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Khan S, Khan AA, Ahmad R, Fatima SM, Khan I. Critical Insights on "Early Versus Late Initiation of Endovascular Therapy in Patients with Severe Cerebral Venous Sinus Thrombosis" by Bücke et al. Neurocrit Care 2024:10.1007/s12028-024-02127-7. [PMID: 39289303 DOI: 10.1007/s12028-024-02127-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2024] [Accepted: 08/28/2024] [Indexed: 09/19/2024]
Affiliation(s)
- Saad Khan
- Saidu Medical College, Saidu Sharif, Swat District, Khyber Pakhtunkhwa, Pakistan.
| | | | - Rizwan Ahmad
- Saidu Medical College, Saidu Sharif, Swat District, Khyber Pakhtunkhwa, Pakistan
| | - Syeda Mashal Fatima
- Saidu Medical College, Saidu Sharif, Swat District, Khyber Pakhtunkhwa, Pakistan
| | - Iftikhar Khan
- FMH College of Medicine and Dentistry, Lahore, Pakistan
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2
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Kühn AL, Puri AS, Salim HA, Musmar B, Ghozy S, Siegler J, Shaikh H, Khalife J, Abdalkader M, Klein P, Nguyen TN, Heit JJ, Regenhardt RW, Diestro JDB, Cancelliere NM, Sweid A, Naamani KE, Hasan Z, Gopinathan A, Amllay A, Meyer L, Dusart A, Bellante F, Forestier G, Rouchaud A, Saleme S, Mounayer C, Fiehler J, Dyzmann C, Kan PT, Singh J, Colasurdo M, Marnat G, Berge J, Barreau X, Sibon I, Nedelcu S, Henninger N, Marotta TR, Stapleton CJ, Rabinov JD, Ota T, Dofuku S, Yeo LL, Tan BYQ, Martinez-Gutierrez JC, Salazar-Marioni S, Sheth S, Renieri L, Capirossi C, Mowla A, Tjoumakaris SI, Jabbour P, Khandelwal P, Biswas A, Clarençon F, Elhorany M, Premat K, Valente I, Pedicelli A, Filipe JP, Varela R, Quintero-Consuegra M, Gonzalez NR, Möhlenbruch MA, Jesser J, Costalat V, Ter Schiphorst A, Yedavalli V, Harker P, Chervak L, Aziz Y, Gory B, Stracke CP, Hecker C, Killer-Oberpfalzer M, Griessenauer CJ, Thomas A, Hsieh CY, Liebeskind DS, Radu RA, Alexandre AM, Fahed R, Tancredi I, Faizy TD, Weyland C, Lubicz B, Patel AB, Pereira VM, Guenego A, Dmytriw AA. Multicenter evaluation of mechanical thrombectomy for distal medium vessel occlusions with National Institute of Health Stroke Scale Scores ≥ 6 and ≤ 6. J Neurol 2024; 271:5853-5863. [PMID: 38967650 DOI: 10.1007/s00415-024-12537-4] [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: 01/06/2024] [Revised: 06/21/2024] [Accepted: 06/24/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND While mechanical thrombectomy is considered standard of care for large vessel occlusions, scientific evidence to support treatment for distal and medium vessel occlusions remains scarce. PURPOSE To evaluate feasibility, safety, and outcomes in patients with low National Institute of Health Stroke Scale scores undergoing mechanical thrombectomy for treatment of distal medium vessel occlusions. MATERIALS AND METHODS Retrospective data review and analysis of prospectively maintained databases at 41 academic centers in North America, Asia, and Europe between January 2017 and January 2022. Characteristics and outcomes were compared between groups with low stroke scale score (≤ 6) versus and higher stroke scale scores (> 6). Propensity score matching using the optimal pair matching method and 1:1 ratio was performed. RESULTS Data were collected on a total of 1068 patients. After propensity score matching, there were a total of 676 patients included in the final analysis, with 338 patients in each group. High successful reperfusion rates were seen in both groups, 90.2% in ≤ 6 and 88.7% in the > 6 stroke scale groups. The frequency of excellent and good functional outcome was seen more common in low versus higher stroke scale score patients (64.5% and 81.1% versus 39.3% and 58.6%, respectively). The 90-day mortality rate observed in the ≤ 6 stroke scale group was 5.3% versus 13.3% in the > 6 stroke scale group. CONCLUSION Mechanical thrombectomy in distal and medium vessel occlusions, specifically in patients with low stroke scale scores is feasible, though it may not necessarily improve outcomes over IVT.
