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Singh N, Kashani N, Zea Vera AG, Tkach A, Ganesh A. Worldwide Survey on Approach to Thrombolysis in Acute Ischemic Stroke With Large Vessel Occlusion. Neurol Clin Pract 2024; 14:e200317. [PMID: 38863660 PMCID: PMC11164043 DOI: 10.1212/cpj.0000000000200317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 04/02/2024] [Indexed: 06/13/2024]
Abstract
Background and Objectives With recent trials suggesting that endovascular thrombectomy (EVT) alone may be noninferior to combined intravenous thrombolysis (IVT) with alteplase and EVT and that tenecteplase is non-inferior to alteplase in treating acute ischemic stroke, we sought to understand current practices around the world for treating acute ischemic stroke with large vessel occlusion (LVO) depending on the center of practice (IVT-capable vs IVT and EVT-capable stroke center). Methods The electronic survey launched by the Practice Current section of Neurology: Clinical Practice included 6 clinical and 8 demographic questions. A single-case scenario was presented of a 65-year-old man presenting with right hemiplegia with aphasia with a duration of 1 hour. Imaging showed left M1-MCA occlusion with no early ischemic changes. The respondents were asked about their treatment approach in 2 settings: the patient presented to (1) the IVT-only capable center and (2) the IVT and EVT-capable center. They were also asked about the thrombolytic agent of choice in current and ideal circumstances for these settings. Results A total of 203 physicians (42.9% vascular neurologists) from 44 countries completed the survey. Most participants (55.2%) spent ≥50% of their time delivering stroke care. The survey results showed that in current practice, more than 90% of respondents would offer IVT + EVT to patients with LVO stroke presenting to either an EVT-capable (91.1%) or IVT-only-capable center (93.6%). Although nearly 80% currently use alteplase for thrombolysis, around 60% would ideally like to switch to tenecteplase independent of the practice setting. These results were similar between stroke and non-stroke neurologists. Discussion Most physicians prefer IVT before EVT in patients with acute ischemic stroke attributable to large vessel occlusion independent of the practice setting.
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Affiliation(s)
- Nishita Singh
- Department of Internal Medicine (NS), Neurology Division, University of Manitoba, Winnipeg, Canada; Department of Clinical Neurosciences (NS, NK, AG), University of Calgary, Alberta, Canada; Department of Diagnostic and Interventional Neuroradiology (NK), Royal University Hospital, University of Saskatchewan, Saskatoon, Canada; Division of Neurology (AGZV), Children's National Hospital, Washington, DC; and Kelowna General Hospital (AT), University of British Columbia, Canada
| | - Nima Kashani
- Department of Internal Medicine (NS), Neurology Division, University of Manitoba, Winnipeg, Canada; Department of Clinical Neurosciences (NS, NK, AG), University of Calgary, Alberta, Canada; Department of Diagnostic and Interventional Neuroradiology (NK), Royal University Hospital, University of Saskatchewan, Saskatoon, Canada; Division of Neurology (AGZV), Children's National Hospital, Washington, DC; and Kelowna General Hospital (AT), University of British Columbia, Canada
| | - Alonso G Zea Vera
- Department of Internal Medicine (NS), Neurology Division, University of Manitoba, Winnipeg, Canada; Department of Clinical Neurosciences (NS, NK, AG), University of Calgary, Alberta, Canada; Department of Diagnostic and Interventional Neuroradiology (NK), Royal University Hospital, University of Saskatchewan, Saskatoon, Canada; Division of Neurology (AGZV), Children's National Hospital, Washington, DC; and Kelowna General Hospital (AT), University of British Columbia, Canada
| | - Aleksander Tkach
- Department of Internal Medicine (NS), Neurology Division, University of Manitoba, Winnipeg, Canada; Department of Clinical Neurosciences (NS, NK, AG), University of Calgary, Alberta, Canada; Department of Diagnostic and Interventional Neuroradiology (NK), Royal University Hospital, University of Saskatchewan, Saskatoon, Canada; Division of Neurology (AGZV), Children's National Hospital, Washington, DC; and Kelowna General Hospital (AT), University of British Columbia, Canada
| | - Aravind Ganesh
- Department of Internal Medicine (NS), Neurology Division, University of Manitoba, Winnipeg, Canada; Department of Clinical Neurosciences (NS, NK, AG), University of Calgary, Alberta, Canada; Department of Diagnostic and Interventional Neuroradiology (NK), Royal University Hospital, University of Saskatchewan, Saskatoon, Canada; Division of Neurology (AGZV), Children's National Hospital, Washington, DC; and Kelowna General Hospital (AT), University of British Columbia, Canada
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Gerschenfeld G, Turc G, Obadia M, Chausson N, Consoli A, Olindo S, Caroff J, Marnat G, Blanc R, Ben Hassen W, Seners P, Guillon B, Wiener E, Bourcier R, Yger M, Cho TH, Checkouri T, Gory B, Smadja D, Sibon I, Richard S, Piotin M, Eker OF, Pico F, Lapergue B, Alamowitch S. Functional Outcome and Hemorrhage Rates After Bridging Therapy With Tenecteplase or Alteplase in Patients With Large Ischemic Core. Neurology 2024; 103:e209398. [PMID: 38862134 DOI: 10.1212/wnl.0000000000209398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND AND OBJECTIVES IV tenecteplase is an alternative to alteplase before mechanical thrombectomy (MT) in patients with large-vessel occlusion (LVO) ischemic stroke. Little data are available on its use in patients with large ischemic core. We aimed to compare the efficacy and safety of both thrombolytics in this population. METHODS We conducted a retrospective analysis of patients with anterior circulation LVO strokes and diffusion-weighed imaging Alberta Stroke Program Early CT Score (DWI-ASPECTS) ≤5 treated with tenecteplase or alteplase before MT from the TETRIS (tenecteplase) and ETIS (alteplase) French multicenter registries. Primary outcome was reduced disability at 3 months (ordinal analysis of the modified Rankin scale [mRS]). Safety outcomes were 3-month mortality, parenchymal hematoma (PH), and symptomatic intracranial hemorrhage (sICH). We used propensity score overlap weighting to reduce baseline differences between treatment groups. RESULTS We analyzed 647 patients (tenecteplase: n = 194; alteplase: n = 453; inclusion period 2015-2022). Median (interquartile range) age was 71 (57-81) years, with NIH Stroke Scale score 19 (16-22), DWI-ASPECTS 4 (3-5), and last seen well-to-IV thrombolysis and puncture times 165 minutes (130-226) and 260 minutes (203-349), respectively. After MT, the successful reperfusion rate was 83.1%. After propensity score overlap weighting, all baseline variables were well balanced between both treatment groups. Compared with patients treated with alteplase, patients treated with tenecteplase had better 3-month mRS (common odds ratio [OR] for reduced disability: 1.37, 1.01-1.87, p = 0.046) and lower 3-month mortality (OR 0.52, 0.33-0.81, p < 0.01). There were no significant differences between thrombolytics for PH (OR 0.84, 0.55-1.30, p = 0.44) and sICH incidence (OR 0.70, 0.42-1.18, p = 0.18). DISCUSSION Our data are encouraging regarding the efficacy and reassuring regarding the safety of tenecteplase compared with that of alteplase in bridging therapy for patients with LVO strokes and a large ischemic core in routine clinical care. These results support its consideration as an alternative to alteplase in bridging therapy for patients with large ischemic cores. TRIALS REGISTRATION INFORMATION NCT03776877 (ETIS registry) and NCT05534360 (TETRIS registry). CLASSIFICATION OF EVIDENCE This study provides Class III evidence that patients with anterior circulation LVO stroke and DWI-ASPECTS ≤5 treated with tenecteplase vs alteplase before MT experienced better functional outcomes and lower mortality at 3 months.
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Affiliation(s)
- Gaspard Gerschenfeld
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Guillaume Turc
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Michael Obadia
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Nicolas Chausson
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Arturo Consoli
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Stephane Olindo
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Jildaz Caroff
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Gaultier Marnat
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Raphael Blanc
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Wagih Ben Hassen
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Pierre Seners
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Benoit Guillon
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Emmanuel Wiener
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Romain Bourcier
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Marion Yger
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Tae-Hee Cho
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Thomas Checkouri
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Benjamin Gory
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Didier Smadja
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Igor Sibon
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Sebastien Richard
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Michel Piotin
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Omer F Eker
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Fernando Pico
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Bertrand Lapergue
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Sonia Alamowitch
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
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3
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Wang Z, Ji K, Fang Q. Endovascular thrombectomy with or without intravenous alteplase in large-core ischemic stroke: a systematic review and meta-analysis. Neurol Sci 2024:10.1007/s10072-024-07653-y. [PMID: 38896187 DOI: 10.1007/s10072-024-07653-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2024] [Accepted: 06/11/2024] [Indexed: 06/21/2024]
Abstract
The role of bridging intravenous thrombolysis (IVT) with alteplase before endovascular thrombectomy (EVT) in treating large core ischemic stroke remains uncertain. We aimed to compare clinical outcomes and safety of EVT with or without bridging IVT in patients with anterior circulation large vessel occlusion (ACLVO) and baseline Alberta Stroke Program Early CT Score (ASPECTS) ≤ 5. We systematically searched PubMed, Web of Science, Cochrane Library, and Embase from inception until November 2023. The primary outcome was 90-day functional independence (modified Rankin Scale [mRS] 0-2). Secondary outcomes included 90-day independent ambulation (mRS 0-3), successful recanalization, any intracranial hemorrhage (ICH), symptomatic ICH (sICH) and 90-day mortality. A random-effects model was used for data pooling. Five high-quality studies, incorporating 2124 patients (41% treated with bridging IVT), were included. Across both unadjusted and adjusted analyses, no significant differences were found between the bridging IVT and EVT-alone groups in terms of functional independence (odds ratios [OR] = 1.36, 95% confidence interval [CI]: 0.90-2.07, P = 0.14; adjusted OR [aOR] = 1.19, 95% CI: 0.68-2.09, P = 0.53) or independent ambulation (OR = 1.14, 95% CI: 0.80-1.62, P = 0.47; aOR = 1.18, 95% CI: 1.00-1.39, P = 0.05) at 90 days. Furthermore, no differences were observed in successful recanalization, any ICH, sICH, and 90-day mortality between the two treatment groups. Bridging IVT exhibits similar functional and safety outcomes compared to EVT alone in ACLVO patients with baseline ASPECTS ≤ 5. Further research is warranted to confirm these findings.
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Affiliation(s)
- Zekun Wang
- Department of Neurology, The First Affiliated Hospital of Soochow University, No.899 Pinghai Road, Gusu District, Suzhou, 215031, Jiangsu Province, China.
| | - Kangxiang Ji
- Department of Neurology, The First Affiliated Hospital of Soochow University, No.899 Pinghai Road, Gusu District, Suzhou, 215031, Jiangsu Province, China
| | - Qi Fang
- Department of Neurology, The First Affiliated Hospital of Soochow University, No.899 Pinghai Road, Gusu District, Suzhou, 215031, Jiangsu Province, China.
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Puggaard R, Laugesen NG, Hansen K, Brandt AH, Stavngaard T, Truelsen TC. Outcome and safety of mechanical thrombectomy in patients with acute ischemic stroke due to internal carotid artery dissection. Interv Neuroradiol 2024:15910199241261753. [PMID: 38870399 DOI: 10.1177/15910199241261753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND Mechanical thrombectomy (MT) in patients with symptoms of acute ischemic stroke (AIS) due to internal carotid artery dissection (ICAD) remains controversial. In this study, we present clinical outcome and safety of MT in acute ICAD compared to other acute carotid artery pathology. METHODS Patients with symptoms of AIS due to internal carotid artery pathology, treated with MT from 2017-2021, were categorized as ICAD or non-ICAD. Baseline and procedural characteristics, complications, and functional outcome at 90 days were compared between the two groups. Factors associated with a favorable outcome (modified Rankin Scale 0-2) were analyzed using multivariate logistic regression. Safety analyses included in-stent thrombosis, perforation, intracranial hemorrhage, and mortality. RESULTS Sixty-seven ICAD patients (14.8%) and 387 non-ICAD patients (85.2%) were enrolled. ICAD patients were younger, median age 53 years (interquartile range (IQR) 47-61) vs. non-ICAD 72 years (IQR 64-79), p < 0.001. Favorable outcome was more common in ICAD patients, 49 ICAD patients (76.6%) vs. 158 non-ICAD patients (42.4%), p < 0.001. Post-procedural symptomatic intracranial hemorrhage occurred in 41 patients, 5 (7.5%) ICAD patients vs. 36 (9.3%) non-ICAD patients, p = 0.6. Mortality differed significantly, 6 (9%) ICAD patients vs. 94 (24.3%) non-ICAD patients, p = 0.01. ICAD was not associated with functional outcome in multivariate analysis, OR = 1.25 [95%confidence interval:0.55-2.86]. CONCLUSION ICAD patients achieved a better 90-day functional outcome compared with non-ICAD patients. ICAD patients did not perform worse in safety measures than non-ICAD patients. Our data provide indirect evidence that MT is of clinical benefit in ICAD patients with symptoms of AIS.
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Affiliation(s)
- Rikke Puggaard
- Cerebrovascular Research Unit Rigshospitalet, Department of Neurology, Rigshospitalet, Copenhagen, Denmark
| | - Nicolaj Grønbæk Laugesen
- Cerebrovascular Research Unit Rigshospitalet, Department of Neurology, Rigshospitalet, Copenhagen, Denmark
| | - Klaus Hansen
- Cerebrovascular Research Unit Rigshospitalet, Department of Neurology, Rigshospitalet, Copenhagen, Denmark
- Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andreas H Brandt
- Neurovascular Section, Department of Radiology, Rigshospitalet, Copenhagen, Denmark
| | - Trine Stavngaard
- Neurovascular Section, Department of Radiology, Rigshospitalet, Copenhagen, Denmark
| | - Thomas C Truelsen
- Cerebrovascular Research Unit Rigshospitalet, Department of Neurology, Rigshospitalet, Copenhagen, Denmark
- Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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5
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Lyu J, Liu Y, Liu F, Liu G, Gao Y, Wei R, Cai Y, Shen X, Zhao D, Zhao X, Xie Y, Yu H, Chai Y, Zhang J, Zhang Y, Xie Y. Therapeutic effect and mechanisms of traditional Chinese medicine compound (Qilong capsule) in the treatment of ischemic stroke. PHYTOMEDICINE : INTERNATIONAL JOURNAL OF PHYTOTHERAPY AND PHYTOPHARMACOLOGY 2024; 132:155781. [PMID: 38870749 DOI: 10.1016/j.phymed.2024.155781] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 05/20/2024] [Accepted: 05/26/2024] [Indexed: 06/15/2024]
Abstract
Background Qilong capsule (QLC) is a well-known traditional Chinese medicine compound extensively used in clinical practice. It has been approved by the China's FDA for the treatment of ischemic stroke (IS). In our clinical trial involving QLC (ClinicalTrials.gov identifier: NCT03174535), we observed the potential of QLC to improve neurological function in IS patients at the 24th week, while ensuring their safety. However, the effectiveness of QLC beyond the initial 12-week period remains uncertain, and the precise mechanisms underlying its action in IS have not been fully elucidated. Purpose In order to further explore the clinical efficacy of QLC in treating IS beyond the initial 12-week period and systematically elucidate its underlying mechanisms. Study Design This study employed an interdisciplinary integration strategy that combines post hoc analysis of clinical trials, transcriptome sequencing, integrated bioinformatics analysis, and animal experiments. Methods In this study, we conducted a post-hoc analysis with 2302 participants to evaluate the effectiveness of QLC at the 12th week. The primary outcome was the proportion of patients achieving functional independence at the 12th week, defined as a score of 0-2 on the modified Rankin Scale (mRS), which ranges from 0 (no symptoms) to 6 (death). Subsequently, we employed RNA sequencing (RNA-Seq) and quantitative reverse transcription polymerase chain reaction (RT-qPCR) techniques in the QLC trial to investigate the potential molecular mechanisms underlying the therapeutic effect of QLC in IS. Simultaneously, we utilized integrated bioinformatics analyses driven by external multi-source data and algorithms to further supplement the exploration and validation of QLC's therapeutic mechanism in treating IS. This encompassed network pharmacology analysis and analyses at the mRNA, cellular, and pathway levels focusing on core targets. Additionally, we developed a disease risk prediction model using machine learning. By identifying differentially expressed core genes (DECGs) between the normal and IS groups, we quantitatively predicted IS occurrence. Furthermore, to assess its protective effects and determine the key regulated pathway, we conducted experiments using a middle cerebral artery occlusion and reperfusion (MACO/R) rat model. Results Our findings demonstrated that the combination of QLC and conventional treatment (CT) significantly improved the proportion of patients achieving functional independence (mRS score 0-2) at the 12th week compared to CT alone (n = 2,302, 88.65 % vs 87.33 %, p = 0.3337; n = 600, 91.33 % vs 84.67 %, p = 0.0165). Transcriptome data revealed that the potential underlying mechanism of QLC for IS is related to the regulation of the NF-κB inflammatory pathway. The RT-qPCR results demonstrated that the regulatory trends of key genes, such as MD-2, were consistent with those observed in the RNA-Seq analysis. Integrated bioinformatics analysis elucidated that QLC regulates the NF-κB signaling pathway by identifying core targets, and machine learning was utilized to forecast the risk of IS onset. The MACO/R rat model experiment confirmed that QLC exerts its anti-CIRI effects by inhibiting the MD-2/TLR-4/NF-κB signaling axis. Conclusion: Our interdisciplinary integration study has demonstrated that the combination of QLC with CT exhibits significant superiority over CT alone in improving functional independence in patients at the 12th week. The potential mechanism underlying QLC's therapeutic effect in IS involves the inhibition of the MD-2/TLR4/NF-κB inflammatory signaling pathway, thereby attenuating cerebral ischemia/reperfusion inflammatory injury and facilitating neurofunctional recovery. The novelty and innovative potential of this study primarily lie in the novel finding that QLC significantly enhances the proportion of patients achieving functional independence (mRS score 0-2) at the 12th week. Furthermore, employing a "multilevel-multimethod" integrated research approach, we elucidated the potential mechanism underlying QLC's therapeutic effect in IS.
