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Safety and Efficacy of Intravenous Alteplase before Endovascular Thrombectomy: A Pooled Analysis with Focus on the Elderly. J Clin Med 2022; 11:jcm11133681. [PMID: 35806966 PMCID: PMC9267603 DOI: 10.3390/jcm11133681] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/17/2022] [Accepted: 06/23/2022] [Indexed: 12/31/2022] Open
Abstract
Current guidelines advocate intravenous thrombolysis (IVT) prior to endovascular thrombectomy (EVT) for all patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO). We evaluated outcomes with and without IVT pretreatment. Our institutional protocols allow AIS patients presenting early (<4 h from onset or last seen normal) who have an Alberta Stroke Program Early CT Score (ASPECTS) ≥6 to undergo EVT without IVT pretreatment if the endovascular team is in the hospital (direct EVT). Rates of recanalization and hemorrhagic transformation (HT) and neurological outcomes were retrospectively compared in consecutive patients undergoing IVT+EVT vs. direct EVT with subanalyses in those ≥80 years and ≥85 years. In the overall cohort (IVT+EVT = 147, direct EVT = 162), and in subsets of patients ≥80 years (IVT+EVT = 51, direct EVT = 50) and ≥85 years (IVT+EVT = 19, direct EVT = 32), the IVT+EVT cohort and the direct EVT group had similar baseline characteristics, underwent EVT after a comparable interval from symptom onset, and reached similar rates of target vessel recanalization. No differences were observed in the HT frequency, or in disability at discharge or after 90 days. Patients receiving direct EVT underwent more stenting of the carotid artery due to stenosis during the EVT procedure (22% vs. 6%, p = 0.001). Direct EVT and IVT+EVT had comparable neurological outcomes in the overall cohort and in the subgroups of patients ≥80 and ≥85 years, suggesting that direct EVT should be considered in patients with an elevated risk for HT.
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202
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Faizy TD, Mlynash M, Marks MP, Christensen S, Kabiri R, Kuraitis GM, Broocks G, Winkelmeier L, Geest V, Nawabi J, Lansberg MG, Albers GW, Fiehler J, Wintermark M, Heit JJ. Intravenous tPA (Tissue-Type Plasminogen Activator) Correlates With Favorable Venous Outflow Profiles in Acute Ischemic Stroke. Stroke 2022; 53:3145-3152. [PMID: 35735008 DOI: 10.1161/strokeaha.122.038560] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Intravenous tPA (tissue-type plasminogen activator) is often administered before endovascular thrombectomy (EVT). Recent studies have questioned whether tPA is necessary given the high rates of arterial recanalization achieved by EVT, but whether tPA impacts venous outflow (VO) is unknown. We investigated whether tPA improves VO profiles on baseline computed tomography (CT) angiography (CTA) images before EVT. METHODS Retrospective multicenter cohort study of patients with acute ischemic stroke due to large vessel occlusion undergoing EVT triage. Included patients underwent CT, CTA, and CT perfusion before EVT. VO profiles were determined by opacification of the vein of Labbé, sphenoparietal sinus, and superficial middle cerebral vein on CTA as 0, not visible; 1, moderate opacification; and 2, full. Pial arterial collaterals were graded on CTA, and tissue-level collaterals were assessed on CT perfusion using the hypoperfusion intensity ratio. Clinical and demographic data were determined from the electronic medical record. Using multivariable regression analysis, we determined the correlation between tPA administration and favorable VO profiles. RESULTS Seven hundred seventeen patients met inclusion criteria. Three hundred sixty-five patients received tPA (tPA+), while 352 patients were not treated with tPA (tPA-). Fewer tPA+ patients had atrial fibrillation (n=128 [35%] versus n=156 [44%]; P=0.012) and anticoagulants/antiplatelet treatment before acute ischemic stroke due to large vessel occlusion onset (n=130 [36%] versus n=178 [52%]; P<0.001) compared with tPA- patients. One hundred eighty-five patients (51%) in the tPA+ and 100 patients (28%) in the tPA- group exhibited favorable VO (P<0.001). Multivariable regression analysis showed that tPA administration was a strong independent predictor of favorable VO profiles (OR, 2.6 [95% CI, 1.7-4.0]; P<0.001) after control for favorable pial arterial CTA collaterals, favorable tissue-level collaterals on CT perfusion, age, presentation National Institutes of Health Stroke Scale, antiplatelet/anticoagulant treatment, history of atrial fibrillation and time from symptom onset to imaging. CONCLUSIONS In patients with acute ischemic stroke due to large vessel occlusion undergoing thrombectomy triage, tPA administration was strongly associated with the presence of favorable VO profiles.
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Affiliation(s)
- Tobias D Faizy
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (T.D.F., R.K., G.B., L.W., V.G., J.F.)
| | - Michael Mlynash
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (M.M., S.C., M.G.L., G.W.A.)
| | - Michael P Marks
- Department of Radiology, Stanford University School of Medicine, CA (M.P.M., G.M.K., J.J.H.)
| | - Soren Christensen
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (M.M., S.C., M.G.L., G.W.A.)
| | - Reza Kabiri
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (T.D.F., R.K., G.B., L.W., V.G., J.F.)
| | - Gabriella M Kuraitis
- Department of Radiology, Stanford University School of Medicine, CA (M.P.M., G.M.K., J.J.H.)
| | - Gabriel Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (T.D.F., R.K., G.B., L.W., V.G., J.F.)
| | - Laurens Winkelmeier
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (T.D.F., R.K., G.B., L.W., V.G., J.F.)
| | - Vincent Geest
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (T.D.F., R.K., G.B., L.W., V.G., J.F.)
| | - Jawed Nawabi
- Department of Radiology, University Medical Center Charité Berlin (J.N.)
| | - Maarten G Lansberg
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (M.M., S.C., M.G.L., G.W.A.)
| | - Gregory W Albers
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (M.M., S.C., M.G.L., G.W.A.)
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (T.D.F., R.K., G.B., L.W., V.G., J.F.)
| | - Max Wintermark
- Department of Neuroradiology, MD Anderson, Houston, TX (M.W.)
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, CA (M.P.M., G.M.K., J.J.H.)
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203
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Clinical Value of Combined Detection of UA and MMP-9 in Evaluating Bleeding Transformation and Prognosis After Thrombolysis in Acute Cerebral Infarction. Appl Biochem Biotechnol 2022; 194:5236-5254. [PMID: 35727407 DOI: 10.1007/s12010-022-03990-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/27/2022] [Indexed: 11/02/2022]
Abstract
This paper presents an in-depth study and analysis of the assessment of hemorrhagic transformation and prognostic outcome after thrombolysis in acute cerebral infarction using a combined test and evaluates its clinical value. The ischemic tissue hemodynamic changes were compared and analyzed by the combined application of magnetic resonance conventional examination. Single-factor and multi-factor Logistic regression analysis was applied to the model group samples to determine the independent influencing factors of hemorrhage and to construct a risk prediction model. The Hosmer-Lemeshow chi-square test was used to test the fit of the model, and the area under the ROC curve was used to test the discriminatory ability of the model. The area under the ROC curve was used to test the discriminatory ability of the model. The main purpose of this study was to investigate the clinical diagnostic value of the combined D-D and Hcy and test for the early detection of patients with acute cerebral infarction disease. There was no significant correlation between single PWI-ASPECTS and clinical prognostic MRS score, which may be related to the site and volume of initial diffusion restriction; the percentage of the mismatched area between DWI-PWI and clinical prognostic mRS score was significantly correlated, which helps clinicians to assess the therapeutic effect of non-thrombolytic therapy and provide an important basis for clinical selection of appropriate interventions in the subacute phase of stroke. The sensitivity of D-D, Hcy, and cTnI in the acute cerebral infarction group was 59.4%, 79.6%, and 49.5%, and the specificity was 73.5%, 70.5%, and 91.1%, respectively, with the area under the curve of 0.606, 0.729, and 0.521. The sensitivity, specificity, and area under the curve of the combined assay were higher than those of the single assay. The detection level of high-risk group was the highest, followed by the low-risk group. Pearson correlation analysis suggests that there is a significant correlation between serum UA and MM-9 level and grace score.
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204
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Wang X, Ye Z, Busse JW, Hill MD, Smith EE, Guyatt GH, Prasad K, Lindsay MP, Yang H, Zhang Y, Liu Y, Tang B, Wang X, Wang Y, Couban RJ, An Z. Endovascular thrombectomy with or without intravenous alteplase for acute ischemic stroke due to large vessel occlusion: a systematic review and meta-analysis of randomized trials. Stroke Vasc Neurol 2022; 7:510-517. [PMID: 35725244 PMCID: PMC9811536 DOI: 10.1136/svn-2022-001547] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Accepted: 05/23/2022] [Indexed: 01/28/2023] Open
Abstract
BACKGROUND Among patients who had an ischaemic stroke presenting directly to a stroke centre where endovascular thrombectomy (EVT) is immediately available, there is uncertainty regarding the role of intravenous thrombolysis agents before or concurrently with EVT. To support a rapid guideline, we conducted a systematic review and meta-analysis to examine the impact of EVT alone versus EVT with intravenous alteplase in patients who had an acute ischaemic stroke due to large vessel occlusion. METHODS In November 2021, we searched MEDLINE, Embase, PubMed, Cochrane, Web of Science, clincialtrials.gov and the ISRCTN registry for randomised controlled trials (RCTs) comparing EVT alone versus EVT with alteplase for acute ischaemic stroke. We conducted meta-analyses using fixed effects models and assessed the certainty of evidence using the GRADE approach. RESULTS In total 6 RCTs including 2334 participants were eligible. Low certainty evidence suggests that, compared with EVT and alteplase, there is possibly a small decrease in the proportion of patients independent with EVT alone (risk ratio (RR) 0.97, 95% CI 0.89 to 1.05; risk difference (RD) -1.5%; 95% CI -5.4% to 2.5%), and possibly a small increase in mortality with EVT alone (RR 1.07, 95% CI 0.88 to 1.29; RD 1.2%, 95% CI -2.0% to 4.9%) . Moderate certainty evidence suggests that there is probably a small decrease in symptomatic intracranial haemorrhage (sICH) with EVT alone (RR 0.75, 95% CI 0.52 to 1.07; RD -1.0%; 95%CI -1.8% to 0.27%). CONCLUSIONS Low certainty evidence suggests that there is possibly a small decrease in the proportion of patients that achieve functional independence and a small increase in mortality with EVT alone. Moderate certainty evidence suggests that there is probably a small decrease in sICH with EVT alone. The accompanying guideline provides contextualised guidance based on this body of evidence. PROSPERO REGISTRATION NUMBER CRD42021249873.
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Affiliation(s)
- Xin Wang
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Zhikang Ye
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China,Michael G DeGroote National Pain Centre, McMaster University, Hamilton, Ontario, Canada
| | - Jason W Busse
- Michael G DeGroote National Pain Centre, McMaster University, Hamilton, Ontario, Canada,Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, Ontario, Canada,Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, Departments of Medicine, Community Health Sciences and Radiology, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Eric E Smith
- Department of Clinical Neurosciences and Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada
| | - Gordon H Guyatt
- Department of Health Research Methods Evidence and Impact, McMaster University, Hamilton, Ontario, Canada
| | - Kameshwar Prasad
- Professor of neurology and Director, Rajendra Institute of Medical Sciences, Ranchi, Jharkhand, India
| | | | - Hui Yang
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Yi Zhang
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China,Department of Pharmacy, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Ying Liu
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Borui Tang
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
| | - Xinrui Wang
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China,Department of Pharmacy, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Yushu Wang
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China,Department of Pharmacy, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, China
| | - Rachel J Couban
- DeGroote Institute for Pain Research and Care, McMaster University, Hamilton, Ontario, Canada
| | - Zhuoling An
- Department of Pharmacy, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, China
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205
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Smith EE, Zerna C, Solomon N, Matsouaka R, Mac Grory B, Saver JL, Hill MD, Fonarow GC, Schwamm LH, Messé SR, Xian Y. Outcomes After Endovascular Thrombectomy With or Without Alteplase in Routine Clinical Practice. JAMA Neurol 2022; 79:768-776. [PMID: 35696198 DOI: 10.1001/jamaneurol.2022.1413] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance The effectiveness and safety of intravenous alteplase given before or concurrently with endovascular thrombectomy (EVT) is uncertain. Randomized clinical trials suggest there is little difference in outcomes but with only modest precision and insufficient power to analyze uncommon outcomes including symptomatic intracranial hemorrhage (sICH). Objective To determine whether 8 prespecified outcomes are different in patients with acute ischemic stroke treated in routine clinical practice with EVT with alteplase compared with patients treated with EVT alone without alteplase. It was hypothesized that alteplase would be associated with higher risk of sICH. Design, Setting, and Participants This was an observational cohort study conducted from February 1, 2019, to June 30, 2020, that included adult patients with acute ischemic stroke treated with EVT within 6 hours of time last known well, after excluding patients without information on discharge destination and patients with in-hospital stroke. Participants were recruited from Get With The Guidelines-Stroke, a large nationwide registry of patients with acute ischemic stroke from 555 hospitals in the US. Exposures Intravenous alteplase or no alteplase. Main Outcomes and Measures Prespecified outcomes were discharge destination, independent ambulation at discharge, modified Rankin score at discharge, discharge mortality, cerebral reperfusion according to modified Thrombolysis in Cerebral Infarction grade, and sICH. Results There were 15 832 patients treated with EVT (median [IQR] age, 72.0 [61.0-82.0] years; 7932 women [50.1%]); 10 548 (66.7%) received alteplase and 5284 (33.4%) did not. Patients treated with alteplase were younger, arrived via Emergency Medical Services sooner, were less likely to have certain comorbidities, including atrial fibrillation, hypertension, and diabetes, but had similar National Institutes of Health Stroke Severity (NIHSS) scores. Compared with patients who did not receive alteplase treatment, patients treated with alteplase were less likely to die (11.1% [1173 of 10 548 patients] vs 13.9% [734 of 5284 patients]; adjusted odds ratio [aOR] 0.83; 95% CI, 0.77-0.89; P < .001), more likely to have no major disability based on modified Rankin scale of 2 or less at discharge (28.5% [2415 of 8490 patients] vs 20.7% [894 of 4322 patients]; aOR, 1.36; 95% CI, 1.28-1.45; P < .001), and to have better reperfusion based on modified Thrombolysis in Cerebral Infarction grade 2b or greater (90.9% [8474 of 9318 patients] vs 88.0% [4140 of 4705 patients]; aOR, 1.39; 95% CI, 1.28-1.50; P < .001). However, alteplase treatment was associated with higher risk of sICH (6.5% [685 of 10 530 patients] vs 5.3% [279 of 5249 patients]; OR, 1.28; 95% CI, 1.16-1.42; P < .001). Conclusions and Relevance In this observational cohort study of patients treated with EVT, intravenous alteplase treatment was associated with better in-hospital survival and functional outcomes but higher sICH risk after adjusting for other covariates.