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Affiliation(s)
- Anna Luisa Kühn
- Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Ajit S Puri
- Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Hamza Adel Salim
- Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Los Angeles, USA.
- Brigham and Women's Hospital, Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA.
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD, USA.
| | - Basel Musmar
- Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Los Angeles, USA
| | - Sherief Ghozy
- Departments of Neurological Surgery & Radiology, Mayo Clinic, Rochester, MN, USA
| | - James Siegler
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA
| | - Hamza Shaikh
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA
| | - Jane Khalife
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA
| | - Mohamad Abdalkader
- Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA
| | - Piers Klein
- Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA
| | - Thanh N Nguyen
- Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA
| | - Jeremy J Heit
- Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, CA, USA
| | - Robert W Regenhardt
- Brigham and Women's Hospital, Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Jose Danilo Bengzon Diestro
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Nicole M Cancelliere
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Ahmad Sweid
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Kareem El Naamani
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Zuha Hasan
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Anil Gopinathan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Abdelaziz Amllay
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anne Dusart
- Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium
| | - Flavio Bellante
- Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium
| | - Géraud Forestier
- Neuroradiology Department, University Hospital of Limoges, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252, Limoges, France
| | - Aymeric Rouchaud
- Neuroradiology Department, University Hospital of Limoges, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252, Limoges, France
| | - Suzana Saleme
- Neuroradiology Department, University Hospital of Limoges, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252, Limoges, France
| | - Charbel Mounayer
- Neuroradiology Department, University Hospital of Limoges, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252, Limoges, France
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Dyzmann
- Neuroradiology Department, Sana Kliniken, Lübeck GmbH, Lübeck, Germany
| | - Peter T Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Jasmeet Singh
- Brigham and Women's Hospital, Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Marco Colasurdo
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Gaultier Marnat
- Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France
| | - Jérôme Berge
- Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France
| | - Xavier Barreau
- Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France
| | - Igor Sibon
- Neurology Department, Bordeaux University Hospital, Bordeaux, France
| | - Simona Nedelcu
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Nils Henninger
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Thomas R Marotta
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Christopher J Stapleton
- Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Los Angeles, USA
| | - James D Rabinov
- Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Los Angeles, USA
| | - Takahiro Ota
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Shogo Dofuku
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Leonard Ll Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Benjamin Y Q Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | | | - Sunil Sheth
- Interventistica Neurovascolare, Ospedale Careggi Di Firenze, Florence, Italy
| | - Leonardo Renieri
- Interventistica Neurovascolare, Ospedale Careggi Di Firenze, Florence, Italy
| | - Carolina Capirossi
- Interventistica Neurovascolare, Ospedale Careggi Di Firenze, Florence, Italy
| | - Ashkan Mowla
- Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), 1200 North State St, Suite 3300, Los Angeles, CA, USA
| | | | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Priyank Khandelwal
- Department of Endovascular Neurosurgery and Neuroradiology NJMS, Newark, NJ, USA
| | - Arundhati Biswas
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Frédéric Clarençon
- Department of Neuroradiology, GRC BioFast, Sorbonne University. Paris VI, Pitié-Salpêtrière Hospital, Paris, France
| | - Mahmoud Elhorany
- Department of Neuroradiology, GRC BioFast, Sorbonne University. Paris VI, Pitié-Salpêtrière Hospital, Paris, France
| | - Kevin Premat
- Department of Neuroradiology, GRC BioFast, Sorbonne University. Paris VI, Pitié-Salpêtrière Hospital, Paris, France
| | - Iacopo Valente
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy
| | - Alessandro Pedicelli
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy
| | - João Pedro Filipe
- Department of Diagnostic and Interventional Neuroradiology, Centro Hospitalar Universitário Do Porto, Porto, Portugal
| | - Ricardo Varela
- Department of Neurology, Centro Hospitalar Universitário Do Porto, Porto, Portugal
| | | | - Nestor R Gonzalez
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Markus A Möhlenbruch
- Sektion Vaskuläre Und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Jessica Jesser
- Sektion Vaskuläre Und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Vincent Costalat
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Adrien Ter Schiphorst
- Department of Neurology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Vivek Yedavalli
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD, USA
| | - Pablo Harker
- Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Lina Chervak
- Department of Neurology and Radiology, University of Cincinnati, Cincinnati, OH, USA
| | - Yasmin Aziz
- Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Benjamin Gory
- Department of Interventional Neuroradiology, Nancy University Hospital, Nancy, France
| | - Christian Paul Stracke
- Department of Radiology, Interventional Neuroradiology Section, University Medical Center, Münster, Germany
| | - Constantin Hecker
- Departments of Neurology and Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Monika Killer-Oberpfalzer
- Departments of Neurology and Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Christoph J Griessenauer
- Departments of Neurology and Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Ajith Thomas
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA
| | | | - David S Liebeskind
- UCLA Stroke Center and Department of Neurology Department, UCLA, Los Angeles, CA, USA
| | - Răzvan Alexandru Radu
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Andrea M Alexandre
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy
| | - Robert Fahed
- Department of Medicine, Division of Neurology, The Ottawa Hospital, Ottawa Hospital Research Institute and University of Ottawa, Ottawa, ON, Canada
| | - Illario Tancredi
- Department of Medicine, Division of Neurology, The Ottawa Hospital, Ottawa Hospital Research Institute and University of Ottawa, Ottawa, ON, Canada
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Charlotte Weyland
- Sektion Vaskuläre Und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Boris Lubicz
- Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Aman B Patel
- Brigham and Women's Hospital, Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Vitor Mendes Pereira
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Adrien Guenego
- Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Adam A Dmytriw
- Brigham and Women's Hospital, Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA.
