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Ringheanu VM, Tekle WG, Preston L, Sarraj A, Hassan AE. Higher number of stent-retriever thrombectomy passes significantly increases risk of mass effect, poor functional outcome, and mortality. Interv Neuroradiol 2023; 29:674-682. [PMID: 35637163 PMCID: PMC10680954 DOI: 10.1177/15910199221104624] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 05/15/2022] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION Endovascular treatment (EVT) is a widely proven method to treat patients diagnosed with intracranial large vessel occlusion (LVO). Through this method of treatment, it has been hypothesized that a lower number of thrombectomy passes is an indicator of higher rates of modified Thrombolysis in Cerebral Infarction 2B-3 (mTICI) reperfusion and favorable outcomes at 90-days defined as modified Rankin Scale 0-2 (mRS). METHODS Through the utilization of a prospectively collected endovascular database between 2012-2020, variables such as demographics, co-morbid conditions, intracerebral hemorrhage, mass effect, mortality rate, and good/poor outcomes regarding mTICI score and mRS assessment at 90-days were examined. The outcomes between patients receiving EVT who were treated with < 3 thrombectomy passes or ≥3 passes were compared. RESULTS Out of 454 patients treated with mechanical thrombectomy of qualifying intracranial internal carotid artery (ICA) or middle cerebral artery occlusion, site of occlusion (ICA, ICA-T M1, and M2/M3), a total of 372 (81.9%) were treated with < 3 passes (average age 70.34 ± 13.75 years, 46.0% women), and 82 (18.1%) were treated with ≥3 passes (average age 70.30 ± 13.72 years, 48.8% women). Significantly higher rates of mass effect (p = 0.043), mRS score 3-6 (p = 0.029), mortality (p = 0.025), and poor reperfusion (p < 0.0001) were noted in patients treated with ≥3 passes. CONCLUSION A higher number of thrombectomy passes, characterized as ≥3 in this study, was associated with significantly worsened patient outcome regarding mRS and mortality. Further research is required to determine whether the number of thrombectomy passes is an accurate predictor of treatment outcome.
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Affiliation(s)
- Victor M. Ringheanu
- Clinical Research Department, Valley Baptist Medical Center, Harlingen, TX, United States
| | - Wondwossen G. Tekle
- Clinical Research Department, Valley Baptist Medical Center, Harlingen, TX, United States
- Department of Neurology, UTRGV School of Medicine, Edinburg, TX, United States
- Neuroscience Department, Valley Baptist Medical Center-Harlingen, TX, United States
| | - Laurie Preston
- Clinical Research Department, Valley Baptist Medical Center, Harlingen, TX, United States
| | - Amrou Sarraj
- Department of Neurology, McGovern Medical School, San Antonio, TX, United States
| | - Ameer E. Hassan
- Clinical Research Department, Valley Baptist Medical Center, Harlingen, TX, United States
- Department of Neurology, UTRGV School of Medicine, Edinburg, TX, United States
- Neuroscience Department, Valley Baptist Medical Center-Harlingen, TX, United States
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252
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Parvathy G, Dey RC, Kutikuppala LVS, Maheshwari AR, Josey E, Chintala JS, Abdullah M, Godugu S. Mechanical thrombectomy for AIS from large vessel occlusion - current trends and future perspectives. Ann Med Surg (Lond) 2023; 85:6021-6028. [PMID: 38098569 PMCID: PMC10718368 DOI: 10.1097/ms9.0000000000001385] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Accepted: 09/28/2023] [Indexed: 12/17/2023] Open
Abstract
Stroke is found to be one of the global top causes of mortality and the major factor in years of life with a handicap (DALYs). Ischemic strokes contributed to nearly 70% of all strokes worldwide. For endovascular thrombectomy in acute ischemic stroke with large vessel obstruction (AIS-LVO), using stent retrievers and/or reperfusion catheters has become the gold standard of therapy. The methodology involved keyword-based search in databases like PubMed, Embase, and Google Scholar for recent publications on mechanical thrombectomy (MT), AIS, large vessel occlusion (Large Vessel Occlusion (LVO)), screening relevant articles, retrieving full texts, and synthesizing key findings on procedural advancements, patient selection, COVID-19 (coronavirus disease 2019) impact, delay effects, effectiveness, clinical outcomes, and future perspectives. Only people with substantial cerebral artery obstruction may do well from MT. This includes the distal carotid artery and the proximal middle cerebral artery (segment M1). The size of a blocked vessel and NIHSS (National Institute of Health Stroke Scale) score are directly connected. Both the 2018 and 2019 versions of the AHA/ASA (American Heart Association/American Stroke Association) Guidelines for the Early Management of Patients with Acute Ischemic Stroke contained the recommendations that cases with AIS-LVO get endovascular therapy when administered during the time frame of 0-6 h after onset (Grade IA evidence). It is questionable whether this group of patients can be managed without the need for intravenous tissue plasminogen activator at the onset. When functional independence [modified Rankin Scale (mRS) score 2] was present at long-term follow-up, the endovascular intervention was favored. Tenecteplase, which differs from alteplase in terms of genetic variation, has a greater half-life and a higher level of fibrin selectivity, enabling bolus infusion. Studies have also demonstrated its efficacy and safety, as well as its long-term cost-effectiveness.
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Affiliation(s)
- Gauri Parvathy
- Department of Internal Medicine, Tbilisi State Medical University, Tbilisi, Georgia
| | - Rohit C. Dey
- Department of Internal Medicine, Altai State Medical University, Barnaul, Russia
| | | | - Aakansh R. Maheshwari
- Department of Internal Medicine, Pacific Medical College and Hospital, Rajasthan, India
| | - Elwy Josey
- Department of Internal Medicine, Dubai Academic Health Corporation
| | - Jyothi S. Chintala
- Department of Anesthesiology, Dr Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Chinaoutpalli, Andhra Pradesh
| | | | - Swathi Godugu
- Department of Internal Medicine, Zaporozhye State Medical University, Zaporozhye, Ukraine
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253
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Guan J, Wang Q, Zhao Q. Lymphocyte to Monocyte Ratio is Independently Associated with Futile Recanalization in Acute Ischemic Stroke After Endovascular Therapy. Neuropsychiatr Dis Treat 2023; 19:2585-2596. [PMID: 38046831 PMCID: PMC10693198 DOI: 10.2147/ndt.s434225] [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: 09/09/2023] [Accepted: 11/16/2023] [Indexed: 12/05/2023] Open
Abstract
Background and Purpose Acute ischemic stroke (AIS) caused by large artery occlusion (LAO) poses considerable risks in terms of mortality and disability. Endovascular treatment (EVT) has emerged as a primary intervention for this condition. However, the occurrence of futile recanalization (FR) following EVT remains common, necessitating the identification of predictive markers for treatment outcomes. Although the lymphocyte to monocyte ratio (LMR) has been linked to various diseases, its association with FR after EVT in AIS patients has not been investigated. Methods An analysis was conducted on patients with AIS who underwent EVT within 24 hours of symptom onset. The success of reperfusion was evaluated using the modified Thrombolysis in Cerebral Infarction (mTICI) scale, with patients achieving an mTICI score of ≥2b being included in the study. Various clinical, radiological, and laboratory variables, including lymphocyte-to-monocyte ratio (LMR), neutrophil-to-lymphocyte ratio (NLR), and platelet-to-lymphocyte ratio (PLR), were collected. Logistic regression analysis was used to determine factors associated with FR, and receiver operating characteristic (ROC) analysis was performed to assess the predictive value of LMR. Results Among the cohort of 101 patients, it was observed that 52.4% experienced FR. Upon admission, lower levels of lymphocyte-to-monocyte ratio (LMR) were found to be associated with older age, higher baseline NIHSS scores, lower ASPECTS, and poorer mRS scores at 90 days. Both univariate and multivariate logistic regression analyses indicated that low LMR independently predicted FR, with an adjusted odds ratio of 0.64 (95% CI = 0.412-0.984, p = 0.042). ROC analysis further demonstrated that LMR had an area under the curve (AUC) of 0.789 for predicting FR. Conclusion This study establishes the potential value of the lymphocyte-to-monocyte ratio (LMR) as a prognostic marker for predicting FR in patients with AIS undergoing EVT. Decreased LMR levels are associated with unfavorable clinical outcomes.
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Affiliation(s)
- Jincheng Guan
- Department of Neurology, People’s Hospital of Longhua, Shenzhen, People’s Republic of China
| | - Qiong Wang
- Department of Neurology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, People’s Republic of China
| | - Qingshi Zhao
- Department of Neurology, People’s Hospital of Longhua, Shenzhen, People’s Republic of China
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254
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Telianidis J, Hunter A, Widdop R, Kemp-Harper B, Pham V, McCarthy C, Chai SY. Inhibition of insulin-regulated aminopeptidase confers neuroprotection in a conscious model of ischemic stroke. Sci Rep 2023; 13:19722. [PMID: 37957163 PMCID: PMC10643421 DOI: 10.1038/s41598-023-46072-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2023] [Accepted: 10/27/2023] [Indexed: 11/15/2023] Open
Abstract
Stroke is a leading cause of mortality and morbidity with a paucity of effective pharmacological treatments. We have previously identified insulin-regulated aminopeptidase (IRAP) as a potential target for the development of a new class of drugs for the treatment of stroke, as global deletion of this gene in mice significantly protected against ischemic damage. In the current study, we demonstrate that small molecular weight IRAP inhibitors reduce infarct volume and improve neurological outcome in a hypertensive animal model of ischemic stroke. The effects of two structurally distinct IRAP inhibitors (HFI419 or SJM164) were investigated in a model of stroke where the middle cerebral artery was transiently occluded with endothelin-1 in the conscious spontaneously hypertensive rat. IRAP inhibitor was administered into the lateral ventricle at 2 or 6 h after stroke, with subsequent doses delivered at 24, 48 and 70 h post-stroke. Functional outcomes were assessed prior to drug treatment, and on day 1 and 3 post-stroke. Histological analyses and neuroinflammatory cytokine profiling were conducted at 72 and 24 h post-stroke respectively. IRAP inhibitor treatment following stroke significantly reduced infarct volume and improved neurological and motor deficits. These protective effects were maintained even when the therapeutic window was extended to 6 h. Examination of the cellular architecture at 72 h post-stroke demonstrated that IRAP expression was upregulated in CD11b positive cells and activated astrocytes. Furthermore, IRAP inhibitor treatment significantly increased gene expression for interleukin 6 and C-C motif chemokine ligand 2 in the ischemic core. This study provides proof-of-principle that selective inhibition of IRAP activity with two structurally distinct IRAP inhibitors reduces infarct volume and improves functional outcome even when the first dose is administered 6 h post-stroke. This is the first direct evidence that IRAP inhibitors are a class of drug with potential use in the treatment of ischemic stroke.
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Affiliation(s)
- Jonathon Telianidis
- Department of Physiology, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC, 3800, Australia
| | - Andrew Hunter
- Department of Physiology, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC, 3800, Australia
| | - Robert Widdop
- Department Pharmacology, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC, 3800, Australia
| | - Barbara Kemp-Harper
- Department Pharmacology, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC, 3800, Australia
| | - Vi Pham
- Drug Discovery Biology, Monash Institute of Pharmaceutical Sciences, Monash University, Parkville, VIC, 3052, Australia
| | - Claudia McCarthy
- Department Pharmacology, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC, 3800, Australia
| | - Siew Yeen Chai
- Department of Physiology, Monash Biomedicine Discovery Institute, Monash University, Clayton, VIC, 3800, Australia.
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255
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Bendszus M, Fiehler J, Subtil F, Bonekamp S, Aamodt AH, Fuentes B, Gizewski ER, Hill MD, Krajina A, Pierot L, Simonsen CZ, Zeleňák K, Blauenfeldt RA, Cheng B, Denis A, Deutschmann H, Dorn F, Flottmann F, Gellißen S, Gerber JC, Goyal M, Haring J, Herweh C, Hopf-Jensen S, Hua VT, Jensen M, Kastrup A, Keil CF, Klepanec A, Kurča E, Mikkelsen R, Möhlenbruch M, Müller-Hülsbeck S, Münnich N, Pagano P, Papanagiotou P, Petzold GC, Pham M, Puetz V, Raupach J, Reimann G, Ringleb PA, Schell M, Schlemm E, Schönenberger S, Tennøe B, Ulfert C, Vališ K, Vítková E, Vollherbst DF, Wick W, Thomalla G. Endovascular thrombectomy for acute ischaemic stroke with established large infarct: multicentre, open-label, randomised trial. Lancet 2023; 402:1753-1763. [PMID: 37837989 DOI: 10.1016/s0140-6736(23)02032-9] [Citation(s) in RCA: 116] [Impact Index Per Article: 116.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2023] [Revised: 09/12/2023] [Accepted: 09/18/2023] [Indexed: 10/16/2023]
Abstract
BACKGROUND Recent evidence suggests a beneficial effect of endovascular thrombectomy in acute ischaemic stroke with large infarct; however, previous trials have relied on multimodal brain imaging, whereas non-contrast CT is mostly used in clinical practice. METHODS In a prospective multicentre, open-label, randomised trial, patients with acute ischaemic stroke due to large vessel occlusion in the anterior circulation and a large established infarct indicated by an Alberta Stroke Program Early Computed Tomographic Score (ASPECTS) of 3-5 were randomly assigned using a central, web-based system (using a 1:1 ratio) to receive either endovascular thrombectomy with medical treatment or medical treatment (ie, standard of care) alone up to 12 h from stroke onset. The study was conducted in 40 hospitals in Europe and one site in Canada. The primary outcome was functional outcome across the entire range of the modified Rankin Scale at 90 days, assessed by investigators masked to treatment assignment. The primary analysis was done in the intention-to-treat population. Safety endpoints included mortality and rates of symptomatic intracranial haemorrhage and were analysed in the safety population, which included all patients based on the treatment they received. This trial is registered with ClinicalTrials.gov, NCT03094715. FINDINGS From July 17, 2018, to Feb 21, 2023, 253 patients were randomly assigned, with 125 patients assigned to endovascular thrombectomy and 128 to medical treatment alone. The trial was stopped early for efficacy after the first pre-planned interim analysis. At 90 days, endovascular thrombectomy was associated with a shift in the distribution of scores on the modified Rankin Scale towards better outcome (adjusted common OR 2·58 [95% CI 1·60-4·15]; p=0·0001) and with lower mortality (hazard ratio 0·67 [95% CI 0·46-0·98]; p=0·038). Symptomatic intracranial haemorrhage occurred in seven (6%) patients with thrombectomy and in six (5%) with medical treatment alone. INTERPRETATION Endovascular thrombectomy was associated with improved functional outcome and lower mortality in patients with acute ischaemic stroke from large vessel occlusion with established large infarct in a setting using non-contrast CT as the predominant imaging modality for patient selection. FUNDING EU Horizon 2020.
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Affiliation(s)
- Martin Bendszus
- Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Jens Fiehler
- Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany; eppdata GmbH, Hamburg, Germany
| | - Fabien Subtil
- Service de Biostatistique, Hospices Civils de Lyon, Lyon, France; Laboratoire de Biométrie et Biologie Évolutive, Université de Lyon, Villeurbanne, France
| | - Susanne Bonekamp
- Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | | | - Blanca Fuentes
- Department of Neurology and Stroke Center, Hospital La Paz Institute for Health Research-La Paz University Hospital-Universidad Autonoma de Madrid, Madrid, Spain
| | - Elke R Gizewski
- Department of Neuroradiology, Medical University Innsbruck, Innsbruck, Austria
| | - Michael D Hill
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Health Science Centre, University of Calgary & Foothills Medical Centre, Calgary, AB, Canada
| | - Antonin Krajina
- Department of Radiology, Faculty of Medicine in Hradec Kralove, Charles University, Czech Republic
| | - Laurent Pierot
- Department of Neuroradiology, Hôpital Maison-Blanche, Université Reims-Champagne-Ardenne, Reims, France
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Aarhus, Denmark
| | - Kamil Zeleňák
- Clinic of Radiology, Jessenius Faculty of Medicine, Comenius University, Martin, Slovakia
| | | | - Bastian Cheng
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Angélique Denis
- Service de Biostatistique, Hospices Civils de Lyon, Lyon, France; Laboratoire de Biométrie et Biologie Évolutive, Université de Lyon, Villeurbanne, France
| | - Hannes Deutschmann
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University Graz, Graz, Austria
| | - Franziska Dorn
- Klinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum Bonn, Bonn, Germany
| | - Fabian Flottmann
- Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Gellißen
- Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Johannes C Gerber
- Institute of Neuroradiology, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany; Dresden Neurovascular Center, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Mayank Goyal
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Health Science Centre, University of Calgary & Foothills Medical Centre, Calgary, AB, Canada
| | - Jozef Haring
- Department of Neurology, Faculty Hospital Trnava, Trnava, Slovakia
| | - Christian Herweh
- Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Silke Hopf-Jensen
- Institut für Diagnostische und Interventionelle Radiologie und Neuroradiologie, DIAKO Krankenhaus gGmbH, Flensburg, Germany
| | - Vi Tuan Hua
- Department of Neurology, Hôpital Maison-Blanche, Université Reims-Champagne-Ardenne, Reims, France
| | - Märit Jensen
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Kastrup
- Klinik für Neurologie, Klinikum Bremen Mitte, Bremen, Germany
| | - Christiane Fee Keil
- Institut für Neuroradiologie, Universitätsklinikum Frankfurt, Frankfurt am Main, Germany
| | - Andrej Klepanec
- Department of Radiology, Faculty Hospital Trnava, Trnava, Slovakia
| | - Egon Kurča
- Clinic of Neurology, Jessenius Faculty of Medicine, Comenius University, Martin, Slovakia
| | - Ronni Mikkelsen
- Department of Neuroradiology, Aarhus University Hospital, Aarhus, Denmark
| | | | - Stefan Müller-Hülsbeck
- Institut für Diagnostische und Interventionelle Radiologie und Neuroradiologie, DIAKO Krankenhaus gGmbH, Flensburg, Germany
| | - Nico Münnich
- Klinikum Dortmund gGmbH, Klinikum der Universität Witten/Herdecke, Dortmund, Germany
| | - Paolo Pagano
- Department of Neuroradiology, Hôpital Maison-Blanche, Université Reims-Champagne-Ardenne, Reims, France
| | - Panagiotis Papanagiotou
- Klinik für Diagnostische und Interventionelle Neuroradiologie, Klinikum Bremen Mitte, Bremen, Germany; Department of Radiology, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Gabor C Petzold
- Vascular Neurology Research Group, German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany; Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Mirko Pham
- Institut für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Volker Puetz
- Department of Neurology, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany; Dresden Neurovascular Center, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Jan Raupach
- Department of Radiology, Faculty of Medicine in Hradec Kralove, Charles University, Czech Republic
| | - Gernot Reimann
- Klinikum Dortmund gGmbH, Klinikum der Universität Witten/Herdecke, Dortmund, Germany
| | | | - Maximilian Schell
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Eckhard Schlemm
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | - Bjørn Tennøe
- Department of Neuroradiology, Oslo University Hospital, Oslo, Norway
| | - Christian Ulfert
- Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Kateřina Vališ
- St Anne's University Hospital Brno, Brno, Czech Republic
| | - Eva Vítková
- Department of Neurology, Faculty of Medicine in Hradec Kralove, Charles University, Czech Republic
| | | | - Wolfgang Wick
- Neurologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Götz Thomalla
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.
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256
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Han N, Ma L, Xie Y, Xu G, Jia Y, Zhang N, Wang H. Application of Sofia Plus catheter tip shaping in the treatment of acute middle cerebral artery occlusion: A case control study. Medicine (Baltimore) 2023; 102:e35864. [PMID: 37960793 PMCID: PMC10637553 DOI: 10.1097/md.0000000000035864] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 10/10/2023] [Indexed: 11/15/2023] Open
Abstract
To explore the safety and efficacy of Sofia Plus distal access catheter tip shaping for treatment of acute middle cerebral artery embolism. This single-center retrospective study involved patients eligible for acute embolic middle cerebral artery occlusion from January 2020 to October 2021. They were divided into a shaping and non-shaping group according to whether the Sofia Plus catheter tip was shaped intraoperatively. Baseline data, preoperative Alberta Stroke Program Early Computed Tomography (ASPECT) score, National Institutes of Health Stroke Scale (NIHSS) score, onset-to-admission time, admission-to-puncture time, Sofia Plus-clot time, puncture-to-reperfusion time, surgical approach, and use of a stent for rescue thrombectomy were compared between the 2 groups. Postoperative symptomatic intracerebral hemorrhage and the modified Rankin scale score at the 90-day follow-up were observed. In total, 54 patients were enrolled in this study (shaping group, 26 patients; non-shaping group, 28 patients). Their mean age was 64.8 ± 14.6 years, and the proportion of men was 68.5% (37/54). Successful recanalization was achieved in all patients. There were no differences in the baseline data (age, sex, history, pre-admission ASPECT score, or NIHSS score) between the shaping and non-shaping groups. Patients treated with a shaped Sofia Plus catheter had a shorter Sofia Plus-clot time [median (25th, 75th percentile: 4 (4, 7) vs 10.5 (5.25, 14) min, P = .006] and puncture-to-reperfusion time [16.5 (12, 30.5) vs 26 (16.25, 38.25) min, P = .036]. There were significant differences in the surgical approaches between the 2 groups. The rates of a favorable outcome (57.7% vs 64.3%, P = .62) and postoperative symptomatic intracerebral hemorrhage (7.7% vs 3.6%, P = .60) were not significantly different between the groups. Sofia Plus catheter tip shaping improved catheter trafficability and reduced the operative time. It was safe and effective for treatment of acute middle cerebral artery thrombotic occlusion.