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Affiliation(s)
- Eric E Smith
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Charlotte Zerna
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | | | | | - Brian Mac Grory
- Duke Clinical Research Center, Durham, North Carolina.,Department of Neurology, Duke University School of Medicine, Durham, North Carolina
| | - Jeffrey L Saver
- Department of Neurology, University of California Los Angeles, Los Angeles
| | - Michael D Hill
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Gregg C Fonarow
- David Geffen School of Medicine, Division of Cardiology, University of California, Los Angeles, Los Angeles
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston
| | - Steven R Messé
- Department of Neurology, University of Pennsylvania, Philadelphia
| | - Ying Xian
- University of Texas Southwestern Medical Center, Dallas
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206
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van der Steen W, van der Ende NA, van Kranendonk KR, Chalos V, van Oostenbrugge RJ, van Zwam WH, Roos YB, van Doormaal PJ, van Es AC, Lingsma HF, Majoie CB, van der Lugt A, Dippel DW, Roozenbeek B, Boiten J, Albert Vos J, Jansen IG, Mulder MJ, Goldhoorn RJB, Compagne KC, Kappelhof M, Brouwer J, den Hartog SJ, Emmer BJ, Coutinho JM, Schonewille WJ, Albert Vos J, Wermer MJ, van Walderveen MA, Staals J, Hofmeijer J, Martens JM, Lycklama à Nijeholt GJ, Boiten J, de Bruijn SF, van Dijk LC, van der Worp HB, Lo RH, van Dijk EJ, Boogaarts HD, de Vries J, de Kort PL, van Tuijl J, Peluso JP, Fransen P, van den Berg JS, van Hasselt BA, Aerden LA, Dallinga RJ, Uyttenboogaart M, Eschgi O, Bokkers RP, Schreuder TH, Heijboer RJ, Keizer K, Yo LS, den Hertog HM, Bulut T, Brouwers PJ, Lycklama GJ, van Walderveen MA, Sprengers ME, Jenniskens SF, van den Berg R, Yoo AJ, Beenen LF, Postma AA, Roosendaal SD, van der Kallen BF, van den Wijngaard IR, Emmer BJ, Martens JM, Yo LS, Vos JA, Bot J, Meijer A, Ghariq E, Bokkers RP, van Proosdij MP, Krietemeijer GM, Peluso JP, Boogaarts HD, Lo R, Dinkelaar W, Auke P, Hammer B, Pegge S, van der Hoorn A, Vinke S, Lycklama à Nijeholt GJ, Boiten J, Vos JA, Hofmeijer J, Martens JM, van der Worp HB, Hofmeijer J, Flach HZ, el Ghannouti N, Sterrenberg M, Pellikaan W, Sprengers R, Elfrink M, Simons M, Vossers M, de Meris J, Vermeulen T, Geerlings A, van Vemde G, Simons T, Messchendorp G, Nicolaij N, Bongenaar H, Bodde K, Kleijn S, Lodico J, Droste H, Wollaert M, Verheesen S, Jeurrissen D, Bos E, Drabbe Y, Sandiman M, Aaldering N, Zweedijk B, Vervoort J, Ponjee E, Romviel S, Kanselaar K, Barning D, Venema E, Geuskens RR, van Straaten T, Ergezen S, Harmsma RR, Muijres D, de Jong A, Berkhemer OA, Boers AM, Huguet J, Groot P, Mens MA, Treurniet KM, Tolhuisen ML, Alves H, Weterings AJ, Kirkels EL, Voogd EJ, Schupp LM, Collette SL, Groot AE, LeCouffe NE, Konduri PR, Prasetya H, Arrarte- Terreros N, Ramos LA, Brown MM, Liebig T, van der Heijden E, Ghannouti N, Fleitour N, Hooijenga I, Puppels C, Pellikaan W, Geerling A, Lindl-Velema A, van Vemde G, de Ridder A, Greebe P, de Bont- Stikkelbroeck J, de Meris J, Haaglanden MC, Janssen K, Licher S, Boodt N, Ros A, Venema E, Slokkers I, Ganpat RJ, Mulder M, Saiedie N, Heshmatollah A, Schipperen S, Vinken S, van Boxtel T, Koets J, Boers M, Santos E, Borst J, Jansen I, Kappelhof M, Lucas M, Geuskens RR, Sales Barros R. Determinants of Symptomatic Intracranial Hemorrhage After Endovascular Stroke Treatment: A Retrospective Cohort Study. Stroke 2022; 53:2818-2827. [PMID: 35674042 PMCID: PMC9389940 DOI: 10.1161/strokeaha.121.036195] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Symptomatic intracranial hemorrhage (sICH) is a serious complication after endovascular treatment for ischemic stroke. We aimed to identify determinants of its occurrence and location.
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Affiliation(s)
- Wouter van der Steen
- Department of Neurology (W.v.d.S., N.A.M.v.d.E., V.C., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Radiology and Nuclear Medicine (W.v.d.S., N.A.M.v.d.E., V.C., P.J.v.D., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Nadinda A.M. van der Ende
- Department of Neurology (W.v.d.S., N.A.M.v.d.E., V.C., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Radiology and Nuclear Medicine (W.v.d.S., N.A.M.v.d.E., V.C., P.J.v.D., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Katinka R. van Kranendonk
- Department of Radiology and Nuclear Medicine (K.R.v.K., C.B.L.M.M.), Maastricht University Medical Center, the Netherlands
| | - Vicky Chalos
- Department of Neurology (W.v.d.S., N.A.M.v.d.E., V.C., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Radiology and Nuclear Medicine (W.v.d.S., N.A.M.v.d.E., V.C., P.J.v.D., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Public Health (V.C., H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Robert J. van Oostenbrugge
- Amsterdam University Medical Center, University of Amsterdam, the Netherlands. Department of Neurology (R.J.v.O.), Maastricht University Medical Center, the Netherlands
| | - Wim H. van Zwam
- Department of Radiology and Nuclear Medicine (W.H.v.Z.), Maastricht University Medical Center, the Netherlands
| | - Yvo B.W.E.M. Roos
- Department of Neurology (Y.B.W.E.M.R.), Maastricht University Medical Center, the Netherlands
| | - Pieter J. van Doormaal
- Department of Radiology and Nuclear Medicine (W.v.d.S., N.A.M.v.d.E., V.C., P.J.v.D., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Adriaan C.G.M. van Es
- Department of Radiology, Leiden University Medical Center, the Netherlands (A.C.G.M.v.E.)
| | - Hester F. Lingsma
- Department of Public Health (V.C., H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Charles B.L.M. Majoie
- Department of Radiology and Nuclear Medicine (K.R.v.K., C.B.L.M.M.), Maastricht University Medical Center, the Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine (W.v.d.S., N.A.M.v.d.E., V.C., P.J.v.D., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Diederik W.J. Dippel
- Department of Neurology (W.v.d.S., N.A.M.v.d.E., V.C., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Bob Roozenbeek
- Department of Neurology (W.v.d.S., N.A.M.v.d.E., V.C., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Radiology and Nuclear Medicine (W.v.d.S., N.A.M.v.d.E., V.C., P.J.v.D., A.v.d.L., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Efficacy and safety of endovascular treatment with or without intravenous alteplase in acute anterior circulation large vessel occlusion stroke: a meta-analysis of randomized controlled trials. Neurol Sci 2022; 43:3551-3563. [PMID: 35314911 DOI: 10.1007/s10072-022-06017-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 03/14/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The current meta-analysis aimed to investigate the efficacy and safety of direct endovascular treatment (EVT) and bridging therapy (EVT with prior intravenous thrombolysis (IVT)) in patients with acute anterior circulation large vessel occlusion (LVO) stroke. METHODS This meta-analysis followed PRISMA guidelines. Eligible RCTs were identified through a systemic search of electronic databases (PubMed, Ovid, Web of Science, and Cochrane Library) from the inception dates to January 10, 2022. The pooled analyses were performed using RevMan 5.3 software. The primary outcome was functional outcome on the modified Rankin Scale (mRS) (range 0 to 5) at 90 days. The secondary outcomes included successful reperfusion, intracranial hemorrhage, and mortality (mRS 6) within 90 days. RESULTS A total of 4 RCTs involving 1633 patients were finally included. Findings of pooled analyses indicated that neither the primary outcomes (no disability (mRS 0), no significant disability despite some symptoms (mRS 1), slight disability (mRS 2), moderate disability (mRS 3), moderately severe disability (mRS 4), severe disability (mRS 5), excellent outcome (mRS 0-1), functional independence outcome (mRS 0-2), and poor outcome (mRS 3-5)) nor the secondary outcomes (successful reperfusion, intracranial hemorrhage, and mortality) in the EVT groups were not statistically significant compared with the IVT plus EVT groups (P > 0.05). In addition, the outcomes of sensitivity analysis implied that the findings of meta-analysis were credible. CONCLUSIONS Among patients with acute ischemic stroke due to LVO of anterior circulation, EVT alone yielded efficacy and safety outcomes similar to IVT plus EVT.
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Abstract
Intravenous thrombolytics and endovascular thrombectomy for ischemic stroke have evolved in parallel. However, the best approach to combine these reperfusion therapies in patients eligible for both strategies remains uncertain. Initial randomized trials of endovascular thrombectomy included administration of intravenous thrombolytics to all eligible patients. However, whether that is of net benefit has been questioned and parallels drawn with treatment of ST-segment-elevation myocardial infarction, where intravenous thrombolytics are only given if first medical contact to percutaneous intervention is expected to be >90 minutes. Six randomized trials of a direct thrombectomy approach versus intravenous thrombolytics followed by endovascular thrombectomy have now reported their results. With exception of a minority of patients in one trial, the trials all used alteplase rather than potentially more effective tenecteplase. This review examines the current state of evidence and implications for clinical practice. Importantly, these trials only apply to patients who present to a hospital with immediate access to endovascular thrombectomy and are not relevant to patients who receive thrombolytic and are then transferred to an endovascular-capable hospital. Although 2 of the 6 randomized trials met their prespecified noninferiority margin, these margins were large compared with the absolute benefit of alteplase. Overall, functional outcome was similar, with slight trends favoring bridging thrombolytics and a significant increase in final reperfusion. Symptomatic hemorrhage was increased by ≈1.8% in the bridging group but death was nonsignificantly lower. The workflow in direct thrombectomy trials involved delaying thrombolytic administration until eligibility for thrombectomy and the trials was established and randomization completed. This reduced the time available for thrombolytics to occur prethrombectomy compared with standard practice. We conclude that, pending individual-patient data meta-analyses, intravenous thrombolytics retain an important role alongside endovascular thrombectomy. Further efforts to accelerate and enhance reperfusion with thrombolytics and perform individual patient-level pooled subgroup analyses are warranted.
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Affiliation(s)
- Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital (B.C.V.C.), University of Melbourne, Parkville, Victoria, Australia
- Florey Institute of Neuroscience and Mental Health (B.C.V.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, the Netherlands (M.K.)
| | - Urs Fischer
- Department of Neurology, Universitätsspital Basel, Switzerland (U.F.)
- Department of Neurology, University Hospital Bern, University of Bern, Switzerland (U.F.)
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Zhou Y, Zhang L, Ospel J, Goyal M, McDonough R, Xing P, Li Z, Zhang X, Zhang Y, Zhang Y, Hong B, Xu Y, Huang Q, Li Q, Yu Y, Zuo Q, Ye X, Yang P, Liu J. Association of Intravenous Alteplase, Early Reperfusion, and Clinical Outcome in Patients With Large Vessel Occlusion Stroke: Post Hoc Analysis of the Randomized DIRECT-MT Trial. Stroke 2022; 53:1828-1836. [PMID: 35240861 DOI: 10.1161/strokeaha.121.037061] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2021] [Accepted: 11/24/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND The added value of intravenous alteplase in reperfusing ischemic brain tissue in patients undergoing endovascular treatment and directly presented to an endovascular treatment-capable hospital is uncertain. We conducted this post hoc analysis of a randomized trial (DIRECT-MT [Direct Intraarterial Thrombectomy in Order to Revascularize Acute Ischemic Stroke Patients With Large Vessel Occlusion Efficiently in Chinese Tertiary Hospitals: A Multicenter Randomized Clinical Trial]) to explore the association of intravenous alteplase, early (preendovascular treatment) reperfusion, and clinical outcome and to determine factors which may modify alteplase treatment effect on early reperfusion. METHODS In this post hoc analysis of the DIRECT-MT randomized trial comparing intravenous alteplase before endovascular treatment versus endovascular treatment only, 623 of 656 randomized patients, with adequate angiographic evaluation for early reperfusion assessment, were included. The association of intravenous alteplase and early reperfusion (defined as expanded Thrombolysis in Cerebral Infarction score ≥2a on angiogram) was assessed using unadjusted comparisons and multivariable logistic regression. RESULTS Among 623 patients included (317 received intravenous alteplase and 306 did not), early reperfusion occurred in 91 (15%) patients and was associated with better functional outcome (modified Rankin Scale score, 0-2 of 49/91 [54%] versus 178/531 [34%]; adjusted odds ratio, 1.92 [95% CI, 1.15-3.21]; P<0.001). Intravenous alteplase was independently associated with early reperfusion (59/317 [19%] versus 32/306 [10%]; adjusted odds ratio, 2.06 [95% CI, 1.27-3.33]; P=0.003), and the alteplase effect was modified by time from randomization to groin puncture (dichotomized by median, ≤33 minutes; adjusted odds ratio, 1.06 [95% CI, 0.53-2.10] versus >33 minutes; adjusted odds ratio, 4.07 [95% CI, 1.86-8.86]; Pinteraction=0.012). CONCLUSIONS For patients with large vessel occlusion directly presenting to an endovascular treatment-capable hospital, intravenous alteplase increases early reperfusion when endovascular treatment gets delayed more than approximately half an hour. Thus, intravenous alteplase should be considered if endovascular treatment delays are anticipated by the treating medical team. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03469206.
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Affiliation(s)
- Yu Zhou
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Lei Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Johanna Ospel
- Department of Radiology, University Hospital Basel, Switzerland (J.O.)
| | - Mayank Goyal
- Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Canada (M.G., R.M.)
| | - Rosalie McDonough
- Department of Clinical Neurosciences and Diagnostic Imaging, University of Calgary Cumming School of Medicine, Canada (M.G., R.M.)
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg Eppendorf, Germany (R.M.)
| | - Pengfei Xing
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Zifu Li
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Xiaoxi Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Yongxin Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Yongwei Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Bo Hong
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Yi Xu
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Qinghai Huang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Qiang Li
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Ying Yu
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Qiao Zuo
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Xiaofei Ye
- Health Statistics Department, Naval Medical University, Shanghai, China (X.Y.)
| | - Pengfei Yang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
| | - Jianmin Liu
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (Y. Zhou, L.Z., P.X., Z.L., X.Z., Yongxin Zhang, Yongwei Zhang, B.H., Y.X., Q.H., Q.L., Y.Y., Q.Z., P.Y., J.L.)
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Krieger P, Zhao A, Croll L, Irvine H, Torres J, Melmed KR, Lord A, Ishida K, Frontera J, Lewis A. Tachycardia is associated with mortality and functional outcome after thrombectomy for acute ischemic stroke. J Stroke Cerebrovasc Dis 2022; 31:106450. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106450] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 03/02/2022] [Accepted: 03/12/2022] [Indexed: 10/18/2022] Open
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211
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Gao L, Moodie M, Yassi N, Davis SM, Bladin CF, Smith K, Bernard S, Stephenson M, Churilov L, Campbell BCV, Zhao H. Long-Term Cost-Effectiveness of Severity-Based Triaging for Large Vessel Occlusion Stroke. Front Neurol 2022; 13:871999. [PMID: 35645977 PMCID: PMC9136079 DOI: 10.3389/fneur.2022.871999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Accepted: 03/31/2022] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose:Pre-hospital severity-based triaging using the Ambulance Clinical Triage For Acute Stroke Treatment (ACT-FAST) algorithm has been demonstrated to substantially reduce time to endovascular thrombectomy in Melbourne, Australia. We aimed to model the cost-effectiveness of an ACT-FAST bypass system from the healthcare system perspective.MethodsA simulation model was developed to estimate the long-term costs and health benefits associated with diagnostic accuracy of the ACT-FAST algorithm. Three-month post stroke functional outcome was projected to the lifetime horizon to estimate the long-term cost-effectiveness between two strategies (ACT-FAST vs. standard care pathways). For ACT-FAST screened true positives (i.e., screened positive and eligible for EVT), a 52 mins time saving was applied unanimously to the onset to arterial time for EVT, while 10 mins delay in thrombolysis was applied for false-positive (i.e., screened positive but was ineligible for EVT) thrombolysis-eligible infarction. Quality-adjusted life year (QALY) was employed as the outcome measure to calculate the incremental cost-effectiveness ratio (ICER) between the ACT-FAST algorithm and the current standard care pathway.ResultsOver the lifetime, ACT-FAST was associated with lower costs (–$45) and greater QALY gains (0.006) compared to the current standard care pathway, resulting in it being the dominant strategy (less costly but more health benefits). Implementing ACT-FAST triaging led to higher proportion of patients received EVT procedure (30 more additional EVT performed per 10,000 patients). The total Net Monetary Benefit from ACT-FAST care estimated at A$0.76 million based on its implementation for a single year.ConclusionsAn ACT-FAST severity-triaging strategy is associated with cost-saving and increased benefits when compared to standard care pathways. Implementing ACT-FAST triaging increased the proportion of patients who received EVT procedure due to more patients arriving at EVT-capable hospitals within the 6-h time window (when imaging selection is less rigorous).