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
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Ntoulias N, Brehm A, Miralbés S, Naravetla B, Spiotta A, Loehr C, Martínez-Galdámez M, McTaggart R, Defreyne L, Vega P, Zaidat OO, Price LL, Liebeskind DS, Möhlenbruch M, Gupta R, Psychogios MN. Trevo 3 Mm and/or AXS Catalyst 5 for the Treatment of Medium Distal Vessel Occlusion Stroke-results from the ASSIST Registry. Clin Neuroradiol 2024:10.1007/s00062-024-01450-y. [PMID: 39179880 DOI: 10.1007/s00062-024-01450-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: 05/21/2024] [Accepted: 07/22/2024] [Indexed: 08/26/2024]
Abstract
BACKGROUND The effect of endovascular therapy (EVT) on the outcome of stroke patients with a medium distal vessel occlusion (MDVO) is unclear. We report the results of MDVO patients treated with the 3 mm Trevo stent retriever (SR) and/or the AXS Catalyst 5 distal access catheter. METHODS Data was derived from a prospective, multicenter global registry (ASSIST registry) which enrolled patients treated with operator preferred EVT technique at 71 sites from January 2019 to January 2022. Three techniques were assessed: SR classic, direct aspiration, and a combined approach. Additional inclusion criteria were (a) EVT performed with the 3 mm Trevo SR and/or AXS Catalyst 5 distal access catheter on the first pass and (b) an occlusion of the M2 segment or M3 segment of the middle cerebral artery or the A1, A2 or A3 segment of the anterior cerebral artery. The primary outcome was achieving an expanded Thrombolysis in Cerebral Infarction (eTICI) score of 2c or 3 on the first pass, with the primary technique as adjudicated by core lab. The primary clinical outcome measure was a 90-day modified Rankin Scale (mRS) score of 0-2. RESULTS A total of 155 patients (10.4% of the ASSIST population) were included. Most patients had an M2 occlusion (93.5%). First pass eTICI reperfusion was achieved in 43.1% of the patients. No modifying effect of the frontline technique was found. The rate of mRS 0-2 (overall 65.0%) did not significantly differ between groups. CONCLUSION The data suggests that the Trevo 3 mm SR and/or the AXS Catalyst 5 may be an option to treat medium distal vessel occlusion, but more data is needed to demonstrate safety and efficacy in this patient cohort. Further improvements are needed regarding materials and techniques to improve reperfusion results in this patient cohort in the future.
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Affiliation(s)
- Nikolaos Ntoulias
- Diagnostic and Interventional Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Alex Brehm
- Diagnostic and Interventional Neuroradiology, University Hospital Basel, Basel, Switzerland
| | | | - Bharath Naravetla
- Interventional Neurology, McLaren Regional Medical Center, Flint, MI, USA
- Interventional Neurology, McLaren Regional Medical Center, Macomb, MI, USA
| | - Alejandro Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Christian Loehr
- Radiology and Neuroradiology, Klinikum Vest Recklinghausen, Recklinghausen, Germany
| | - Mario Martínez-Galdámez
- Interventional Neuroradiology/Endovascular Neurosurgery, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
| | - Ryan McTaggart
- Interventional Neuroradiology, Rhode Island Hospital, Providence, RI, USA
| | - Luc Defreyne
- Vascular and Interventional Radiology, Ghent University Hospital, Ghent, Belgium
| | - Pedro Vega
- Radiology, Hospital Universitario Central de Asturias-HUCA, Oviedo, Spain
| | - Osama O Zaidat
- euroscience Department, Bon Secours Mercy Health St. Vincent Medical Center, Toledo, OH, USA
| | | | - David S Liebeskind
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, USA
| | | | - Rishi Gupta
- Wellstar Medical Group, Neurosurgery, WellStar Health System, Marietta, GA, USA
| | - Marios-Nikos Psychogios
- Diagnostic and Interventional Neuroradiology, University Hospital Basel, Basel, Switzerland.