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Affiliation(s)
- Ning Han
- Neurointerventional department, Hebei General Hospital, Shijiazhuang, Hebei, China
- Hebei Provincial Key Laboratory of Cerebral Networks and Cognitive Disorders, Shijiazhuang, Hebei, China
| | - Liang Ma
- Neurointerventional department, Hebei General Hospital, Shijiazhuang, Hebei, China
- Hebei Provincial Key Laboratory of Cerebral Networks and Cognitive Disorders, Shijiazhuang, Hebei, China
| | - Yanzhao Xie
- Neurointerventional department, Hebei General Hospital, Shijiazhuang, Hebei, China
- Hebei Provincial Key Laboratory of Cerebral Networks and Cognitive Disorders, Shijiazhuang, Hebei, China
| | - Guodong Xu
- Neurointerventional department, Hebei General Hospital, Shijiazhuang, Hebei, China
- Hebei Provincial Key Laboratory of Cerebral Networks and Cognitive Disorders, Shijiazhuang, Hebei, China
| | - Yangjuan Jia
- Department of Emergency Medicine, Hebei General Hospital, Shijiazhuang, Hebei, China
| | - Ning Zhang
- Department of Ultrasound, Hebei General Hospital, Shijiazhuang, Hebei, China
| | - Hebo Wang
- Hebei Provincial Key Laboratory of Cerebral Networks and Cognitive Disorders, Shijiazhuang, Hebei, China
- Neurology Department, Hebei General Hospital, Shijiazhuang, Hebei, China
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257
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Webb M, Essibayi MA, Al Kasab S, Maier IL, Psychogios MN, Grossberg JA, Alawieh A, Wolfe SQ, Arthur A, Dumont T, Kan P, Kim JT, De Leacy R, Osbun J, Rai A, Jabbour P, Park MS, Crosa R, Levitt MR, Polifka A, Yoshimura S, Matouk C, Williamson RW, Fragata I, Chowdhry SA, Starke RM, Samaniego EA, Cuellar H, Spiotta A, Mascitelli J. Predictors of Angiographic Outcome After Failed Thrombectomy for Large Vessel Occlusion: Insights from the Stroke Thrombectomy and Aneurysm Registry. Neurosurgery 2023; 93:1168-1179. [PMID: 37377425 DOI: 10.1227/neu.0000000000002560] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2022] [Accepted: 04/17/2023] [Indexed: 06/29/2023] Open
Abstract
BACKGROUND Mechanical thrombectomy failure (MTF) occurs in approximately 15% of cases. OBJECTIVE To investigate factors that predict MTF. METHODS This was a retrospective review of prospectively collected data from the Stroke Thrombectomy and Aneurysm Registry. Patients who underwent mechanical thrombectomy (MT) for large vessel occlusion (LVO) were included. Patients were categorized by mechanical thrombectomy success (MTS) (≥mTICI 2b) or MTF ( RESULTS A total of 6780 patients were included, and 1001 experienced anterior circulation MTF. Patients in the MTF group were older (73 vs 72, P = .044) and had higher poor premorbid modified Rankin Scale (mRS) (10.8% vs 8.4%, P = .017). Onset to puncture time was greater in the MTF group (273 vs 260 min, P = .08). No significant differences were found between the access site, use of balloon guide catheter, frontline technique, or first-pass devices between the MTF and MTS groups. More complications occurred in the MTF group (14% vs 5.8%), including symptomatic intracerebral hemorrhage (9.4% vs 6.1%) and craniectomies (10% vs 2.8%) ( P < .001). On UVA, age, poor pretreatment mRS, increased number of passes, and increased procedure time were associated with MTF. Internal carotid artery, M1, and M2 occlusions had decreased odds of MTF. Poor preprocedure mRS, number of passes, and procedure time remained significant on MVA. A subgroup analysis of posterior circulation LVO revealed that number of passes and total procedure time correlated with increased odds of MTF ( P < .001) while rescue stenting was associated with less odds of MTF (odds ratio 0.20, 95% CI 0.06-0.63). Number of passes remained significant on MVA of posterior circulation occlusion subgroup analysis. CONCLUSION Anterior circulation MTF is associated with more complications and worse outcomes. No differences were found between techniques or devises used for the first pass during MT. Rescue intracranial stenting may decrease the likelihood of MTF for posterior circulation MT.
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Affiliation(s)
- Matthew Webb
- Department of Neurosurgery, University of Texas Health Science Center San Antonio, San Antonio , Texas , USA
| | | | - Sami Al Kasab
- Medical University of South Carolina, Charleston , South Carolina , USA
| | - Ilko L Maier
- University Medical Center Göttingen, Göttingen , Germany
| | | | | | | | | | - Adam Arthur
- University of Tennessee Health Science Center, Memphis , Tennessee , USA
| | - Travis Dumont
- Bannner University of Arizona Medical Center, Tucson , Arizona , USA
| | - Peter Kan
- University of Texas Medical Branch, Galveston , Texas , USA
| | - Joon-Tae Kim
- Chonnam National University Hospital, Gwangju , South Korea
| | | | - Joshua Osbun
- Washington University in St. Louis, St. Louis , Missouri , USA
| | - Ansaar Rai
- Department of Neuroradiology, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Pascal Jabbour
- Department of Neuroradiology, School of Medicine, West Virginia University, Morgantown, West Virginia, USA
| | - Min S Park
- Thomas Jefferson University Hospital, Philadelphia , Pennsylvania , USA
| | - Roberto Crosa
- University of Virginia, Charlottesville , Virginia , USA
| | - Michael R Levitt
- Centro Endovascular Neurológico, Médica Uruguaya, Montevideo , Uruguay
| | - Adam Polifka
- University of Washington, Seattle , Washington , USA
| | | | | | | | - Isabel Fragata
- Allegheny General Hospital, Pittsburgh , Pennsylvania , USA
| | | | - Robert M Starke
- NorthShore University Health System, Evanston , Illinois , USA
| | | | | | - Alejandro Spiotta
- Medical University of South Carolina, Charleston , South Carolina , USA
| | - Justin Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center San Antonio, San Antonio , Texas , USA
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Barlinn K, Langezaal LCM, Dippel DWJ, van Zwam WH, Roessler M, Roos YBWEM, Emmer BJ, van Oostenbrugge RJ, Gerber JC, Yoo AJ, Pontes-Neto OM, Mazighi M, Audebert HJ, Michel P, Schonewille WJ, Puetz V. Early Intubation in Endovascular Therapy for Basilar Artery Occlusion: A Post Hoc Analysis of the BASICS Trial. Stroke 2023; 54:2745-2754. [PMID: 37871243 DOI: 10.1161/strokeaha.123.043669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 08/30/2023] [Indexed: 10/25/2023]
Abstract
BACKGROUND The optimal anesthetic management for endovascular therapy (EVT) in patients with posterior circulation stroke remains unclear. Our objective was to investigate the impact of early intubation in patients enrolled in the BASICS trial (Basilar Artery International Cooperation Study). METHODS BASICS was a multicenter, randomized, controlled trial that compared the efficacy of EVT compared with the best medical care alone in patients with basilar artery occlusion. In this post hoc analysis, early intubation within the first 24 hours of the estimated time of basilar artery occlusion was examined as an additional covariate using regression modeling. We estimated the adjusted relative risks (RRs) for favorable outcomes, defined as modified Rankin Scale scores of 0 to 3 at 90 days. An adjusted common odds ratio was estimated for a shift in the distribution of modified Rankin Scale scores at 90 days. RESULTS Of 300 patients in BASICS, 289 patients were eligible for analysis (151 in the EVT group and 138 in the best medical care group). compared with medical care alone, EVT was related to a higher risk of early intubation (RR, 1.29 [95% CI, 1.09-1.53]; P<0.01), and early intubation was negatively associated with favorable outcome (RR, 0.61 [95% CI, 0.45-0.84]; P=0.002). Whereas there was no overall treatment effect of EVT on favorable outcome (RR, 1.22 [95% CI, 0.95-1.55]; P=0.121), EVT was associated with favorable outcome (RR, 1.34 [95% CI, 1.05-1.71]; P=0.018) and a shift toward lower modified Rankin Scale scores (adjusted common odds ratio, 1.63 [95% CI, 1.04-2.57]; P=0.033) if adjusted for early intubation. CONCLUSIONS In this post hoc analysis of the neutral BASICS trial, early intubation was linked to unfavorable outcomes, which might mitigate a potential benefit from EVT by indirect effects due to an increased risk of early intubation. This relationship may be considered when assessing the efficacy of EVT in patients with basilar artery occlusion in future trials.
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Affiliation(s)
- Kristian Barlinn
- Department of Neurology (K.B., V.P.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
- Dresden Neurovascular Center (K.B., J.C.G., V.P.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | | | - Diederik W J Dippel
- Department of Neurology, Erasmus University Medical Center, Rotterdam, the Netherlands (D.W.J.D.)
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine (W.H.v.Z.), School for Cardiovascular Diseases (CARIM), Maastricht University Medical Center, the Netherlands
| | - Martin Roessler
- BARMER Institute for Health Care System Research (bifg), Berlin, Germany (M.R.)
| | - Yvo B W E M Roos
- Department of Neurology (Y.B.W.E.M.R.), Amsterdam University Medical Center, the Netherlands
| | - Bart J Emmer
- Department of Radiology (B.J.E.), Amsterdam University Medical Center, the Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology (R.J.v.O.), School for Cardiovascular Diseases (CARIM), Maastricht University Medical Center, the Netherlands
| | - Johannes C Gerber
- Dresden Neurovascular Center (K.B., J.C.G., V.P.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
- Institute of Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany (J.C.G.)
| | - Albert J Yoo
- Department of Radiology, Texas Stroke Institute, Dallas-Fort Worth (A.J.Y.)
| | - Octavio M Pontes-Neto
- Stroke Service, Neurology Division, Department of Neuroscience and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, Brazil (O.M.P.-N.)
| | - Mikael Mazighi
- Departments of Neurology, Lariboisiere Hospital, and Interventional Neuroradiology, Foundation Rothschild Hospital, FHU Neurovasc, INSERM 1144, Paris Cite University, France (M.M.)
| | - Heinrich J Audebert
- Department of Neurology and Center for Stroke Research, Charité Universitätsmedizin Berlin, Germany (H.J.A.)
| | - Patrik Michel
- The Stroke Center, Neurology Service, Lausanne University Hospital, Switzerland (P.M.)
| | - Wouter J Schonewille
- Department of Neurology, St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.)
| | - Volker Puetz
- Department of Neurology (K.B., V.P.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
- Dresden Neurovascular Center (K.B., J.C.G., V.P.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
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Lekoubou A, Nguyen C, Kwon M, Nyalundja AD, Agrawal A. Post-stroke Everything. Curr Neurol Neurosci Rep 2023; 23:785-800. [PMID: 37837566 DOI: 10.1007/s11910-023-01308-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/22/2023] [Indexed: 10/16/2023]
Abstract
PURPOSE OF REVIEW This review aims at providing updates on selected post-stroke complications. We examined recent advances in diagnosing and treating the following post-stroke complications: cognitive impairment, epilepsy, depression, fatigue, tremors, dysphagia, and pain. RECENT FINDINGS Advances in understanding the mechanisms of post-stroke complications, in general, are needed despite advances made in understanding, treating, and preventing these complications. There are growing progresses in integrating new tools to diagnose post-stroke cognitive impairment. The potential role of acute stroke reperfusion treatment in post-stroke epilepsy and its impact on other stroke complications is getting more transparent. Post-stroke depression remains underestimated and new tools to diagnose depression after stroke are being developed. New promising pharmacological approaches to treating post-stroke pain are emerging. Tremors related to stroke are poorly understood and under-evaluated, while treatment towards post-stroke dysphagia has benefited from new non-pharmacological to pharmacological approaches. CONCLUSIONS An integrative approach to stroke complications and collaborations between providers across specialties are more likely to improve stroke outcomes.
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Affiliation(s)
- Alain Lekoubou
- Department of Neurology, Penn State University, Hershey Medical Center, Hershey, PA, USA.
| | - Clever Nguyen
- Department of Neurology, Penn State University, Hershey Medical Center, Hershey, PA, USA
| | - Michelle Kwon
- Department of Neurology, Penn State University, Hershey Medical Center, Hershey, PA, USA
| | - Arsene Daniel Nyalundja
- Faculty of Medicine, Center for Tropical Diseases and Global Health (CTDGH), Université Catholique de Bukavu (UCB), Bukavu, Democratic Republic of Congo
| | - Ankita Agrawal
- College of Medicine, Nepalese Army Institute of Health Sciences, Kathmandu, Nepal
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260
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Findlay MC, Grandhi R, Nelson JR, Lucke-Wold B, Chowdhury MAB, Hoh BL, Steinberg J, Santiago-Dieppa D, Khalessi A, Ikeda DS, Ravindra VM. How do children fare compared with adults? Comparing relative outcomes after thrombectomy for acute ischemic stroke due to large-vessel occlusion. J Stroke Cerebrovasc Dis 2023; 32:107350. [PMID: 37717373 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107350] [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: 07/06/2023] [Revised: 08/25/2023] [Accepted: 09/07/2023] [Indexed: 09/19/2023] Open
Abstract
OBJECTIVE Safety and efficacy data for endovascular thrombectomy for acute ischemic stroke secondary to large-vessel occlusion in children are lacking compared with those for adults. We undertook an updated systematic review and meta-analysis of endovascular thrombectomy in children and compared their outcomes with adult data. METHODS We searched PubMed, Medline, and EMBASE databases to identify prospective and retrospective studies describing patients <18 years treated with endovascular thrombectomy for acute ischemic stroke due to large-vessel occlusion. RESULTS Eight pediatric studies were included (n = 192). Most patients were male (53.1 %), experienced anterior circulation large-vessel occlusion (81.8 %), and underwent endovascular thrombectomy by stent retreiver (70.7 %). The primary outcome was change in National Institutes of Health Stroke Scale score from presentation to 24 h after thrombectomy. Secondary outcomes included modified Rankin scale score improvement and 90-day score, recanalization rates, procedural complications, and mortality rates. After treatment, 88.5% of children had successful recanalization; the mean National Institutes of Health Stroke Scale score reduction was 7.37 (95 % CI 5.11-9.63, p < 0.01). The mean reduction of 6.87 (95 %CI 5.00-8.73, p < 0.01) for adults in 5 clinical trials (n = 634) was similar (Qb = 0.11; p = 0.74). Children experienced higher rates of good neurological outcome (76.1 % vs. 46.0 %, p < 0.01) and revascularization (88.5 % vs. 72.3 %, p < 0.01), fewer major periprocedural complications (3.6 % vs. 30.4 %, p < 0.01), and lower mortality (1.0 % vs. 12.9 %, p < 0.01). CONCLUSIONS Endovascular thrombectomy may be safe and effective treatment for acute ischemic stroke due to large-vessel occlusion in children. The aggregated data demonstrated high rates of revascularization, favorable long-term neurological outcomes, and low complication rates.
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Affiliation(s)
- Matthew C Findlay
- School of Medicine, University of Utah, 30 North 1900 East, Salt Lake City, UT 84132, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Dr. E, Salt Lake City, UT 84132, USA
| | - Jayson R Nelson
- School of Medicine, University of Utah, 30 North 1900 East, Salt Lake City, UT 84132, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, 1505 SW Archer Rd., Gainesville, FL 32608, USA
| | | | - Brian L Hoh
- Department of Neurosurgery, University of Florida, 1505 SW Archer Rd., Gainesville, FL 32608, USA
| | - Jeffrey Steinberg
- Department of Neurosurgery, University of California San Diego, 9500 Gilman Dr., La Jolla, CA 92093, USA
| | - David Santiago-Dieppa
- Department of Neurosurgery, University of California San Diego, 9500 Gilman Dr., La Jolla, CA 92093, USA
| | - Alexander Khalessi
- Department of Neurosurgery, University of California San Diego, 9500 Gilman Dr., La Jolla, CA 92093, USA
| | - Daniel S Ikeda
- Department of Neurosurgery, Walter Reed National Military Medical Center, 4494 Palmer Rd. N, Bethesda, MD 20814, USA
| | - Vijay M Ravindra
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Dr. E, Salt Lake City, UT 84132, USA; Department of Neurosurgery, University of California San Diego, 9500 Gilman Dr., La Jolla, CA 92093, USA; Department of Neurological Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Dr., San Diego, CA 92134, USA.
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261
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Wei W, Zhang J, Xie S, Fan D, Chen Y, Zhong C, Chen L, Zhang Y, Shi S. Endovascular therapy versus medical management for acute ischemic stroke with large infarct core: Systematic review and meta-analysis of randomized controlled trials. Clin Neurol Neurosurg 2023; 234:108007. [PMID: 37797364 DOI: 10.1016/j.clineuro.2023.108007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2023] [Accepted: 09/29/2023] [Indexed: 10/07/2023]
Abstract
OBJECTIVE To compare the efficacy and safety of endovascular therapy (EVT) versus best medical management (BMM) in patients with acute ischemic stroke (AIS) with large infarct core. METHODS We searched Pubmed, Embase and Cochrane Central Register of Controlled Trials for published randomized clinical trials (RCTs) from inception to February 18, 2023. We defined patients with large core infarcts as having an Alberta Stroke Program early computed tomography score (ASPECTS) of 3-5. The primary outcome was functional independence, defined as a score of 0-2 on the modified Rankin scale (mRS) at 90 days. Secondary outcome was independent ambulation defined as mRS 0-3 at 90 days. Safety outcomes were mortality at 90 days, symptomatic intracranial hemorrhage (sICH) and any intracranial hemorrhage (ICH). RESULTS The overall treatment effect was more favourable to EVT group. EVT was significantly correlated with improvement of functional independence at 90 days (mRS 0-2) (RR = 2.40; 95 % CI, 1.82-3.16; P < 0.01; I2 = 0 %) and independent ambulation (mRS 0-3) (RR = 1,78; 95 % CI, 1.28-2.48; P < 0.01; I2 = 58 %) at 90 days. 90-day mortality was not significantly different between the two groups(RR = 0.95; 95 % CI, 0.78-1.16; P > 0.05; I2 = 0 %). The risk of sICH and any ICH was higher in EVT group than in BMM group. CONCLUSION Compared with BMM, EVT may improve functional outcomes in patients with ASPECTS 3-5, despite being associated with an increased risk of sICH and any ICH.
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Affiliation(s)
- Wenqian Wei
- Department of Neurology, The Second Affiliated Hospital of Guangxi Medical University, No. 166 Daxuedong Road, Nanning, Guangxi 530007, China
| | - Jian Zhang
- Department of Neurology, The Second Affiliated Hospital of Guangxi Medical University, No. 166 Daxuedong Road, Nanning, Guangxi 530007, China
| | - Shuyu Xie
- Department of Neurology, The Second Affiliated Hospital of Guangxi Medical University, No. 166 Daxuedong Road, Nanning, Guangxi 530007, China
| | - Dongmei Fan
- Department of Neurology, The Second Affiliated Hospital of Guangxi Medical University, No. 166 Daxuedong Road, Nanning, Guangxi 530007, China
| | - Yiyun Chen
- Department of Neurology, The Second Affiliated Hospital of Guangxi Medical University, No. 166 Daxuedong Road, Nanning, Guangxi 530007, China
| | - Chongxu Zhong
- Department of Neurology, The Second Affiliated Hospital of Guangxi Medical University, No. 166 Daxuedong Road, Nanning, Guangxi 530007, China
| | - Liufei Chen
- Department of Neurology, The Second Affiliated Hospital of Guangxi Medical University, No. 166 Daxuedong Road, Nanning, Guangxi 530007, China
| | - Yueling Zhang
- Department of Neurology, The Second Affiliated Hospital of Guangxi Medical University, No. 166 Daxuedong Road, Nanning, Guangxi 530007, China.
| | - Shengliang Shi
- Department of Neurology, The Second Affiliated Hospital of Guangxi Medical University, No. 166 Daxuedong Road, Nanning, Guangxi 530007, China.
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Wang J, Shang S, Dun W, Chen C, Gao F, Yu J, Han J, Liu F. Short-term efficacy of stenting as a rescue therapy for acute atherosclerotic occlusion in anterior cerebral circulation. Front Neurol 2023; 14:1238998. [PMID: 38020588 PMCID: PMC10646575 DOI: 10.3389/fneur.2023.1238998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 09/25/2023] [Indexed: 12/01/2023] Open
Abstract
Purpose The study aimed to explore the efficacy and safety of the Neuroform EZ stent in treating acute anterior circulation large artery occlusion. Methods The clinical data of 42 consecutive patients with acute anterior circulation large atherosclerotic occlusion who were treated with the Neuroform EZ stent from January 2018 to August 2019 in our stroke care center, including baseline characteristics, images, therapeutic condition, and follow-up data were retrospectively analyzed. Results There were 42 mechanical thrombectomy (MT) failure cases of intracranial atherosclerotic stenosis with rescue Neuroform EZ stent implantation, of which 78.6% (33/42) had a good prognosis and 88.1% (37/42) showed no re-stenosis at follow-up. The average time from puncture to recanalization is 79.50 ± 14.19 min. The successful rate of intraoperative stent release is 97.6%, while there is one case of stent displacement, three cases of thrombus escape, and six cases of hemorrhage. Conclusion Rescue therapy of the Neuroform EZ stent for acute anterior circulation large atherosclerotic occlusion can archive good short-term imaging and clinical results, while long-term follow-up is still needed to verify.