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Affiliation(s)
- Lan Gao
- Deakin Health Economics, Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, VIC, Australia
- *Correspondence: Lan Gao
| | - Marj Moodie
- Deakin Health Economics, Institute for Health Transformation, Faculty of Health, Deakin University, Geelong, VIC, Australia
| | - Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, VIC, Australia
| | - Stephen M. Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Christopher F. Bladin
- Ambulance Victoria, Melbourne, VIC, Australia
- Department of Neurology, Faculty of Medicine, Nursing and Health Sciences, Eastern Health and Eastern Health Clinical School, Monash University, Melbourne, VIC, Australia
| | - Karen Smith
- Ambulance Victoria, Melbourne, VIC, Australia
| | | | | | - Leonid Churilov
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
- Department of Medicine, Austin Health, University of Melbourne, Melbourne, VIC, Australia
| | - Bruce C. V. Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
- Ambulance Victoria, Melbourne, VIC, Australia
| | - Henry Zhao
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
- Ambulance Victoria, Melbourne, VIC, Australia
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212
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Zhao J, Zhu W, Qi Y, Xu G, Liu L, Liu J. Effect of supraglottic airway devices versus endotracheal intubation general anesthesia on outcomes in patients undergoing mechanical thrombectomy: A prospective randomized clinical trial. Medicine (Baltimore) 2022; 101:e29074. [PMID: 35550459 PMCID: PMC9276097 DOI: 10.1097/md.0000000000029074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 02/24/2022] [Indexed: 01/04/2023] Open
Abstract
BACKGROUND There are still controversies about the optimal anesthesia protocol for patients with acute ischemic stroke (AIS) undergoing mechanical thrombectomy (MT). The aim of this study was to explore the effect of supraglottic airway device (SAD) versus endotracheal intubation (EI) general anesthesia on clinical and angiographic outcomes in patients with AIS undergoing MT. METHODS One hundred sixteen patients with large-vessel occlusion stroke were randomized to receive either SAD or EI general anesthesia. The primary outcome was the rate of occurrence of >20% fall in mean arterial pressure (MAP). Secondary outcomes included hemodynamics, successful recanalization, time metrics, satisfaction score of neurointerventionalist, number of passes performed, the conversion rate from SAD to EI, the National Institutes of Health Stroke Scale score, and Alberta Stroke Program Early CT Score before and 24 hours after surgery, length of stay in the stroke unit and hospital, complications and functional independence at discharge, and 90 days after stroke. RESULTS Both the lowest systolic blood pressure and lowest diastolic blood pressure were significantly lower in the EI group (P = .001). The consumption of vasoactive agents, the occurrence of >20% reduction in MAP and time spent with >20% fall in MAP were significantly higher in the EI group (P < .05). Compared with the EI group, the time for door-to-puncture was significantly shorter in the SAD group (P = .015). There were no significant differences with respect to puncture-to-reperfusion time, number of passes performed, rates of successful recanalization, National Institutes of Health Stroke Scale score, and Alberta Stroke Program Early CT Score 24 hours after surgery. The satisfaction score of neurointerventionalist was significantly lower in the EI group (P = .043). Conversion rate from SAD to EI was 7.41%. There were no significant differences with respect to complications, mortality, and mean Modified Rankin Scale scores both at discharge and 90-day after stroke. However, length of stroke unit and hospital stays were significantly shorter in the SAD group (P < .05). CONCLUSION AIS patients undergoing MT with SAD general anesthesia led to more stable hemodynamics, higher satisfaction score of neurointerventionalist, shorter door-to-puncture time, length of stroke unit, and hospital stay. However, there were no significant differences between the 2 groups on the angiographic and functional outcomes both at discharge and 90 days after stroke.
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213
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Derraz I. The End of Tissue-Type Plasminogen Activator's Reign? Stroke 2022; 53:2683-2694. [PMID: 35506385 DOI: 10.1161/strokeaha.122.039287] [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
Mechanical thrombectomy is a highly effective treatment for acute ischemic stroke caused by large-vessel occlusion in the anterior cerebral circulation, significantly increasing the likelihood of recovery to functional independence. Until recently, whether intravenous thrombolysis before mechanical thrombectomy provided additional benefits to patients with acute ischemic stroke-large-vessel occlusion remained unclear. Given that reperfusion is a key factor for clinical outcome in patients with acute ischemic stroke-large-vessel occlusion and the efficacy of both intravenous thrombolysis and mechanical thrombectomy is time-dependent, achieving complete reperfusion with a single pass should be the primary angiographic goal. However, it remains undetermined whether extending the procedure with additional endovascular attempts or local lytics administration safely leads to higher reperfusion grades and whether there are significant public health and cost implications. Here, we outline the current state of knowledge and research avenues that remain to be explored regarding the consistent therapeutic benefit of intravenous thrombolysis in anterior circulation strokes and the potential place of adjunctive intra-arterial lytics administration, including alternative thrombolytic agent place.
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Affiliation(s)
- Imad Derraz
- Department of Neuroradiology, Hôpital Guide Chauliac, Montpellier University Medical Center, France
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214
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Matsumoto S, Mikami T, Iwagami M, Briasoulis A, Ikeda T, Takagi H, Kuno T. Mechanical Thrombectomy and Intravenous Thrombolysis in Patients with Acute Stroke: A Systematic Review and Network Meta-Analysis. J Stroke Cerebrovasc Dis 2022; 31:106491. [PMID: 35468495 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106491] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2022] [Accepted: 04/03/2022] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES The benefit and risk of administration of tissue plasminogen activator (tPA) before endovascular mechanical thrombectomy (E-MT) in acute stroke has been actively debated. We therefore aimed to investigate the efficacy and safety of three therapeutic strategies for acute stroke: direct E-MT, E-MT with pre-administration of tPA, and tPA alone with a network meta-analysis. MATERIALS AND METHODS PUBMED and EMBASE were searched from September to November 2021 for randomized control trials that compared direct E-MT, E-MT with tPA, and tPA alone therapies in acute stroke. The primary outcome was functional independence, defined as modified Rankin Scale score of 0-2, at 90 days. All-cause mortality, symptomatic intracranial hemorrhage, and successful revascularization were also evaluated. RESULTS We identified 11 randomized controlled trials with a total of 3,640 patients with acute stroke. Compared to E-MT with tPA, direct E-MT provided comparable outcomes regarding functional independence (relative risk (RR): 1.02; 95% confidence interval (CI): 0.88-1.19, I2 = 36.6%) and all-cause mortality (RR: 1.05; 95% CI: 0.85-1.31, I2 = 0%). The incidence of symptomatic intracranial hemorrhage was not significantly different between direct E-MT and E-MT with tPA (RR: 0.83; 95% CI: 0.57-1.20, I2 = 0%). Direct E-MT had favorable functional independence (RR: 1.41; 95% CI: 1.15-1.74, I2 = 36.6%) and higher successful revascularization rate (RR: 1.60; 95% CI: 1.33-1.93, I2 = 61.2%) than tPA alone. CONCLUSIONS Direct E-MT alone led to acceptable outcomes even in comparison to E-MT with tPA, whereas additional tPA did not cause higher risk of symptomatic intracranial hemorrhage.
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Affiliation(s)
- Shingo Matsumoto
- Division of Cardiovascular Medicine, Department of Internal Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | | | - Masao Iwagami
- Department of Health Services Research, University of Tsukuba, Tsukuba, Japan
| | - Alexandros Briasoulis
- Division of Cardiovascular Medicine, Section of Heart Failure and Transplantation, University of Iowa, IA, USA
| | - Takanori Ikeda
- Division of Cardiovascular Medicine, Department of Internal Medicine, Toho University Faculty of Medicine, Tokyo, Japan
| | - Hisato Takagi
- Department of Cardiovascular Surgery, Shizuoka Medical Center, Shizuoka, Japan
| | - Toshiki Kuno
- Division of Cardiology, Montefiore Medical Center, Albert Einstein College of Medicine, 111 East 210th St, Bronx, NY 10467-2401, USA.
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215
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Platko S, Bensabeur F, Rotsching N, Wagner J, Markert RJ, Terry JB, Cheng-Ching E. Intravenous thrombolysis prior to mechanical thrombectomy does not affect clinical or procedural outcomes in patients with large vessel occlusion acute ischemic stroke. J Clin Neurosci 2022; 100:120-123. [PMID: 35453099 DOI: 10.1016/j.jocn.2022.04.016] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Revised: 04/11/2022] [Accepted: 04/15/2022] [Indexed: 11/16/2022]
Abstract
Mechanical thrombectomy (MT) has revolutionized the care of large vessel occlusion acute ischemic strokes (LVOAIS). However, the benefit of intravenous thrombolysis prior to MT remains unproven. Two recent trials showed equivocal results regarding the benefits of pre-MT intravenous thrombolysis in predominantly Asian populations. We evaluated clinical outcomes and procedural metrics for patients with LVOAIS who were treated with MT alone compared to those who were treated with both intravenous tPA and MT. In a retrospective study, LVOAIS patients treated with MT, with or without preceding intravenous thrombolysis, between January of 2017 and December of 2019 were identified. Patients were treated according to contemporary guidelines. Baseline demographic and clinical characteristics, procedural metrics, and clinical outcomes were collected. Among LVOAIS patients, those treated with intravenous thrombolysis and MT did not differ from those with MT alone on clinical outcomes at three months. Further, the two groups did not differ on thrombectomy procedure times, recanalization rates, and symptomatic intracranial hemorrhage rates. In our patients with LVOAIS, intravenous thrombolysis combined with MT offered no advantage compared to MT alone in clinical outcomes or recanalization rates. Our results are consistent with earlier studies in other populations. In addition, our results suggest that IV tPA does not impact the ease of clot removal by MT. Further studies will evaluate how newly available thrombolytic agents may benefit patients eligible for MT.
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Affiliation(s)
- Steven Platko
- Department of Neurology, Wright State University Boonshoft School of Medicine, Dayton OH, United States; Clinical Neuroscience Institute, Premier Health, Dayton OH, United States
| | - Fatima Bensabeur
- Department of Neurology, Wright State University Boonshoft School of Medicine, Dayton OH, United States; Clinical Neuroscience Institute, Premier Health, Dayton OH, United States
| | - Nicholas Rotsching
- Department of Neurology, Wright State University Boonshoft School of Medicine, Dayton OH, United States
| | - Jacob Wagner
- Department of Neurology, Wright State University Boonshoft School of Medicine, Dayton OH, United States
| | - Ronald J Markert
- Department of Neurology, Wright State University Boonshoft School of Medicine, Dayton OH, United States
| | - John B Terry
- Department of Neurology, Wright State University Boonshoft School of Medicine, Dayton OH, United States; Clinical Neuroscience Institute, Premier Health, Dayton OH, United States
| | - Esteban Cheng-Ching
- Department of Neurology, Wright State University Boonshoft School of Medicine, Dayton OH, United States; Clinical Neuroscience Institute, Premier Health, Dayton OH, United States.
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Abstract
The treatment of acute ischemic stroke continues to advance. The mainstay of treatment remains intravenous thrombolysis with alteplase. Recent studies demonstrated that later treatment with alteplase is beneficial in patients selected with advanced imaging techniques. Tenecteplase has been evaluated as an alternative thrombolytic drug and evidence suggests that it is as least as effective as alteplase and may lyse large vessel clots more effectively. Endovascular therapy with mechanical thrombectomy has now been shown to be beneficial up to 24 hours after stroke onset in carefully selected patients with proximal, large vessel occlusions. Ongoing studies are evaluating the effectiveness of thrombectomy in patients with more distal vessel occlusions and patients with proximal large vessel occlusions with larger ischemic core volumes and also in patients with milder neurological deficits. Cytoprotection is another potential acute stroke therapy that has not demonstrated efficacy in prior clinical trials. It should be reconsidered as an adjunct to reperfusion and a variety of new clinical trials can be envisioned to evaluate the potential benefits of cytoprotection in patients before and after reperfusion.
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Affiliation(s)
- Yunyun Xiong
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China (Y.X.).,Chinese Institute of Brain Research (Y.X.)
| | - Ajay K Wakhloo
- Department of Neurointerventional Radiology Beth Israel Lahey Health Medical Center, Tufts University School of Medicine, Burlington' MA (A.K.W.)
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School' Boston' MA (M.F.)
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217
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Liu Y, Hong Z, Li Y, Li S, Liu Q, Xie S, Wang J, Wang J, Zheng M. Effect of intravenous thrombolysis combined with mechanical thrombectomy on neurological function and short-term prognosis of patients with acute cerebral infarction. Am J Transl Res 2022; 14:2376-2382. [PMID: 35559387 PMCID: PMC9091080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2021] [Accepted: 08/09/2021] [Indexed: 06/15/2023]
Abstract
OBJECTIVE This study was to assess the effect of intravenous thrombolysis combined with mechanical thrombectomy on neurological function and the short-term prognosis of patients with acute cerebral infarction (ACI). METHODS A total of 120 patients with ACI admitted to our hospital from January 2019 to January 2020 were selected as research objects, and randomized into Group A (n=60) or Group B (n=60). Patients in both groups were treated with intravenous thrombolysis. Group B received ACI conventional treatment and intravenous thrombolysis, while Group A was additionally given mechanical thrombectomy. Then the neurological function scores, serum factor levels, vascular recanalization rate, incidence of adverse reactions, Thrombolysis in Myocardial Infarction (TIMI) grade flow, and effective rate of treatment were compared between the two groups. The clinical trial is available at https://clinicaltrials.gov/, ClinicalTrials.gov Identifier: NCT03502411. RESULTS The neurological function scores of Group A were apparently lower than those of Group B one month after treatment (P<0.001). After treatment, Group A yielded a superior serum factor level compared to Group B (P<0.001), and also showed a higher recanalization rate of blood vessels and a notably lower adverse reaction rate (all P<0.05). CONCLUSION Intravenous thrombolysis combined with mechanical thrombectomy can accelerate the recovery of neurological function in patients with ACI, and yield a more promising outcome in terms of the patient's vascular recanalization rate compared with the monotherapy. It can also reduce the adverse reaction rate of patients to ensure a better short-term prognosis.