- Department of Neuroradiology, University Hospital Basel, Petersgraben 4, 4031, Basel, Switzerland.
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4
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Srinivas T, Ran K, Nair SK, Hung A, Young CC, Tamargo RJ, Huang J, Marsh E, Hillis A, Yedavalli V, Urrutia V, Gailloud P, Caplan JM, Gonzalez LF, Xu R. Racial disparities in functional outcomes following mechanical thrombectomy in a cohort of patients with ischemic stroke. J Neurointerv Surg 2024; 16:857-863. [PMID: 37532451 DOI: 10.1136/jnis-2023-020634] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 07/23/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND Non-Hispanic Black (NHB) patients experience increased prevalence of stroke risk factors and stroke incidence compared with non-Hispanic White (NHW) patients. However, little is known about >90-day post-stroke functional outcomes following mechanical thrombectomy. OBJECTIVE To describe patient characteristics, evaluate stroke risk factors, and analyze the adjusted impact of race on long-term functional outcomes to better identify and limit sources of disparity in post-stroke care. METHODS We retrospectively reviewed 326 patients with ischemic stroke who underwent thrombectomy at two centers between 2019 and 2022. Race was self-reported as NHB, NHW, or non-Hispanic Other. Stroke risk factors, insurance status, procedural parameters, and post-stroke functional outcomes were collected. Good outcomes were defined as modified Rankin Scale score ≤2 and/or discharge disposition to home/self-care. To assess the impact of race on outcomes at 3-, 6-, and 12-months' follow-up, we performed univariate and multivariate logistic regression. RESULTS Patients self-identified as NHB (42%), NHW (53%), or Other (5%). 177 (54.3%) patients were female; the median (IQR) age was 67.5 (59-77) years. The median (IQR) National Institutes of Health Stroke Scale score was 15 (10-20). On univariate analysis, NHB patients were more likely to have poor short- and long-term functional outcomes, which persisted on multivariate analysis as significant at 3 and 6 months but not at 12 months (3 months: OR=2.115, P=0.04; 6 months: OR=2.423, P=0.048; 12 months: OR=2.187, P=0.15). NHB patients were also more likely to be discharged to rehabilitation or hospice/death than NHW patients after adjusting for confounders (OR=1.940, P=0.04). CONCLUSIONS NHB patients undergoing thrombectomy for ischemic stroke experience worse 3- and 6-month functional outcomes than NHW patients after adjusting for confounders. Interestingly, this disparity was not detected at 12 months. Future research should focus on identifying social determinants in the short-term post-stroke recovery period to improve parity in stroke care.
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Affiliation(s)
- Tara Srinivas
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kathleen Ran
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Sumil K Nair
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Alice Hung
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Christopher C Young
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elizabeth Marsh
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Argye Hillis
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Vivek Yedavalli
- Department of Radiology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Victor Urrutia
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Philippe Gailloud
- Division of Interventional Neuroradiology, Johns Hopkins Hospital, Baltimore, Maryland, USA
| | - Justin M Caplan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - L Fernando Gonzalez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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5
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Salim HA, Yedavalli V, Musmar B, Adeeb N, E L Naamani K, Henninger N, Sundararajan SH, Kühn AL, Khalife J, Ghozy S, Scarcia L, Tan BYQ, Heit JJ, Regenhardt RW, Cancelliere NM, Bernstock JD, Rouchaud A, Fiehler J, Essibayi MA, Sheth SA, Puri AS, Barreau X, Colasurdo M, Renieri L, Dyzmann C, Marotta T, Spears J, Mowla A, Jabbour P, Filipe JP, Biswas A, Harker P, Clarençon F, Radu RA, Siegler JE, Nguyen TN, Varela R, Ota T, Gonzalez N, Moehlenbruch MA, Altschul D, Gory B, Costalat V, Stracke CP, Aziz-Sultan MA, Hecker C, Shaikh H, Liebeskind DS, Baker A, Pedicelli A, Alexandre A, Faizy TD, Tancredi I, Kalsoum E, Lubicz B, Patel AB, Mendes Pereira V, Guenego A, Dmytriw AA. Endovascular therapy versus best medical management