded to treatment or center identity by central core laboratory were regarded as PP population. Propensity score matching with covariate adjusted analysis was performed. RESULTS During 2014 to 2017, 293 patients (257 thrombectomy, 36 control) from 26 centers in 10 countries fulfilled intention-to-treat and 200 (170 thrombectomy, 30 control) PP criteria; enrollment of controls was limited by rapid uptake of thrombectomy. In PP analysis, median age was 71 versus 71 years, and baseline National Institutes of Health Stroke Scale 17 versus 17 in the thrombectomy and control arms, respectively. The propensity score matching analysis for PP showed a significant shift for modified Rankin Scale at 3 months favoring the thrombectomy group (odds ratio, 3.8 [95% CI, 1.61-8.95]; P=0.002). Regarding safety, there were 4 cases of symptomatic intracranial hemorrhage in the thrombectomy group (2.4%) and none in the control group. CONCLUSIONS In clinical practice, thrombectomy for patients with large artery occlusion stroke is superior to standard of care in our study. Registration: URL: https://www.clinicaltrials.gov. Unique Identifier: NCT02326428.
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Affiliation(s)
- Niaz Ahmed
- Department of Neurology (N.A.), Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience (N.A., S.H., N.W.), Karolinska Institutet, Stockholm, Sweden
| | - Kennedy R Lees
- School of Medicine, Dentistry and Nursing, University of Glasgow, United Kingdom (K.R.L.)
| | - Rudiger von Kummer
- Department of Diagnostic and Interventional Neuroradiology, University of Dresden, Germany (R.v.K.)
| | - Staffan Holmin
- Department of Neuroradiology (S.H.), Karolinska University Hospital, Stockholm, Sweden.,Department of Clinical Neuroscience (N.A., S.H., N.W.), Karolinska Institutet, Stockholm, Sweden
| | - Irene Escudero-Martinez
- Department of Neurology, University Hospital Virgen del Rocío, Sevilla, Spain (I.E.-M.).,Neurovascular Research Laboratory, Instituto de Biomedicina de Sevilla-IBiS, Spain (I.E.-M.)
| | - Matteo Bottai
- Institute of Environmental Medicine, Biostatistics (M.B.), Karolinska Institutet, Stockholm, Sweden
| | - Olav Jansen
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, Campus Kiel, Germany (O.J.)
| | - Nils Wahlgren
- Department of Clinical Neuroscience (N.A., S.H., N.W.), Karolinska Institutet, Stockholm, Sweden
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163
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Ume KL, Dandapat S, Weber MW, Zevallos CB, Fifer A, Levy A, Delfino K, Ortega-Gutierrez S, Siddiqui FM. Absent hyperdense middle cerebral artery sign is associated with poor functional outcome after mechanical thrombectomy. Int J Stroke 2021; 17:101-108. [PMID: 33557722 DOI: 10.1177/1747493021991972] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND The hyperdense middle cerebral artery sign on computed tomography indicates proximal middle cerebral artery occlusion. Recent reports suggest an association between the hyperdense sign and successful reperfusion. The prognostic value of the hyperdense middle cerebral artery sign in patients receiving mechanical thrombectomy has not been extensively studied. AIMS Our study aims to evaluate the association between the hyperdense middle cerebral artery sign and functional outcome in patients with M1 occlusions that had undergone mechanical thrombectomy. METHODS We conducted a single-center retrospective observational cohort study of 102 consecutive patients presenting with acute M1 occlusions that had undergone mechanical thrombectomy. Patients were stratified into cohorts based on the presence of hyperdense middle cerebral artery sign visually assessed on computed tomography by two readers. The outcomes of interests were functional disability measured by the ordinal Modified Rankin Scale (mRS) at 90 days, mortality, reperfusion status and hemorrhagic conversion. RESULTS Out of the 102 patients with M1 occlusions, 71 had hyperdense middle cerebral artery sign. There was no significant difference between the cohorts in age, baseline mRS, NIHSS, ASPECTS, and time to reperfusion. The absence of hyperdense middle cerebral artery sign was associated with increased odds of being dependent or dying (higher mRS) (OR: 3.24, 95% CI: 1.30-8.06, p = 0.011) after adjusting for other significant predictors, including age, female sex, hypertension, presenting serum glucose, ASPECTS, CTA collateral score, and successful reperfusion. CONCLUSION The absence of hyperdense middle cerebral artery sign is associated with worse functional outcome in patients presenting with M1 occlusions undergoing thrombectomy.
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Affiliation(s)
- Kiddy L Ume
- Department of Neurology, 12249Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Sudeepta Dandapat
- Department of Neurology, University of Iowa Medical Center, Iowa City, IA, USA
| | - Matthew W Weber
- Department of Neurology, 12249Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Cynthia B Zevallos
- Department of Neurology, University of Iowa Medical Center, Iowa City, IA, USA
| | - Amber Fifer
- Department of Neurology, 12249Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Abigail Levy
- Department of Neurology, 12249Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Kristin Delfino
- Department of Neurology, 12249Southern Illinois University School of Medicine, Springfield, IL, USA
| | - Santiago Ortega-Gutierrez
- Department of Neurology, University of Iowa Medical Center, Iowa City, IA, USA.,Department of Neurosurgery and Radiology, University of Iowa Medical Center, Iowa City, IA, USA
| | - Fazeel M Siddiqui
- Department of Neurology, 12249Southern Illinois University School of Medicine, Springfield, IL, USA.,Department of Neurology, Metro Health University of Michigan, Grand Rapids, MI, USA
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164
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Imura T, Iwamoto Y, Inagawa T, Imada N, Tanaka R, Toda H, Inoue Y, Araki H, Araki O. Decision Tree Algorithm Identifies Stroke Patients Likely Discharge Home After Rehabilitation Using Functional and Environmental Predictors. J Stroke Cerebrovasc Dis 2021; 30:105636. [PMID: 33545520 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105636] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Revised: 12/19/2020] [Accepted: 01/18/2021] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND AND PURPOSE The importance of environmental factors for stroke patients to achieve home discharge was not scientifically proven. There are limited studies on the application of the decision tree algorithm with various functional and environmental variables to identify stroke patients with a high possibility of home discharge. The present study aimed to identify the factors, including functional and environmental factors, affecting home discharge after stroke inpatient rehabilitation using the machine learning method. METHOD This was a cohort study on data from the maintained database of all patients with stroke who were admitted to the convalescence rehabilitation ward of our facility. In total, 1125 stroke patients were investigated. We developed three classification and regression tree (CART) models to identify the possibility of home discharge after inpatient rehabilitation. RESULTS Among three models, CART model incorporating basic information, functional factor, and environmental factor variables achieved the highest accuracy for identification of home discharge. This model identified FIM dressing of the upper body (score of ≤2 or >2) as the first single discriminator for home discharge. Performing house renovation was associated with a high possibility of home discharge even in patients with stroke who had a poor FIM score in the ability to dress the upper body (≤2) at admission into the convalescence rehabilitation ward. Interestingly, many patients who performed house renovation have achieved home discharge regardless of the degree of lower limb paralysis. CONCLUSION We identified the influential factors for realizing home discharge using the decision tree algorithm, including environmental factors, in patients with convalescent stroke.
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Affiliation(s)
- Takeshi Imura
- Department of Rehabilitation, Faculty of Health Sciences, Hiroshima Cosmopolitan University, Hiroshima, Japan; Department of Rehabilitation, Araki Neurosurgical Hospital, Hiroshima, Japan.
| | - Yuji Iwamoto
- Department of Rehabilitation, Araki Neurosurgical Hospital, Hiroshima, Japan; Graduate School of Humanities and Social Sciences, Hiroshima University, Hiroshima, Japan.
| | - Tetsuji Inagawa
- Department of Neurosurgery, Araki Neurosurgical Hospital, Hiroshima, Japan.
| | - Naoki Imada
- Department of Rehabilitation, Araki Neurosurgical Hospital, Hiroshima, Japan.
| | - Ryo Tanaka
- Graduate School of Humanities and Social Sciences, Hiroshima University, Hiroshima, Japan
| | - Haruki Toda
- Artificial Intelligence Research Center (AIRC), National Institute of Advanced Industrial Science and Technology (AIST), Tokyo Japan
| | - Yu Inoue
- Research Institute of Health and Welfare, Kibi International University, Okayama, Japan
| | - Hayato Araki
- Department of Neurosurgery, Araki Neurosurgical Hospital, Hiroshima, Japan
| | - Osamu Araki
- Department of Neurosurgery, Araki Neurosurgical Hospital, Hiroshima, Japan
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165
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Waqas M, Gong AD, Levy BR, Dossani RH, Vakharia K, Cappuzzo JM, Becker A, Sonig A, Tutino VM, Almayman F, Davies JM, Snyder KV, Siddiqui AH, Levy EI. Is Endovascular Therapy for Stroke Cost-Effective Globally? A Systematic Review of the Literature. J Stroke Cerebrovasc Dis 2021; 30:105557. [PMID: 33556672 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105557] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2020] [Revised: 12/11/2020] [Accepted: 12/13/2020] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVES Cost-effectiveness of endovascular therapy (EVT) is a key consideration for broad use of this approach for emergent large vessel occlusion stroke. We evaluated the evidence on cost-effectiveness of EVT in comparison with best medical management from a global perspective. MATERIALS AND METHODS This systematic review of studies published between January 2010 and May 2020 evaluated the cost effectiveness of EVT for patients with large vessel occlusion acute ischemic stroke. The gain in quality adjusted life year (QALY) and incremental cost-effectiveness ratio (ICER), expressed as cost per QALY resulting from EVT, were recorded. The study setting (country, economic perspective), decision model, and data sources used in economic models of EVT cost-effectiveness were recorded. RESULTS Twenty-five original studies from 12 different countries were included in our review. Five of these studies were reported from a societal perspective; 18 were reported from a healthcare system perspective. Two studies used real-world data. The time horizon varied from 1 year to a lifetime; however, 18 studies reported a time horizon of >10 years. Twenty studies reported using outcome data from randomized, controlled clinical trials for their models. Nineteen studies reported using a Markov model. Incremental QALYs ranged from 0.09-3.5. All studies but 1 reported that EVT was cost-effective. CONCLUSIONS Evidence from different countries and economic perspectives suggests that EVT for stroke treatment is cost-effective. Most cost-effectiveness studies are based on outcome data from randomized clinical trials. However, there is a need to study the cost-effectiveness of EVT based solely on real-world outcome data.