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Affiliation(s)
- Jian Lyu
- NMPA Key Laboratory for Clinical Research and Evaluation of Traditional Chinese Medicine & National Clinical Research Center for Chinese Medicine Cardiology, XiYuan Hospital, China Academy of Chinese Medical Sciences, No.1 Xiyuan playground Road, Haidian District, Beijing, 100091, PR China.
| | - Yi Liu
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, No.16 Nanxiaojie, Inner Dongzhimen, Dongcheng District, Beijing, 100700, PR China
| | - Fumei Liu
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, No.16 Nanxiaojie, Inner Dongzhimen, Dongcheng District, Beijing, 100700, PR China
| | - Guangyu Liu
- NMPA Key Laboratory for Clinical Research and Evaluation of Traditional Chinese Medicine & National Clinical Research Center for Chinese Medicine Cardiology, XiYuan Hospital, China Academy of Chinese Medical Sciences, No.1 Xiyuan playground Road, Haidian District, Beijing, 100091, PR China
| | - Yang Gao
- Dongfang Hospital, Beijing University of Chinese Medicine, No. 6 Fangxingyuan, Fengtai District, Beijing, 100078, PR China
| | - Ruili Wei
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, No.16 Nanxiaojie, Inner Dongzhimen, Dongcheng District, Beijing, 100700, PR China
| | - Yefeng Cai
- Guangdong Provincial Hospital of Traditional Chinese Medicine, No.111 Dade Road, Yuexiu District, Guangzhou, 510120, Guangdong, PR China
| | - Xiaoming Shen
- The First Affiliated Hospital of Henan University of Chinese Medicine, No.19 Renmin Road, Jinshui District, Zhengzhou, 450000, Henan, PR China
| | - Dexi Zhao
- Affiliated Hospital of Changchun University of Chinese Medicine, No.1478 Gongnong Road, Chaoyang District, Changchun, 130021, Jilin, PR China
| | - Xingquan Zhao
- Beijing Tiantan Hospital, Capital Medical University, No.119 South Fourth Ring West Road, Fengtai District, Beijing,100070, PR China
| | - Yingzhen Xie
- Dongzhimen Hospital, Beijing University of Chinese Medicine, No.5 Hai Yun Cang, Dongcheng District, Beijing,100700, PR China
| | - Haiqing Yu
- Taiyuan Chinese Medicine Hospital, No. 2 Baling South Street, Xinghualing District, Taiyuan 030009, Shanxi, PR China
| | - Yan Chai
- Department of Epidemiology, University of California, Los Angeles, 405 Hilgard Avenue, CA90095, USA
| | - Jingxiao Zhang
- Center for Applied Statistics, School of Statistics, Renmin University of China, 100872, Beijing, China
| | - Yunling Zhang
- NMPA Key Laboratory for Clinical Research and Evaluation of Traditional Chinese Medicine & National Clinical Research Center for Chinese Medicine Cardiology, XiYuan Hospital, China Academy of Chinese Medical Sciences, No.1 Xiyuan playground Road, Haidian District, Beijing, 100091, PR China.
| | - Yanming Xie
- Institute of Basic Research in Clinical Medicine, China Academy of Chinese Medical Sciences, No.16 Nanxiaojie, Inner Dongzhimen, Dongcheng District, Beijing, 100700, PR China.
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6
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Cai L, Wang L, Campbell BCV, Wu Y, Abdalkader M, Alemseged F, Kaesmacher J, Puetz V, Nagel S, Strbian D, Knapen RRMM, Li C, Ye S, Tian P, Chen J, Li R, Hu W, Qiu Z, Nguyen TN, Schonewille WJ, Guo Q, Dai Z. Endovascular thrombectomy with versus without intravenous thrombolysis in patients with acute basilar artery occlusion: a systematic review and meta-analysis. J Neurol 2024; 271:3039-3049. [PMID: 38597945 DOI: 10.1007/s00415-024-12353-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 03/24/2024] [Accepted: 03/25/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND AND PURPOSE The benefit and safety of intravenous thrombolysis before endovascular thrombectomy in patients with acute ischemic stroke caused by basilar artery occlusion (BAO) remains unclear. This article aims to investigate the clinical outcomes and safety of endovascular thrombectomy with versus without intravenous thrombolysis in acute BAO stroke patients. METHODS We conducted a comprehensive search of PubMed, Embase, Cochrane, and Web of Science databases to identify relevant literature pertaining to patients with acute BAO who underwent endovascular thrombectomy alone or intravenous thrombolysis bridging with endovascular thrombectomy (bridging therapy), until January 10, 2024. The primary outcome was functional independence, defined as a score of 0-2 on the modified Rankin Scale at 90 days. The safety outcome was mortality at 90 days and symptomatic intracranial hemorrhage within 48 h. Effect sizes were computed as risk ratio (RR) with random-effect models. This study was registered in PROSPERO (CRD42023462293). RESULTS A total of 528 articles were obtained through the search and articles that did not meet the inclusion criteria were excluded. Finally, 2 RCTs and 10 cohort studies met the inclusion criteria. The findings revealed that the endovascular thrombectomy alone group had a lower rate of functional independence compared to the bridging therapy group (29% vs 38%; RR 0.78, 95% CI 0.68-0.88, p < 0.001), lower independent ambulation (39% vs 45%; RR 0.89, 95% CI 0.82-0.98, p = 0.01), and higher mortality (36% vs 28%, RR 1.22, 95% CI 1.08-1.37, p = 0.001). However, no differences were detected in symptomatic intracranial hemorrhage between the two groups (6% vs 4%; RR 1.12, 95% CI 0.74-1.71, p = 0.58). CONCLUSION Intravenous thrombolysis plus endovascular thrombectomy seemed to led to better functional independence, independent ambulation, and lower risk of mortality without increasing the incidence of intracranial hemorrhage compared to endovascular thrombectomy alone. However, given the non-randomized nature of this study, further studies are needed to confirm these findings.
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Affiliation(s)
- Lingyu Cai
- Neurology, The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China
| | - Liaoyuan Wang
- The Third District of Air Force Special Service Sanatorium, Hangzhou, 310002, Zhejiang, China
| | - Bruce C V Campbell
- Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VC, Australia
| | - Yuelu Wu
- Neurology, The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China
| | - Mohamad Abdalkader
- Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, USA
| | - Fana Alemseged
- Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VC, Australia
| | - Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Volker Puetz
- Dresden Neurovascular Center, University Clinics Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, and University of Helsinki, Helsinki, Finland
| | - Robrecht R M M Knapen
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Chuanhui Li
- Department of Neurology, The Stroke Center, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Shitai Ye
- Neurology, The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China
| | - Pengli Tian
- Neurology, The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China
| | - Jingjing Chen
- Neurology, The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China
| | - Ruitian Li
- Community Health Service Center of Sandun Town, Hangzhou, China
| | - Wei Hu
- Department of Neurology, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Zhongming Qiu
- Neurology, The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China
| | - Thanh N Nguyen
- Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, USA
| | | | - Qifeng Guo
- Neurology, The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China.
| | - Zhao Dai
- Neurology, The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China.
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7
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Mujanovic A, Dobrocky T, Pfeilschifter W, Remonda L, Caroff J, Behme D, Seiffge DJ, Cereda CW, Kägi G, Leyon J, Piechowiak EI, Costalat V, Wagner J, Chabert E, Meinel TR, Jansen O, Alonso A, Loehr C, Liebeskind DS, Gralla J, Fischer U, Kaesmacher J. Value of intravenous alteplase before thrombectomy among patients with tandem lesions and emergent carotid artery stenting: A subgroup analysis of the SWIFT DIRECT trial. Eur J Neurol 2024; 31:e16256. [PMID: 38409874 DOI: 10.1111/ene.16256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/26/2024] [Accepted: 02/07/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND AND PURPOSE The value of intravenous thrombolysis (IVT) in eligible tandem lesion patients undergoing endovascular treatment (EVT) is unknown. We investigated treatment effect heterogeneity of EVT + IVT versus EVT-only in tandem lesion patients. Additional analyses were performed for patients undergoing emergent internal carotid artery (ICA) stenting. METHODS SWIFT DIRECT randomized IVT-eligible patients to either EVT + IVT or EVT-only. Primary outcome was 90-day functional independence (modified Rankin Scale score 0-2) after the index event. Secondary endpoints were reperfusion success, 24 h intracranial hemorrhage rate, and 90-day all-cause mortality. Interaction models were fitted for all predefined outcomes. RESULTS Among 408 included patients, 63 (15.4%) had a tandem lesion and 33 (52.4%) received IVT. In patients with tandem lesions, 20 had undergone emergent ICA stenting (EVT + IVT: 9/33, 27.3%; EVT: 11/30, 36.7%). Tandem lesion did not show treatment effect modification of IVT on rates of functional independence (tandem lesion EVT + IVT vs. EVT: 63.6% vs. 46.7%, non-tandem lesion EVT + IVT vs. EVT: 65.6% vs. 58.2%; p for interaction = 0.77). IVT also did not increase the risk of intracranial hemorrhage among tandem lesion patients (tandem lesion EVT + IVT vs. EVT: 34.4% vs. 46.7%, non-tandem lesion EVT + IVT vs. EVT: 33.5% vs. 26.3%; p for interaction = 0.15). No heterogeneity was noted for other endpoints (p for interaction > 0.05). CONCLUSIONS No treatment effect heterogeneity of EVT + IVT versus EVT-only was observed among tandem lesion patients. Administering IVT in patients with anticipated emergent ICA stenting seems safe, and the latter should not be a factor to consider when deciding to administer IVT before EVT.
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Affiliation(s)
- Adnan Mujanovic
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Tomas Dobrocky
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Waltraud Pfeilschifter
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Luca Remonda
- Department of Neuroradiology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Jildaz Caroff
- Department of Interventional Neuroradiology, NEURI Brain Vascular Center, Bicêtre Hospital, Paris-Saclay University, Le Kremlin-Bicêtre, France
| | - Daniel Behme
- Department for Neuroradiology, Otto von Guericke University Hospital Magdeburg, University of Magdeburg, Magdeburg, Germany
| | - David J Seiffge
- Department of Neurology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Carlo W Cereda
- Stroke Center, Neurology, Neurocenter of Southern Switzerland (EOC), Lugano, Switzerland
| | - Georg Kägi
- Department of Neurology, Cantonal Hospital St. Gallen, University of St. Gallen, St. Gallen, Switzerland
| | - Joe Leyon
- Department of Neuroradiology, St. George's University Hospital, London, UK
| | - Eike I Piechowiak
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Vincent Costalat
- Department of Neuroradiology, University Hospital Montpellier, Montpellier, France
| | - Judith Wagner
- Department of Neurology, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
- Department of Neurology, Evangelisches Klinikum Gelsenkirchen, Academic Hospital University Essen-Duisburg, Gelsenkirchen, Germany
| | - Emmanuel Chabert
- Department of Neuroradiology, University Hospital Clermont-Ferrand, Clermont-Ferrand, France
| | - Thomas R Meinel
- Department of Neurology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Olav Jansen
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, University of Kiel, Kiel, Germany
| | - Angelika Alonso
- Department of Neurology, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Christian Loehr
- Department of Radiology and Neuroradiology, Klinikum Vest, Recklinghausen, Germany
| | - David S Liebeskind
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, USA
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Johannes Kaesmacher
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
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8
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Khan MO, Shah SA, Mahmood S, Aijaz A, Jatoi NN, Shakil F, Nusrat K, Siddiqui OM, Hameed I. Is endovascular treatment alone as effective and safe as that with preceding intravenous thrombolysis for acute ischemic stroke? A meta-analysis of randomized controlled trials. J Neurosurg Sci 2024; 68:338-347. [PMID: 37389453 DOI: 10.23736/s0390-5616.23.06058-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
INTRODUCTION This meta-analysis aimed to evaluate the safety and efficacy of direct endovascular therapy (EVT) and bridging therapy (EVT with preceding intravenous thrombolysis i.e. IVT), in acute anterior circulation, large vessel occlusion stroke. EVIDENCE ACQUISITION Following the PRISMA guidelines, a systematic literature review of the English language literature was conducted using PubMed, Cochrane CENTRAL, SCOPUS and ClinicalTrials.gov. Outcomes of interest were measured by the modified Rankin Scale (mRS), and included: no disability (mRS0), no significant disability despite some symptoms (mRS1), slight disability (mRS2), moderate disability (mRS3), moderately severe disability (mRS4), severe disability (mRS5), mortality (mRS6). Additionally, we inspected patients having excellent outcome, functional independence outcome, and poor outcome, along with successful reperfusion and intracranial hemorrhage. We calculated pooled risk ratios (RRs) and their corresponding 95% confidence intervals (CI). EVIDENCE SYNTHESIS A total of seven RCTs involving 2,392 patients were finally included. The chances of achieving successful reperfusion were significantly more with IVT+EVT as compared to EVT alone (RR: 0.97; 95% CI: 0.94, 1.00; P=0.03) (I2=0%). There was no significant difference in the number of patients having outcomes ranging from mRS0 to mRS6, excellent outcome, functional independence, poor outcome or incidence of intracranial hemorrhage, who underwent either EVT alone or IVT+EVT. CONCLUSIONS Additional trials are needed to determine if the absence of significant differences is due to insufficient sample size or if the combination therapy is truly not beneficial.
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Affiliation(s)
- Mohammad O Khan
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Syeda A Shah
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Samar Mahmood
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Ashnah Aijaz
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Nadia N Jatoi
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Firzah Shakil
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Khushboo Nusrat
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Omer M Siddiqui
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Ishaque Hameed
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan -
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Qin B, Wei T, Gao W, Qin HX, Liang YM, Qin C, Chen H, Yang MX. Real-world setting comparison of bridging therapy versus direct mechanical thrombectomy for acute ischemic stroke: A meta-analysis. Clinics (Sao Paulo) 2024; 79:100394. [PMID: 38820696 PMCID: PMC11177057 DOI: 10.1016/j.clinsp.2024.100394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 04/15/2024] [Accepted: 05/13/2024] [Indexed: 06/02/2024] Open
Abstract
BACKGROUND AND PURPOSE Intravenous Thrombolysis (IVT) prior to Mechanical Thrombectomy (MT) for Acute Ischaemic Stroke (AIS) due to Large-Vessel Occlusion (LVO) remains controversial. Therefore, the authors performed a meta-analysis of the available real-world evidence focusing on the efficacy and safety of Bridging Therapy (BT) compared with direct MT in patients with AIS due to LVO. METHODS Four databases were searched until 01 February 2023. Retrospective and prospective studies from nationwide or health organization registry databases that compared the clinical outcomes of BT and direct MT were included. Odds Ratios (ORs) and 95 % Confidence Intervals (CIs) for efficacy and safety outcomes were pooled using a random-effects model. RESULTS Of the 12 studies, 86,695 patients were included. In patients with AIS due to LVO, BT group was associated with higher odds of achieving excellent functional outcome (modified Rankin Scale score 0-1) at 90 days (OR = 1.48, 95 % CI 1.25-1.75), favorable discharge disposition (to the home with or without services) (OR = 1.33, 95 % CI 1.29-1.38), and decreased mortality at 90 days (OR = 0.62, 95 % CI 0.56-0.70), as compared with the direct MT group. In addition, the risk of symptomatic intracranial hemorrhage did not increase significantly in the BT group. CONCLUSION The present meta-analysis indicates that BT was associated with favorable outcomes in patients with AIS due to LVO. These findings support the current practice in a real-world setting and strengthen their validity. For patients eligible for both IVT and MT, BT remains the standard treatment until more data are available.
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Affiliation(s)
- Bin Qin
- Department of Neurology, Liuzhou People's Hospital, Liuzhou, Guangxi, China; Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China; Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Tao Wei
- Department of Neurology, Liuzhou People's Hospital, Liuzhou, Guangxi, China; Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China
| | - Wen Gao
- Department of Neurology, Liuzhou People's Hospital, Liuzhou, Guangxi, China; Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China
| | - Hui-Xun Qin
- Department of Neurology, Liuzhou People's Hospital, Liuzhou, Guangxi, China; Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China
| | - Yu-Ming Liang
- Department of Neurology, Liuzhou People's Hospital, Liuzhou, Guangxi, China; Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China
| | - Cheng Qin
- Department of Neurology, Liuzhou People's Hospital, Liuzhou, Guangxi, China; Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China
| | - Hong Chen
- Department of Neurology, Liuzhou People's Hospital, Liuzhou, Guangxi, China; Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China
| | - Ming-Xiu Yang
- Department of Neurology, Liuzhou People's Hospital, Liuzhou, Guangxi, China; Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China.
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Yuan G, Zhang J, Ye Z, Sun J, Huo X, Pan Y, Wang M, Peng X, Zheng C, Lei X, Miao Z, Cai X. Effectiveness and safety of bridging therapy and endovascular therapy in patients with large cerebral infarctions: from ANGEL-ASPECT. Stroke Vasc Neurol 2024:svn-2024-003120. [PMID: 38777348 DOI: 10.1136/svn-2024-003120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 05/07/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND AND PURPOSE The benefits of thrombolytic therapy before endovascular thrombectomy in cases of acute ischaemic stroke, with a large infarction volume, remain unclear. This analysis aims to evaluate the effectiveness and safety of bridging therapy and endovascular therapy among patients with large cerebral infarctions. METHODS In this post-hoc analysis of the multicentre prospective study of ANGEL-ASPECT (Acute Anterior Circulation Large Vessel Occlusive Patients with a Large Infarct Core), participants were divided into two groups: an endovascular therapy group and a bridging therapy group. The primary outcome was the modified Rankin Scale (mRS) score at 90 days. The primary safety outcome was symptomatic intracranial haemorrhage. Ordinal logistic regression was performed to compare the primary endpoint between the two groups. Subgroup analyses were conducted to further explore potential risk factors associated with the outcomes. RESULTS 122 patients were included, of whom 77 (63%) underwent endovascular therapy and 45 (37%) underwent bridging therapy. The median scores on mRS at 90 days of the bridging therapy group and the endovascular therapy group were 3 (2-5) and 4 (2-6), with no significant differences (common OR 1.36; 95% CI 0.71 to 2.61). Symptomatic intracranial haemorrhage was reported in three patients who were in the endovascular and bridging therapy groups (relative risk (RR) 1.71; 95% CI 0.36 to 8.12). The mortality between two groups did not differ (RR 0.75; 95% CI 0.37 to 1.54). CONCLUSIONS Our study indicated that endovascular therapy alone might be a viable option for patients with large cerebral infarctions, displaying no noticeable disparity in outcomes compared with bridging therapy.
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Affiliation(s)
- Guangxiong Yuan
- Emergency, Xiangtan Central Hospital, Xiangtan, Hunan, China
| | - Jun Zhang
- School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Zekang Ye
- Department of Neurology, Lishui Central Hospital and Fifth Affiliated Hospital of Wenzhou Medical College, Lishui, Zhejiang, China
- Lishui Clinical Research Center for Neurological Diseases, Lishui, Zhejiang, China
| | - Jingping Sun
- Department of Neurology, Lishui Central Hospital and Fifth Affiliated Hospital of Wenzhou Medical College, Lishui, Zhejiang, China
- Lishui Clinical Research Center for Neurological Diseases, Lishui, Zhejiang, China
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuesong Pan
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Mengxing Wang
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiao Peng
- Department of Neurology, Lishui Central Hospital and Fifth Affiliated Hospital of Wenzhou Medical College, Lishui, Zhejiang, China
- Lishui Clinical Research Center for Neurological Diseases, Lishui, Zhejiang, China
| | - Chanjuan Zheng
- Lishui Clinical Research Center for Neurological Diseases, Lishui, Zhejiang, China
| | - Xueyao Lei
- Lishui Clinical Research Center for Neurological Diseases, Lishui, Zhejiang, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xueli Cai
- School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Department of Neurology, Lishui Central Hospital and Fifth Affiliated Hospital of Wenzhou Medical College, Lishui, Zhejiang, China
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11
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Hilkens NA, Casolla B, Leung TW, de Leeuw FE. Stroke. Lancet 2024:S0140-6736(24)00642-1. [PMID: 38759664 DOI: 10.1016/s0140-6736(24)00642-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/19/2024] [Accepted: 03/26/2024] [Indexed: 05/19/2024]
Abstract
Stroke affects up to one in five people during their lifetime in some high-income countries, and up to almost one in two in low-income countries. Globally, it is the second leading cause of death. Clinically, the disease is characterised by sudden neurological deficits. Vascular aetiologies contribute to the most common causes of ischaemic stroke, including large artery disease, cardioembolism, and small vessel disease. Small vessel disease is also the most frequent cause of intracerebral haemorrhage, followed by macrovascular causes. For acute ischaemic stroke, multimodal CT or MRI reveal infarct core, ischaemic penumbra, and site of vascular occlusion. For intracerebral haemorrhage, neuroimaging identifies early radiological markers of haematoma expansion and probable underlying cause. For intravenous thrombolysis in ischaemic stroke, tenecteplase is now a safe and effective alternative to alteplase. In patients with strokes caused by large vessel occlusion, the indications for endovascular thrombectomy have been extended to include larger core infarcts and basilar artery occlusion, and the treatment time window has increased to up to 24 h from stroke onset. Regarding intracerebral haemorrhage, prompt delivery of bundled care consisting of immediate anticoagulation reversal, simultaneous blood pressure lowering, and prespecified stroke unit protocols can improve clinical outcomes. Guided by underlying stroke mechanisms, secondary prevention encompasses pharmacological, vascular, or endovascular interventions and lifestyle modifications.