in distal medium middle cerebral artery acute ischaemic stroke: a multinational multicentre propensity score-matched study. J Neurol Neurosurg Psychiatry 2024:jnnp-2024-333669. [PMID: 39043567 DOI: 10.1136/jnnp-2024-333669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 06/24/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND The efficacy of endovascular treatment (EVT) in acute ischaemic stroke due to distal medium vessel occlusion (DMVO) remains uncertain. Our study aimed to evaluate the safety and efficacy of EVT compared with the best medical management (BMM) in DMVO. METHODS In this prospectively collected, retrospectively reviewed, multicentre cohort study, we analysed data from the Multicentre Analysis of primary Distal medium vessel occlusions: effect of Mechanical Thrombectomy registry. Patients with acute ischaemic stroke due to DMVO in the M2, M3 and M4 segments who underwent EVT or received BMM were included. Primary outcome measures comprised 10 co-primary endpoints, including functional independence (mRS 0-2), excellent outcome (mRS 0-1), mortality (mRS 6) and haemorrhagic complications. Propensity score matching was employed to balance the cohorts. RESULTS Among 2125 patients included in the primary analysis, 1713 received EVT and 412 received BMM. After propensity score matching, each group comprised 391 patients. At 90 days, no significant difference was observed in achieving mRS 0-2 between EVT and BMM (adjusted OR 1.00, 95% CI 0.67 to 1.50, p>0.99). However, EVT was associated with higher rates of symptomatic intracerebral haemorrhage (8.4% vs 3.0%, adjusted OR 3.56, 95% CI 1.69 to 7.48, p<0.001) and any intracranial haemorrhage (37% vs 19%, adjusted OR 2.61, 95% CI 1.81 to 3.78, p<0.001). Mortality rates were similar between groups (13% in both, adjusted OR 1.48, 95% CI 0.87 to 2.51, p=0.15). CONCLUSION Our findings suggest that while EVT does not significantly improve functional outcomes compared with BMM in DMVO, it is associated with higher risks of haemorrhagic complications. These results support a cautious approach to the use of EVT in DMVO and highlight the need for further prospective randomised trials to refine treatment strategies.
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Affiliation(s)
- Hamza Adel Salim
- Radiology, Johns Hopkins Medicine, Baltimore, Maryland, USA
- Neuroendovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
- Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
| | | | - Basel Musmar
- Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
| | - Nimer Adeeb
- Neurosurgery, BIDMC, Shreveport, Louisiana, USA
| | | | - Nils Henninger
- Neurology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Sri Hari Sundararajan
- New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | | | - Jane Khalife
- Cooper Hospital University Medical Center, Camden, New Jersey, USA
| | - Sherief Ghozy
- Radiology Neuroradiology Department, Mayo Clinic, Rochester, Minnesota, USA
| | - Luca Scarcia
- Policlinico Universitario Agostino Gemelli, Roma, Lazio, Italy
| | | | | | - Robert W Regenhardt
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston MA, Boston, Massachusetts, USA
| | | | | | - Aymeric Rouchaud
- Interventional Neuroradiology, Hopital Bicetre, Paris Kremlin Bicêtre, France
- Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jens Fiehler
- Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | - Sunil A Sheth
- Neurology, University of Texas - Houston, Houston, Texas, USA
| | - Ajit S Puri
- Radiology and Neurosurgery, Univ Massachusetts, Worcester, Massachusetts, USA
| | | | | | - Leonardo Renieri
- Interventional Neurovascular Unit, Azienda Ospedaliero Universitaria Careggi, Firenze, Italy
| | | | | | - Julian Spears
- Department of Medical Imaging, Division of Diagnostic and Therapeutic Neuroradiology, St. Michael's Hospital, University of Toronto, Department of Medical Imaging, Division of Diagnostic and Therapeutic Neuroradiology, St. Michael's Hospital, University of Toronto, Pessac, France
- Department of Surgery, Division of Neurosurgery, University of Toronto, Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Askan Mowla
- USC Keck School of Medicine, Los Angeles, California, USA
| | - Pascal Jabbour
- Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Arundhati Biswas
- Neurosurgery, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Frédéric Clarençon
- Interventional Neuroradiology, University Hospital Pitié Salpêtrière, Paris, France
| | | | - James E Siegler
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thanh N Nguyen
