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Kandregula S, Savardekar AR, Sharma P, McLarty J, Kosty J, Trosclair K, Cuellar H, Guthikonda B. Direct thrombectomy versus bridging thrombolysis with mechanical thrombectomy in middle cerebral artery stroke: a real-world analysis through National Inpatient Sample data. Neurosurg Focus 2021; 51:E4. [PMID: 34198246 DOI: 10.3171/2021.4.focus21132] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/07/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE A paradigm shift in the management of acute ischemic stroke (AIS) due to large-vessel occlusion (LVO) occurred after 2015 when 7 randomized controlled trials demonstrated better outcomes using second-generation thrombectomy devices combined with best medical management than did stand-alone intravenous thrombolysis (IVT) with tissue plasminogen activator (tPA). All recently published landmark trials were designed to study the outcome of mechanical thrombectomy (MT); therefore, the majority of the patients enrolled in these trials received intravenous tPA. Currently, initiating IVT before MT is a matter of debate. Recent trials (DIRECT-MT, DEVT) exploring this clinical question showed noninferiority of MT alone compared with the combined treatment. With this uncertainty, the authors aimed to explore real-world data through the latest National Inpatient Sample (NIS) to compare the safety and outcomes of MT alone with bridging IVT and MT in AIS due to LVO in the middle cerebral artery (MCA). METHODS NIS data from 2017 to 2018 were analyzed to compare the outcomes and safety profiles of patients who underwent MT+IVT with those who underwent MT alone. RESULTS A total of 2895 patients were included in the final analysis (MT, n = 1669; MT+IVT, n = 1226). The mean National Institutes of Health Stroke Scale score was 16.2 (SD 6.1) in the MT group and 16.6 (SD 5.97) in the MT+IVT group (p = 0.04). With respect to comorbidities, the two groups did not differ in rates of hypertension (p = 0.730), atrial fibrillation/flutter (p = 0.828), and smoking status (p = 0.914). The rate of diabetes mellitus was significantly higher in the MT group (28%) than in the MT+IVT group (22.1%) (p < 0.001). The frequency of intracerebral hemorrhage (ICH) in the MT group was 17.7% (n = 296) and 21.5% (n = 263) in the MT+IVT group (p = 0.012). Intraventricular hemorrhage (p = 0.875), subarachnoid hemorrhage (p = 0.99), and vasospasm (p = 0.976) did not differ significantly between the groups. The primary outcome considered was disability status between the groups; 23.8% of patients in the MT+IVT group had minimal disability versus 18.2% in the MT group (p = 0.001). The risk of progressing to severe disability from minimal disability decreased with the addition of IVT to MT (OR 0.762, 95% CI 0.637-0.912). The adjusted odds ratio for ICH in the MT+IVT group was 1.28 (95% CI 1.043-1.571, p = 0.018) and 2.676 (95% CI 1.259-5.686, p = 0.01) for access-site hemorrhages. CONCLUSIONS In the analysis of the NIS database, the MT+IVT group had significantly higher rates of minimal disability at the time of hospital discharge versus the MT-alone group, despite a higher rate of ICH. The question of whether to treat patients with MT+IVT rather than MT alone is currently being addressed in ongoing prospective clinical trials (SWIFT-DIRECT [NCT03494920], MR CLEAN-NO IV [ISRCTN80619088], and DIRECT-SAFE [NCT03494920]). The results of these studies will contribute to greater understanding and progressive improvement in outcomes for AIS patients.
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Affiliation(s)
| | | | | | - Jerry McLarty
- 3Department of Oncology, Feist-Weiller Cancer Center, Ochsner LSU Health Shreveport, Louisiana
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302
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Ospel JM, McDonough R, Kunz WG, Goyal M. Is concurrent intravenous alteplase in patients undergoing endovascular treatment for large vessel occlusion stroke cost-effective even if the cost of alteplase is only US$1? J Neurointerv Surg 2021; 14:568-572. [PMID: 34187871 DOI: 10.1136/neurintsurg-2021-017817] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 06/08/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND The added value of intravenous (IV) alteplase in large vessel occlusion (LVO) stroke over and beyond endovascular treatment (EVT) is controversial. We compared the long-term costs and cost-effectiveness of a direct-to-EVT paradigm in LVO stroke patients presenting directly to the mothership hospital to concurrent EVT and IV alteplase. METHODS We used a decision model consisting of a short-run model to analyze costs and functional outcomes within 90 days after the index stroke and a long-run Markov state transition model (cycle length of 12 months) to estimate expected lifetime costs and outcomes. Outcome data were from the DIRECT-MT trial (NCT03469206). Incremental cost-effectiveness ratios and net monetary benefits were calculated and probabilistic sensitivity analysis was performed. Analysis was performed from a healthcare perspective and a societal perspective using both a minimal assumed alteplase cost of US$1 and true alteplase cost. RESULTS When assuming a minimal cost of alteplase of $1, EVT with concurrent IV alteplase resulted in incremental lifetime cost of $5664 (healthcare perspective)/$4804 (societal perspective) and a decrement of 0.25 quality-adjusted life years (QALYs) compared with EVT only, indicating dominance of the EVT only approach. Net monetary benefits were consistently higher for EVT only compared with EVT with concurrent alteplase. Probabilistic sensitivity analysis showed increased costs without an increase in QALYs for EVT and concurrent IV alteplase compared with EVT only. Results were even more in favor of EVT when the true cost of alteplase was used for analysis. CONCLUSION EVT without concurrent alteplase is the preferred strategy from a health economic standpoint.
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Affiliation(s)
- Johanna Maria Ospel
- Radiology, Universitatsspital Basel, Basel, Switzerland.,Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Rosalie McDonough
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Diagnostic and Interventional Neuroradiology, Department of Diagnostic and Interventional Neuroradiology, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | | | - Mayank Goyal
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada .,Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
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303
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Katsanos AH, Turc G, Psychogios M, Kaesmacher J, Palaiodimou L, Stefanou MI, Magoufis G, Shoamanesh A, Themistocleous M, Sacco S, Fiehler J, Gralla J, Strbian D, Alexandrov AV, Fischer U, Tsivgoulis G. Utility of Intravenous Alteplase Prior to Endovascular Stroke Treatment: A Systematic Review and Meta-analysis of RCTs. Neurology 2021; 97:e777-e784. [PMID: 34144996 DOI: 10.1212/wnl.0000000000012390] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2021] [Accepted: 05/24/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To provide a critical appraisal on the evidence from randomized controlled clinical trials (RCTs) on the utility of direct endovascular treatment (dEVT) compared to the combination of endovascular treatment preceded by IV thrombolysis (bridging therapy [BT]) for patients with acute large vessel occlusion (LVO). METHODS Eligible RCTs were identified by searching Medline and Scopus. We calculated the corresponding odds ratios (ORs) and 95% confidence intervals (CIs) and pooled estimates using random-effects models. The primary outcome was the probability of modified Rankin scale (mRS) score of 0 to 2 at 3 months. RESULTS We included 3 studies comprising 1,092 patients. No difference between the dEVT and BT groups was detected for the outcomes of mRS score of 0 to 2 (OR 1.08, 95% CI 0.85-1.38; adjusted OR 1.11, 95% CI 0.76-1.63), mRS score of 0 to 1 (OR 1.10, 95% CI 0.84-1.43; adjusted OR 1.16, 95% CI 0.84-1.61), and functional improvement at 3 months (common OR 1.08, 95% CI 0.88-1.34; adjusted common OR 1.09, 95% CI 0.86-1.37). Patients receiving dEVT had significantly lower likelihood of successful recanalization before the endovascular procedure compared to those receiving BT (OR 0.37, 95% CI 0.18-0.77). Patients receiving dEVT had lower intracranial bleeding rates compared to those receiving BT (OR 0.67, 95% CI 0.49-0.92) but without a significant difference in the probability of symptomatic intracranial hemorrhage. No differences in all-cause mortality, serious adverse events, or procedural complications between the 2 groups were uncovered. CONCLUSIONS We detected no differences in functional outcomes of IV thrombolysis-eligible patients with an acute LVO receiving dEVT compared to BT. Because uncertainty for most endpoints remains large and the available data are not able to exclude the possibility of overall benefit or harm, further RCTs are needed.
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Affiliation(s)
- Aristeidis H Katsanos
- From the Division of Neurology (A.H.K., A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Department of Neurology (G. Turc), GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne; Université de Paris (G. Turc); INSERM U1266 (G. Turc); FHU Neurovasc (G. Turc), Paris, France; Department of Neuroradiology (M.P.), Clinic for Radiology and Nuclear Medicine, University Hospital Basel; Department of Diagnostic and Interventional Neuroradiology and Department of Diagnostic, Interventional and Pediatric Radiology (J.K., J.G.), Inselspital University Hospital Bern, Switzerland; Second Department of Neurology (L.P., M.I.S., G. Tsivgoulis), Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens; Stroke Unit (G.M.), Metropolitan Hospital, Piraeus; Department of Neurosurgery (M.T.), Pediatric Hospital of Athens, Agia Sophia, Greece; Neuroscience Section (S.S.), Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, Italy; Department of Diagnostic and Interventional Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Neurological Research Unit (D.S.), Department of Neurology, Neurocenter, Helsinki University Hospital, Finland; Department of Neurology (A.V.A., G. Tsivgoulis), University of Tennessee Health Science Center, Memphis; and Department of Neurology (U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland.
| | - Guillaume Turc
- From the Division of Neurology (A.H.K., A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Department of Neurology (G. Turc), GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne; Université de Paris (G. Turc); INSERM U1266 (G. Turc); FHU Neurovasc (G. Turc), Paris, France; Department of Neuroradiology (M.P.), Clinic for Radiology and Nuclear Medicine, University Hospital Basel; Department of Diagnostic and Interventional Neuroradiology and Department of Diagnostic, Interventional and Pediatric Radiology (J.K., J.G.), Inselspital University Hospital Bern, Switzerland; Second Department of Neurology (L.P., M.I.S., G. Tsivgoulis), Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens; Stroke Unit (G.M.), Metropolitan Hospital, Piraeus; Department of Neurosurgery (M.T.), Pediatric Hospital of Athens, Agia Sophia, Greece; Neuroscience Section (S.S.), Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, Italy; Department of Diagnostic and Interventional Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Neurological Research Unit (D.S.), Department of Neurology, Neurocenter, Helsinki University Hospital, Finland; Department of Neurology (A.V.A., G. Tsivgoulis), University of Tennessee Health Science Center, Memphis; and Department of Neurology (U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Marios Psychogios
- From the Division of Neurology (A.H.K., A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Department of Neurology (G. Turc), GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne; Université de Paris (G. Turc); INSERM U1266 (G. Turc); FHU Neurovasc (G. Turc), Paris, France; Department of Neuroradiology (M.P.), Clinic for Radiology and Nuclear Medicine, University Hospital Basel; Department of Diagnostic and Interventional Neuroradiology and Department of Diagnostic, Interventional and Pediatric Radiology (J.K., J.G.), Inselspital University Hospital Bern, Switzerland; Second Department of Neurology (L.P., M.I.S., G. Tsivgoulis), Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens; Stroke Unit (G.M.), Metropolitan Hospital, Piraeus; Department of Neurosurgery (M.T.), Pediatric Hospital of Athens, Agia Sophia, Greece; Neuroscience Section (S.S.), Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, Italy; Department of Diagnostic and Interventional Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Neurological Research Unit (D.S.), Department of Neurology, Neurocenter, Helsinki University Hospital, Finland; Department of Neurology (A.V.A., G. Tsivgoulis), University of Tennessee Health Science Center, Memphis; and Department of Neurology (U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Johannes Kaesmacher
- From the Division of Neurology (A.H.K., A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Department of Neurology (G. Turc), GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne; Université de Paris (G. Turc); INSERM U1266 (G. Turc); FHU Neurovasc (G. Turc), Paris, France; Department of Neuroradiology (M.P.), Clinic for Radiology and Nuclear Medicine, University Hospital Basel; Department of Diagnostic and Interventional Neuroradiology and Department of Diagnostic, Interventional and Pediatric Radiology (J.K., J.G.), Inselspital University Hospital Bern, Switzerland; Second Department of Neurology (L.P., M.I.S., G. Tsivgoulis), Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens; Stroke Unit (G.M.), Metropolitan Hospital, Piraeus; Department of Neurosurgery (M.T.), Pediatric Hospital of Athens, Agia Sophia, Greece; Neuroscience Section (S.S.), Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, Italy; Department of Diagnostic and Interventional Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Neurological Research Unit (D.S.), Department of Neurology, Neurocenter, Helsinki University Hospital, Finland; Department of Neurology (A.V.A., G. Tsivgoulis), University of Tennessee Health Science Center, Memphis; and Department of Neurology (U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Lina Palaiodimou
- From the Division of Neurology (A.H.K., A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Department of Neurology (G. Turc), GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne; Université de Paris (G. Turc); INSERM U1266 (G. Turc); FHU Neurovasc (G. Turc), Paris, France; Department of Neuroradiology (M.P.), Clinic for Radiology and Nuclear Medicine, University Hospital Basel; Department of Diagnostic and Interventional Neuroradiology and Department of Diagnostic, Interventional and Pediatric Radiology (J.K., J.G.), Inselspital University Hospital Bern, Switzerland; Second Department of Neurology (L.P., M.I.S., G. Tsivgoulis), Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens; Stroke Unit (G.M.), Metropolitan Hospital, Piraeus; Department of Neurosurgery (M.T.), Pediatric Hospital of Athens, Agia Sophia, Greece; Neuroscience Section (S.S.), Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, Italy; Department of Diagnostic and Interventional Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Neurological Research Unit (D.S.), Department of Neurology, Neurocenter, Helsinki University Hospital, Finland; Department of Neurology (A.V.A., G. Tsivgoulis), University of Tennessee Health Science Center, Memphis; and Department of Neurology (U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Maria Ioanna Stefanou
- From the Division of Neurology (A.H.K., A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Department of Neurology (G. Turc), GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne; Université de Paris (G. Turc); INSERM U1266 (G. Turc); FHU Neurovasc (G. Turc), Paris, France; Department of Neuroradiology (M.P.), Clinic for Radiology and Nuclear Medicine, University Hospital Basel; Department of Diagnostic and Interventional Neuroradiology and Department of Diagnostic, Interventional and Pediatric Radiology (J.K., J.G.), Inselspital University Hospital Bern, Switzerland; Second Department of Neurology (L.P., M.I.S., G. Tsivgoulis), Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens; Stroke Unit (G.M.), Metropolitan Hospital, Piraeus; Department of Neurosurgery (M.T.), Pediatric Hospital of Athens, Agia Sophia, Greece; Neuroscience Section (S.S.), Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, Italy; Department of Diagnostic and Interventional Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Neurological Research Unit (D.S.), Department of Neurology, Neurocenter, Helsinki University Hospital, Finland; Department of Neurology (A.V.A., G. Tsivgoulis), University of Tennessee Health Science Center, Memphis; and Department of Neurology (U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - George Magoufis
- From the Division of Neurology (A.H.K., A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Department of Neurology (G. Turc), GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne; Université de Paris (G. Turc); INSERM U1266 (G. Turc); FHU Neurovasc (G. Turc), Paris, France; Department of Neuroradiology (M.P.), Clinic for Radiology and Nuclear Medicine, University Hospital Basel; Department of Diagnostic and Interventional Neuroradiology and Department of Diagnostic, Interventional and Pediatric Radiology (J.K., J.G.), Inselspital University Hospital Bern, Switzerland; Second Department of Neurology (L.P., M.I.S., G. Tsivgoulis), Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens; Stroke Unit (G.M.), Metropolitan Hospital, Piraeus; Department of Neurosurgery (M.T.), Pediatric Hospital of Athens, Agia Sophia, Greece; Neuroscience Section (S.S.), Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, Italy; Department of Diagnostic and Interventional Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Neurological Research Unit (D.S.), Department of Neurology, Neurocenter, Helsinki University Hospital, Finland; Department of Neurology (A.V.A., G. Tsivgoulis), University of Tennessee Health Science Center, Memphis; and Department of Neurology (U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Ashkan Shoamanesh