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Affiliation(s)
- Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Andrew D Gong
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.
| | - Bennett R Levy
- George Washington School of Medicine and Health Sciences, Washington, DC, USA.
| | - Rimal H Dossani
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA
| | - Kunal Vakharia
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Justin M Cappuzzo
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Alexander Becker
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Ashish Sonig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Vincent M Tutino
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Biomedical Engineering, University at Buffalo, Buffalo, NY, USA; Department of Pathology and Anatomical Sciences, University at Buffalo, State University of New York, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY USA.
| | - Faisal Almayman
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA.
| | - Jason M Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY USA; Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Kenneth V Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY USA.
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, 100 High Street, Suite B4, Buffalo, NY 14203, USA; Department of Neurosurgery, Gates Vascular Institute, Kaleida Health, Buffalo, NY, USA; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY USA; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA.
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166
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Rivera R, Amudio C, Brunetti E, Catalan P, Sordo JG, Badilla L, Echeverria D, Cruz JP, Ojeda H, Bravo L, Bravo F, Gonzalez W, Orellana ML, Pinto C, Merino-Osorio C, Oportus M, Salazar A, Nogueira RG. Breaking the breach in Latin America: A pilot study of mechanical thrombectomy in the public healthcare system in Chile. Interv Neuroradiol 2021; 27:114-118. [PMID: 32873104 PMCID: PMC7903558 DOI: 10.1177/1591019920956405] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2020] [Revised: 08/11/2020] [Indexed: 02/02/2023] Open
Abstract
BACKGROUND Mechanical Thrombectomy (MT) is the standard of care for treatment of large vessel occlusion stroke. Until the beginning of 2020 MT was not funded nor widely implemented at the public healthcare level in Chile. OBJECTIVE To describe the results of a pilot program created to provide access to public MT in Santiago - Chile. METHODS Analysis from a prospectively collected database of MT cases performed between September 2017 and September 2019 in one center. A stroke network was developed with a single MT capable stroke center and five primary stroke centers. The primary efficacy endpoint was the rate of functional independence (mRS 0-2) at 90 days. Successful reperfusion was defined as 2 b-3 according to the thrombolysis in cerebral infarction scale. Safety outcomes include the rates of symptomatic intracranial hemorrhage and 90-day mortality. RESULTS A total of 100 patients were treated over the study period. Their mean age was 62.8 ± 11.8 years and median baseline National Institute of Health Stroke Scale (NIHSS) measurement was 17. Seventy-seven percent of the patients received intra venous thrombolysis. Successful reperfusion was achieved in 95% of the cases. NIHSS at 24 hours showed a median drop of 7 points from baseline (p < 0.00001) and 50% of the follow-up patients were functionally independent at 90 days. Symptomatic Intracerebral hemorrhage occurred in 5% of the patients and 90-day all case mortality was 11%. CONCLUSIONS We demonstrated the feasibility of a publicly funded MT program in Chile, with similar results as other international randomized control trials.
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Affiliation(s)
- Rodrigo Rivera
- Neuroradiology Department, Instituto de Neurocirugia Dr. Asenjo,
Santiago, Chile
| | - Cristian Amudio
- Critical Care Department, Instituto de Neurocirugia Dr. Asenjo,
Santiago, Chile
| | - Enzo Brunetti
- Critical Care Department, Instituto de Neurocirugia Dr. Asenjo,
Santiago, Chile
| | - Pascual Catalan
- Critical Care Department, Instituto de Neurocirugia Dr. Asenjo,
Santiago, Chile
| | - Juan Gabriel Sordo
- Neuroradiology Department, Instituto de Neurocirugia Dr. Asenjo,
Santiago, Chile
| | - Lautaro Badilla
- Neuroradiology Department, Instituto de Neurocirugia Dr. Asenjo,
Santiago, Chile
| | - Daniel Echeverria
- Neuroradiology Department, Instituto de Neurocirugia Dr. Asenjo,
Santiago, Chile
| | - Juan Pablo Cruz
- Neuroradiology Department, Instituto de Neurocirugia Dr. Asenjo,
Santiago, Chile
| | - Hector Ojeda
- Critical Care Department, Instituto de Neurocirugia Dr. Asenjo,
Santiago, Chile
| | - Loreto Bravo
- Neuroradiology Department, Instituto de Neurocirugia Dr. Asenjo,
Santiago, Chile
| | - Fabian Bravo
- Neuroradiology Department, Instituto de Neurocirugia Dr. Asenjo,
Santiago, Chile
| | - Walter Gonzalez
- Neuroradiology Department, Instituto de Neurocirugia Dr. Asenjo,
Santiago, Chile
| | - Maria Luisa Orellana
- Neuroradiology Department, Instituto de Neurocirugia Dr. Asenjo,
Santiago, Chile
| | - Camila Pinto
- Neuroradiology Department, Instituto de Neurocirugia Dr. Asenjo,
Santiago, Chile
| | | | - Monica Oportus
- Anesthesia Unit, Instituto de Neurocirugia Dr. Asenjo, Santiago,
Chile
| | - Alejandro Salazar
- Anesthesia Unit, Instituto de Neurocirugia Dr. Asenjo, Santiago,
Chile
| | - Raul G Nogueira
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital
and Department of Neurology, Emory University School of Medicine, Atlanta, GA,
USA
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Sarmah D, Banerjee M, Datta A, Kalia K, Dhar S, Yavagal DR, Bhattacharya P. Nanotechnology in the diagnosis and treatment of stroke. Drug Discov Today 2021; 26:585-592. [PMID: 33242696 DOI: 10.1016/j.drudis.2020.11.018] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2020] [Revised: 11/05/2020] [Accepted: 11/16/2020] [Indexed: 01/28/2023]
Abstract
Increasing developments in the field of nanotechnology have ignited its use in stroke diagnosis and treatment. The benefits of structural modification, ease of synthesis, and biocompatibility support the use of nanomaterials in the clinic. The pathophysiology of stroke is complex, involving different brain regions; hence, therapeutic agents are required to be delivered to specific regions. Nanoparticles (NPs) can be engineered to help improve the delivery and release of therapeutic agents in a localized manner, especially in the penumbra. This contributes not only to therapy, but also to neurosurgery and neuroimaging. Nanomaterials also offer high efficacy with few adverse effects. In this review, we provide a concise summary of the caveats associated with nanotechnology with respect to stroke therapy and diagnosis.
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Affiliation(s)
- Deepaneeta Sarmah
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Mainak Banerjee
- Department of Biochemistry and Molecular Biology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Aishika Datta
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Kiran Kalia
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India
| | - Shanta Dhar
- Department of Biochemistry and Molecular Biology, University of Miami Miller School of Medicine, Miami, FL, USA; Sylvester Comprehensive Cancer Center, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Dileep R Yavagal
- Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Pallab Bhattacharya
- Department of Pharmacology and Toxicology, National Institute of Pharmaceutical Education and Research (NIPER), Ahmedabad, Gandhinagar, Gujarat 382355, India.
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168
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Potts MB, Abdalla RN, Golnari P, Sukumaran M, Palmer AH, Hurley MC, Shaibani A, Jahromi BS, Ansari SA. Analysis of Mechanical Thrombectomy for Acute Ischemic Stroke on Nights and Weekends Versus Weekdays at Comprehensive Stroke Centers. J Stroke Cerebrovasc Dis 2021; 30:105632. [PMID: 33517033 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105632] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 01/13/2021] [Accepted: 01/17/2021] [Indexed: 11/18/2022] Open
Abstract
OBJECTIVE The "weekend effect" has been shown to affect outcomes in acute ischemic stroke. We sought to compare metrics and outcomes of emergent stroke thrombectomy at three affiliated comprehensive stroke centers on weekdays versus nights/weekends for a three-year period beginning in 2015, when thrombectomy became common practice for large vessel occlusion acute ischemic stroke. METHODS We performed a retrospective analysis of all stroke thrombectomy patients treated from 2015 to 2018 to compare standard thrombectomy metrics and outcomes in patients presenting during weekdays or nights/weekends. RESULTS Two hundred-sixteen mechanical thrombectomy cases were evaluated, with 50.9% of patients presenting on weekdays and 49.1% presenting on nights/weekends. There were no statistical differences in baseline characteristics in demographics, stroke risk factors, or stroke severity, but patients presenting on nights/weekends had longer times from last known normal to presentation (130 versus 72.5 minutes, p=0.03). Door-to-groin times were delayed in patients presenting on nights/weekends compared to weekdays (median 104.5 versus 86 minutes, respectively; p=0.007) but groin-to-reperfusion times were similar (51.5 versus 48 minutes, respectively; p=0.4). Successful reperfusion was similar in both groups (90.6% nights/weekends versus 90% weekdays; p=1.0) as were the incidence of symptomatic intracerebral hemorrhage (10.4% nights/weekend versus 7.3% weekdays; p=0.48) and 90-day good functional outcomes based on the modified Rankin Scale did not differ between the two groups in a shift analysis (p=0.545). CONCLUSIONS Despite delays in door-to-groin puncture times in acute ischemic stroke patients presenting on nights/weekends compared to weekdays, we did not identify significant differences in successful reperfusion or functional outcomes in this cohort. Further studies are warranted to continue to evaluate differences in stroke care on nights/weekends versus weekdays.
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Affiliation(s)
- Matthew B Potts
- Department of Neurological Surgery, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, 676 N. St. Clair St., Suite 2210, Chicago, IL 60611, United States; Department of Radiology, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, Chicago, IL 60611, United States.
| | - Ramez N Abdalla
- Department of Neurological Surgery, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, 676 N. St. Clair St., Suite 2210, Chicago, IL 60611, United States; Department of Radiology, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, Chicago, IL 60611, United States.
| | - Pedram Golnari
- Department of Neurological Surgery, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, 676 N. St. Clair St., Suite 2210, Chicago, IL 60611, United States.
| | - Madhav Sukumaran
- Department of Neurological Surgery, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, 676 N. St. Clair St., Suite 2210, Chicago, IL 60611, United States.
| | - Aaron H Palmer
- Department of Neurological Surgery, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, 676 N. St. Clair St., Suite 2210, Chicago, IL 60611, United States.
| | - Michael C Hurley
- Department of Neurological Surgery, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, 676 N. St. Clair St., Suite 2210, Chicago, IL 60611, United States; Department of Radiology, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, Chicago, IL 60611, United States.
| | - Ali Shaibani
- Department of Neurological Surgery, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, 676 N. St. Clair St., Suite 2210, Chicago, IL 60611, United States; Department of Radiology, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, Chicago, IL 60611, United States.
| | - Babak S Jahromi
- Department of Neurological Surgery, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, 676 N. St. Clair St., Suite 2210, Chicago, IL 60611, United States; Department of Radiology, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, Chicago, IL 60611, United States.
| | - Sameer A Ansari
- Department of Neurological Surgery, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, 676 N. St. Clair St., Suite 2210, Chicago, IL 60611, United States; Department of Radiology, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, Chicago, IL 60611, United States; Department of Neurology, Northwestern Memorial Hospital, Feinberg School of Medicine of Northwestern University, Chicago, IL 60611, United States.