- Neurology, Neurosurgery, Radiology, Boston University Medical Center, Boston, Massachusetts, USA
| | - Ricardo Varela
- Neurology, University of California, Los Angeles, Los Angeles, California, USA
| | - Takahiro Ota
- Radiological Sciences, Catholic University of Sacred Heart, "A. Gemelli" Hospital, Rome, Italy
| | - Nestor Gonzalez
- Radiology and Neuroradiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Benjamin Gory
- Hôpital Civil Marie Curie à Lodelinsart, Charleroi, Belgium
| | | | | | | | - Constantin Hecker
- Institute of Neurointervention, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Hamza Shaikh
- Interventional Neuroradiology Department, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - David S Liebeskind
- Neurology, University of California, Los Angeles, Los Angeles, California, USA
| | - Amanda Baker
- Montefiore Medical Center, New York, New York, USA
| | - Alessandro Pedicelli
- Radiological Sciences, Catholic University of Sacred Heart, "A. Gemelli" Hospital, Rome, Italy
| | - Andrea Alexandre
- Radiology and Neuroradiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Erwah Kalsoum
- Neuroradiology, Henri Mondor Hospital, Créteil, France
| | - Boris Lubicz
- Centre Universitair Bruxelles Hôpital Erasme, Bruxelles, Belgium
| | - Aman B Patel
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Adrien Guenego
- Interventional Neuroradiology Department, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
- Neurovascular Centre, Divisions of Therapeutic Neuroradiology and Neurosurgery, St. Michael Hospital, University of Toronto, Toronto, ON, Canada
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6
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Yedavalli V, Koneru M, Hamam O, Hoseinyazdi M, Marsh EB, Llinas R, Urrutia V, Leigh R, Gonzalez F, Xu R, Caplan J, Huang J, Lu H, Wintermark M, Heit J, Guenego A, Albers G, Nael K, Hillis A. Pretreatment CTP Collateral Parameters Predict Good Outcomes in Successfully Recanalized Middle Cerebral Artery Distal Medium Vessel Occlusions. Clin Neuroradiol 2024; 34:341-349. [PMID: 38155255 DOI: 10.1007/s00062-023-01371-2] [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: 09/05/2023] [Accepted: 11/23/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND/PURPOSE Distal medium vessel occlusions (DMVOs) account for a large percentage of vessel occlusions resulting in acute ischemic stroke (AIS) with disabling symptoms. We aim to assess whether pretreatment quantitative CTP collateral status (CS) parameters can serve as imaging biomarkers for good clinical outcomes prediction in successfully recanalized middle cerebral artery (MCA) DMVOs. METHODS We performed a retrospective analysis of consecutive patients with AIS secondary to primary MCA-DMVOs who were successfully recanalized by mechanical thrombectomy (MT) defined as modified thrombolysis in cerebral infarction (mTICI) 2b, 2c, or 3. We evaluated the association between the CBV index and HIR independently with good clinical outcomes (modified Rankin score 0-2) using Spearman rank correlation, logistic regression, and ROC analyses. RESULTS From 22 August 2018 to 18 October 2022 8/22/2018 to 10/18/2022, 60 consecutive patients met our inclusion criteria (mean age 71.2 ± 13.9 years old [mean ± SD], 35 female). The CBV index (r = -0.693, p < 0.001) and HIR (0.687, p < 0.001) strongly correlated with 90-day mRS. A CBV index ≥ 0.7 (odds ratio, OR, 2.27, range 6.94-21.23 [OR] 2.27 [6.94-21.23], p = 0.001)) and lower likelihood of prior stroke (0.13 [0.33-0.86]), p = 0.024)) were independently associated with good outcomes. The ROC analysis demonstrated good performance of the CBV index in predicting good 90-day mRS (AUC 0.73, p = 0.003) with a threshold of 0.7 for optimal sensitivity (71% [52.0-85.8%]) and specificity (76% [54.9-90.6%]). The HIR also demonstrated adequate performance in predicting good 90-day mRS (AUC 0.77, p = 0.001) with a threshold of 0.3 for optimal sensitivity (64.5% [45.4-80.8%]) and specificity (76.0% [54.9-90.6%]). CONCLUSION A CBV index ≥ 0.7 may be independently associated with good clinical outcomes in our cohort of AIS caused by MCA-DMVOs that were successfully treated with MT. Furthermore, a HIR < 0.3 is also associated with good clinical outcomes. This is the first study of which we are aware to identify a CBV index threshold for MCA-DMVOs.
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Affiliation(s)
- Vivek Yedavalli
- Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Phipps B112-D, 21287, Baltimore, MD, USA.