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Affiliation(s)
- Yongchang Liu
- Department of Neurovascular Intervention, Cangzhou Central Hospital Cangzhou, China
| | - Zhen Hong
- Department of Neurovascular Intervention, Cangzhou Central Hospital Cangzhou, China
| | - Yan Li
- Department of Neurovascular Intervention, Cangzhou Central Hospital Cangzhou, China
| | - Shaoquan Li
- Department of Neurovascular Intervention, Cangzhou Central Hospital Cangzhou, China
| | - Qingran Liu
- Department of Neurovascular Intervention, Cangzhou Central Hospital Cangzhou, China
| | - Songwang Xie
- Department of Neurovascular Intervention, Cangzhou Central Hospital Cangzhou, China
| | - Junyong Wang
- Department of Neurovascular Intervention, Cangzhou Central Hospital Cangzhou, China
| | - Jian Wang
- Department of Neurovascular Intervention, Cangzhou Central Hospital Cangzhou, China
| | - Mingming Zheng
- Department of Neurovascular Intervention, Cangzhou Central Hospital Cangzhou, China
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Amini M, van Leeuwen N, Eijkenaar F, van de Graaf R, Samuels N, van Oostenbrugge R, van den Wijngaard IR, van Doormaal PJ, Roos YBWEM, Majoie C, Roozenbeek B, Dippel D, Burke J, Lingsma HF, Dippel DWJ, van der Lugt A, Majoie CBLM, Roos YBWEM, van Oostenbrugge RJ, van Zwam WH, Boiten J, Vos JA, Brouwer J, den Hartog SJ, Hinsenveld WH, Kappelhof M, Compagne KCJ, Goldhoorn RJB, Mulder MJHL, Jansen IGH, Dippel DWJ, Roozenbeek B, van der Lugt A, van Es ACGM, Majoie CBLM, Roos YBWEM, Emmer BJ, Coutinho JM, Schonewille WJ, Vos JA, Wermer MJH, van Walderveen MAA, Staals J, van Oostenbrugge RJ, van Zwam WH, Hofmeijer J, Martens JM, Lycklama à Nijeholt GJ, Boiten J, de Bruijn SF, van Dijk LC, van der Worp HB, Lo RH, van Dijk EJ, Boogaarts HD, de Vries J, de Kort PLM, van Tuijl J, Peluso JJP, Fransen P, van den Berg JSP, van Hasselt BAAM, Aerden LAM, Dallinga RJ, Uyttenboogaart M, Eschgi O, Bokkers RPH, Schreuder THCML, Heijboer RJJ, Keizer K, Yo LSF, den Hertog HM, Sturm EJC, Brouwers P, Majoie CBLM, van Zwam WH, van der Lugt A, Lycklama à Nijeholt GJ, van Walderveen MAA, Sprengers MES, Jenniskens SFM, van den Berg R, Yoo AJ, Beenen LFM, Postma AA, Roosendaal SD, van der Kallen BFW, van den Wijngaard IR, van Es ACGM, Emmer BJ, Martens JM, Yo LSF, Vos JA, Bot J, van Doormaal PJ, Meijer A, Ghariq E, Bokkers RPH, van Proosdij MP, Krietemeijer GM, Peluso JP, Boogaarts HD, Lo R, Gerrits D, Dinkelaar W, Appelman APA, Hammer B, Pegge S, van der Hoorn A, Vinke S, Dippel DWJ, van der Lugt A, Majoie CBLM, Roos YBWEM, van Oostenbrugge RJ, van Zwam WH, Lycklama à Nijeholt GJ, Boiten J, Vos JA, Schonewille WJ, Hofmeijer J, Martens JM, van der Worp HB, Lo RH, van Oostenbrugge RJ, Hofmeijer J, Flach HZ, Lingsma HF, el Ghannouti N, Sterrenberg M, Puppels C, Pellikaan W, Sprengers R, Elfrink M, Simons M, Vossers M, de Meris J, Vermeulen T, Geerlings A, van Vemde G, Simons T, van Rijswijk C, Messchendorp G, Nicolaij N, Bongenaar H, Bodde K, Kleijn S, Lodico J, Droste H, Wollaert M, Verheesen S, Jeurrissen D, Bos E, Drabbe Y, Sandiman M, Elfrink M, Aaldering N, Zweedijk B, Khalilzada M, Vervoort J, Droste H, Nicolaij N, Simons M, Ponjee E, Romviel S, Kanselaar K, Bos E, Barning D, Venema E, Chalos V, Geuskens RR, van Straaten T, Ergezen S, Harmsma RRM, Muijres D, de Jong A, Berkhemer OA, Boers AMM, Huguet J, Groot PFC, Mens MA, van Kranendonk KR, Treurniet KM, Jansen IGH, Tolhuisen ML, Alves H, Weterings AJ, Kirkels ELF, Voogd EJHF, Schupp LM, Collette S, Groot AED, LeCouffe NE, Konduri PR, Prasetya H, Arrarte-Terreros N, Ramos LA. Estimation of treatment effects in observational stroke care data: comparison of statistical approaches. BMC Med Res Methodol 2022; 22:103. [PMID: 35399057 PMCID: PMC8996562 DOI: 10.1186/s12874-022-01590-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 03/22/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Introduction
Various statistical approaches can be used to deal with unmeasured confounding when estimating treatment effects in observational studies, each with its own pros and cons. This study aimed to compare treatment effects as estimated by different statistical approaches for two interventions in observational stroke care data.
Patients and methods
We used prospectively collected data from the MR CLEAN registry including all patients (n = 3279) with ischemic stroke who underwent endovascular treatment (EVT) from 2014 to 2017 in 17 Dutch hospitals. Treatment effects of two interventions – i.e., receiving an intravenous thrombolytic (IVT) and undergoing general anesthesia (GA) before EVT – on good functional outcome (modified Rankin Scale ≤2) were estimated. We used three statistical regression-based approaches that vary in assumptions regarding the source of unmeasured confounding: individual-level (two subtypes), ecological, and instrumental variable analyses. In the latter, the preference for using the interventions in each hospital was used as an instrument.
Results
Use of IVT (range 66–87%) and GA (range 0–93%) varied substantially between hospitals. For IVT, the individual-level (OR ~ 1.33) resulted in significant positive effect estimates whereas in instrumental variable analysis no significant treatment effect was found (OR 1.11; 95% CI 0.58–1.56). The ecological analysis indicated no statistically significant different likelihood (β = − 0.002%; P = 0.99) of good functional outcome at hospitals using IVT 1% more frequently. For GA, we found non-significant opposite directions of points estimates the treatment effect in the individual-level (ORs ~ 0.60) versus the instrumental variable approach (OR = 1.04). The ecological analysis also resulted in a non-significant negative association (0.03% lower probability).
Discussion and conclusion
Both magnitude and direction of the estimated treatment effects for both interventions depend strongly on the statistical approach and thus on the source of (unmeasured) confounding. These issues should be understood concerning the specific characteristics of data, before applying an approach and interpreting the results. Instrumental variable analysis might be considered when unobserved confounding and practice variation is expected in observational multicenter studies.
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Broocks G, Meyer L, Ruppert C, Haupt W, Faizy TD, Van Horn N, Bechstein M, Kniep H, Elsayed S, Kemmling A, Barow E, Fiehler J, Hanning U. Effect of Intravenous Alteplase on Functional Outcome and Secondary Injury Volumes in Stroke Patients with Complete Endovascular Recanalization. J Clin Med 2022; 11:jcm11061565. [PMID: 35329891 PMCID: PMC8949925 DOI: 10.3390/jcm11061565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/04/2022] [Accepted: 03/08/2022] [Indexed: 11/22/2022] Open
Abstract
Intravenous thrombolytic therapy with alteplase (IVT) is a standard of care in ischemic stroke, while recent trials investigating direct endovascular thrombectomy (EVT) approaches showed conflicting results. Yet, the effect of IVT on secondary injury volumes in patients with complete recanalization has not been analyzed. We hypothesized that IVT is associated with worse functional outcome and aggravated secondary injury volumes when administered to patients who subsequently attained complete reperfusion after EVT. Anterior circulation ischemic stroke patients with complete reperfusion after thrombectomy defined as thrombolysis in cerebral infarctions (TICI) scale 3 after thrombectomy admitted between January 2013–January 2021 were analyzed. Primary endpoints were the proportion of patients with functional independence defined as modified Rankin Scale (mRS) score 0–2 at day 90, and secondary injury volumes: Edema volume in follow-up imaging measured using quantitative net water uptake (NWU), and the rate of symptomatic intracerebral hemorrhage (sICH). A total of 219 patients were included and 128 (58%) patients received bridging IVT before thrombectomy. The proportion of patients with functional independence was 28% for patients with bridging IVT, and 34% for patients with direct thrombectomy (p = 0.35). The rate of sICH was significantly higher after bridging IVT (20% versus 7.7%, p = 0.01). Multivariable logistic and linear regression analysis confirmed the independent association of bridging IVT with sICH (aOR: 2.78, 95% CI: 1.02–7.56, p = 0.046), and edema volume (aOR: 8.70, 95% CI: 2.57–14.85, p = 0.006). Bridging IVT was associated with increased edema volume and risk for sICH as secondary injury volumes. The results of this study encourage direct EVT approaches, particularly in patients with higher likelihood of successful EVT.
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Affiliation(s)
- Gabriel Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
- Correspondence:
| | - Lukas Meyer
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Celine Ruppert
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Wolfgang Haupt
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Tobias D. Faizy
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Noel Van Horn
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Matthias Bechstein
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Helge Kniep
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Sarah Elsayed
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Andre Kemmling
- Department of Neuroradiology, Philipps-University Marburg, 35037 Marburg, Germany;
- Department of Neuroradiology, University Medical Center Schleswig-Holstein, Campus Lübeck, 23538 Lübeck, Germany
| | - Ewgenia Barow
- Department of Neurology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany;
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Uta Hanning
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
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Cv Campbell B. Should the Extent of Infarction Modify the Decision to Use Bridging Thrombolytic Prior to Endovascular Thrombectomy? Eur J Neurol 2022; 29:1567-1568. [PMID: 35262235 PMCID: PMC9313809 DOI: 10.1111/ene.15322] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2022] [Accepted: 03/07/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Bruce Cv Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
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Zhong AJ, Kamal H, Uddin A, Feldstein E, Shapiro SD, Chung JY, Ogarro M, Friedman R, Simmons J, Graifman G, Kurian C, Kaur G, Mayer SA, Chong J, Gandhi CD, Al-Mufti F. Transcarotid Access for Mechanical Thrombectomy in Acute Ischemic Stroke: A Meta-Analysis and Systematic Review. J Stroke Cerebrovasc Dis 2022; 31:106428. [PMID: 35279005 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106428] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2021] [Revised: 02/14/2022] [Accepted: 02/20/2022] [Indexed: 10/18/2022] Open
Abstract
OBJECTIVES Despite the success of mechanical thrombectomy in large vessel acute ischemic stroke, recanalization may fail due to difficult anatomic access or peripheral arterial occlusive disease. In these cases, transcarotid access may be used as an alternative, but it has not gained prominence due to safety concerns. Our objective was to assess the efficacy and safety of transcarotid access for mechanical thrombectomy. MATERIALS AND METHODS Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines were used to perform a systematic review with articles published from 2010 to 2020 summarizing pre-intervention characteristics, techniques utilized, and outcomes of patients undergoing mechanical thrombectomy via trans-carotid puncture. We performed a meta-analysis of clinical outcomes, reperfusion times and overall complications rates of trans-carotid approach. RESULTS Six studies describing 80 total attempts at carotid access, 72 of which were successful (90% success rate), were included. Direct carotid puncture was most often used as a rescue technique (87% of patients) secondary to failed femoral access. Successful recanalization was achieved in 76% of patients. 90 day modified Rankin Scale ≤ 2 was achieved in 28% of patients. Carotid puncture-reperfusion time was 32 min (CI = 24-40, p < 0.001). Cervical complications occurred at a rate of 26.5% (95% CI = 17%-38%). Only 1.3% (1/80 patients) had a fatal outcome and 96% of complications required no intervention. CONCLUSIONS Our results on the safety and efficacy of transcarotid access suggests that this approach is a viable alternative to failed thrombectomy when transfemoral or trans-radial access may be impractical.
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Affiliation(s)
- Allison J Zhong
- New York Medical College School of Medicine, Valhalla, NY, USA
| | - Haris Kamal
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, 100 Woods Road, Valhalla, NY 10595, USA
| | - Anaz Uddin
- New York Medical College School of Medicine, Valhalla, NY, USA
| | - Eric Feldstein
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, 100 Woods Road, Valhalla, NY 10595, USA
| | - Steven D Shapiro
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, 100 Woods Road, Valhalla, NY 10595, USA; Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Joon Yong Chung
- New York Medical College School of Medicine, Valhalla, NY, USA
| | - Maziyah Ogarro
- New York Medical College School of Medicine, Valhalla, NY, USA
| | | | - Josh Simmons
- New York Medical College School of Medicine, Valhalla, NY, USA
| | | | - Christeena Kurian
- Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Gurmeen Kaur
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, 100 Woods Road, Valhalla, NY 10595, USA; Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Stephan A Mayer
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, 100 Woods Road, Valhalla, NY 10595, USA; Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Ji Chong
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, 100 Woods Road, Valhalla, NY 10595, USA; Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, 100 Woods Road, Valhalla, NY 10595, USA; Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, 100 Woods Road, Valhalla, NY 10595, USA; Department of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, USA.
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Patra DP, Demaerschalk BM, Chong BW, Krishna C, Bendok BR. A Renaissance in Modern and Future Endovascular Stroke Care. Neurosurg Clin N Am 2022; 33:169-183. [DOI: 10.1016/j.nec.2021.12.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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Broderick JP, Hill MJ. Advances in Stroke: Treatments-Acute. Stroke 2022; 53:999-1003. [PMID: 35176877 DOI: 10.1161/strokeaha.122.036976] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
| | - Michael J Hill
- Department of Clinical Neurosciences, University of Calgary, Alberta, Canada (M.J.H.)
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Trifan G, Biller J, Testai FD. Mechanical Thrombectomy vs Bridging Therapy for Anterior Circulation Large Vessel Occlusion Stroke: Systematic Review and Meta-analysis. Neurology 2022; 98:e1361-e1373. [PMID: 35173017 DOI: 10.1212/wnl.0000000000200029] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 01/03/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND and Purpose: Current guidelines recommend the use of mechanical thrombectomy (MT) plus intravenous thrombolysis (aka bridging therapy, [BT]) for patients with anterior circulation large vessel occlusion (LVO) stroke. However, clinical equipoise exists in relation to the use of BT versus MT alone. Our objective is to compare the efficacy and safety of BT to MT for anterior circulation LVO. METHODS A systematic search of biomedical literature databases was performed from inception to October 29, 2021 to identify prospective and retrospective studies comparing the rates for functional independence (modified Rankin Scale score 0-2) and mortality at 90 days, symptomatic hemorrhage (sICH), and successful recanalization rates for MT and BT. Effect size was represented by odds ratio (OR) and analysis was done using random effects meta-analysis. Heterogeneity was assessed by I2 and Cochrane's Q statistics. RESULTS Overall, 41 studies with 14885 patients were included. Mean age ± standard deviation (years) was 69±11 for BT and 70±11 for MT. All studies used alteplase as thrombolytic agent. BT group had 29% higher odds for functional independence (OR=1.29, 95% CI 1.16-1.44, I2=42%), 25% higher odds of successful reperfusion (OR=1.25, 95% CI=1.08-1.44, I2=42%) and a 31% decrease in odds for mortality (OR=.69, 95% CI .60-.80, I2=47%) compared with MT. sICH prevalence was similar between groups (OR=1.10, 95% CI=.95-1.28, I2=0%). Six of the studies were randomized clinical trials (RCT) with intention-to-treat analysis done in patients presenting directly to MT-capable centers. When analysis was restricted to these six RCT (n= 2333), no differences were observed in functional independence (OR=1.08, 95% CI=.91-1.27, I2=0%), sICH (OR=1.37, 95% CI=.95-1.97, I2=0%) or mortality (OR=.93, 95% CI=.74-1.16, I2=0%) between groups. However, successful reperfusion favored BT group (OR=1.35, 95% CI=1.06-1.73, I2=0%). DISCUSSION The odds for functional independence, successful reperfusion and mortality for the entire dataset favored the use of BT over MT (medium heterogeneity and low quality of the evidence). When analysis was restricted to RCT, both treatments had similar functional and safety outcomes (no heterogeneity), but recanalization rates favored BT group (no heterogeneity). Because these findings may differ in patients that present to non-MT-capable centers or with the use of other thrombolytic agents, further RCTs are needed.