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169
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Gottula AL, Barreto AD, Adeoye O. Alteplase and Adjuvant Therapies for Acute Ischemic Stroke. Semin Neurol 2021; 41:16-27. [PMID: 33472270 DOI: 10.1055/s-0040-1722720] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Acute ischemic stroke (AIS) is a time sensitive medical emergency and a leading cause of morbidity and mortality worldwide. Intravenous (IV) recombinant tissue plasminogen activator (IV alteplase) is currently the only proven effective medication for the treatment of AIS with promising adjuvant medications currently under investigation. Recent advances in endovascular thrombectomy have broadened therapeutic options in specific patient populations, with modern treatment strategies utilizing advanced imaging modalities to extend the window for treatment. In all cases, rapid treatment remains a priority. The future of IV alteplase and the changing standard for treatment of AIS remain unwritten with the increasing evidence for imaging selection for both endovascular thrombectomy and IV alteplase, while novel adjuncts are under investigation. In this article, we review the history of IV alteplase investigations for stroke, evidence for thrombectomy as an adjunct to IV alteplase, and the potential of novel adjuvant therapeutics currently under investigation.
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Affiliation(s)
- Adam L Gottula
- Department of Emergency Medicine, University of Cincinnati, Cincinnati, Ohio
| | - Andrew D Barreto
- Department of Neurology, University of Texas Houston, Houston, Texas
| | - Opeolu Adeoye
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, Missouri
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170
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Carvalho de Campos Martins E, Luiz de Melo Bernardi F, Maia Junior OT, Micari A, Hopkins LN, Cremonesi A, Castriota F. Similarities and Differences Between Primary Percutaneous Coronary Intervention and Mechanical Thrombectomy. JACC Cardiovasc Interv 2021; 13:1683-1696. [PMID: 32703592 DOI: 10.1016/j.jcin.2020.03.055] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2020] [Revised: 03/27/2020] [Accepted: 03/31/2020] [Indexed: 02/06/2023]
Abstract
Acute ischemic stroke is among the leading causes of mortality and disability worldwide. Since 2015, as was the case for primary percutaneous coronary intervention for acute myocardial infarction, catheter-based reperfusion via mechanical thrombectomy (MT) has become the gold-standard treatment for acute ischemic stroke caused by large-vessel occlusion. Despite that, only a fraction of the world's population currently would be able to undergo MT in time, mostly because of the scarcity of 24/7 coverage by neurointerventionalists to deal with this enormous burden. Interventional cardiologists have thus been considered a logical option to aid in combating this vast demand to diminish the burden of acute ischemic stroke. However, despite some seemingly evident similarities between primary percutaneous coronary intervention and MT, for interventional cardiologists to enter this new field, they must be well trained and fully aware of all the clinical, technical, and environmental differences between these two scenarios. The main objective of this state-of-the-art paper is to serve as an introductory and comprehensive guide to familiarize the interventional cardiology community with the most critical technical aspects of MT.
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Affiliation(s)
| | | | | | - Antonio Micari
- Cardiovascular Unit, Humanitas Gavazzeni Hospital, Bergamo, Italy
| | - Leo Nelson Hopkins
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York; Jacobs Institute, Buffalo, New York
| | | | - Fausto Castriota
- Cardiovascular Unit, Humanitas Gavazzeni Hospital, Bergamo, Italy
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171
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Lv H, Li J, Che Y. miR-31 from adipose stem cell-derived extracellular vesicles promotes recovery of neurological function after ischemic stroke by inhibiting TRAF6 and IRF5. Exp Neurol 2021; 342:113611. [PMID: 33460643 DOI: 10.1016/j.expneurol.2021.113611] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 12/31/2020] [Accepted: 01/09/2021] [Indexed: 01/06/2023]
Abstract
Ischemic stroke affects many people in the world, but the underlying mechanism is not completely understood. In this study, we investigated the effect of microRNA (miR)-31 on ischemic stroke. We also determined downstream signaling pathway of miR-31 in recovery of neurological function in ischemic stroke. Middle cerebral artery occlusion (MCAO) in mice was used to mimic human stroke. Foot fault test and mNSS were used to evaluate neurological deficits in mice after stroke. TTC staining in brain tissues was used for determining infarct volume. We extracted and identified extracellular vesicles (EVs) derived from adipose-derived stem cells (ADSCs) to study the impact of miR-31 and TRAF6 by miR-31 overexpression or TRAF6 knockdown on stroke recovery. Primary mouse neuron exposed to oxygen-glucose deprivation (OGD) was used to mimic neuronal ischemic injury. RT-qPCR and Western blot analysis were used for determination of mRNA and protein expression, respectively. MTT assay was used for studying cell survival. TUNEL staining was sued for neuron apoptosis. Starbase website and dual luciferase reporter gene assay were utilized to predicted and verify binding relationship between miR-31 and TRAF6. Neurological functions were improved by miR-31 from ADSC-derived EVs, as suggested by improved foot fault and mNSS. miR-31 from ADSC-derived EVs also reduced infarct volume and neuronal cell apoptosis after stroke in mice. Similarly, in neuronal cell culture, miR-31 from ADSC-derived EVs reduced the expression of apoptosis-related factors cleaved caspase-3 and Bax, increased the survival, and reduced apoptosis of neuronal cells after OGD. miR-31 was found to downregulate the expression of TRAF6 by binding to the 3'-untranslated region (3'-UTR) of TRAF6, which in turn upregulated IRF5 expression. Increased expression of IRF5 led to increased neuron apoptosis after OGD. In conclusion, miR-31 from ADSC-derived EVs can downregulate expression of TRAF6 and IRF5, leading to reduced neuronal damage induced by ischemic stroke.
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Affiliation(s)
- Hui Lv
- Department of Neurology, the Fourth Affiliated Hospital of China Medical University, Shenyang 110032, PR China
| | - Jie Li
- Department of Neurology, the Fourth Affiliated Hospital of China Medical University, Shenyang 110032, PR China
| | - Yuqin Che
- Department of Neurology, the Fourth Affiliated Hospital of China Medical University, Shenyang 110032, PR China.
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172
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Recanalization Therapy for Acute Ischemic Stroke with Large Vessel Occlusion: Where We Are and What Comes Next? Transl Stroke Res 2021; 12:369-381. [PMID: 33409732 PMCID: PMC8055567 DOI: 10.1007/s12975-020-00879-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 11/15/2020] [Accepted: 11/18/2020] [Indexed: 12/18/2022]
Abstract
In the past 5 years, the success of multiple randomized controlled trials of recanalization therapy with endovascular thrombectomy has transformed the treatment of acute ischemic stroke with large vessel occlusion. The evidence from these trials has now established endovascular thrombectomy as standard of care. This review will discuss the chronological evolution of large vessel occlusion treatment from early medical therapy with tissue plasminogen activator to the latest mechanical thrombectomy. Additionally, it will highlight the potential areas in endovascular thrombectomy for acute ischemic stroke open to exploration and further progress in the next decade.
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173
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Feng J, Zhu Z, Waqas A, Chen L. Endovascular thrombectomy for the treatment of ischemic stroke: An updated meta-analysis for a randomized controlled trial. JOURNAL OF NEURORESTORATOLOGY 2021. [DOI: 10.26599/jnr.2021.9040014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022] Open
Abstract
Objective: To evaluate whether endovascular thrombectomy combined with intravenous thrombolysis is superior to the standard treatment of intravenous thrombolysis for the treatment of ischemic stroke. Methods: A meta-analysis of 12 studies obtained by searching PubMed and Web of Science database was performed to determine whether the difference in mortality (within 7 days or 90 days), functional outcome (modified Rankin Scale, 0-2), hemorrhage (symptomatic intracerebral hemorrhage, and subarachnoid hemorrhage), and recurrent ischemic stroke rate at 90 days between patients who underwent mechanical intravenous thrombolysis with (intervention) and without (control) endovascular thrombectomy. Results: As compared with the control group, patients in the intervention group had lower 90-day mortality [summary risk ratio (RR) = 0.83, 95% confidence interval (CI): 0.69-0.99; n = 1309/1070], higher recanalization rate (RR = 2.24, 95% CI: 1.97-2.56; n = 504/497), better functional outcome (modified Rankin score: 0-2; RR = 1.41, 95% CI: 1.29-1.54; n = 1702/1502), and higher rate of subarachnoid hemorrhage (RR = 2.40, 95% CI: 1.45-3.99; n = 1046/875) without significant difference in the 7-day mortality (RR = 1.12, 95% CI: 0.84-1.50; n = 951/773), symptomatic intracranial hemorrhage (RR = 1.12, 95% CI: 0.82-1.54; n = 1707/1507), or recurrent ischemic stroke (RR = 0.90, 95% CI: 0.52-1.54; n = 718/506). Conclusion: Our results demonstrated that patients in the intervention group had lower mortality and better functional outcomes than the control group. Although patients in the intervention group had a higher rate of subarachnoid hemorrhage; hence, endovascular thrombectomy combined with intravenous thrombolysis is still a beneficial intervention for a defined population of stroke patients.
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174
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Abstract
Endovascular therapy (EVT) has become the standard treatment for large-vessel occlusion (LVO) acute ischemic stroke (AIS). EVT is now indicated in patients up to 24h from their last known well, provided that the patient meets specific clinical and imaging criteria. Improvements in thrombectomy devices, techniques, and operator experience have allowed successful EVT of ICA terminus, M1-MCA occlusions as well as proximal M2-MCA, basilar artery occlusions, and revascularization of tandem lesions. Mechanical thrombectomy failures still occur due to several factors, however, highlighting the need for further device and technical improvements. An ongoing debate exists regarding the need for pre-EVT thrombolytic agents, thrombectomy techniques, distal occlusions, anesthesia methods, the role of advanced neuroimaging, the treatment of patients with larger infarct core, and those presenting with milder stroke symptoms. Many of these questions are the subject of current or upcoming clinical trials. This review aims to provide an outline and discussion about the established recommendations and emerging topics regarding EVT for LVO AIS.