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Affiliation(s)
- Jianyi Wang
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi, China
| | - Suhang Shang
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi, China
| | - Wanghuan Dun
- Department of Rehabilitation, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi, China
| | - Chen Chen
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi, China
| | - Fan Gao
- Clinical Research Center, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi, China
| | - Jia Yu
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi, China
| | - Jianfeng Han
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi, China
| | - Fude Liu
- Department of Neurology, The First Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shanxi, China
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263
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Le Floch A, Clarençon F, Rouchaud A, Kyheng M, Labreuche J, Sibon I, Boulouis G, Gory B, Richard S, Caroff J, Blanc R, Seners P, Eker OF, Cho TH, Consoli A, Bourcier R, Guillon B, Dargazanli C, Arquizan C, Denier C, Eugene F, Vannier S, Gentric JC, Gauberti M, Naggara O, Rosso C, Turc G, Ozkul-Wermester O, Cognard C, Albucher JF, Timsit S, Bourdain F, Le Bras A, Richter S, Moulin S, Pop R, Heck O, Moreno R, L'Allinec V, Lapergue B, Marnat G. Influence of prior intravenous thrombolysis in patients treated with mechanical thrombectomy for M2 occlusions: insight from the Endovascular Treatment in Ischemic Stroke (ETIS) registry. J Neurointerv Surg 2023; 15:e289-e297. [PMID: 36460462 DOI: 10.1136/jnis-2022-019672] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2022] [Accepted: 11/16/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Intravenous thrombolysis (IVT) for patients treated with mechanical thrombectomy (MT) for proximal occlusions has recently been questioned through randomized trials. However, few patients with M2 occlusions were included. We investigated the influence of prior IVT for patients presenting M2 occlusions treated with MT in comparison with MT alone. METHODS We conducted a retrospective analysis of the Endovascular Treatment in Ischemic Stroke (ETIS) registry, a multicenter observational study. Data from consecutive patients treated with MT for M2 occlusions between January 2015 and January 2022 at 26 comprehensive stroke centers were analyzed. The primary endpoint was 90-day modified Rankin Scale score of 0-2. Outcomes were compared using propensity score approaches. We also performed sensitivity analysis in relevant subgroups of patients. RESULTS Among 1132 patients with M2 occlusions treated with MT, 570 received prior IVT. The two groups were comparable after propensity analysis. The rate of favorable functional outcome was significantly higher in the IVT+MT group compared with the MT alone group (59.8% vs 44.7%; adjusted OR 1.38, 95% CI 1.10 to 1.75, P=0.008). Hemorrhagic and procedural complications were similar in both groups. In sensitivity analysis excluding patients with anticoagulation treatment, favorable recanalization was more frequent in the IVT+MT group (OR 1.37, 95% CI 1.11 to 1.70, P=0.004). CONCLUSIONS In cases of M2 occlusions, prior IVT combined with MT resulted in better functional outcome than MT alone, without increasing the rate of hemorrhagic or procedural complications. These results suggest the benefit of IVT in patients undergoing MT for M2 occlusions.
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Affiliation(s)
- Agathe Le Floch
- Neuroradiology, CHU Bordeaux GH Pellegrin, Bordeaux, Aquitaine, France
| | - Frédéric Clarençon
- Interventional neuroradiology, University Hospital Pitié Salpêtrière, Paris, France
| | - Aymeric Rouchaud
- Interventional neuroradiology, Centre Hospitalier Universitaire de Limoges, Limoges, France
- CNRS, XLIM, UMR 7252, Université de Limoges, Limoges, Nouvelle-Aquitaine, France
| | - Maeva Kyheng
- Biostatistics, CHU Lille, Lille, Hauts-de-France, France
| | | | - Igor Sibon
- Neurology, CHU de Bordeaux, Bordeaux, France
| | | | - Benjamin Gory
- Diagnostic and Interventional Neuroradiology, Centre Hospitalier Universitaire de Nancy, Nancy, France
| | - Sébastien Richard
- Neurology Stroke Unit, University Hospital Centre Nancy, Nancy, France
| | - Jildaz Caroff
- Department of Interventional Neuroradiology - NEURI Brain Vascular Center, Bicêtre Hospital, APHP, Le Kremlin Bicêtre, France
| | - Raphaël Blanc
- Departement of interventional neuroradiology, Fondation Rothschild, Paris, Île-de-France, France
| | - Pierre Seners
- Neurology, Fondation Rothschild, Paris, Île-de-France, France
| | - Omer F Eker
- Neuroradiology, Hospices Civils de Lyon, Bron, France
| | - Tae-Hee Cho
- Neurology, CHU Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Arturo Consoli
- Interventional Neuroradiologie, Hopital Foch, Suresnes, Ile-de-France, France
| | | | - Benoit Guillon
- Stroke unit, CHU Nantes, Nantes, Pays de la Loire, France
| | - Cyril Dargazanli
- Department of Neuroradiology, University Hospital Centre Montpellier, Montpellier, Occitanie, France
| | - Caroline Arquizan
- Neurology, CHU Montpellier, Montpellier, Languedoc-Roussillon, France
| | | | | | | | | | | | - Olivier Naggara
- Neuroradiology, GHU Paris Pôle Neuro Sainte-Anne, Paris, Île-de-France, France
| | - Charlotte Rosso
- Neurology, Hôpital Universitaire Pitié Salpêtrière, Paris, Île-de-France, France
| | - Guillaume Turc
- Neurology, GHU Paris Pôle Neuro Sainte-Anne, Paris, Île-de-France, France
| | | | - Christophe Cognard
- Diagnostic and Therapeutic Neuroradiology, CHU Toulouse, Toulouse, Occitanie, France
| | | | | | - Frederic Bourdain
- Neurology, Centre Hospitalier de la Cote Basque, Bayonne, Aquitaine, France
| | - Anthony Le Bras
- Department of Radiology, Centre Hospitalier Bretagne Atlantique, Vannes, Bretagne, France
- Neuroradiology, CHU Rennes Service de radiologie et d'imagerie médicale, Rennes, France
| | | | - Solène Moulin
- Neurology, University Hospital Centre Reims, Reims, Champagne-Ardenne, France
| | - Raoul Pop
- Neuroradiolology, CHU Strasbourg, Strasbourg, Alsace, France
| | - Olivier Heck
- Neurology, CHU Grenoble Alpes, Grenoble, Auvergne-Rhone-Alpes, France
| | - Ricardo Moreno
- Department Of Neuroradiology, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | | | | | - Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, CHU Bordeaux GH Pellegrin, Bordeaux, Aquitaine, France
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Yedavalli V, Kihira S, Shahrouki P, Hamam O, Tavakkol E, McArthur M, Qiao J, Johanna F, Doshi A, Vagal A, Khatri P, Srinivasan A, Chaudhary N, Bahr-Hosseini M, Colby GP, Nour M, Jahan R, Duckwiler G, Arnold C, Saver JL, Mocco J, Liebeskind DS, Nael K. CTP-based estimated ischemic core: A comparative multicenter study between Olea and RAPID software. J Stroke Cerebrovasc Dis 2023; 32:107297. [PMID: 37738915 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107297] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2023] [Revised: 08/01/2023] [Accepted: 08/03/2023] [Indexed: 09/24/2023] Open
Abstract
BACKGROUND AND PURPOSE CTP is increasingly used to assess eligibility for endovascular therapy (EVT) in patients with large vessel occlusions (LVO). There remain variability and inconsistencies between software packages for estimation of ischemic core. We aimed to use heterogenous data from four stroke centers to perform a comparative analysis for CTP-estimated ischemic core between RAPID (iSchemaView) and Olea (Olea Medical). METHODS In this retrospective multicenter study, patients with anterior circulation LVO who underwent pretreatment CTP, successful EVT (defined TICI ≥ 2b), and follow-up MRI included. Automated CTP analysis was performed using Olea platform [rCBF < 25% and differential time-to-peak (dTTP)>5s] and RAPID (rCBF < 30%). The CTP estimated core volumes were compared against the final infarct volume (FIV) on post treatment MRI-DWI. RESULTS A total of 151 patients included. The CTP-estimated ischemic core volumes (mean ± SD) were 18.7 ± 18.9 mL on Olea and 10.5 ± 17.9 mL on RAPID significantly different (p < 0.01). The correlation between CTP estimated core and MRI final infarct volume was r = 0.38, p < 0.01 for RAPID and r = 0.39, p < 0.01 for Olea. Both software platforms demonstrated a strong correlation with each other (r = 0.864, p < 0.001). Both software overestimated the ischemic core volume above 70 mL in 4 patients (2.6%). CONCLUSIONS Substantial variation between Olea and RAPID CTP-estimated core volumes exists, though rates of overcalling of large core were low and identical. Both showed comparable core volume correlation to MRI infarct volume.
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Affiliation(s)
- V Yedavalli
- Johns Hopkins University School of Medicine, Baltimore, MD, United States.
| | - S Kihira
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - P Shahrouki
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - O Hamam
- Massachussetts General Hospital, Boston, MA, United States
| | - E Tavakkol
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - M McArthur
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - J Qiao
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - Fifi Johanna
- Mount Sinai School of Medicine, New York, NY, United States
| | - A Doshi
- Mount Sinai School of Medicine, New York, NY, United States
| | - A Vagal
- University of Cincinnati School of Medicine, Cincinnati, OH, United States
| | - P Khatri
- University of Cincinnati School of Medicine, Cincinnati, OH, United States
| | - A Srinivasan
- University of Michigan School of Medicine, Ann Arbor, MI, United States
| | - N Chaudhary
- University of Michigan School of Medicine, Ann Arbor, MI, United States
| | - M Bahr-Hosseini
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - G P Colby
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - M Nour
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - R Jahan
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - G Duckwiler
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - C Arnold
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - J L Saver
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - J Mocco
- Mount Sinai School of Medicine, New York, NY, United States
| | - D S Liebeskind
- David Geffen School of Medicine at the University of California - Los Angeles, United States
| | - K Nael
- David Geffen School of Medicine at the University of California - Los Angeles, United States
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Lv S, Geng X, Yun HJ, Ding Y. Phenothiazines reduced autophagy in ischemic stroke through endoplasmic reticulum (ER) stress-associated PERK-eIF2α pathway. Exp Neurol 2023; 369:114524. [PMID: 37673390 DOI: 10.1016/j.expneurol.2023.114524] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2023] [Revised: 08/15/2023] [Accepted: 08/27/2023] [Indexed: 09/08/2023]
Abstract
BACKGROUND Neuroprotective effects have been the main focus of new treatment modalities for ischemic stroke. Phenothiazines, or chlorpromazine plus promethazine (C + P), are known to prevent the generation of free radicals and uptake of Ca2+ by plasma membrane; they have a potential as a treatment for acute ischemic stroke (AIS). This study aims to investigate the role of endoplasmic reticulum (ER) stress-associated PERK-eIF2α pathway underlying the phenothiazine-induced neuroprotective effects after cerebral ischemia/reperfusion (I/R) injury. METHODS A total of 49 male Sprague Dawley rats (280-320 g) were randomly divided into 4 groups (n = 7 per group): (1) sham, (2) I/R that received 2 h of middle cerebral artery occlusion (MCAO), followed by 6 or 24 h of reperfusion, (3) MCAO treated by C + P without temperature control and (4) MCAO treated by C + P with temperature control. Human neuroblastoma (SH-SY5Y) cells were used in 5 groups: (1) control, (2) oxygen-glucose deprivation (OGD) for 2 h followed by reoxygenation (OGD/R), (3) OGD/R with C + P; (4) OGD/R with PERK inhibitor, GSK2656157, and (5) OGD/R with C + P and GSK2656157. The molecules of ER stress, unfolded protein response (UPR) (Bip, PERK, p-PERK, p-PERK/PERK, eIF2α, p-eIF2α, p-eIF2α/eIF2α), autophagy (ATG12, LC3II/I), and apoptosis (BAX, Bcl-XL) were measured at mRNA levels by real time PCR and protein levels by Western blotting. RESULTS In ischemic rats followed by reperfusion, expression of Bip, p-PERK/PERK, p-eIF2α/eIF2α, ATG12, and LC3II/I, as well as BAX were all significantly increased. These markers were significantly reduced by C + P at both 6 and 24 h of reperfusion. Anti-apoptotic Bcl-XL expression was increased, while pro-apoptotic BAX expression was decreased by C + P. In SH-SY5Y cell lines, both C + P and GSK2656157 significantly reduced the level of autophagy and apoptosis after I/R, respectively. The combination of GSK2656157 and C + P did not promote the same effect, suggesting that C + P did not induce any neuroprotective effect by inhibiting autophagy and apoptosis through the PERK-eIF2α pathway when this pathway was already blocked by GSK2656157. In general, the reduction in body temperature by phenothiazines was associated with better neuroprotection but it did not reach significant levels. CONCLUSION The combined treatment of C + P plays a crucial role in stroke therapy by inhibiting ER stress-mediated autophagy, thereby leading to reduced apoptosis and increased neuroprotection. Our findings highlight the PERK-eIF2α pathway as a central mechanism through which C + P exerts its beneficial effects. The results from this study may pave the way for the development of more targeted and effective treatments for stroke patients.
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Affiliation(s)
- Shuyu Lv
- Luhe Institute of Neuroscience, Capital Medical University, Beijing, China; Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Xiaokun Geng
- Luhe Institute of Neuroscience, Capital Medical University, Beijing, China; Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China; Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, United States.
| | - Ho Jun Yun
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, United States
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, United States
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266
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Liu Q, He S, Lin Y, Tan S, Zhou J, Yang J. Prior statin use in acute ischemic stroke patients with mechanical thrombectomy: A prospective cohort study in China. Clin Neurol Neurosurg 2023; 234:107988. [PMID: 37769498 DOI: 10.1016/j.clineuro.2023.107988] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Revised: 09/16/2023] [Accepted: 09/20/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND AND PURPOSE Mechanical thrombectomy (MT) has been proven to be effective for selected patients with acute ischemic stroke (AIS). However, conflicting findings have suggested the association between prior statin use and outcomes in AIS patients with MT, with a particular lack of information in the Chinese population. Via a prospective cohort study, we explored the safety and efficacy of prior statin use in Chinese AIS patients with MT. METHODS We consecutively enrolled AIS patients treated with MT from the First Affiliated Hospital of Chengdu Medical College and Nanjing First Hospital between June 2015 and June 2022 who were under prior statin use or not. Safety and efficacy outcomes were prospectively followed. The primary outcomes were defined as 90-day favorable outcomes (mRS score 0-2). Secondary outcomes included successful recanalization (TICI≥2b), early neurological improvement (decrease of National Institutes of Health Stroke Scale (NIHSS) score ≥ 4 points at 24 h), symptomatic intracerebral hemorrhage (sICH), and death at 90 days. RESULTS We enrolled 334 patients in total, 50 of whom (15.0%) undertaken statins administration before AIS. 117 (35.0%) patients had favorable outcomes at 90 days, 288 (86.2%) patients had successful recanalization, 108 (32.3%) patients achieved early neurological improvement, 41 (12.3%) patients had sICH and 73 (21.9%) patients died within 90 days. The 90-day favorable outcomes were not significantly different (adjusted OR=0.853, 95% CI 0.449-1.620, P = 0.626) between prior statins use group and no statins use group. There was no significant difference in recanalization (adjusted OR=1.466, 95% CI 0.536-4.009, P = 0.456), early neurological improvement (adjusted OR=1.568, 95% CI 0.811-3.032, P = 0.181), sICH (adjusted OR=0.850, 95% CI 0.325-2.224, P = 0.741), ICH (adjusted OR=1.029, 95% CI 0.479-2.490, P = 0.942), and 90-day mortality (adjusted OR=0.381, 95% CI 0.091-1.586, P = 0.185) between the two groups. CONCLUSIONS Prior statin use may be safe for Chinese AIS patients with MT, but its efficacy warrants further research.
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Affiliation(s)
- Quan Liu
- Department of Emergency, Chengdu Second People's Hospital, Chengdu, China
| | - Song He
- Department of Neurology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Yapeng Lin
- Department of Neurology, The First Affiliated Hospital of Chengdu Medical College, Chengdu, China
| | - Song Tan
- Department of Neurology, Sichuan Provincial People's Hospital, School of Medicine,University of Electronic Science and Technology of China, Chengdu, China
| | - Junshan Zhou
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China.
| | - Jie Yang
- Department of Neurology, Sichuan Provincial People's Hospital, School of Medicine,University of Electronic Science and Technology of China, Chengdu, China.
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267
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Pressman E, Goldman H, Wang C, Mhaskar R, Guerrero WR, Mokin M, Vakharia K. A meta-analysis and systematic review of endovascular thrombectomy versus medical management for acute basilar artery occlusion. Clin Neurol Neurosurg 2023; 234:107986. [PMID: 37806051 DOI: 10.1016/j.clineuro.2023.107986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 09/14/2023] [Accepted: 09/20/2023] [Indexed: 10/10/2023]
Abstract
OBJECTIVE Acute basilar artery occlusion (BAO) is a devastating neurologic event. As endovascular thrombectomy (EVT) became more prevalent for anterior circulation strokes, investigations were conducted in the posterior circulation. Its success in improving outcomes compared to standard medical therapy (SMT) after BAO has been debated. METHODS We conducted a systematic review and meta-analysis of all randomized controlled trials (RCTs) and observational cohort studies evaluating EVT compared to SMT in acute BAO. We queried PubMed, Embase, and Cochrane for studies. Primary outcome was good functional outcome at 90 days (modified Rankin scale (mRS) ≤ 3). We analyzed studies for risk of bias (ROB) and calculated pooled risk ratios (RRs), odds ratios (ORs), and mean differences (MDs) with 95% confidence intervals (95%CI) using the random effects model for our primary outcome and secondary positive outcomes and harms. RESULTS We identified four RCTs (991 patients randomized) and three cohort studies (1030 patients treated in-trial) that fit inclusion criteria. Three RCTs had low ROB, one had serious ROB. One cohort study had high ROB, one had moderate ROB, and one had low ROB. EVT was statistically significantly more associated with good functional outcome than SMT in RCTs (RR=1.54, 95%CI=1.16-2.04, p = 0.003) and trended towards significance in cohort studies (RR=2.64, 95%CI=0.87-8.00, p = 0.09). Mean mRS at 90 days was lower in EVT patients in RCTs (MD=-0.65, 95%CI=-1.07--0.22, p = 0.003) though not cohort studies (MD =-0.84, 95%CI=-2.48-0.79, p = 0.31). Symptomatic intracerebral hemorrhage (sICH) was statistically significantly associated with EVT in RCTs (OR=6.36, 95%CI=2.24-18.07, p < 0.001) and statistically non-significantly in cohort studies (OR=4.51, 95CI=1.00-20.33, p = 0.05). Mortality at 90 days was statistically lower with EVT than with SMT in both RCTs (OR=0.76, 95%CI=0.65-0.88, p < 0.001) cohort studies (OR=0.36, 95%CI=0.26-0.50, p < 0.001) CONCLUSION: EVT is associated with greater rates of good functional outcomes and lower rates of death and disability despite higher rates of periprocedural sICH.
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Affiliation(s)
- Elliot Pressman
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Hannah Goldman
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Christopher Wang
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Rahul Mhaskar
- Department of Internal Medicine, University of South Florida, Tampa, FL, USA
| | - Waldo R Guerrero
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Maxim Mokin
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Kunal Vakharia
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA.
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268
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Behrndtz A, Blauenfeldt RA, Johnsen SP, Valentin JB, Gude MF, Al-Jazi MA, von Weitzel-Mudersbach P, Modrau B, Damgaard D, Hougaard KD, Hjort N, Diedrichsen T, Poulsen M, Schmitz ML, Fisher M, Andersen G, Simonsen CZ. Transport Strategy in Patients With Suspected Acute Large Vessel Occlusion Stroke: TRIAGE-STROKE, a Randomized Clinical Trial. Stroke 2023; 54:2714-2723. [PMID: 37800374 PMCID: PMC10589426 DOI: 10.1161/strokeaha.123.043875] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/01/2023] [Accepted: 08/10/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND When patients with acute ischemic stroke present with suspected large vessel occlusion in the catchment area of a primary stroke center (PSC), the benefit of direct transport to a comprehensive stroke center (CSC) has been suggested. Equipoise remains between transport strategies and the best transport strategy is not well established. METHODS We conducted a national investigator-driven, multicenter, randomized, assessor-blinded clinical trial. Patients eligible for intravenous thrombolysis (IVT) who were suspected for large vessel occlusion were randomized 1:1 to admission to the nearest PSC (prioritizing IVT) or direct CSC admission (prioritizing endovascular therapy). The primary outcome was functional improvement at day 90 for all patients with acute ischemic stroke, measured as shift towards a lower score on the modified Rankin Scale score. RESULTS From September 2018 to May 2022, we enrolled 171 patients of whom 104 had acute ischemic stroke. The trial was halted before full recruitment. Baseline characteristics were well balanced. Primary analysis of shift in modified Rankin Scale (ordinal logistic regression) revealed an odds ratio for functional improvement at day 90 of 1.42 (95% CI, 0.72-2.82, P=0.31). Onset to groin time for patients with large vessel occlusion was 35 minutes (P=0.007) shorter when patients were transported to a CSC first, whereas onset to needle (IVT) was 30 minutes (P=0.012) shorter when patients were transported to PSC first. IVT was administered in 67% of patients in the PSC group versus 78% in the CSC group and EVT was performed in 53% versus 63% of the patients, respectively. CONCLUSIONS This trial investigated the benefit of bypassing PSC. We included only IVT-eligible patients presenting <4 hours from onset and with suspected large vessel occlusion. Lack of power prevented the results from showing effect on functional outcome for patients going directly to CSC. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03542188.