- From the Division of Neurology (A.H.K., A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Department of Neurology (G. Turc), GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne; Université de Paris (G. Turc); INSERM U1266 (G. Turc); FHU Neurovasc (G. Turc), Paris, France; Department of Neuroradiology (M.P.), Clinic for Radiology and Nuclear Medicine, University Hospital Basel; Department of Diagnostic and Interventional Neuroradiology and Department of Diagnostic, Interventional and Pediatric Radiology (J.K., J.G.), Inselspital University Hospital Bern, Switzerland; Second Department of Neurology (L.P., M.I.S., G. Tsivgoulis), Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens; Stroke Unit (G.M.), Metropolitan Hospital, Piraeus; Department of Neurosurgery (M.T.), Pediatric Hospital of Athens, Agia Sophia, Greece; Neuroscience Section (S.S.), Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, Italy; Department of Diagnostic and Interventional Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Neurological Research Unit (D.S.), Department of Neurology, Neurocenter, Helsinki University Hospital, Finland; Department of Neurology (A.V.A., G. Tsivgoulis), University of Tennessee Health Science Center, Memphis; and Department of Neurology (U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Marios Themistocleous
- From the Division of Neurology (A.H.K., A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Department of Neurology (G. Turc), GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne; Université de Paris (G. Turc); INSERM U1266 (G. Turc); FHU Neurovasc (G. Turc), Paris, France; Department of Neuroradiology (M.P.), Clinic for Radiology and Nuclear Medicine, University Hospital Basel; Department of Diagnostic and Interventional Neuroradiology and Department of Diagnostic, Interventional and Pediatric Radiology (J.K., J.G.), Inselspital University Hospital Bern, Switzerland; Second Department of Neurology (L.P., M.I.S., G. Tsivgoulis), Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens; Stroke Unit (G.M.), Metropolitan Hospital, Piraeus; Department of Neurosurgery (M.T.), Pediatric Hospital of Athens, Agia Sophia, Greece; Neuroscience Section (S.S.), Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, Italy; Department of Diagnostic and Interventional Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Neurological Research Unit (D.S.), Department of Neurology, Neurocenter, Helsinki University Hospital, Finland; Department of Neurology (A.V.A., G. Tsivgoulis), University of Tennessee Health Science Center, Memphis; and Department of Neurology (U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Simona Sacco
- From the Division of Neurology (A.H.K., A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Department of Neurology (G. Turc), GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne; Université de Paris (G. Turc); INSERM U1266 (G. Turc); FHU Neurovasc (G. Turc), Paris, France; Department of Neuroradiology (M.P.), Clinic for Radiology and Nuclear Medicine, University Hospital Basel; Department of Diagnostic and Interventional Neuroradiology and Department of Diagnostic, Interventional and Pediatric Radiology (J.K., J.G.), Inselspital University Hospital Bern, Switzerland; Second Department of Neurology (L.P., M.I.S., G. Tsivgoulis), Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens; Stroke Unit (G.M.), Metropolitan Hospital, Piraeus; Department of Neurosurgery (M.T.), Pediatric Hospital of Athens, Agia Sophia, Greece; Neuroscience Section (S.S.), Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, Italy; Department of Diagnostic and Interventional Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Neurological Research Unit (D.S.), Department of Neurology, Neurocenter, Helsinki University Hospital, Finland; Department of Neurology (A.V.A., G. Tsivgoulis), University of Tennessee Health Science Center, Memphis; and Department of Neurology (U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Jens Fiehler
- From the Division of Neurology (A.H.K., A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Department of Neurology (G. Turc), GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne; Université de Paris (G. Turc); INSERM U1266 (G. Turc); FHU Neurovasc (G. Turc), Paris, France; Department of Neuroradiology (M.P.), Clinic for Radiology and Nuclear Medicine, University Hospital Basel; Department of Diagnostic and Interventional Neuroradiology and Department of Diagnostic, Interventional and Pediatric Radiology (J.K., J.G.), Inselspital University Hospital Bern, Switzerland; Second Department of Neurology (L.P., M.I.S., G. Tsivgoulis), Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens; Stroke Unit (G.M.), Metropolitan Hospital, Piraeus; Department of Neurosurgery (M.T.), Pediatric Hospital of Athens, Agia Sophia, Greece; Neuroscience Section (S.S.), Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, Italy; Department of Diagnostic and Interventional Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Neurological Research Unit (D.S.), Department of Neurology, Neurocenter, Helsinki University Hospital, Finland; Department of Neurology (A.V.A., G. Tsivgoulis), University of Tennessee Health Science Center, Memphis; and Department of Neurology (U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Jan Gralla
- From the Division of Neurology (A.H.K., A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Department of Neurology (G. Turc), GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne; Université de Paris (G. Turc); INSERM U1266 (G. Turc); FHU Neurovasc (G. Turc), Paris, France; Department of Neuroradiology (M.P.), Clinic for Radiology and Nuclear Medicine, University Hospital Basel; Department of Diagnostic and Interventional Neuroradiology and Department of Diagnostic, Interventional and Pediatric Radiology (J.K., J.G.), Inselspital University Hospital Bern, Switzerland; Second Department of Neurology (L.P., M.I.S., G. Tsivgoulis), Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens; Stroke Unit (G.M.), Metropolitan Hospital, Piraeus; Department of Neurosurgery (M.T.), Pediatric Hospital of Athens, Agia Sophia, Greece; Neuroscience Section (S.S.), Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, Italy; Department of Diagnostic and Interventional Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Neurological Research Unit (D.S.), Department of Neurology, Neurocenter, Helsinki University Hospital, Finland; Department of Neurology (A.V.A., G. Tsivgoulis), University of Tennessee Health Science Center, Memphis; and Department of Neurology (U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Daniel Strbian
- From the Division of Neurology (A.H.K., A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Department of Neurology (G. Turc), GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne; Université de Paris (G. Turc); INSERM U1266 (G. Turc); FHU Neurovasc (G. Turc), Paris, France; Department of Neuroradiology (M.P.), Clinic for Radiology and Nuclear Medicine, University Hospital Basel; Department of Diagnostic and Interventional Neuroradiology and Department of Diagnostic, Interventional and Pediatric Radiology (J.K., J.G.), Inselspital University Hospital Bern, Switzerland; Second Department of Neurology (L.P., M.I.S., G. Tsivgoulis), Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens; Stroke Unit (G.M.), Metropolitan Hospital, Piraeus; Department of Neurosurgery (M.T.), Pediatric Hospital of Athens, Agia Sophia, Greece; Neuroscience Section (S.S.), Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, Italy; Department of Diagnostic and Interventional Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Neurological Research Unit (D.S.), Department of Neurology, Neurocenter, Helsinki University Hospital, Finland; Department of Neurology (A.V.A., G. Tsivgoulis), University of Tennessee Health Science Center, Memphis; and Department of Neurology (U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Andrei V Alexandrov
- From the Division of Neurology (A.H.K., A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Department of Neurology (G. Turc), GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne; Université de Paris (G. Turc); INSERM U1266 (G. Turc); FHU Neurovasc (G. Turc), Paris, France; Department of Neuroradiology (M.P.), Clinic for Radiology and Nuclear Medicine, University Hospital Basel; Department of Diagnostic and Interventional Neuroradiology and Department of Diagnostic, Interventional and Pediatric Radiology (J.K., J.G.), Inselspital University Hospital Bern, Switzerland; Second Department of Neurology (L.P., M.I.S., G. Tsivgoulis), Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens; Stroke Unit (G.M.), Metropolitan Hospital, Piraeus; Department of Neurosurgery (M.T.), Pediatric Hospital of Athens, Agia Sophia, Greece; Neuroscience Section (S.S.), Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, Italy; Department of Diagnostic and Interventional Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Neurological Research Unit (D.S.), Department of Neurology, Neurocenter, Helsinki University Hospital, Finland; Department of Neurology (A.V.A., G. Tsivgoulis), University of Tennessee Health Science Center, Memphis; and Department of Neurology (U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Urs Fischer
- From the Division of Neurology (A.H.K., A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Department of Neurology (G. Turc), GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne; Université de Paris (G. Turc); INSERM U1266 (G. Turc); FHU Neurovasc (G. Turc), Paris, France; Department of Neuroradiology (M.P.), Clinic for Radiology and Nuclear Medicine, University Hospital Basel; Department of Diagnostic and Interventional Neuroradiology and Department of Diagnostic, Interventional and Pediatric Radiology (J.K., J.G.), Inselspital University Hospital Bern, Switzerland; Second Department of Neurology (L.P., M.I.S., G. Tsivgoulis), Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens; Stroke Unit (G.M.), Metropolitan Hospital, Piraeus; Department of Neurosurgery (M.T.), Pediatric Hospital of Athens, Agia Sophia, Greece; Neuroscience Section (S.S.), Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, Italy; Department of Diagnostic and Interventional Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Neurological Research Unit (D.S.), Department of Neurology, Neurocenter, Helsinki University Hospital, Finland; Department of Neurology (A.V.A., G. Tsivgoulis), University of Tennessee Health Science Center, Memphis; and Department of Neurology (U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Georgios Tsivgoulis
- From the Division of Neurology (A.H.K., A.S.), McMaster University/Population Health Research Institute, Hamilton, Ontario, Canada; Department of Neurology (G. Turc), GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne; Université de Paris (G. Turc); INSERM U1266 (G. Turc); FHU Neurovasc (G. Turc), Paris, France; Department of Neuroradiology (M.P.), Clinic for Radiology and Nuclear Medicine, University Hospital Basel; Department of Diagnostic and Interventional Neuroradiology and Department of Diagnostic, Interventional and Pediatric Radiology (J.K., J.G.), Inselspital University Hospital Bern, Switzerland; Second Department of Neurology (L.P., M.I.S., G. Tsivgoulis), Attikon Hospital, School of Medicine, National and Kapodistrian University of Athens; Stroke Unit (G.M.), Metropolitan Hospital, Piraeus; Department of Neurosurgery (M.T.), Pediatric Hospital of Athens, Agia Sophia, Greece; Neuroscience Section (S.S.), Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, Italy; Department of Diagnostic and Interventional Neuroradiology (J.F.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Neurological Research Unit (D.S.), Department of Neurology, Neurocenter, Helsinki University Hospital, Finland; Department of Neurology (A.V.A., G. Tsivgoulis), University of Tennessee Health Science Center, Memphis; and Department of Neurology (U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
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304
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Affiliation(s)
- Kyriakos Lobotesis
- Imaging Department, Imperial College Healthcare NHS Trust, Charing Cross Hospital, London, United Kingdom (K.L.)
| | - Brian H Buck
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, Canada (B.H.B.)
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Maier IL, Leha A, Badr M, Allam I, Bähr M, Jamous A, Hesse A, Psychogios MN, Behme D, Liman J. Inhouse Bridging Thrombolysis Is Associated With Improved Functional Outcome in Patients With Large Vessel Occlusion Stroke: Findings From the German Stroke Registry. Front Neurol 2021; 12:649108. [PMID: 34177759 PMCID: PMC8222775 DOI: 10.3389/fneur.2021.649108] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 04/20/2021] [Indexed: 01/17/2023] Open
Abstract
Background: Endovascular treatment (EVT) for large vessel occlusion stroke (LVOS) is highly effective. To date, it remains controversial if intravenous thrombolysis (IVT) prior to EVT is superior compared with EVT alone. The aim of our study was to specifically address the question, whether bridging IVT directly prior to EVT has additional positive effects on reperfusion times, successful reperfusion, and functional outcomes compared with EVT alone. Methods: Patients with LVOS in the anterior circulation eligible for EVT with and without prior IVT and direct admission to endovascular centers (mothership) were included in this multicentric, retrospective study. Patient data was derived from the German Stroke Registry (an open, multicenter, and prospective observational study). Outcome parameters included groin-to-reperfusion time, successful reperfusion [defined as a Thrombolysis in Cerebral Infarction (TICI) scale 2b-3], change in National Institute of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), and mortality at 90 days. Results: Of the 881 included mothership patients with anterior circulation LVOS, 486 (55.2%) received bridging therapy with i.v.-rtPA prior to EVT, and 395 (44.8%) received EVT alone. Adjusted, multivariate linear mixed effect models revealed no difference in groin-to-reperfusion time between the groups (48 ± 36 vs. 49 ± 34 min; p = 0.299). Rates of successful reperfusion (TICI ≥ 2b) were higher in patients with bridging IVT (fixed effects estimate 0.410, 95% CI, 0.070; 0.750, p = 0.018). There was a trend toward a higher improvement in the NIHSS during hospitalization [ΔNIHSS: bridging-IVT group 8 (IQR, 9.8) vs. 4 (IQR 11) points in the EVT alone group; fixed effects estimate 1.370, 95% CI, −0.490; 3.240, p = 0.149]. mRS at 90 days follow-up was lower in the bridging IVT group [3 (IQR, 4) vs. 4 (IQR, 4); fixed effects estimate −0.350, 95% CI, −0.680; −0.010, p = 0.041]. There was a non-significantly lower 90 day mortality in the bridging IVT group compared with the EVT alone group (22.4% vs. 33.6%; fixed effects estimate 0.980, 95% CI −0.610; 2.580, p = 0.351). Rates of any intracerebral hemorrhage did not differ between both groups (4.1% vs. 3.8%, p = 0.864). Conclusions: This study provides evidence that bridging IVT might improve rates of successful reperfusion and long-term functional outcome in mothership patients with anterior circulation LVOS eligible for EVT.
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Affiliation(s)
- Ilko L Maier
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Andreas Leha
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Mostafa Badr
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Ibrahim Allam
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Mathias Bähr
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Ala Jamous
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - Amelie Hesse
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | | | - Daniel Behme
- Department of Neuroradiology, University Hospital Magdeburg, Magdeburg, Germany
| | - Jan Liman
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
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Controversies in Imaging of Patients with Acute Ischemic Stroke: AJR Expert Panel Narrative Review. AJR Am J Roentgenol 2021; 217:1027-1037. [PMID: 34106758 DOI: 10.2214/ajr.21.25846] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
The development of reperfusion therapies has profoundly impacted stroke care, initially with the advent of IV thrombolytic (IVT) treatment and, more recently, with the development and refinement of endovascular treatment (EVT). Progress in neuroimaging has supported the paradigm shift of stroke care, and advanced neuroimaging now has a fundamental role in triaging patients for both IVT and EVT. As the standard of care for acute ischemic stroke (AIS) evolves, controversies remain in certain clinical scenarios. This article explores the use of multimodality imaging for treatment selection of AIS in the context of recent guidelines, highlighting controversial topics and providing guidance for clinical practice. Results of major randomized trials supporting EVT are reviewed. Advantages and disadvantages of CT, CTA, MRI, and MRA in stroke diagnosis are summarized, with attention to level 1 evidence supporting the role of vascular imaging and perfusion imaging. Patient selection is compared between approaches based on time thresholds and physiologic approaches based on infarct core measurement using imaging. Moreover, various imaging approaches to core measurement are described. As ongoing studies push treatment boundaries, advanced imaging is expected to help identify a widening range of patients who may benefit from therapy.