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Affiliation(s)
- Fabio Settecase
- Neuroradiology Division, Department of Radiology, University of British Columbia, Vancouver, BC, Canada; Diagnostic and Interventional Neuroradiology Division, Department of Radiology, Vancouver General Hospital, Vancouver, BC, Canada; Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, United States.
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175
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Vakhitov KM, Cherniakov IS, Khotchenkov MV, Vintskovskiĭ SG, Kmetik ÉG, Vinokurov AI. [Stagewise treatment of tandem lesions of the internal carotid artery in patients with ischaemic stroke]. ANGIOLOGIIA I SOSUDISTAIA KHIRURGIIA = ANGIOLOGY AND VASCULAR SURGERY 2021; 27:50-58. [PMID: 35050249 DOI: 10.33529/angio2021408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
AIM The study was aimed at assessing the results of a stagewise approach to surgical treatment of patients with ischaemic stroke and tandem lesions of coronary arteries. PATIENTS AND METHODS We analysed the results of treating a total of 19 patients with ischaemic stroke having endured in 2017-2018 surgical interventions for tandem lesions of the internal carotid artery. All 19 patients with tandem lesions underwent as the first stage of surgical treatment recanalization of the intracranial portion of the internal carotid artery. Nine patients were subjected to thromboextraction followed by carotid stenting (Group One), ten underwent thromboextraction and carotid endarterectomy (Group Two). One patient was subjected to simultaneous endovascular intervention at the intra- and extracranial level, in 18 patients reconstruction of the internal carotid artery at the extracranial level (second stage) was performed within a postponed period (3-5 days). In the postoperative period we assessed neurological deficit and the results of 90-day survival. RESULTS No deterioration of neurological deficit was observed after the first stage of surgical treatment. There were statistically significant differences in the degree of regression of a stagewise treatment at discharge, with predominance in the second group. The 90-day survival rate had no prevalence in either group, despite 1 lethal outcome in a patient with simultaneous thromboextraction and stenting of the extracranial portion of the internal carotid artery. CONCLUSION Adequate prevention of haemorrhagic transformation of the damaged zone of cerebral tissue in patients with ischaemic stroke caused by tandem lesions of carotid arteries may be ensured by means of selecting stagewise treatment, i. e., postponed elimination of extracranial stenosis of the internal carotid artery. Given a small sample size, the study requires further examination and assessment of the obtained results.
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Affiliation(s)
- K M Vakhitov
- Department of Vascular Surgery and Renal Transplantation, Leningrad Regional Clinical Hospital, Saint Petersburg, Russia
| | - I S Cherniakov
- Department of Vascular Surgery and Renal Transplantation, Leningrad Regional Clinical Hospital, Saint Petersburg, Russia
| | - M V Khotchenkov
- Department of Vascular Surgery and Renal Transplantation, Leningrad Regional Clinical Hospital, Saint Petersburg, Russia
| | - S G Vintskovskiĭ
- Department of Vascular Surgery and Renal Transplantation, Leningrad Regional Clinical Hospital, Saint Petersburg, Russia
| | - É G Kmetik
- Department of Vascular Surgery and Renal Transplantation, Leningrad Regional Clinical Hospital, Saint Petersburg, Russia
| | - A Iu Vinokurov
- Department of Vascular Surgery and Renal Transplantation, Leningrad Regional Clinical Hospital, Saint Petersburg, Russia
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176
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Yahav-Dovrat A, Saban M, Merhav G, Lankri I, Abergel E, Eran A, Tanne D, Nogueira RG, Sivan-Hoffmann R. Evaluation of Artificial Intelligence-Powered Identification of Large-Vessel Occlusions in a Comprehensive Stroke Center. AJNR Am J Neuroradiol 2020; 42:247-254. [PMID: 33384294 DOI: 10.3174/ajnr.a6923] [Citation(s) in RCA: 46] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 09/13/2020] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE Artificial intelligence algorithms have the potential to become an important diagnostic tool to optimize stroke workflow. Viz LVO is a medical product leveraging a convolutional neural network designed to detect large-vessel occlusions on CTA scans and notify the treatment team within minutes via a dedicated mobile application. We aimed to evaluate the detection accuracy of the Viz LVO in real clinical practice at a comprehensive stroke center. MATERIALS AND METHODS Viz LVO was installed for this study in a comprehensive stroke center. All consecutive head and neck CTAs performed from January 2018 to March 2019 were scanned by the algorithm for detection of large-vessel occlusions. The system results were compared with the formal reports of senior neuroradiologists used as ground truth for the presence of a large-vessel occlusion. RESULTS A total of 1167 CTAs were included in the study. Of these, 404 were stroke protocols. Seventy-five (6.4%) patients had a large-vessel occlusion as ground truth; 61 were detected by the system. Sensitivity was 0.81, negative predictive value was 0.99, and accuracy was 0.94. In the stroke protocol subgroup, 72 (17.8%) of 404 patients had a large-vessel occlusion, with 59 identified by the system, showing a sensitivity of 0.82, negative predictive value of 0.96, and accuracy of 0.89. CONCLUSIONS Our experience evaluating Viz LVO shows that the system has the potential for early identification of patients with stroke with large-vessel occlusions, hopefully improving future management and stroke care.
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Affiliation(s)
- A Yahav-Dovrat
- From the Department of Radiology (A.Y.-D., G.M., A.E., R.S.-H.)
| | - M Saban
- Faculty of Social health and Welfare (M.S.), Haifa University, Haifa, Israel
| | - G Merhav
- From the Department of Radiology (A.Y.-D., G.M., A.E., R.S.-H.)
| | - I Lankri
- Faculty of Medicine (I.L.), Technion Israel institute of Technology, Haifa, Israel
| | - E Abergel
- Unit of Interventional Neuroradiology (E.A., R.S.-H.)
| | - A Eran
- From the Department of Radiology (A.Y.-D., G.M., A.E., R.S.-H.)
| | - D Tanne
- Stroke and Cognition Institute (D.T.), Rambam Health Care Campus, Haifa, Israel
| | - R G Nogueira
- Neuroendovascular Service (R.G.N.), Marcus Stroke and Neuroscience Center Grady Memorial Hospital, Atlanta, Georgia.,Departments of Neurology, Neurosurgery, and Radiology (R.G.N.), Emory University School of Medicine, Atlanta, Georgia
| | - R Sivan-Hoffmann
- From the Department of Radiology (A.Y.-D., G.M., A.E., R.S.-H.) .,Unit of Interventional Neuroradiology (E.A., R.S.-H.)
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177
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Patel P, Yavagal D, Khandelwal P. Hyperacute Management of Ischemic Strokes: JACC Focus Seminar. J Am Coll Cardiol 2020; 75:1844-1856. [PMID: 32299596 DOI: 10.1016/j.jacc.2020.03.006] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 03/03/2020] [Accepted: 03/06/2020] [Indexed: 11/16/2022]
Abstract
Acute ischemic stroke is the leading cause of disability and among the leading causes of mortality worldwide. Intravenous tissue plasminogen activator has been a cornerstone for treatment of acute ischemic stroke for more than 20 years; however, its use is limited due to a narrow therapeutic window, several contraindications, and low efficacy to recanalize the artery in large vessel occlusion. Recently, the addition of endovascular mechanical thrombectomy of large artery occlusion has revolutionized the stroke treatment for most disabling strokes. The paper reviews updates to the thrombolytic treatment as well as catheter-based treatment, and results from recent trials in the selection of patients in an extended time window using perfusion imaging.
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Affiliation(s)
- Pratit Patel
- Departments of Neurological Surgery, Rutgers University-New Jersey Medical School, Newark, New Jersey
| | - Dileep Yavagal
- Department of Neurology and Neurological Surgery, Jackson Memorial & University of Miami Hospitals, University of Miami Miller School of Medicine, Miami, Florida
| | - Priyank Khandelwal
- Departments of Neurological Surgery, Rutgers University-New Jersey Medical School, Newark, New Jersey.
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178
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Boulos MI, Dharmakulaseelan L, Brown DL, Swartz RH. Trials in Sleep Apnea and Stroke: Learning From the Past to Direct Future Approaches. Stroke 2020; 52:366-372. [PMID: 33349009 DOI: 10.1161/strokeaha.120.031709] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Few randomized controlled trials have evaluated the effectiveness of continuous positive airway pressure (CPAP) in reducing recurrent vascular events and mortality in poststroke obstructive sleep apnea (OSA). To date, results have been mixed, most studies were underpowered and definitive conclusions are not available. Using lessons learned from prior negative trials in stroke, we reappraise prior randomized controlled trials that examined the use of CPAP in treating poststroke OSA and propose the following considerations: (1) Intervention-based changes, such as ensuring that patients are using CPAP for at least 4 hours per night (eg, through use of improvements in CPAP technology that make it easier for patients to use), as well as considering alternative treatment strategies for poststroke OSA; (2) Population-based changes (ie, including stroke patients with severe and symptomatic OSA and CPAP noncompliers); and (3) Changes to timing of intervention and follow-up (ie, early initiation of CPAP therapy within the first 48 hours of stroke and long-term follow-up calculated in accordance with sample size to ensure adequate power). Given the burden of vascular morbidity and mortality in stroke patients with OSA, there is a strong need to learn from past negative trials and explore innovative stroke prevention strategies to improve stroke-free survival.