- Department of Neurology, Stanford University School of Medicine, Stanford, Ca, USA.
| | - Manisha Koneru
- Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Phipps B112-D, 21287, Baltimore, MD, USA
| | - Omar Hamam
- Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Phipps B112-D, 21287, Baltimore, MD, USA
| | - Meisam Hoseinyazdi
- Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Phipps B112-D, 21287, Baltimore, MD, USA
| | | | - Raf Llinas
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Victor Urrutia
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Richard Leigh
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Fernando Gonzalez
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Justin Caplan
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | - Hanzhang Lu
- Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Phipps B112-D, 21287, Baltimore, MD, USA
| | - Max Wintermark
- Department of Radiology, University of Texas, MD Anderson, TX, USA
| | - Jeremy Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Adrien Guenego
- Department of Radiology, Université libre de Bruxelles, Bruxelles, Belgium
| | - Greg Albers
- Department of Radiology, Université libre de Bruxelles, Bruxelles, Belgium
| | - Kambiz Nael
- Department of Radiology, David Geffen UCLA School of Medicine, Los Angeles, Ca, USA
| | - Argye Hillis
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA
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7
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Mohammaden MH, Souza Viana L, Abdelhamid H, Olive-Gadea M, Rodrigo-Gisbert M, Requena M, Martins PN, Matsoukas S, Schuldt BR, Fifi JT, Farooqui M, Vivanco-Suarez J, Ortega-Gutierrez S, Klein P, Abdalkader M, Vigilante N, Siegler JE, Moreira Ferreira F, Peng S, Alaraj A, Haussen DC, Nguyen TN, Nogueira RG. Endovascular Versus Medical Management in Distal Medium Vessel Occlusion Stroke: The DUSK Study. Stroke 2024; 55:1489-1497. [PMID: 38787927 DOI: 10.1161/strokeaha.123.045228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 03/21/2024] [Indexed: 05/26/2024]
Abstract
BACKGROUND Endovascular treatment (EVT) is part of the usual care for proximal vessel occlusion strokes. However, the safety and effectiveness of EVT for distal medium vessel occlusions remain unclear. We sought to compare the clinical outcomes of EVT to medical management (MM) for isolated distal medium vessel occlusions. METHODS This is a retrospective analysis of prospectively collected data from seven comprehensive stroke centers. Patients were included if they had isolated distal medium vessel occlusion strokes due to middle cerebral artery M3/M4, anterior cerebral artery A2/A3, or posterior cerebral artery P1/P2 segments. Patients treated with EVT or MM were compared with multivariable logistic regression and inverse probability of treatment weighting. The primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included 90-day good (mRS score, 0-2) and excellent (mRS score, 0-1) outcomes. Safety measures included symptomatic intracranial hemorrhage and 90-day mortality. RESULTS A total of 321 patients were included in the analysis (EVT, 179; MM, 142; 40.8% treated with intravenous thrombolysis). In the inverse probability of treatment weighting model, there were no significant differences between EVT and MM in terms of the overall degree of disability (mRS ordinal shift; adjusted odds ratio [aOR], 1.25 [95% CI, 0.95-1.64]; P=0.110), rates of good (mRS score, 0-2; aOR, 1.32 [95% CI, 0.97-1.80]; P=0.075) and excellent (aOR, 1.32 [95% CI, 0.94-1.85]; P=0.098) outcomes, or mortality (aOR, 1.20 [95% CI, 0.78-1.85]; P=0.395) at 90 days. The multivariable regression model showed similar findings. Moreover, there was no difference between EVT and MM in rates of symptomatic intracranial hemorrhage in the multivariable regression model (aOR, 0.57 [95% CI, 0.21-1.58]; P=0.277), but the inverse probability of treatment weighting model showed a lower likelihood of symptomatic intracranial hemorrhage (aOR, 0.46 [95% CI, 0.24-0.85]; P=0.013) in the EVT group. CONCLUSIONS This multicenter study failed to demonstrate any significant outcome differences among patients with isolated distal medium vessel occlusions treated with EVT versus MM. These findings reinforce clinical equipoise. Randomized clinical trials are ongoing and will provide more definite evidence.
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Affiliation(s)
- Mahmoud H Mohammaden
- Department of Neurology, Emory University School of Medicine-Atlanta, GA (M.H.M., L.S.V., H.A., P.N.M., F.M.F., D.C.H.)
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, GA (M.H.M., L.S.V., H.A., P.N.M., F.M.F., D.C.H.)
- Department of Neurology, Faculty of Medicine, South Valley University, Qena, Egypt (M.H.M.)
| | - Lorena Souza Viana
- Department of Neurology, Emory University School of Medicine-Atlanta, GA (M.H.M., L.S.V., H.A., P.N.M., F.M.F., D.C.H.)