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Affiliation(s)
- Nina A Hilkens
- Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands; Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands
| | - Barbara Casolla
- Université Nice Cote d'Azur UR2CA-URRIS, Stroke Unit, CHU Pasteur 2, Nice, France
| | - Thomas W Leung
- Division of Neurology, Department of Medicine and Therapeutics, The Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Frank-Erik de Leeuw
- Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands; Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands.
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12
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Jan K, Chong JY. Treatment of Acute Ischemic Stroke: The Last 30 Years of Trials and Tribulations. Cardiol Rev 2024; 32:203-216. [PMID: 38520336 DOI: 10.1097/crd.0000000000000663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/25/2024]
Abstract
The landscape of acute ischemic stroke management has undergone a substantial transformation over the past 3 decades, mirroring our enhanced comprehension of the pathology and progress in diagnostic techniques, therapeutic interventions, and preventive measures. The 1990s marked a pivotal moment in stroke care with the integration of intravenous thrombolytics. However, the most significant paradigm shift in recent years has undoubtedly been the advent of endovascular thrombectomy. This article endeavors to deliver an exhaustive analysis of this revolutionary progression.
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Affiliation(s)
- Kalimullah Jan
- From the Vascular Neurology Fellow, New York Medical College, Westchester Medical Center, Valhalla, NY
| | - Ji Y Chong
- Stroke Center, New York Medical College, Westchester Medical Center, Valhalla, NY
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13
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Cheng X, Chen Q, Ren Q, Ma H, Zhao Y, Jiao S. Total cerebral small vessel disease burden and stroke outcomes in large vessel occlusion stroke receiving endovascular treatment: A systematic review and meta-analysis. J Clin Neurosci 2024; 123:179-185. [PMID: 38583374 DOI: 10.1016/j.jocn.2024.04.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Revised: 03/30/2024] [Accepted: 04/03/2024] [Indexed: 04/09/2024]
Abstract
BACKGROUND Cerebral small vessel disease (CSVD) is prevalent in the population, especially among the elderly. Various types of CSVD markers commonly coexist, and the neurological function outcome is affected by their combined effect. Studies investigating the association between total CSVD burden and stroke outcomes in large vessel occlusion (LVO) stroke receiving endovascular treatment (EVT) are expanding but have not been systematically assessed. METHODS We systematically searched the PubMed, Embase, and Cochrane databases for relevant clinical studies. The total CSVD burden score summarized the markers of CSVD, including lacunes, white matter hyperintensities (WMHs), cerebral microbleeds (CMBs), and enlarged perivascular spaces (EPVSs), which was a comprehensive index of overall CSVD burden. The pooled odds ratios (ORs) were used to calculate the association between high total CSVD burden score and outcomes of EVT in patients with LVO stroke. The primary outcome was poor functional outcome, which was defined as a modified Rankin Scale score (mRS) ≥ 3 at 90 days after EVT. The secondary outcomes were symptomatic intracranial hemorrhage (sICH) and poor collateral flow. RESULTS Overall, 6 eligible studies with 1,774 patients with LVO stroke undergoing EVT were pooled in meta-analysis. High overall CSVD burden score was significantly associated with increased risks of poor functional outcome at 90 days (pooled OR 2.86, 95 % CI 1.31-6.25, p = 0.008). Besides, high overall CSVD burden score was associated with sICH (pooled OR 2.07, 95 % CI 0.38-5.17; p = 0.118) and poor collateral flow (pooled OR 1.57, 95 % CI 0.75-3.27; p = 0.232), but were not statistically significant. CONCLUSIONS High overall CSVD burden was associated with increased risks of unfavorable outcomes in patients with LVO stroke undergoing EVT.
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Affiliation(s)
- Xiaofang Cheng
- Department of Neurology, Bethune International Peace Hospital, Shijiazhuang, Hebei, China.
| | - Quanhui Chen
- Department of Gastroenterology, Bethune International Peace Hospital, Shijiazhuang, Hebei, China
| | - Qiuxia Ren
- Department of Neurology, Bethune International Peace Hospital, Shijiazhuang, Hebei, China
| | - Haoyuan Ma
- Department of Neurology, Bethune International Peace Hospital, Shijiazhuang, Hebei, China
| | - Yan Zhao
- Medical Service Department, Bethune International Peace Hospital, Shijiazhuang, Hebei, China
| | - Shusheng Jiao
- Department of Neurology, Bethune International Peace Hospital, Shijiazhuang, Hebei, China
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14
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Bao Q, Huang X, Wu X, Huang H, Zhang X, Yang M. Safety and efficacy of intravenous thrombolysis before mechanical thrombectomy in patients with atrial fibrillation. Syst Rev 2024; 13:118. [PMID: 38689365 PMCID: PMC11061942 DOI: 10.1186/s13643-024-02532-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 04/13/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Intravenous thrombolysis (IVT) before endovascular thrombectomy (EVT) is the standard treatment for patients with acute ischemic stroke caused by large vessel occlusion (AIS-LVO). However, the efficacy and safety of IVT before EVT in AIS-LVO patients with atrial fibrillation (AF) remains controversial. Thus, this study aims to assess the benefit of IVT plus EVT and direct EVT alone in AIS-LVO patients with AF. METHOD Relevant studies that evaluated the outcomes of IVT plus EVT versus direct EVT alone in AIS-LVO patients with AF were systematically searched in PubMed, Embase, and Cochrane Library from inception to August 10, 2023. The outcomes included successful reperfusion (score of 2b to 3 for thrombolysis in cerebral infarction), symptomatic intracerebral hemorrhage (sICH), good clinical outcome (modified Rankin scale score ≤ 2) at 3 months, and 3-month mortality. RESULT Eight eligible observational studies involving 6998 (3827 in the IVT plus EVT group and 3171 in the direct EVT group) patients with AIS-LVO complicated by AF were included. Compared with direct EVT, IVT plus EVT resulted in better 3-month clinical outcomes (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.05-1.54) and lower 3-month mortality (OR 0.78, 95% CI 0.68-0.88). However, the incidence of sICH (OR 1.26, 95% CI 0.91-1.75) and the rate of successful reperfusion (OR 0.98, 95% CI 0.83-1.17) were not significantly different between treatment modalities. CONCLUSION IVT plus EVT leads to better functional outcomes and lower mortality in AIS-LVO patients with AF. Withholding IVT plus EVT from patients with AF alone may not be justified.
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Affiliation(s)
- Qiangji Bao
- Department of Neurosurgery, Guang'an People's Hospital, Guang'an, Sichuan, China
| | - Xiaodong Huang
- Department of Neurosurgery, Taihe Hospital Affiliated Hospital of Hubei University of Medicine, Shiyan, Hubei, China
| | - Xinting Wu
- Department of Anesthesia, Guang'an People's Hospital, Guang'an, Sichuan, 638000, China
| | - Hao Huang
- Department of Neurosurgery, Guang'an People's Hospital, Guang'an, Sichuan, China
| | - Xiaoqiang Zhang
- Department of Neurosurgery, Guang'an People's Hospital, Guang'an, Sichuan, China.
| | - Mingfei Yang
- Department of Neurosurgery, Qinghai Provincial People's Hospital, Xining, Qinghai, 810007, China.
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Tan KS, Pandian JD, Liu L, Toyoda K, Leung TWH, Uchiyama S, Kuroda S, Suwanwela NC, Aaron S, Chang HM, Venketasubramanian N. Stroke in Asia. Cerebrovasc Dis Extra 2024; 14:58-75. [PMID: 38657577 DOI: 10.1159/000538928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 04/08/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND There is a significant burden of stroke in Asia. Asia has the largest population in the world in 2023, estimated at 4.7 billion. Approximately 9.5-10.6 million strokes will be anticipated annually in the backdrop of a diverse group of well-developed and less developed countries with large disparities in stroke care resources. In addition, Asian countries are in varying phases of epidemiological transition. SUMMARY In this review, we examined recent epidemiological features of ischaemic stroke and intracerebral haemorrhage in Asia with recent developments in hyperacute stroke reperfusion therapy and technical improvements in intracerebral haemorrhage. The article also discussed the spectrum of cerebrovascular diseases in Asia, which include intracranial atherosclerosis, intracerebral haemorrhage, infective aetiologies of stroke, moyamoya disease, vascular dissection, radiation vasculopathy, and cerebral venous thrombosis. KEY MESSAGES The review of selected literature and recent updates calls for attention to the different requirements for resources within Asia and highlights the breadth of cerebrovascular diseases still requiring further research and more effective therapies.
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Affiliation(s)
- Kay Sin Tan
- Division of Neurology, Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | | | - Thomas Wai Hon Leung
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China
| | - Shinichiro Uchiyama
- Centre for Brain and Cerebral Vessels, Sanno Medical Centre, International University of Health and Welfare, Tokyo, Japan
| | - Sathoshi Kuroda
- Department of Neurosurgery, Toyama University, Toyama, Japan
| | - Nijasri C Suwanwela
- Chulalongkorn Stroke Centre, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sanjith Aaron
- Department of Medicine, Christian Medical College, Vellore, India
| | - Hui Meng Chang
- Department of Neurology, National Neuroscience Institute, Singapore General Hospital, Singapore, Singapore
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Yan Y, Zhang K, Zhong W, Yan S, Zhang B, Cheng J, Lou M. Influencing factors of futile recanalization after endovascular intervention in patients with acute basilar artery occlusion. Zhejiang Da Xue Xue Bao Yi Xue Ban 2024; 53:141-150. [PMID: 38501295 PMCID: PMC11057989 DOI: 10.3724/zdxbyxb-2023-0425] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/24/2023] [Accepted: 12/21/2023] [Indexed: 03/20/2024]
Abstract
OBJECTIVES To explore the influence factors for futile recanalization following endovascular treatment (EVT) in patients with acute basilar artery occlusion (BAO). METHODS Clinical data of patients with acute BAO, who underwent endovascular treatment within 24 h of onset from January 2017 to November 2022, were retrospectively analyzed. The futile recanalization was defined as modified thrombolysis in cerebral infarction (mTICI) grade ≥2b or 3 after successful reperfusion, but the modified Rankin Scale score >2 at 3 months after EVT. Binary logistic regression model was used to analyze the influencing factors of futile recanalization. RESULTS A total of 471 patients with a median age of 68 (57, 74) years were included and 68.9% were males, among whom 298 (63.27%) experienced futile recanalization. Multivariate analysis revealed that concomitant atrial fibrillation (OR=0.456, 95%CI: 0.282-0.737, P<0.01), bridging thrombolysis (OR=0.640, 95%CI: 0.416-0.985, P<0.05), achieving mTICI grade 3 (OR=0.554, 95%CI: 0.334-0.918, P<0.05), arterial occlusive lesion (AOL) grade 3 (OR=0.521, 95%CI: 0.326-0.834, P<0.01), and early postoperative statin therapy (OR=0.509, 95%CI: 0.273-0.948, P<0.05) were protective factors for futile recanalization after EVT in acute BAO patients. High baseline National Institutes of Health Stroke Scale (NIHSS) score (OR=1.068, 95%CI: 1.049-1.087, P<0.01), coexisting hypertension (OR=1.571, 95%CI: 1.017-2.427, P<0.05), multiple retrieval attempts (OR=1.237, 95%CI: 1.029-1.488, P<0.05) and postoperative hemorrhagic transformation (OR=8.497, 95%CI: 2.879-25.076, P<0.01) were risk factors. For trial of ORG 10172 in acute stroke treatment (TOAST) classification, cardiogenic embolism (OR=0.321, 95%CI: 0.193-0.534, P<0.01) and other types (OR=0.499, 95%CI: 0.260-0.961, P<0.05) were related to lower incidence of futile recanalization. CONCLUSIONS The incidence of futile recanalization after EVT in patients with acute BAO is high. Bridging venous thrombolysis before operation and an early postoperative statin therapy may reduce the incidence of futile recanalization.
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Affiliation(s)
- Yi Yan
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China.
- Department of Neurology, Zhenhai People's Hospital, Ningbo 315202, Zhejiang Province, China.
| | - Kemeng Zhang
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Wansi Zhong
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Shenqiang Yan
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China
| | - Bing Zhang
- Department of Neurology, Huzhou Central Hospital, Huzhou 313099, Zhejiang Province, China
| | - Jianhua Cheng
- Department of Neurology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325015, Zhejiang Province, China
| | - Min Lou
- Department of Neurology, the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou 310009, China.
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Liu Y, Li Y, Li S, Xie S, Wang J, Wang J, Hong Z. Observation of efficacy of rt-PA thrombolysis combined with Solitaire AB stent mechanical thrombectomy in patients with acute ischemic stroke: a retrospective analysis. Int J Neurosci 2024:1-9. [PMID: 38598308 DOI: 10.1080/00207454.2024.2341911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Accepted: 04/07/2024] [Indexed: 04/12/2024]
Abstract
OBJECTIVE To observe and analyze the efficacy of recombinant tissue-plasminogen activator (rt-PA) thrombolysis combined with Solitaire AB stent mechanical thrombectomy in patients with acute ischemic stroke. METHODS Clinical efficacy, neurological function, oxidative stress response, adverse reactions, and quality of life were compared between the two groups. RESULTS Lower NIHSS scores were observed among patients who received treatment within 2 h after stroke onset when compared with those in a timeframe of 2-6 h, suggesting better neurological function recovery of the patients with early intervention and thus emphasizing the importance of early treatment for patients with stroke onset. Clinical efficacy in the combination group was significantly higher than in the control group (p < 0.05). After treatment, Paraoxonase-1 (PON-1) levels were higher, while lipoprotein-associated phospholipase A2 (Lp-PLA2) and Serum Amyloid A (SAA) levels were lower in the combination group compared to the control group (p < 0.05). The incidence of adverse reactions was significantly lower in the combination group (p < 0.05). At discharge, we observed significantly more patients with good recovery in the combination group when compared to the control group (p < 0.05), suggesting better quality of life of the patients, while this statistical significance was no longer observable at 90 days after discharge (p > 0.05). CONCLUSION For acute ischemic stroke patients, rt-PA thrombolysis combined with Solitaire AB stent mechanical thrombectomy treatment is effective. It promotes neurological function recovery, improves vascular stenosis, reduces inflammation and adverse reactions, and enhances quality of life, showing promising clinical applications.
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Affiliation(s)
- Yongchang Liu
- Department of Neurovascular Intervention, Cangzhou Central Hospital, Cangzhou, China
| | - Yan Li
- Department of Neurovascular Intervention, Cangzhou Central Hospital, Cangzhou, China
| | - Shaoquan Li
- Department of Neurovascular Intervention, Cangzhou Central Hospital, Cangzhou, China
| | - Songwang Xie
- Department of Neurovascular Intervention, Cangzhou Central Hospital, Cangzhou, China
| | - Junyong Wang
- Department of Neurovascular Intervention, Cangzhou Central Hospital, Cangzhou, China
| | - Jian Wang
- Department of Neurovascular Intervention, Cangzhou Central Hospital, Cangzhou, China
| | - Zhen Hong
- Department of Neurovascular Intervention, Cangzhou Central Hospital, Cangzhou, China
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18
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Selman CJ, Lee KJ, Ferguson KN, Whitehead CL, Manley BJ, Mahar RK. Statistical analyses of ordinal outcomes in randomised controlled trials: a scoping review. Trials 2024; 25:241. [PMID: 38582924 PMCID: PMC10998402 DOI: 10.1186/s13063-024-08072-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 03/22/2024] [Indexed: 04/08/2024] Open
Abstract
BACKGROUND Randomised controlled trials (RCTs) aim to estimate the causal effect of one or more interventions relative to a control. One type of outcome that can be of interest in an RCT is an ordinal outcome, which is useful to answer clinical questions regarding complex and evolving patient states. The target parameter of interest for an ordinal outcome depends on the research question and the assumptions the analyst is willing to make. This review aimed to provide an overview of how ordinal outcomes have been used and analysed in RCTs. METHODS The review included RCTs with an ordinal primary or secondary outcome published between 2017 and 2022 in four highly ranked medical journals (the British Medical Journal, New England Journal of Medicine, The Lancet, and the Journal of the American Medical Association) identified through PubMed. Details regarding the study setting, design, the target parameter, and statistical methods used to analyse the ordinal outcome were extracted. RESULTS The search identified 309 studies, of which 144 were eligible for inclusion. The most used target parameter was an odds ratio, reported in 78 (54%) studies. The ordinal outcome was dichotomised for analysis in 47 ( 33 % ) studies, and the most common statistical model used to analyse the ordinal outcome on the full ordinal scale was the proportional odds model (64 [ 44 % ] studies). Notably, 86 (60%) studies did not explicitly check or describe the robustness of the assumptions for the statistical method(s) used. CONCLUSIONS The results of this review indicate that in RCTs that use an ordinal outcome, there is variation in the target parameter and the analytical approaches used, with many dichotomising the ordinal outcome. Few studies provided assurance regarding the appropriateness of the assumptions and methods used to analyse the ordinal outcome. More guidance is needed to improve the transparent reporting of the analysis of ordinal outcomes in future trials.
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Affiliation(s)
- Chris J Selman
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia.