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Affiliation(s)
- Mark I Boulos
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (M.I.B., L.D., R.H.S.).,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute (M.I.B., L.D., R.H.S.), Sunnybrook Health Sciences Centre, Toronto, Canada.,Sleep Laboratory (M.I.B., R.H.S.), Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Laavanya Dharmakulaseelan
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (M.I.B., L.D., R.H.S.).,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute (M.I.B., L.D., R.H.S.), Sunnybrook Health Sciences Centre, Toronto, Canada
| | - Devin L Brown
- Department of Neurology, University of Michigan, Ann Arbor (D.L.B.)
| | - Richard H Swartz
- Division of Neurology, Department of Medicine, Sunnybrook Health Sciences Centre, University of Toronto, Canada (M.I.B., L.D., R.H.S.).,Hurvitz Brain Sciences Research Program, Sunnybrook Research Institute (M.I.B., L.D., R.H.S.), Sunnybrook Health Sciences Centre, Toronto, Canada.,Sleep Laboratory (M.I.B., R.H.S.), Sunnybrook Health Sciences Centre, Toronto, Canada
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179
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Zhang SR, Phan TG, Sobey CG. Targeting the Immune System for Ischemic Stroke. Trends Pharmacol Sci 2020; 42:96-105. [PMID: 33341247 DOI: 10.1016/j.tips.2020.11.010] [Citation(s) in RCA: 70] [Impact Index Per Article: 17.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Revised: 11/20/2020] [Accepted: 11/24/2020] [Indexed: 12/11/2022]
Abstract
Stroke is responsible for almost 6 million deaths and more than 10% of all mortalities each year, and two-thirds of stroke survivors remain disabled. With treatments for ischemic stroke still limited to clot lysis and/or mechanical removal, new therapeutic targets are desperately needed. In this review, we provide an overview of the complex mechanisms of innate and adaptive immune cell-mediated inflammatory injury, that exacerbates infarct development for several days after stroke. We also highlight the features of poststroke systemic immunodepression that commonly leads to infections and some mortalities, and argue that safe and effective therapies will need to balance pro- and anti-inflammatory mechanisms in a time-sensitive manner, to maximize the likelihood of an improved long-term outcome.
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Affiliation(s)
- Shenpeng R Zhang
- Department of Physiology, Anatomy, and Microbiology, and Centre for Cardiovascular Biology and Disease Research, School of Life Sciences, La Trobe University, Bundoora, Victoria, Australia
| | - Thanh G Phan
- Clinical Trials, Imaging, and Informatics (CTI) Division, Stroke and Ageing Research (STARC), Department of Medicine, School of Clinical Sciences at Monash Health, Monash University, Clayton, Victoria, Australia
| | - Christopher G Sobey
- Department of Physiology, Anatomy, and Microbiology, and Centre for Cardiovascular Biology and Disease Research, School of Life Sciences, La Trobe University, Bundoora, Victoria, Australia.
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180
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The Poststroke Peripheral Immune Response Is Differentially Regulated by Leukemia Inhibitory Factor in Aged Male and Female Rodents. OXIDATIVE MEDICINE AND CELLULAR LONGEVITY 2020; 2020:8880244. [PMID: 33376583 PMCID: PMC7746465 DOI: 10.1155/2020/8880244] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Revised: 11/11/2020] [Accepted: 11/26/2020] [Indexed: 01/19/2023]
Abstract
Background The goal of this study was to determine whether leukemia inhibitory factor (LIF) promotes anti-inflammatory activity after stroke in a sex-dependent manner. Methods Aged (18-month-old) Sprague-Dawley rats of both sexes underwent sham surgery or permanent middle cerebral artery occlusion (MCAO). Animals received three doses of intravenous LIF (125 μg/kg) or PBS at 6, 24, and 48 h before euthanization at 72 h. Spleen weights were measured immediately following euthanization. Western blot was used to measure protein levels of CCL8, CD11b, CXCL9, CXCL10, IL-12 p40, IL-3, and the LIF receptor (LIFR) in spleen tissue. ELISA was used to measure IL-1β, IL-6, TNFα, and IFNγ in spleen tissue. A Griess Assay was used to indirectly quantify NO levels via measurement of nitrite. Levels of cellular markers and inflammatory mediators were normalized to the baseline (sham) group from each sex. Statistical analysis was performed using two-way ANOVA and followed by Fisher's LSD post hoc test. Results Aged female rats showed a significantly lower spleen weight after MCAO, but showed a significant increase in spleen size after LIF treatment. This effect was observed in aged male rats, but not to as great of an extent. CD11b levels were significantly higher in the spleens of MCAO+PBS males compared to their female counterparts, but there was no significant difference in CD11b levels between MCAO+LIF males and females. LIF significantly increased CXCL9 after LIF treatment in aged male and female rats. LIFR and IL-3 were upregulated after LIF treatment in aged females. Splenic nitrate increased after MCAO but decreased after LIF treatment in aged females. Splenic nitrate levels did not increase after MCAO but did increase after LIF treatment in aged males. The following cytokines/chemokines were not altered by sex or treatment: TNFα, IL-6, IL-12 p40, CCL8, IFNγ, and CXCL10. Conclusions LIF treatment after permanent MCAO induces sex-dependent effects on the poststroke splenic response and the production of proinflammatory cytokines among aged rats.
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Hussein O, Sawalha K, Elazim AA, Greene-Chandos D, Torbey MT. Hyperbaric oxygen therapy after acute ischemic stroke with large penumbra: a case report. THE EGYPTIAN JOURNAL OF NEUROLOGY, PSYCHIATRY AND NEUROSURGERY 2020. [DOI: 10.1186/s41983-020-00225-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Hyperbaric oxygen therapy (HBOT) for the treatment of acute stroke has been under the radar for a long time. Previous studies have not been able to prove efficacy. Several factors might have contributed to such inconsistent results. The timing of delivering the hyperbaric oxygen in relation to the stage of stroke evolution may be an important factor. This was not taken into account in the previous studies as there was no feasible and standardized method to assess the penumbra in the acute phase. Now with the perfusion scan appearing as a key player in the acute stroke management, precise stroke patient selection for hyperbaric oxygen therapy deserves a second chance similar to mechanical thrombectomy.
Case presentation
A 62-year-old female patient who presented with acute large vessel stroke was not eligible for chemical or mechanical thrombectomy. There was a large penumbra on imaging. She got treated with several sessions of hyperbaric oxygen over a 2-week period immediately after stroke. The patient showed significant improvement on the follow-up perfusion imaging as well as some clinical improvement. The more impressive radiological improvement was probably due to the presence of relatively large core infarction at baseline affecting functional brain areas. The patient continued to improve clinically on her 6-month follow up visit.
Conclusion
Our case demonstrates immediate stroke-related penumbra improvement associated with HBOT. Based on that, we anticipate a potential role for HBOT in acute stroke management considering precise patient selection. Future randomized controlled trials are needed and should take that in consideration.
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182
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Iwamoto Y, Imura T, Tanaka R, Imada N, Inagawa T, Araki H, Araki O. Development and Validation of Machine Learning-Based Prediction for Dependence in the Activities of Daily Living after Stroke Inpatient Rehabilitation: A Decision-Tree Analysis. J Stroke Cerebrovasc Dis 2020; 29:105332. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105332] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2020] [Revised: 08/03/2020] [Accepted: 09/12/2020] [Indexed: 01/19/2023] Open
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Kühn AL, Vardar Z, Kraitem A, King RM, Anagnostakou V, Puri AS, Gounis MJ. Biomechanics and hemodynamics of stent-retrievers. J Cereb Blood Flow Metab 2020; 40:2350-2365. [PMID: 32428424 PMCID: PMC7820689 DOI: 10.1177/0271678x20916002] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2019] [Revised: 03/09/2020] [Accepted: 03/10/2020] [Indexed: 12/29/2022]
Abstract
In 2015, multiple randomized clinical trials showed an unparalleled treatment benefit of stent-retriever thrombectomy as compared to standard medical therapy for the treatment of a large artery occlusion causing acute ischemic stroke. A short time later, the HERMES collaborators presented the patient-level pooled analysis of five randomized clinical trials, establishing class 1, level of evidence A for stent-retriever thrombectomy, in combination with intravenous thrombolysis when indicated to treat ischemic stroke. In the years following, evidence continues to mount for expanded use of this therapy for a broader category of patients. The enabling technology that changed the tide to support endovascular treatment of acute ischemic stroke is the stent-retriever. This review summarizes the history of intra-arterial treatment of stroke, introduces the biomechanics of embolus extraction with stent-retrievers, describes technical aspects of the intervention, provides a description of hemodynamic implications of stent-retriever embolectomy, and proposes future directions for a more comprehensive, multi-modal endovascular approach for the treatment of acute ischemic stroke.
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Affiliation(s)
- Anna Luisa Kühn
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Zeynep Vardar
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Afif Kraitem
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Robert M King
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Vania Anagnostakou
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Ajit S Puri
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, MA, USA
| | - Matthew J Gounis
- New England Center for Stroke Research, Department of Radiology, University of Massachusetts Medical School, Worcester, MA, USA
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184
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Machi P, Luft A, Winklhofer S, Anagnostakou V, Kulcsár Z. Endovascular treatment of acute ischemic stroke. J Neurosurg Sci 2020; 65:259-268. [PMID: 33245221 DOI: 10.23736/s0390-5616.20.05109-7] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Endovascular treatment of acute ischemic stroke has become the first choice of treatment in large cerebral vessel occlusions, with a very high efficacy in terms of revascularization and reducing disability of affected patients. Revolutionizing acute therapy, it induced important paradigm shifts in the concepts of time and salvageable brain. In this review we focus on the current concepts of patient selection, imaging, techniques and perspectives of endovascular stroke treatment.
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Affiliation(s)
- Paolo Machi
- Service of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals, Geneva, Switzerland
| | - Andreas Luft
- Department of Neurology, University Hospital of Zurich, Zurich, Switzerland.,Clinical Neurocenter, University Hospital of Zurich, Zurich, Switzerland
| | - Sebastian Winklhofer
- Clinical Neurocenter, University Hospital of Zurich, Zurich, Switzerland.,Department of Neuroradiology, University Hospital of Zurich, Zurich, Switzerland
| | - Vaia Anagnostakou
- Department of Radiology, New England Center for Research, University of Massachusetts Medical School, Worcester, MA, USA
| | - Zsolt Kulcsár
- Clinical Neurocenter, University Hospital of Zurich, Zurich, Switzerland - .,Department of Neuroradiology, University Hospital of Zurich, Zurich, Switzerland.,Center of Applied Biotechnology and Molecular Medicine, University of Zurich, Zurich, Switzerland
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185
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Ospel JM, Singh N, Almekhlafi MA, Menon BK, Butt A, Poppe AY, Jadhav A, Silver FL, Shah R, Dowlatshahi D, O'Hare AM, Demchuk AM, Goyal M, Hill MD. Early Recanalization With Alteplase in Stroke Because of Large Vessel Occlusion in the ESCAPE Trial. Stroke 2020; 52:304-307. [PMID: 33213288 DOI: 10.1161/strokeaha.120.031591] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE Quantitating the effect of intravenous alteplase on the technical outcome of early recanalization of large vessel occlusions aids understanding. We report the prevalence of early recanalization in patients with stroke because of large vessel occlusion treated with and without intravenous alteplase and endovascular thrombectomy, and its association with clinical outcome. METHODS Patients with acute ischemic stroke with large vessel occlusion from the ESCAPE trial (Endovascular Treatment for Small Core and Anterior Circulation Proximal Occlusion With Emphasis on Minimizing CT to Recanalization Times Trial) were included in this post hoc analysis. Outcomes of interest were the prevalence of early recanalization (1) and good outcome (2), defined as modified Rankin Scale score of 0 to 2 at 90 days. RESULTS Among 147 patients who did not receive endovascular thrombectomy, early recanalization occurred in 4/30 (13.3%) patients without and 48/117 (41.0%) patients with intravenous alteplase (adjusted risk ratios, 3.2 [95% CI, 1.2-8.1]). Good outcome was achieved by 34/116 (29.3%) of patients who received intravenous alteplase versus 10/29 (34.5%) who did not receive alteplase (adjusted risk ratios, 1.0 [95% CI, 0.6-1.5) and by 20/52 (38.5%) patients with versus 24/93 (25.8%) without early recanalization (adjusted risk ratios, 1.9 [95% CI, 1.2-2.9]). CONCLUSIONS Early recanalization was confirmed as a strong predictor of good outcome in patients who did not undergo endovascular thrombectomy and was improved with intravenous alteplase, yet a majority of patients (59.0%) did not achieve early reperfusion. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT01778335.