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307
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Sarraj A, Grotta J, Albers GW, Hassan AE, Blackburn S, Day A, Sitton C, Abraham M, Cai C, Dannenbaum M, Pujara D, Hicks W, Budzik R, Vora N, Arora A, Alenzi B, Tekle WG, Kamal H, Mir O, Barreto AD, Lansberg M, Gupta R, Martin-Schild S, Savitz S, Tsivgoulis G. Clinical and Neuroimaging Outcomes of Direct Thrombectomy vs Bridging Therapy in Large Vessel Occlusion: Analysis of the SELECT Cohort Study. Neurology 2021; 96:e2839-e2853. [PMID: 33875560 PMCID: PMC8205460 DOI: 10.1212/wnl.0000000000012063] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2020] [Accepted: 03/11/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the comparative safety and efficacy of direct endovascular thrombectomy (dEVT) compared to bridging therapy (BT; IV tissue plasminogen activator + EVT) and to assess whether BT potential benefit relates to stroke severity, size, and initial presentation to EVT vs non-EVT center. METHODS In a prospective multicenter cohort study of imaging selection for endovascular thrombectomy (Optimizing Patient Selection for Endovascular Treatment in Acute Ischemic Stroke [SELECT]), patients with anterior circulation large vessel occlusion (LVO) presenting to EVT-capable centers within 4.5 hours from last known well were stratified into BT vs dEVT. The primary outcome was 90-day functional independence (modified Rankin Scale [mRS] score 0-2). Secondary outcomes included a shift across 90-day mRS grades, mortality, and symptomatic intracranial hemorrhage. We also performed subgroup analyses according to initial presentation to EVT-capable center (direct vs transfer), stroke severity, and baseline infarct core volume. RESULTS We identified 226 LVOs (54% men, mean age 65.6 ± 14.6 years, median NIH Stroke Scale [NIHSS] score 17, 28% received dEVT). Median time from arrival to groin puncture did not differ in patients with BT when presenting directly (dEVT 1.43 [interquartile range (IQR) 1.13-1.90] hours vs BT 1.58 [IQR 1.27-2.02] hours, p = 0.40) or transferred to EVT-capable centers (dEVT 1.17 [IQR 0.90-1.48] hours vs BT 1.27 [IQR 0.97-1.87] hours, p = 0.24). BT was associated with higher odds of 90-day functional independence (57% vs 44%, adjusted odds ratio [aOR] 2.02, 95% confidence interval [CI] 1.01-4.03, p = 0.046) and functional improvement (adjusted common OR 2.06, 95% CI 1.18-3.60, p = 0.011) and lower likelihood of 90-day mortality (11% vs 23%, aOR 0.20, 95% CI 0.07-0.58, p = 0.003). No differences in any other outcomes were detected. In subgroup analyses, patients with BT with baseline NIHSS scores <15 had higher functional independence likelihood compared to those with dEVT (aOR 4.87, 95% CI 1.56-15.18, p = 0.006); this association was not evident for patients with NIHSS scores ≥15 (aOR 1.05, 95% CI 0.40-2.74, p = 0.92). Similarly, functional outcomes improvements with BT were detected in patients with core volume strata (ischemic core <50 cm3: aOR 2.10, 95% CI 1.02-4.33, p = 0.044 vs ischemic core ≥50 cm3: aOR 0.41, 95% CI 0.01-16.02, p = 0.64) and transfer status (transferred: aOR 2.21, 95% CI 0.93-9.65, p = 0.29 vs direct to EVT center: aOR 1.84, 95% CI 0.80-4.23, p = 0.15). CONCLUSIONS BT appears to be associated with better clinical outcomes, especially with milder NIHSS scores, smaller presentation core volumes, and those who were "dripped and shipped." We did not observe any potential benefit of BT in patients with more severe strokes. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov Identifier: NCT02446587. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that for patients with ischemic stroke from anterior circulation LVO within 4.5 hours from last known well, BT compared to dEVT leads to better 90-day functional outcomes.
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Affiliation(s)
- Amrou Sarraj
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece.
| | - James Grotta
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Gregory W Albers
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Ameer E Hassan
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Spiros Blackburn
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Arthur Day
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Clark Sitton
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Michael Abraham
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Chunyan Cai
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Mark Dannenbaum
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Deep Pujara
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - William Hicks
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Ronald Budzik
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Nirav Vora
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Ashish Arora
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Bader Alenzi
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Wondwossen G Tekle
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Haris Kamal
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Osman Mir
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Andrew D Barreto
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Maarten Lansberg
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Rishi Gupta
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Sheryl Martin-Schild
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Sean Savitz
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
| | - Georgios Tsivgoulis
- From the Departments of Neurology (A.S., J.G., D.P., H.K., A.D.B.), Neurosurgery (S.B., A.D., M.D.), Radiology (C.S.), and Clinical and Translational Science (C.C.), University of Texas at Houston; Department of Neurology (G.W.A., M.L.), Stanford University, CA; Department of Neurology (A.E.H., W.G.T.), University of Texas Rio Grande Valley, Harlingen; Department of Neurology (M.A.), Kansas University Medical Center, Kansas City; Department of Neurology (W.H., R.B., N.V.), OhioHealth-Riverside Methodist Hospital, Columbus; Cone Health (A.A.), Greensboro, NC; Department of Neurology (B.A.), St. Vincent Mercy Health Medical Center, Toledo, OH; Department of Neurology (O.M.), New York University Langone Health, New York; Department of Neurology (R.G.), WellStar Health System, Atlanta, GA; Department of Neurology (S.M.-S.), Touro Infirmary and New Orleans East Hospital, LA; Department of Neurology (S.S.), Institute for Stroke and Cerebrovascular Diseases-UTHealth, Houston; University of Tennessee Health Science Center (G.T.), Memphis; and Second Department of Neurology (G.T.), National & Kapodistrian University of Athens, Greece
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Riou-Comte N, Gory B, Soudant M, Zhu F, Xie Y, Humbertjean L, Mione G, Oppenheim C, Guillemin F, Bracard S, Richard S. Clinical imaging factors of excellent outcome after thrombolysis in large-vessel stroke: a THRACE subgroup analysis. Stroke Vasc Neurol 2021; 6:631-639. [PMID: 34103393 PMCID: PMC8717776 DOI: 10.1136/svn-2020-000852] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 04/09/2021] [Accepted: 04/14/2021] [Indexed: 11/30/2022] Open
Abstract
Background For patients with stroke with large-vessel occlusion (LVO), study of factors predicting response to intravenous thrombolysis (IVT) would allow identifying subgroups with high expected gain, and those for whom it could be considered as futile, and even detrimental. From patients included in the Mechanical Thrombectomy After Intravenous Alteplase vs Alteplase Alone After Stroke trial, we investigated clinical-imaging factors associated with optimal response to IVT. Methods We included patients receiving IVT alone. Excellent outcome was defined by a 3-month modified Rankin Scale (mRS) score ≤1. Clinical-imaging predictors were assessed on multivariate analysis after multiple imputations. The predictive performance of the model was assessed with the C-statistic. Results Among 247 patients with LVO treated with IVT alone, 77 (31%) showed 3-month mRS ≤1. Predictors of 3-month mRS ≤1 were no medical history of hypertension (OR 2.43; 95% CI 1.74 to 3.38; p=0.007); no current smoking (OR 2.76; 95% CI 1.79 to 4.26; p=0.02); onset-to-IVT time (OR 0.47 per hour increase; 95% CI 0.23 to 0.78; p=0.003); diffusion-weighted imaging (DWI) volume (OR 0.78 per 10 mL increase; 95% CI 0.68 to 0.89; p=0.0004); presence of susceptibility vessel sign (SVS) (OR 7.89; 95% CI 1.65 to 37.78; p=0.01) and SVS length (OR 0.87 per mm increase; 95% CI 0.80 to 0.94; p=0.001). The prediction models showed a C-statistic=0.79 (95% CI 0.79 to 0.80). Conclusions In patients with stroke with anterior-circulation LVO treated with IVT alone, predictors of excellent outcome at 3 months were no medical history of hypertension or current smoking, reduced onset-to-IVT time, small DWI volume, presence of SVS and short SVS length. These predictive factors could help practitioners in decision-making for IVT implementation in reperfusion strategies, all the more for the drip and ship paradigm. Trial registration number NCT01062698.
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Affiliation(s)
- Nolwenn Riou-Comte
- Department of Neurology-Stroke Unit, CIC-P 1433, INSERMU1116, Université de Lorraine, Nancy Regional University Hospital Center, Nancy, France
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, INSERM U1254, IADI, Université de Lorraine, Nancy Regional University Hospital Center, Nancy, France
| | - Marc Soudant
- Clinical Investigation Centre-Clinical Epidemiology 1433, INSERM, Université de Lorraine, Nancy Regional University Hospital Center, Nancy, France
| | - François Zhu
- Department of Diagnostic and Therapeutic Neuroradiology, INSERM U1254, IADI, Université de Lorraine, Nancy Regional University Hospital Center, Nancy, France
| | - Yu Xie
- Department of Diagnostic and Therapeutic Neuroradiology, INSERM U1254, IADI, Université de Lorraine, Nancy Regional University Hospital Center, Nancy, France
| | - Lisa Humbertjean
- Department of Neurology-Stroke Unit, CIC-P 1433, INSERMU1116, Université de Lorraine, Nancy Regional University Hospital Center, Nancy, France
| | - Gioia Mione
- Department of Neurology-Stroke Unit, CIC-P 1433, INSERMU1116, Université de Lorraine, Nancy Regional University Hospital Center, Nancy, France
| | - Catherine Oppenheim
- Department of Neuroradiology, INSERM U894, Université Paris-Descartes, Sainte-Anne Hospital, Paris, France
| | - Francis Guillemin
- Clinical Investigation Centre-Clinical Epidemiology 1433, INSERM, Université de Lorraine, Nancy Regional University Hospital Center, Nancy, France
| | - Serge Bracard
- Department of Diagnostic and Therapeutic Neuroradiology, INSERM U1254, IADI, Université de Lorraine, Nancy Regional University Hospital Center, Nancy, France
| | - Sébastien Richard
- Department of Neurology-Stroke Unit, CIC-P 1433, INSERMU1116, Université de Lorraine, Nancy Regional University Hospital Center, Nancy, France
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309
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Ahmed N, Mazya M, Nunes AP, Moreira T, Ollikainen JP, Escudero-Martínez I, Bigliardi G, Dorado L, Dávalos A, Egido JA, Tassi R, Strbian D, Zini A, Nichelli P, Herzig R, Jurák L, Hurtikova E, Tsivgoulis G, Peeters A, Nevšímalová M, Brozman M, Cavallo R, Lees KR, Mikulík R, Toni D, Holmin S. Safety and Outcomes of Thrombectomy in Ischemic Stroke With vs Without IV Thrombolysis. Neurology 2021; 97:e765-e776. [PMID: 34088873 DOI: 10.1212/wnl.0000000000012327] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 05/20/2021] [Indexed: 01/19/2023] Open
Abstract
OBJECTIVE To test the hypothesis that IV thrombolysis (IVT) treatment before endovascular thrombectomy (EVT) is associated with better outcomes in patients with anterior circulation large artery occlusion (LAO) stroke, we examined a large real-world database, the Safe Implementation of Treatment in Stroke-International Stroke Thrombectomy Register (SITS-ISTR). METHODS We identified centers recording ≥10 consecutive patients in the SITS-ISTR, with at least 70% available modified Rankin Scale (mRS) scores at 3 months during 2014 to 2019. We defined LAO as intracranial internal carotid artery, first and second segment of middle cerebral artery, and first segment of anterior cerebral artery. Main outcomes were functional independence (mRS score 0-2) and death at 3 months and symptomatic intracranial hemorrhage (SICH) per modified SITS-Monitoring Study. We performed propensity score-matched (PSM) and multivariable logistic regression analyses. RESULTS Of 6,350 patients from 42 centers, 3,944 (62.1%) received IVT. IVT + EVT-treated patients had less frequent atrial fibrillation, ongoing anticoagulation, previous stroke, heart failure, and prestroke disability. PSM analysis showed that IVT + EVT-treated patients had a higher rate of functional independence than patients treated with EVT alone (46.4% vs 40.3%, p < 0.001) and a lower rate of death at 3 months (20.3% vs 23.3%, p = 0.035). SICH rates (3.5% vs 3.0%, p = 0.42) were similar in both groups. Multivariate adjustment yielded results consistent with PSM. CONCLUSION Pretreatment with IVT was associated with favorable outcomes in EVT-treated LAO stroke in the SITS-ISTR. These findings, while indicative of international routine clinical practice, are limited by observational design, unmeasured confounding, and possible residual confounding by indication. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that IVT before EVT increases the probability of functional independence at 3 months compared to EVT alone.