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Affiliation(s)
- Anne Behrndtz
- Department of Neurology (A.B., R.A.B., D.D., K.D.H., N.H., T.D., M.P., M.L.S., G.A., C.Z.S.), Aarhus University Hospital, Denmark
- Department of Clinical Medicine, Aarhus University, Denmark (A.B., R.A.B., C.Z.S.)
| | - Rolf A. Blauenfeldt
- Department of Neurology (A.B., R.A.B., D.D., K.D.H., N.H., T.D., M.P., M.L.S., G.A., C.Z.S.), Aarhus University Hospital, Denmark
- Department of Neurology (B.M.), Aarhus University Hospital, Denmark
| | - Søren P. Johnsen
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University and Aalborg University Hospital (S.P.J., J.B.V.)
| | - Jan B. Valentin
- Danish Center for Clinical Health Services Research, Department of Clinical Medicine, Aalborg University and Aalborg University Hospital (S.P.J., J.B.V.)
| | - Martin F. Gude
- Prehospital Emergency Medical Services, Central Denmark Region (M.F.G.), Goedstrup Hospital
| | | | | | - Boris Modrau
- Department of Neurology (B.M.), Aarhus University Hospital, Denmark
| | - Dorte Damgaard
- Department of Neurology (A.B., R.A.B., D.D., K.D.H., N.H., T.D., M.P., M.L.S., G.A., C.Z.S.), Aarhus University Hospital, Denmark
| | - Kristina Dupont Hougaard
- Department of Neurology (A.B., R.A.B., D.D., K.D.H., N.H., T.D., M.P., M.L.S., G.A., C.Z.S.), Aarhus University Hospital, Denmark
| | - Niels Hjort
- Department of Neurology (A.B., R.A.B., D.D., K.D.H., N.H., T.D., M.P., M.L.S., G.A., C.Z.S.), Aarhus University Hospital, Denmark
| | - Tove Diedrichsen
- Department of Neurology (A.B., R.A.B., D.D., K.D.H., N.H., T.D., M.P., M.L.S., G.A., C.Z.S.), Aarhus University Hospital, Denmark
| | - Marika Poulsen
- Department of Neurology (A.B., R.A.B., D.D., K.D.H., N.H., T.D., M.P., M.L.S., G.A., C.Z.S.), Aarhus University Hospital, Denmark
| | - Marie Louise Schmitz
- Department of Neurology (A.B., R.A.B., D.D., K.D.H., N.H., T.D., M.P., M.L.S., G.A., C.Z.S.), Aarhus University Hospital, Denmark
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston (M.F.)
| | - Grethe Andersen
- Department of Neurology (A.B., R.A.B., D.D., K.D.H., N.H., T.D., M.P., M.L.S., G.A., C.Z.S.), Aarhus University Hospital, Denmark
| | - Claus Z. Simonsen
- Department of Neurology (A.B., R.A.B., D.D., K.D.H., N.H., T.D., M.P., M.L.S., G.A., C.Z.S.), Aarhus University Hospital, Denmark
- Department of Clinical Medicine, Aarhus University, Denmark (A.B., R.A.B., C.Z.S.)
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269
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Xi Y, Ma J, Lu S. Favorable neuroprotective effect of intra-arterial application of edaravone dexborneol in ischemic stroke rats. J Stroke Cerebrovasc Dis 2023; 32:107356. [PMID: 37740991 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 08/07/2023] [Accepted: 09/11/2023] [Indexed: 09/25/2023] Open
Abstract
OBJECTIVE The aim of this study was to investigate the neuroprotective effects of intra-arterial administration of edaravone dexborneol in rats with acute ischemic stroke and determine the optimal dose. MATERIALS AND METHODS Firstly, 120 male Sprague-Dawley rats (265-300 g) were selected to establish ischemic stroke models and were randomly divided into groups of sham-operation (Sham group), cerebral ischemia-reperfusion (IS group), permanent focal ischemia (PI group) and treatment (2MG group: 2 mg/kg, 4MG group: 4 mg/kg, 6MG group: 6 mg/kg) groups. There are 20 rats in each group, and ten rats in each group were randomly selected for Longa score and 2,3,5-triphenyl tetrazolium chloride staining to observe the changes in neurological function and the proportion of cerebral infarct volume in each group. Secondly, the remaining ten rats in each group were scored for Longa and tested for free radicals (hydroxyl radical; peroxynitrite; nitric oxide) and pro-inflammatory cytokines (interleukin 6; interleukin-1β; tumor necrosis factor-α). We monitored changes in the indicators in each group of rats. RESULTS There were no significant differences among the enrolled Sprague-Dawley rats concerning age, sex, and feeding conditions. Edaravone dexborneol could significantly reduce the cerebral levels of hydroxyl radical, interleukin 6, interleukin-1β, tumor necrosis factor-α, and their behavioral scores of acute ischemic stroke rats after a single dose in the carotid artery. The results suggested that 4 mg/kg might be an appropriate dose. CONCLUSIONS A single intra-arterial administration of edaravone dexborneol can improve neurobehavioral function and alleviate cerebral injury in acute ischemic stroke rats through anti-inflammatory and free radical scavenging effects.
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Affiliation(s)
- Yalin Xi
- Department of Neurology, Binzhou Medical University Hospital, No. 661 Huanghe 2nd Road, Binzhou, Shandong, China
| | - Jingxia Ma
- Department of Neurology, Binzhou Medical University Hospital, No. 661 Huanghe 2nd Road, Binzhou, Shandong, China
| | - Shujun Lu
- Department of Neurology, Binzhou Medical University Hospital, No. 661 Huanghe 2nd Road, Binzhou, Shandong, China.
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270
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Sanmartin MX, Katz JM, Wang J, Malhotra A, Sangha K, Bastani M, Martinez G, Sanelli PC. Cost-effectiveness of endovascular thrombectomy in acute stroke patients with large ischemic core. J Neurointerv Surg 2023; 15:e166-e171. [PMID: 36175016 DOI: 10.1136/jnis-2022-019460] [Citation(s) in RCA: 13] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2022] [Accepted: 09/14/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Evidence has shown that endovascular thrombectomy (EVT) treatment improves clinical outcomes. Yet, its benefit remains uncertain in patients with large established infarcts as defined by ASPECTS (Alberta Stroke Program Early CT Score) <6. This study evaluates the cost-effectiveness of EVT, compared with standard care (SC), in acute ischemic stroke (AIS) patients with ASPECTS 3-5. METHODS An economic evaluation study was performed combining a decision tree and Markov model to estimate lifetime costs (2021 US$) and quality-adjusted life years (QALYs) of AIS patients with ASPECTS 3-5. Incremental cost-effectiveness ratios (ICERs), net monetary benefits (NMBs), and deterministic one-way and two-way sensitivity analyses were performed. Probabilistic sensitivity analyses were also performed to evaluate the robustness of our model. RESULTS Compared with SC, the cost-effectiveness analyses revealed that EVT yields higher lifetime benefits (2.20 QALYs vs 1.41 QALYs) with higher lifetime healthcare cost per patient ($285 861 vs $272 954). The difference in health benefits between EVT and SC was 0.79 QALYs, equivalent to 288 additional days of healthy life per patient. Even though EVT is more costly than SC alone, it is still cost-effective given better outcomes with ICER of $16 239/QALY. The probabilistic sensitivity analyses indicated that EVT was the most cost-effective strategy in 98.8% (9882 of 10 000) of iterations at the willingness-to-pay threshold of $100 000 per QALY. CONCLUSIONS The results of this study suggest that EVT is cost-effective in AIS patients with a large ischemic core (ASPECTS 3-5), compared with SC alone over the patient's lifetime.
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Affiliation(s)
- Maria X Sanmartin
- Siemens Healthineers USA, Malvern, Pennsylvania, USA
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Jeffrey M Katz
- Department of Neurosurgery, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Jason Wang
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Kinpritma Sangha
- Siemens Healthineers USA, Malvern, Pennsylvania, USA
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Mehrad Bastani
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Gabriela Martinez
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Pina C Sanelli
- Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, New York, USA
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset, New York, USA
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271
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Pelletier J, Koyfman A, Long B. Pearls for the Emergency Clinician: Posterior Circulation Stroke. J Emerg Med 2023; 65:e414-e426. [PMID: 37806810 DOI: 10.1016/j.jemermed.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 06/29/2023] [Accepted: 07/15/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Posterior circulation (PC) stroke in adults is a rare, frequently misdiagnosed, serious condition that carries a high rate of morbidity. OBJECTIVE OF THE REVIEW This review evaluates the presentation, diagnosis, and management of PC stroke in the emergency department (ED) based on current evidence. DISCUSSION PC stroke presents most commonly with dizziness or vertigo and must be distinguished from more benign diagnoses. Emergency clinicians should consider this condition in patients with dizziness, even in younger patients and those who do not have traditional stroke risk factors. Neurologic examination for focal neurologic deficit, dysmetria, dysarthria, ataxia, and truncal ataxia is essential, as is the differentiation of acute vestibular syndrome vs. spontaneous episodic vestibular syndrome vs. triggered episodic vestibular syndrome. The HINTS (head impulse, nystagmus, and test of skew) examination can be useful for identifying dizziness presentations concerning for stroke when performed by those with appropriate training. However, it should only be used in patients with continuous dizziness who have ongoing nystagmus. Contrast tomography (CT), CT angiography, and CT perfusion have limited sensitivity for identifying PC strokes, and although magnetic resonance imaging is the gold standard, it may miss some PC strokes early in their course. Thrombolysis is recommended in patients presenting within the appropriate time window for thrombolytic therapy, and although some data suggest endovascular therapy for basilar artery and posterior cerebral artery infarcts is beneficial, its applicability for all PC strokes remains to be determined. CONCLUSIONS An understanding of PC stroke can assist emergency clinicians in diagnosing and managing this disease.
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Affiliation(s)
- Jessica Pelletier
- Department of Emergency Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, Texas
| | - Brit Long
- San Antonio Uniformed Services Health Education Consortium, Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas.
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272
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van Kranendonk KR, Kappelhof M, Bruggeman AAE, Rinkel LA, Treurniet KM, LeCouffe N, Emmer BJ, Coutinho JM, Wolff L, van Zwam WH, van Oostenbrugge RJ, van der Lugt A, Dippel DWJ, Roos YBWEM, Marquering HA, Majoie CBLM. Hemorrhage rates in patients with acute ischemic stroke treated with intravenous alteplase and thrombectomy versus thrombectomy alone. J Neurointerv Surg 2023; 15:e262-e269. [PMID: 36396434 DOI: 10.1136/jnis-2022-019569] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2022] [Accepted: 11/01/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND Intravenous alteplase treatment (IVT) for acute ischemic stroke carries a risk of intracranial hemorrhage (ICH). However, reperfusion of an occluded vessel itself may contribute to the risk of ICH. We determined whether IVT and reperfusion are associated with ICH or its volume in the Multicenter Randomized Clinical trial of Endovascular treatment for Acute ischemic stroke in the Netherlands (MR CLEAN)-NO IV trial. METHODS The MR CLEAN-NO IV trial randomized patients with acute ischemic stroke due to large vessel occlusion to receive either IVT followed by endovascular treatment (EVT) or EVT alone. ICH was classified according to the Heidelberg bleeding classification on follow-up MRI or CT approximately 8 hours-7 days after stroke. Hemorrhage volume was measured with ITK-snap. Successful reperfusion was defined as extended Thrombolysis In Cerebral Infarction (eTICI) score of 2b-3. Multinomial and binary adjusted logistic regression were used to determine the association of IVT and reperfusion with ICH subtypes. RESULTS Of 539 included patients, 173 (32%) developed ICH and 30 suffered from symptomatic ICH (sICH) (6%). Of the patients with ICH, 102 had hemorrhagic infarction, 47 had parenchymal hematoma, 44 had SAH, and six had other ICH. Reperfusion was associated with a decreased risk of SAH, and IVT was not associated with SAH (eTICI 2b-3: adjusted OR 0.45, 95% CI 0.21 to 0.97; EVT without IVT: OR 1.6, 95% CI 0.91 to 2.8). Reperfusion status and IVT were not associated with overall ICH, hemorrhage volume, and sICH (sICH: EVT without IVT, OR 0.96, 95% CI 0.41 to 2.25; eTICI 2b-3, OR 0.49, 95% CI 0.23 to 1.05). CONCLUSION Neither IVT administration before EVT nor successful reperfusion after EVT were associated with ICH, hemorrhage volume, and sICH. SAH occurred more often in patients for whom successful reperfusion was not achieved.
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Affiliation(s)
- Katinka R van Kranendonk
- Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, Noord-Holland, The Netherlands
| | - Manon Kappelhof
- Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, Noord-Holland, The Netherlands
| | - Agnetha A E Bruggeman
- Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, Noord-Holland, The Netherlands
| | - Leon A Rinkel
- Neurology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Kilian M Treurniet
- Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, Noord-Holland, The Netherlands
- Radiology, Haaglanden Medical Center Bronovo, Den Haag, Zuid-Holland, The Netherlands
| | - Natalie LeCouffe
- Neurology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Bart J Emmer
- Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, Noord-Holland, The Netherlands
| | - Jonathan M Coutinho
- Neurology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Lennard Wolff
- Radiology & Nuclear Medicine, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Wim H van Zwam
- Radiology, Maastricht University Cardiovascular Research Institute Maastricht, Maastricht, Limburg, The Netherlands
| | - Robert J van Oostenbrugge
- Neurology, Maastricht University Cardiovascular Research Institute Maastricht, Maastricht, Limburg, The Netherlands
| | - Aad van der Lugt
- Radiology & Nuclear Medicine, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | | | - Yvo B W E M Roos
- Neurology, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Henk A Marquering
- Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, Noord-Holland, The Netherlands
- Biomedical Engineering and Physics, Amsterdam UMC Location AMC, Amsterdam, North Holland, The Netherlands
| | - Charles B L M Majoie
- Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, Noord-Holland, The Netherlands
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Eagles ME, Beall RF, Ben-Israel D, Wong JH, Hill MD, Spackman E. Neighbourhood deprivation, distance to nearest comprehensive stroke centre and access to endovascular thrombectomy for ischemic stroke: a population-based study. CMAJ Open 2023; 11:E1181-E1187. [PMID: 38114260 PMCID: PMC10743637 DOI: 10.9778/cmajo.20230046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Endovascular thrombectomy (EVT) has revolutionized ischemic stroke care. We aimed to assess whether neighbourhood socioeconomic status is predictive of access to EVT after receipt of alteplase for ischemic stroke among patients living in Alberta, Canada, and whether this relation is mediated by the distance a person lives to the nearest comprehensive stroke centre (CSC). METHODS We performed a retrospective study including all people older than 18 years living in Alberta who were admitted to hospital with an ischemic stroke and who received intravenous alteplase treatment between Jan. 1, 2017, and Dec. 31, 2019. Data were obtained through administrative data sets. The primary outcome was treatment with EVT. We assigned neighbourhood deprivation quintile based on the Material and Social Deprivation Index. We used logistic regression modelling to assess for a relation between deprivation and treatment with EVT. We adjusted for age, sex, stroke severity and distance to the nearest CSC. We calculated the average causal mediation effect of distance to the nearest CSC on the relation between neighbourhood deprivation level and treatment with EVT. RESULTS The study cohort consisted of 1335 patients, of whom 181 (13.6%) had missing data and were excluded from the main regression analysis. Endovascular thrombectomy was performed or attempted in 314 patients (23.5%). In the primary model, patients from the most deprived neighbourhoods were less likely than those from less deprived neighbourhoods to have received EVT (adjusted odds ratio 0.43, 95% confidence interval 0.24 to 0.77). Neighbourhood deprivation level was not significantly associated with EVT when distance to the nearest CSC was included as a covariate. Mediation analysis suggested that 48% of the total effect that neighbourhood deprivation level had on the odds of receiving EVT was attributable to the distance a person lived from the nearest CSC. INTERPRETATION The results suggest that people from more deprived neighbourhoods in Alberta were less likely to be treated with EVT than those from less deprived neighbourhoods. Improving access to EVT for people living in remote locations may improve the equitable distribution of this treatment.
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Affiliation(s)
- Matthew E Eagles
- Department of Clinical Neurosciences (Eagles, Ben-Israel, Wong, Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary; Department of Community Health Sciences (Eagles, Beall, Ben-Israel, Hill, Spackman), Cumming School of Medicine and O'Brien Institute for Public Health, University of Calgary, Calgary, Alta.
| | - Reed F Beall
- Department of Clinical Neurosciences (Eagles, Ben-Israel, Wong, Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary; Department of Community Health Sciences (Eagles, Beall, Ben-Israel, Hill, Spackman), Cumming School of Medicine and O'Brien Institute for Public Health, University of Calgary, Calgary, Alta
| | - David Ben-Israel
- Department of Clinical Neurosciences (Eagles, Ben-Israel, Wong, Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary; Department of Community Health Sciences (Eagles, Beall, Ben-Israel, Hill, Spackman), Cumming School of Medicine and O'Brien Institute for Public Health, University of Calgary, Calgary, Alta
| | - John H Wong
- Department of Clinical Neurosciences (Eagles, Ben-Israel, Wong, Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary; Department of Community Health Sciences (Eagles, Beall, Ben-Israel, Hill, Spackman), Cumming School of Medicine and O'Brien Institute for Public Health, University of Calgary, Calgary, Alta
| | - Michael D Hill
- Department of Clinical Neurosciences (Eagles, Ben-Israel, Wong, Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary; Department of Community Health Sciences (Eagles, Beall, Ben-Israel, Hill, Spackman), Cumming School of Medicine and O'Brien Institute for Public Health, University of Calgary, Calgary, Alta
| | - Eldon Spackman
- Department of Clinical Neurosciences (Eagles, Ben-Israel, Wong, Hill), Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary; Department of Community Health Sciences (Eagles, Beall, Ben-Israel, Hill, Spackman), Cumming School of Medicine and O'Brien Institute for Public Health, University of Calgary, Calgary, Alta
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English SW, Chhabra N, Hanus AE, Basharath R, Miller M, Butterfield RJ, Zhang N, Demaerschalk BM. Prehospital stroke scales outperform National Institutes of Health Stroke Scale in predicting large vessel occlusion in a large academic telestroke network. J Telemed Telecare 2023:1357633X231204066. [PMID: 37899587 DOI: 10.1177/1357633x231204066] [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: 10/31/2023]
Abstract
INTRODUCTION Prehospital telestroke evaluations may improve stroke triage compared to paramedic-applied large vessel occlusion scales, but ambulance-based video National Institutes of Health Stroke Scale assessments are challenging. The accuracy of telestroke-administered large vessel occlusion scales has not been investigated, so we sought to evaluate this further. METHODS This retrospective study included all in-hospital telestroke encounters in a large academic telestroke network from 2019 to 2020. We retrospectively calculated seven large vessel occlusion scales using the in-hospital telestroke National Institutes of Health Stroke Scale (Rapid Arterial oCclusion Evaluation, Cincinnati Stroke Triage Assessment Tool, Field Assessment Stroke Triage for Emergency Destination, 3-Item Stroke Scale, Prehospital Acute Stroke Severity, Vision-Aphasia-Neglect, and Gaze-Face-Arm-Speech-Time). Diagnostic performance was assessed via sensitivity, specificity, negative predictive value, positive predictive value, positive likelihood ratio, negative likelihood ratio, and accuracy using established scale thresholds. These results were compared to the National Institutes of Health Stroke Scale at thresholds of 6, 8, and 10. The area under curve was calculated using c-statistics by treating scales as continuous variables. RESULTS A total of 625 patients were included; 111 (17.8%) patients had an anterior large vessel occlusion, 118 (18.9%) patients had any large vessel occlusion, and 182 (29.1%) patients had stroke mimic diagnosis. The mean age (SD) was 67.9 (15.9), 48.3% were female, and 93.4% were white. The Mean National Institutes of Health Stroke Scale (SD) was 14.9 (8.4) for patients with anterior large vessel occlusion, 4.7 (5.0) for patients with non-large vessel occlusion ischemic stroke, and 4.4 (5.8) for stroke mimic (p < 0.001). Compared to the National Institutes of Health Stroke Scale, Field Assessment Stroke Triage for Emergency Destination, and Rapid Arterial oCclusion Evaluation scales demonstrated higher accuracy and area under curve for large vessel occlusion detection. DISCUSSION Both the Field Assessment Stroke Triage for Emergency Destination and Rapid Arterial oCclusion Evaluation scales outperformed the National Institutes of Health Stroke Scale for large vessel occlusion detection in patients evaluated by in-hospital telestroke. These scales may be valid alternatives to the National Institutes of Health Stroke Scale examination in this setting.
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Affiliation(s)
- Stephen W English
- Department of Neurology, Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA
| | - Nikita Chhabra
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, USA
| | - Abigail E Hanus
- Department of Neurology, Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA
| | - Rida Basharath
- Department of Neurology, Mayo Clinic College of Medicine and Science, Jacksonville, FL, USA
| | - Monet Miller
- Mayo Clinic Alix School of Medicine, Scottsdale, AZ, USA
| | | | - Nan Zhang
- Department of Quantitative Health Sciences, Mayo Clinic, Phoenix, AZ, USA
| | - Bart M Demaerschalk
- Department of Neurology, Mayo Clinic College of Medicine and Science, Scottsdale, AZ, USA
- Center for Digital Health, Mayo Clinic, Rochester, MI, USA
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Li Y, Schappell LE, Polizu C, DiPersio J, Tsirka SE, Halterman MW, Nadkarni NA. Evolving Clinical-Translational Investigations of Cerebroprotection in Ischemic Stroke. J Clin Med 2023; 12:6715. [PMID: 37959180 PMCID: PMC10649331 DOI: 10.3390/jcm12216715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2023] [Revised: 10/17/2023] [Accepted: 10/19/2023] [Indexed: 11/15/2023] Open
Abstract
Ischemic stroke is a highly morbid disease, with over 50% of large vessel stroke (middle cerebral artery or internal carotid artery terminus occlusion) patients suffering disability despite maximal acute reperfusion therapy with thrombolysis and thrombectomy. The discovery of the ischemic penumbra in the 1980s laid the foundation for a salvageable territory in ischemic stroke. Since then, the concept of neuroprotection has been a focus of post-stroke care to (1) minimize the conversion from penumbra to core irreversible infarct, (2) limit secondary damage from ischemia-reperfusion injury, inflammation, and excitotoxicity and (3) to encourage tissue repair. However, despite multiple studies, the preclinical-clinical research enterprise has not yet created an agent that mitigates post-stroke outcomes beyond thrombolysis and mechanical clot retrieval. These translational gaps have not deterred the scientific community as agents are under continuous investigation. The NIH has recently promoted the concept of cerebroprotection to consider the whole brain post-stroke rather than just the neurons. This review will briefly outline the translational science of past, current, and emerging breakthroughs in cerebroprotection and use of these foundational ideas to develop a novel paradigm for optimizing stroke outcomes.