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Affiliation(s)
- Johanna M Ospel
- Department of Clinical Neurosciences (J.M.O., N.S., M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Department of Neuroradiology, University Hospital Basel, Switzerland (J.M.O.)
| | - Nishita Singh
- Department of Clinical Neurosciences (J.M.O., N.S., M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada
| | - Mohammed A Almekhlafi
- Department of Clinical Neurosciences (J.M.O., N.S., M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Department of Radiology (M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Department of Community Health Sciences (M.A.A., B.K.M., M.D.H.), University of Calgary, Canada.,Hotchkiss Brain Institute (M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada
| | - Bijoy K Menon
- Department of Clinical Neurosciences (J.M.O., N.S., M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Department of Radiology (M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Department of Community Health Sciences (M.A.A., B.K.M., M.D.H.), University of Calgary, Canada.,Hotchkiss Brain Institute (M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada
| | - Asif Butt
- Department of Medicine (Neurology), University of Alberta, Edmonton, Canada (A.B.)
| | - Alexandre Y Poppe
- Department of Clinical Neurosciences, Centre Hospitalier de l'Université de Montréal, Montréal, Canada (A.Y.P.)
| | - Ashutov Jadhav
- Department of Neurology, University of Pittsburgh Medical Center, PA (A.J.)
| | - Frank L Silver
- Department of Medicine (Neurology), Toronto Western Hospital, University Health Network, Canada (F.L.S.)
| | - Ruchir Shah
- Erlanger Medical Centre (Neurosciences), Chattanooga, TN (R.S.)
| | - Dar Dowlatshahi
- Department of Medicine (Neurology), University of Ottawa, Canada (D.D.)
| | - Alan M O'Hare
- Department of Radiology (Neuroradiology), Beaumont Hospital, Dublin, Ireland (A.M.O.)
| | - Andrew M Demchuk
- Department of Clinical Neurosciences (J.M.O., N.S., M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Department of Radiology (M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Hotchkiss Brain Institute (M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada
| | - Mayank Goyal
- Department of Clinical Neurosciences (J.M.O., N.S., M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Department of Radiology (M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Hotchkiss Brain Institute (M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences (J.M.O., N.S., M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Department of Radiology (M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada.,Department of Community Health Sciences (M.A.A., B.K.M., M.D.H.), University of Calgary, Canada.,Department of Medicine (M.D.H.), University of Calgary, Canada.,Hotchkiss Brain Institute (M.A.A., B.K.M., A.M.D., M.G., M.D.H.), University of Calgary, Canada
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Friedrich B, Boeckh-Behrens T, Krüssmann V, Mönch S, Kirschke J, Kreiser K, Berndt M, Lehm M, Wunderlich S, Zimmer C, Kaesmacher J, Maegerlein C. A short history of thrombectomy - Procedure and success analysis of different endovascular stroke treatment techniques. Interv Neuroradiol 2020; 27:249-256. [PMID: 33167756 PMCID: PMC8044626 DOI: 10.1177/1591019920961883] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Background The historical development of interventional stroke treatment shows a wide variation of different techniques and materials used. Thus, the question of the present work is whether the technical and procedural differences of thrombectomy techniques lead to different technical and clinical results. Methods and results Analysis of a mixed retrospective/prospective database of all endovascular treated patients with an occlusion of the Carotid-T or M1 segment of the MCA at a single comprehensive stroke center since 2008. Patients were classified regarding the technical approach used. Six hundred sixty-eight patients were available for the final analysis. Reperfusion rates ranged between 56% and 100% depending on the technical approach. The use of balloon guide catheters and most recently the establishment of combination techniques using balloon guide catheters, aspiration catheters and stent retrievers have shown a further significant increase in the rates of successful recanalization, full recanalization and first-pass recanalization. Additionally, the technical development of interventional techniques has led to a subsequent drop in complications, embolization into previously unaffected territories in particular. Conclusion Technical success of MT has improved substantially over the past decade owing to improved materials and procedural innovations. Combination techniques including flow modulation have emerged to be the most effective approach and should be considered as a standard of care. Level of evidence: Level 3, retrospective study.
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Affiliation(s)
- B Friedrich
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - T Boeckh-Behrens
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - V Krüssmann
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - S Mönch
- Department of Radiology, University Hospital, LMU Munich, Germany
| | - J Kirschke
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - K Kreiser
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - M Berndt
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - M Lehm
- Department of Radiology, München Klinik, Munich, Germany
| | - S Wunderlich
- Department of Neurology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - C Zimmer
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - J Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland.,Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland.,University Institute of Diagnostic, Interventional and Pediatric Radiology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - C Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
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Li KHC, Jesuthasan A, Kui C, Davies R, Tse G, Lip GYH. Acute ischemic stroke management: concepts and controversies.A narrative review. Expert Rev Neurother 2020; 21:65-79. [PMID: 33047640 DOI: 10.1080/14737175.2021.1836963] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
INTRODUCTION Amongst the 25.7 million survivors and 6.5 million deaths from stroke between 1990 and 2013, ischemic strokes accounted for approximately 70% and 50% of the cases, respectively. With patients still suffering from complications and stroke recurrence, more questions have been raised as to how we can better improve patient management. AREAS COVERED The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement and Newcastle-Ottawa Scale (NOS) were adopted to ensure a comprehensive inclusion of quality literature from various sources. PubMed and Embase were searched for evidence on thrombolysis, mechanical thrombectomy, artificial intelligence (AI), antiplatelet therapy, anticoagulation and hypertension management. EXPERT OPINION The directions of future research in these areas are dependent on the current level of validation. Endovascular therapy and applications of AI are relatively new compared to the other areas discussed in this review. As such, future studies need to focus on validating their efficacy. As for thrombolysis, antiplatelet and anticoagulation therapy, their efficacy has been well-established and future research efforts should be directed toward adjusting its use according to patient-specific factors, starting with factors with the most clinical relevance and prevalence.
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Affiliation(s)
- Ka Hou Christien Li
- Medicine, Newcastle University , Newcastle, UK.,Arrowe Park Acute Stroke Unit, Wirral University Teaching Hospital NHS Foundation Trust , Wirral, UK
| | | | | | - Ruth Davies
- Arrowe Park Acute Stroke Unit, Wirral University Teaching Hospital NHS Foundation Trust , Wirral, UK
| | - Gary Tse
- Tianjin Key Laboratory of Ionic-Molecular Function of Cardiovascular Disease, Department of Cardiology, Tianjin Institute of Cardiology, Second Hospital of Tianjin Medical University , Tianjin, China
| | - Gregory Y H Lip
- Liverpool Centre for Cardiovascular Science, University of Liverpool and Liverpool Heart & Chest Hospital , Liverpool, UK.,Department of Clinical Medicine, Aalborg University , Aalborg, Denmark
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Effectiveness of Endovascular Therapy for Patients with Acute Ischemic Stroke: A Meta-Analysis of Randomized Controlled Trials. World Neurosurg 2020; 143:e1-e18. [DOI: 10.1016/j.wneu.2020.07.156] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2019] [Revised: 07/29/2019] [Accepted: 07/30/2019] [Indexed: 01/19/2023]
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189
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Yoshimoto T, Tanaka K, Yamagami H, Uchida K, Inoue M, Koge J, Ihara M, Toyoda K, Imamura H, Ohara N, Morimoto T, Sakai N, Yoshimura S. Treatment Outcomes by Initial Neurological Deficits in Acute Stroke Patients with Basilar Artery Occlusion: The RESCUE Japan Registry 2. J Stroke Cerebrovasc Dis 2020; 29:105256. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105256] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 08/11/2020] [Accepted: 08/14/2020] [Indexed: 01/01/2023] Open
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190
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Tsuji K, Tsuji A, Yoshimura Y, Ogawa N, Nakazawa T, Nozaki K. Rupture of Anterior Communicating Artery Aneurysm after Intravenous Thrombolysis for Acute Ischemic Stroke: A Case Report. JOURNAL OF NEUROENDOVASCULAR THERAPY 2020; 15:240-245. [PMID: 37501693 PMCID: PMC10370924 DOI: 10.5797/jnet.cr.2020-0053] [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: 03/16/2020] [Accepted: 08/08/2020] [Indexed: 07/29/2023]
Abstract
Objective Rupture of intracranial aneurysms after tissue plasminogen activator (t-PA) administration for acute ischemic stroke with an unruptured cerebral aneurysm is rare. We report a case of ruptured cerebral aneurysm after t-PA administration. Case Presentation A 74-year-old woman with dysarthria and left hemiparesis was admitted to our hospital, and acute lacunar infarction was found in the right corona radiata. One hour after t-PA administration, she complained of sudden headache and nausea, and her consciousness level deteriorated. Subarachnoid hemorrhage due to rupture of the anterior communicating aneurysm was confirmed and coil embolization was performed. Conclusion T-PA administration for acute ischemic stroke with an unruptured cerebral aneurysm risks rupture of the cerebral aneurysm, and careful judgment is needed in each case.