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Affiliation(s)
- Niaz Ahmed
- From the Department of Neurology (N.A., M.M., T.M.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A., M.M., T.M., S.H.), Karolinska Institutet, Solna, Sweden; Stroke Unit (A.P.N.), Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; Department of Neurology (J.P.O.), Tampere University Hospital, Tampere, Finland; Department of Neurology (I.E.-M.), University Hospital Virgen del Rocío, Sevilla and Biomedicine Institute of Sevilla, Spain; Department of Neurology (G.B.), Ospedale Civile "S.Agostino-Estense"-Azienda Ospedaliera Universitaria di Modena, Italy; Department of Neurology (L.D., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (J.A.E.), Hospital Clínico San Carlos, Madrid, Spain; Stroke Unit Azienda Ospedaliera Universitaria Senese (R.T.), Siena, Italy; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; IRCCS Istituto delle Scienze Neurologiche di Bologna (A.Z.), Department of Neurology and Stroke Center, Maggiore Hospital; Department of Biomedical (P.N.), Metabolical and Neurosciences, Università degli studi di Modena e Reggio Emilia, Italy; Department of Neurology (R.H.), Comprehensive Stroke Centre, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic; Neurocentre (L.J.), Regional Hospital Liberec, Czech Republic; Department of Neurology University Hospital Ostrava (E.H.), Czech Republic; Second Department of Neurology (G.T., A.P.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.P.), Cliniques Universitaires St-Luc, Brussels; Department of Neurology (M.N.), Nemocnice Ceske Budejovice, Czech Republic; Constantine the Philosopher University Nitra (M.B.), Faculty of Social Sciences and Health, Slovakia; Department of Neurology (R.C.), Ospedale San Giovanni Bosco, Turin, Italy; School of Medicine (K.R.L.), Dentistry and Nursing, University of Glasgow, UK; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Human Neurosciences (D.T.), La Sapienza, Rome, Italy; and Department of Neuroradiology (S.H.), Karolinska University Hospital, Solna, Sweden.
| | - Michael Mazya
- From the Department of Neurology (N.A., M.M., T.M.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A., M.M., T.M., S.H.), Karolinska Institutet, Solna, Sweden; Stroke Unit (A.P.N.), Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; Department of Neurology (J.P.O.), Tampere University Hospital, Tampere, Finland; Department of Neurology (I.E.-M.), University Hospital Virgen del Rocío, Sevilla and Biomedicine Institute of Sevilla, Spain; Department of Neurology (G.B.), Ospedale Civile "S.Agostino-Estense"-Azienda Ospedaliera Universitaria di Modena, Italy; Department of Neurology (L.D., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (J.A.E.), Hospital Clínico San Carlos, Madrid, Spain; Stroke Unit Azienda Ospedaliera Universitaria Senese (R.T.), Siena, Italy; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; IRCCS Istituto delle Scienze Neurologiche di Bologna (A.Z.), Department of Neurology and Stroke Center, Maggiore Hospital; Department of Biomedical (P.N.), Metabolical and Neurosciences, Università degli studi di Modena e Reggio Emilia, Italy; Department of Neurology (R.H.), Comprehensive Stroke Centre, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic; Neurocentre (L.J.), Regional Hospital Liberec, Czech Republic; Department of Neurology University Hospital Ostrava (E.H.), Czech Republic; Second Department of Neurology (G.T., A.P.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.P.), Cliniques Universitaires St-Luc, Brussels; Department of Neurology (M.N.), Nemocnice Ceske Budejovice, Czech Republic; Constantine the Philosopher University Nitra (M.B.), Faculty of Social Sciences and Health, Slovakia; Department of Neurology (R.C.), Ospedale San Giovanni Bosco, Turin, Italy; School of Medicine (K.R.L.), Dentistry and Nursing, University of Glasgow, UK; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Human Neurosciences (D.T.), La Sapienza, Rome, Italy; and Department of Neuroradiology (S.H.), Karolinska University Hospital, Solna, Sweden
| | - Ana Paiva Nunes
- From the Department of Neurology (N.A., M.M., T.M.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A., M.M., T.M., S.H.), Karolinska Institutet, Solna, Sweden; Stroke Unit (A.P.N.), Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; Department of Neurology (J.P.O.), Tampere University Hospital, Tampere, Finland; Department of Neurology (I.E.-M.), University Hospital Virgen del Rocío, Sevilla and Biomedicine Institute of Sevilla, Spain; Department of Neurology (G.B.), Ospedale Civile "S.Agostino-Estense"-Azienda Ospedaliera Universitaria di Modena, Italy; Department of Neurology (L.D., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (J.A.E.), Hospital Clínico San Carlos, Madrid, Spain; Stroke Unit Azienda Ospedaliera Universitaria Senese (R.T.), Siena, Italy; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; IRCCS Istituto delle Scienze Neurologiche di Bologna (A.Z.), Department of Neurology and Stroke Center, Maggiore Hospital; Department of Biomedical (P.N.), Metabolical and Neurosciences, Università degli studi di Modena e Reggio Emilia, Italy; Department of Neurology (R.H.), Comprehensive Stroke Centre, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic; Neurocentre (L.J.), Regional Hospital Liberec, Czech Republic; Department of Neurology University Hospital Ostrava (E.H.), Czech Republic; Second Department of Neurology (G.T., A.P.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.P.), Cliniques Universitaires St-Luc, Brussels; Department of Neurology (M.N.), Nemocnice Ceske Budejovice, Czech Republic; Constantine the Philosopher University Nitra (M.B.), Faculty of Social Sciences and Health, Slovakia; Department of Neurology (R.C.), Ospedale San Giovanni Bosco, Turin, Italy; School of Medicine (K.R.L.), Dentistry and Nursing, University of Glasgow, UK; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Human Neurosciences (D.T.), La Sapienza, Rome, Italy; and Department of Neuroradiology (S.H.), Karolinska University Hospital, Solna, Sweden
| | - Tiago Moreira
- From the Department of Neurology (N.A., M.M., T.M.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A., M.M., T.M., S.H.), Karolinska Institutet, Solna, Sweden; Stroke Unit (A.P.N.), Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; Department of Neurology (J.P.O.), Tampere University Hospital, Tampere, Finland; Department of Neurology (I.E.-M.), University Hospital Virgen del Rocío, Sevilla and Biomedicine Institute of Sevilla, Spain; Department of Neurology (G.B.), Ospedale Civile "S.Agostino-Estense"-Azienda Ospedaliera Universitaria di Modena, Italy; Department of Neurology (L.D., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (J.A.E.), Hospital Clínico San Carlos, Madrid, Spain; Stroke Unit Azienda Ospedaliera Universitaria Senese (R.T.), Siena, Italy; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; IRCCS Istituto delle Scienze Neurologiche di Bologna (A.Z.), Department of Neurology and Stroke Center, Maggiore Hospital; Department of Biomedical (P.N.), Metabolical and Neurosciences, Università degli studi di Modena e Reggio Emilia, Italy; Department of Neurology (R.H.), Comprehensive Stroke Centre, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic; Neurocentre (L.J.), Regional Hospital Liberec, Czech Republic; Department of Neurology University Hospital Ostrava (E.H.), Czech Republic; Second Department of Neurology (G.T., A.P.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.P.), Cliniques Universitaires St-Luc, Brussels; Department of Neurology (M.N.), Nemocnice Ceske Budejovice, Czech Republic; Constantine the Philosopher University Nitra (M.B.), Faculty of Social Sciences and Health, Slovakia; Department of Neurology (R.C.), Ospedale San Giovanni Bosco, Turin, Italy; School of Medicine (K.R.L.), Dentistry and Nursing, University of Glasgow, UK; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Human Neurosciences (D.T.), La Sapienza, Rome, Italy; and Department of Neuroradiology (S.H.), Karolinska University Hospital, Solna, Sweden
| | - Jyrki P Ollikainen
- From the Department of Neurology (N.A., M.M., T.M.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A., M.M., T.M., S.H.), Karolinska Institutet, Solna, Sweden; Stroke Unit (A.P.N.), Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; Department of Neurology (J.P.O.), Tampere University Hospital, Tampere, Finland; Department of Neurology (I.E.-M.), University Hospital Virgen del Rocío, Sevilla and Biomedicine Institute of Sevilla, Spain; Department of Neurology (G.B.), Ospedale Civile "S.Agostino-Estense"-Azienda Ospedaliera Universitaria di Modena, Italy; Department of Neurology (L.D., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (J.A.E.), Hospital Clínico San Carlos, Madrid, Spain; Stroke Unit Azienda Ospedaliera Universitaria Senese (R.T.), Siena, Italy; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; IRCCS Istituto delle Scienze Neurologiche di Bologna (A.Z.), Department of Neurology and Stroke Center, Maggiore Hospital; Department of Biomedical (P.N.), Metabolical and Neurosciences, Università degli studi di Modena e Reggio Emilia, Italy; Department of Neurology (R.H.), Comprehensive Stroke Centre, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic; Neurocentre (L.J.), Regional Hospital Liberec, Czech Republic; Department of Neurology University Hospital Ostrava (E.H.), Czech Republic; Second Department of Neurology (G.T., A.P.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.P.), Cliniques Universitaires St-Luc, Brussels; Department of Neurology (M.N.), Nemocnice Ceske Budejovice, Czech Republic; Constantine the Philosopher University Nitra (M.B.), Faculty of Social Sciences and Health, Slovakia; Department of Neurology (R.C.), Ospedale San Giovanni Bosco, Turin, Italy; School of Medicine (K.R.L.), Dentistry and Nursing, University of Glasgow, UK; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Human Neurosciences (D.T.), La Sapienza, Rome, Italy; and Department of Neuroradiology (S.H.), Karolinska University Hospital, Solna, Sweden
| | - Irene Escudero-Martínez
- From the Department of Neurology (N.A., M.M., T.M.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A., M.M., T.M., S.H.), Karolinska Institutet, Solna, Sweden; Stroke Unit (A.P.N.), Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; Department of Neurology (J.P.O.), Tampere University Hospital, Tampere, Finland; Department of Neurology (I.E.-M.), University Hospital Virgen del Rocío, Sevilla and Biomedicine Institute of Sevilla, Spain; Department of Neurology (G.B.), Ospedale Civile "S.Agostino-Estense"-Azienda Ospedaliera Universitaria di Modena, Italy; Department of Neurology (L.D., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (J.A.E.), Hospital Clínico San Carlos, Madrid, Spain; Stroke Unit Azienda Ospedaliera Universitaria Senese (R.T.), Siena, Italy; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; IRCCS Istituto delle Scienze Neurologiche di Bologna (A.Z.), Department of Neurology and Stroke Center, Maggiore Hospital; Department of Biomedical (P.N.), Metabolical and Neurosciences, Università degli studi di Modena e Reggio Emilia, Italy; Department of Neurology (R.H.), Comprehensive Stroke Centre, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic; Neurocentre (L.J.), Regional Hospital Liberec, Czech Republic; Department of Neurology University Hospital Ostrava (E.H.), Czech Republic; Second Department of Neurology (G.T., A.P.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.P.), Cliniques Universitaires St-Luc, Brussels; Department of Neurology (M.N.), Nemocnice Ceske Budejovice, Czech Republic; Constantine the Philosopher University Nitra (M.B.), Faculty of Social Sciences and Health, Slovakia; Department of Neurology (R.C.), Ospedale San Giovanni Bosco, Turin, Italy; School of Medicine (K.R.L.), Dentistry and Nursing, University of Glasgow, UK; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Human Neurosciences (D.T.), La Sapienza, Rome, Italy; and Department of Neuroradiology (S.H.), Karolinska University Hospital, Solna, Sweden
| | - Guido Bigliardi
- From the Department of Neurology (N.A., M.M., T.M.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A., M.M., T.M., S.H.), Karolinska Institutet, Solna, Sweden; Stroke Unit (A.P.N.), Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; Department of Neurology (J.P.O.), Tampere University Hospital, Tampere, Finland; Department of Neurology (I.E.-M.), University Hospital Virgen del Rocío, Sevilla and Biomedicine Institute of Sevilla, Spain; Department of Neurology (G.B.), Ospedale Civile "S.Agostino-Estense"-Azienda Ospedaliera Universitaria di Modena, Italy; Department of Neurology (L.D., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (J.A.E.), Hospital Clínico San Carlos, Madrid, Spain; Stroke Unit Azienda Ospedaliera Universitaria Senese (R.T.), Siena, Italy; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; IRCCS Istituto delle Scienze Neurologiche di Bologna (A.Z.), Department of Neurology and Stroke Center, Maggiore Hospital; Department of Biomedical (P.N.), Metabolical and Neurosciences, Università degli studi di Modena e Reggio Emilia, Italy; Department of Neurology (R.H.), Comprehensive Stroke Centre, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic; Neurocentre (L.J.), Regional Hospital Liberec, Czech Republic; Department of Neurology University Hospital Ostrava (E.H.), Czech Republic; Second Department of Neurology (G.T., A.P.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.P.), Cliniques Universitaires St-Luc, Brussels; Department of Neurology (M.N.), Nemocnice Ceske Budejovice, Czech Republic; Constantine the Philosopher University Nitra (M.B.), Faculty of Social Sciences and Health, Slovakia; Department of Neurology (R.C.), Ospedale San Giovanni Bosco, Turin, Italy; School of Medicine (K.R.L.), Dentistry and Nursing, University of Glasgow, UK; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Human Neurosciences (D.T.), La Sapienza, Rome, Italy; and Department of Neuroradiology (S.H.), Karolinska University Hospital, Solna, Sweden
| | - Laura Dorado
- From the Department of Neurology (N.A., M.M., T.M.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A., M.M., T.M., S.H.), Karolinska Institutet, Solna, Sweden; Stroke Unit (A.P.N.), Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; Department of Neurology (J.P.O.), Tampere University Hospital, Tampere, Finland; Department of Neurology (I.E.-M.), University Hospital Virgen del Rocío, Sevilla and Biomedicine Institute of Sevilla, Spain; Department of Neurology (G.B.), Ospedale Civile "S.Agostino-Estense"-Azienda Ospedaliera Universitaria di Modena, Italy; Department of Neurology (L.D., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (J.A.E.), Hospital Clínico San Carlos, Madrid, Spain; Stroke Unit Azienda Ospedaliera Universitaria Senese (R.T.), Siena, Italy; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; IRCCS Istituto delle Scienze Neurologiche di Bologna (A.Z.), Department of Neurology and Stroke Center, Maggiore Hospital; Department of Biomedical (P.N.), Metabolical and Neurosciences, Università degli studi di Modena e Reggio Emilia, Italy; Department of Neurology (R.H.), Comprehensive Stroke Centre, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic; Neurocentre (L.J.), Regional Hospital Liberec, Czech Republic; Department of Neurology University Hospital Ostrava (E.H.), Czech Republic; Second Department of Neurology (G.T., A.P.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.P.), Cliniques Universitaires St-Luc, Brussels; Department of Neurology (M.N.), Nemocnice Ceske Budejovice, Czech Republic; Constantine the Philosopher University Nitra (M.B.), Faculty of Social Sciences and Health, Slovakia; Department of Neurology (R.C.), Ospedale San Giovanni Bosco, Turin, Italy; School of Medicine (K.R.L.), Dentistry and Nursing, University of Glasgow, UK; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Human Neurosciences (D.T.), La Sapienza, Rome, Italy; and Department of Neuroradiology (S.H.), Karolinska University Hospital, Solna, Sweden