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Affiliation(s)
- Yinghui Li
- Department of Neurology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794-8651, USA; (Y.L.); (L.E.S.); (C.P.); (J.D.); (M.W.H.)
| | - Laurel E. Schappell
- Department of Neurology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794-8651, USA; (Y.L.); (L.E.S.); (C.P.); (J.D.); (M.W.H.)
- Department of Pharmacological Sciences, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794-8651, USA;
| | - Claire Polizu
- Department of Neurology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794-8651, USA; (Y.L.); (L.E.S.); (C.P.); (J.D.); (M.W.H.)
| | - James DiPersio
- Department of Neurology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794-8651, USA; (Y.L.); (L.E.S.); (C.P.); (J.D.); (M.W.H.)
| | - Stella E. Tsirka
- Department of Pharmacological Sciences, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794-8651, USA;
| | - Marc W. Halterman
- Department of Neurology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794-8651, USA; (Y.L.); (L.E.S.); (C.P.); (J.D.); (M.W.H.)
| | - Neil A. Nadkarni
- Department of Neurology, Renaissance School of Medicine, Stony Brook University, Stony Brook, NY 11794-8651, USA; (Y.L.); (L.E.S.); (C.P.); (J.D.); (M.W.H.)
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276
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Ash M, Dimisko L, Chalhoub RM, Howard BM, Cawley CM, Matouk C, Pabaney A, Spiotta AM, Jabbour P, Maier I, Wolfe SQ, Rai AT, Kim JT, Psychogios MN, Mascitelli JR, Starke RM, Shaban A, Yoshimura S, De Leacy R, Kan P, Fragata I, Polifka AJ, Arthur AS, Park MS, Crosa RJ, Williamson R, Dumont TM, Levitt MR, Al Kasab S, Tjoumakaris SI, Liman J, Saad H, Samaniego EA, Fargen KM, Grossberg JA, Alawieh A. Comprehensive analysis of the impact of procedure time and the 'golden hour' in subpopulations of stroke thrombectomy patients. J Neurointerv Surg 2023:jnis-2023-020792. [PMID: 37875342 DOI: 10.1136/jnis-2023-020792] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/19/2023] [Indexed: 10/26/2023]
Abstract
OBJECTIVE To evaluate the effect of procedure time on thrombectomy outcomes in different subpopulations of patients undergoing endovascular thrombectomy (EVT), given the recently expanded indications for EVT. METHODS This multicenter study included patients undergoing EVT for acute ischemic stroke at 35 centers globally. Procedure time was defined as time from groin puncture to successful recanalization (Thrombolysis in Cerebral Infarction score ≥2b) or abortion of procedure. Patients were stratified based on stroke location, use of IV tissue plasminogen activator (tPA), Alberta Stroke Program Early CT score, age group, and onset-to-groin time. Primary outcome was the 90-day modified Rankin Scale (mRS) score, with scores 0-2 designating good outcome. Secondary outcome was postprocedural symptomatic intracranial hemorrhage (sICH). Multivariate analyses were performed using generalized linear models to study the impact of procedure time on outcomes in each subpopulation. RESULTS Among 8961 patients included in the study, a longer procedure time was associated with higher odds of poor outcome (mRS score 3-6), with 10% increase in odds for each 10 min increment. When procedure time exceeded the 'golden hour', poor outcome was twice as likely. The golden hour effect was consistent in patients with anterior and posterior circulation strokes, proximal or distal occlusions, in patients with large core infarcts, with or without IV tPA treatment, and across age groups. Procedures exceeding 1 hour were associated with a 40% higher sICH rate. Posterior circulation strokes, delayed presentation, and old age were the variables most sensitive to procedure time. CONCLUSIONS In this work we demonstrate the universality of the golden hour effect, in which procedures lasting more than 1 hour are associated with worse clinical outcomes and higher rates of sICH across different subpopulations of patients undergoing EVT.
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Affiliation(s)
- Makenna Ash
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Laurie Dimisko
- Nell Hodgson Woodruff School of Nursing, Emory Healthcare, Atlanta, Georgia, USA
| | - Reda M Chalhoub
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Brian M Howard
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - C Michael Cawley
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Charles Matouk
- Department of Neurosurgery, Yale University, New Haven, Connecticut, USA
| | - Aqueel Pabaney
- Department of Neurosurgery, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ilko Maier
- Department of Neurology, University Medicine Goettingen, Goettingen, NS, Germany
| | - Stacey Q Wolfe
- Department of Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Ansaar T Rai
- Department of Interventional Neuroradiology, West Virginia University Rockefeller Neuroscience Institute, Morgantown, West Virginia, USA
| | - Joon-Tae Kim
- Department of Neurosurgery and Radiology, Chonnam National University, Gwangju, Jeollanam-do, Korea
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Justin R Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- University of Miami School of Medicine, Miami, Florida, USA
| | - Amir Shaban
- Department of Neurology, University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Reade De Leacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Isabel Fragata
- Department of Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Adam J Polifka
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Adam S Arthur
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Min S Park
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Roberto Javier Crosa
- Department of Endovascular Neurosurgery, Médica Uruguaya, Montevideo, Montevideo, Uruguay
| | - Richard Williamson
- Stroke and Cerebrovascular Center, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - Travis M Dumont
- Department of Surgery, Division of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Sami Al Kasab
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jan Liman
- Department of Neurology, University Medicine Goettingen, Goettingen, NS, Germany
| | - Hassan Saad
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Edgar A Samaniego
- Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Kyle M Fargen
- Department of Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Jonathan A Grossberg
- Department of Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ali Alawieh
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
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Migdady I, Johnson-Black PH, Leslie-Mazwi T, Malhotra R. Current and Emerging Endovascular and Neurocritical Care Management Strategies in Large-Core Ischemic Stroke. J Clin Med 2023; 12:6641. [PMID: 37892779 PMCID: PMC10607145 DOI: 10.3390/jcm12206641] [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: 09/16/2023] [Revised: 10/17/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023] Open
Abstract
The volume of infarcted tissue in patients with ischemic stroke is consistently associated with increased morbidity and mortality. Initial studies of endovascular thrombectomy for large-vessel occlusion excluded patients with established large-core infarcts, even when large volumes of salvageable brain tissue were present, due to the high risk of hemorrhagic transformation and reperfusion injury. However, recent retrospective and prospective studies have shown improved outcomes with endovascular thrombectomy, and several clinical trials were recently published to evaluate the efficacy of endovascular management of patients presenting with large-core infarcts. With or without thrombectomy, patients with large-core infarcts remain at high risk of in-hospital complications such as hemorrhagic transformation, malignant cerebral edema, seizures, and others. Expert neurocritical care management is necessary to optimize blood pressure control, mitigate secondary brain injury, manage cerebral edema and elevated intracranial pressure, and implement various neuroprotective measures. Herein, we present an overview of the current and emerging evidence pertaining to endovascular treatment for large-core infarcts, recent advances in neurocritical care strategies, and their impact on optimizing patient outcomes.
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Affiliation(s)
- Ibrahim Migdady
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurological Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Phoebe H. Johnson-Black
- Department of Neurosurgery, Division of Neurocritical Care, UCLA David Geffen School of Medicine, Ronald Reagan Medical Center, Los Angeles, CA 90095, USA;
| | | | - Rishi Malhotra
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurological Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
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278
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Li L, Lv J, Han JJ, Gao Y, Yan ZX, Wu Q, Zhang XL, Gao F. Nomogram model of functional outcome for endovascular treatment in patients with acute basilar artery occlusion. Front Neurol 2023; 14:1277189. [PMID: 37928150 PMCID: PMC10621789 DOI: 10.3389/fneur.2023.1277189] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2023] [Accepted: 09/29/2023] [Indexed: 11/07/2023] Open
Abstract
Background and purpose The efficacy and safety of endovascular treatment (EVT) in acute basilar artery occlusion (ABAO) has been confirmed by four randomized clinical trials. Nevertheless, the predictors of a 90-day favorable outcome after EVT have not been elucidated. We attempted to establish a nomogram for the prediction of a 90-day favorable outcome in ABAO patients with EVT. Methods Clinical data of ABAO patients with EVT were obtained from two nationwide clinical trial registries in China. Factors associated with a 90-day favorable outcome were screened by multivariable step-wise regression on the basis of univariable analysis. A nomogram was established to predict 90-day favorable outcome after EVT. Results The proportion of ABAO patients with a favorable outcome was 41.53% (157/378). Seven variables, including baseline National Institutes of Health Stroke Scale (NIHSS) <20 [odds ratio (OR): 8.330; P-value < 0.0001], posterior circulation Alberta Stroke Program Early CT (pc-ASPECT) score ≥7 (OR: 1.948; P-value = 0.0296), Pons-Midbrain Index (PMI) score < 2 (OR: 2.108; P-value = 0.0128), Posterior Circulation Collateral Score (PC-CS) ≥5 (OR: 3.288; P-value < 0.0001), local anesthesia (OR: 0.389; P-value = 0.0017), time from onset to recanalization (OTR) <330 min (OR: 2.594; P-value = 0.0013), and no occurrence of early neurological deterioration (END; OR: 0.039; P-value < 0.0001) were included into the nomogram, with C-index values of 0.8730 and 0.8857 in the training and the internal validation set, respectively. Conclusions The proposed nomogram provided a reliable prognostic scale, which can be employed in clinical settings for the selection and clinical management of ABAO patients. Registration https://www.clinicaltrials.gov, identifier: NCT03370939.
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Affiliation(s)
- Lei Li
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jin Lv
- Department of Radiotherapy, The PLA Rocket Force Characteristic Medical Center, Beijing, China
| | - Jian-jia Han
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuan Gao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhao-xuan Yan
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Qi Wu
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiao-li Zhang
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Howell DM, Li T, Quellhorst E, Katz JM, Arora R, Berkowitz J. Reducing Door-In to Door-Out Time for Patients Receiving a Mechanical Thrombectomy Using AutoLaunch Protocol. Open Access Emerg Med 2023; 15:367-371. [PMID: 37868690 PMCID: PMC10590110 DOI: 10.2147/oaem.s427945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 10/11/2023] [Indexed: 10/24/2023] Open
Abstract
Background Door-in to door-out (DIDO) time for large vessel occlusion (LVO) stroke is an emerging stroke performance measure. Initial presentation at a non-Comprehensive Stroke Center (CSC) requires a transfer process that minimizes delays. Our objective was to assess whether DIDO time for stroke patients was reduced after implementation of an AutoLaunch protocol for interfacility transfers. Methods This was a pre-post analysis of an AutoLaunch protocol for all acute stroke patients transferred to a CSC for mechanical thrombectomy. The distribution of DIDO times between patients transferred via the AutoLaunch and traditional dispatch protocols were compared. Results We evaluated 92 interfacility transfers, with 22 utilizing the AutoLaunch protocol and 70 utilizing traditional dispatch. Among AutoLaunch transfers, the median DIDO time was 85 minutes (IQR: 71, 133), while the median DIDO time among the traditional transfers was 109 minutes (IQR, 84, 144) (p=0.044). Conclusion Implementation of an AutoLaunch protocol for patients with suspected LVO was associated with a reduction in DIDO time to CSCs. Further studies should evaluate patient outcomes based on transfer strategies.
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Affiliation(s)
- Devin M Howell
- Department of Emergency Medicine, Northwell Health, Manhasset, NY, USA
- Center for Emergency Medical Services, Northwell Health, Syosset, NY, USA
| | - Timmy Li
- Department of Emergency Medicine, Northwell Health, Manhasset, NY, USA
| | | | - Jeffrey M Katz
- Department of Neurology, Northwell Health, Manhasset, NY, USA
| | - Rohan Arora
- Department of Neurology, Northwell Health, Manhasset, NY, USA
| | - Jonathan Berkowitz
- Center for Emergency Medical Services, Northwell Health, Syosset, NY, USA
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280
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Li X, Duan W, Du L, Chu D, Wang P, Yang Z, Qu X, Yang Z, Batinic-Haberle I, Spasojevic I, Warner DS, Crapo JD, Treggiari MM, Sheng H. Intracarotid Infusion of Redox-Active Manganese Porphyrin, MnTnBuOE-2-PyP 5+, following Reperfusion Improves Long-Term, 28-Day Post-Stroke Outcomes in Rats. Antioxidants (Basel) 2023; 12:1861. [PMID: 37891940 PMCID: PMC10603962 DOI: 10.3390/antiox12101861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2023] [Revised: 10/02/2023] [Accepted: 10/05/2023] [Indexed: 10/29/2023] Open
Abstract
Endovascular mechanical thrombectomy, combined with a tissue plasminogen activator (t-PA), is efficacious as a standard care for qualifying ischemic stroke patients. However, > 50% of thrombectomy patients still have poor outcomes. Manganese porphyrins, commonly known as mimics of superoxide dismutases, are potent redox-active catalytic compounds that decrease oxidative/nitrosative stress and in turn decrease inflammatory responses, mitigating therefore the secondary injury of the ischemic brain. This study investigates the effect of intracarotid MnTnBuOE-2-PyP5+ (BMX-001) administration on long-term, 28-day post-stroke recovery in a clinically relevant setting. The 90 min of transient middle cerebral artery occlusion was performed in young, aged, male, female, and spontaneous hypertension rats. All physiological parameters, including blood pressure, blood gas, glucose, and temperature, were well controlled during ischemia. Either BMX-001 or a vehicle solution was infused through the carotid artery immediately after the removal of filament, mimicking endovascular thrombectomy, and was followed by 7 days of subcutaneous injection. Neurologic deficits and infarct volume were assessed at 28 days in a blinded manner. The effects of BMX-001 on the carotid arterial wall and blood-brain barrier permeability and its interaction with t-PA were assessed in normal rats. There were no intra-group differences in physiological variables. BMX-001-treated stroke rats regained body weight earlier, performed better in behavioral tests, and had smaller brain infarct size compared to the vehicle-treated group. No vascular wall damage and blood-brain barrier permeability changes were detected after the BMX-001 infusion. There was no drug interaction between BMX-001 and t-PA. Intracarotid BMX-001 infusion was safe, and it significantly improved stroke outcomes in rats. These findings indicate that BMX-001 is a candidate drug as an adjunct treatment for thrombectomy procedure to further improve the neurologic outcomes of thrombectomy patients. This study warrants further clinical investigation of BMX-001 as a new stroke therapy.
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Affiliation(s)
- Xuan Li
- Multidisciplinary Neuroprotection Laboratories, Center of Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA; (X.L.); (W.D.); (L.D.); (D.C.); (P.W.); (Z.Y.); (X.Q.); (D.S.W.); (M.M.T.)
| | - Weina Duan
- Multidisciplinary Neuroprotection Laboratories, Center of Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA; (X.L.); (W.D.); (L.D.); (D.C.); (P.W.); (Z.Y.); (X.Q.); (D.S.W.); (M.M.T.)
| | - Li Du
- Multidisciplinary Neuroprotection Laboratories, Center of Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA; (X.L.); (W.D.); (L.D.); (D.C.); (P.W.); (Z.Y.); (X.Q.); (D.S.W.); (M.M.T.)
| | - Dongmei Chu
- Multidisciplinary Neuroprotection Laboratories, Center of Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA; (X.L.); (W.D.); (L.D.); (D.C.); (P.W.); (Z.Y.); (X.Q.); (D.S.W.); (M.M.T.)
| | - Peng Wang
- Multidisciplinary Neuroprotection Laboratories, Center of Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA; (X.L.); (W.D.); (L.D.); (D.C.); (P.W.); (Z.Y.); (X.Q.); (D.S.W.); (M.M.T.)
| | - Zhong Yang
- Multidisciplinary Neuroprotection Laboratories, Center of Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA; (X.L.); (W.D.); (L.D.); (D.C.); (P.W.); (Z.Y.); (X.Q.); (D.S.W.); (M.M.T.)
| | - Xingguang Qu
- Multidisciplinary Neuroprotection Laboratories, Center of Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA; (X.L.); (W.D.); (L.D.); (D.C.); (P.W.); (Z.Y.); (X.Q.); (D.S.W.); (M.M.T.)
| | - Zhenxing Yang
- Department of Neurosurgery, Duke University Medical Center, Durham, NC 27710, USA;
| | - Ines Batinic-Haberle
- Department of Radiation Oncology, Duke University Medical Center, Durham, NC 27710, USA;
| | - Ivan Spasojevic
- Pharmacokinetics and Pharmacodynamics Core, Duke Cancer Institute, and Department of Medicine, Duke University Medical Center, Durham, NC 27710, USA
| | - David S. Warner
- Multidisciplinary Neuroprotection Laboratories, Center of Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA; (X.L.); (W.D.); (L.D.); (D.C.); (P.W.); (Z.Y.); (X.Q.); (D.S.W.); (M.M.T.)
- Department of Neurosurgery, Duke University Medical Center, Durham, NC 27710, USA;
- Department of Neurobiology, Duke University Medical Center, Durham, NC 27710, USA
| | | | - Miriam M. Treggiari
- Multidisciplinary Neuroprotection Laboratories, Center of Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA; (X.L.); (W.D.); (L.D.); (D.C.); (P.W.); (Z.Y.); (X.Q.); (D.S.W.); (M.M.T.)
| | - Huaxin Sheng
- Multidisciplinary Neuroprotection Laboratories, Center of Perioperative Organ Protection, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA; (X.L.); (W.D.); (L.D.); (D.C.); (P.W.); (Z.Y.); (X.Q.); (D.S.W.); (M.M.T.)
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Chen JH, Lin SC, Hong CT, Chan L. Outcomes of Endovascular Treatment versus Standard Medical Treatment for Acute Ischemic Stroke with Basilar Artery Occlusion: A Systematic Review and Meta-Analysis. J Clin Med 2023; 12:6444. [PMID: 37892581 PMCID: PMC10607126 DOI: 10.3390/jcm12206444] [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: 09/01/2023] [Revised: 09/23/2023] [Accepted: 10/08/2023] [Indexed: 10/29/2023] Open
Abstract
BACKGROUND Although endovascular treatment (EVT) is beneficial for large vessel occlusion in anterior circulation stroke, whether these benefits exist for basilar artery occlusion (BAO) remains unclear. This systematic review and meta-analysis compared the outcomes of patients with BAO undergoing EVT and standard medical treatment (SMT). METHODS The PubMed, Embase, and Cochrane Library databases were searched for eligible randomized control trials (RCTs) and non-RCTs involving patients with acute ischemic stroke and BAO undergoing EVT or SMT. The following outcomes were assessed: 90-day functional outcomes (favorable outcome and functional independence: modified Rankin scale [mRS] score of 0-3 or 0-2, respectively), mortality, and symptomatic intracranial hemorrhage (sICH) incidence. The summary effect sizes were determined as risk ratios (RRs) through the Mantel-Haenszel method with a random-effects model. RESULTS Four RCTs and four non-RCTs were included. Compared with SMT, EVT resulted in a higher proportion of patients with 90-day mRS scores of 0-3 (RR: 1.54 [1.16-2.06] in RCTs and 1.88 [1.11-3.19] in non-RCTs), a higher proportion of patients achieving functional independence (90-day mRS score of 0-2; RR: 1.83 [1.07-3.12] and 1.84 [0.97-3.48], respectively), a lower risk of mortality (RR: 0.76 [0.65-0.89] and 0.72 [0.62-0.83], respectively), and a higher sICH risk (RR: 5.98 [2.11-16.97] and 4.95 [2.40-10.23], respectively). Severe neurological deficits, intravenous thrombolysis, and higher posterior circulation Acute Stroke Prognosis Early Computed Tomography Score (pc-ASPECTS) were associated with EVT benefits. CONCLUSION In patients with BAO, EVT results in superior functional outcomes, lower mortality risk, and higher sICH risk than does SMT, independent of age and sex. Higher National Institutes of Health Stroke Scale scores, intravenous thrombolysis, and higher pc-ASPECTSs before treatment are associated with greater benefits from EVT.
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Affiliation(s)
- Jia-Hung Chen
- Department of Neurology, Shuang-Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (J.-H.C.); (S.-C.L.); (C.-T.H.)
| | - Sheng-Chieh Lin
- Department of Neurology, Shuang-Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (J.-H.C.); (S.-C.L.); (C.-T.H.)
| | - Chien-Tai Hong
- Department of Neurology, Shuang-Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (J.-H.C.); (S.-C.L.); (C.-T.H.)
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
| | - Lung Chan
- Department of Neurology, Shuang-Ho Hospital, Taipei Medical University, New Taipei City 23561, Taiwan; (J.-H.C.); (S.-C.L.); (C.-T.H.)
- Department of Neurology, School of Medicine, College of Medicine, Taipei Medical University, Taipei 11031, Taiwan
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282
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Ali A, Testai FD, Trifan G. Efficacy and Safety of Mechanical Thrombectomy in Elderly and Non-Elderly Patients with Large Vessel Occlusion Stroke: Systematic Review and Meta-Analysis. Cerebrovasc Dis 2023; 53:372-381. [PMID: 37812917 DOI: 10.1159/000533204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/20/2023] [Indexed: 10/11/2023] Open
Abstract
INTRODUCTION Mechanical thrombectomy (MT) is recommended for large vessel occlusion (LVO) stroke. However, most of the studies that investigated the superiority of MT over best medical management (BMM) alone included preponderantly non-elderly patients. Thus, there is uncertainty in relation to the efficacy of MT in the elderly. We aim to compare the effect of BMM to BMM plus MT among elderly and non-elderly patients with LVO. METHODS We performed a systematic search of medical databases from inception to April 2023 to identify randomized studies that reported the functional outcome at 90 days by age for patients with LVO treated with MT versus BMM. Patients were divided into elderly (>70 or >80 years, depending on the cutoff used in each study) and non-elderly. Outcomes were defined as excellent (modified Rankin Scale [mRS] ≤1), good (mRS ≤3), poor (mRS ≥5), or death. Effect sizes were calculated by using random effects meta-analyses. Results were represented by odds ratio (OR) and their 95% confidence intervals (95% CIs). RESULTS A total of 2,195 patients were included in the analysis (≥70 years, 7 trials, n = 696; ≥80 years, 2 trials, n = 139). Non-elderly patients treated with MT had higher odds of excellent outcome (OR: 3.05; 95% CI: 2.23-4.18) and good outcome (OR: 2.70; 95% CI: 1.94-3.74), and lower odds of poor outcome (OR: 0.54; 95% CI: 0.40-0.72) and death (OR: 0.63; 95% CI: 0.41-0.96). Similarly, elderly patients treated with MT had higher odds of excellent (OR: 2.39; 95% CI: 1.05-5.45) and good outcomes (OR: 2.18; 95% CI: 1.43-3.33) and lower odds of poor outcome (OR: 0.48; 95% CI: 0.33-0.70) and mortality (OR: 0.50; 0.26-0.95). When outcomes were analyzed by age subgroups, MT was associated with higher odds of good outcome in patients ≥70 years (OR: 1.95, 95% CI: 1.26-3.03) and ≥80 years (OR: 4.43, 95% CI: 1.02-19.23). CONCLUSION MT increases the likelihood of achieving a good outcome in elderly and non-elderly patients without increasing the risk of severe disability or death. MT, when otherwise clinically indicated, should be considered over BMM alone in both age groups.