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Jia ZY, Zhang YX, Cao YZ, Zhao LB, Shi HB, Zhang L, Li ZF, Shen HJ, Lou M, Zhang YW, Yin GC, Ye XF, Yang PF, Liu S, Liu JM, Direct-Mt Investigators T. Effect of baseline infarct size on endovascular thrombectomy with or without intravenous alteplase in stroke patients: a subgroup analysis of a randomized trial (DIRECT-MT). Eur J Neurol 2022; 29:1643-1651. [PMID: 35143095 DOI: 10.1111/ene.15276] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 02/03/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND DIRECT-MT showed that endovascular thrombectomy was non-inferior to thrombectomy preceded by intravenous alteplase with regard to functional outcome in patients with acute ischemic stroke. In this post-hoc analysis, we examined whether infarct size modified the effect of alteplase. METHODS All patients with baseline Alberta Stroke Program Early Computed Tomography Score (ASPECTS) grade were included. The primary outcome was the 90-day modified Rankin Scale (mRS) score. Multivariable ordinal logistic regression analysis was used to calculate the adjusted common odds ratio (OR) for better functional outcome based on the mRS for thrombectomy alone versus combination therapy. An interaction term was entered to test for an interaction with baseline ASPECTS subgroups: 0-4 versus 5-7 versus 8-10. RESULTS Of 649 patients, 323 (49.8%) were in the thrombectomy-alone group and 326 (50.2%) in the combination-therapy group. There was no significant treatment-by-trichotomized ASPECTS interaction with alteplase prior to endovascular treatment for the primary endpoint of ordinal mRS (p-value interaction term relative to ASPECTS 8-10: ASPECTS 0-4, p=0.386; ASPECTS 5-7, p=0.936). Adjusted common OR for improvement in the 90-day mRS with thrombectomy alone compared with combination therapy were 1.99 (95% confidence intervals, 0.72-5.46) for ASPECTS 0-4, 1.07 (0.62-1.86) for ASPECTS 5-7, and 1.03 (0.74-1.45) for ASPECTS 8-10. There was no significant difference in the safety outcomes between the two groups. CONCLUSIONS Baseline infarct size may not modify the effect of alteplase prior to endovascular thrombectomy with regard to favorable functional outcomes and adverse events.
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Affiliation(s)
- Zhen Yu Jia
- Department of Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Yong Xin Zhang
- Department of Neurosurgery, Naval Medical University Changhai hospital, Shanghai, China
| | - Yue Zhou Cao
- Department of Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Lin Bo Zhao
- Department of Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Hai Bin Shi
- Department of Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Lei Zhang
- Department of Neurosurgery, Naval Medical University Changhai hospital, Shanghai, China
| | - Zi Fu Li
- Department of Neurosurgery, Naval Medical University Changhai hospital, Shanghai, China
| | - Hong Jian Shen
- Department of Neurosurgery, Naval Medical University Changhai hospital, Shanghai, China
| | - Min Lou
- Department of Neurology, Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Yong Wei Zhang
- Department of Neurology, Naval Medical University Changhai Hospital, Shanghai, China
| | - Guo Cong Yin
- Department of Neurology, Hangzhou First People's Hospital of Zhejiang University, Hangzhou, China
| | - Xiao Fei Ye
- Department of Statistics, Naval Medical University, Shanghai, China
| | - Peng Fei Yang
- Department of Neurosurgery, Naval Medical University Changhai hospital, Shanghai, China
| | - Sheng Liu
- Department of Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Jian Min Liu
- Department of Neurosurgery, Naval Medical University Changhai hospital, Shanghai, China
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Turc G, Tsivgoulis G, Audebert HJ, Boogaarts H, Bhogal P, De Marchis GM, Fonseca AC, Khatri P, Mazighi M, Pérez de la Ossa N, Schellinger PD, Strbian D, Toni D, White P, Whiteley W, Zini A, van Zwam W, Fiehler J. European Stroke Organisation (ESO)-European Society for Minimally Invasive Neurological Therapy (ESMINT) expedited recommendation on indication for intravenous thrombolysis before mechanical thrombectomy in patients with acute ischemic stroke and anterior circulation large vessel occlusion. J Neurointerv Surg 2022; 14:209. [PMID: 35115395 DOI: 10.1136/neurintsurg-2021-018589] [Citation(s) in RCA: 61] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 01/09/2022] [Indexed: 12/30/2022]
Abstract
Six randomized controlled clinical trials have assessed whether mechanical thrombectomy (MT) alone is non-inferior to intravenous thrombolysis (IVT) plus MT within 4.5 hours of symptom onset in patients with anterior circulation large vessel occlusion (LVO) ischemic stroke and no contraindication to IVT. An expedited recommendation process was initiated by the European Stroke Organisation (ESO) and conducted with the European Society of Minimally Invasive Neurological Therapy (ESMINT) according to ESO standard operating procedure based on the GRADE system. We identified two relevant Population, Intervention, Comparator, Outcome (PICO) questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote evidence-based recommendations. Expert opinion was provided if insufficient evidence was available to provide recommendations based on the GRADE approach.For stroke patients with anterior circulation LVO directly admitted to a MT-capable center ('mothership') within 4.5 hours of symptom onset and eligible for both treatments, we recommend IVT plus MT over MT alone (moderate evidence, strong recommendation). MT should not prevent the initiation of IVT, nor should IVT delay MT. In stroke patients with anterior circulation LVO admitted to a center without MT facilities and eligible for IVT ≤4.5 hours and MT, we recommend IVT followed by rapid transfer to a MT capable-center ('drip-and-ship') in preference to omitting IVT (low evidence, strong recommendation). Expert consensus statements on ischemic stroke on awakening from sleep are also provided. Patients with anterior circulation LVO stroke should receive IVT in addition to MT if they have no contraindications to either treatment.
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Affiliation(s)
- Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Université de Paris, INSERM U1266, FHU NeuroVasc, Paris, France
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Heinrich J Audebert
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin & Center for Stroke Research Berlin, Berlin, Germany
| | - Hieronymus Boogaarts
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pervinder Bhogal
- Department of Interventional Neuroradiology, Royal London Hospital, Barts NHS Trust, London, UK
| | - Gian Marco De Marchis
- Neurology and Stroke Center, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Ana Catarina Fonseca
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria-CHLN, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Mikaël Mazighi
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France.,Stroke Unit, Lariboisière Hospital AP-HP-Nord, FHU NeuroVasc, Université de Paris, Paris, France
| | | | - Peter D Schellinger
- Departments of Neurology and Neurogeriatrics, Johannes Wesling Medical Center Minden, University hospitals of the Ruhr-University of Bochum, Bochum, Germany
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Danilo Toni
- Hospital Policlinico Umberto I, Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Philip White
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - William Whiteley
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Wim van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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227
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Roland M, Markaki I, Andersson T, Arnberg F, Sjöstrand C. Mechanical thrombectomy in stroke patients of working age: Real-world outcomes in Sweden. Eur Stroke J 2022; 7:41-47. [PMID: 35300257 PMCID: PMC8921781 DOI: 10.1177/23969873211067883] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2021] [Accepted: 12/02/2021] [Indexed: 11/18/2022] Open
Abstract
Introduction Outcomes after mechanical thrombectomy (MT) in young stroke patients remain elusive due to small patient cohorts. We sought to determine outcomes after MT in stroke patients between ages 18 and 64 years and compare with outcomes in older patients in a large national stroke cohort. Patients and methods We used the Swedish National Stroke Registry and the Swedish National Endovascular Thrombectomy Registry to identify all patients treated with MT for anterior circulation occlusions. We examined outcome measures in terms of functional independence at 90 days (modified Rankin Scale score of 0–2), symptomatic intracerebral hemorrhage (sICH), and mortality at 90 days with multivariable logistic regression analysis. Results Of 2143 patients, 565 were between 18 and 64 years (26.4%) and 1179 (55.0%) were males. Analysis showed that patient aged 18–64 achieved higher rate of functional independence at 90 days (46.2% vs 28.4%, p < .001), had less often sICH (5.5% vs 6.8%, p = .008), and lower 90-day mortality rate (6.9% vs 17.7%, p < .001). Increasing age was associated with a lesser probability of functional independence at 90 days (adjusted odds ratio (aOR), 0.94; [95% confidence intervals (CIs) 0.93–0.95]), higher odds of mortality at 90 days (aOR, 1.05; [95% CIs 1.03–1.06]), and of sICH (aOR 1.03; [95% CIs 1.01–1.05]). Conclusion Patients aged 18–64 years demonstrated better outcome after thrombectomy regarding functional independence, sICH, and mortality at 90 days when compared to older ages.
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Affiliation(s)
- Mihae Roland
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Ioanna Markaki
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Center of Neurology, Academic Specialist Center, Stockholm, Sweden
| | - Tommy Andersson
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
| | - Fabian Arnberg
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Christina Sjöstrand
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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228
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Turc G, Tsivgoulis G, Audebert H, Boogaarts H, Bhogal P, De Marchis GM, Fonseca AC, Khatri P, Mazighi M, Pérez de la Ossa N, Schellinger PD, Strbian D, Toni D, White P, Whiteley W, Zini A, van Zwam W, Fiehler J. EXPRESS: European Stroke Organisation (ESO) – European Society for Minimally Invasive Neurological Therapy (ESMINT) expedited recommendation on indication for intravenous thrombolysis before mechanical thrombectomy in patients with acute ischaemic stroke and anterior circulation large vessel occlusion. Eur Stroke J 2022; 7:I-XXVI. [PMID: 35300256 PMCID: PMC8921785 DOI: 10.1177/23969873221076968] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 01/13/2022] [Indexed: 11/15/2022] Open
Abstract
Six randomized controlled clinical trials have assessed whether mechanical thrombectomy (MT) alone is non-inferior to intravenous thrombolysis (IVT) plus MT within 4.5 hours of symptom onset in patients with anterior circulation large vessel occlusion (LVO) ischaemic stroke and no contraindication to IVT. An expedited recommendation process was initiated by the European Stroke Organisation (ESO) and conducted with the European Society of Minimally Invasive Neurological Therapy (ESMINT) according to ESO standard operating procedure based on the GRADE system. We identified two relevant Population, Intervention, Comparator, Outcome (PICO) questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote evidence-based recommendations. Expert opinion was provided if insufficient evidence was available to provide recommendations based on the GRADE approach.
For stroke patients with anterior circulation LVO directly admitted to a MT-capable centre (“mothership”) within 4.5 hours of symptom onset and eligible for both treatments, we recommend IVT plus MT over MT alone (moderate evidence, strong recommendation). MT should not prevent the initiation of IVT, nor should IVT delay MT. In stroke patients with anterior circulation LVO admitted to a centre without MT facilities and eligible for IVT ≤4.5 hrs and MT, we recommend IVT followed by rapid transfer to a MT capable-centre (“drip-and-ship”) in preference to omitting IVT (low evidence, strong recommendation). Expert consensus statements on ischaemic stroke on awakening from sleep are also provided. Patients with anterior circulation LVO stroke should receive IVT in addition to MT if they have no contraindications to either treatment.
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Affiliation(s)
| | - Georgios Tsivgoulis
- Department of Neuology, University Hospital of AlexandroupolisDemocritus University of Thrace
| | | | | | | | | | | | - Pooja Khatri
- NeurologyUniversity of Cincinnati Medical Center
| | | | | | | | | | - Danilo Toni
- Human NeurosciencesSapienza University of Rome
| | - Phil White
- Institute of Neuroscience (Stroke Research Group)Newcastle University
| | | | | | - Wim van Zwam
- NeurologyMaastricht University Faculty of Health Medicine and Life Sciences
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229
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Podlasek A, Dhillon PS, Butt W, Grunwald IQ, England TJ. To bridge or not to bridge: summary of the new evidence in endovascular stroke treatment. Stroke Vasc Neurol 2022; 7:179-181. [PMID: 35105731 PMCID: PMC9240584 DOI: 10.1136/svn-2021-001465] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 01/20/2022] [Indexed: 11/04/2022] Open
Affiliation(s)
- Anna Podlasek
- Tayside Innovation MedTech Ecosystem (TIME), University of Dundee, Dundee, UK .,NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Permesh Singh Dhillon
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK.,Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Waleed Butt
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Interventional Neuroradiology, University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Iris Q Grunwald
- Tayside Innovation MedTech Ecosystem (TIME), University of Dundee, Dundee, UK
| | - Timothy J England
- Stroke, Division of Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK.,Stroke, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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230
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Lee JS, Lee SJ, Hong JM, Alverne FJAM, Lima FO, Nogueira RG. Endovascular Treatment of Large Vessel Occlusion Strokes Due to Intracranial Atherosclerotic Disease. J Stroke 2022; 24:3-20. [PMID: 35135056 PMCID: PMC8829471 DOI: 10.5853/jos.2021.01375] [Citation(s) in RCA: 33] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 12/08/2021] [Indexed: 11/23/2022] Open
Abstract
Mechanical thrombectomy (MT) has become the gold-standard for patients with acute large vessel occlusion strokes (LVOS). MT is highly effective in the treatment of embolic occlusions; however, underlying intracranial atherosclerotic disease (ICAD) represents a therapeutic challenge, often requiring pharmacological and/or mechanical rescue treatment. Glycoprotein IIb/IIIa inhibitors have been suggested as the best initial approach, if reperfusion can be achieved after thrombectomy, with angioplasty and/or stenting being reserved for the more refractory cases. In this review, we focus on the therapeutic considerations surrounding the endovascular treatment of ICAD-related acute LVOS.
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Affiliation(s)
- Jin Soo Lee
- Department of Neurology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Seong-Joon Lee
- Department of Neurology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Ji Man Hong
- Department of Neurology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | | | | | - Raul G. Nogueira
- Department of Neurology and Neurosurgery, University of Pittsburg Medical Center, UPMC Stroke Institute, Pittsburg, PA, USA
- Correspondence: Raul G. Nogueira Department of Neurology and Neurosurgery, University of Pittsburg Medical Center, UPMC Stroke Institute, C-400 PUH, 200 Lothrop Street, Pittsburgh, PA 15213, USA Tel: +1-412-647-8080 Fax: +1-412-647-8445 E-mail:
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231
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232
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Mitchell PJ, Yan B, Churilov L, Dowling RJ, Bush S, Nguyen T, Campbell BC, Donnan GA, Miao Z, Davis SM. DIRECT-SAFE: A Randomized Controlled Trial of DIRECT Endovascular Clot Retrieval versus Standard Bridging Therapy. J Stroke 2022; 24:57-64. [PMID: 35135060 PMCID: PMC8829478 DOI: 10.5853/jos.2021.03475] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 12/27/2021] [Indexed: 12/01/2022] Open
Abstract
Background and Purpose The benefit regarding co-treatment with intravenous (IV) thrombolysis before mechanical thrombectomy in acute ischemic stroke with large vessel occlusion remains unclear. To test the hypothesis that clinical outcome of ischemic stroke patients with intracranial internal carotid artery, middle cerebral artery or basilar artery occlusion treated with direct endovascular thrombectomy within 4.5 hours will be non-inferior compared with that of standard bridging IV thrombolysis followed by endovascular thrombectomy.
Methods To randomize 780 patients 1:1 to direct thrombectomy or bridging IV thrombolysis with thrombectomy. An international-multicenter prospective randomized open label blinded endpoint trial (PROBE) (ClincalTrials.gov identifier: NCT03494920).
Results Primary endpoint is functional independence defined as modified Rankin Scale (mRS) 0–2 or return to baseline at 90 days. Secondary end points include ordinal mRS analysis, good angiographic reperfusion (modified Thrombolysis in Cerebral Infarction score [mTICI] 2b–3), safety endpoints include symptomatic intracerebral hemorrhage and death.