| | - Antoni Dávalos
- From the Department of Neurology (N.A., M.M., T.M.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A., M.M., T.M., S.H.), Karolinska Institutet, Solna, Sweden; Stroke Unit (A.P.N.), Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; Department of Neurology (J.P.O.), Tampere University Hospital, Tampere, Finland; Department of Neurology (I.E.-M.), University Hospital Virgen del Rocío, Sevilla and Biomedicine Institute of Sevilla, Spain; Department of Neurology (G.B.), Ospedale Civile "S.Agostino-Estense"-Azienda Ospedaliera Universitaria di Modena, Italy; Department of Neurology (L.D., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (J.A.E.), Hospital Clínico San Carlos, Madrid, Spain; Stroke Unit Azienda Ospedaliera Universitaria Senese (R.T.), Siena, Italy; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; IRCCS Istituto delle Scienze Neurologiche di Bologna (A.Z.), Department of Neurology and Stroke Center, Maggiore Hospital; Department of Biomedical (P.N.), Metabolical and Neurosciences, Università degli studi di Modena e Reggio Emilia, Italy; Department of Neurology (R.H.), Comprehensive Stroke Centre, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic; Neurocentre (L.J.), Regional Hospital Liberec, Czech Republic; Department of Neurology University Hospital Ostrava (E.H.), Czech Republic; Second Department of Neurology (G.T., A.P.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.P.), Cliniques Universitaires St-Luc, Brussels; Department of Neurology (M.N.), Nemocnice Ceske Budejovice, Czech Republic; Constantine the Philosopher University Nitra (M.B.), Faculty of Social Sciences and Health, Slovakia; Department of Neurology (R.C.), Ospedale San Giovanni Bosco, Turin, Italy; School of Medicine (K.R.L.), Dentistry and Nursing, University of Glasgow, UK; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Human Neurosciences (D.T.), La Sapienza, Rome, Italy; and Department of Neuroradiology (S.H.), Karolinska University Hospital, Solna, Sweden
| | - Jose A Egido
- From the Department of Neurology (N.A., M.M., T.M.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A., M.M., T.M., S.H.), Karolinska Institutet, Solna, Sweden; Stroke Unit (A.P.N.), Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; Department of Neurology (J.P.O.), Tampere University Hospital, Tampere, Finland; Department of Neurology (I.E.-M.), University Hospital Virgen del Rocío, Sevilla and Biomedicine Institute of Sevilla, Spain; Department of Neurology (G.B.), Ospedale Civile "S.Agostino-Estense"-Azienda Ospedaliera Universitaria di Modena, Italy; Department of Neurology (L.D., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (J.A.E.), Hospital Clínico San Carlos, Madrid, Spain; Stroke Unit Azienda Ospedaliera Universitaria Senese (R.T.), Siena, Italy; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; IRCCS Istituto delle Scienze Neurologiche di Bologna (A.Z.), Department of Neurology and Stroke Center, Maggiore Hospital; Department of Biomedical (P.N.), Metabolical and Neurosciences, Università degli studi di Modena e Reggio Emilia, Italy; Department of Neurology (R.H.), Comprehensive Stroke Centre, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic; Neurocentre (L.J.), Regional Hospital Liberec, Czech Republic; Department of Neurology University Hospital Ostrava (E.H.), Czech Republic; Second Department of Neurology (G.T., A.P.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.P.), Cliniques Universitaires St-Luc, Brussels; Department of Neurology (M.N.), Nemocnice Ceske Budejovice, Czech Republic; Constantine the Philosopher University Nitra (M.B.), Faculty of Social Sciences and Health, Slovakia; Department of Neurology (R.C.), Ospedale San Giovanni Bosco, Turin, Italy; School of Medicine (K.R.L.), Dentistry and Nursing, University of Glasgow, UK; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Human Neurosciences (D.T.), La Sapienza, Rome, Italy; and Department of Neuroradiology (S.H.), Karolinska University Hospital, Solna, Sweden
| | - Rossana Tassi
- From the Department of Neurology (N.A., M.M., T.M.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A., M.M., T.M., S.H.), Karolinska Institutet, Solna, Sweden; Stroke Unit (A.P.N.), Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; Department of Neurology (J.P.O.), Tampere University Hospital, Tampere, Finland; Department of Neurology (I.E.-M.), University Hospital Virgen del Rocío, Sevilla and Biomedicine Institute of Sevilla, Spain; Department of Neurology (G.B.), Ospedale Civile "S.Agostino-Estense"-Azienda Ospedaliera Universitaria di Modena, Italy; Department of Neurology (L.D., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (J.A.E.), Hospital Clínico San Carlos, Madrid, Spain; Stroke Unit Azienda Ospedaliera Universitaria Senese (R.T.), Siena, Italy; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; IRCCS Istituto delle Scienze Neurologiche di Bologna (A.Z.), Department of Neurology and Stroke Center, Maggiore Hospital; Department of Biomedical (P.N.), Metabolical and Neurosciences, Università degli studi di Modena e Reggio Emilia, Italy; Department of Neurology (R.H.), Comprehensive Stroke Centre, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic; Neurocentre (L.J.), Regional Hospital Liberec, Czech Republic; Department of Neurology University Hospital Ostrava (E.H.), Czech Republic; Second Department of Neurology (G.T., A.P.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.P.), Cliniques Universitaires St-Luc, Brussels; Department of Neurology (M.N.), Nemocnice Ceske Budejovice, Czech Republic; Constantine the Philosopher University Nitra (M.B.), Faculty of Social Sciences and Health, Slovakia; Department of Neurology (R.C.), Ospedale San Giovanni Bosco, Turin, Italy; School of Medicine (K.R.L.), Dentistry and Nursing, University of Glasgow, UK; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Human Neurosciences (D.T.), La Sapienza, Rome, Italy; and Department of Neuroradiology (S.H.), Karolinska University Hospital, Solna, Sweden
| | - Daniel Strbian
- From the Department of Neurology (N.A., M.M., T.M.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A., M.M., T.M., S.H.), Karolinska Institutet, Solna, Sweden; Stroke Unit (A.P.N.), Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; Department of Neurology (J.P.O.), Tampere University Hospital, Tampere, Finland; Department of Neurology (I.E.-M.), University Hospital Virgen del Rocío, Sevilla and Biomedicine Institute of Sevilla, Spain; Department of Neurology (G.B.), Ospedale Civile "S.Agostino-Estense"-Azienda Ospedaliera Universitaria di Modena, Italy; Department of Neurology (L.D., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (J.A.E.), Hospital Clínico San Carlos, Madrid, Spain; Stroke Unit Azienda Ospedaliera Universitaria Senese (R.T.), Siena, Italy; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; IRCCS Istituto delle Scienze Neurologiche di Bologna (A.Z.), Department of Neurology and Stroke Center, Maggiore Hospital; Department of Biomedical (P.N.), Metabolical and Neurosciences, Università degli studi di Modena e Reggio Emilia, Italy; Department of Neurology (R.H.), Comprehensive Stroke Centre, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic; Neurocentre (L.J.), Regional Hospital Liberec, Czech Republic; Department of Neurology University Hospital Ostrava (E.H.), Czech Republic; Second Department of Neurology (G.T., A.P.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.P.), Cliniques Universitaires St-Luc, Brussels; Department of Neurology (M.N.), Nemocnice Ceske Budejovice, Czech Republic; Constantine the Philosopher University Nitra (M.B.), Faculty of Social Sciences and Health, Slovakia; Department of Neurology (R.C.), Ospedale San Giovanni Bosco, Turin, Italy; School of Medicine (K.R.L.), Dentistry and Nursing, University of Glasgow, UK; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Human Neurosciences (D.T.), La Sapienza, Rome, Italy; and Department of Neuroradiology (S.H.), Karolinska University Hospital, Solna, Sweden
| | - Andrea Zini
- From the Department of Neurology (N.A., M.M., T.M.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A., M.M., T.M., S.H.), Karolinska Institutet, Solna, Sweden; Stroke Unit (A.P.N.), Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; Department of Neurology (J.P.O.), Tampere University Hospital, Tampere, Finland; Department of Neurology (I.E.-M.), University Hospital Virgen del Rocío, Sevilla and Biomedicine Institute of Sevilla, Spain; Department of Neurology (G.B.), Ospedale Civile "S.Agostino-Estense"-Azienda Ospedaliera Universitaria di Modena, Italy; Department of Neurology (L.D., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (J.A.E.), Hospital Clínico San Carlos, Madrid, Spain; Stroke Unit Azienda Ospedaliera Universitaria Senese (R.T.), Siena, Italy; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; IRCCS Istituto delle Scienze Neurologiche di Bologna (A.Z.), Department of Neurology and Stroke Center, Maggiore Hospital; Department of Biomedical (P.N.), Metabolical and Neurosciences, Università degli studi di Modena e Reggio Emilia, Italy; Department of Neurology (R.H.), Comprehensive Stroke Centre, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic; Neurocentre (L.J.), Regional Hospital Liberec, Czech Republic; Department of Neurology University Hospital Ostrava (E.H.), Czech Republic; Second Department of Neurology (G.T., A.P.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.P.), Cliniques Universitaires St-Luc, Brussels; Department of Neurology (M.N.), Nemocnice Ceske Budejovice, Czech Republic; Constantine the Philosopher University Nitra (M.B.), Faculty of Social Sciences and Health, Slovakia; Department of Neurology (R.C.), Ospedale San Giovanni Bosco, Turin, Italy; School of Medicine (K.R.L.), Dentistry and Nursing, University of Glasgow, UK; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Human Neurosciences (D.T.), La Sapienza, Rome, Italy; and Department of Neuroradiology (S.H.), Karolinska University Hospital, Solna, Sweden
| | - Paolo Nichelli
- From the Department of Neurology (N.A., M.M., T.M.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A., M.M., T.M., S.H.), Karolinska Institutet, Solna, Sweden; Stroke Unit (A.P.N.), Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; Department of Neurology (J.P.O.), Tampere University Hospital, Tampere, Finland; Department of Neurology (I.E.-M.), University Hospital Virgen del Rocío, Sevilla and Biomedicine Institute of Sevilla, Spain; Department of Neurology (G.B.), Ospedale Civile "S.Agostino-Estense"-Azienda Ospedaliera Universitaria di Modena, Italy; Department of Neurology (L.D., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (J.A.E.), Hospital Clínico San Carlos, Madrid, Spain; Stroke Unit Azienda Ospedaliera Universitaria Senese (R.T.), Siena, Italy; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; IRCCS Istituto delle Scienze Neurologiche di Bologna (A.Z.), Department of Neurology and Stroke Center, Maggiore Hospital; Department of Biomedical (P.N.), Metabolical and Neurosciences, Università degli studi di Modena e Reggio Emilia, Italy; Department of Neurology (R.H.), Comprehensive Stroke Centre, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic; Neurocentre (L.J.), Regional Hospital Liberec, Czech Republic; Department of Neurology University Hospital Ostrava (E.H.), Czech Republic; Second Department of Neurology (G.T., A.P.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.P.), Cliniques Universitaires St-Luc, Brussels; Department of Neurology (M.N.), Nemocnice Ceske Budejovice, Czech Republic; Constantine the Philosopher University Nitra (M.B.), Faculty of Social Sciences and Health, Slovakia; Department of Neurology (R.C.), Ospedale San Giovanni Bosco, Turin, Italy; School of Medicine (K.R.L.), Dentistry and Nursing, University of Glasgow, UK; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Human Neurosciences (D.T.), La Sapienza, Rome, Italy; and Department of Neuroradiology (S.H.), Karolinska University Hospital, Solna, Sweden
| | - Roman Herzig
- From the Department of Neurology (N.A., M.M., T.M.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A., M.M., T.M., S.H.), Karolinska Institutet, Solna, Sweden; Stroke Unit (A.P.N.), Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; Department of Neurology (J.P.O.), Tampere University Hospital, Tampere, Finland; Department of Neurology (I.E.-M.), University Hospital Virgen del Rocío, Sevilla and Biomedicine Institute of Sevilla, Spain; Department of Neurology (G.B.), Ospedale Civile "S.Agostino-Estense"-Azienda Ospedaliera Universitaria di Modena, Italy; Department of Neurology (L.D., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (J.A.E.), Hospital Clínico San Carlos, Madrid, Spain; Stroke Unit Azienda Ospedaliera Universitaria Senese (R.T.), Siena, Italy; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; IRCCS Istituto delle Scienze Neurologiche di Bologna (A.Z.), Department of Neurology and Stroke Center, Maggiore Hospital; Department of Biomedical (P.N.), Metabolical and Neurosciences, Università degli studi di Modena e Reggio Emilia, Italy; Department of Neurology (R.H.), Comprehensive Stroke Centre, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic; Neurocentre (L.J.), Regional Hospital Liberec, Czech Republic; Department of Neurology University Hospital Ostrava (E.H.), Czech Republic; Second Department of Neurology (G.T., A.P.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.P.), Cliniques Universitaires St-Luc, Brussels; Department of Neurology (M.N.), Nemocnice Ceske Budejovice, Czech Republic; Constantine the Philosopher University Nitra (M.B.), Faculty of Social Sciences and Health, Slovakia; Department of Neurology (R.C.), Ospedale San Giovanni Bosco, Turin, Italy; School of Medicine (K.R.L.), Dentistry and Nursing, University of Glasgow, UK; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Human Neurosciences (D.T.), La Sapienza, Rome, Italy; and Department of Neuroradiology (S.H.), Karolinska University Hospital, Solna, Sweden
| | - Lubomír Jurák
- From the Department of Neurology (N.A., M.M., T.M.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A., M.M., T.M., S.H.), Karolinska Institutet, Solna, Sweden; Stroke Unit (A.P.N.), Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; Department of Neurology (J.P.O.), Tampere University Hospital, Tampere, Finland; Department of Neurology (I.E.-M.), University Hospital Virgen del Rocío, Sevilla and Biomedicine Institute of Sevilla, Spain; Department of Neurology (G.B.), Ospedale Civile "S.Agostino-Estense"-Azienda Ospedaliera Universitaria di Modena, Italy; Department of Neurology (L.D., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (J.A.E.), Hospital Clínico San Carlos, Madrid, Spain; Stroke Unit Azienda Ospedaliera Universitaria Senese (R.T.), Siena, Italy; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; IRCCS Istituto delle Scienze Neurologiche di Bologna (A.Z.), Department of Neurology and Stroke Center, Maggiore Hospital; Department of Biomedical (P.N.), Metabolical and Neurosciences, Università degli studi di Modena e Reggio Emilia, Italy; Department of Neurology (R.H.), Comprehensive Stroke Centre, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic; Neurocentre (L.J.), Regional Hospital Liberec, Czech Republic; Department of Neurology University Hospital Ostrava (E.H.), Czech Republic; Second Department of Neurology (G.T., A.P.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.P.), Cliniques Universitaires St-Luc, Brussels; Department of Neurology (M.N.), Nemocnice Ceske Budejovice, Czech Republic; Constantine the Philosopher University Nitra (M.B.), Faculty of Social Sciences and Health, Slovakia; Department of Neurology (R.C.), Ospedale San Giovanni Bosco, Turin, Italy; School of Medicine (K.R.L.), Dentistry and Nursing, University of Glasgow, UK; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Human Neurosciences (D.T.), La Sapienza, Rome, Italy; and Department of Neuroradiology (S.H.), Karolinska University Hospital, Solna, Sweden