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Affiliation(s)
- Aisha Ali
- Department of Neurology and Rehabilitation, University of Illinois at Chicago, College of Medicine, Chicago, Illinois, USA
| | - Fernando D Testai
- Department of Neurology and Rehabilitation, University of Illinois at Chicago, College of Medicine, Chicago, Illinois, USA
| | - Gabriela Trifan
- Department of Neurology and Rehabilitation, University of Illinois at Chicago, College of Medicine, Chicago, Illinois, USA
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283
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Hayakawa M. Cancer-Associated Stroke and Acute Endovascular Reperfusion Therapy. JOURNAL OF NEUROENDOVASCULAR THERAPY 2023; 17:272-280. [PMID: 38025257 PMCID: PMC10657734 DOI: 10.5797/jnet.ra.2023-0056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 09/19/2023] [Indexed: 12/01/2023]
Abstract
Since stroke is often associated with cancer, acute stroke patients with cancer undergoing endovascular therapy (EVT) are not uncommon. Reportedly, the proportion of such cases is approximately 6%-7% of all stroke EVT cases. Ischemic stroke in patients with active cancer (cancer-associated stroke) includes not only strokes caused by cancer-related hypercoagulability but also coincident strokes due to common etiologies, strokes associated with tumor emboli, direct tumor invasion of blood vessels, and strokes associated with cancer therapy. Stroke caused by cancer-related hypercoagulability itself encompasses various entities, including paradoxical embolism, stroke due to nonbacterial thrombotic endocarditis, and in situ arterial occlusion due to disseminated intravascular coagulation or thrombotic microangiopathy. Thus, diverse mechanisms contribute to cancer-associated stroke, emphasizing the need to consider individualized treatment strategies for acute cases involving large vessel occlusion. Observational studies have shown that EVT for cancer-associated stroke results in poorer clinical outcomes, but with comparable rates of successful reperfusion and symptomatic intracranial hemorrhage when compared with stroke patients without cancer. This suggests that denying patients EVT solely on the basis of comorbid active cancer is inappropriate, and decision-making should be shared with the patients and their families, preferably through a multidisciplinary team approach. Thrombi retrieved from patients with stroke caused by cancer-related hypercoagulability have unique characteristics, being predominantly platelet rich and difficult to retrieve. Preprocedural imaging and serum biomarkers, including the hyperdense vessel sign on non-contrast CT, susceptibility vessel sign on T2* or susceptibility-weighted MRI, three-territory sign on MRI, and D-dimer levels, are valuable in evaluating the stroke subtype and thrombus features. Thrombectomy techniques, such as contact aspiration and stent retriever monotherapy, have shown varying degrees of effectiveness for stroke caused by cancer-related hypercoagulability, warranting further study. After reperfusion therapy, appropriate treatment for the prevention of stroke recurrence should be initiated, considering the specific stroke subtypes. In conclusion, cancer-associated stroke encompasses diverse subtypes, and thrombi associated with stroke caused by cancer-related hypercoagulability present various challenges for thrombectomy. Individualized treatment approaches based on underlying mechanisms are essential for improving outcomes in acute stroke patients with active cancer. Optimization of preprocedural diagnosis, EVT techniques, and secondary prevention of stroke caused by cancer-related hypercoagulability will lead to better management of these patients and enhance their quality of life.
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Affiliation(s)
- Mikito Hayakawa
- Department of Stroke and Cerebrovascular Diseases, University of Tsukuba Hospital, Tsukuba, Ibaraki, Japan
- Department of Neurology, Institute of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
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284
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Kellner CP, Mocco J. Long-awaited success on the intracerebral hemorrhage front. J Neurointerv Surg 2023; 15:937-938. [PMID: 37532453 DOI: 10.1136/jnis-2023-020532] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/30/2023] [Indexed: 08/04/2023]
Affiliation(s)
| | - J Mocco
- Neurosurgery, Mount Sinai Health System, New York, New York, USA
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285
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Li S, Zhang Y, Zhang X, Zhang G, Han N, Ma H, Ge H, Zhao Y, Zhang L, Wang Y, Shi W, Ma X, Tian Y, Xiao Y, Niu Y, Qiao L, Chang M. The Functional Prognosis of Rescue Conscious Sedation During Mechanical Thrombectomy on Patients with Acute Anterior Circulation Ischemic Stroke: A Single-Center Retrospective Study. Neurol Ther 2023; 12:1777-1789. [PMID: 37531028 PMCID: PMC10444930 DOI: 10.1007/s40120-023-00528-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 07/20/2023] [Indexed: 08/03/2023] Open
Abstract
INTRODUCTION Based on real-world case data, this study intends to explore and analyze the impact of rescue conscious sedation (CS) on the clinical outcomes of patients with anterior circulation acute ischemic stroke (AIS) receiving mechanical thrombectomy (MT). METHODS This retrospective study enrolled patients with anterior circulation AIS who received MT and were treated with either single local anesthesia (LA) or rescue CS during MT between January 2018 and October 2021. We used univariate and multivariate logistic regression methods to compare the impact of LA and CS on the clinical outcomes of patients with AIS who received MT, including the mRS at 90 days, the incidence of poststroke pneumonia (PSP), the incidence of symptomatic intracranial cerebral hemorrhage (sICH), and the mortality rate. RESULTS We reviewed 314 patient cases with AIS who received MT. Of all patients, 164 met our search criteria. Eighty-nine patients received LA, and 75 patients received rescue CS. There was no significant difference between the two groups in the 90-day good prognosis (45.3% vs. 51.7%, p = 0.418) and mortality (17.3% vs. 22.5%, p = 0.414). Compared with the LA group, the incidence of postoperative pneumonia in the rescue CS group (44% vs. 25.8%, p = 0.015) was more significant. Multivariate stepwise logistic regression analysis revealed that intraoperative remedial CS was independently associated with PSP following MT. In a subgroup analysis, rescue CS was found to significantly increase the incidence of PSP in patients with dysphagia (OR = 7.307, 95% CI 2.144-24.906, p = 0.001). As the severity of the National Institutes of Health Stroke Scale (NIHSS) increased, intraoperative rescue CS was found to increase the risk of PSP (OR = 1.155, 95% CI 1.034-1.290, p = 0.011) by 5.1% compared to that of LA (OR = 1.104, 95% CI 1.013-1.204, p = 0.024). CONCLUSION Compared to LA, rescue CS during MT does not significantly improve the 90 days of good prognosis and reduce the incidence of sICH and mortality in patients with anterior circulation AIS. However, it has a significantly increased risk of poststroke pneumonia (PSP), particularly in patients with dysphagia.
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Affiliation(s)
- Shilin Li
- Department of Neurology, The Affiliated Hospital of Northwest University, Xi'an No.3 Hospital, Xi'an, 710069, China
| | - Yu Zhang
- The College of Life Sciences, Northwest University, Xi'an, China
| | - Xiaobo Zhang
- The College of Life Sciences, Northwest University, Xi'an, China
| | - Gejuan Zhang
- Department of Neurology, The Affiliated Hospital of Northwest University, Xi'an No.3 Hospital, Xi'an, 710069, China
| | - Nannan Han
- Department of Neurology, The Affiliated Hospital of Northwest University, Xi'an No.3 Hospital, Xi'an, 710069, China
| | - Haojun Ma
- Department of Neurology, The Affiliated Hospital of Northwest University, Xi'an No.3 Hospital, Xi'an, 710069, China
| | - Hanming Ge
- Department of Neurology, The Affiliated Hospital of Northwest University, Xi'an No.3 Hospital, Xi'an, 710069, China
| | - Yong Zhao
- Department of Neurology, The Affiliated Hospital of Northwest University, Xi'an No.3 Hospital, Xi'an, 710069, China
| | - Leshi Zhang
- Department of Neurology, The Affiliated Hospital of Northwest University, Xi'an No.3 Hospital, Xi'an, 710069, China
| | - Yanfei Wang
- Department of Neurology, The Affiliated Hospital of Northwest University, Xi'an No.3 Hospital, Xi'an, 710069, China
| | - Wenzhen Shi
- Xi'an Key Laboratory of Cardiovascular and Cerebrovascular Diseases, Medical Research Center, The Aliated Hospital of Northwest University, Xi'an No.3 Hospital, Xi'an, China
| | - Xiaojuan Ma
- Xi'an Key Laboratory of Cardiovascular and Cerebrovascular Diseases, Medical Research Center, The Aliated Hospital of Northwest University, Xi'an No.3 Hospital, Xi'an, China
| | - Yizhuo Tian
- Key Laboratory of Resource Biology and Biotechnology in Western China, Ministry of Education, School of Medicine, Northwest University, Xi'an, China
| | - Yixuan Xiao
- Key Laboratory of Resource Biology and Biotechnology in Western China, Ministry of Education, School of Medicine, Northwest University, Xi'an, China
| | - Yinuo Niu
- Key Laboratory of Resource Biology and Biotechnology in Western China, Ministry of Education, School of Medicine, Northwest University, Xi'an, China
| | - Lin Qiao
- Department of Anesthesiology, Xi'an No.5 Hospital, Xi'an, China
| | - Mingze Chang
- Department of Neurology, The Affiliated Hospital of Northwest University, Xi'an No.3 Hospital, Xi'an, 710069, China.
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286
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Gentile L, Pracucci G, Saia V, Falcou A, Biraschi F, Zini A, Simonetti L, Riva L, Bigliardi G, Vallone S, Nencini P, Limbucci N, Diomedi M, Da Ros V, Longoni M, Ruggiero M, Tassinari T, Allegretti L, Cerrato P, Rubino E, Bergui M, Cavallo R, Naldi A, Comelli C, Cappellari M, Zivelonghi C, Plebani M, De Vito A, Merli N, Saletti A, Musolino RF, Ferraù L, Vinci SL, Sacco S, Orlandi B, De Santis F, Filauri P, Ruiz L, Sepe FN, Gallesio I, Petruzzellis M, Chiumarulo L, Sangalli D, Salmaggi A, Filizzolo M, Moller J, Melis M, Comelli S, Magoni M, Gilberti N, Gasparotti R, Invernizzi P, Pavia M, Pinto V, Laspada S, Marcheselli S, Ajello D, Viaro F, Baracchini C, Causin F, Giannini N, Caselli MC, Mancuso M, Cosottini M, Scoditti U, Menozzi R, Russo M, Amistá P, Napoletano R, Romano DG, Tassi R, Bracco S, Carimati F, Versino M, Giorgianni A, De Boni A, Fasano A, Barbarini L, Paladini A, Franchini E, Dall'Ora E, Comai A, Giovanni F, Pedicelli A, Sallustio F, Casetta I, Fainardi E, Mangiafico S, Toni D. Mechanical thrombectomy in patients with heart failure: the Italian registry of Endovascular Treatment in Acute Stroke. Neurol Sci 2023; 44:3577-3585. [PMID: 37199875 DOI: 10.1007/s10072-023-06830-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 04/26/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Heart failure (HF) is the second most important cardiac risk factor for stroke after atrial fibrillation (AF). Few data are available on mechanical thrombectomy (MT) in acute ischemic stroke (AIS) patients with HF. METHODS The source of data is the multicentre Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS). All AIS patients ≥ 18 years receiving MT were categorised in two groups: HF and no-HF. Baseline clinical and neuroradiological findings on admission were analysed. RESULTS Of 8924 patients, 642 (7.2%) had HF. Compared to the no-HF group, HF patients had higher prevalence of cardiovascular risk factors. Rate of complete recanalisation (TICI 2b-3) was 76.9% in HF vs 78.1% in no-HF group (p = 0.481). Rate of symptomatic intracerebral haemorrhage at 24-h non-contrast computed tomography (NCCT) was 7.6% in HF vs 8.3% in no-HF patients (p = 0.520). At 3 months, 36.4% of HF patients and 48.2% of no-HF patients (p < 0.001) had mRS 0-2, and mortality was, respectively, 30.7% and 18.5% (p < 0.001). In multivariate logistic regression, HF was independently associated with mortality at 3 months (OR 1.53, 1.24-1.88 95% CI, p < 0.001). In multivariate ordinal regression, HF patients had a probability of transitioning to a higher mRS level of 1.23 (1.05-1.44 95% CI, p = 0.012). The propensity score analysis of two groups matched for age, sex, and NIHSS at admission yielded the same results. CONCLUSION MT is safe and effective in HF patients with AIS. Patients with HF and AIS suffered from higher 3-month mortality and unfavourable outcome regardless of acute treatments.
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Affiliation(s)
- Luana Gentile
- Department of Neurology and Metropolitan Stroke Center, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Maggiore Hospital, Bologna, Italy
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy
| | - Giovanni Pracucci
- Department of NEUROFARBA, Neuroscience Section, University of Florence, Florence, Italy
| | - Valentina Saia
- Neurology and Stroke Unit, Santa Corona Hospital, Pietra Ligure, Italy
| | - Anne Falcou
- Emergency Department, Stroke Unit, Policlinico Umberto I Hospital, Rome, Italy
| | - Francesco Biraschi
- Department of Human Neurosciences, Interventional Neuroradiology, Policlinico Umberto I, Sapienza University of Rome, Rome, Italy
| | - Andrea Zini
- Department of Neurology and Metropolitan Stroke Center, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Maggiore Hospital, Bologna, Italy
| | - Luigi Simonetti
- Neuroradiology Department, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Maggiore Hospital, Bologna, Italy
| | - Letizia Riva
- Cardiology Unit, Maggiore Hospital, Bologna, Italy
| | - Guido Bigliardi
- Stroke Unit, Neurology Unit, Department of Neuroscience, Azienda Ospedaliera Universitaria Di Modena, Ospedale Civile Baggiovara, Modena, Italy
| | - Stefano Vallone
- Neuroradiology Unit, Ospedale Civile Di Baggiovara, Azienda Ospedaliera Universitaria Di Modena, Modena, Italy
| | - Patrizia Nencini
- Department of NEUROFARBA, Neuroscience Section, University of Florence, Florence, Italy
| | - Nicola Limbucci
- Department of Interventional Neuroradiology, Careggi University Hospital, Florence, Italy
| | - Marina Diomedi
- Stroke Unit, Department of Systems Medicine, University of Tor Vergata, Rome, Italy
| | - Valerio Da Ros
- Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Marco Longoni
- Department of Neurology and Stroke Unit Cesena-Forlì, Bufalini Hospital, AUSL Romagna, Cesena, Italy
| | - Maria Ruggiero
- Neuroradiology Unit, Bufalini Hospital, AUSL Romagna, Cesena, Italy
| | - Tiziana Tassinari
- Neurology and Stroke Unit, Santa Corona Hospital, Pietra Ligure, Italy
| | - Luca Allegretti
- Department of Interventional Neuroradiology, Santa Corona Hospital, Pietra Ligure, Italy
| | - Paolo Cerrato
- Stroke Unit, AOU Città Della Salute E Della Scienza, Molinette Hospital, Turin, Italy
| | - Elisa Rubino
- Stroke Unit, AOU Città Della Salute E Della Scienza, Molinette Hospital, Turin, Italy
| | - Mauro Bergui
- Neuroscience Department, University of Torino, Turin, Italy
| | | | - Andrea Naldi
- Neurology Unit, San Giovanni Bosco Hospital, Turin, Italy
| | - Chiara Comelli
- Interventional Neuroradiology Unit, San Giovanni Bosco Hospital, Turin, Italy
| | - Manuel Cappellari
- Stroke Unit, Department of Neuroscience, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Cecilia Zivelonghi
- Stroke Unit, Department of Neuroscience, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Mauro Plebani
- Interventional Neurovascular Unit, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | - Nicola Merli
- Neurology Unit, University Hospital Arcispedale S. Anna, Ferrara, Italy
| | - Andrea Saletti
- Department of Radiology, Neuroradiology Unit, Azienda Ospedaliera Universitaria, Arcispedale S. Anna, Ferrara, Italy
| | - Rosa Fortunata Musolino
- Department of Clinical and Experimental Medicine, U.O.S.D. Stroke Unit, AOU Policlinico G. Martino, University of Messina, Messina, Italy
| | - Ludovica Ferraù
- Department of Clinical and Experimental Medicine, U.O.S.D. Stroke Unit, AOU Policlinico G. Martino, University of Messina, Messina, Italy
| | - Sergio Lucio Vinci
- Department of Biomedical, Dental, Morphological and Functional Imaging Sciences, Neuroradiology Unit, University of Messina, Messina, Italy
| | - Simona Sacco
- Stroke Unit and Neurology Unit, S.S. Filippo and Nicola Hospital, Avezzano, Italy
| | - Berardino Orlandi
- Stroke Unit and Neurology Unit, S.S. Filippo and Nicola Hospital, Avezzano, Italy
| | - Federica De Santis
- Stroke Unit and Neurology Unit, S.S. Filippo and Nicola Hospital, Avezzano, Italy
| | - Pietro Filauri
- Neuroradiology Unit, SS. Filippo and Nicola Hospital, Avezzano, Italy
| | - Luigi Ruiz
- Stroke Unit, SS. Antonio E Biagio E Cesare Arrigo Hospital, Alessandria, Italy
| | | | - Ivan Gallesio
- Neuroradiology Unit, SS. Antonio E Biagio E Cesare Arrigo Hospital, Alessandria, Italy
| | - Marco Petruzzellis
- Neurology Unit and Stroke Unit, Department of Basic Medical Sciences, Neurosciences and Sense Organs, University of Bari, Bari, Italy
| | | | | | | | - Marco Filizzolo
- Interventional Neuroradiology Unit, AOOR Villa Sofia-Cervello, Palermo, Italy
| | | | | | - Simone Comelli
- Vascular and Interventional Neuroradiology Department, ARNAS G. Brotzu, Cagliari, Italy
| | - Mauro Magoni
- Stroke Unit, SpedaliCivili, Vascular Neurology, Brescia, Italy
| | - Nicola Gilberti
- Stroke Unit, SpedaliCivili, Vascular Neurology, Brescia, Italy
| | | | - Paolo Invernizzi
- Neurology Unit, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Marco Pavia
- Neuroradiology Unit, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Vincenza Pinto
- Neurology and Stroke Unit, Perrino Hospital, Brindisi, Italy
| | | | | | - Daniele Ajello
- Neuroradiology Unit, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Federica Viaro
- Stroke Unit and Neurosonology Laboratory, Padua University Hospital, Padua, Italy
| | - Claudio Baracchini
- Stroke Unit and Neurosonology Laboratory, Padua University Hospital, Padua, Italy
| | - Francesco Causin
- Department of Diagnostic Imaging and Interventional Radiology, Neuroradiology, Padua University Hospital, Padua, Italy
| | - Nicola Giannini
- Department Neurology and Stroke Unit, Azienda Ospedaliera Universitaria Di Pisa, Pisa, Italy
| | - Maria Chiara Caselli
- Department Neurology and Stroke Unit, Azienda Ospedaliera Universitaria Di Pisa, Pisa, Italy
| | - Michelangelo Mancuso
- Department Neurology and Stroke Unit, Azienda Ospedaliera Universitaria Di Pisa, Pisa, Italy
| | - Mirco Cosottini
- Department of Translational Research and New Technology in Medicine and Surgery, Azienda Ospedaliera Universitaria Di Pisa, Pisa, Italy
| | - Umberto Scoditti
- Stroke Unit, Neurology Unit, Department of Medicine and Surgery, University Hospital of Parma, Parma, Italy
| | - Roberto Menozzi
- Neuroradiology Unit, University Hospital of Parma, Parma, Italy
| | - Monia Russo
- Stroke Unit, Ospedale S. Maria Misericordia, Rovigo, Italy
| | - Pietro Amistá
- Neuroradiology Unit, Ospedale S. Maria Misericordia, Rovigo, Italy
| | - Rosa Napoletano
- Stroke Unit, S. Giovanni Di Dio E Ruggi d'Aragona Hospital, Salerno, Italy
| | - Daniele Giuseppe Romano
- Unita Operativa Radiologia Vascolare, S. Giovanni Di Dio E Ruggi d'Aragona Hospital, Salerno, Italy
| | - Rossana Tassi
- Stroke Unit, Department of Emergency and Transplantation, Azienda Ospedaliera Universitaria Senese, Policlinico "Santa Maria Alle Scotte", Siena, Italy
| | - Sandra Bracco
- UO Neurointerventistica, Azienda Ospedaliera Universitaria Senese, Policlinico "Santa Maria Alle Scotte", Siena, Italy
| | - Federico Carimati
- Department of Neurology and Stroke Unit, Circolo e Fondazione Macchi Hospital, ASST Settelaghi, Varese, Italy
| | - Maurizio Versino
- Department of Neurology and Stroke Unit, Circolo e Fondazione Macchi Hospital, ASST Settelaghi, Varese, Italy
| | - Andrea Giorgianni
- Neuroradiology Department, Circolo e Fondazione Macchi Hospital, ASST Settelaghi, Varese, Italy
| | | | - Antonio Fasano
- Department of Neurology, Vito Fazzi Hospital, Lecce, Italy
| | | | | | - Enrica Franchini
- Department of Neurology and Stroke Unit, Bolzano Central Hospital, Bolzano, Italy
| | - Elisa Dall'Ora
- Department of Neurology and Stroke Unit, Bolzano Central Hospital, Bolzano, Italy
| | - Alessio Comai
- Neuroradiology Unit, Bolzano Central Hospital, Bolzano, Italy
| | - Frisullo Giovanni
- Department of Neurology and Stroke Unit, Catholic University, Rome, Italy
| | - Alessandro Pedicelli
- Dipartimento Di Diagnostica Per Immagini, UOSA Neuroradiologia Interventistica, RadioterapiaOncologica Ed Ematologia, Fondazione PoliclinicoUniversitarioA.Gemelli Di Roma, Rome, Italy
| | - Fabrizio Sallustio
- Unitá Di Trattamento Neurovascolare, Ospedale Dei Castelli-ASL6, Rome, Italy
| | - Ilaria Casetta
- Neurology Unit, University Hospital Arcispedale S. Anna, Ferrara, Italy
| | - Enrico Fainardi
- Dipartimento Di Scienze Biomediche, Sperimentali E Cliniche, Università Degli Studi Di Firenze, Ospedale Universitario Careggi, NeuroradiologiaFlorence, Italy
| | - Salvatore Mangiafico
- Interventional Neuroradiology Consultant at IRCCS NeuromedPozzilli (IS), and Adjunct Professor of Interventional Neuroradiology at Tor Vergata University, Sapienza University and S. Andrea Hospital, Rome, Italy
| | - Danilo Toni
- Department of Human Neuroscience, Sapienza University of Rome, Rome, Italy.