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Affiliation(s)
- Keiichi Tsuji
- Department of Neurosurgery, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Atsushi Tsuji
- Department of Neurosurgery, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Yayoi Yoshimura
- Department of Neurosurgery, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Nobuhiro Ogawa
- Department of Neurology, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Takuya Nakazawa
- Department of Neurosurgery, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Kazuhiko Nozaki
- Department of Neurosurgery, Shiga University of Medical Science, Otsu, Shiga, Japan
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191
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Thongphetsavong Gautam A, Seh H, Jain A, Mechri I, Jan van Doormaal P, Dammers R, Volovici V. Open Microvascular Thrombectomy for Acute Intracranial Large Vessel Occlusion: Microsurgery in the Endovascular Thrombectomy Era. World Neurosurg 2020; 145:e278-e290. [PMID: 33068805 DOI: 10.1016/j.wneu.2020.10.040] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2020] [Revised: 10/06/2020] [Accepted: 10/07/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND Open microsurgical thrombectomy for acute intracranial large vessel occlusion (LVO) has been the subject of dozens of case reports and series. However, no clear indications exist to define its role in the management of acute ischemic stroke. Our aim was to review all the available data on open microsurgical thrombectomy, for both spontaneous as well as iatrogenic intracranial vessel occlusion, in terms of indication and results. METHODS Of the 390 articles screened, 33 were included after full text screening. RESULTS A total of 232 patients were reported, of whom 208 received microsurgical thrombectomy and 24 received bypass for large vessel occlusion. Patients were divided into a historic cohort (before 2002) and a recent cohort (articles published after 2002). Patients from the historic cohort were younger: median age, 55 years (interquartile range, 34-57 years) versus 69 years (interquartile range, 63-75 years) in the recent cohort (P < 0.01). The procedure was successful more often in the recent cohort (65% of patients in the historic cohort vs. 98% of patients in the recent cohort) and more patients experienced neurologic improvement (56% of patients in the historic cohort vs. 69% in the recent cohort). CONCLUSIONS In the era of endovascular thrombectomy, open microsurgical techniques might still play a role in highly selected patients. The reported patients show that microsurgical thrombectomy seems efficient and effective in improving patient outcome. Ideally, a multidisciplinary approach with vascular neurosurgeons trained and skilled in microvascular techniques is recommended.
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Affiliation(s)
| | - Hadil Seh
- University of Medicine and Pharmacy "Grigore T. Popa", Iasi, Romania
| | - Anamika Jain
- University of Medicine and Pharmacy "Grigore T. Popa", Iasi, Romania
| | - Imen Mechri
- University of Medicine and Pharmacy "Grigore T. Popa", Iasi, Romania
| | - Pieter Jan van Doormaal
- Division of Interventional Neuroradiology, Department of Radiology, Erasmus MC Rotterdam, the Netherlands
| | - Ruben Dammers
- Department of Neurosurgery, Erasmus MC Rotterdam, the Netherlands
| | - Victor Volovici
- Department of Neurosurgery, Erasmus MC Rotterdam, the Netherlands.
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192
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Endovascular model of ischemic stroke in swine guided by real-time MRI. Sci Rep 2020; 10:17318. [PMID: 33057149 PMCID: PMC7560864 DOI: 10.1038/s41598-020-74411-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2020] [Accepted: 09/28/2020] [Indexed: 01/07/2023] Open
Abstract
Modeling stroke in animals is essential for testing efficacy of new treatments; however, previous neuroprotective therapies, based on systemic delivery in rodents failed, exposing the need for model with improved clinical relevance. The purpose of this study was to develop endovascular approach for inducing ischemia in swine. To achieve that goal, we used intra-arterial administration of thrombin mixed with gadolinium and visualized the occlusion with real-time MRI. Placement of the microcatheter proximally to rete allowed trans-catheter perfusion of the ipsilateral hemisphere as visualized by contrast-enhanced perfusion MR scans. Dynamic T2*w MRI facilitated visualization of thrombin + Gd solution transiting through cerebral vasculature and persistent hyperintensities indicated occlusion. Area of trans-catheter perfusion dynamically quantified on representative slice before and after thrombin administration (22.20 ± 6.31 cm2 vs. 13.28 ± 4.71 cm2 respectively) indicated significantly reduced perfusion. ADC mapping showed evidence of ischemia as early as 27 min and follow-up T2w scans confirmed ischemic lesion (3.14 ± 1.41 cm2). Animals developed contralateral neurological deficits but were ambulatory. Our study has overcome long lasting challenge of inducing endovascular stroke model in pig. We were able to induce stroke using minimally invasive endovascular approach and observe in real-time formation of the thrombus, blockage of cerebral perfusion and eventually stroke lesion.
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193
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Coutinho JM, Ferro JM, Stam J. Endovascular Treatment for Cerebral Venous Thrombosis. World Neurosurg 2020; 144:194-195. [PMID: 33039694 DOI: 10.1016/j.wneu.2020.09.119] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Affiliation(s)
- Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
| | - Jose M Ferro
- Department of Neurology, Hospital Santa Maria, Lisbon, Portugal
| | - Jan Stam
- Department of Neurology, Amsterdam University Medical Centers, Amsterdam, The Netherlands
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194
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McCarthy DJ, Tonetti DA, Stone J, Starke RM, Narayanan S, Lang MJ, Jadhav AP, Gross BA. More expansive horizons: a review of endovascular therapy for patients with low NIHSS scores. J Neurointerv Surg 2020; 13:146-151. [PMID: 33028674 DOI: 10.1136/neurintsurg-2020-016583] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/08/2020] [Accepted: 09/13/2020] [Indexed: 11/03/2022]
Abstract
While the landmark 2015 stroke trials demonstrated that endovascular therapy (EVT) was superior to medical management for the treatment of acute ischemic stroke due to large vessel occlusion, the efficacy of EVT for patients presenting with a low NIHSS score remains undetermined. We conducted a review of the EVT low National Institutes of Health Stroke Scale (NIHSS) stroke literature, identifying 24 quantitative and six qualitative publications. Details of study designs and outcome were extracted and critically discussed.All identified qualitative studies were retrospective. There was significant study design heterogeneity, with 18 unique study designs between the 24 identified quantitative manuscripts. Study investigations included low NIHSS EVT feasibility (n=6), EVT versus best medical management (BMM; n=10), EVT versus intravenous therapy (IVT, n=3), and low NIHSS score versus high NIHSS score (n=3). From single-arm EVT feasibility studies, the reported ranges of modified Thrombolysis in Cerebral Infarction and symptomatic intracranial hemorrhage were 78-97% and 0-10%, respectively. The EVT versus BMM literature had heterogeneous results with 40% reporting benefit with EVT and 60% reporting neutral findings. None of the studies comparing EVT with IVT reported a difference between the two revascularization therapies. The four identified meta-analyses had incongruent inclusion criteria and conflicting results. Two randomized trials are currently investigating EVT in patients with a low NIHSS score. Selected meta-analyses do suggest a potential benefit of EVT over BMM; however, current and future randomized clinical trials will better elucidate the efficacy of EVT in this patient population.
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Affiliation(s)
- David J McCarthy
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Daniel A Tonetti
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jeremy Stone
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami MILLER School of Medicine, Miami Beach, Florida, USA.,Department of Neurosurgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Sandra Narayanan
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael J Lang
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ashutosh P Jadhav
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Bradley A Gross
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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195
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Chumnanvej S, Chumnanvej S. Autologous bone-marrow mononuclear stem cell therapy in patients with stroke: a meta-analysis of comparative studies. Biomed Eng Online 2020; 19:74. [PMID: 32993677 PMCID: PMC7526242 DOI: 10.1186/s12938-020-00819-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Accepted: 09/20/2020] [Indexed: 12/29/2022] Open
Abstract
Background There is a need to promote recovery after stroke with novel therapeutic interventions. Of them, bone-marrow mononuclear cell (BM-MNC) therapy offers promising outcomes in preclinical and clinical models. Aims To investigate the efficacy and safety of BM-MNCs versus traditional medical care of stroke patients. Summary of review A meta-analysis was conducted involving controlled prospective studies and randomized clinical trials (RCTs) which investigated the changes in the scores of neurological functions (the National Institutes of Health Stroke Scale [NIHSS]), the indices of functional recovery (the Barthel Index [BI] and the modified Rankin scale [mRS]) at 3 and 6 month post-transplantation. A total of nine studies (five RCTs) recruited 469 stroke patients (65.5% males, 49.25% received the intervention). There were no significant differences in NIHSS, BI, or mRS scores after 3 months of follow-up. However, the BI indices of BM-MNCs-receiving patients improved significantly after 6 months (standardized mean difference = 1.17, 95% confidence interval, 0.23 to 2.10, P = 0.01) as compared to traditional treatment. The risk of mortality and adverse events and the proportion of patients with favorable outcomes (mRS ≤ 3) were similar in both groups. Conclusion Both the BM-MNCs and medical stroke treatment have similar outcomes in terms of safety and short-term efficacy, while the effect of therapy is significant only after 6 months. More well-designed, large sized RCTs are needed to confirm the efficacy of stem cell therapy over long periods of follow-up.
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Affiliation(s)
- Sorayouth Chumnanvej
- Neurosurgery Division, Department of Surgery, Faculty of Medicine Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Siriluk Chumnanvej
- Department of Anesthesiology and Operating Room, Phramongkutklao Hospital, Bangkok, Thailand.