| | - Eva Hurtikova
- From the Department of Neurology (N.A., M.M., T.M.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A., M.M., T.M., S.H.), Karolinska Institutet, Solna, Sweden; Stroke Unit (A.P.N.), Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; Department of Neurology (J.P.O.), Tampere University Hospital, Tampere, Finland; Department of Neurology (I.E.-M.), University Hospital Virgen del Rocío, Sevilla and Biomedicine Institute of Sevilla, Spain; Department of Neurology (G.B.), Ospedale Civile "S.Agostino-Estense"-Azienda Ospedaliera Universitaria di Modena, Italy; Department of Neurology (L.D., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (J.A.E.), Hospital Clínico San Carlos, Madrid, Spain; Stroke Unit Azienda Ospedaliera Universitaria Senese (R.T.), Siena, Italy; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; IRCCS Istituto delle Scienze Neurologiche di Bologna (A.Z.), Department of Neurology and Stroke Center, Maggiore Hospital; Department of Biomedical (P.N.), Metabolical and Neurosciences, Università degli studi di Modena e Reggio Emilia, Italy; Department of Neurology (R.H.), Comprehensive Stroke Centre, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic; Neurocentre (L.J.), Regional Hospital Liberec, Czech Republic; Department of Neurology University Hospital Ostrava (E.H.), Czech Republic; Second Department of Neurology (G.T., A.P.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.P.), Cliniques Universitaires St-Luc, Brussels; Department of Neurology (M.N.), Nemocnice Ceske Budejovice, Czech Republic; Constantine the Philosopher University Nitra (M.B.), Faculty of Social Sciences and Health, Slovakia; Department of Neurology (R.C.), Ospedale San Giovanni Bosco, Turin, Italy; School of Medicine (K.R.L.), Dentistry and Nursing, University of Glasgow, UK; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Human Neurosciences (D.T.), La Sapienza, Rome, Italy; and Department of Neuroradiology (S.H.), Karolinska University Hospital, Solna, Sweden
| | - Georgios Tsivgoulis
- From the Department of Neurology (N.A., M.M., T.M.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A., M.M., T.M., S.H.), Karolinska Institutet, Solna, Sweden; Stroke Unit (A.P.N.), Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; Department of Neurology (J.P.O.), Tampere University Hospital, Tampere, Finland; Department of Neurology (I.E.-M.), University Hospital Virgen del Rocío, Sevilla and Biomedicine Institute of Sevilla, Spain; Department of Neurology (G.B.), Ospedale Civile "S.Agostino-Estense"-Azienda Ospedaliera Universitaria di Modena, Italy; Department of Neurology (L.D., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (J.A.E.), Hospital Clínico San Carlos, Madrid, Spain; Stroke Unit Azienda Ospedaliera Universitaria Senese (R.T.), Siena, Italy; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; IRCCS Istituto delle Scienze Neurologiche di Bologna (A.Z.), Department of Neurology and Stroke Center, Maggiore Hospital; Department of Biomedical (P.N.), Metabolical and Neurosciences, Università degli studi di Modena e Reggio Emilia, Italy; Department of Neurology (R.H.), Comprehensive Stroke Centre, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic; Neurocentre (L.J.), Regional Hospital Liberec, Czech Republic; Department of Neurology University Hospital Ostrava (E.H.), Czech Republic; Second Department of Neurology (G.T., A.P.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.P.), Cliniques Universitaires St-Luc, Brussels; Department of Neurology (M.N.), Nemocnice Ceske Budejovice, Czech Republic; Constantine the Philosopher University Nitra (M.B.), Faculty of Social Sciences and Health, Slovakia; Department of Neurology (R.C.), Ospedale San Giovanni Bosco, Turin, Italy; School of Medicine (K.R.L.), Dentistry and Nursing, University of Glasgow, UK; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Human Neurosciences (D.T.), La Sapienza, Rome, Italy; and Department of Neuroradiology (S.H.), Karolinska University Hospital, Solna, Sweden
| | - Andre Peeters
- From the Department of Neurology (N.A., M.M., T.M.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A., M.M., T.M., S.H.), Karolinska Institutet, Solna, Sweden; Stroke Unit (A.P.N.), Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; Department of Neurology (J.P.O.), Tampere University Hospital, Tampere, Finland; Department of Neurology (I.E.-M.), University Hospital Virgen del Rocío, Sevilla and Biomedicine Institute of Sevilla, Spain; Department of Neurology (G.B.), Ospedale Civile "S.Agostino-Estense"-Azienda Ospedaliera Universitaria di Modena, Italy; Department of Neurology (L.D., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (J.A.E.), Hospital Clínico San Carlos, Madrid, Spain; Stroke Unit Azienda Ospedaliera Universitaria Senese (R.T.), Siena, Italy; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; IRCCS Istituto delle Scienze Neurologiche di Bologna (A.Z.), Department of Neurology and Stroke Center, Maggiore Hospital; Department of Biomedical (P.N.), Metabolical and Neurosciences, Università degli studi di Modena e Reggio Emilia, Italy; Department of Neurology (R.H.), Comprehensive Stroke Centre, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic; Neurocentre (L.J.), Regional Hospital Liberec, Czech Republic; Department of Neurology University Hospital Ostrava (E.H.), Czech Republic; Second Department of Neurology (G.T., A.P.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.P.), Cliniques Universitaires St-Luc, Brussels; Department of Neurology (M.N.), Nemocnice Ceske Budejovice, Czech Republic; Constantine the Philosopher University Nitra (M.B.), Faculty of Social Sciences and Health, Slovakia; Department of Neurology (R.C.), Ospedale San Giovanni Bosco, Turin, Italy; School of Medicine (K.R.L.), Dentistry and Nursing, University of Glasgow, UK; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Human Neurosciences (D.T.), La Sapienza, Rome, Italy; and Department of Neuroradiology (S.H.), Karolinska University Hospital, Solna, Sweden
| | - Miroslava Nevšímalová
- From the Department of Neurology (N.A., M.M., T.M.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A., M.M., T.M., S.H.), Karolinska Institutet, Solna, Sweden; Stroke Unit (A.P.N.), Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; Department of Neurology (J.P.O.), Tampere University Hospital, Tampere, Finland; Department of Neurology (I.E.-M.), University Hospital Virgen del Rocío, Sevilla and Biomedicine Institute of Sevilla, Spain; Department of Neurology (G.B.), Ospedale Civile "S.Agostino-Estense"-Azienda Ospedaliera Universitaria di Modena, Italy; Department of Neurology (L.D., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (J.A.E.), Hospital Clínico San Carlos, Madrid, Spain; Stroke Unit Azienda Ospedaliera Universitaria Senese (R.T.), Siena, Italy; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; IRCCS Istituto delle Scienze Neurologiche di Bologna (A.Z.), Department of Neurology and Stroke Center, Maggiore Hospital; Department of Biomedical (P.N.), Metabolical and Neurosciences, Università degli studi di Modena e Reggio Emilia, Italy; Department of Neurology (R.H.), Comprehensive Stroke Centre, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic; Neurocentre (L.J.), Regional Hospital Liberec, Czech Republic; Department of Neurology University Hospital Ostrava (E.H.), Czech Republic; Second Department of Neurology (G.T., A.P.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.P.), Cliniques Universitaires St-Luc, Brussels; Department of Neurology (M.N.), Nemocnice Ceske Budejovice, Czech Republic; Constantine the Philosopher University Nitra (M.B.), Faculty of Social Sciences and Health, Slovakia; Department of Neurology (R.C.), Ospedale San Giovanni Bosco, Turin, Italy; School of Medicine (K.R.L.), Dentistry and Nursing, University of Glasgow, UK; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Human Neurosciences (D.T.), La Sapienza, Rome, Italy; and Department of Neuroradiology (S.H.), Karolinska University Hospital, Solna, Sweden
| | - Miroslav Brozman
- From the Department of Neurology (N.A., M.M., T.M.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A., M.M., T.M., S.H.), Karolinska Institutet, Solna, Sweden; Stroke Unit (A.P.N.), Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; Department of Neurology (J.P.O.), Tampere University Hospital, Tampere, Finland; Department of Neurology (I.E.-M.), University Hospital Virgen del Rocío, Sevilla and Biomedicine Institute of Sevilla, Spain; Department of Neurology (G.B.), Ospedale Civile "S.Agostino-Estense"-Azienda Ospedaliera Universitaria di Modena, Italy; Department of Neurology (L.D., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (J.A.E.), Hospital Clínico San Carlos, Madrid, Spain; Stroke Unit Azienda Ospedaliera Universitaria Senese (R.T.), Siena, Italy; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; IRCCS Istituto delle Scienze Neurologiche di Bologna (A.Z.), Department of Neurology and Stroke Center, Maggiore Hospital; Department of Biomedical (P.N.), Metabolical and Neurosciences, Università degli studi di Modena e Reggio Emilia, Italy; Department of Neurology (R.H.), Comprehensive Stroke Centre, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic; Neurocentre (L.J.), Regional Hospital Liberec, Czech Republic; Department of Neurology University Hospital Ostrava (E.H.), Czech Republic; Second Department of Neurology (G.T., A.P.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.P.), Cliniques Universitaires St-Luc, Brussels; Department of Neurology (M.N.), Nemocnice Ceske Budejovice, Czech Republic; Constantine the Philosopher University Nitra (M.B.), Faculty of Social Sciences and Health, Slovakia; Department of Neurology (R.C.), Ospedale San Giovanni Bosco, Turin, Italy; School of Medicine (K.R.L.), Dentistry and Nursing, University of Glasgow, UK; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Human Neurosciences (D.T.), La Sapienza, Rome, Italy; and Department of Neuroradiology (S.H.), Karolinska University Hospital, Solna, Sweden
| | - Roberto Cavallo
- From the Department of Neurology (N.A., M.M., T.M.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A., M.M., T.M., S.H.), Karolinska Institutet, Solna, Sweden; Stroke Unit (A.P.N.), Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; Department of Neurology (J.P.O.), Tampere University Hospital, Tampere, Finland; Department of Neurology (I.E.-M.), University Hospital Virgen del Rocío, Sevilla and Biomedicine Institute of Sevilla, Spain; Department of Neurology (G.B.), Ospedale Civile "S.Agostino-Estense"-Azienda Ospedaliera Universitaria di Modena, Italy; Department of Neurology (L.D., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (J.A.E.), Hospital Clínico San Carlos, Madrid, Spain; Stroke Unit Azienda Ospedaliera Universitaria Senese (R.T.), Siena, Italy; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; IRCCS Istituto delle Scienze Neurologiche di Bologna (A.Z.), Department of Neurology and Stroke Center, Maggiore Hospital; Department of Biomedical (P.N.), Metabolical and Neurosciences, Università degli studi di Modena e Reggio Emilia, Italy; Department of Neurology (R.H.), Comprehensive Stroke Centre, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic; Neurocentre (L.J.), Regional Hospital Liberec, Czech Republic; Department of Neurology University Hospital Ostrava (E.H.), Czech Republic; Second Department of Neurology (G.T., A.P.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.P.), Cliniques Universitaires St-Luc, Brussels; Department of Neurology (M.N.), Nemocnice Ceske Budejovice, Czech Republic; Constantine the Philosopher University Nitra (M.B.), Faculty of Social Sciences and Health, Slovakia; Department of Neurology (R.C.), Ospedale San Giovanni Bosco, Turin, Italy; School of Medicine (K.R.L.), Dentistry and Nursing, University of Glasgow, UK; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Human Neurosciences (D.T.), La Sapienza, Rome, Italy; and Department of Neuroradiology (S.H.), Karolinska University Hospital, Solna, Sweden
| | - Kennedy R Lees
- From the Department of Neurology (N.A., M.M., T.M.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A., M.M., T.M., S.H.), Karolinska Institutet, Solna, Sweden; Stroke Unit (A.P.N.), Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; Department of Neurology (J.P.O.), Tampere University Hospital, Tampere, Finland; Department of Neurology (I.E.-M.), University Hospital Virgen del Rocío, Sevilla and Biomedicine Institute of Sevilla, Spain; Department of Neurology (G.B.), Ospedale Civile "S.Agostino-Estense"-Azienda Ospedaliera Universitaria di Modena, Italy; Department of Neurology (L.D., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (J.A.E.), Hospital Clínico San Carlos, Madrid, Spain; Stroke Unit Azienda Ospedaliera Universitaria Senese (R.T.), Siena, Italy; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; IRCCS Istituto delle Scienze Neurologiche di Bologna (A.Z.), Department of Neurology and Stroke Center, Maggiore Hospital; Department of Biomedical (P.N.), Metabolical and Neurosciences, Università degli studi di Modena e Reggio Emilia, Italy; Department of Neurology (R.H.), Comprehensive Stroke Centre, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic; Neurocentre (L.J.), Regional Hospital Liberec, Czech Republic; Department of Neurology University Hospital Ostrava (E.H.), Czech Republic; Second Department of Neurology (G.T., A.P.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.P.), Cliniques Universitaires St-Luc, Brussels; Department of Neurology (M.N.), Nemocnice Ceske Budejovice, Czech Republic; Constantine the Philosopher University Nitra (M.B.), Faculty of Social Sciences and Health, Slovakia; Department of Neurology (R.C.), Ospedale San Giovanni Bosco, Turin, Italy; School of Medicine (K.R.L.), Dentistry and Nursing, University of Glasgow, UK; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Human Neurosciences (D.T.), La Sapienza, Rome, Italy; and Department of Neuroradiology (S.H.), Karolinska University Hospital, Solna, Sweden
| | - Robert Mikulík
- From the Department of Neurology (N.A., M.M., T.M.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A., M.M., T.M., S.H.), Karolinska Institutet, Solna, Sweden; Stroke Unit (A.P.N.), Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; Department of Neurology (J.P.O.), Tampere University Hospital, Tampere, Finland; Department of Neurology (I.E.-M.), University Hospital Virgen del Rocío, Sevilla and Biomedicine Institute of Sevilla, Spain; Department of Neurology (G.B.), Ospedale Civile "S.Agostino-Estense"-Azienda Ospedaliera Universitaria di Modena, Italy; Department of Neurology (L.D., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (J.A.E.), Hospital Clínico San Carlos, Madrid, Spain; Stroke Unit Azienda Ospedaliera Universitaria Senese (R.T.), Siena, Italy; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; IRCCS Istituto delle Scienze Neurologiche di Bologna (A.Z.), Department of Neurology and Stroke Center, Maggiore Hospital; Department of Biomedical (P.N.), Metabolical and Neurosciences, Università degli studi di Modena e Reggio Emilia, Italy; Department of Neurology (R.H.), Comprehensive Stroke Centre, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic; Neurocentre (L.J.), Regional Hospital Liberec, Czech Republic; Department of Neurology University Hospital Ostrava (E.H.), Czech Republic; Second Department of Neurology (G.T., A.P.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.P.), Cliniques Universitaires St-Luc, Brussels; Department of Neurology (M.N.), Nemocnice Ceske Budejovice, Czech Republic; Constantine the Philosopher University Nitra (M.B.), Faculty of Social Sciences and Health, Slovakia; Department of Neurology (R.C.), Ospedale San Giovanni Bosco, Turin, Italy; School of Medicine (K.R.L.), Dentistry and Nursing, University of Glasgow, UK; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Human Neurosciences (D.T.), La Sapienza, Rome, Italy; and Department of Neuroradiology (S.H.), Karolinska University Hospital, Solna, Sweden