- Emergency Department, Stroke Unit, Policlinico Umberto I Hospital, Rome, Italy.
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Brandler ES, Isenberg DL, Herres J, Zhao H, Kraus CK, Ackerman D, Sigal A, Kuc A, Nomura JT, Wojcik S, Mullen MT, Gentile NT. Delay in hospital presentation is the main reason large vessel occlusion stroke patients do not receive intravenous thrombolysi. J Am Coll Emerg Physicians Open 2023; 4:e13048. [PMID: 37840864 PMCID: PMC10568043 DOI: 10.1002/emp2.13048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/12/2023] [Accepted: 09/18/2023] [Indexed: 10/17/2023] Open
Abstract
Objectives Intravenous thrombolysis (IVT) and endovascular therapy (EVT) are the mainstays of treatment for large vessel occlusion stroke (LVOS). Prior studies have examined why patients have not received IVT, the most cited reasons being last-known-well (LKW) to hospital arrival of >4.5 hours and minor/resolving stroke symptoms. Given that LVOS patients typically present moderate-to-severe neurologic deficits, these patients should be easier to identify and treat than patients with minor strokes. This investigation explores why IVT was not administered to a cohort of LVOS patients who underwent EVT. Methods This is an analysis of the Optimizing the Use of Prehospital Stroke Systems of Care (OPUS-REACH) registry, which contains patients from 9 endovascular centers who underwent EVT between 2015 and 2020. The exposure of interest was the receipt of intravenous thrombolysis. Descriptive summary statistics are presented as means and SDs for continuous variables and as frequencies with percentages for categorical variables. Two-sample t tests were used to compare continuous variables and the chi-square test was used to compare categorical variables between those who received IVT and those who did not receive EVT. Results Two thousand forty-three patients were included and 60% did not receive IVT. The most common reason for withholding IVT was LKW to arrival of >4.5 (57.2%). The second most common contraindication was oral anticoagulation (15.5%). On multivariable analysis, 2 factors were associated with not receiving IVT: increasing age (odds ratio [OR] 0.86; 95% confidence interval [CI] 0.78-0.93) and increasing time from LKW-to hospital arrival (OR 0.45 95% CI 0.46-0.49). Conclusion Like prior studies, the most frequent reason for exclusion from IVT was a LKW to hospital presentation of >4.5 hours; the second reason was anticoagulation. Efforts must be made to increase awareness of the time-sensitive nature of IVT and evaluate the safety of IVT in patients on oral anticoagulants.
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Affiliation(s)
- Ethan S. Brandler
- Department of Emergency MedicineState University of New York‐Stony BrookStony BrookNew YorkUSA
| | - Derek L. Isenberg
- Department of Emergency MedicineLewis Katz School of Medicine at Temple UniversityPhiladelphiaPennsylvaniaUSA
| | - Joseph Herres
- Department of Emergency MedicineJefferson Einstein – Thomas Jefferson UniversityPhiladelphiaPennsylvaniaUSA
| | - Huaqing Zhao
- Department of Emergency MedicineLewis Katz School of Medicine at Temple UniversityPhiladelphiaPennsylvaniaUSA
| | - Chadd K. Kraus
- Department of Emergency MedicineGeisinger HealthDanvillePennsylvaniaUSA
| | - Daniel Ackerman
- Department of NeurologySt. Luke's University HealthBethlehemPennsylvaniaUSA
| | - Adam Sigal
- Department of Emergency MedicineReading HospitalWest ReadingPennsylvaniaUSA
| | - Alexander Kuc
- Department of Emergency MedicineCooper University HealthCamdenNew JerseyUSA
| | - Jason T. Nomura
- Department of Emergency MedicineChristiana CareNewarkDelawareUSA
| | - Susan Wojcik
- Department of Emergency MedicineState University of New York‐UpstateSyracuseNew YorkUSA
| | - Michael T. Mullen
- Department of NeurologyLewis Katz School of Medicine at Temple UniversityPhiladelphiaUSA
| | - Nina T. Gentile
- Department of Emergency MedicineLewis Katz School of Medicine at Temple UniversityPhiladelphiaPennsylvaniaUSA
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288
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Requena M, Piñana C, Olive-Gadea M, Hernández D, Boned S, De Dios M, Rodrigo M, Rivera E, Muchada M, Cuevas JL, Rubiera M, García-Tornel Á, Gramegna LL, Molina C, Ribo M, Tomasello A. Combined technique as first approach in mechanical thrombectomy: Efficacy and safety of REACT catheter combined with stent retriever. Interv Neuroradiol 2023; 29:504-509. [PMID: 35491662 PMCID: PMC10549706 DOI: 10.1177/15910199221095798] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2022] [Accepted: 04/04/2022] [Indexed: 11/17/2022] Open
Abstract
INTRODUCTION Mechanical thrombectomy (MT) with combined treatment including both a stent retriever and distal aspiration catheter may improve recanalization rates in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Here, we evaluated the effectiveness and safety of the REACT aspiration catheter used with a stent retriever. METHODS This prospective study included consecutive adult patients who underwent MT with a combined technique using REACT 68 and/or 71 between June 2020 and July 2021. The primary endpoints were final and first pass mTICI 2b-3 and mTICI 2c-3 recanalization. Analysis was performed after first pass and after each attempt. Secondary safety outcomes included procedural complications, symptomatic intracranial hemorrhage (sICH) at 24 h, in-hospital mortality, and 90-day functional independence (modified Rankin Scale [mRS] 0-2). RESULTS A total of 102 patients were included (median age 78; IQR: 73-87; 50.0% female). At baseline, median NIHSS score was 19 (IQR: 11-21), and ASPECTS was 9 (IQR: 8-10). Final mTICI 2b-3 recanalization was achieved in 91 (89.2%) patients and mTICI 2c-3 was achieved in 66 (64.7%). At first pass, mTICI 2b-3 was achieved in 55 (53.9%) patients, and mTICI 2c-3 in 37 (36.3%). The rate of procedural complications was 3.9% (4/102), sICH was 6.8% (7/102), in-hospital mortality was 12.7% (13/102), and 90-day functional independence was 35.6% (36/102). CONCLUSION A combined MT technique using a stent retriever and REACT catheter resulted in a high rate of successful recanalization and first pass recanalization in a sample of consecutive patients with AIS due to LVO in clinical use.
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Affiliation(s)
- Manuel Requena
- Unitat d’Ictus, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Neurorradiologia Intervencionista, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d’Hebron Institut de Recerca, Barcelona, Spain
| | - Carlos Piñana
- Neurorradiologia Intervencionista, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Marta Olive-Gadea
- Unitat d’Ictus, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d’Hebron Institut de Recerca, Barcelona, Spain
| | - David Hernández
- Neurorradiologia Intervencionista, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Sandra Boned
- Unitat d’Ictus, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d’Hebron Institut de Recerca, Barcelona, Spain
| | - Marta De Dios
- Neurorradiologia Intervencionista, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Marc Rodrigo
- Unitat d’Ictus, Hospital Universitari Vall d’Hebron, Barcelona, Spain
| | - Eila Rivera
- Neurorradiologia Intervencionista, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d’Hebron Institut de Recerca, Barcelona, Spain
| | - Marián Muchada
- Unitat d’Ictus, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d’Hebron Institut de Recerca, Barcelona, Spain
| | - José Luis Cuevas
- Neurorradiologia Intervencionista, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d’Hebron Institut de Recerca, Barcelona, Spain
- Servicio Neurocirugía, Hospital de Puerto Montt, Puerto Montt, Chile
| | - Marta Rubiera
- Unitat d’Ictus, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d’Hebron Institut de Recerca, Barcelona, Spain
| | - Álvaro García-Tornel
- Unitat d’Ictus, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d’Hebron Institut de Recerca, Barcelona, Spain
| | - Laura Ludovica Gramegna
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Functional and Molecular Neuroimaging Unit, Bologna, Italy
- Department of Biomedical and NeuroMotor Sciences, University of Bologna, Bologna, Italy
| | - Carlos Molina
- Unitat d’Ictus, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d’Hebron Institut de Recerca, Barcelona, Spain
| | - Marc Ribo
- Unitat d’Ictus, Hospital Universitari Vall d’Hebron, Barcelona, Spain
- Grup de Recerca en Ictus, Vall d’Hebron Institut de Recerca, Barcelona, Spain
| | - Alejandro Tomasello
- Neurorradiologia Intervencionista, Hospital Universitari Vall d’Hebron, Barcelona, Spain
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289
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El Naamani K, Khanna O, Mastorakos P, Momin AA, Yudkoff CJ, Jain P, Hunt A, Pedapati V, Syal A, Lawall CL, Carey PM, El Fadel O, Zakar RM, Ghanem M, Muharremi E, Jreij G, Abbas R, Amllay A, Gooch MR, Herial NA, Jabbour P, Rosenwasser RH, Tjoumakaris SI. Predictors of Transfemoral Access Site Complications in Neuroendovascular Procedures: A large Single-Center Cohort Study. Clin Neurol Neurosurg 2023; 233:107916. [PMID: 37651797 DOI: 10.1016/j.clineuro.2023.107916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2023] [Revised: 07/17/2023] [Accepted: 07/27/2023] [Indexed: 09/02/2023]
Abstract
OBJECTIVE The transfemoral (TF) route has historically been the preferred access site for endovascular procedures. However, despite its widespread use, TF procedures may confer morbidity as a result of access site complications. The aim of this study is to provide the rate and predictors of TF access site complications for neuroendovascular procedures. METHODS This is a single center retrospective study of TF neuroendovascular procedures performed between 2017 and 2022. The incidence of complications and associated risk factors were analyzed across a large cohort of patients. RESULTS The study comprised of 2043 patients undergoing transfemoral neuroendovascular procedures. The composite rate of access site complications was 8.6 % (n = 176). These complications were divided into groin hematoma formation (n = 118, 5.78 %), retroperitoneal hematoma (n = 14, 0.69 %), pseudoaneurysm formation (n = 40, 1.96 %), and femoral artery occlusion (n = 4, 0.19 %). The cross-over to trans radial access rate was 1.1 % (n = 22). On univariate analysis, increasing age (OR=1.0, p = 0.06) coronary artery disease (OR=1.7, p = 0.05) peripheral vascular disease (OR=1.9, p = 0.07), emergent mechanical thrombectomy procedures (OR=2.1, p < 0.001) and increasing sheath size (OR=1.3, p < 0.001) were associated with higher TF access site complications. On multivariate analysis, larger sheath size was an independent risk factor for TF access site complications (OR=1.8, p = 0.02). CONCLUSION Several pertinent factors contribute towards the incidence of TF access site complications. Factors associated with TF access site complications include patient demographics (older age) and clinical risk factors (vascular disease), as well as periprocedural factors (sheath size).
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Affiliation(s)
- Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Omaditya Khanna
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Panagiotis Mastorakos
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA; School of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Arbaz A Momin
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Clifford J Yudkoff
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Paarth Jain
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Adam Hunt
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Vinay Pedapati
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Amit Syal
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Charles L Lawall
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Preston M Carey
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Omar El Fadel
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Rida M Zakar
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA; School of Medicine, Saint Joseph University, Beirut, Lebanon
| | - Marc Ghanem
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - E Muharremi
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - George Jreij
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Abdelaziz Amllay
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Michael R Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
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290
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Lin KW, Chen YJ, Hou SW, Tang SC, Chiang WC, Tsai LK, Lee CW, Lee YC, Chien YC, Hsieh MJ, Jeng JS, Huei-Ming Ma M. Effect of using G-FAST to recognize emergent large vessel occlusion: A city-wide community experience. J Formos Med Assoc 2023; 122:1069-1076. [PMID: 37120338 DOI: 10.1016/j.jfma.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Revised: 03/19/2023] [Accepted: 04/10/2023] [Indexed: 05/01/2023] Open
Abstract
BACKGROUND/PURPOSE A prehospital bypass strategy was suggested for large vessel occlusion. This study aimed to evaluate the effect of a bypass strategy using the gaze-face-arm-speech-time test (G-FAST) implemented in a metropolitan community. METHODS Pre-notified patients with positive Cincinnati Prehospital Stroke Scale and symptom onset <3 h from July 2016 to December 2017 (pre-intervention period) and those with positive G-FAST and symptom onset <6 h from July 2019 to December 2020 (intervention period) were included. Patients aged <20 years and those with missing in-hospital data were excluded. The primary outcomes were the rates of receiving endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT). The secondary outcomes were total prehospital time, door-to-computed tomography (CT) time, door-to-needle (DTN) time, and door-to-puncture (DTP) time. RESULTS We included 802 and 695 pre-notified patients from the pre-intervention and intervention periods, respectively. The characteristics of the patients in the two periods were similar. In the primary outcomes, pre-notified patients during the intervention period showed higher rates of receiving EVT (4.49% vs. 15.25%, p < 0.001) and IVT (15.34% vs. 21.58%, p = 0.002). In the secondary outcomes, pre-notified patients during intervention period had longer total prehospital time (mean 23.38 vs 25.23 min, p < 0.001), longer door-to-CT time (median 10 vs 11 min, p < 0.001), longer DTN time (median 53 vs 54.5 min, p < 0.001) but shorter DTP time (median 141 vs 139.5 min, p < 0.001). CONCLUSION The prehospital bypass strategy with G-FAST showed benefits for stroke patients.
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Affiliation(s)
- Kai-Wei Lin
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan
| | - Ying-Ju Chen
- Department of Emergency Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Sheng-Wen Hou
- Department of Emergency Medicine, Shin-Kong Wu Ho-Su Memorial Hospital, Taiwan
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Wen-Chu Chiang
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Emergency Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Taiwan
| | - Li-Kai Tsai
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chung-Wei Lee
- Department of Medical Imaging, National Taiwan University Hospital, Taipei, Taiwan
| | - Yu-Ching Lee
- Department of Industrial Engineering and Engineering Management, National Tsing Hua University, Hsinchu, Taiwan
| | - Yu-Chun Chien
- Emergency Medical Services Division, National Fire Agency, Ministry of the Interior, Taiwan
| | - Ming-Ju Hsieh
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan.
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Matthew Huei-Ming Ma
- Department of Emergency Medicine, National Taiwan University Hospital, Taipei, Taiwan; Department of Emergency Medicine, National Taiwan University Hospital Yun-Lin Branch, Yun-Lin County, Taiwan
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291
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Pouget AM, Costa N, Mounié M, Gombault-Datzenko E, Derumeaux H, Pagès A, Rouzaud-Laborde C, Molinier L. Mechanical Thrombectomy with Intravenous Thrombolysis versus Thrombolysis Alone for the Treatment of Stroke: A Systematic Review of Economic Evaluations. J Vasc Interv Radiol 2023; 34:1749-1759.e2. [PMID: 37331591 DOI: 10.1016/j.jvir.2023.06.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Revised: 05/25/2023] [Accepted: 06/08/2023] [Indexed: 06/20/2023] Open
Abstract
Mechanical thrombectomy has revolutionized the management of stroke by improving the recanalization rates and reducing deleterious consequences. It is now the standard of care despite the high financial cost. A considerable number of studies have evaluated its cost effectiveness. Therefore, this study aimed to identify economic evaluations of mechanical thrombectomy with thrombolysis compared with thrombolysis alone to provide an update of existing evidence, focusing on the period after proof of effectiveness of mechanical thrombectomy. Twenty-one studies were included in the review: 18 were model-based economic evaluations to simulate long-term outcomes and costs, and 19 were conducted in high-income countries. Incremental cost-effectiveness ratios ranged from -$5,670 to $74,216 per quality-adjusted life year. Mechanical thrombectomy is cost-effective in high-income countries and in the populations selected for clinical trials. However, most of the studies used the same data. There is a lack of real-world and long-term data to analyze the cost effectiveness of mechanical thrombectomy in treating the global burden of stroke.
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Affiliation(s)
- Alix Marie Pouget
- Health Economic Unit, Toulouse University Hospital, Toulouse, France; Department of Pharmacy, Toulouse University Hospital, Toulouse, France; French National Institute for Health and Medical Research (INSERM), Mixed Research Unit 1297 (UMR), Institute of Metabolic and Cardiac Diseases (I2MC), Toulouse III University, Toulouse, France.
| | - Nadège Costa
- Health Economic Unit, Toulouse University Hospital, Toulouse, France; French National Institute for Health and Medical Research (INSERM), Mixed Research Unit 1297 (UMR), Centre for Epidemiology and Population Health Research (for CERPOP), Toulouse III University, Toulouse, France
| | - Michael Mounié
- Health Economic Unit, Toulouse University Hospital, Toulouse, France; French National Institute for Health and Medical Research (INSERM), Mixed Research Unit 1297 (UMR), Centre for Epidemiology and Population Health Research (for CERPOP), Toulouse III University, Toulouse, France
| | - Eugénie Gombault-Datzenko
- Health Economic Unit, Toulouse University Hospital, Toulouse, France; French National Institute for Health and Medical Research (INSERM), Mixed Research Unit 1297 (UMR), Centre for Epidemiology and Population Health Research (for CERPOP), Toulouse III University, Toulouse, France
| | - Hélène Derumeaux
- Health Economic Unit, Toulouse University Hospital, Toulouse, France; French National Institute for Health and Medical Research (INSERM), Mixed Research Unit 1297 (UMR), Centre for Epidemiology and Population Health Research (for CERPOP), Toulouse III University, Toulouse, France
| | - Arnaud Pagès
- Health Economic Unit, Toulouse University Hospital, Toulouse, France
| | - Charlotte Rouzaud-Laborde
- Department of Pharmacy, Toulouse University Hospital, Toulouse, France; French National Institute for Health and Medical Research (INSERM), Mixed Research Unit 1297 (UMR), Institute of Metabolic and Cardiac Diseases (I2MC), Toulouse III University, Toulouse, France
| | - Laurent Molinier
- Health Economic Unit, Toulouse University Hospital, Toulouse, France; French National Institute for Health and Medical Research (INSERM), Mixed Research Unit 1297 (UMR), Centre for Epidemiology and Population Health Research (for CERPOP), Toulouse III University, Toulouse, France
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292
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Take Y, Osakabe M, Okawara M, Yamaguchi H, Maeda T, Kurita H. Efficacy, safety, and predictors for functional outcomes of mechanical thrombectomy in patients aged over 90 years with acute ischemic stroke and literature review. Clin Neurol Neurosurg 2023; 233:107934. [PMID: 37591040 DOI: 10.1016/j.clineuro.2023.107934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/01/2023] [Accepted: 08/06/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND No evidence supports the efficacy and safety of mechanical thrombectomy (MT) in patients aged ≥ 90 years with acute ischemic stroke (AIS). This study clarifies the efficacy, safety, and predictors of MTs in patients aged ≥ 90 years by investigating our results and reviewing previous studies. METHODS We retrospectively investigated data from 80 consecutive patients who underwent MT at our hospital between 2018 and 2021. We analyzed outcomes using the modified Thrombolysis in the Cerebral Infarction (mTICI) scale and modified Rankin Scale (mRS). Functional outcomes were investigated at 90 days or discharge. RESULTS We obtained functional outcomes mRS ≤ 3 patients in 41.6%. The mortality rate was 16.6%. The rate of successful recanalization was 75%. Comparison mRS ≤ 3 and mRS ≥ 4 at 90 days or discharge showed statistical significance in the National Institute of Health Stroke Scale, the location of occluded vessels, and mTICI ≥ 2b at the first pass. Univariable logistic regression analysis indicated that the Alberta Stroke Program Early Computed Tomography Score was a predictor of mRS ≤ 3. CONCLUSIONS The efficacy is lower than that of patients aged < 90; however, MT is effective even in patients aged ≥ 90 years. The safety of MT in patients aged ≥ 90 years was similar to that in those aged < 90 years. Neuro-interventionalists should consider predictors and take the best strategies to achieve successful recanalization in patients aged ≥ 90 years with AIS.