- Department of Paediatrics, University of Melbourne, Parkville, VIC, 3052, Australia.
| | - Katherine J Lee
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Kristin N Ferguson
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Clare L Whitehead
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
- Department of Maternal Fetal Medicine, The Royal Women's Hospital, Parkville, VIC, 3052, Australia
| | - Brett J Manley
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
- Newborn Research, The Royal Women's Hospital, Parkville, VIC, 3052, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
| | - Robert K Mahar
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, VIC, 3052, Australia
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19
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Gory B, Finitsis S, Olivot JM, Richard S, Marnat G, Sibon I, Viguier A, Cognard C, Mazighi M, Chamorro A, Lapergue B, Maïer B. Intravenous Thrombolysis before Complete Angiographic Reperfusion: Beyond Angiographic Assessment to Target Microvascular Obstruction? Ann Neurol 2024; 95:762-773. [PMID: 38148607 DOI: 10.1002/ana.26867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 12/28/2023]
Abstract
OBJECTIVE Recent data have suggested that ineffective tissue reperfusion despite successful angiographic reperfusion was partly responsible for unfavorable outcomes after endovascular therapy (EVT) and might be modulated by intravenous thrombolysis (IVT) use before EVT. To specifically decipher the effect played by IVT before EVT, we compared the clinical and safety outcomes of patients who experienced a complete reperfusion at the end of EVT according to IVT use before EVT. METHODS The Endovascular Treatment in Ischemic Stroke (ETIS) registry is an ongoing, prospective, observational study at 21 centers that perform EVT in France. Patients were included if they had an anterior large vessel occlusion of the intracranial internal carotid artery or middle cerebral artery (M1/M2 segments) and complete reperfusion (expanded Thrombolysis in Cerebral Infarction score = 3) with EVT within 6 hours, between January 2015 and December 2021. The cohort was divided into two groups according to IVT use before EVT, and propensity score matching (PSM) was used to balance the two groups. Primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included favorable outcome (mRS 0-2) at 90 days. Safety outcomes included symptomatic intracranial hemorrhage and 90-day mortality. Outcomes were estimated with multivariate logistic models adjusted for age, National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT Score, and time from symptom onset to puncture. RESULTS Among 5,429 patients included in the ETIS registry, 1,093 were included in the study, including 651 patients with complete recanalization treated with IVT before EVT. After PSM, 488 patients treated with IVT before EVT were compared to 337 patients without IVT. In the matched cohort analysis, the IVT+EVT group had a favorable shift in the overall mRS score distribution (adjusted odds ratio [aOR] = 1.41, 95% confidence interval [CI] = 1.04-1.91, p = 0.023) and higher rates of favorable outcome (61.1% vs 48.7%, aOR = 1.49, 95% CI = 1.02-2.20, p = 0.041) at 90 days compared with the EVT alone group. Rates of symptomatic intracerebral hemorrhage were comparable between both groups (6.0% vs 4.3%, aOR = 1.16, 95% CI = 0.53-2.54, p = 0.709). INTERPRETATION In clinical practice, even after complete angiographic reperfusion by EVT, prior IVT use improves clinical outcomes of patients without increasing bleeding risk. ANN NEUROL 2024;95:762-773.
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Affiliation(s)
- Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, CHRU-Nancy, Nancy, France
- INSERM U1254, IADI, Université de Lorraine, 54511, Vandoeuvre-les-Nancy, France
| | - Stephanos Finitsis
- Aristotle University of Thessaloniki, Ahepa Hospital, Thessaloniki, Greece
| | - Jean-Marc Olivot
- Department of Vascular Neurology, University Hospital of Toulouse, Toulouse, France
| | - Sébastien Richard
- Department of Neurology, Stroke Unit, Université de Lorraine, CHRU-Nancy, Nancy, France
- CIC-P 1433, INSERM U1116, CHRU-Nancy, Nancy, France
| | - Gaultier Marnat
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
| | - Igor Sibon
- Neurology Department, University Hospital of Bordeaux, Bordeaux, France
| | - Alain Viguier
- Department of Vascular Neurology, University Hospital of Toulouse, Toulouse, France
| | | | - Mikael Mazighi
- Department of Interventional Neuroradiology, Hôpital Fondation A. de Rothschild, Paris, France
- Department of Neurology, Hôpital Lariboisière, Paris, France
- Université Paris-Cité, Paris, France
- Université Paris-Cité and Université Sorbonne Paris Nord, Paris, France
| | - Angel Chamorro
- Department of Neuroscience, Comprehensive Stroke Center, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Bertrand Lapergue
- Department of Neurology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - Benjamin Maïer
- Department of Interventional Neuroradiology, Hôpital Fondation A. de Rothschild, Paris, France
- Université Paris-Cité, Paris, France
- Université Paris-Cité and Université Sorbonne Paris Nord, Paris, France
- Department of Neurology, Hôpital Saint-Joseph, Paris, France
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20
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Chen F, Wu L, Zhang M, Kan M, Chen H, Wang X, Qu J. Autophagy-related 5 in acute ischemic stroke: Variation and linkage with neurofunction, and survival. Ann Clin Transl Neurol 2024; 11:856-865. [PMID: 38530706 PMCID: PMC11021666 DOI: 10.1002/acn3.51992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/04/2023] [Accepted: 07/22/2023] [Indexed: 03/28/2024] Open
Abstract
OBJECTIVE Autophagy-related 5 (ATG5) facilitates the pathologic process of acute ischemic stroke (AIS) via multiple ways. This study aimed to identify the association of serum ATG5 with clinical outcomes in AIS patients. METHODS Serum ATG5 from 280 AIS patients were detected at admission, Day (D)1, D3, D7, D30, and D90 after admission by enzyme-linked immunosorbent assay. The median (interquartile range) follow-up was 21.1 (5.9-43.9) months. Another 50 healthy controls (HCs) were also enrolled for serum ATG5 determination. RESULTS ATG5 was elevated (p < 0.001) (vs. HCs), and positively correlated with hyperlipidemia (p = 0.016), and the national institutes of health stroke scale score (p = 0.001) in AIS patients. Interestingly, ATG5 was increased from admission to D1, but gradually decreased until D90 (p < 0.001). Besides, 85 (30.4%) and 195 (69.6%) AIS patients were assessed as modified Rankin Scale (mRS) >2 and mRS ≤2 at D90, respectively. ATG5 at admission, D1, D3, D30, and D90 was elevated in AIS patients with mRS >2 versus those with mRS ≤2 (all p < 0.050). ATG5 at admission, D1, D3, D7, D30, or D90 was elevated in relapsed (vs. non-relapsed) or died (vs. survived) AIS patients (all p < 0.050). Recurrence-free survival was shortened in AIS patients with high (≥52.0 ng/mL) ATG5 versus those with low (<52.0 ng/mL) ATG5 at admission, D3, D7, and D30 (all p < 0.050); overall survival was shorter in AIS patients with high (vs. low) ATG5 at D7 and D30 (both p < 0.050). INTERPRETATION Serum ATG5 elevates at first, thereafter gradually declines, whose elevation associates with neurological dysfunction, recurrence, and death risk in AIS patients.
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Affiliation(s)
- Fan Chen
- Department II of EmergencyHandan Central HospitalHandan056008China
| | - Linxia Wu
- Department II of EmergencyHandan Central HospitalHandan056008China
| | - Meng Zhang
- Department II of EmergencyHandan Central HospitalHandan056008China
| | - Minchen Kan
- Department II of EmergencyHandan Central HospitalHandan056008China
| | - Huimin Chen
- Department II of EmergencyHandan Central HospitalHandan056008China
| | - Xiaohua Wang
- Department I of Neonatal WardHandan Central HospitalHandan056008China
| | - Juanjuan Qu
- Department II of EmergencyHandan Central HospitalHandan056008China
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21
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Sedghi A, Kaiser DPO, Cuberi A, Schreckenbauer S, Wojciechowski C, Friehs I, Reichmann H, Barlinn J, Barlinn K, Puetz V, Siepmann T. Intravenous Thrombolysis Before Thrombectomy Improves Functional Outcome After Stroke Independent of Reperfusion Grade. J Am Heart Assoc 2024; 13:e031854. [PMID: 38456409 PMCID: PMC11009998 DOI: 10.1161/jaha.123.031854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 01/17/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND We studied the association of bridging intravenous thrombolysis (IVT) before thrombectomy for anterior circulation large-vessel occlusion and functional outcome and scrutinized its dependence on grade of reperfusion and distal thrombus migration. METHODS AND RESULTS We included consecutive patients with anterior circulation large-vessel occlusion from our prospective registry of thrombectomy-eligible patients treated from January 1, 2017 to January 1, 2023 at a tertiary stroke center in Germany in this retrospective cohort study. To evaluate the association of bridging IVT and functional outcome quantified via modified Rankin Scale score at 90 days we used multivariable logistic and lasso regression including interaction terms with grade of reperfusion quantified via modified Thrombolysis in Cerebral Infarction (mTICI) scale and distal thrombus migration adjusted for demographic and cardiovascular risk profiles, clinical and imaging stroke characteristics, onset-to-recanalization time and distal thrombus migration. We performed sensitivity analysis using propensity score matching. In our study population of 1000 thrombectomy-eligible patients (513 women; median age, 77 years [interquartile range, 67-84]), IVT emerged as a predictor of favorable functional outcome (modified Rankin Scale score, 0-2) independent of modified mTICI score (adjusted odds ratio, 0.49 [95% CI, 0.32-0.75]; P=0.001). In those who underwent thrombectomy (n=812), the association of IVT and favorable functional outcome was reproduced (adjusted odds ratio, 0.49 [95% CI, 0.31-0.74]; P=0.001) and was further confirmed on propensity score analysis, where IVT led to a 0.35-point decrease in 90-day modified Rankin Scale score (ß=-0.35 [95 CI%, -0.68 to 0.01]; P=0.04). The additive benefit of IVT remained independent of modified mTICI score (ß=-1.79 [95% CI, -3.43 to -0.15]; P=0.03) and distal thrombus migration (ß=-0.41 [95% CI, -0.69 to -0.13]; P=0.004) on interaction analysis. Consequently, IVT showed an additive association with functional outcome in the subpopulation of patients undergoing thrombectomy who achieved successful reperfusion (mTICI ≥2b; ß=-0.46 [95% CI, -0.74 to -0.17]; P=0.002) and remained beneficial in those with unsuccessful reperfusion (mTICI ≤2a; ß=-0.47 [95% CI, -0.96 to 0.01]; P=0.05). CONCLUSIONS In thrombectomy-eligible patients with anterior circulation large-vessel occlusion, IVT improves functional outcome independent of grade of reperfusion and distal thrombus migration.
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Affiliation(s)
- Annahita Sedghi
- Dresden Neurovascular Center, Department of Neurology, Medical Faculty and University Hospital Carl Gustav CarusDresden University of TechnologyDresdenGermany
- Division of Health Care SciencesDresden International UniversityDresdenGermany
| | - Daniel P. O. Kaiser
- Dresden Neurovascular Center, Institute of Neuroradiology, Medical Faculty and University Hospital Carl Gustav Carus, Dresden University of TechnologyDresdenGermany
| | - Ani Cuberi
- Institute of Radiology, Medical Faculty and University Hospital Carl Gustav Carus, Dresden University of TechnologyDresdenGermany
| | - Sonja Schreckenbauer
- Dresden Neurovascular Center, Department of Neurology, Medical Faculty and University Hospital Carl Gustav CarusDresden University of TechnologyDresdenGermany
| | - Claudia Wojciechowski
- Dresden Neurovascular Center, Department of Neurology, Medical Faculty and University Hospital Carl Gustav CarusDresden University of TechnologyDresdenGermany
| | - Ingeborg Friehs
- Department of Cardiac SurgeryBoston Children’s Hospital, Harvard Medical SchoolBostonMAUSA
| | - Heinz Reichmann
- Dresden Neurovascular Center, Department of Neurology, Medical Faculty and University Hospital Carl Gustav CarusDresden University of TechnologyDresdenGermany
| | - Jessica Barlinn
- Dresden Neurovascular Center, Department of Neurology, Medical Faculty and University Hospital Carl Gustav CarusDresden University of TechnologyDresdenGermany
| | - Kristian Barlinn
- Dresden Neurovascular Center, Department of Neurology, Medical Faculty and University Hospital Carl Gustav CarusDresden University of TechnologyDresdenGermany
| | - Volker Puetz
- Dresden Neurovascular Center, Department of Neurology, Medical Faculty and University Hospital Carl Gustav CarusDresden University of TechnologyDresdenGermany
| | - Timo Siepmann
- Dresden Neurovascular Center, Department of Neurology, Medical Faculty and University Hospital Carl Gustav CarusDresden University of TechnologyDresdenGermany
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22
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Zhang W, Chen S, Ma B, Ding Y, Liu X, He C, Wang B, Yuan M. Trifluoperazine regulates blood-brain barrier permeability via the MLCK/p-MLC pathway to promote ischemic stroke recovery. iScience 2024; 27:109156. [PMID: 38439960 PMCID: PMC10910233 DOI: 10.1016/j.isci.2024.109156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2023] [Revised: 12/19/2023] [Accepted: 02/02/2024] [Indexed: 03/06/2024] Open
Abstract
Blood-brain barrier (BBB) disruption following ischemic stroke (IS) can induce significant aftereffects. Elevated calmodulin (CaM) expression following stroke causes calcium overload-a key contributor to BBB collapse. Trifluoperazine (TFP), a CaM inhibitor, reduces CaM overexpression following IS. However, it remains unclear whether TFP participates in BBB repair after IS. We administered TFP to mice subjected to middle cerebral artery occlusion (MCAO) and bEnd.3 cells subjected to oxygen-glucose deprivation (OGD). TFP treatment in MCAO mice reduced cerebral CaM expression and infarct size and decreased BBB permeability. OGD-treated bEnd.3 cells showed significantly increased CaM protein levels and reduced tight junction (TJ) protein levels; these changes were reversed by TFP treatment. Our results found that TFP administration in mice inhibited actin contraction following cerebral ischemia-reperfusion by suppressing the MLCK/p-MLC pathway, thereby attenuating cell retraction, improving TJ protein integrity, and reducing BBB permeability. Consequently, this treatment may promote neurological function recovery after IS.
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Affiliation(s)
- Wentao Zhang
- The Second Affiliated Hospital, Department of Neurology, Hengyang Medical School, University of South China, Hengyang, Hunan 421001, China
| | - Sisi Chen
- The Second Affiliated Hospital, Department of Neurology, Hengyang Medical School, University of South China, Hengyang, Hunan 421001, China
| | - Bin Ma
- The Second Affiliated Hospital, Department of Neurology, Hengyang Medical School, University of South China, Hengyang, Hunan 421001, China
| | - Yingmei Ding
- The Second Affiliated Hospital, Department of Neurology, Hengyang Medical School, University of South China, Hengyang, Hunan 421001, China
| | - Xiaofen Liu
- The Second Affiliated Hospital, Department of Neurology, Hengyang Medical School, University of South China, Hengyang, Hunan 421001, China
| | - Caijun He
- The Second Affiliated Hospital, Department of Neurology, Hengyang Medical School, University of South China, Hengyang, Hunan 421001, China
| | - Biao Wang
- The Second Affiliated Hospital, Department of Neurology, Hengyang Medical School, University of South China, Hengyang, Hunan 421001, China
| | - Mei Yuan
- The Second Affiliated Hospital, Department of Neurology, Hengyang Medical School, University of South China, Hengyang, Hunan 421001, China
- Affiliated Nanhua Hospital, Department of Neurology, Hengyang Medical School, University of South China, Hengyang, Hunan 421001, China
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23
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Nogueira RG, Kimura K, Matsumaru Y, Suzuki K, Qiu Z, Zi W, Moran TP, Li F, Sang H, Luo W, Liu S, Yuan J, Song J, Huang J, Takeuchi M, Morimoto M, Otsuka T, Yang Q. Systemic THrombolysis Randomization IN Endovascular Stroke Therapy (SHRINE) Collaboration: a patient-level pooled analysis of the SKIP and DEVT Trials. J Neurointerv Surg 2024; 16:359-364. [PMID: 37290918 DOI: 10.1136/jnis-2023-020307] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 04/29/2023] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To evaluate the non-inferiority of endovascular treatment (EVT) alone versus intravenous thrombolysis (IVT) followed by EVT and to assess its heterogeneity across prespecified subgroups. METHODS We pooled data from two trials (SKIP in Japan; DEVT in China). Individual patient data were pooled to assess outcomes and heterogeneity of treatment effect. The primary outcome was functional independence (modified Rankin Scale score 0-2) at 90 days. Safety outcomes included symptomatic intracranial hemorrhage (sICH) and 90-day mortality. RESULTS We included 438 patients (217 EVT alone; 221 combined IVT+EVT). The meta-analysis failed to demonstrate the non-inferiority of EVT alone over combined IVT+EVT in achieving 90-day functional independence (56.7% vs 51.6%; adjusted common odds ratio (cOR)=1.27, 95% CI 0.84 to 1.92, pnon-inferiority=0.06). Effect sizes favoring EVT alone were present with stroke onset to puncture time longer than 180 min (cOR=2.28, 95% CI 1.18 to 4.38, pinteraction ≤180 vs >180 min=0.02) and intracranial internal carotid artery ICA occlusions (for ICA cOR=3.04, 95% CI 1.10 to 8.43, pinteraction ICA vs MCA=0.08). The rates of sICH (6.5% vs 9.0%; cOR=0.77, 95% CI 0.37 to 1.61) and 90-day mortality (12.9% vs 13.6%; cOR=1.05, 95% CI 0.58 to 1.89) were comparable. CONCLUSIONS The cumulative data of these two recent Asian trials failed to unequivocally demonstrate the non-inferiority of EVT alone over combined IVT+EVT. However, our study suggests a potential role for more individualized decision-making. Specifically, Asian patients with stroke onset to EVT longer than 180 min, as well as those with intracranial ICA occlusions and those with atrial fibrillation might have better outcomes with EVT alone than with combined IVT+EVT.
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Affiliation(s)
- Raul G Nogueira
- Department of Neurology and Neurosurgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Yuji Matsumaru
- Division of Stroke Prevention and Treatment, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Zhongming Qiu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
- Department of Neurology, 903th Hospital of PLA, Hangzhou, Zhejiang, China
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Timothy P Moran
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Hongfei Sang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Weidong Luo
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Shuai Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Junjie Yuan
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jiaxing Song
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jiacheng Huang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | | | - Masafumi Morimoto
- Department of Neurosurgery, Yokohama Shintoshi Neurosurgery Hospital, Kanagawa, Yokohama, Japan
| | - Toshiaki Otsuka
- Department of Hygiene and Public Health, Nippon Medical School, Bunkyo-ku, Japan
| | - Qingwu Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
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24
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Li Z, Zhou Y, Zhang X, Zhang L, Zhang Y, Xing P, Zhang Y, Huang Q, Li Q, Zuo Q, Ye X, Liu J, Yang P. Effect of Clot Burden Score on Safety and Efficacy of Intravenous Alteplase Prior to Mechanical Thrombectomy in Acute Ischemic Stroke: A Subgroup Analysis of a Randomized Phase 3 Trial. AJNR Am J Neuroradiol 2024; 45:296-301. [PMID: 38388688 DOI: 10.3174/ajnr.a8134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 12/04/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND AND PURPOSE Whether thrombus burden in acute ischemic stroke modify the effect of intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) remains uncertain. We aim to investigate the treatment effect of stratified clot burden score (CBS) on the efficacy and safety of direct versus bridging MT. MATERIALS AND METHODS This is an exploratory subgroup analysis of a randomized trial evaluating the effect of CBS on clinical outcome in the DIRECT-MT trial. CBS was divided into 3 groups (0-3, 4-6, and 7-10) based on preoperative CTA, where higher scores indicated a lower clot burden. We report the adjusted common odds ratio for a shift toward better outcomes on the mRS after thrombectomy alone compared with combination treatment by stratified CBS groups. RESULTS No modification effect of mRS distribution was observed by CBS subgroups (CBS 0-3: adjusted common ratio odds 1.519 [95% CI, 0.928-2.486]; 4-6: 0.924 [0.635-1.345]; 7-10: 1.040 [0.481-2.247]). Patients with CBS 4-6 had a higher rate of early reperfusion (adjusted OR (aOR), 0.3 [95% CI, 0.1-0.9]), final reperfusion (aOR 0.5 [95% CI, 0.3-0.9]), and fewer thrombectomy attempts (aOR 0.4 [95% CI, 0.1-0.7]). Patients with CBS 7-10 had a higher rate of asymptomatic intracranial hemorrhage (14.9% versus 36.8%, P = .0197) for bridging MT. No significant difference was observed in other safety outcomes by trichotomized CBS. CONCLUSIONS The subgroup analysis of DIRECT-MT suggested that thrombus burden did not alter the treatment effect of IVT before MT on functional outcomes in CBS subgroups.