Conclusions DIRECT-SAFE will provide unique information regarding the impact of direct thrombectomy in patients with large vessel occlusion, including patients with basilar artery occlusion, with comparison across different ethnic groups.
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Affiliation(s)
- Peter J. Mitchell
- Department of Radiology, The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
- Correspondence: Peter J. Mitchell Department of Radiology, The Royal Melbourne Hospital, University of Melbourne, City Campus, Level 1, 300 Grattan Street, Parkville 3050, Australia Tel: +61-3-9342-6450 Fax: +61-3-9342-8369 E-mail:
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Leonid Churilov
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
- Melbourne Medical School, University of Melbourne, Parkville, Australia
| | - Richard J. Dowling
- Department of Radiology, The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Steven Bush
- Department of Radiology, The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Thang Nguyen
- Comprehensive Stroke Centre, Department of Neurology, The People’s Hospital 115, Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Bruce C.V. Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
- The Florey Institute of neuroscience and Mental Health, Parkville, Australia
| | - Geoffrey A. Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Stephen M. Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
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233
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Siow I, Tan BY, Lee KS, Ong N, Toh E, Gopinathan A, Yang C, Bhogal P, Lam E, Spooner O, Meyer L, Fiehler J, Papanagiotou P, Kastrup A, Alexandrou M, Zubel S, Wu Q, Mpotsaris A, Maus V, Anderson T, Gontu V, Arnberg F, Lee TH, Chan BP, Seet RC, Teoh HL, Sharma VK, Yeo LL. Bridging Thrombolysis versus Direct Mechanical Thrombectomy in Stroke Due to Basilar Artery Occlusion. J Stroke 2022; 24:128-137. [PMID: 35135066 PMCID: PMC8829485 DOI: 10.5853/jos.2021.02082] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2021] [Accepted: 10/07/2021] [Indexed: 12/02/2022] Open
Abstract
Background and Purpose Mechanical thrombectomy (MT) is an effective treatment for patients with basilar artery occlusion (BAO) acute ischemic stroke. It remains unclear whether bridging intravenous thrombolysis (IVT) prior to MT confers any benefit. This study compared the outcomes of acute BAO patients who were treated with direct MT versus combined IVT plus MT.
Methods This multicenter retrospective cohort study included patients who were treated for acute BAO from eight comprehensive stroke centers between January 2015 and December 2019. Patients received direct MT or combined bridging IVT plus MT. Primary outcome was favorable functional outcome defined as modified Rankin Scale 0–3 measured at 90 days. Secondary outcome measures included mortality and symptomatic intracranial hemorrhage (sICH).
Results Among 322 patients, 127 (39.4%) patients underwent bridging IVT followed by MT and 195 (60.6%) underwent direct MT. The mean±standard deviation age was 67.5±14.1 years, 64.0% were male and median National Institutes of Health Stroke Scale was 16 (interquartile range, 8 to 25). At 90-day, the rate of favorable functional outcome was similar between the bridging IVT and direct MT groups (39.4% vs. 34.4%, P=0.361). On multivariable analyses, bridging IVT was not as Comorbidisociated with favorable functional outcome, mortality or sICH. In subgroup analyses, patients with underlying atherosclerosis treated with bridging IVT compared to direct MT had a higher rate of favorable functional outcome at 90 days (37.2% vs. 15.5%, P=0.013).
Conclusions Functional outcomes were similar in BAO patients treated with bridging IVT versus direct MT. In the subgroup of patients with underlying large-artery atherosclerosis stroke mechanism, bridging IVT may potentially confer benefit and this warrants further investigation.
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Affiliation(s)
- Isabel Siow
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Benjamin Y.Q. Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Keng Siang Lee
- Bristol Medical School, University of Bristol, Bristol, UK
| | - Natalie Ong
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Emma Toh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Anil Gopinathan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Interventional Radiology, Department of Diagnostic Imaging, National University Health System, Singapore
| | - Cunli Yang
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Interventional Radiology, Department of Diagnostic Imaging, National University Health System, Singapore
| | - Pervinder Bhogal
- Department of Interventional Neuroradiology, The Royal London Hospital, Barts NHS Trust, London, UK
| | - Erika Lam
- Stroke Department, The Royal London Hospital, Barts NHS Trust, London, UK
| | - Oliver Spooner
- Stroke Department, The Royal London Hospital, Barts NHS Trust, London, UK
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Panagiotis Papanagiotou
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte, Bremen, Germany
- First Department of Radiology, School of Medicine, National & Kapodistrian University of Athens, Athens, Greece
| | - Andreas Kastrup
- Department of Neurology, Hospital Bremen-Mitte, Bremen, Germany
| | - Maria Alexandrou
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte, Bremen, Germany
| | - Seraphine Zubel
- Department of Neuroradiology, University Hospital Magdeburg, Magdeburg, Germany
| | - Qingyu Wu
- Department of Neuroradiology, University Hospital Magdeburg, Magdeburg, Germany
| | | | - Volker Maus
- Institute of Diagnostic and Interventional Radiology, Neuroradiology and Nuclear Medicine, University Hospital Knappschaftskrankenhaus Bochum, Bochum, Germany
| | - Tommy Anderson
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
| | - Vamsi Gontu
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Fabian Arnberg
- Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
| | - Tsong Hai Lee
- Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Bernard P.L. Chan
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Raymond C.S. Seet
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Hock Luen Teoh
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Vijay K. Sharma
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Health System, Singapore
| | - Leonard L.L. Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Health System, Singapore
- Correspondence: Leonard L.L. Yeo Division of Neurology, Department of Medicine, National University Health System, 5 Lower Kent Ridge Rd, 119074, Singapore Tel: +65-9061-6139 Fax: +65-6777-8065 E-mail:
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234
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Sibon I, Mazighi M, Smadja D. Decision-Making Process for the Management of Acute Stroke in Patients on Oral Anticoagulant: From Guidelines to Clinical Routine. Front Neurol 2022; 12:794001. [PMID: 35069423 PMCID: PMC8766998 DOI: 10.3389/fneur.2021.794001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2021] [Accepted: 12/10/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The occurrence of both ischaemic (IS) and haemorrhagic stroke in patients on anticoagulation is a major issue due to the frequency of their prescriptions in westernised countries and the expected impact of anticoagulant activity on recanalization during an IS or on the outcomes associated with intracerebral haemorrhage (ICH). Several guidelines are available but sometimes differ in their conclusions or regarding specific issues, and their application in routine emergency settings may be limited by particular individual issues or heterogeneous local specificities. Methods: Based on the current guidelines and additional published data, the algorithms proposed in this paper aim to help the decision-making process regarding stroke management in the setting of concurrent anticoagulants by addressing specific clinical situations based on clinical variables commonly encountered in real-world practise. Results: For patients on non-vitamin K oral anticoagulants, reversion can be achieved with specific antidotes, but only idarucizumab, the specific dabigatran antidote, is indicated in both IS and ICH. Due to the low risk of a prothrombotic effect, idarucizumab can be immediately used in IS patients eligible for thrombolysis before the dabigatran concentration is known. To optimise ICH management, the time since symptom onset, with thresholds proposed at 6 and 9 hours based on the expected timing of haematoma expansion, could also to be taken into account. Conclusions: Anticoagulant reversal in patients presenting with a stroke remains a major issue, and algorithms based on a step-by-step approach may be useful for clinical practise. Real-life studies strongly support the benefits of idarucizumab availability in stroke units and emergency departments.
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Affiliation(s)
- Igor Sibon
- Stroke Unit, Department of Neurology, Bordeaux University Hospital, Bordeaux, France
| | - Mikael Mazighi
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, University of Paris, Laboratory of Vascular Translational Sciences, Paris, France
| | - Didier Smadja
- Stroke Unit, INSERM U895, Department of Neurology, Centre Hospitalier Sud-Francilien, Paris-Saclay University, Corbeil-Essonnes, France
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235
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Xing P, Zhang X, Shen H, Shen F, Zhang L, Li Z, Zhang Y, Hong B, Shi H, Han H, Ye X, Zhang Y, Yang P, Liu J. Effect of stroke etiology on endovascular thrombectomy with or without intravenous alteplase: a subgroup analysis of DIRECT-MT. J Neurointerv Surg 2022; 14:1200-1206. [PMID: 35017204 DOI: 10.1136/neurintsurg-2021-018275] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Accepted: 12/10/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Stroke etiology might influence the clinical outcomes in patients with large vessel occlusion receiving endovascular treatment (EVT) with or without thrombolysis. OBJECTIVE To examine whether stroke etiology resulted in different efficacy and safety in patients treated with EVT-alone or EVT preceded by intravenous alteplase (combined therapy). METHODS We assessed the efficacy and safety of treatment strategy based on prespecified stroke etiology, cardioembolism (CE), large-artery atherosclerosis (LAA), and undetermined cause (UC) for patients enrolled in the DIRECT-MT trial. The primary outcome was the modified Rankin Scale (mRS) score at 90 days. Multivariate ordinal logistic regression analysis was used to calculate the adjusted common OR for a shift of better mRS score for EVT-alone versus combined therapy. A term was entered to test for interaction. RESULTS In this study, 656 patients were grouped into three prespecified stroke etiologic subgroups. The adjusted common ORs for improvement in the 90-day ordinal mRS score with EVT-alone were 1.2 (95% CI 0.8 to 1.8) for CE, 1.6 (95% CI 0.8 to 3.3) for LAA, and 0.8 (95% CI 0.5 to 1.3) for UC. Compared with CE, EVT-alone was more likely to result in an mRS score of 0-1 (pinteraction=0.047) and extended Thrombolysis in Cerebral Infarction ≥2b (pinteraction=0.041) in the LAA group. The differences in mortality and symptomatic intracranial hemorrhage within 90 days were not significant between the subgroups (p>0.05). CONCLUSIONS The results did not support the hypothesis that a specific treatment strategy based on stroke etiology should be used for patients with large vessel occlusion (NCT03469206).
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Affiliation(s)
- Pengfei Xing
- Department of Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xiaoxi Zhang
- Department of Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Hongjian Shen
- Department of Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Fang Shen
- Department of Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Lei Zhang
- Department of Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Zifu Li
- Department of Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yongxin Zhang
- Department of Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Bo Hong
- Department of Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Huaizhang Shi
- Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang, China
| | - Hongxing Han
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong, China
| | - Xiaofei Ye
- Department of Health Statistics, Naval Medical University, Shanghai, China
| | - Yongwei Zhang
- Department of Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Pengfei Yang
- Department of Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jianmin Liu
- Department of Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
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Serum Exosomal mir-340-5p Promotes Angiogenesis in Brain Microvascular Endothelial Cells During Oxygen-Glucose Deprivation. Neurochem Res 2022; 47:907-920. [PMID: 34993704 DOI: 10.1007/s11064-021-03492-x] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Revised: 11/15/2021] [Accepted: 11/17/2021] [Indexed: 02/07/2023]
Abstract
Ischemic stroke (IS) is a cerebrovascular disease with high morbidity, recurrence, and mortality. The purpose of the present study was to investigate the role and mechanism of human serum exosomes on angiogenesis after IS. The middle cerebral artery occlusion (MCAO) in vivo model and oxygen-glucose deprivation (OGD) in vitro model were established. Human serum exosomes from healthy samples (NC-exo) and IS samples (IS-exo) were injected into MCAO mice. Neurobehavioral tests were performed to assess the extent of neurological deficits. The infarct volume was assessed by 2,3,5-triphenyl tetrazolium chloride (TTC) staining, and the levels of inflammatory cytokines were analyzed by enzyme-linked immunosorbent assay (ELISA). In addition, human serum exosomes were cocultured with brain microvascular endothelial cells (BMECs). Cell Counting Kit-8 (CCK-8), Transwell, and tubule formation assays were performed to investigate the proliferation, migration, invasion, length, and branching of BMECs. The miRNA expression profiles of NC-exo and IS-exo were analyzed by high-throughput sequencing and compared. Bioinformatics and luciferase reporter assays were performed to evaluate the relationship between miR-340-5p and CD147. Serum NC-exo and IS-exo had protective effects on IS injury and promoted BMEC angiogenesis. Interestingly, the protective effect of IS-exo was weaker than that of NC-exo. In addition, miR-340-5p was downregulated in IS-exo, and miR-340-5p accelerated angiogenesis of BMECs after OGD. Mechanistically, CD147 was confirmed as a direct target of miR-340-5p. Finally, miR-340-5p promoted angiogenesis by directly targeting CD147. Serum exosome-derived miR-340-5p promote angiogenesis in OGD-induced BMECs by targeting CD147.
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237
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Adusumilli G, Pederson JM, Hardy N, Kallmes KM, Hutchison K, Kobeissi H, Heiferman DM, Heit JJ. Mechanical Thrombectomy With and Without Intravenous Tissue Plasminogen Activator for Acute Ischemic Stroke: A Systematic Review and Meta-Analysis Using Nested Knowledge. Front Neurol 2022; 12:759759. [PMID: 34975722 PMCID: PMC8719452 DOI: 10.3389/fneur.2021.759759] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Accepted: 11/23/2021] [Indexed: 12/18/2022] Open
Abstract
Background: Mechanical thrombectomy (MT) is now the standard-of-care treatment for acute ischemic stroke (AIS) of the anterior circulation and may be performed irrespective of intravenous tissue plasminogen activator (IV-tPA) eligibility prior to the procedure. This study aims to understand better if tPA leads to higher rates of reperfusion and improves functional outcomes in AIS patients after MT and to simultaneously evaluate the functionality and efficiency of a novel semi-automated systematic review platform. Methods: The Nested Knowledge AutoLit semi-automated systematic review platform was utilized to identify randomized control trials published between 2010 and 2021 reporting the use of mechanical thrombectomy and IV-tPA (MT+tPA) vs. MT alone for AIS treatment. The primary outcome was the rate of successful recanalization, defined as thrombolysis in cerebral infarction (TICI) scores ≥2b. Secondary outcomes included 90-day modified Rankin Scale (mRS) 0-2, 90-day mortality, distal embolization to new territory, and symptomatic intracranial hemorrhage (sICH). A separate random effects model was fit for each outcome measure. Results: We subjectively found Nested Knowledge to be highly streamlined and effective at sourcing the correct literature. Four studies with 1,633 patients, 816 in the MT+tPA arm and 817 in the MT arm, were included in the meta-analysis. In each study, patient populations consisted of only tPA-eligible patients and all imaging and clinical outcomes were adjudicated by an independent and blinded core laboratory. Compared to MT alone, patients treated with MT+tPA had higher odds of eTICI ≥2b (OR = 1.34 [95% CI: 1.10; 1.63]). However, there were no statistically significant differences in the rates of 90-day mRS 0-2 (OR = 0.98 [95% CI: 0.77; 1.24]), 90-day mortality (OR = 0.94 [95% CI: 0.67; 1.32]), distal emboli (OR = 0.94 [95% CI: 0.25; 3.60]), or sICH (OR = 1.17 [95% CI: 0.80; 1.72]). Conclusions: Administering tPA prior to MT may improve the rates of recanalization compared to MT alone in tPA-eligible patients being treated for AIS, but a corresponding improvement in functional and safety outcomes was not present in this review. Further studies looking at the role of tPA before mechanical thrombectomy in different cohorts of patients could better clarify the role of tPA in the treatment protocol for AIS.