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Affiliation(s)
- Yushiro Take
- Saitama Medical University International Medical Center, Department of Cerebrovascular Surgery, Hidaka, Saitama 320-1298, Japan; Ohkawara Neurosurgical Hospital, Muroran, Hokkaido 050-0082, Japan.
| | - Manabu Osakabe
- Ohkawara Neurosurgical Hospital, Muroran, Hokkaido 050-0082, Japan
| | - Mai Okawara
- Ohkawara Neurosurgical Hospital, Muroran, Hokkaido 050-0082, Japan
| | | | - Takahiro Maeda
- Ohkawara Neurosurgical Hospital, Muroran, Hokkaido 050-0082, Japan
| | - Hiroki Kurita
- Saitama Medical University International Medical Center, Department of Cerebrovascular Surgery, Hidaka, Saitama 320-1298, Japan
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293
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Ostmeier S, Axelrod B, Verhaaren BFJ, Christensen S, Mahammedi A, Liu Y, Pulli B, Li LJ, Zaharchuk G, Heit JJ. Non-inferiority of deep learning ischemic stroke segmentation on non-contrast CT within 16-hours compared to expert neuroradiologists. Sci Rep 2023; 13:16153. [PMID: 37752162 PMCID: PMC10522706 DOI: 10.1038/s41598-023-42961-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2023] [Accepted: 09/17/2023] [Indexed: 09/28/2023] Open
Abstract
We determined if a convolutional neural network (CNN) deep learning model can accurately segment acute ischemic changes on non-contrast CT compared to neuroradiologists. Non-contrast CT (NCCT) examinations from 232 acute ischemic stroke patients who were enrolled in the DEFUSE 3 trial were included in this study. Three experienced neuroradiologists independently segmented hypodensity that reflected the ischemic core on each scan. The neuroradiologist with the most experience (expert A) served as the ground truth for deep learning model training. Two additional neuroradiologists' (experts B and C) segmentations were used for data testing. The 232 studies were randomly split into training and test sets. The training set was further randomly divided into 5 folds with training and validation sets. A 3-dimensional CNN architecture was trained and optimized to predict the segmentations of expert A from NCCT. The performance of the model was assessed using a set of volume, overlap, and distance metrics using non-inferiority thresholds of 20%, 3 ml, and 3 mm, respectively. The optimized model trained on expert A was compared to test experts B and C. We used a one-sided Wilcoxon signed-rank test to test for the non-inferiority of the model-expert compared to the inter-expert agreement. The final model performance for the ischemic core segmentation task reached a performance of 0.46 ± 0.09 Surface Dice at Tolerance 5mm and 0.47 ± 0.13 Dice when trained on expert A. Compared to the two test neuroradiologists the model-expert agreement was non-inferior to the inter-expert agreement, [Formula: see text]. The before, CNN accurately delineates the hypodense ischemic core on NCCT in acute ischemic stroke patients with an accuracy comparable to neuroradiologists.
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Affiliation(s)
| | - Brian Axelrod
- Department of Computer Science, Stanford University, Stanford, USA
| | | | | | | | | | | | - Li-Jia Li
- Stanford School of Medicine, Stanford, USA
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294
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Toubasi AA, Al-Sayegh TN, Albustanji FH, Al-Harasis LM. Endovascular Treatment plus Medical Treatment versus Medical Treatment Alone in Ischemic Stroke: A Systematic Review and Meta-Analysis. Eur Neurol 2023; 86:295-304. [PMID: 37748451 DOI: 10.1159/000531285] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Accepted: 05/23/2023] [Indexed: 09/27/2023]
Abstract
INTRODUCTION This study was conducted to assess the hypothesis that endovascular treatment in addition to medical treatment improve stroke mortality and post-stroke disability. METHODS In this systematic review and meta-analysis, the studies were included if they were randomized controlled trials in design and compared between endovascular treatment and medical therapy versus medical therapy alone in stroke management. RESULTS The search yielded 22 articles that included 5,049 patients. The analysis showed significant association between the intervention and reduction in disability measured by Modified Rankin Scale (mRS) (mRS = 0-2) (odds ratio [OR] = 1.61; 95% confidence intervals [95% CI]: 1.27-2.06) and National Institute of Health Stroke Scale (NIHSS) (NIHSS = 0-15) (OR = 2.13; 95% CI: 1.04-4.34). Also, we found a significant difference in disability scores between the intervention and the medical therapy group (mRS weighted mean difference [WMD] = -0.59; 95% CI: -1.15 to -0.02, NIHSS WMD = -4.52; 95% CI: -6.32 to -2.72). Additionally, there was significant reduction in mortality in the intervention group (OR = 0.79; 95% CI: 0.68-0.92). There was no significant difference in the rate of any serious adverse effects between the two study groups except for asymptomatic intracerebral hemorrhage. CONCLUSION Our study provides strong evidence stemmed from randomized clinical trials that endovascular treatment combined with medical therapy is superior to medical therapy alone in the management of stroke.
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Affiliation(s)
- Ahmad A Toubasi
- Faculty of Medicine, The University of Jordan, Amman, Jordan
| | | | | | - Layla M Al-Harasis
- Faculty of Medicine, The Jordan University of Science and Technology, Irbid, Jordan
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295
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Jeong HY, Nam TM, Lee SH, Jang JH, Kim YZ, Kim KH, Ryu KH, Kim DH, Kwan BS, Bak H, Kim SH. Impact on Endovascular Thrombectomy for Acute Ischemic Stroke of Aortic Arch Calcification on Chest X-ray. J Clin Med 2023; 12:6115. [PMID: 37834759 PMCID: PMC10573594 DOI: 10.3390/jcm12196115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 09/15/2023] [Accepted: 09/20/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Vascular conditions can affect the recanalization rates after endovascular thrombectomy (EVT) for acute ischemic stroke (AIS). Chest radiography can assess the conditions of the aortic arch based on the presence or absence of aortic arch calcification (AoAC). The aim of this study was to investigate the relationship between AoAC on chest radiography and first-pass successful recanalization (modified thrombolysis in cerebral infarction 2b/3 after the first-pass). METHODS We compared the rate of first-pass successful recanalization between patients with and without AoAC. A total of 193 patients with anterior circulation occlusion who underwent EVT between January 2017 and December 2021 were included. RESULTS AoAC was observed in 80 (41.5%) patients. Patients with AoAC were older (74.5 ± 7.78 vs. 63.9 ± 12.4 years, p < 0.001), had more EVT attempts (3.04 ± 1.95 vs. 2.01 ± 1.34 times, p < 0.001), and a longer procedural time (71.7 ± 31.2 vs. 48.7 ± 23.1 min, p < 0.001) than those without AoAC. Moreover, Patients with AoAC showed a lower incidence of first-pass successful recanalization (18.8% vs. 47.8%, p < 0.001) and a higher incidence of postprocedural hemorrhage (45.0% vs. 27.7%, p = 0.015) than those without AoAC. On multivariate analysis, AoAC was independently associated with first-pass successful recanalization (odds ratio: 0.239 [0.121-0.475], p < 0.001). CONCLUSIONS AoAC on chest radiography can be used as a preoperative predictor of successful first-pass recanalization in patients undergoing EVT for AIS.
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Affiliation(s)
- Hyeon Yeong Jeong
- Department of Neurosurgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon 51353, Republic of Korea; (H.Y.J.); (T.M.N.); (S.H.L.); (J.H.J.); (Y.Z.K.); (K.H.K.)
| | - Taek Min Nam
- Department of Neurosurgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon 51353, Republic of Korea; (H.Y.J.); (T.M.N.); (S.H.L.); (J.H.J.); (Y.Z.K.); (K.H.K.)
| | - Sang Hyuk Lee
- Department of Neurosurgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon 51353, Republic of Korea; (H.Y.J.); (T.M.N.); (S.H.L.); (J.H.J.); (Y.Z.K.); (K.H.K.)
| | - Ji Hwan Jang
- Department of Neurosurgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon 51353, Republic of Korea; (H.Y.J.); (T.M.N.); (S.H.L.); (J.H.J.); (Y.Z.K.); (K.H.K.)
| | - Young Zoon Kim
- Department of Neurosurgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon 51353, Republic of Korea; (H.Y.J.); (T.M.N.); (S.H.L.); (J.H.J.); (Y.Z.K.); (K.H.K.)
| | - Kyu Hong Kim
- Department of Neurosurgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon 51353, Republic of Korea; (H.Y.J.); (T.M.N.); (S.H.L.); (J.H.J.); (Y.Z.K.); (K.H.K.)
| | - Kyeong Hwa Ryu
- Department of Radiology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon 51353, Republic of Korea;
| | - Do-Hyung Kim
- Department of Neurology, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon 51353, Republic of Korea;
| | - Byung Soo Kwan
- Department of Internal Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon 51353, Republic of Korea;
| | - Hyerang Bak
- Department of Family Medicine, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon 51353, Republic of Korea;
| | - Seung Hwan Kim
- Department of Neurosurgery, Samsung Changwon Hospital, Sungkyunkwan University School of Medicine, Changwon 51353, Republic of Korea; (H.Y.J.); (T.M.N.); (S.H.L.); (J.H.J.); (Y.Z.K.); (K.H.K.)
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296
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Nogueira RG, Haussen DC, Smith EE, Sun JL, Xian Y, Alhanti B, Blanco R, Mac Grory B, Doheim MF, Bhatt DL, Fonarow GC, Hassan AE, Joundi RA, Mocco J, Frankel MR, Schwamm LH. Higher Procedural Volumes Are Associated with Faster Treatment Times, Better Functional Outcomes, and Lower Mortality in Patients Undergoing Endovascular Treatment for Acute Ischemic Stroke. Ann Neurol 2023. [PMID: 37731004 DOI: 10.1002/ana.26803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 08/22/2023] [Accepted: 09/18/2023] [Indexed: 09/22/2023]
Abstract
OBJECTIVE We aimed to characterize the association of hospital procedural volumes with outcomes among acute ischemic stroke (AIS) patients undergoing endovascular therapy (EVT). METHODS This was a retrospective, observational cohort study using data prospectively collected from January 1, 2016 to December 31, 2019 in the Get with the Guidelines-Stroke registry. Participants were derived from a cohort of 60,727 AIS patients treated with EVT within 24 hours at 626 hospitals. The primary cohort excluded patients with pretreatment National Institutes of Health Stroke Scale (NIHSS) < 6, onset-to-treatment time > 6 hours, and interhospital transfers. There were 2 secondary cohorts: (1) the EVT metrics cohort excluded patients with missing data on time from door to arterial puncture and (2) the intravenous thrombolysis (IVT) metrics cohort only included patients receiving IVT ≤4.5 hours after onset. RESULTS The primary cohort (mean ± standard deviation age = 70.7 ± 14.8 years; 51.2% female; median [interquartile range] baseline NIHSS = 18.0 [13-22]; IVT use, 70.2%) comprised 21,209 patients across 595 hospitals. The EVT metrics cohort and IVT metrics cohort comprised 47,262 and 16,889 patients across 408 and 601 hospitals, respectively. Higher procedural volumes were significantly associated with higher odds (expressed as adjusted odds ratio [95% confidence interval] for every 10-case increase in volume) of discharge to home (1.03 [1.02-1.04]), functional independence at discharge (1.02 [1.01-1.04]), and lower rates of in-hospital mortality (0.96 [0.95-0.98]). All secondary measures were also associated with procedural volumes. INTERPRETATION Among AIS patients primarily presenting to EVT-capable hospitals (excluding those transferred from one facility to another and those suffering in-hospital strokes), EVT at hospitals with higher procedural volumes was associated with faster treatment times, better discharge outcomes, and lower rates of in-hospital mortality. ANN NEUROL 2023.
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Affiliation(s)
- Raul G Nogueira
- Departments of Neurology and Neurosurgery, University of Pittsburgh Medical Center Stroke Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Diogo C Haussen
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | - Eric E Smith
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | | | - Ying Xian
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX, USA
| | | | | | | | - Mohamed F Doheim
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh, Pittsburgh, PA, USA
| | - Deepak L Bhatt
- Mount Sinai Heart, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Gregg C Fonarow
- Division of Cardiology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | - Ameer E Hassan
- University of Texas Rio Grande Valley-Valley Baptist Medical Center, Harlingen, TX, USA
| | - Raed A Joundi
- Division of Neurology, Hamilton Health Sciences, McMaster University and Population Health Research Institute, Hamilton, Ontario, Canada
| | - J Mocco
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michael R Frankel
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | - Lee H Schwamm
- Department of Neurology, Massachusetts General Hospital, Boston, MA, USA
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297
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Piscopo A, Zanaty M, Dlouhy K. Contemporary Methods for Detection and Intervention of Distal Medium and Small Vessel Occlusions. J Clin Med 2023; 12:6071. [PMID: 37763011 PMCID: PMC10531921 DOI: 10.3390/jcm12186071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2023] [Revised: 09/10/2023] [Accepted: 09/14/2023] [Indexed: 09/29/2023] Open
Abstract
The efficacy of using mechanical thrombectomy for proximal large vessel occlusions has been demonstrated in multiple large-scale trials and has further raised the question of its potential utility for distal medium and small vessel occlusions (DMSVOs). Their longer, more tortuous course and smaller corresponding vascular territories render a significant challenge for detection and intervention. The aim of this study is to provide a comprehensive overview of the current imaging and endovascular intervention options for DMSVOs and review the current works in the literature. Compared with traditional computed tomography angiography (CTA) and CT perfusion, recent advances such as multiphase CTA and maps derived from the time-to-maximum parameter coupled with artificial intelligence have demonstrated increased sensitivity for the detection of DMSVOs. Furthermore, newer generations of mini stent retrievers and thromboaspiration devices have allowed for the access and navigation of smaller and more fragile distal arteries. Preliminary studies have suggested that mechanical thrombectomy using this newer generation of devices is both safe and feasible in distal medium-sized vessels, such as M2. However, endovascular intervention utilizing such contemporary methods and devices must be balanced at the discretion of operator experience and favorable vascular anatomy. Further large-scale multicenter clinical trials are warranted to elucidate the indications for as well as to strengthen the safety and efficacy of this approach.
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Affiliation(s)
| | - Mario Zanaty
- Department of Neurosurgery, University of Iowa Hospital and Clinics, Iowa City, IA 52242, USA; (A.P.); (K.D.)
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298
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Chen Z, Ying Y, Lu X, Sun S, Huang Q, Shao J, Li P, Chen L. The Safety and Efficacy of Emergency Stenting during Bridging Therapy: A Single-Center Retrospective Study. Cerebrovasc Dis 2023; 53:420-427. [PMID: 37717580 DOI: 10.1159/000534134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2023] [Accepted: 09/07/2023] [Indexed: 09/19/2023] Open
Abstract
INTRODUCTION The objective of this study was to investigate the safety and efficacy of emergency stenting for patients with ischemic stroke treated with bridging therapy. METHODS Patients with onset of stroke who underwent bridging therapy were included in the two groups with emergency stenting (ESG) and without stenting (NSG). To avoid the bias due to confounding variables, subjects were further assigned in two groups using 1:1 propensity score matching (PSM). The safety outcomes include the incidence of intracranial hemorrhage (ICH), parenchymal hemorrhage type 2 (PH2), symptomatic intracranial hemorrhage (sICH), fatal hemorrhage, and mortality. The efficacy outcomes include successful recanalization, 3-month favorable outcome (modified Rankin Scale [mRS]: 0-2). RESULTS 175 patients treated with bridging therapy were included in this study, with 52 patients in the ES group and 123 patients in the groups without ES, and with 30 patients in each group after PSM. No significant differences in the incidences of ICH, PH2, sICH, fatal hemorrhage, and mortality were found between the two groups with ES and without ES before and after PSM (p > 0.05 for all groups). The analysis without PSM showed that the group with ES had a higher rate of successful recanalization (98.1 vs. 88.6%, p = 0.041) than the group without ES, but no significant difference was seen (96.6 vs. 93.3%, p = 0.554) between the two groups after PSM. There was no difference in favorable outcome between the two groups before and after matching as well (p > 0.05). CONCLUSIONS It is safe and effective for patients with onset of ischemic stroke to receive emergency stenting during bridging therapy, without increasing the risk of hemorrhagic transformation and mortality.
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Affiliation(s)
- Zhengwen Chen
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China,
- Department of Stroke Center, Affiliated Hospital of Nantong University, Nantong, China,
| | - Yaoyu Ying
- Department of Medical Affairs, The Second Affiliated Hospital of Soochow University, Suzhou, China
- Department of Epidemiology and Biostatistics, Schoool of Public Health, Medical College of Soochow University, Suzhou, China
| | - Xiaojian Lu
- Department of Stroke Center, Affiliated Hospital of Nantong University, Nantong, China
| | - Shuqing Sun
- Department of Stroke Center, Affiliated Hospital of Nantong University, Nantong, China
| | - Qingfeng Huang
- Department of Stroke Center, Affiliated Hospital of Nantong University, Nantong, China
| | - Junjie Shao
- Department of Stroke Center, Affiliated Hospital of Nantong University, Nantong, China
| | - Peicheng Li
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Long Chen
- Department of Interventional Radiology, The First Affiliated Hospital of Soochow University, Suzhou, China
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299
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Shibuya K, Hasegawa H, Suzuki T, Takahashi H, Nishiyama K, Oishi M, Fujii Y. Investigation of Mechanical Thrombectomy in Elderly Patients over 85 Years Old: A Multicenter Study. Neurol Med Chir (Tokyo) 2023; 63:393-399. [PMID: 37380448 PMCID: PMC10556208 DOI: 10.2176/jns-nmc.2023-0039] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Accepted: 04/19/2023] [Indexed: 06/30/2023] Open
Abstract
In Japan, which has a super-aging society, there are increasing opportunities to perform mechanical thrombectomy for the elderly; however, there is no recorded evidence of thrombectomy for the elderly. This study examined the usefulness of thrombectomy in the elderly. We retrospectively analyzed patient data using a multicenter acute ischemic stroke registry (NGT-FAST). We examined outcomes in patients 75 years and older who underwent thrombectomies between January 1, 2021, and December 31, 2021. The patients were divided into two groups: the 75-84-year-old group and the 85+-year-old group. There was no difference in the pretreatment National Institutes of Health Stroke Scale score or Alberta Stroke Program Early Computed Tomography Score between the two groups, but the 85+-year-old group had a significantly lower rate of pre-stroke modified Rankin Scale (mRS) score of 0-2. There were no differences in time from onset to treatment or effective recanalization rate, but complications tended to be more common in the 85+-year-old group. The number of patients with a good outcome at discharge (an mRS score of 0-3) was significantly lower in the 85+-year-old group than in the 75-84-year-old group. In addition, 90.9% of patients in the 85+-year-old group with a pre-stroke mRS score of 3 deteriorated after treatment. The pre-stroke mRS score is very important in determining the indication for thrombectomy in the elderly because their preoperative condition is more likely to influence the outcome than that of younger patients.
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Affiliation(s)
- Kohei Shibuya
- Department of Neurosurgery, Brain Research Institute, Niigata University
| | - Hitoshi Hasegawa
- Department of Neurosurgery, Brain Research Institute, Niigata University
| | - Tomoaki Suzuki
- Department of Neurosurgery, Brain Research Institute, Niigata University
| | - Haruhiko Takahashi
- Department of Neurosurgery, Brain Research Institute, Niigata University
| | - Kei Nishiyama
- Department of Emergency Medicine, Niigata University
| | - Makoto Oishi
- Department of Neurosurgery, Brain Research Institute, Niigata University
| | - Yukihiko Fujii
- Department of Neurosurgery, Brain Research Institute, Niigata University
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300
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Mirmozaffari M, Kamal N. The Application of Data Envelopment Analysis to Emergency Departments and Management of Emergency Conditions: A Narrative Review. Healthcare (Basel) 2023; 11:2541. [PMID: 37761738 PMCID: PMC10530342 DOI: 10.3390/healthcare11182541] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Revised: 08/30/2023] [Accepted: 09/11/2023] [Indexed: 09/29/2023] Open
Abstract
The healthcare industry is one application for data envelopment analysis (DEA) that can have significant benefits for standardizing health service delivery. This narrative review focuses on the application of DEA in emergency departments (EDs) and the management of emergency conditions such as acute ischemic stroke and acute myocardial infarction (AMI). This includes benchmarking the proportion of patients that receive treatment for these emergency conditions. The most frequent primary areas of study motivating work in DEA, EDs and management of emergency conditions including acute management of stroke are sorted into five distinct clusters in this study: (1) using basic DEA models for efficiency analysis in EDs, i.e., applying variable return to scale (VRS), or constant return to scale (CRS) to ED operations; (2) combining advanced and basic DEA approaches in EDs, i.e., applying super-efficiency with basic DEA or advanced DEA approaches such as additive model (ADD) and slack-based measurement (SBM) to clarify the dynamic aspects of ED efficiency throughout the duration of a first-aid program for AMI or heart attack; (3) applying DEA time series models in EDs like the early use of thrombolysis and percutaneous coronary intervention (PCI) in AMI treatment, and endovascular thrombectomy (EVT) in acute ischemic stroke treatment, i.e., using window analysis and Malmquist productivity index (MPI) to benchmark the performance of EDs over time; (4) integrating other approaches with DEA in EDs, i.e., combining simulations, machine learning (ML), multi-criteria decision analysis (MCDM) by DEA to reduce patient waiting times, and futile transfers; and (5) applying various DEA models for the management of acute ischemic stroke, i.e., using DEA to increase the number of eligible acute ischemic stroke patients receiving EVT and other medical ischemic stroke treatment in the form of thrombolysis (alteplase and now Tenecteplase). We thoroughly assess the methodological basis of the papers, offering detailed explanations regarding the applied models, selected inputs and outputs, and all relevant methodologies. In conclusion, we explore several ways to enhance DEA's status, transforming it from a mere technical application into a strong methodology that can be utilized by healthcare managers and decision-makers.
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Affiliation(s)
- Mirpouya Mirmozaffari
- Department of Industrial Engineering, Dalhousie University, 5269 Morris Street, Halifax, NS B3H 4R2, Canada;
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