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Affiliation(s)
- Zifu Li
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yu Zhou
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xiaoxi Zhang
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Lei Zhang
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yongwei Zhang
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Pengfei Xing
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yongxin Zhang
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qinghai Huang
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qiang Li
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qiao Zuo
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xiaofei Ye
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jianmin Liu
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Pengfei Yang
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
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Kaesmacher J, Cavalcante F, Kappelhof M, Treurniet KM, Rinkel L, Liu J, Yan B, Zi W, Kimura K, Eker OF, Zhang Y, Piechowiak EI, van Zwam W, Liu S, Strbian D, Uyttenboogaart M, Dobrocky T, Miao Z, Suzuki K, Zhang L, van Oostenbrugge R, Meinel TR, Guo C, Seiffge D, Yin C, Bütikofer L, Lingsma H, Nieboer D, Yang P, Mitchell P, Majoie C, Fischer U, Roos Y, Gralla J. Time to Treatment With Intravenous Thrombolysis Before Thrombectomy and Functional Outcomes in Acute Ischemic Stroke: A Meta-Analysis. JAMA 2024; 331:764-777. [PMID: 38324409 PMCID: PMC10851137 DOI: 10.1001/jama.2024.0589] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2023] [Accepted: 01/16/2024] [Indexed: 02/09/2024]
Abstract
Importance The benefit of intravenous thrombolysis (IVT) for acute ischemic stroke declines with longer time from symptom onset, but it is not known whether a similar time dependency exists for IVT followed by thrombectomy. Objective To determine whether the benefit associated with IVT plus thrombectomy vs thrombectomy alone decreases with treatment time from symptom onset. Design, Setting, and Participants Individual participant data meta-analysis from 6 randomized clinical trials comparing IVT plus thrombectomy vs thrombectomy alone. Enrollment was between January 2017 and July 2021 at 190 sites in 15 countries. All participants were eligible for IVT and thrombectomy and presented directly at thrombectomy-capable stroke centers (n = 2334). For this meta-analysis, only patients with an anterior circulation large-vessel occlusion were included (n = 2313). Exposure Interval from stroke symptom onset to expected administration of IVT and treatment with IVT plus thrombectomy vs thrombectomy alone. Main Outcomes and Measures The primary outcome analysis tested whether the association between the allocated treatment (IVT plus thrombectomy vs thrombectomy alone) and disability at 90 days (7-level modified Rankin Scale [mRS] score range, 0 [no symptoms] to 6 [death]; minimal clinically important difference for the rates of mRS scores of 0-2: 1.3%) varied with times from symptom onset to expected administration of IVT. Results In 2313 participants (1160 in IVT plus thrombectomy group vs 1153 in thrombectomy alone group; median age, 71 [IQR, 62 to 78] years; 44.3% were female), the median time from symptom onset to expected administration of IVT was 2 hours 28 minutes (IQR, 1 hour 46 minutes to 3 hours 17 minutes). There was a statistically significant interaction between the time from symptom onset to expected administration of IVT and the association of allocated treatment with functional outcomes (ratio of adjusted common odds ratio [OR] per 1-hour delay, 0.84 [95% CI, 0.72 to 0.97], P = .02 for interaction). The benefit of IVT plus thrombectomy decreased with longer times from symptom onset to expected administration of IVT (adjusted common OR for a 1-step mRS score shift toward improvement, 1.49 [95% CI, 1.13 to 1.96] at 1 hour, 1.25 [95% CI, 1.04 to 1.49] at 2 hours, and 1.04 [95% CI, 0.88 to 1.23] at 3 hours). For a mRS score of 0, 1, or 2, the predicted absolute risk difference was 9% (95% CI, 3% to 16%) at 1 hour, 5% (95% CI, 1% to 9%) at 2 hours, and 1% (95% CI, -3% to 5%) at 3 hours. After 2 hours 20 minutes, the benefit associated with IVT plus thrombectomy was not statistically significant and the point estimate crossed the null association at 3 hours 14 minutes. Conclusions and Relevance In patients presenting at thrombectomy-capable stroke centers, the benefit associated with IVT plus thrombectomy vs thrombectomy alone was time dependent and statistically significant only if the time from symptom onset to expected administration of IVT was short.
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Affiliation(s)
- Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Fabiano Cavalcante
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Kilian M. Treurniet
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
- Department of Radiology, Haaglanden Medical Center, the Hague, the Netherlands
| | - Leon Rinkel
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Jianmin Liu
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
- Oriental Pan-Vascular Devices Innovations College, University of Shanghai for Science and Technology, Shanghai, China
| | - Bernard Yan
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Omer F. Eker
- Department of Neuroradiology, Hospices Civils de Lyon, Lyon, France
| | - Yongwei Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Eike I. Piechowiak
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Wim van Zwam
- Department of Radiology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Sheng Liu
- Department of Radiology, Jiangsu Provincial People’s Hospital of Nanjing Medical University, Nanjing, China
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Maarten Uyttenboogaart
- Department of Neurology, University Medical Center Groningen, Groningen, the Netherlands
| | - Tomas Dobrocky
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Lei Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Robert van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Thomas R. Meinel
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Changwei Guo
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - David Seiffge
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Congguo Yin
- Department of Neurology, Hangzhou First People’s Hospital of Zhejiang University, Hangzhou, China
| | | | - Hester Lingsma
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherland
| | - Daan Nieboer
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherland
| | - Pengfei Yang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
- Oriental Pan-Vascular Devices Innovations College, University of Shanghai for Science and Technology, Shanghai, China
| | - Peter Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Charles Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Urs Fischer
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
- Department of Neurology, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Yvo Roos
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
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He Q, Meng C, Jia M, Tan J, Huang K, Gan H, Li L, Zhao J. NLRP6 deficiency inhibits neuroinflammation and ameliorates brain injury in ischemic stroke by blocking NLRs inflammasomes activation through proteasomal degradation of pro-caspase-1. Neurobiol Dis 2024; 192:106434. [PMID: 38341160 DOI: 10.1016/j.nbd.2024.106434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Revised: 02/05/2024] [Accepted: 02/06/2024] [Indexed: 02/12/2024] Open
Abstract
Innate inflammation is crucial for ischemic stroke development. NLRP6, a nucleotide-binding and oligomerization domain-like receptors (NLRs) family member, regulates innate inflammation. Whether NLRP6 regulates neurological damage and neuroinflammation during ischemic stroke remains unclear. We report that NLRP6 is abundantly expressed in microglia and significantly upregulated in the ischemic brain. The brain injury severity was alleviated in NLRP6-deficient mice after ischemic stroke, as evidenced by reduced cerebral infarct volume, decreased neurological deficit scores, improved histopathological morphological changes, ameliorated neuronal denaturation, and relief of sensorimotor dysfunction. In the co-culture OGD/R model, NLRP6 deficiency prevented neuronal death and attenuated microglial cell injury. NLRP6 deficiency blocked several NLRs inflammasomes' activation and abrogated inflammasome-related cytokine production by decreasing the expression of the common effector pro-caspase-1. NLRP6 deficiency reduced pro-caspase-1's protein level by inducing proteasomal degradation. These findings confirm the neuroprotective role of NLRP6 deficiency in ischemic stroke and its underlying regulation mechanism in neuroinflammation and provide a potential therapeutic target for ischemic stroke.
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Affiliation(s)
- Qi He
- Department of Pathophysiology, Chongqing Medical University, Chongqing 400010, China; Center for Neuroscience Research, Chongqing Medical University, Chongqing 400010, China
| | - Changchang Meng
- Zunyi Medical University Zhuhai Campus, Zhuhai, Guangdong Province 519000, China
| | - Mengjie Jia
- Department of Pathophysiology, Chongqing Medical University, Chongqing 400010, China; Center for Neuroscience Research, Chongqing Medical University, Chongqing 400010, China
| | - Junyi Tan
- Department of Pathophysiology, Chongqing Medical University, Chongqing 400010, China; Center for Neuroscience Research, Chongqing Medical University, Chongqing 400010, China
| | - Keli Huang
- Department of Pathophysiology, Chongqing Medical University, Chongqing 400010, China; Center for Neuroscience Research, Chongqing Medical University, Chongqing 400010, China
| | - Hui Gan
- Center for Neuroscience Research, Chongqing Medical University, Chongqing 400010, China
| | - Lingyu Li
- Center for Neuroscience Research, Chongqing Medical University, Chongqing 400010, China; Department of Pathology, Chongqing Medical University, Chongqing, 400010, China
| | - Jing Zhao
- Department of Pathophysiology, Chongqing Medical University, Chongqing 400010, China; Center for Neuroscience Research, Chongqing Medical University, Chongqing 400010, China.
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27
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Pop R, Räty S, Riva R, Marnat G, Dobrocky T, Alexandre PL, Lefebvre M, Albucher JF, Boulanger M, Di Maria F, Richard S, Soize S, Piechowiak EI, Liman J, Reich A, Ribo M, Meinel T, Mpotsaris A, Liebeskind DS, Gralla J, Fischer U, Kaesmacher J. Effect of Bridging Thrombolysis on the Efficacy of Stent Retriever Thrombectomy Techniques : Insights from the SWIFT-DIRECT trial. Clin Neuroradiol 2024; 34:93-103. [PMID: 37640839 DOI: 10.1007/s00062-023-01340-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 07/11/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND There are little available data regarding the influence of intravenous thrombolysis (IVT) on the efficacy of different first line endovascular treatment (EVT) techniques. METHODS We used the dataset of the SWIFT-DIRECT trial which randomized 408 patients to IVT + EVT or EVT alone at 48 international sites. The protocol required the use of a stent retriever (SR), but concomitant use of a balloon guide catheter (BGC) and/or distal aspiration (DA) catheter was left to the discretion of the operators. Four first line techniques were applied in the study population: SR, SR + BGC, SR + DA, SR + DA + BGC. To assess whether the effect of allocation to IVT + EVT versus EVT alone was modified by the first line technique, interaction models were fitted for predefined outcomes. The primary outcome was first pass mTICI 2c‑3 reperfusion (FPR). RESULTS This study included 385 patients of whom 172 were treated with SR + DA, 121 with SR + DA + BGC, 57 with SR + BGC and 35 with SR. There was no evidence that the effect of IVT + EVT versus EVT alone would be modified by the choice of first line technique; however, allocation to IVT + EVT increased the odds of FPR by a factor of 1.68 (95% confidence interval, CI 1.11-2.54). CONCLUSION This post hoc analysis does not suggest treatment effect heterogeneity of IVT + EVT vs EVT alone in different stent retriever techniques but provides evidence for increased FPR if bridging IVT is administered before stent retriever thrombectomy.
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Affiliation(s)
- Raoul Pop
- Interventional Neuroradiology Department, Strasbourg University Hospitals, Strasbourg, France.
- INSERM U1255, University of Strasbourg, Strasbourg, France.
- Institut de Chirurgie Minime Invasive Guidée par l'Image, Strasbourg, France.
| | - Silja Räty
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Roberto Riva
- Department of Neuroradiology, Hospices Civils de Lyon, Lyon, France
| | - Gaultier Marnat
- Department of Interventional and Diagnostic Neuroradiology, CHU Bordeaux, University of Bordeaux, Bordeaux, France
| | - Tomas Dobrocky
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Pierre Louis Alexandre
- Department of Diagnostic and Interventional Neuroradiology, Centre Hospitalier Universitaire de Nantes, Nantes Université, Nantes, France
| | | | | | - Marion Boulanger
- Service de Neurologie, Université Caen Normandie, CHU Caen Normandie, Caen, France
| | - Federico Di Maria
- Department of Stroke and Diagnostic and Interventional Neuroradiology, Foch Hospital, Suresnes, France
| | - Sébastien Richard
- Department of Neurology, Stroke Unit, CHRU-Nancy, INSERM U1116, Université de Lorraine, Nancy, France
| | | | - Eike Immo Piechowiak
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jan Liman
- Department of Neurology, University Medical Center Goettingen, Goettingen, Germany
- Department of Neurology, University Medical Center Nuremberg, Paracelsus Private University, Nuremberg, Germany
| | - Arno Reich
- Department of Neurology, University Hospital RWTH Aachen, Aachen, Germany
| | - Marc Ribo
- Stroke Unit. Department of Neurology, Vall d'Hebron Hospital, Barcelona, Spain
| | - Thomas Meinel
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - David S Liebeskind
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles, USA
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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28
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Al-Mufti F, Marden FA, Burkhardt JK, Raper D, Schirmer CM, Baker A, Chen PR, Bulsara KR, Narsinh KH, Amans MR, Cooper J, Yaghi S, Al-Kawaz M, Hetts SW. Endovascular therapy for anterior circulation emergent large vessel occlusion stroke in patients with large ischemic cores: a report of the SNIS Standards and Guidelines Committee. J Neurointerv Surg 2024:jnis-2023-021444. [PMID: 38395601 DOI: 10.1136/jnis-2023-021444] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2024] [Accepted: 01/26/2024] [Indexed: 02/25/2024]
Abstract
BACKGROUND Early clinical trials validating endovascular therapy (EVT) for emergent large vessel occlusion (ELVO) ischemic stroke in the anterior circulation initially focused on patients with small or absent completed infarctions (ischemic cores) to maximize the probability of detecting a clinically meaningful and statistically significant benefit of EVT. Subsequently, real-world experience suggested that patients with large core ischemic strokes (LCS) at presentation may also benefit from EVT. Several large, retrospective, and prospective randomized clinical trials have recently been published that further validate this approach. These guidelines aim to provide an update for endovascular treatment of LCS. METHODS A structured literature review of LCS studies available since 2019 and grading the strength and quality of the evidence was performed. Recommendations were made based on these new data by consensus of the authors, with additional input from the full SNIS Standards and Guidelines Committee and the SNIS Board of Directors. RESULTS The management of ELVO strokes with large ischemic cores continues to evolve. The expert panel agreed on several recommendations: Recommendation 1: In patients with anterior circulation ELVO who present within 24 hours of last known normal with large infarct core (70-149 mL or ASPECTS 3-5) and meet other criteria of RESCUE-Japan LIMIT, SELECT2, ANGEL-ASPECT, TESLA, TENSION, or LASTE trials, thrombectomy is indicated (Class I, Level A). Recommendations 2-7 flow directly from recommendation 1. Recommendation 2: EVT in patients with LCS aged 18-85 years is beneficial (Class I, Level A). Recommendation 3: EVT in patients with LCS >85 years of age may be beneficial (Class I, Level B-R). Recommendation 4: Patients with LCS and NIHSS score 6-30 benefit from EVT in LCS (Class I, Level A). Recommendation 5: Patients with LCS and NIHSS score <6 and >30 may benefit from EVT in LCS (Class IIa, Level A). Recommendation 6: Patients with LCS and low baseline mRS (0-1) benefit from EVT (Class I, Level A). Recommendation 7: Patients with LCS and time of last known well 0-24 hours benefit from EVT (Class I, Level A). Recommendation 8: It is recommended that patients with ELVO LCS who also meet the criteria for on-label or guideline-directed use of IV thrombolysis receive IV thrombolysis, irrespective of whether endovascular treatments are being considered (Class I, Level B-NR). CONCLUSIONS The indications for endovascular treatment of ELVO strokes continue to expand and now include patients with large ischemic cores on presentation. Further prospective randomized studies, including follow-up to assess the population-based efficacy of treating patients with LCS, are warranted.
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Affiliation(s)
- Fawaz Al-Mufti
- Departments of Neurology and Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Franklin A Marden
- Interventional Neuroradiology, Alexian Brothers Medical Center, Elk Grove Village, Illinois, USA
| | - Jan Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Daniel Raper
- Departments of Neurological Surgery, Radiology, and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Clemens M Schirmer
- Department of Neurosurgery, Geisinger Health System, Wilkes-Barre, Pennsylvania, USA
| | - Amanda Baker
- Departments of Radiology, Biomedical Imaging, and Neurological Surgery, UCSF, San Francisco, California, USA
| | - Peng Roc Chen
- Neurosurgery, The University of Texas Health Science Center at Houston Vivian L Smith Department of Neurosurgery, Houston, Texas, USA
| | - Ketan R Bulsara
- Division of Neurosurgery, University of Connecticut, Farmington, Connecticut, USA
| | - Kazim H Narsinh
- Departments of Radiology, Biomedical Imaging, and Neurological Surgery, University of California San Francisco, San Francisco, California, USA
| | - Matthew Robert Amans
- Departments of Radiology, Biomedical Imaging, and Neurological Surgery, UCSF, San Francisco, California, USA
| | - Jared Cooper
- Department of Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Shadi Yaghi
- Department of Neurology, Warren Alpert School of Medicine at Brown University, Providence, Rhode Island, USA
- Department of Neurology, Rhode Island Hospital, Providence, Rhode Island, USA
| | - Mais Al-Kawaz
- Departments of Neurology, Neurosurgery, and Radiology, University of Kentucky, Lexington, Kentucky, USA
- Mount Sinai Health System, New York, New York, USA
| | - Steven W Hetts
- Radiology, Biomedical Imaging, and Neurological Surgery, UCSF, San Francisco, California, USA
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Zhao J, Liu S, Li K, Yang Y, Zhao Y, Zhu X. RBM3 Promotes Anti-inflammatory Responses in Microglia and Serves as a Neuroprotective Target of Ischemic Stroke. Mol Neurobiol 2024:10.1007/s12035-024-04052-4. [PMID: 38386136 DOI: 10.1007/s12035-024-04052-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 02/09/2024] [Indexed: 02/23/2024]
Abstract
Ischemic stroke is a major cause of death and disability in adults. Hypothermic treatment is successful in treating neonatal cerebral ischemia, but its application is restricted in adult patients due to complex management strategies and severe adverse effects. Two homologous RNA-binding proteins, RBM3 and CIRP, are the only known cold-inducible proteins in vertebrates, and their expression levels are robustly elevated by mild to moderate hypothermia. In previous studies, we and others have demonstrated that both RBM3 and CIRP mediate the neuroprotective and neurogenic effects of hypothermia in cell and animal models. However, CIRP can also be detrimental to neurons by triggering neuroinflammatory responses, complicating its post-stroke functions. In this study, we compared the properties of the two cold-inducible RNA-binding proteins after ischemic stroke. Our results indicated that RBM3 expression was stimulated in the ischemic brain of stroke patients, while CIRP expression was not. In an experimental model, RBM3 can ameliorate ischemic-like insult by promoting neuronal survival and eliciting anti-inflammatory responses in activated microglia, while the impact of CIRP was intriguing. Collectively, our data supported the notion that RBM3 may be a more promising therapeutic target than CIRP for treating ischemic stroke. We further demonstrated that zr17-2, a small molecule initially identified to target CIRP, can specifically target RBM3 but not CIRP in microglia. zr17-2 demonstrated anti-inflammatory and neuroprotective effects after ischemic stroke both in vitro and in vivo, suggesting its potential therapeutic value.