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196
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Jovin TG, Desai SM, Aghaebrahim A, Ducruet AF, Giurgiutiu DV, Gross BA, Hammer M, Jankowitz BT, Jumaa MA, Kenmuir C, Linares G, Reddy V, Rocha M, Starr M, Totoraitis V, Wechsler L, Zaidi S, Jadhav AP. Neurothrombectomy for Acute Ischemic Stroke Across Clinical Trial Design and Technique: A Single Center Pooled Analysis. Front Neurol 2020; 11:1047. [PMID: 33071935 PMCID: PMC7543690 DOI: 10.3389/fneur.2020.01047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/10/2020] [Indexed: 01/01/2023] Open
Abstract
Introduction: The practice of endovascular therapy has evolved dramatically over the last 10 years with randomized clinical trials investigating the benefit of thrombectomy in select patient populations based on time of presentation, imaging criteria, and procedural technique. We sought to understand the benefit of thrombectomy in patients treated within the context of a clinical trial at a single academic center. Methods: Patient-level data recorded in case forms and core-lab adjudicated data were analyzed from patients enrolled in RCTs investigating the benefit of endovascular thrombectomy over medical management (IMSIII, MR RESCUE, ESCAPE, SWIFT PRIME, and DAWN) between 2007 and 2017 at a single academic referral center. Results: A total of 134 patients (intervention group, n = 81; medical group, n = 53) were identified across five clinical trials (IMSIII, n = 46; MR RESCUE, n = 4; ESCAPE, n = 24; SWIFT PRIME, n = 14; DAWN, n = 46). There were no significant differences between the treatment arm and control arm in terms of age, gender, baseline NIHSS, ASPECTS, and site of occlusion. Rates of good outcome were superior in the intervention group with early neurological recovery (NIHSS of 0–1 or increase NIHSS of 8 points at 24 h) at a higher rate of 49% vs. 17% (p = <0.001) and higher rates of functional independence (90 day mRS 0–2 of 53% vs. 26%, p = 0.002). In multivariate logistic regression analysis, lower NIHSS and younger age were predictors of good outcome. There were comparable rates of good outcome irrespective of clinical trial, imaging selection criteria (CTP vs. MRI), early vs. late time window (0–6 h vs. 6–24 h) and procedural technique (Merci vs. Solitaire/Trevo device). There were no differences in rates of sICH, PH-2 or mortality in the intervention group vs. medical group. Conclusions: At a large academic center, the benefit of endovascular therapy over medical therapy is observed irrespective of clinical trial design, patient selection or procedural technique.
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Affiliation(s)
- Tudor G Jovin
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Shashvat M Desai
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Amin Aghaebrahim
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Andrew F Ducruet
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Dan-Victor Giurgiutiu
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Bradley A Gross
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Maxim Hammer
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Brian T Jankowitz
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Mouhammad A Jumaa
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Cynthia Kenmuir
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Guillermo Linares
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Vivek Reddy
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Marcelo Rocha
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Matthew Starr
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Viktoria Totoraitis
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Lawrence Wechsler
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Syed Zaidi
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Ashutosh P Jadhav
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
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197
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Zhao Z, Zhang J, Jiang X, Wang L, Yin Z, Hall M, Wang Y, Lai L. Is Endovascular Treatment Still Good for Ischemic Stroke in Real World?: A Meta-Analysis of Randomized Control Trial and Observational Study in the Last Decade. Stroke 2020; 51:3250-3263. [PMID: 32921259 DOI: 10.1161/strokeaha.120.029742] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE Although endovascular treatment (EVT) for acute ischemic stroke is classified as I evidence, outcomes after EVT in real-world practice appear to be less superior than those in randomized clinical trials (RCTs). Additionally, the effect of EVT is unclear compared with medical treatment (MT) for patients with mild symptoms defined by National Institutes of Health Stroke Scale score <6 or with severe symptoms defined by Alberta Stroke Program Early CT Score <6. METHODS Literatures were searched in big databases and major meetings from December 6, 2009, to December 6, 2019, including RCTs and observational studies comparing EVT against MT for patients with acute ischemic stroke. Observational studies were precategorized into 3 groups based on imaging data on admission: mild stroke group with National Institutes of Health Stroke Scale score <6, severe stroke group with Alberta Stroke Program Early CT Score <6 or ischemic core ≥50 mL, and normal stroke group for all others. Outcome was measured as modified Rankin Scale score of 0 to 2, mortality at 90 days, and symptomatic intracranial hemorrhage (sICH) at 24 hours. RESULTS Fifteen RCTs (n=3694) and 37 observational studies (n=9090) were included. EVT was associated with higher modified Rankin Scale 0 to 2 rate and lower mortality in RCTs and normal stroke group, whereas EVT was associated with higher sICH rate in normal stroke group, and no difference of sICH rate appeared between EVT and MT in RCTs. In severe stroke group, EVT was associated with higher modified Rankin Scale 0 to 2 rate and lower mortality, whereas no difference of sICH rate was found. In mild stroke group, there was no difference in modified Rankin Scale 0 to 2 rate between EVT and MT, whereas EVT was associated with higher mortality and sICH rate. CONCLUSIONS Evidence from RCTs and observational studies supports the use of EVT as the first-line choice for eligible patients corresponding to the latest guideline. For patients with Alberta Stroke Program Early CT Score <6, EVT showed superiority over MT, also in line with the guidelines. On the contrary to the guideline, our data do not support EVT for patients with National Institutes of Health Stroke Scale score <6.
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Affiliation(s)
- Zixu Zhao
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Jiangxi, PR China (Z.Z., J.Z., X.J., Y.W., L.L.).,Queen Mary School, Jiangxi Medical College (Z.Z., J.Z.), Nanchang University, Jiangxi, PR China
| | - Jiarui Zhang
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Jiangxi, PR China (Z.Z., J.Z., X.J., Y.W., L.L.).,Queen Mary School, Jiangxi Medical College (Z.Z., J.Z.), Nanchang University, Jiangxi, PR China
| | - Xin Jiang
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Jiangxi, PR China (Z.Z., J.Z., X.J., Y.W., L.L.).,The First Clinical Medical School, Jiangxi Medical College (X.J.), Nanchang University, Jiangxi, PR China
| | - Li Wang
- Centre for Evidence-Based Medicine, School of Public Health (L.W.), Nanchang University, Jiangxi, PR China
| | - Zixiao Yin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, PR China (Z.Y.)
| | - Michael Hall
- Institute of Ophthalmology, University College London, United Kingdom (M.H.)
| | - Yang Wang
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Jiangxi, PR China (Z.Z., J.Z., X.J., Y.W., L.L.)
| | - Lingfeng Lai
- Department of Neurosurgery, The First Affiliated Hospital of Nanchang University, Jiangxi, PR China (Z.Z., J.Z., X.J., Y.W., L.L.)
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198
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Goyal M, van Zwam W, Moret J, Ospel JM. Neurointervention in the 2020s: Where are We Going? Clin Neuroradiol 2020; 31:1-5. [PMID: 32915252 PMCID: PMC7485210 DOI: 10.1007/s00062-020-00953-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 08/08/2020] [Indexed: 12/17/2022]
Affiliation(s)
- Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada. .,Department of Radiology, University of Calgary, Calgary, Canada.
| | - Wim van Zwam
- Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht, School for Mental Health and Sciences, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Jacques Moret
- The Brain Vascular Center, Baujon University Hospital, Paris, France
| | - Johanna Maria Ospel
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
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199
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Catapano JS, Ducruet AF, Frisoli FA, Nguyen CL, Louie CE, Labib MA, Baranoski JF, Cole TS, Whiting AC, Albuquerque FC, Lawton MT. Predictors of the development of takotsubo cardiomyopathy in aneurysmal subarachnoid hemorrhage and outcomes in patients with intra-aortic balloon pumps. J Neurosurg 2020; 135:38-43. [PMID: 32886915 DOI: 10.3171/2020.5.jns20536] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2020] [Accepted: 05/18/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Takotsubo cardiomyopathy (TC) in patients with aneurysmal subarachnoid hemorrhage (aSAH) is associated with high morbidity and mortality. Previous studies have shown that female patients presenting with a poor clinical grade are at the greatest risk for developing TC. Intra-aortic balloon pumps (IABPs) are known to support cardiac function in severe cases of TC, and they may aid in the treatment of vasospasm in these patients. In this study, the authors investigated risk factors for developing TC in the setting of aSAH and outcomes among patients requiring IABPs. METHODS The authors retrospectively reviewed the records of 1096 patients who had presented to their institution with aSAH. Four hundred five of these patients were originally enrolled in the Barrow Ruptured Aneurysm Trial, and an additional 691 patients from a subsequent prospectively maintained aSAH database were analyzed. Medical records were reviewed for the presence of TC according to the modified Mayo Clinic criteria. Outcomes were determined at the last follow-up, with a poor outcome defined as a modified Rankin Scale (mRS) score > 2. RESULTS TC was identified in 26 patients with aSAH. Stepwise multivariate logistic regression analysis identified female sex (OR 8.2, p = 0.005), Hunt and Hess grade > III (OR 7.6, p < 0.001), aneurysm size > 7 mm (OR 3, p = 0.011), and clinical vasospasm (OR 2.9, p = 0.037) as risk factors for developing TC in the setting of aSAH. TC patients, even with IABP placement, had higher rates of poor outcomes (77% vs 47% with an mRS score > 2, p = 0.004) and mortality at the last follow-up (27% vs 11%, p = 0.018) than the non-TC patients. However, aggressive intra-arterial endovascular treatment for vasospasm was associated with good outcomes in the TC patients versus nonaggressive treatment (100% with mRS ≤ 2 at last follow-up vs 53% with mRS > 2, p = 0.040). CONCLUSIONS TC after aSAH tends to occur in female patients with large aneurysms, poor clinical grades, and clinical vasospasm. These patients have significantly higher rates of poor neurological outcomes, even with the placement of an IABP. However, aggressive intra-arterial endovascular therapy in select patients with vasospasm may improve outcome.
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200
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Bhatia K, Bhagavan S, Bains N, French B, Siddiq F, Gomez CR, Qureshi AI. Current Endovascular Treatment of Acute Ischemic Stroke. MISSOURI MEDICINE 2020; 117:480-489. [PMID: 33311759 PMCID: PMC7723144] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Acute ischemic stroke is one of the leading causes of death and long-term disability in the United States. Intravenous thrombolysis with recombinant tissue-type plasminogen activator (rt-PA) has been the mainstay of acute therapy. However, multiple randomized clinical trials have been published that have shown higher rates of recanalization and improved functional outcomes with endovascular therapy compared with intravenous rt-PA in patients with ischemic stroke from large vessel occlusion. This article provides an update and discusses the role of endovascular therapy in management of acute ischemic stroke.
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Affiliation(s)
- Kunal Bhatia
- MSMA member since 2020, University of Missouri - Columbia School of Medicine/MU Health Care in Columbia, Missouri
| | - Sachin Bhagavan
- University of Missouri - Columbia School of Medicine/MU Health Care in Columbia, Missouri
| | - Navpreet Bains
- University of Missouri - Columbia School of Medicine/MU Health Care in Columbia, Missouri
| | - Brandi French
- University of Missouri - Columbia School of Medicine/MU Health Care in Columbia, Missouri
| | - Farhan Siddiq
- University of Missouri - Columbia School of Medicine/MU Health Care in Columbia, Missouri
| | - Camilo R Gomez
- University of Missouri - Columbia School of Medicine/MU Health Care in Columbia, Missouri
| | - Adnan I Qureshi
- University of Missouri - Columbia School of Medicine/MU Health Care in Columbia, Missouri
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