| | - Danilo Toni
- From the Department of Neurology (N.A., M.M., T.M.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A., M.M., T.M., S.H.), Karolinska Institutet, Solna, Sweden; Stroke Unit (A.P.N.), Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; Department of Neurology (J.P.O.), Tampere University Hospital, Tampere, Finland; Department of Neurology (I.E.-M.), University Hospital Virgen del Rocío, Sevilla and Biomedicine Institute of Sevilla, Spain; Department of Neurology (G.B.), Ospedale Civile "S.Agostino-Estense"-Azienda Ospedaliera Universitaria di Modena, Italy; Department of Neurology (L.D., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (J.A.E.), Hospital Clínico San Carlos, Madrid, Spain; Stroke Unit Azienda Ospedaliera Universitaria Senese (R.T.), Siena, Italy; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; IRCCS Istituto delle Scienze Neurologiche di Bologna (A.Z.), Department of Neurology and Stroke Center, Maggiore Hospital; Department of Biomedical (P.N.), Metabolical and Neurosciences, Università degli studi di Modena e Reggio Emilia, Italy; Department of Neurology (R.H.), Comprehensive Stroke Centre, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic; Neurocentre (L.J.), Regional Hospital Liberec, Czech Republic; Department of Neurology University Hospital Ostrava (E.H.), Czech Republic; Second Department of Neurology (G.T., A.P.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.P.), Cliniques Universitaires St-Luc, Brussels; Department of Neurology (M.N.), Nemocnice Ceske Budejovice, Czech Republic; Constantine the Philosopher University Nitra (M.B.), Faculty of Social Sciences and Health, Slovakia; Department of Neurology (R.C.), Ospedale San Giovanni Bosco, Turin, Italy; School of Medicine (K.R.L.), Dentistry and Nursing, University of Glasgow, UK; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Human Neurosciences (D.T.), La Sapienza, Rome, Italy; and Department of Neuroradiology (S.H.), Karolinska University Hospital, Solna, Sweden
| | - Staffan Holmin
- From the Department of Neurology (N.A., M.M., T.M.), Karolinska University Hospital; Department of Clinical Neuroscience (N.A., M.M., T.M., S.H.), Karolinska Institutet, Solna, Sweden; Stroke Unit (A.P.N.), Hospital de São José, Centro Hospitalar Universitário de Lisboa Central, Lisboa, Portugal; Department of Neurology (J.P.O.), Tampere University Hospital, Tampere, Finland; Department of Neurology (I.E.-M.), University Hospital Virgen del Rocío, Sevilla and Biomedicine Institute of Sevilla, Spain; Department of Neurology (G.B.), Ospedale Civile "S.Agostino-Estense"-Azienda Ospedaliera Universitaria di Modena, Italy; Department of Neurology (L.D., A.D.), Hospital Universitari Germans Trias i Pujol, Badalona; Department of Neurology (J.A.E.), Hospital Clínico San Carlos, Madrid, Spain; Stroke Unit Azienda Ospedaliera Universitaria Senese (R.T.), Siena, Italy; Department of Neurology (D.S.), Helsinki University Central Hospital, Finland; IRCCS Istituto delle Scienze Neurologiche di Bologna (A.Z.), Department of Neurology and Stroke Center, Maggiore Hospital; Department of Biomedical (P.N.), Metabolical and Neurosciences, Università degli studi di Modena e Reggio Emilia, Italy; Department of Neurology (R.H.), Comprehensive Stroke Centre, Charles University, Faculty of Medicine in Hradec Králové and University Hospital Hradec Králové, Czech Republic; Neurocentre (L.J.), Regional Hospital Liberec, Czech Republic; Department of Neurology University Hospital Ostrava (E.H.), Czech Republic; Second Department of Neurology (G.T., A.P.), National and Kapodistrian University of Athens, Greece; Department of Neurology (G.T., A.P.), Cliniques Universitaires St-Luc, Brussels; Department of Neurology (M.N.), Nemocnice Ceske Budejovice, Czech Republic; Constantine the Philosopher University Nitra (M.B.), Faculty of Social Sciences and Health, Slovakia; Department of Neurology (R.C.), Ospedale San Giovanni Bosco, Turin, Italy; School of Medicine (K.R.L.), Dentistry and Nursing, University of Glasgow, UK; International Clinical Research Center and Department of Neurology (R.M.), St. Anne's University Hospital and Masaryk University, Brno, Czech Republic; Department of Human Neurosciences (D.T.), La Sapienza, Rome, Italy; and Department of Neuroradiology (S.H.), Karolinska University Hospital, Solna, Sweden
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310
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Podlasek A, Dhillon PS, Butt W, Grunwald IQ, England TJ. Direct mechanical thrombectomy without intravenous thrombolysis versus bridging therapy for acute ischemic stroke: A meta-analysis of randomized controlled trials. Int J Stroke 2021; 16:621-631. [PMID: 34003709 DOI: 10.1177/17474930211021353] [Citation(s) in RCA: 30] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Direct mechanical thrombectomy may result in similar outcomes compared to a bridging approach with intravenous thrombolysis (IVT + MT) in acute ischemic stroke. Recent randomized controlled trials have varied in their design and noninferiority margin. AIM We sought to meta-analyze accumulated trial data to assess the difference and non-inferiority in clinical and procedural outcomes between direct mechanical thrombectomy and bridging therapy. SUMMARY OF REVIEW We conducted a systematic review of electronic databases following the preferred reporting items for systematic reviews and meta-analyses guidelines. Random effects meta-analyses were conducted for the pooled data. The primary outcome was good functional outcome at 90 days (modified Rankin scale (mRS) ≤ 2). Secondary outcomes included excellent functional outcome (mRS ≤ 1), mortality, any intracranial hemorrhage, symptomatic intracranial hemorrhage, successful reperfusion (thrombolysis in cerebral infarction ≥ 2 b), and procedure-related complications. Four randomized controlled trials comprising 1633 patients (817 direct mechanical thrombectomy, 816 bridging therapy) were included. There were no statistical differences for the 90-day good functional outcome (OR = 1.02, 95% CI 0.84-1.25, p = 0.54, I2 = 0%), and the absolute risk difference was 1% (95% CI: -4% to 5%). The lower 95% CI falls within the strictest noninferiority margin of -10% among included randomized control trials. Direct mechanical thrombectomy reduced the odds of successful reperfusion (OR = 0.76, 95% CI: 0.60-0.97, p = 0.03, I2 = 0%) and any intracranial hemorrhage (OR = 0.65, 95% CI: 0.49-0.86, p = 0.003, I2 = 38%). There was no difference in the remaining secondary outcomes. The risk of bias for all studies was low. CONCLUSION The combined trial data assessing direct mechanical thrombectomy versus bridging therapy showed no difference in improving good functional outcome. The wide noninferiority thresholds set by individual trials are in contrast with the clinical consensus on minimally important differences. However, our pooled analysis indicates noninferiority of direct mechanical thrombectomy with a 4% margin of confidence. The application of these findings is limited to patients presenting directly to mechanical thrombectomy-capable centers and real-world workflow times may differ against those achieved in a trial setting.
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Affiliation(s)
- Anna Podlasek
- NIHR Nottingham Biomedical Research Center, University of Nottingham, Nottingham, UK.,Neuroscience and Vascular Simulation, 2369Anglia Ruskin University, Cambridge, UK
| | - Permesh Singh Dhillon
- NIHR Nottingham Biomedical Research Center, University of Nottingham, Nottingham, UK.,Interventional Neuroradiology, 9820Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Waleed Butt
- Interventional Neuroradiology, 9820Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Iris Q Grunwald
- Neuroscience and Vascular Simulation, 2369Anglia Ruskin University, Cambridge, UK.,Division of Imaging Science and Technology, School of Medicine, University of Dundee, Dundee, UK
| | - Timothy J England
- Stroke, Division of Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, UK.,Stroke, 2102University Hospitals of Derby and Burton NHS Foundation Trust, Derby, United Kingdom
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311
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Magoufis G, Safouris A, Raphaeli G, Kargiotis O, Psychogios K, Krogias C, Palaiodimou L, Spiliopoulos S, Polizogopoulou E, Mantatzis M, Finitsis S, Karapanayiotides T, Ellul J, Bakola E, Brountzos E, Mitsias P, Giannopoulos S, Tsivgoulis G. Acute reperfusion therapies for acute ischemic stroke patients with unknown time of symptom onset or in extended time windows: an individualized approach. Ther Adv Neurol Disord 2021; 14:17562864211021182. [PMID: 34122624 PMCID: PMC8175833 DOI: 10.1177/17562864211021182] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 05/10/2021] [Indexed: 02/05/2023] Open
Abstract
Recent randomized controlled clinical trials (RCTs) have revolutionized acute ischemic stroke care by extending the use of intravenous thrombolysis and endovascular reperfusion therapies in time windows that have been originally considered futile or even unsafe. Both systemic and endovascular reperfusion therapies have been shown to improve outcome in patients with wake-up strokes or symptom onset beyond 4.5 h for intravenous thrombolysis and beyond 6 h for endovascular treatment; however, they require advanced neuroimaging to select stroke patients safely. Experts have proposed simpler imaging algorithms but high-quality data on safety and efficacy are currently missing. RCTs used diverse imaging and clinical inclusion criteria for patient selection during the dawn of this novel stroke treatment paradigm. After taking into consideration the dismal prognosis of nonrecanalized ischemic stroke patients and the substantial clinical benefit of reperfusion therapies in selected late presenters, we propose rescue reperfusion therapies for acute ischemic stroke patients not fulfilling all clinical and imaging inclusion criteria as an option in a subgroup of patients with clinical and radiological profiles suggesting low risk for complications, notably hemorrhagic transformation as well as local or remote parenchymal hemorrhage. Incorporating new data to treatment algorithms may seem perplexing to stroke physicians, since treatment and imaging capabilities of each stroke center may dictate diverse treatment pathways. This narrative review will summarize current data that will assist clinicians in the selection of those late presenters that will most likely benefit from acute reperfusion therapies. Different treatment algorithms are provided according to available neuroimaging and endovascular treatment capabilities.
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Affiliation(s)
- Georgios Magoufis
- Interventional Neuroradiology Unit, Metropolitan Hospital, Piraeus, Greece
| | - Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
- Interventional Neuroradiology Unit, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Guy Raphaeli
- Interventional Neuroradiology Unit, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
| | | | - Klearchos Psychogios
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Lina Palaiodimou
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional Radiology Unit, “ATTIKON” University General Hospital, Athens, Greece
| | - Eftihia Polizogopoulou
- Emergency Medicine Clinic, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Michael Mantatzis
- Department of Radiology, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Stephanos Finitsis
- Department of Interventional Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodore Karapanayiotides
- Second Department of Neurology, Aristotle University of Thessaloniki, School of Medicine, Faculty of Health Sciences, AHEPA University Hospital, Thessaloniki, Greece
| | - John Ellul
- Department of Neurology, University Hospital of Patras, School of Medicine, University of Patras, Patras, Greece
| | - Eleni Bakola
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Elias Brountzos
- Second Department of Radiology, Interventional Radiology Unit, “ATTIKON” University General Hospital, Athens, Greece
| | - Panayiotis Mitsias
- Department of Neurology Medical School, University of Crete, Heraklion, Crete, Greece
| | - Sotirios Giannopoulos
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian, University of Athens, School of Medicine, “Attikon” University Hospital, Iras 39, Gerakas Attikis, Athens, 15344, Greece
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA
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312
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Yeo LLL, Chen VHE, Leow AST, Meyer L, Fiehler J, Tu TM, Tham CH, Sia CH, Jamous A, Behme D, Kastrup A, Papanagiotou P, Styczen H, Forsting M, Lee TH, Chu CL, Fischer S, Maus V, Abdullayev N, Kabbasch C, Mönch S, Maegerlein C, Arnberg F, Andersson T, Holmin S, Teoh HL, Paliwal P, Ahmad A, Gopinathan A, Yang C, Seet RCS, Chan BPL, Sharma VK, Tan BYQ. Outcomes in young adults with acute ischemic stroke undergoing endovascular thrombectomy: A real-world multicenter experience. Eur J Neurol 2021; 28:2736-2744. [PMID: 33960072 DOI: 10.1111/ene.14899] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/22/2021] [Accepted: 04/24/2021] [Indexed: 11/29/2022]
Abstract
Endovascular thrombectomy (EVT) is the standard of care for anterior circulation acute ischemic stroke (AIS) with large vessel occlusion (LVO). Young patients with AIS-LVO have distinctly different underlying stroke mechanisms and etiologies. Much is unknown about the safety and efficacy of EVT in this population of young AIS-LVO patients. All consecutive AIS-LVO patients aged 50 years and below were included in this multicenter cohort study. The primary outcome measured was functional recovery at 90 days, with modified Rankin Scale of 0-2 deemed as good functional outcome. A total of 275 AIS-LVO patients that underwent EVT from 10 tertiary centers in Germany, Sweden, Singapore, and Taiwan were included. Successful reperfusion was achieved in 85.1% (234/275). Good functional outcomes were achieved in 66.0% (182/275). Arterial dissection was the most prevalent stroke etiology (42/195, 21.5%). National Institutes of Health Stroke Scale (NIHSS) score at presentation was inversely related to good functional outcomes (aOR: 0.92, 95% CI: 0.88-0.96 per point increase, p < 0.001). Successful reperfusion (aOR: 3.22, 95% CI: 1.44-7.21, p = 0.005), higher ASPECTS (aOR: 1.21, 95% CI: 1.01-1.44, p = 0.036), and bridging intravenous thrombolysis (aOR: 2.37, 95% CI: 1.29-4.34, p = 0.005) independently predicted good functional outcomes. Successful reperfusion was inversely associated with in-hospital mortality (aOR: 0.14, 95% CI: 0.03-0.57, p = 0.006). History of hypertension strongly predicted in-hospital mortality (aOR: 4.59, 95% CI: 1.10-19.13, p = 0.036). While differences in functional outcomes exist across varying stroke aetiologies, high rates of successful reperfusion and good outcomes are generally achieved in young AIS-LVO patients undergoing EVT.