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Affiliation(s)
- Junyi Zhao
- The Brain Cognition and Brain Disease Institute (BCBDI), Shenzhen Institute of Advanced Technology (SIAT), Chinese Academy of Sciences, Shenzhen, China
- Shenzhen Key Laboratory of Neuroimmunomodulation for Neurological Diseases, Shenzhen, China
| | - Siyu Liu
- The Brain Cognition and Brain Disease Institute (BCBDI), Shenzhen Institute of Advanced Technology (SIAT), Chinese Academy of Sciences, Shenzhen, China
- Shenzhen Key Laboratory of Neuroimmunomodulation for Neurological Diseases, Shenzhen, China
| | - Kunyu Li
- The Brain Cognition and Brain Disease Institute (BCBDI), Shenzhen Institute of Advanced Technology (SIAT), Chinese Academy of Sciences, Shenzhen, China
| | - Yulu Yang
- The Brain Cognition and Brain Disease Institute (BCBDI), Shenzhen Institute of Advanced Technology (SIAT), Chinese Academy of Sciences, Shenzhen, China
- School of Life Sciences, University of Science and Technology of China, Hefei, China
| | - Yue Zhao
- The Brain Cognition and Brain Disease Institute (BCBDI), Shenzhen Institute of Advanced Technology (SIAT), Chinese Academy of Sciences, Shenzhen, China
- Shenzhen Key Laboratory of Neuroimmunomodulation for Neurological Diseases, Shenzhen, China
| | - Xinzhou Zhu
- The Brain Cognition and Brain Disease Institute (BCBDI), Shenzhen Institute of Advanced Technology (SIAT), Chinese Academy of Sciences, Shenzhen, China.
- Shenzhen Key Laboratory of Neuroimmunomodulation for Neurological Diseases, Shenzhen, China.
- Shenzhen-Hong Kong Institute of Brain Science-Shenzhen Fundamental Research Institutions, Shenzhen, China.
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30
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Gong Z, Zeng L, Jiang B, Zhu R, Wang J, Li M, Shao A, Lv Z, Zhang M, Guo L, Li G, Sun J, Chen Y. Dynamic cerebral blood flow assessment based on electromagnetic coupling sensing and image feature analysis. Front Bioeng Biotechnol 2024; 12:1276795. [PMID: 38449677 PMCID: PMC10915240 DOI: 10.3389/fbioe.2024.1276795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2023] [Accepted: 02/07/2024] [Indexed: 03/08/2024] Open
Abstract
Dynamic assessment of cerebral blood flow (CBF) is crucial for guiding personalized management and treatment strategies, and improving the prognosis of stroke. However, a safe, reliable, and effective method for dynamic CBF evaluation is currently lacking in clinical practice. In this study, we developed a CBF monitoring system utilizing electromagnetic coupling sensing (ECS). This system detects variations in brain conductivity and dielectric constant by identifying the resonant frequency (RF) in an equivalent circuit containing both magnetic induction and electrical coupling. We evaluated the performance of the system using a self-made physical model of blood vessel pulsation to test pulsatile CBF. Additionally, we recruited 29 healthy volunteers to monitor cerebral oxygen (CO), cerebral blood flow velocity (CBFV) data and RF data before and after caffeine consumption. We analyzed RF and CBFV trends during immediate responses to abnormal intracranial blood supply, induced by changes in vascular stiffness, and compared them with CO data. Furthermore, we explored a method of dynamically assessing the overall level of CBF by leveraging image feature analysis. Experimental testing substantiates that this system provides a detection range and depth enhanced by three to four times compared to conventional electromagnetic detection techniques, thereby comprehensively covering the principal intracranial blood supply areas. And the system effectively captures CBF responses under different intravascular pressure stimulations. In healthy volunteers, as cerebral vascular stiffness increases and CO decreases due to caffeine intake, the RF pulsation amplitude diminishes progressively. Upon extraction and selection of image features, widely used machine learning algorithms exhibit commendable performance in classifying overall CBF levels. These results highlight that our proposed methodology, predicated on ECS and image feature analysis, enables the capture of immediate responses of abnormal intracranial blood supply triggered by alterations in vascular stiffness. Moreover, it provides an accurate diagnosis of the overall CBF level under varying physiological conditions.
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Affiliation(s)
- Zhiwei Gong
- School of Pharmacy and Bioengineering, Chongqing University of Technology, Chongqing, China
| | - Lingxi Zeng
- School of Pharmacy and Bioengineering, Chongqing University of Technology, Chongqing, China
| | - Bin Jiang
- College of Artificial Intelligence, Chongqing University of Technology, Chongqing, China
| | - Rui Zhu
- School of Pharmacy and Bioengineering, Chongqing University of Technology, Chongqing, China
| | - Junjie Wang
- College of Artificial Intelligence, Chongqing University of Technology, Chongqing, China
| | - Mingyan Li
- College of Artificial Intelligence, Chongqing University of Technology, Chongqing, China
| | - Ansheng Shao
- School of Pharmacy and Bioengineering, Chongqing University of Technology, Chongqing, China
| | - Zexiang Lv
- School of Pharmacy and Bioengineering, Chongqing University of Technology, Chongqing, China
| | - Maoting Zhang
- College of Biomedical Engineering, Army Medical University, Chongqing, China
| | - Lei Guo
- School of Information and Communication Engineering, Dalian University of Technology, Dalian, Liaoning, China
| | - Gen Li
- School of Pharmacy and Bioengineering, Chongqing University of Technology, Chongqing, China
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, China
| | - Jian Sun
- College of Biomedical Engineering, Army Medical University, Chongqing, China
| | - Yujie Chen
- Department of Neurosurgery, Southwest Hospital, Army Medical University, Chongqing, China
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31
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Luchowski P, Szmygin M, Barton E, Prus K, Szmygin H, Pyra K, Ficek R, Rejdak K. Poor Prestroke Glycemic Control Increases the Rate of Symptomatic Intracranial Hemorrhage after Mechanical Thrombectomy. J Clin Med 2024; 13:1227. [PMID: 38592044 PMCID: PMC10932016 DOI: 10.3390/jcm13051227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Revised: 02/15/2024] [Accepted: 02/19/2024] [Indexed: 04/10/2024] Open
Abstract
(1) Background: Diabetes is a well-established risk factor for acute ischemic stroke (AIS). This study evaluated the impact of prestroke glycemic control in diabetic patients on their 3-month clinical outcome after mechanical thrombectomy (MT). (2) Methods: AIS patients with a premorbid modified Rankin scale (mRS) score of 0-2 who were admitted within 6 h after stroke onset and treated with MT between January 2020 and August 2023 were retrospectively analyzed. The study evaluated the effect of prestroke glycemic control on the stroke severity, reperfusion rate, symptomatic intracranial hemorrhage (sICH) and favorable clinical outcome (modified Rankin scale score 0-2) at 3 months after endovascular treatment. (3) Results: A total of 364 patients were analyzed, with 275 cases of non-diabetes (ND), 66 of well-controlled diabetes (WCD) and 23 of poorly controlled diabetes (PCD). There was no significant difference in the baseline neurological deficit expressed according to the National Institutes of Health Stroke Scale among the three groups. The time from stroke onset to groin puncture was similar in the ND, WCD and PCD groups (median 215 min, 194.5 min and 222.5 min, respectively). There was no significant difference in the favorable 3-month clinical outcomes among these three groups (35.2% of ND patients, 42.4% of WCD patients and 39.1% of PCD patients) or full recovery (12.4% of ND patients, 11.0% of WCD patients and 17.4% of PCD patients). The rate of sICH was significantly higher in the PCD group as compared to the ND and WDP groups (21.7% of PCD patients versus 7.6% of ND patients, p = 0.038, and 6.0% of WCD patients, p = 0.046), but the 3-month mortality did not differ between the three groups (21.8% of ND group, 19.7% of WCD group and 26.1% of PCD group). (4) Conclusions: This study shows that poor prestroke glycemic control in AIS diabetic patients does not change the chance of a good clinical functional outcome after endovascular treatment. However, the increased risk of hemorrhagic complications in this group of patients should be considered.
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Affiliation(s)
- Piotr Luchowski
- Department of Neurology and Neurological Nursing, Medical University of Lublin, 20-954 Lublin, Poland;
| | - Maciej Szmygin
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-954 Lublin, Poland; (M.S.); (K.P.)
| | - Elzbieta Barton
- Department of Neurology and Neurological Nursing, Medical University of Lublin, 20-954 Lublin, Poland;
| | - Katarzyna Prus
- Department of Neurology, Medical University of Lublin, 20-954 Lublin, Poland; (K.P.); (R.F.); (K.R.)
| | - Hanna Szmygin
- Department of Endocrinology, Center of Oncology of the Lublin Region St. Jana z Dukli, 20-090 Lublin, Poland;
| | - Krzysztof Pyra
- Department of Interventional Radiology and Neuroradiology, Medical University of Lublin, 20-954 Lublin, Poland; (M.S.); (K.P.)
| | - Remigiusz Ficek
- Department of Neurology, Medical University of Lublin, 20-954 Lublin, Poland; (K.P.); (R.F.); (K.R.)
| | - Konrad Rejdak
- Department of Neurology, Medical University of Lublin, 20-954 Lublin, Poland; (K.P.); (R.F.); (K.R.)
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Silva GS, Alves MM, Barros FCD, Frudit ME, Pontes-Neto OM, Mont'Alverne FJ, Rebello LC, Carbonera LA, Abud DG, Lima F, de Souza AC, Liebeskind D, Mosmann G, Bezerra D, Saver J, Cardoso F, Nogueira RG, Martins SO. The role of intravenous thrombolysis before mechanical Thrombectomy: A subgroup analysis of the RESILIENT trial. J Neurol Sci 2024; 457:122853. [PMID: 38182456 DOI: 10.1016/j.jns.2023.122853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 11/20/2023] [Accepted: 12/17/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Randomized trials have recently evaluated the non-inferiority of direct thrombectomy versus intravenous thrombolysis (IVT) followed by endovascular therapy in anterior circulation large vessel occlusion (LVO) stroke in patients eligible for IVT within 4.5 h from stroke onset with controversial results. We aimed to assess the effect of IVT on the clinical outcome of mechanical thrombectomy (MT) in the RESILIENT trial. METHODS RESILIENT was a randomized, prospective, multicenter, controlled trial assessing the safety and efficacy of thrombectomy versus medical treatment alone. A total of 221 patients were enrolled. The trial showed a substantial benefit of MT when added to medical management. All eligible patients received intravenous tPA within the 4.5-h-window. Ordinal logistic and binary regression analyses using intravenous tPA as an interaction term were performed with adjustments for potential confounders, including age, baseline NIHSS score, occlusion site, and ASPECTS. A p-value <0.05 was considered statistically significant. RESULTS Among 221 randomized patients (median NIHSS, 18 IQR [14-21]), 155 (70%) were treated with IVT. There was no difference in the mRS ordinal shift and frequency of functional independence between patients who received or not IV tPA; the odds ratio for the ordinal mRS shift was 2.63 [1.48-4.69] for the IVT group and 1.54 [0.63-3.74] for the no IVT group, with a p-value of 0.42. IVT also did not affect the frequency of good recanalization (TICI 2b or higher) and hemorrhagic transformation. CONCLUSIONS The large effect size of MT on LVO outcomes was not significantly affected by IVT. TRIAL REGISTRATION RESILIENT ClinicalTrials.gov number, NCT02216643.
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Affiliation(s)
- Gisele Sampaio Silva
- Universidade Federal de São Paulo, São Paulo, Brazil; Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | | | | | | | | | | | | | | | - Daniel Giansante Abud
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil
| | | | | | | | | | | | - Jeffrey Saver
- Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
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Suzuki K, Katano T, Numao S, Nishi Y, Kutsuna A, Kanamaru T, Saito T, Aoki J, Nishiyama Y, Kimura K. The effect of asymptomatic intracranial hemorrhage after mechanical thrombectomy on clinical outcome. J Neurol Sci 2024; 457:122868. [PMID: 38246126 DOI: 10.1016/j.jns.2024.122868] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/03/2024] [Accepted: 01/04/2024] [Indexed: 01/23/2024]
Abstract
BACKGROUND AND OBJECTIVE Whether asymptomatic intracranial hemorrhage (ICH) affects the clinical outcomes in patients with acute large vessel occlusion treated with mechanical thrombectomy (MT) remains unclear. This study aimed to address this uncertainty. METHODS We retrospectively analyzed patients with acute ischemic stroke and internal carotid or middle cerebral (M1 segment) artery occlusion treated with MT between April 2011 and March 2021 at a single center. All patients had a premorbid modified Rankin scale (mRS) score ≤ 2 and an anterior circulation occlusion and underwent magnetic resonance imaging at admission. Asymptomatic ICH was defined as ICH without symptomatic ICH defined by the SITS-MOST criteria. A favorable outcome was defined as an mRS score ≤ 2 at 90 days after stroke onset. RESULTS Our study included 349 patients; 62% were men, the median age was 76 [67-83] years, and the median National Institutes of Health Stroke Scale (NIHSS) score was 15 [8-21]. As determined via computed tomography, 103 (30%) patients had ICH (20 symptomatic and 83 asymptomatic). The favorable outcome rate was significantly lower for asymptomatic vs. no ICH (30% vs. 67%, p < 0.01). In a multivariate regression analysis, a high NIHSS score (odds ratio [OR], 1.06; 95% confidence interval [CI], 1.02-1.10; p < 0.01) and low Alberta Stroke Program Early CT Score (OR, 0.78; 95% CI, 0.65-0.92; p < 0.01) were independent risk factors for ICH. CONCLUSIONS Asymptomatic ICH is associated with poor clinical outcome at 90 days after stroke onset.
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Affiliation(s)
- Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan.
| | - Takehiro Katano
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | | | - Yuji Nishi
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Akihito Kutsuna
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Takuya Kanamaru
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Tomonari Saito
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Junya Aoki
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | | | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
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Colasurdo M, Chen H, Schrier C, Khalid M, Khunte M, Miller TR, Cherian J, Malhotra A, Gandhi D. Predictors for large vessel recanalization before stroke thrombectomy: the HALT score. J Neurointerv Surg 2024; 16:237-242. [PMID: 37100595 DOI: 10.1136/jnis-2023-020220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/16/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Large vessel recanalization (LVR) before endovascular therapy (EVT) for acute large vessel ischemic strokes is a poorly understood phenomenon. Better understanding of predictors for LVR is important for optimizing stroke triage and patient selection for bridging thrombolysis. METHODS In this retrospective cohort study, consecutive patients presenting to a comprehensive stroke center for EVT treatment were identified from 2018 to 2022. Demographic information, clinical characteristics, intravenous thrombolysis (IVT) use, and LVR before EVT were recorded. Factors independently associated with different rates of LVR were identified, and a prediction model for LVR was constructed. RESULTS 640 patients were identified. 57 (8.9%) patients had LVR before EVT. A minority (36.4%) of LVR patients had significant improvements in National Institutes of Health Stroke Scale. Independent predictors for LVR were identified and used to construct the 8-point HALT score: hyperlipidemia (1 point), atrial fibrillation (1 point), location of vascular occlusion (internal carotid: 0 points, M1: 1 point, M2: 2 points, vertebral/basilar: 3 points), and thrombolysis at least 1.5 hours before angiography (3 points). The HALT score had an area under the receiver-operating curve (AUC) of 0.85 (95% CI 0.81 to 0.90, P<0.001) for predicting LVR. LVR before EVT occurred in only 1 of 302 patients (0.3%) with low (0-2) HALT scores. CONCLUSIONS IVT at least 1.5 hours before angiography, site of vascular occlusion, atrial fibrillation, and hyperlipidemia are independent predictors for LVR. The 8-point HALT score proposed in this study may be a valuable tool for predicting LVR before EVT.
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Affiliation(s)
- Marco Colasurdo
- Division of Interventional Neuroradiology, Department of Diagnostic Radiology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Huanwen Chen
- Division of Interventional Neuroradiology, Department of Diagnostic Radiology, University of Maryland Medical Center, Baltimore, Maryland, USA
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Chad Schrier
- Department of Neurology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Mazhar Khalid
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Mihir Khunte
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Timothy R Miller
- Division of Interventional Neuroradiology, Department of Diagnostic Radiology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Jacob Cherian
- Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Dheeraj Gandhi
- Division of Interventional Neuroradiology, Department of Diagnostic Radiology, University of Maryland Medical Center, Baltimore, Maryland, USA
- Department of Neurology, University of Maryland Medical Center, Baltimore, Maryland, USA
- Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
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35
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Hou L, Zhang Y. Peripheral blood mononuclear cell low molecular mass protein 7 in acute ischemic stroke: vertical change from admission to discharge and correlation with disability, stroke recurrence, and death. Front Immunol 2024; 15:1296835. [PMID: 38404572 PMCID: PMC10885349 DOI: 10.3389/fimmu.2024.1296835] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2023] [Accepted: 01/18/2024] [Indexed: 02/27/2024] Open
Abstract
Objective Low molecular mass protein 7 (LMP7) aggravates abnormal T cell differentiation and atherosclerosis, but its clinical role in acute ischemic stroke (AIS) is still unclear. This study aimed to investigate the correlation of peripheral blood mononuclear cell (PBMC) LMP7 with T cell subsets, disease severity, and prognosis in AIS patients. Methods A total of 162 AIS patients were enrolled for detecting PBMC LMP7 and T helper (Th) 1, Th2, and Th17 cells via reverse transcriptase-polymerase chain reaction and flow cytometry, respectively. In addition, PBMC LMP7 at discharge was also quantified. Results Increased LMP7 at admission was associated with decreased Th2 cells (P=0.014), elevated Th17 cells (P<0.001), C-reactive protein (P=0.005), National Institutes of Health Stroke Scale (NIHSS) score (P=0.007), and disease severity (defined by NIHSS score) (P=0.010). LMP7 at admission reflected a high risk of stroke recurrence (area under curve (AUC): 0.748, 95% confidence interval (CI): 0.564-0.932), but not mRS score at month 3 (M3) >2 (AUC: 0.585, 95%CI: 0.479-0.691), or death (AUC: 0.723, 95%CI: 0.338-1.000). LMP7 at discharge was reduced compared to that at admission (P<0.001). LMP7 at discharge was positively correlated with the risk of stroke recurrence (AUC: 0.849, 95%CI: 0.735-0.963) and death (AUC: 0.919, 95%CI: 0.836-1.000), but had a weak capacity to reflect mRS score at M3 >2 (AUC: 0.671, 95%CI: 0.578-0.765). Conclusion PBMC LMP7 positively correlates with Th17 cells, inflammation, and disease severity in AIS patients, meanwhile, its level at discharge shows a good ability to reflect the risks of stroke recurrence and death.
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Affiliation(s)
- Lujia Hou
- Department of Neurology, YongJia People’s Hospital, Wenzhou, China
| | - Yanlei Zhang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
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Liu J, Gu Y, Zhang DZ. Cerebral circulation time on DSA after thrombectomy associated with hemorrhagic transformation in acute ischemic stroke. Acta Neurochir (Wien) 2024; 166:64. [PMID: 38315216 DOI: 10.1007/s00701-024-05959-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2023] [Accepted: 01/04/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND To investigate the association between cerebral circulation time (CCT) on digital subtraction angiography immediately after thrombectomy and hemorrhagic transformation (HT) in acute ischemic stroke (AIS). METHODS Retrospectively enrolled consecutive AIS patients presented with large vessel occlusion who received thrombectomy and achieved successful recanalization between January 2019 and June 2021. The time interval from the beginning of the siphon segment of internal carotid artery visualization until the end of the arterial phase during cerebral angiography was calculated as CCT. The independent association of CCT with HT was evaluated using logistic regression analyses. The receiver operating characteristic curve was analyzed to evaluate the association between CCT and HT. RESULTS Two hundred and twenty-four patients were included, of whom 86 (38.4%) suffered HT. Compared with patients without HT, patients with HT were of advanced age, less commonly male, had more diabetes mellitus, had higher baseline National Institutes of Health Stroke Scale score, lower Alberta Stroke Program Early Computed Tomographic Score, and shorter CCT (P < 0.05). Multivariable logistic regression suggested that CCT was independently associated with HT (adjusted odds ratio, 0.170; 95% confidence interval, 0.004-0.450; P < 0.001). According to the receiver operating characteristic curve, the optimal cut-off value for the strong correlation between CCT and HT was 1.72 s, which had 76.6% sensitivity, 81.6% specificity, and the area under the curve was 0.846. CONCLUSION Shorter post-thrombectomy CCT was independently associated with HT.