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Affiliation(s)
- Gautam Adusumilli
- Department of Radiology and Neurosurgery, Stanford University, Stanford, CA, United States
| | - John M Pederson
- Nested Knowledge, Inc, St. Paul, MN, United States.,Superior Medical Experts, Inc, St. Paul, MN, United States
| | - Nicole Hardy
- Nested Knowledge, Inc, St. Paul, MN, United States
| | | | | | - Hassan Kobeissi
- Central Michigan University College of Medicine, Mt. Pleasant, MI, United States
| | - Daniel M Heiferman
- Semmes-Murphey Clinic, Department of Neurosurgery, Memphis, TN, United States
| | - Jeremy J Heit
- Department of Radiology and Neurosurgery, Stanford University, Stanford, CA, United States
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238
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Dicpinigaitis AJ, Gandhi CD, Shah SP, Galea VP, Cooper JB, Feldstein E, Shapiro SD, Kamal H, Kurian C, Kaur G, Tyagi R, Biswas A, Rosenberg J, Bauerschmidt A, Bowers CA, Mayer SA, Al-Mufti F. Endovascular thrombectomy with and without preceding intravenous thrombolysis for treatment of large vessel anterior circulation stroke: A cross-sectional analysis of 50,000 patients. J Neurol Sci 2022; 434:120168. [DOI: 10.1016/j.jns.2022.120168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 12/28/2021] [Accepted: 01/19/2022] [Indexed: 10/19/2022]
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239
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Li G, Wang C, Wang S, Xiong Y, Zhao X. Tenecteplase in Ischemic Stroke: Challenge and Opportunity. Neuropsychiatr Dis Treat 2022; 18:1013-1026. [PMID: 35586365 PMCID: PMC9109727 DOI: 10.2147/ndt.s360967] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 04/15/2022] [Indexed: 11/30/2022] Open
Abstract
PURPOSE OF REVIEW Intravenous thrombolysis is the first-line therapy for ischemic stroke, and alteplase has been used as an intravenous thrombolysis drug for over 20 years. However, considering its low rate of recanalization and risk of intracerebral hemorrhage, alteplase may not be the optimal thrombolytic drug of choice for ischemic stroke. Tenecteplase (TNK) is a genetically engineered, mutant, tissue plasminogen activator that is a potential substitute to alteplase in ischemic stroke. The pharmacokinetic advantages of TNK include greater fibrin selectivity than alteplase and prolonged half-life time. In this review, we have summarized the clinical trials of TNK in ischemic stroke. RECENT FINDINGS Clinical trials showed a higher recanalization rate of TNK over alteplase without increasing the rate of intracerebral hemorrhage. However, not all clinical trials showed superiority of TNK over alteplase in functional outcomes and early neurological improvement. TNK was superior to alteplase in terms of recanalization in patients who fulfilled the imaging mismatch criteria and in those planning to undergo mechanical thrombectomy. SUMMARY TNK has the potential to substitute alteplase for ischemic stroke therapy. Future TNK clinical trials that target functional outcomes are warranted.
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Affiliation(s)
- Guangshuo Li
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Chuanying Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Shang Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
| | - Yunyun Xiong
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China.,Chinese Institute of Brain Research, Beijing, People's Republic of China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China.,China National Clinical Research Center for Neurological Diseases, Beijing, People's Republic of China
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240
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Ju H, Liu C, Zhang G, Xu C, Wang H, Fan H. Neuroprotective potential of nuclear factor erythroid 2-related factor 2 (Nrf2)/antioxidant response element signaling modulator cucurbitacin I upon glucose and oxygen deprivation/reperfusion (OGD/RP). Hum Exp Toxicol 2022; 41:9603271221104450. [PMID: 35632987 DOI: 10.1177/09603271221104450] [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: 11/17/2022]
Abstract
This study aimed to investigate the inhibitory effect and mechanism of Cucurbitacin I (Cu I) on apoptosis, oxidative stress, and mitophagy in PC12 cells with glucose and oxygen deprivation/reperfusion (OGD/RP) injury. OGD/RP cell injury model was established by gas anoxic cell incubator and glucose-free medium. The cells were divided into the control group, OGD/RP group, OGD/RP + Cu I group, and OGD/RP + Cu I + 2 µM nuclear factor erythroid 2-related factor 2 (Nrf2) inhibitor ML385 group. The results showed that apoptotic rate and reactive oxygen species (ROS) production were significantly increased in OGD/RP group, which were reversed by Cu I pretreatment. Meanwhile, western blot analysis proved that Cu I inhibited OGD/RP-induced mitophagy, manifested as the decreased expression of PTEN-induced kinase 1 (PINK1) and parkin RBR E3 ubiquitin-protein ligase (Parkin), and light chain 3 (LC3) Ⅱ∕LC3 I, as well as the increased expression of P62. Furthermore, immunofluorescence (IF) staining showed that Cu I reduced the co-localized puncta of LC3 with TOM20 in OGD/RP-induced PC12 cells. Similarly, transmission electron microscope finding is consistent with the IF results. Mechanically, after Cu I and OGD/RP treatments, nuclear Nrf2 expression and the levels of downstream target genes were significantly upregulated compared with OGD/RP alone treatment. Nrf2 inhibition reversed the protective effects of Cu I on OGD/RP-induced injury in PC12 cells. The present study provides evidence of the neuroprotective effect of Cu I unraveling its potential as a potential therapeutic candidate for the treatment of ischemic stroke.
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Affiliation(s)
- Hu Ju
- Department of Neurosurgery, Qinghai University Affiliated Hospital, Chengxi District, Xining, Qinghai, China
| | - Chuanchuan Liu
- Key Laboratory of Hydatid Research, Qinghai University Affiliated Hospital, Qinghai Province Key Laboratory of Hydatid Disease Research, Chengxi District, Xining, Qinghai, China
| | - Guanghua Zhang
- Department of Neurosurgery, Qinghai University Affiliated Hospital, Chengxi District, Xining, Qinghai, China
| | - Changlin Xu
- Department of Neurosurgery, Qinghai University Affiliated Hospital, Chengxi District, Xining, Qinghai, China
| | - Hu Wang
- 599265Health Commission of Qinghai Province, Chengxi District, Xining, Qinghai, China
| | - Haining Fan
- Department of Hepatopancreatobiliary Surgery, Qinghai University Affiliated Hospital, Qinghai Province Key Laboratory of Hydatid Disease Research, Chengxi District, Xining, Qinghai, China
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241
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Prajapati C, Huded V, Mahajan N, Kulkarni A, Manual D. Comparing Bridging Thrombolysis with Direct Thrombectomy in Stroke due to Large Vessel Occlusion- Indian Experience (LVO-Direct). Ann Indian Acad Neurol 2022; 25:869-874. [PMID: 36561014 PMCID: PMC9764911 DOI: 10.4103/aian.aian_1062_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2021] [Revised: 02/02/2022] [Accepted: 03/20/2022] [Indexed: 12/25/2022] Open
Abstract
Objectives Intravenous thrombolysis alone has poor recanalization rates in large vessel occlusion strokes. Bridging thrombolysis has evolved as a standard treatment approach in emergent large vessel occlusions. Patients who undergo thrombectomy have a higher probability of favorable outcomes irrespective of the use of prior intravenous thrombolysis. Our aim was to compare bridging thrombolysis with direct thrombectomy in ischemic stroke due to large vessel occlusion. Methods We included patients from our stroke registry, with large vessel occlusion strokes, presenting <4.5 hr from onset. Bridging thrombolysis was the standard approach. Direct thrombectomy was done in patients with contraindications to intravenous thrombolysis. The primary outcome was the modified Rankin scale at 3 months. Secondary outcomes were National Institute of Health Stroke Scale at 24 hr post-procedure, door to puncture time, puncture to recanalization time, the extent of recanalization, and the number of passes required. Safety outcomes were any occurrence of intracranial hemorrhage or other complications related to procedure or death. Logistic regression analysis was used to find the factors affecting the outcome. Results Total 76 patients were included, 29 underwent bridging thrombolysis and 47 underwent direct thrombectomy. A favorable outcome (mRS 0-2) was achieved in 19 (65.5%) patients in the bridging group and 25 (58.1%) patients in the direct group (P = 0.4, Chi-square test). There was no significant difference in any of the secondary outcomes as well. Symptomatic intracranial hemorrhage occurred in 2 (2.6%) patients and a total of 10 (13.9%) were dead at 3-month follow-up, comparable in both groups. Conclusion Direct thrombectomy has comparable outcomes to bridging thrombolysis in emergent large vessel occlusions.
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Affiliation(s)
- Chintan Prajapati
- Division of Interventional Neurology, Department of Neurology, Mazumdar Shaw Medical Centre, Narayana Health City, Bengaluru, Karnataka, India
| | - Vikram Huded
- Division of Interventional Neurology, Department of Neurology, Mazumdar Shaw Medical Centre, Narayana Health City, Bengaluru, Karnataka, India,Address for correspondence: Dr. Vikram Huded, Division of Interventional Neurology, Department of Neurology, Narayana Health City, Bengaluru, Karnataka, India. E-mail:
| | - Niranjan Mahajan
- Division of Interventional Neurology, Department of Neurology, Mazumdar Shaw Medical Centre, Narayana Health City, Bengaluru, Karnataka, India
| | - Anirudh Kulkarni
- Division of Interventional Neurology, Department of Neurology, Mazumdar Shaw Medical Centre, Narayana Health City, Bengaluru, Karnataka, India
| | - Delitia Manual
- Department of Biostatistics, Narayana Health City, Bengaluru, Karnataka, India
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242
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Chen J, Wan TF, Xu TC, Chang GC, Chen HS, Liu L. Direct Endovascular Thrombectomy or With Prior Intravenous Thrombolysis for Acute Ischemic Stroke: A Meta-Analysis. Front Neurol 2021; 12:752698. [PMID: 34966345 PMCID: PMC8710447 DOI: 10.3389/fneur.2021.752698] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2021] [Accepted: 10/28/2021] [Indexed: 01/01/2023] Open
Abstract
Background and purpose: It is unclear whether endovascular thrombectomy alone compared with intravenous thrombolysis combination with endovascular thrombectomy can achieve similar neurological outcomes in patients with acute large vessel occlusion stroke. We aimed to perform a systematic review and meta-analysis of randomized controlled trials to compare endovascular thrombectomy alone or intravenous thrombolysis plus endovascular thrombectomy in this population. Methods: We systematically searched PubMed, Embase, and ClinicalTrials.gov. We restricted our search to randomized clinical trials that examined the clinical outcomes of endovascular thrombectomy alone vs. intravenous thrombolysis plus endovascular thrombectomy. The Cochrane risk of bias tool was used to assess study quality. Random-effects meta-analyses were used for evaluating all outcomes. Results: Total three randomized controlled trials with 1,092 individuals enrolled were included in the meta-analysis, including 543 (49.7%) who received endovascular thrombectomy alone and 549 (50.3%) who received intravenous thrombolysis plus endovascular thrombectomy. The primary outcome of 90-day functional independence (modified Rankin scale (mRS) score ≤ 2) was 44.6% (242/543) in the endovascular thrombectomy alone group vs. 42.8% (235/549) in the alteplase with endovascular thrombectomy group (odds ratio (OR), 1.08 [95% CI, 0.85–1.38]; P = 0.0539). Among pre-specified secondary outcomes, no significant between-group differences were found in excellent outcome (mRS score ≤ 1) (OR, 1.12 [95% CI, 0.85–1.47]; P = 0.418), mortality at 90 days (OR, 0.93 [95% CI, 0.68–1.29]; P = 0.673), successful reperfusion (thrombolysis in cerebral infarction 2b-3) (OR, 0.75 [95% CI, 0.54–1.05]; P = 0.099), and symptomatic intracranial hemorrhage (OR, 0.72 [95% CI, 0.45–1.15]; P = 0.171). Conclusions: Among patients with acute ischemic stroke in the anterior circulation within 4.5 h from the onset, endovascular thrombectomy alone was non-inferior to combined intravenous thrombolysis and endovascular thrombectomy.
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Affiliation(s)
- Jing Chen
- Department of Neurology, Central Hospital of Baoji, Baoji, China
| | - Teng-Fei Wan
- Department of Critical Care Medicine, The General Hospital of Northern Theater Command, Shenyang, China
| | - Tian-Ce Xu
- Department of Neurology, The General Hospital of Northern Theater Command, Shenyang, China
| | - Guo-Can Chang
- Department of Neurology, The General Hospital of Northern Theater Command, Shenyang, China
| | - Hui-Sheng Chen
- Department of Neurology, The General Hospital of Northern Theater Command, Shenyang, China
| | - Liang Liu
- Department of Neurology, The General Hospital of Northern Theater Command, Shenyang, China
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243
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Gropen TI, Ivankova NV, Beasley M, Hess EP, Mittman B, Gazi M, Minor M, Crawford W, Floyd AB, Varner GL, Lyerly MJ, Shoemaker CC, Owens J, Wilson K, Gray J, Kamal S. Trauma Communications Center Coordinated Severity-Based Stroke Triage: Protocol of a Hybrid Type 1 Effectiveness-Implementation Study. Front Neurol 2021; 12:788273. [PMID: 34938265 PMCID: PMC8686821 DOI: 10.3389/fneur.2021.788273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 11/15/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Mechanical thrombectomy (MT) can improve the outcomes of patients with large vessel occlusion (LVO), but a minority of patients with LVO are treated and there are disparities in timely access to MT. In part, this is because in most regions, including Alabama, the emergency medical service (EMS) transports all patients with suspected stroke, regardless of severity, to the nearest stroke center. Consequently, patients with LVO may experience delayed arrival at stroke centers with MT capability and worse outcomes. Alabama's trauma communications center (TCC) coordinates EMS transport of trauma patients by trauma severity and regional hospital capability. Our aims are to develop a severity-based stroke triage (SBST) care model based on Alabama's trauma system, compare the effectiveness of this care pathway to current stroke triage in Alabama for improving broad, equitable, and timely access to MT, and explore stakeholder perceptions of the intervention's feasibility, appropriateness, and acceptability. Methods: This is a hybrid type 1 effectiveness-implementation study with a multi-phase mixed methods sequential design and an embedded observational stepped wedge cluster trial. We will extend TCC guided stroke severity assessment to all EMS regions in Alabama; conduct stakeholder interviews and focus groups to aid in development of region and hospital specific prehospital and inter-facility stroke triage plans for patients with suspected LVO; implement a phased rollout of TCC Coordinated SBST across Alabama's six EMS regions; and conduct stakeholder surveys and interviews to assess context-specific perceptions of the intervention. The primary outcome is the change in proportion of prehospital stroke system patients with suspected LVO who are treated with MT before and after implementation of TCC Coordinated SBST. Secondary outcomes include change in broad public health impact before and after implementation and stakeholder perceptions of the intervention's feasibility, appropriateness, and acceptability using a mixed methods approach. With 1200 to 1300 total observations over 36 months, we have 80% power to detect a 15% improvement in the primary endpoint. Discussion: This project, if successful, can demonstrate how the trauma system infrastructure can serve as the basis for a more integrated and effective system of emergency stroke care.
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Affiliation(s)
- Toby I Gropen
- Division of Cerebrovascular Disease, The University of Alabama at Birmingham, Birmingham, AL, United States
| | | | - Mark Beasley
- The University of Alabama at Birmingham, Birmingham, AL, United States
| | - Erik P Hess
- Vanderbilt University Medical Center, Nashville, TN, United States
| | - Brian Mittman
- Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Melissa Gazi
- The University of Alabama at Birmingham, Birmingham, AL, United States
| | - Michael Minor
- The University of Alabama at Birmingham, Birmingham, AL, United States
| | - William Crawford
- The Office of Emergency Medical Services, Alabama Department of Public Health, Montgomery, AL, United States
| | - Alice B Floyd
- The Office of Emergency Medical Services, Alabama Department of Public Health, Prattville, AL, United States
| | - Gary L Varner
- The Office of Emergency Medical Services, Alabama Department of Public Health, Montgomery, AL, United States
| | - Michael J Lyerly
- The University of Alabama at Birmingham, Birmingham, AL, United States
| | | | - Jackie Owens
- Mobile Infirmary Medical Center, Mobile, AL, United States
| | - Kent Wilson
- The Office of Emergency Medical Services, Alabama Department of Public Health, Prattville, AL, United States
| | - Jamie Gray
- The Office of Emergency Medical Services, Alabama Department of Public Health, Montgomery, AL, United States
| | - Shaila Kamal
- The University of Alabama at Birmingham, Birmingham, AL, United States
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244
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Affiliation(s)
- Bruce C V Campbell
- Departments of Medicine and Neurology, Melbourne Brain Centre at The Royal Melbourne Hospital, and the Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia (B.C.V.C.)
| | - Thanh N Nguyen
- Department of Neurology, Radiology, Boston Medical Center, Boston University School of Medicine, MA (T.N.N.)