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Affiliation(s)
- Leonard Leong-Litt Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Vanessa Hui En Chen
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
| | - Aloysius Sheng-Ting Leow
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tian-Ming Tu
- Department of Neurology, National Neuroscience Institute, Singapore City, Singapore
| | - Carol Huilian Tham
- Department of Neurology, National Neuroscience Institute, Singapore City, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Center, Singapore City, Singapore
| | - Ala Jamous
- Institute of Neuroradiology, University Medical Center Goettingen, Goettingen, Germany
| | - Daniel Behme
- Institute of Neuroradiology, University Medical Center Goettingen, Goettingen, Germany
| | - Andreas Kastrup
- Department of Neurology, Klinikum Bremen-Mitte, Bremen, Germany
| | - Panagiotis Papanagiotou
- Department of Neuroradiology, Hospital Bremen-Mitte, Bremen, Germany.,Areteion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Hanna Styczen
- Institute of Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Michael Forsting
- Institute of Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Tsong-Hai Lee
- Stroke Section, Department of Neurology, College of Medicine, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Chan-Lin Chu
- Stroke Section, Department of Neurology, College of Medicine, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Sebastian Fischer
- Department of Radiology, Neuroradiology and Nuclear Medicine, University Medical Center Bochum-Langendreer, Bochum, Germany
| | - Volker Maus
- Department of Radiology, Neuroradiology and Nuclear Medicine, University Medical Center Bochum-Langendreer, Bochum, Germany
| | - Nuran Abdullayev
- Institute of Radiology and Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Christoph Kabbasch
- Institute of Radiology and Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Sebastian Mönch
- Department of Diagnostic and Interventional Neuroradiology, Technical University Munich, Munich, Germany
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Technical University Munich, Munich, Germany
| | - Fabian Arnberg
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Tommy Andersson
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
| | - Staffan Holmin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Hock-Luen Teoh
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
| | - Prakash Paliwal
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
| | - Aftab Ahmad
- Division of Neurology, Ng Teng Fong Hospital, Singapore City, Singapore
| | - Anil Gopinathan
- Division of Interventional Radiology, Department of Diagnostic Imaging, National University Health System, Singapore City, Singapore
| | - Cunli Yang
- Division of Interventional Radiology, Department of Diagnostic Imaging, National University Health System, Singapore City, Singapore
| | - Raymond Chee-Seong Seet
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
| | - Bernard Poon-Lap Chan
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore
| | - Vijay K Sharma
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
| | - Benjamin Yong-Qiang Tan
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
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313
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Kimura K, Otsuka T, Suzuki K. Functional Outcomes Among Patients With Acute Ischemic Stroke After Mechanical Thrombectomy With or Without Intravenous Thrombolysis-Reply. JAMA 2021; 325:2020. [PMID: 34003227 DOI: 10.1001/jama.2021.4037] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Toshiaki Otsuka
- Department of Hygiene and Public Health, Nippon Medical School, Tokyo, Japan
| | - Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan
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314
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Mai H, Chen T, Zhao B. Functional Outcomes Among Patients With Acute Ischemic Stroke After Mechanical Thrombectomy With or Without Intravenous Thrombolysis. JAMA 2021; 325:2019-2020. [PMID: 34003229 DOI: 10.1001/jama.2021.4034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Affiliation(s)
- Hui Mai
- Department of Neurology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Tao Chen
- Department of Clinical Sciences, Liverpool School of Tropical Medicine, Liverpool, England
| | - Bin Zhao
- Department of Neurology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
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315
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Incorrect P Value and Figure Label Error. JAMA 2021; 325:1795. [PMID: 33944890 PMCID: PMC8097491 DOI: 10.1001/jama.2021.5454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
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316
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Michel P, Diepers M, Mordasini P, Schubert T, Bervini D, Rouvé JD, Gasche Y, Schwegler G, Bonvin C, Nedeltchev K, Carrera E, Kägi G, Cereda C, Nyffeler T, Wetzel S, Wegener S, Gensicke H, Engelter S, Arnold M. Acute revascularization in ischemic stroke: Updated Swiss guidelines. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2021. [DOI: 10.1177/2514183x21999228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
In acute ischemic stroke, intravenous thrombolysis (IVT) and acute endovascular therapy (EVT) have been shown to reduce long-term disability in randomized trials. International guidelines are partially not up to date and may not address situations for which there is limited scientific evidence. The goals of the present guidelines are to summarize the current scientific data for acute revascularization treatments to make sure that all Swiss Centers apply a similar, evidence, or consensus-based treatment standard. A multidisciplinary working group of the Swiss Stroke Society (SSS) searched and reviewed the literature on new randomized controlled trials (RCTs), large case series, meta-analyses, and other guidelines since the previous recommendations in 2009 to elaborate the consensus guidelines. The new RCTs have confirmed the effectiveness of IVT in various populations up to 4.5 h and proven the benefit of acute EVT up to approximately 8 h. For patients with unknown onset (including wake-up stroke), IVT and EVT can be effective up to 24 h after last proof of good health if patients are selected with advanced neuroimaging. Multiple case series and meta-analyses allow narrowing down the indications and relative and absolute contraindications to optimize the benefit–risk ratio of acute revascularization.
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Affiliation(s)
- Patrik Michel
- Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Michael Diepers
- Neuroradiology Division, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Pasquale Mordasini
- Institute for Diagnostic and Interventional Neuroradiology, Inselspital Bern and University of Bern, Berne, Switzerland
| | - Tilman Schubert
- Diagnostic and Interventional Neuroradiology, Department of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - David Bervini
- Department of Neurosurgery, Inselspital Bern and University of Bern, Berne, Switzerland
| | - Jean-Daniel Rouvé
- Anesthesiology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Yvan Gasche
- Department of Anesthesiology, Pharmacology, Intensive Care & Emergency Medicine, University of Geneva, Geneva, Switzerland
| | - Guido Schwegler
- Division of Neurology, Hospital Limmattal, Schlieren, Switzerland
| | - Christophe Bonvin
- Division of Neurology and Stroke Unit, Hôpital du Valais, Sion, Switzerland
| | | | - Emmanuel Carrera
- Neurology Service, University Hospitals of Geneva, Geneva, Switzerland
| | - Georg Kägi
- Department of Neurology, Cantonal Hospital, St. Gallen, Switzerland
| | - Carlo Cereda
- Department of Neurology, Neurocentro della Svizzera Italiana, Lugano Civic Hospital, Lugano, Switzerland
| | - Thomas Nyffeler
- Neurozentrum, Cantonal Hospital Lucerne, Lucerne, Switzerland
| | | | - Susanne Wegener
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Henrik Gensicke
- Department of Neurology and Stroke Centre, University Hospital Basel, Basel, Switzerland
| | - Stefan Engelter
- Department of Neurology and Stroke Centre, University Hospital Basel, Basel, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital Bern and University of Bern, Bern, Switzerland
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317
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Chen ZJ, Li XF, Liang CY, Cui L, Yang LQ, Xia YM, Cao W, Gao BL. Comparison of Prior Bridging Intravenous Thrombolysis With Direct Endovascular Thrombectomy for Anterior Circulation Large Vessel Occlusion: Systematic Review and Meta-Analysis. Front Neurol 2021; 12:602370. [PMID: 33995238 PMCID: PMC8120007 DOI: 10.3389/fneur.2021.602370] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 03/15/2021] [Indexed: 12/23/2022] Open
Abstract
Background: Whether bridging treatment combining intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT) is superior to direct EVT alone for emergent large vessel occlusion (LVO) in the anterior circulation is unknown. A systematic review and a meta-analysis were performed to investigate and assess the effect and safety of bridging treatment vs. direct EVT in patients with LVO in the anterior circulation. Methods: PubMed, EMBASE, and the Cochrane library were searched to assess the effect and safety of bridging treatment and direct EVT in LVO. Functional independence, mortality, asymptomatic and symptomatic intracranial hemorrhage (aICH and sICH, respectively), and successful recanalization were evaluated. The risk ratio and the 95% CI were analyzed. Results: Among the eight studies included, there was no significant difference in the long-term functional independence (OR = 1.008, 95% CI = 0.845–1.204, P = 0.926), mortality (OR = 1.060, 95% CI = 0.840–1.336, P = 0.624), recanalization rate (OR = 1.015, 95% CI = 0.793–1.300, P = 0.905), and the incidence of sICH (OR = 1.320, 95% CI = 0.931–1.870, P = 0.119) between bridging therapy and direct EVT. After adjusting for confounding factors, bridging therapy showed a lower recanalization rate (effect size or ES = −0.377, 95% CI = −0.684 to −0.070, P = 0.016), but there was no significant difference in the long-term functional independence (ES = 0.057, 95% CI = −0.177 to 0.291, P = 0.634), mortality (ES = 0.693, 95% CI = −0.133 to 1.519, P = 0.100), and incidence of sICH (ES = −0.051, 95% CI = −0.687 to 0.585, P = 0.875) compared with direct EVT. Meanwhile, in the subgroup analysis of RCT, no significant difference was found in the long-term functional independence (OR = 0.927, 95% CI = 0.727–1.182, P = 0.539), recanalization rate (OR = 1.331, 95% CI = 0.948–1.867, P = 0.099), mortality (OR = 1.072, 95% CI = 0.776–1.481, P = 0.673), and sICH incidence (OR = 1.383, 95% CI = 0.806–2.374, P = 0.977) between patients receiving bridging therapy and those receiving direct DVT. Conclusion: For stroke patients with acute anterior circulation occlusion and who are eligible for intravenous thrombolysis, there is no significant difference in the clinical effect between direct EVT and bridging therapy, which needs to be verified by more randomized controlled trials.
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Affiliation(s)
- Zhao-Ji Chen
- The Third ward of Neurology Department, Affiliated Hospital of Hebei University, Baoding, China
| | - Xiao-Fang Li
- The Third ward of Neurology Department, Affiliated Hospital of Hebei University, Baoding, China
| | - Cheng-Yu Liang
- The Third ward of Neurology Department, Affiliated Hospital of Hebei University, Baoding, China
| | - Lei Cui
- The Third ward of Neurology Department, Affiliated Hospital of Hebei University, Baoding, China
| | - Li-Qing Yang
- The Third ward of Neurology Department, Affiliated Hospital of Hebei University, Baoding, China
| | - Yan-Min Xia
- The Third ward of Neurology Department, Affiliated Hospital of Hebei University, Baoding, China
| | - Wei Cao
- The Third ward of Neurology Department, Affiliated Hospital of Hebei University, Baoding, China
| | - Bu-Lang Gao
- The Third ward of Neurology Department, Affiliated Hospital of Hebei University, Baoding, China
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318
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Anadani M, Marnat G, Consoli A, Papanagiotou P, Nogueira RG, Spiotta AM, Bourcier R, Kyheng M, Labreuche J, Siddiqui AH, Ribo M, de Havenon A, Fischer U, Sibon I, Dargazanli C, Arquizan C, Cognard C, Olivot JM, Anxionnat R, Audibert G, Mazighi M, Blanc R, Lapergue B, Richard S, Gory B. Endovascular therapy with or without intravenous thrombolysis in acute stroke with tandem occlusion. J Neurointerv Surg 2021; 14:314-320. [PMID: 33911016 DOI: 10.1136/neurintsurg-2020-017202] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 04/12/2021] [Accepted: 04/14/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND Endovascular therapy (EVT) is effective and safe in patients with tandem occlusion. The benefit of intravenous thrombolysis (IVT) prior to EVT in acute tandem occlusion is debatable. OBJECTIVE To compare EVT alone with EVT plus IVT in patients with acute ischemic stroke due to anterior circulation tandem occlusions. METHODS This is an individual patient pooled analysis of the Thrombectomy In TANdem lesions (TITAN) and Endovascular Treatment in Ischemic Stroke (ETIS) Registries. Patients were divided into two groups based on prior IVT treatment: (1) IVT+ group, which included patients who received IVT prior to EVT, (2) IVT- group, which included patients who did not receive IVT prior to EVT. Propensity score (inverse probability of treatment weighting (IPTW)) was used to reduce baseline between-group differences. The primary outcome was favorable outcome-that is, modified Rankin Scale (mRS) score 0 to 2 at 90 days. RESULTS Overall, 602 consecutive patients with an acute stroke with tandem occlusion were included (380 and 222 in the bridging therapy and EVT alone groups, respectively). Onset to imaging time was shorter in the IVT+ group (median 103 vs 140 min). In contrast, imaging to puncture time was longer in the IVT+ group (median 107 vs 91 min). In IPTW analysis, the IVT+ group had higher odds of favorable outcome, excellent outcome (90-day mRS score 0-1), and successful reperfusion (modified Thrombolysis in Cerebral Infarction score 2b/3 at the end of EVT). There was no difference in the risk of significant hemorrhagic complications between groups. In secondary analysis of patients treated with acute cervical internal carotid artery stenting, bridging therapy was associated with higher odds of favorable outcome and lower odds of mortality at 90 days. CONCLUSIONS Our results suggest that bridging therapy in patients with acute ischemic stroke due to anterior tandem occlusion is safe and may improve functional outcome, even in the setting of acute cervical internal carotid artery stenting during EVT.
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Affiliation(s)
- Mohammad Anadani
- Washington University School of Medicine in Saint Louis, Saint Louis, Missouri, USA.,Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Gaultier Marnat
- Department of Interventional and Diagnostic Neuroradiology, Bordeaux University Hospital, Bordeaux, France
| | - Arturo Consoli
- Department of Diagnostic and Interventional Neuroradiology, Hospital Foch, Suresnes, France.,Interventional Neurovascular Unit, Azienda Ospedaliero Universitaria Careggi, Firenze, Italy
| | - Panagiotis Papanagiotou
- Klinikum Bremen-Mitte gGmbH, Bremen, Germany.,National and Kapodistrian University of Athens - Aretaiio Hospital, Athens, Greece
| | - Raul G Nogueira
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Romain Bourcier
- Department of Neuroradiology, Nantes University Hospital, Nantes, France
| | - Maeva Kyheng
- Université Lille, CHU Lille, EA 2694 - Santé publique : épidémiologie et qualité des soins, Université de Lille, Lille, Hauts-de-France, France
| | - Julien Labreuche
- Université Lille, CHU Lille, EA 2694 - Santé publique : épidémiologie et qualité des soins, Université de Lille, Lille, Hauts-de-France, France
| | - Adnan H Siddiqui
- Department of Neurosurgery, University at Buffalo, Buffalo, New York, USA
| | - Marc Ribo
- Stroke Unit, Neurology, Hospital Vall d'Hebron, Barcelona, Spain
| | - Adam de Havenon
- Department of Neurology, University of Utah, Salt Lake City, Utah, USA
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Igor Sibon
- Department of Neurology, Stroke Unit, Bordeaux University Hospital, Bordeaux, France
| | - Cyril Dargazanli
- Department of Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
| | | | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, Toulouse University Hospital, Toulouse, France
| | - Jean Marc Olivot
- Department of Neurology, Toulouse University Hospital, Toulouse, France
| | - René Anxionnat
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, CHRU-Nancy, Nancy, France.,Université de Lorraine, IADI, INSERM U1254, Nancy, France
| | - Gérard Audibert
- Department of Anesthesiology and Surgical Intensive Care, Université de Lorraine, CHRU-Nancy, Nancy, France
| | - Mikael Mazighi
- Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France
| | - Raphael Blanc
- Department of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France
| | - Bertrand Lapergue
- Department of Neurology, Stroke Unit, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - Sébastien Richard
- Department of Neurology, Stroke Unit, Université de Lorraine, CHRU-Nancy, Nancy, France
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, CHRU-Nancy, Nancy, France .,Université de Lorraine, IADI, INSERM U1254, Nancy, France
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319
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Xiong Y, Pan Y, Nogueira RG, Ren Z, Jovin TG, Wang Y. Treating acute large vessel occlusion stroke: to bridge or not to bridge? Stroke Vasc Neurol 2021; 6:324-327. [PMID: 33903180 PMCID: PMC8485227 DOI: 10.1136/svn-2021-000952] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 03/02/2021] [Accepted: 03/03/2021] [Indexed: 11/04/2022] Open
Affiliation(s)
- Yunyun Xiong
- 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
| | - Yuesong Pan
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Raul G Nogueira
- Neurology, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Zeguang Ren
- Neurosurgery, Cleveland Clinic Martin Health, Port St Lucie, Florida, USA
| | - Tudor G Jovin
- Cooper Neurologic Institute, Cooper University Hospital, Camden, New Jersey, USA.,Neurology, Cooper Medical School of Rowan University, Camden, New Jersey, USA
| | - Yongjun Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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320
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Goyal M, Ospel JM, Hill MD. Will there be a rapid change towards an EVT-only paradigm? Interv Neuroradiol 2021; 27:744-745. [PMID: 33887973 PMCID: PMC8640264 DOI: 10.1177/15910199211011880] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/04/2022] Open
Affiliation(s)
- Mayank Goyal
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,Department of Radiology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Johanna M Ospel
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada.,Department of Radiology, University of Calgary, Calgary, Canada
| | - Michael D Hill
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
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321
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Radecki RP, Spiegel RS. Bridging Oceans and Thrombolysis: April 2021 Annals of Emergency Medicine Journal Club. Ann Emerg Med 2021; 77:464-465. [PMID: 33766279 DOI: 10.1016/j.annemergmed.2021.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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