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Affiliation(s)
- Jianyu Liu
- Department of Interventional Radiology, Jiangsu Taizhou People's Hospital, Hailing District, Taizhou, Jiangsu, China
| | - Yuanyuan Gu
- Department of Emergency Medicine, The Affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou, China
| | - Da-Zhong Zhang
- Department of Interventional Radiology, Jiangsu Taizhou People's Hospital, Hailing District, Taizhou, Jiangsu, China.
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Yang W, Zhang H, Zhang L, Li Z, Xing P, Shen H, Zhang Y, Zhang X, Ye X, Huang Q, Xu Y, Zhang Y, Liu J, Li C, Yang P. Thrombectomy alone vs thrombectomy with over 2/3-dose intravenous thrombolysis pretreatment in the DIRECT-MT trial. J Neuroradiol 2024; 51:52-58. [PMID: 37120144 DOI: 10.1016/j.neurad.2023.04.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 04/19/2023] [Accepted: 04/24/2023] [Indexed: 05/01/2023]
Abstract
BACKGROUND The DIRECT-MT trial showed that endovascular thrombectomy (EVT) alone was noninferior to EVT preceded by intravenous alteplase. However, the infusion of intravenous alteplase was uncompleted before the initiation of EVT in most cases of this trial. Therefore, the additional benefit and risk of over 2/3-dose intravenous alteplase pretreatment remain to be assessed. METHODS We assessed patients with acute anterior circulation ischemic stroke who received EVT alone or with over 2/3-dose intravenous alteplase pretreatment from the DIRECT-MT trial. Patients were assigned to the thrombectomy-alone group and the alteplase pretreatment group. The primary outcome was the distribution of modified Rankin Scale (mRS) at 90 days. The interaction of treatment allocation and collateral capacity was assessed. RESULTS A total of 393 patients (thrombectomy alone: 315; alteplase pretreatment: 78) were identified. The thrombectomy alone was comparable with alteplase pretreatment prior to the thrombectomy on the distribution of mRS at 90 days without significant effect modification by collateral capacity (adjusted common odds ratio (acOR), 1.12; 95% CI, 0.72-1.74; adjusted P for interaction = 0.83). Successful reperfusion before thrombectomy and the number of passes in the thrombectomy alone group differed significantly from the alteplase pretreatment group (2.6% vs. 11.5%; corrected P = 0.02 and 2 vs. 1; corrected P = 0.003). There was no interaction between treatment allocation and collateral capacity on all outcomes. CONCLUSIONS EVT alone and EVT preceded by over 2/3-dose intravenous alteplase might have equal efficacy and safety for patients with acute anterior circulation large vessel occlusion, except for successful perfusion before thrombectomy and the number of passes.
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Affiliation(s)
- Wenjin Yang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Hongjian Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Lei Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Zifu Li
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Pengfei Xing
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Hongjian Shen
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Yongxin Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Xiaoxi Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Xiaofei Ye
- Health Statistics Department, Naval Medical University, Shanghai, China
| | - Qinghai Huang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Yi Xu
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Yongwei Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Jianmin Liu
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Conghui Li
- Department of Neurosurgery, First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Pengfei Yang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China.
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van der Sluijs PM, Su R, Cornelissen SAP, van Es ACGM, Lycklama A Nijeholt G, Roozenbeek B, van Doormaal PJ, Hofmeijer J, van der Lugt A, van Walsum T. Clinical consequence of vessel perforations during endovascular treatment of acute ischemic stroke. Neuroradiology 2024; 66:237-247. [PMID: 38010403 DOI: 10.1007/s00234-023-03246-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 10/30/2023] [Indexed: 11/29/2023]
Abstract
PURPOSE Endovascular treatment (EVT) of acute ischemic stroke can be complicated by vessel perforation. We studied the incidence and determinants of vessel perforations. In addition, we studied the association of vessel perforations with functional outcome, and the association between location of perforation on digital subtraction angiography (DSA) and functional outcome, using a large EVT registry. METHODS We included all patients in the MR CLEAN Registry who underwent EVT. We used DSA to determine whether EVT was complicated by a vessel perforation. We analyzed the association with baseline clinical and interventional parameters using logistic regression models. Functional outcome was measured using the modified Rankin Scale at 90 days. The association between vessel perforation and angiographic imaging features and functional outcome was studied using ordinal logistic regression models adjusted for prognostic parameters. These associations were expressed as adjusted common odds ratios (acOR). RESULTS Vessel perforation occurred in 74 (2.6%) of 2794 patients who underwent EVT. Female sex (aOR 2.0 (95% CI 1.2-3.2)) and distal occlusion locations (aOR 2.2 (95% CI 1.3-3.5)) were associated with increased risk of vessel perforation. Functional outcome was worse in patients with vessel perforation (acOR 0.38 (95% CI 0.23-0.63)) compared to patients without a vessel perforation. No significant association was found between location of perforation and functional outcome. CONCLUSION The incidence of vessel perforation during EVT in this cohort was low, but has severe clinical consequences. Female patients and patients treated at distal occlusion locations are at higher risk.
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Affiliation(s)
- P Matthijs van der Sluijs
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands.
| | - R Su
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - S A P Cornelissen
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - A C G M van Es
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | | | - B Roozenbeek
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - P J van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - J Hofmeijer
- Department of Neurology, Rijnstate Hospital, Arnhem, The Netherlands
- Department of Clinical Neurophysiology, University of Twente, Enschede, The Netherlands
| | - A van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - T van Walsum
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
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Che F, Wang A, Ju Y, Liu L, Ma N, Cheng Z, Duan H, Zhao X, Geng X. Prevalence and Impact of Medical Complications on Clinical Outcomes in Acute Ischemic Stroke Patients After Endovascular Therapy - Data From a Comprehensive Stroke Unit in China. World Neurosurg 2024; 182:e386-e399. [PMID: 38030069 DOI: 10.1016/j.wneu.2023.11.113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 11/22/2023] [Accepted: 11/23/2023] [Indexed: 12/01/2023]
Abstract
OBJECTIVE We aim to assess the incidence and impact of in-hospital medical complications (MCs) on clinical outcomes in acute ischemic stroke (AIS) patients after endovascular therapy (EVT). METHODS AIS patients who underwent EVT were consecutively recruited from January 2019 to July 2022. The primary outcome was a poor 3-month functional outcome, defined as a modified Rankin Scale score (mRS) of 3-6. The safety variables were symptomatic intracerebral hemorrhage and mortality at 7 and 30 days. RESULTS A total of 306 (50.1%) patients experienced at least one of the MCs. The most common MC was pneumonia (42.6%). Multivariate analysis revealed that the setting of MCs was an independent predictor of a poor 3-month functional outcome (adjusted odds ratio [aOR] 4.40, 95% confidence interval [CI] 3.01-6.42; P < 0.001). In the subgroup analysis, this trend was significant, especially in the patients aged 60-75 years (aOR 5.87, 95% CI 3.45-9.97; P < 0.001) or with baseline NIHSS (≤16) (aOR 5.05, 95% CI 2.84-9.01; P < 0.001). For individuals, cardiac events (aOR 8.56, 95% CI 4.05-18.09; P < 0.001), pneumonia (aOR 5.08, 95% CI 3.42-7.55; P < 0.001), and gastrointestinal bleeding (GIB) (aOR 6.12, 95% CI 3.40-11.01; P < 0.001) were independently associated with the poor 3-month outcome. The setting of MCs was independently associated with symptomatic intracerebral hemorrhage (aOR 2.11, 95% CI 1.22-3.64; P = 0.007) and mortality at 30 days (aOR 2.11, 95% CI 1.22-3.64; P = 0.007) after adjustment, but not with mortality at 7 days. CONCLUSIONS MCs in AIS patients after EVT have a high incidence, despite successful reperfusion, adversely affecting clinical outcomes and increasing short-term mortality.
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Affiliation(s)
- Fengli Che
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Anxin Wang
- Tiantan Neuroimaging Center for Excellence, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yi Ju
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhe Cheng
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Honglian Duan
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- Tiantan Neuroimaging Center for Excellence, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; Research Unit of Artificial Intelligence in Cerebrovascular Disease, Chinese Academy of Medical Sciences, Beijing, China
| | - Xiaokun Geng
- Department of Neurology, Beijing Luhe Hospital, Capital Medical University, Beijing, China.
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Jia M, Jin F, Li S, Ren C, Ruchi M, Ding Y, Zhao W, Ji X. No-reflow after stroke reperfusion therapy: An emerging phenomenon to be explored. CNS Neurosci Ther 2024; 30:e14631. [PMID: 38358074 PMCID: PMC10867879 DOI: 10.1111/cns.14631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 01/02/2024] [Accepted: 01/21/2024] [Indexed: 02/16/2024] Open
Abstract
In the field of stroke thrombectomy, ineffective clinical and angiographic reperfusion after successful recanalization has drawn attention. Partial or complete microcirculatory reperfusion failure after the achievement of full patency of a former obstructed large vessel, known as the "no-reflow phenomenon" or "microvascular obstruction," was first reported in the 1960s and was later detected in both experimental models and patients with stroke. The no-reflow phenomenon (NRP) was reported to result from intraluminal occlusions formed by blood components and extraluminal constriction exerted by the surrounding structures of the vessel wall. More recently, an emerging number of clinical studies have estimated the prevalence of the NRP in stroke patients following reperfusion therapy, ranging from 3.3% to 63% depending on its evaluation methods or study population. Studies also demonstrated its detrimental effects on infarction progress and neurological outcomes. In this review, we discuss the research advances, underlying pathogenesis, diagnostic techniques, and management approaches concerning the no-reflow phenomenon in the stroke population to provide a comprehensive understanding of this phenomenon and offer references for future investigations.
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Affiliation(s)
- Milan Jia
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Feiyang Jin
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Sijie Li
- Department of Emergency, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Changhong Ren
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Mangal Ruchi
- Department of NeurosurgeryWayne State University School of MedicineDetroitMichiganUSA
| | - Yuchuan Ding
- Department of NeurosurgeryWayne State University School of MedicineDetroitMichiganUSA
| | - Wenbo Zhao
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Xunming Ji
- Department of Neurosurgery, Xuanwu HospitalCapital Medical UniversityBeijingChina
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van Voorst H, Pitkänen J, van Poppel L, de Vries L, Mojtahedi M, Martou L, Emmer BJ, Roos YBWEM, van Oostenbrugge R, Postma AA, Marquering HA, Majoie CBLM, Curtze S, Melkas S, Bentley P, Caan MWA. Deep learning-based white matter lesion volume on CT is associated with outcome after acute ischemic stroke. Eur Radiol 2024:10.1007/s00330-024-10584-z. [PMID: 38285103 DOI: 10.1007/s00330-024-10584-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2023] [Revised: 12/12/2023] [Accepted: 12/16/2023] [Indexed: 01/30/2024]
Abstract
BACKGROUND Intravenous thrombolysis (IVT) before endovascular treatment (EVT) for acute ischemic stroke might induce intracerebral hemorrhages which could negatively affect patient outcomes. Measuring white matter lesions size using deep learning (DL-WML) might help safely guide IVT administration. We aimed to develop, validate, and evaluate a DL-WML volume on CT compared to the Fazekas scale (WML-Faz) as a risk factor and IVT effect modifier in patients receiving EVT directly after IVT. METHODS We developed a deep-learning model for WML segmentation on CT and validated with internal and external test sets. In a post hoc analysis of the MR CLEAN No-IV trial, we associated DL-WML volume and WML-Faz with symptomatic-intracerebral hemorrhage (sICH) and 90-day functional outcome according to the modified Rankin Scale (mRS). We used multiplicative interaction terms between WML measures and IVT administration to evaluate IVT treatment effect modification. Regression models were used to report unadjusted and adjusted common odds ratios (cOR/acOR). RESULTS In total, 516 patients from the MR CLEAN No-IV trial (male/female, 291/225; age median, 71 [IQR, 62-79]) were analyzed. Both DL-WML volume and WML-Faz are associated with sICH (DL-WML volume acOR, 1.78 [95%CI, 1.17; 2.70]; WML-Faz acOR, 1.53 95%CI [1.02; 2.31]) and mRS (DL-WML volume acOR, 0.70 [95%CI, 0.55; 0.87], WML-Faz acOR, 0.73 [95%CI 0.60; 0.88]). Only in the unadjusted IVT effect modification analysis WML-Faz was associated with more sICH if IVT was given (p = 0.046). Neither WML measure was associated with worse mRS if IVT was given. CONCLUSION DL-WML volume and WML-Faz had a similar relationship with functional outcome and sICH. Although more sICH might occur in patients with more severe WML-Faz receiving IVT, no worse functional outcome was observed. CLINICAL RELEVANCE STATEMENT White matter lesion severity on baseline CT in acute ischemic stroke patients has a similar predictive value if measured with deep learning or the Fazekas scale. Safe administration of intravenous thrombolysis using white matter lesion severity should be further studied. KEY POINTS White matter damage is a predisposing risk factor for intracranial hemorrhage in patients with acute ischemic stroke but remains difficult to measure on CT. White matter lesion volume on CT measured with deep learning had a similar association with symptomatic intracerebral hemorrhages and worse functional outcome as the Fazekas scale. A patient-level meta-analysis is required to study the benefit of white matter lesion severity-based selection for intravenous thrombolysis before endovascular treatment.
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Affiliation(s)
- Henk van Voorst
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands.
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands.
| | - Johanna Pitkänen
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Laura van Poppel
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Lucas de Vries
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
- Informatics Institute, University of Amsterdam, Amsterdam, The Netherlands
| | - Mahsa Mojtahedi
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Laura Martou
- Department of Brain Sciences, Imperial College London, Charing Cross Hospital, London, England
| | - Bart J Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Robert van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Alida A Postma
- Department of Radiology and Nuclear Medicine, School for Mental health and sciences (Mhens), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Henk A Marquering
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Meibergdreef 9, 1105 AZ, Amsterdam, The Netherlands
| | - Sami Curtze
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Susanna Melkas
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Paul Bentley
- Department of Brain Sciences, Imperial College London, Charing Cross Hospital, London, England
| | - Matthan W A Caan
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam, The Netherlands
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Guo S, Qin S, Tan S, Su H, Chen X. Endovascular thrombectomy without versus with different pre-intravenous thrombolysis in acute ischemic stroke: a network meta-analysis of randomized controlled trials. Front Neurol 2024; 15:1344961. [PMID: 38348167 PMCID: PMC10860706 DOI: 10.3389/fneur.2024.1344961] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Accepted: 01/15/2024] [Indexed: 02/15/2024] Open
Abstract
Background The current guideline recommended the use of intravenous thrombolysis (IVT) before Endovascular thrombectomy (EVT), but the effectiveness and safety of tenecteplase compare to alteplase in patients before EVT remain uncertain. Methods We searched PubMed, Embase, Web of Science, and the Cochrane Library to identify eligible articles from inception until September 16, 2023. The primary outcome was functional independence (mRS 0-2) at 90 days. Secondary outcomes included excellent outcome (mRS 0-1) at 90 days, all-cause mortality at follow-up, successful reperfusion (TICI 2b-3) after the end of EVT, symptomatic intracranial hemorrhage (sICH) or any intracranial hemorrhage (aICH). The PROSPERO registration number is CRD42023470419. Results Eight randomized controlled trials (RCTs) were included involving 2,836 acute ischemic stroke (AIS) patients. Compared to EVT alone, tenecteplase (0.25 mg/kg and 0.4 mg/kg) + EVT and 0.9 mg/kg alteplase + EVT were significant difference associated with higher successful reperfusion (TICI 2b-3) after the end of EVT (RR = 2.31; 95% CI 1.15-4.63; RR = 2.31; 95% CI 1.00-5.33; RR = 1.05; 95% CI 1.01-1.09). And compared to 0.25 mg/kg tenecteplase + EVT, alteplase (0.6 mg/kg and 0.9 mg/kg) + EVT were significant difference associated with lower successful reperfusion (TICI 2b-3) after the end of EVT (RR = 0.45; 95% CI 0.22-0.90; RR = 0.45; 95% CI 0.23-0.91). The risk of aICH (RR = 1.50; 95% CI 1.07-2.09) was significantly higher for 0.6 mg/kg alteplase + EVT than EVT alone. There was no significant difference in functional independence (mRS 0-2), excellent outcome (mRS 0-1), all-cause mortality or sICH among the different IVT strategies (0.25 mg/kg or 0.4 mg/kg tenecteplase and 0.6 mg/kg or 0.9 mg/kg alteplase) before EVT. Conclusion The use of alteplase before EVT may potentially improve the successful reperfusion after EVT compared to tenecteplase. Due to the insufficient sample size, more high-quality RCTs are needed to confirm effectiveness and safety of tenecteplase compare to alteplase in patients before EVT. Systematic review registration https://www.crd.york.ac.uk/prospero/, identifier: CRD42023470419.
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Affiliation(s)
| | | | | | - Henghai Su
- Department of Pharmacy, Guangxi Academy of Medical Sciences and the People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
| | - Xiaoyu Chen
- Department of Pharmacy, Guangxi Academy of Medical Sciences and the People’s Hospital of Guangxi Zhuang Autonomous Region, Nanning, China
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43
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Wu X, Chen T, Han Y, Wang K, Zhou J. Left atrial myxoma as a rare cause of stroke. Heliyon 2024; 10:e23897. [PMID: 38223711 PMCID: PMC10784162 DOI: 10.1016/j.heliyon.2023.e23897] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 12/13/2023] [Accepted: 12/15/2023] [Indexed: 01/16/2024] Open
Abstract
Cerebrovascular events may attribute to the fragmentation of a cardiac tumor. Due to the small number of reported cases of large vascular occlusion-acute ischemic stroke (LVO-AIS) associated with atrial myxoma, current guidelines still follow the principle of intravenous thrombolysis priority, even if LVO-AIS patients are eligible for mechanical thrombectomy, and have not recommended the timing of cardiac surgery or preoperative anticoagulation and antithrombotic therapy. Surgical removal is the definitive therapy for cardiac myxomas, especially for left-sided myxomas. With this case, we aim to demonstrate the main challenges that clinicians may encounter when dealing with patients with AIS secondary to cardiac myxoma: the difficulties with clinical diagnosis, strategies for reperfusion therapy, and therapeutic management of cardiac myxoma.