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245
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Nguyen TN, Fischer U. Treatment Effect of Intravenous Thrombolysis Bridging to Mechanical Thrombectomy on Vessel Occlusion Site. Stroke 2021; 53:17-19. [PMID: 34915740 DOI: 10.1161/strokeaha.121.037603] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Thanh N Nguyen
- Department of Neurology and Radiology, Boston Medical Center, Boston University School of Medicine, MA (T.N.N.)
| | - Urs Fischer
- Department of Neurology, University Hospital Bern, University of Bern, Switzerland (U.F.).,Department of Neurology, University Hospital Basel, University of Basel, Switzerland (U.F.)
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246
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Zhou Y, Xing P, Li Z, Zhang X, Zhang L, Zhang Y, Zhang Y, Hong B, Xu Y, Huang Q, Li Q, Zhao K, Zou C, Yu Y, Zuo Q, Liu S, Zhang L, Majoie CBLM, Roos YBWEM, Treurniet KM, Ye X, Peng Y, Yang P, Liu J. Effect of Occlusion Site on the Safety and Efficacy of Intravenous Alteplase Before Endovascular Thrombectomy: A Prespecified Subgroup Analysis of DIRECT-MT. Stroke 2021; 53:7-16. [PMID: 34915738 DOI: 10.1161/strokeaha.121.035267] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Recent trials showed thrombectomy alone was comparable to bridging therapy in patients with anterior circulation large vessel occlusion eligible for both intravenous alteplase and endovascular thrombectomy. We performed this study to examine whether occlusion site modifies the effect of intravenous alteplase before thrombectomy. METHODS This is a prespecified subgroup analysis of a randomized trial evaluating risk and benefit of intravenous alteplase before thrombectomy (DIRECT-MT [Direct Intra-Arterial Thrombectomy in Order to Revascularize AIS Patients With Large Vessel Occlusion Efficiently in Chinese Tertiary Hospitals]). Among 658 randomized patients, 640 with baseline occlusion site information were included. The primary outcome was the score on the modified Rankin Scale at 90 days. Multivariable ordinal logistic regression analysis with an interaction term was used to estimate treatment effect modification by occlusion location (internal carotid artery versus M1 versus M2). We report the adjusted common odds ratio for a shift toward better outcome on the modified Rankin Scale after thrombectomy alone compared with combination treatment adjusted for age, the National Institutes of Health Stroke Scale score at baseline, the time from stroke onset to randomization, the modified Rankin Scale score before stroke onset, and collateral score per the DIRECT-MT statistical analysis plan. RESULTS The overall adjusted common odds ratio was 1.08 (95% CI, 0.82-1.43) with thrombectomy alone compared with combination treatment, and there was no significant treatment-by-occlusion site interaction (P=0.47). In subgroups based on occlusion location, we found the following adjusted common odds ratios: 0.99 (95% CI, 0.62-1.59) for internal carotid artery occlusions, 1.12 (95% CI, 0.77-1.64) for M1 occlusions, and 1.22 (95% CI, 0.53-2.79) for M2 occlusions. No treatment-by-occlusion site interactions were observed for dichotomized modified Rankin Scale distributions and successful reperfusion (extended thrombolysis in Cerebral Infarction score ≥2b) before thrombectomy. Differences in symptomatic hemorrhage rate were not significant between occlusion locations (internal carotid artery occlusion: 7.02% in bridging therapy versus 7.14% for thrombectomy alone, P=0.97; M1 occlusion: 5.06% versus 2.48%, P=0.22; M2 occlusion: 9.09% versus 4.76%; P=0.78). CONCLUSIONS In this prespecified subgroup of a randomized trial, we found no evidence that occlusion location can inform intravenous alteplase decisions in endovascular treatment eligible patients directly presenting at endovascular treatment capable centers. Future studies are needed to confirm our findings. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03469206.
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Affiliation(s)
- Yu Zhou
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
| | - Pengfei Xing
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
| | - Zifu Li
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
| | - Xiaoxi Zhang
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
| | - Lei Zhang
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
| | - Yongxin Zhang
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
| | - Yongwei Zhang
- Department of Neurology, Naval Medical University Changhai hospital, Shanghai, China (Yongwei Zhang)
| | - Bo Hong
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
| | - Yi Xu
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
| | - Qinghai Huang
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
| | - Qiang Li
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
| | - Kaijun Zhao
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
| | - Chao Zou
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
| | - Ying Yu
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
| | - Qiao Zuo
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
| | - Shen Liu
- Department of interventional radiology, Jiangsu Provincial People's Hospital of Nanjing Medical University, Nanjing, China (S.L.)
| | - Liyong Zhang
- Department of Neurosurgery, Linyi People's Hospital of Qingdao University, Linyi, China (L.Z.)
| | - Charles B L M Majoie
- Department of Neurology, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands (C.B.L.M.M., Y.B.W.E.M.R., K.M.T.)
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands (C.B.L.M.M., Y.B.W.E.M.R., K.M.T.)
| | - K M Treurniet
- Department of Neurology, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands (C.B.L.M.M., Y.B.W.E.M.R., K.M.T.)
- Department of Radiology, Haaglanden Medical Center, The Hague, the Netherlands (K.M.T.)
| | - Xiaofei Ye
- Health Statistics Department, Naval Medical University, Shanghai, China (X.Y.)
| | - Ya Peng
- Department of Neurosurgery, Third Affiliated Hospital of Soochow University, Changzhou, China (Y.P.)
| | - Pengfei Yang
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
| | - Jianmin Liu
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
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Zhao Y, Zhang X, Chen X, Wei Y. Neuronal injuries in cerebral infarction and ischemic stroke: From mechanisms to treatment (Review). Int J Mol Med 2021; 49:15. [PMID: 34878154 PMCID: PMC8711586 DOI: 10.3892/ijmm.2021.5070] [Citation(s) in RCA: 110] [Impact Index Per Article: 36.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 04/13/2021] [Indexed: 11/10/2022] Open
Abstract
Stroke is the leading cause of disabilities and cognitive deficits, accounting for 5.2% of all mortalities worldwide. Transient or permanent occlusion of cerebral vessels leads to ischemic strokes, which constitutes the majority of strokes. Ischemic strokes induce brain infarcts, along with cerebral tissue death and focal neuronal damage. The infarct size and neurological severity after ischemic stroke episodes depends on the time period since occurrence, the severity of ischemia, systemic blood pressure, vein systems and location of infarcts, amongst others. Ischemic stroke is a complex disease, and neuronal injuries after ischemic strokes have been the focus of current studies. The present review will provide a basic pathological background of ischemic stroke and cerebral infarcts. Moreover, the major mechanisms underlying ischemic stroke and neuronal injuries are summarized. This review will also briefly summarize some representative clinical trials and up-to-date treatments that have been applied to stroke and brain infarcts.
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Affiliation(s)
- Yunfei Zhao
- Department of Molecular and Cell Biology, University of California Berkeley, Berkeley, CA 94720, USA
| | - Xiaojing Zhang
- Shanghai Licheng Bio‑Technique Co. Ltd., Shanghai 201900, P.R. China
| | - Xinye Chen
- Shanghai Licheng Bio‑Technique Co. Ltd., Shanghai 201900, P.R. China
| | - Yun Wei
- Shanghai Licheng Bio‑Technique Co. Ltd., Shanghai 201900, P.R. China
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248
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Du H, Lei H, Ambler G, Fang S, He R, Yuan Q, Werring DJ, Liu N. Intravenous Thrombolysis Before Mechanical Thrombectomy for Acute Ischemic Stroke: A Meta-Analysis. J Am Heart Assoc 2021; 10:e022303. [PMID: 34779235 PMCID: PMC9075352 DOI: 10.1161/jaha.121.022303] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background Whether intravenous thrombolysis before mechanical thrombectomy provides additional benefit for functional outcome in acute ischemic stroke remains uncertain. We performed a meta‐analysis to compare the outcomes of direct mechanical thrombectomy (dMT) to mechanical thrombectomy with bridging using intravenous thrombolysis (bridging therapy [BT]) in patients with acute ischemic stroke. Methods and Results We performed a literature search in the PubMed, Excerpta Medica database, and Cochrane Central Register of Controlled Trials from January 1, 2003, to April 26, 2021. We included randomized clinical trials and observational studies that reported the 90‐day functional outcome in patients with acute ischemic stroke undergoing dMT compared with BT. The 12 included studies (3 randomized controlled trials and 9 observational studies) yielded 3924 participants (mean age, 68.0 years [SD, 13.1 years]; women, 44.2%; 1887 participants who received dMT and 2037 participants who received BT). A meta‐analysis of randomized controlled trial and observational data revealed similar 90‐day functional independence (odds ratio [OR], 1.04; 95% CI, 0.90–1.19), mortality (OR, 1.03; 95% CI, 0.78–1.36), and successful recanalization (OR, 0.93; 95% CI, 0.76–1.14) for patients treated with dMT or BT. Compared with those in the BT group, patients in the dMT group were less likely to experience symptomatic intracranial hemorrhage (OR, 0.68; 95% CI, 0.51–0.91; P=0.008) or any intracranial hemorrhage (OR, 0.71; 95% CI, 0.61–0.84; P<0.001). Conclusions In this meta‐analysis of patients with acute ischemic stroke, we found no significant differences in 90‐day functional outcome or mortality between dMT and BT, but a lower rate of symptomatic intracranial hemorrhage for dMT. These findings support the use of dMT without intravenous thrombolysis bridging therapy. Registration URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: 42021234664.
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Affiliation(s)
- Houwei Du
- Department of Neurology Stroke Research Center Fujian Medical University Union Hospital Fuzhou China.,Institute of Clinical Neurology Fujian Medical University Fuzhou China
| | - Hanhan Lei
- Department of Neurology Stroke Research Center Fujian Medical University Union Hospital Fuzhou China.,Institute of Clinical Neurology Fujian Medical University Fuzhou China
| | - Gareth Ambler
- Statistical Science University College London London United Kingdom
| | - Shuangfang Fang
- Department of Neurology Stroke Research Center Fujian Medical University Union Hospital Fuzhou China.,Institute of Clinical Neurology Fujian Medical University Fuzhou China
| | - Raoli He
- Department of Neurology Stroke Research Center Fujian Medical University Union Hospital Fuzhou China.,Institute of Clinical Neurology Fujian Medical University Fuzhou China
| | - Qilin Yuan
- Department of Neurology Stroke Research Center Fujian Medical University Union Hospital Fuzhou China.,Institute of Clinical Neurology Fujian Medical University Fuzhou China
| | - David J Werring
- University College London Queen Square Institute of Neurology London United Kingdom
| | - Nan Liu
- Department of Neurology Stroke Research Center Fujian Medical University Union Hospital Fuzhou China.,Department of Rehabilitation Fujian Medical University Union Hospital Fuzhou China
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249
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Measuring the effect of thrombosis, thrombus maturation and thrombolysis on clot mechanical properties in an in-vitro model. J Biomech 2021; 129:110731. [PMID: 34601216 DOI: 10.1016/j.jbiomech.2021.110731] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2021] [Revised: 07/23/2021] [Accepted: 07/25/2021] [Indexed: 01/05/2023]
Abstract
Changes in acute ischemic stroke thrombi structure and composition may result in significant differences in treatment responsiveness. Ischemic stroke patients are often treated with a thrombolytic agent to dissolve thrombi, however these patients may subsequently undergo mechanical thrombectomy to remove the occlusive clot. We set out to determine if rt-PA thrombolysis treatment of blood clots changes their mechanical properties, which in turn may impact mechanical thrombectomy. Using a design-of-experiment approach, ovine clot analogues were prepared with varying composition and further exposed to different levels of compaction force to simulate the effect of arterial blood pressure. Finally, clots were treated with three r-tPA doses for different durations. Clot mass and mechanical behaviour was analysed to assess changes due to (i) Platelet driven contraction (ii) Compaction force and (iii) Thrombolysis. Clots that were exposed to r-tPA for longer duration showed significant reduction in clot mass (p < 0.001). Exposure time to r-tPA (p < 0.001) was shown to be an independent predictor of lower clot stiffness. A decrease in energy dissipation ratio during mechanical compression was associated with longer exposure time in r-tPA (p = 0.001) and a higher platelet concentration ratio (p = 0.018). The dose of r-tPA was not a significant factor in reducing clot mass or changing mechanical properties of the clots. Fibrinolysis reduces clot stiffness which may explain increased distal clot migration observed in patients treated with r-tPA and should be considered as a potential clot modification factor before mechanical thrombectomy.
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250
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Zhao Z, Hu X, Wang J, Wang J, Hou Y, Chen S. Zinc finger E-Box binding homeobox 2 (ZEB2)-induced astrogliosis protected neuron from pyroptosis in cerebral ischemia and reperfusion injury. Bioengineered 2021; 12:12917-12930. [PMID: 34852714 PMCID: PMC8809936 DOI: 10.1080/21655979.2021.2012551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2021] [Revised: 11/24/2021] [Accepted: 11/25/2021] [Indexed: 11/15/2022] Open
Abstract
Ischemia injury can cause cell death or impairment of neuron and astrocytes, and thus induce loss of nerve function. central nervous systems injury induces an aberrant activation of astrocytes called astrogliosis. Pyroptosis, which is a kind of programmed cell death, was proved play an important role in ischemia injury. Zinc Finger E-Box Binding Homeobox 2 (ZEB2) promoted neuron astrogliosis, which play a protected role in neuron regeneration. However, its precise mechanism remains unclear. This study investigated the mechanism of ZEB2 on astrogliosis and neuron regeneration after cerebral ischemia reperfusion condition. To confirm our hypothesis, Neurons and astrocytes were isolated from fetal Sprague Dawley rats, in vivo Middle Cerebral Artery Occlusion/reperfusion (MCAO/R) rat model and in vitro oxygen-glucose deprivation/reperfusion (OGD/R)-treated astrocytes and neurocytes model were constructed. Our results showed that ZEB2 was expressed in nucleus of astrocyte and upregulated after OGD/R induction, ZEB2 promoted astrogliosis. Further upregulation of ZEB2 promoted the astrogliosis, which promoted neuron proliferation and regeneration by decreased pyroptosis. Moreover, this finding was further confirmed in vivo MCAO/R rat model. Overexpression of ZEB2 promoted astrogliosis, which decreased infarct volume and accumulated recovery of neurological function by alleviated pyroptosis. This finding revealed that ZEB2 was a regulator of the astrogliosis after ischemia/reperfusion injury, and then astrogliosis promoted neuron regeneration via decreased neuron pyroptosis. Therefore, ZEB2 may be a potential therapeutic target for ischemia/reperfusion injury.
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Affiliation(s)
- Zhixin Zhao
- Department of Neurosurgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Zhejiang Province, China
| | - Xiaoming Hu
- Department of Neurosurgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Zhejiang Province, China
| | - Jie Wang
- Department of Neurosurgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Zhejiang Province, China
| | - Jianfeng Wang
- Department of Neurosurgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Zhejiang Province, China
| | - Yong Hou
- Department of Neurosurgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Zhejiang Province, China
| | - Suyun Chen
- Department of Clinical Laboratory, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Zhejiang Province, China
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