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Affiliation(s)
- Xindi Wu
- Department of Intensive Care Unit, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine affiliated to Shanghai Traditional Chinese Medicine, Shanghai, China
| | - Tongyu Chen
- Department of Cardiothoracic Surgery, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine affiliated to Shanghai Traditional Chinese Medicine, Shanghai, China
| | - Yan Han
- Department of Neurology, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine affiliated to Shanghai Traditional Chinese Medicine, Shanghai, China
| | - Ke Wang
- Department of Clinical Research Institute of Acupuncture and Anaesthetic, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine affiliated to Shanghai Traditional Chinese Medicine, Shanghai, China
| | - Jia Zhou
- Department of Cardiothoracic Surgery, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine affiliated to Shanghai Traditional Chinese Medicine, Shanghai, China
- Department of Clinical Research Institute of Acupuncture and Anaesthetic, Yueyang Hospital of Integrated Traditional Chinese and Western Medicine affiliated to Shanghai Traditional Chinese Medicine, Shanghai, China
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44
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Bilgin C, Tolba H, Ghozy S, Kobeissi H, Hassankhani A, Senol YC, Arul S, Kadirvel R, Kallmes DF. Effects of intravenous thrombolysis on stent retriever and aspiration thrombectomy outcomes: a systematic review and meta-analysis of the randomized controlled trials. J Neurointerv Surg 2024; 16:163-170. [PMID: 37258225 DOI: 10.1136/jnis-2023-020360] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2023] [Accepted: 05/03/2023] [Indexed: 06/02/2023]
Abstract
BACKGROUND Risks and benefits of intravenous thrombolysis (IVT) in patients undergoing mechanical thrombectomy (MT) have been a topic of interest. However, IVT's specific effects on stent retriever (SR) and aspiration thrombectomy (ASP) outcomes remain largely unexplored. In this meta-analysis, we aimed to investigate the effects of IVT on SR and ASP thrombectomy outcomes. METHODS In accordance with PRISMA guidelines, a systematic literature review was conducted using Medline, Embase, Scopus, Web of Science, and Cochrane Center of Clinical Trials databases. Outcomes of interest included successful recanalization (modified Thrombolysis In Cerebral Infarction (mTICI) ≥2b), modified first pass efficacy (mFPE), functional independence (modified Rankin Scale (mRS) ≤2), symptomatic intracranial hemorrhage (sICH), and embolization to new territories (ENT). RESULTS Four randomized controlled trials with 1176 patients were included. SR and ASP resulted in similar mTICI ≥2b, mFPE, and mRS 0-2 rates in patients with and without IVT administration. SR without IVT was associated with a significantly lower rate of mFPE compared with the SR+IVT (RR 0.85, 95% CI 0.74 to 0.97). Furthermore, ASP without IVT resulted in a lower rate of mRS 0-2 than the ASP+IVT with a strong trend towards significance (RR 0.78, 95% CI 0.60 to 1.01). Finally, bridging therapy did not increase sICH and ENT rates after ASP or SR thrombectomy. CONCLUSIONS Our findings suggest that SR and ASP thrombectomy have comparable safety and efficacy profiles, regardless of prior IVT administration. Additionally, our results indicate that the addition of IVT may improve certain efficacy outcomes based on the employed first-line MT technique.
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Affiliation(s)
- Cem Bilgin
- Department of Radiology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Hatem Tolba
- Department of Neurology, Medical College of Wisconsin, Wauwatosa, Wisconsin, USA
| | - Sherief Ghozy
- Department of Radiology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Hassan Kobeissi
- Central Michigan University College of Medicine, Mount Pleasant, Michigan, USA
| | - Amir Hassankhani
- Department of Radiology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Yigit Can Senol
- Department of Neurologic Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Santhosh Arul
- Department of Radiology, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - Ramanathan Kadirvel
- Department of Neurologic Surgery, Mayo Clinic Rochester, Rochester, Minnesota, USA
| | - David F Kallmes
- Department of Radiology, Mayo Clinic Rochester, Rochester, Minnesota, USA
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Maïer B, Di Meglio L, Desilles JP, Solo Nomenjanahary M, Delvoye F, Kyheng M, Boursin P, Ollivier V, Dupont S, Rambaud T, Hamdani M, Labreuche J, Blanc R, Piotin M, Halimi JM, Mazighi M, Ho-Tin-Noe B. Neutrophil activation in patients treated with endovascular therapy is associated with unfavorable outcomes and mitigated by intravenous thrombolysis. J Neurointerv Surg 2024; 16:131-137. [PMID: 37068937 DOI: 10.1136/jnis-2022-020020] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 03/25/2023] [Indexed: 04/19/2023]
Abstract
BACKGROUND Accumulating evidence indicates that neutrophil activation (NA) contributes to microvascular thromboinflammation in acute ischemic stroke (AIS) due to a large vessel occlusion. Preclinical data have suggested that intravenous thrombolysis (IVT) before endovascular therapy (EVT) could dampen microvascular thromboinflammation. In this study we investigated the association between NA dynamics and stroke outcome, and the impact of IVT on NA in patients with AIS treated with EVT. METHODS A single-center prospective study was carried out, including patients treated with EVT for whom three blood samples (before, within 1 hour, 24 hours post-EVT) were drawn to measure plasma myeloperoxidase (MPO) concentration as a marker of NA. Unfavorable outcome was defined as a modified Rankin score of 3-6 at 3 months. RESULTS Between 2016 and 2020, 179 patients were included. The plasma MPO concentration peaked significantly 1 hour post-EVT (median increase 21.0 ng/mL (IQR -2.1-150)) and returned to pre-EVT baseline values 24 hours after EVT (median change from baseline -0.8 ng/mL (IQR -7.6-6.7)). This peak was strongly associated with unfavorable outcomes at 3 months (aOR 0.53 (95% CI 0.34 to 0.84), P=0.007). IVT before EVT abolished this 1 hour post-EVT MPO peak. Changes in plasma MPO concentration (baseline to 1 hour post-EVT) were associated with unfavorable outcomes only in patients not treated with IVT before EVT (aOR 0.54 (95% CI 0.33 to 0.88, P=0.013). However, we found no significant heterogeneity in the associations between changes in plasma MPO concentration and outcomes. CONCLUSIONS A peak in plasma MPO concentration occurs early after EVT and is associated with unfavorable outcomes. IVT abolished the post-EVT MPO peak and may modulate the association between NA and outcomes.
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Affiliation(s)
- Benjamin Maïer
- Interventional Neuroradiology Department, Fondation Rothschild Hospital, Paris, France
- UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, F-75006 Paris, France, Université de Paris Cité, Inserm, Paris, France
- Neurology Department, Hôpital Saint-Joseph, Paris, France
- FHU NeuroVasc, Paris, France
| | - Lucas Di Meglio
- Interventional Neuroradiology Department, Fondation Rothschild Hospital, Paris, France
- UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, F-75006 Paris, France, Université de Paris Cité, Inserm, Paris, France
| | - Jean-Philippe Desilles
- Interventional Neuroradiology Department, Fondation Rothschild Hospital, Paris, France
- UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, F-75006 Paris, France, Université de Paris Cité, Inserm, Paris, France
- FHU NeuroVasc, Paris, France
| | - Mialitiana Solo Nomenjanahary
- UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, F-75006 Paris, France, Université de Paris Cité, Inserm, Paris, France
| | - François Delvoye
- Interventional Neuroradiology Department, Fondation Rothschild Hospital, Paris, France
| | - Maeva Kyheng
- Interventional Neuroradiology Department, Fondation Rothschild Hospital, Paris, France
| | - Perrine Boursin
- Interventional Neuroradiology Department, Fondation Rothschild Hospital, Paris, France
| | - Véronique Ollivier
- UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, F-75006 Paris, France, Université de Paris Cité, Inserm, Paris, France
| | - Sébastien Dupont
- UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, F-75006 Paris, France, Université de Paris Cité, Inserm, Paris, France
| | - Thomas Rambaud
- UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, F-75006 Paris, France, Université de Paris Cité, Inserm, Paris, France
| | - Mylène Hamdani
- Interventional Neuroradiology Department, Fondation Rothschild Hospital, Paris, France
| | | | - Raphaël Blanc
- Interventional Neuroradiology Department, Fondation Rothschild Hospital, Paris, France
| | - Michel Piotin
- Interventional Neuroradiology Department, Fondation Rothschild Hospital, Paris, France
| | - Jean-Michel Halimi
- Nephrology Department, Tours Hospital, Tours, France
- EA4245-Transplantation, Immunology and Inflammation, University of Tours, Tours, France
| | - Mikaël Mazighi
- Interventional Neuroradiology Department, Fondation Rothschild Hospital, Paris, France
- UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, F-75006 Paris, France, Université de Paris Cité, Inserm, Paris, France
- FHU NeuroVasc, Paris, France
- Department of Neurology, Lariboisiere Hospital, Université Paris Cité, Paris, France
| | - Benoit Ho-Tin-Noe
- UMRS-1144, Optimisation Thérapeutique en Neuropsychopharmacologie, F-75006 Paris, France, Université de Paris Cité, Inserm, Paris, France
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Bilgin C, Ibrahim M, Ghozy S, Jabal MS, Shehata M, Kobeissi H, Kadirvel R, Brinjikji W, Rabinstein AA, Kallmes DF. Disability-free outcomes after mechanical thrombectomy: A systematic review and meta-analysis of the randomized controlled trials. Interv Neuroradiol 2024:15910199231224826. [PMID: 38179678 DOI: 10.1177/15910199231224826] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2024] Open
Abstract
BACKGROUND The modified Rankin Scale (mRS) score of ≤2 (functional independence) has been the most common primary endpoint of modern mechanical thrombectomy (MT) trials. However, unlike mRS 0-1, mRS score of 2 indicates disability. An important proportion of the mRS 2 patients are home dependent and report a significant decrease in their quality of life. PURPOSE To investigate excellent outcome (mRS 0-1) rates after MT. METHODS We systematically searched Ovid MEDLINE, Ovid EMBASE, Cochrane Central Register of Controlled Trials, Scopus, and Web of Science databases. Randomized controlled trials (RCTs) investigating the role of modern MT in acute ischemic stroke were screened. Posterior circulation and large-core infarct trials were excluded from the study. The data regarding excellent outcomes (mRS: 0-1), functional independence (mRS: 0-2), and reperfusion were collected. RESULTS Twenty-two RCTs comprising 5692 patients were included in the meta-analysis. The overall mRS 0-1 rate was 31.24% (95% CI = 26.95-36.2). The rate of successful reperfusion was 81.8% (95% CI = 77.93-85.86). MT achieved significantly higher rates of mRS 0-1 compared to standard care alone (OR = 2.04; 95% CI = 1.64-2.55; P-value < 0.001), with no heterogeneity detected among studies (I2= 0%; P-value = 0.52). The direct MT and MT plus intravenous thrombolytic treatment groups' excellent outcome rates were comparable (OR = 0.98; 95% CI = 0.82-1.18; P-value = 0.863). Also, aspiration and stent retriever thrombectomy techniques provided similar excellent outcome rates (OR = 0.76; 95% CI = 0.55-1.05; P-value = 0.141). CONCLUSIONS Our results prove the additional benefit of MT over standard care, using a stricter definition for favorable functional outcome. Nearly one-third of patients presenting with large artery occlusion and treated with MT had no disability at 90 days. While this is remarkable, our results also indicate that reperfusion alone is often not enough to prevent disability and underline the need for better neuroprotection strategies.
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Affiliation(s)
- Cem Bilgin
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | | | - Mostafa Shehata
- Department of Radiology, M.D. Anderson Cancer Center, Houston, TX, USA
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Morsi RZ, Zhang Y, Carrión-Penagos J, Desai H, Tannous E, Kothari S, Khamis A, Darzi AJ, Tarabichi A, Bastin R, Hneiny L, Thind S, Coleman E, Brorson JR, Mendelson S, Mansour A, Prabhakaran S, Kass-Hout T. Endovascular Thrombectomy With or Without Thrombolysis for Stroke: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Neurohospitalist 2024; 14:23-33. [PMID: 38235037 PMCID: PMC10790620 DOI: 10.1177/19418744231200046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024] Open
Abstract
Background To this date, whether to administer intravenous thrombolysis (IVT) prior to endovascular thrombectomy (EVT) for stroke patients still stirs some debate. We aimed to systematically update the evidence from randomized trials comparing EVT alone vs EVT with bridging IVT. Methods We searched MEDLINE, EMBASE, and the Cochrane Library to identify randomized controlled trials (RCTs) comparing EVT with or without IVT in patients presenting with stroke secondary to a large vessel occlusion. We conducted meta-analyses using random-effects models to compare functional independence, mortality, and symptomatic intracranial hemorrhage (sICH), between EVT and EVT with IVT. We assessed risk of bias using the Cochrane risk-of-bias tool and certainty of evidence for each outcome using the GRADE approach. Results Of 11,111 citations, we included 6 studies with a total of 2336 participants. We found low-certainty evidence of possibly a small decrease in the proportion of patients with functional independence (risk difference [RD] -2.0%, 95% CI -5.9% to 2.0%), low-certainty evidence that there is possibly a small increase in mortality (RD 1.0%, 95% CI -2.2% to 4.7%), and moderate-certainty evidence that there is probably a decrease in sICH (RD -1.0%, 95% CI -1.6% to .7%) for patients with EVT alone compared to EVT plus IVT, respectively. Conclusion Low-certainty evidence shows that there is possibly a small decrease in functional independence, low-certainty evidence shows that there is possibly a small increase in mortality, and moderate-certainty evidence that there is probably a decrease in sICH for patients with EVT alone compared to EVT plus IVT.
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Affiliation(s)
- Rami Z. Morsi
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Yuan Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Harsh Desai
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Elie Tannous
- Department of Pathology, Albany Medical Center, Albany, NY, USA
| | - Sachin Kothari
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Assem Khamis
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Andrea J. Darzi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Ammar Tarabichi
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Reena Bastin
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Layal Hneiny
- Wegner Health Sciences Information Center, University of South Dakota, Sioux Falls, SD, USA
| | - Sonam Thind
- Section of Neurosurgery, Department of Surgery, University of Chicago, Chicago, IL, USA
| | - Elisheva Coleman
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - James R. Brorson
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Scott Mendelson
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Ali Mansour
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | | | - Tareq Kass-Hout
- Department of Neurology, University of Chicago, Chicago, IL, USA
- Section of Neurosurgery, Department of Surgery, University of Chicago, Chicago, IL, USA
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Marè A, Lorenzut S, Janes F, Gentile C, Marinig R, Tereshko Y, Gigli GL, Valente M, Merlino G. Comparison of pharmacokinetic properties of alteplase and tenecteplase. The future of thrombolysis in acute ischemic stroke. Expert Opin Drug Metab Toxicol 2024; 20:25-36. [PMID: 38275111 DOI: 10.1080/17425255.2024.2311168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2023] [Accepted: 01/24/2024] [Indexed: 01/27/2024]
Abstract
INTRODUCTION The drug most frequently used for thrombolysis in cases of acute ischemic stroke (AIS) is alteplase. However, there is moderate-to-high-quality evidence that tenecteplase has similar or higher efficacy and safety. With improved pharmacokinetic properties over alteplase, tenecteplase could be a significant advantage in treating AIS. AREAS COVERED After conducting an extensive search on Scopus and PubMed, this manuscript reviews and compares the pharmacokinetic properties of alteplase and tenecteplase. Additionally, it provides information on pharmacodynamics, clinical efficacy, safety, tolerability, and drug-drug interactions. EXPERT OPINION The pharmacokinetic profile of alteplase and tenecteplase is derived from studies in patients with acute myocardial infarction. Thanks to its pharmacokinetic properties, tenecteplase is the drug closest to being the ideal fibrinolytic for AIS. Its longer half-life enables a single-bolus administration, which is particularly useful in emergencies. Tenecteplase has proven to have a good efficacy and safety profile in randomized clinical trials. Although we are awaiting the results of the ongoing phase 3 randomized clinical trials, we believe that tenecteplase has the potential to revolutionize the treatment of AIS through thrombolysis.
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Affiliation(s)
- Alessandro Marè
- Clinical Neurology, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | - Simone Lorenzut
- Stroke Unit, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | - Francesco Janes
- Clinical Neurology, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
- Stroke Unit, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | - Carolina Gentile
- Stroke Unit, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | - Roberto Marinig
- Stroke Unit, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | - Yan Tereshko
- Clinical Neurology, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | | | - Mariarosaria Valente
- Clinical Neurology, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
- DAME, University of Udine, Udine, Italy
| | - Giovanni Merlino
- Clinical Neurology, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
- Stroke Unit, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
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49
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Chen E, Zhou D, Deng R. Serum resolvin D1 potentially predicts neurofunctional recovery, the risk of recurrence and death in patients with acute ischemic stroke. Biomed Rep 2024; 20:10. [PMID: 38124765 PMCID: PMC10731167 DOI: 10.3892/br.2023.1698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2023] [Accepted: 10/24/2023] [Indexed: 12/23/2023] Open
Abstract
Resolvin D1 (RvD1) represses inflammation, oxidative damage and neural injury related to acute ischemic stroke (AIS) progression. The present study aimed to explore the association of serum RvD1 with disease features, neurological recovery and prognosis in patients with AIS. A total of 212 patients with newly diagnosed AIS, whose serum RvD1 was quantified at admission and at discharge using an ELISA were enrolled in the current study. The modified Rankin scale (mRS) score was noted at 3 months after patient enrolment (M3), and patients were followed up for a median duration of 11.4 (range, 1.1-21.0) months. The median RvD1 in patients with AIS at admission was 1.07 (range, 0.11-9.29) ng/ml and it was negatively correlated with the neutrophil/lymphocyte ratio (r=-0.160; P=0.009) and C-reactive protein level (r=-0.272; P<0.001), but it was not correlated with comorbidities or other biochemical indexes. RvD1 at admission was lower in patients with mRS >2 at M3 (P=0.001), recurrence (P=0.001) or death (P=0.032) compared with that in patients without the aforementioned characteristics, which had a general ability to estimate mRS >2 at M3 [area under curve (AUC), 0.633], as well as lower risk of recurrence (AUC, 0.745) and death (AUC, 0.757) according to receiver operator characteristic (ROC) curve analyses. The median RvD1 was raised to 1.70 (range, 0.30-16.62) ng/ml at discharge. RvD1 at discharge was able to forecast mRS >2 at M3 (AUC, 0.678) and was able to predict the risk of recurrence (AUC, 0.796) and death (AUC, 0.826) in the ROC curve analyses. Increased serum RvD1 was associated with an attenuated inflammation status, and predicted improved neurological recovery, and lower risk of recurrence and death in patients with AIS. More specifically, its level at discharge exhibits a better prognostic utility than that at admission.
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Affiliation(s)
- Enzhuo Chen
- Department of Neurology, Tongren Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai 200336, P.R. China
| | - Dong Zhou
- Department of Organic Chemistry, Shanghai Institute of Organic Chemistry, Chinese Academy of Sciences, Shanghai 200032, P.R. China
| | - Ruoyu Deng
- Health Management, University of Montpellier, Montpellier 34090, France
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Cuadra-Campos MDC, Vásquez-Tirado GA, Bravo-Sotero MDC. Direct mechanical thrombectomy versus bridging therapy in acute ischemic stroke: A systematic review and meta-analysis of randomized clinical trials. World Neurosurg X 2024; 21:100250. [PMID: 38173685 PMCID: PMC10762454 DOI: 10.1016/j.wnsx.2023.100250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2023] [Accepted: 11/28/2023] [Indexed: 01/05/2024] Open
Affiliation(s)
| | - Gustavo Adolfo Vásquez-Tirado
- Faculty of Medicine, Universidad Privada Antenor Orrego, Trujillo, Peru
- Intensive Care Unit, Hospital Regional Docente de Trujillo, Trujillo, Peru
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