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, GA (M.H.M., L.S.V., H.A., P.N.M., F.M.F., D.C.H.)
| | - Hend Abdelhamid
- Department of Neurology, Emory University School of Medicine-Atlanta, GA (M.H.M., L.S.V., H.A., P.N.M., F.M.F., D.C.H.)
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, GA (M.H.M., L.S.V., H.A., P.N.M., F.M.F., D.C.H.)
| | - Marta Olive-Gadea
- Department of Neurology, Hospital Universitario Vall d'Hebron, Barcelona, Spain (M.O.-G., M.R.-G., M.R.)
| | - Marc Rodrigo-Gisbert
- Department of Neurology, Hospital Universitario Vall d'Hebron, Barcelona, Spain (M.O.-G., M.R.-G., M.R.)
| | - Manuel Requena
- Department of Neurology, Hospital Universitario Vall d'Hebron, Barcelona, Spain (M.O.-G., M.R.-G., M.R.)
| | - Pedro N Martins
- Department of Neurology, Emory University School of Medicine-Atlanta, GA (M.H.M., L.S.V., H.A., P.N.M., F.M.F., D.C.H.)
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, GA (M.H.M., L.S.V., H.A., P.N.M., F.M.F., D.C.H.)
| | - Stavros Matsoukas
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (S.M., B.R.S., J.T.F.)
| | - Braxton R Schuldt
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (S.M., B.R.S., J.T.F.)
| | - Johanna T Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY (S.M., B.R.S., J.T.F.)
| | - Mudassir Farooqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City (M.F., J.V.-S., S.O.-G.)
| | - Juan Vivanco-Suarez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City (M.F., J.V.-S., S.O.-G.)
| | - Santiago Ortega-Gutierrez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City (M.F., J.V.-S., S.O.-G.)
| | - Piers Klein
- Department of Neurology, Radiology, Boston University Chobanian and Avedisian School of Medicine, MA (P.K., M.A., T.N.N.)
| | - Mohamad Abdalkader
- Department of Neurology, Radiology, Boston University Chobanian and Avedisian School of Medicine, MA (P.K., M.A., T.N.N.)
| | - Nicholas Vigilante
- Department of Neurology, Cooper University Medical Center, Camden, NJ (N.V., J.E.S.)
| | - James E Siegler
- Department of Neurology, Cooper University Medical Center, Camden, NJ (N.V., J.E.S.)
| | - Felipe Moreira Ferreira
- Department of Neurology, Emory University School of Medicine-Atlanta, GA (M.H.M., L.S.V., H.A., P.N.M., F.M.F., D.C.H.)
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, GA (M.H.M., L.S.V., H.A., P.N.M., F.M.F., D.C.H.)
| | - Sophia Peng
- Department of Neurosurgery, University of Illinois at Chicago (S.P., A.A.)
| | - Ali Alaraj
- Department of Neurosurgery, University of Illinois at Chicago (S.P., A.A.)
| | - Diogo C Haussen
- Department of Neurology, Emory University School of Medicine-Atlanta, GA (M.H.M., L.S.V., H.A., P.N.M., F.M.F., D.C.H.)
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, GA (M.H.M., L.S.V., H.A., P.N.M., F.M.F., D.C.H.)
| | - Thanh N Nguyen
- Department of Neurology, Radiology, Boston University Chobanian and Avedisian School of Medicine, MA (P.K., M.A., T.N.N.)
| | - Raul G Nogueira
- Department of Neurology, Neurosurgery, University of Pittsburgh Medical Center, PA (R.G.N.)
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8
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Mohammaden MH, Doheim MF, Abdelhamid H, Matsoukas S, Schuldt BR, Fifi JT, Kuybu O, Gross BA, Al-Bayati AR, Dolia J, Grossberg JA, Olive-Gadea M, Rodrigo-Gisbert M, Requena M, Monteiro A, Yu S, Siegler JE, Rodriguez-Calienes A, Galecio-Castillo M, Ortega-Gutierrez S, Cortez GM, Hanel RA, Aghaebrahim A, Hassan AE, Nguyen TN, Abdalkader M, Klein P, Salem MM, Burkhardt JK, Jankowitz BT, Colasurdo M, Kan P, Hafeez M, Tanweer O, Peng S, Alaraj A, Siddiqui AH, Nogueira RG, Haussen DC. Anesthesia modality in endovascular treatment for distal medium vessel occlusion stroke: intention-to-treat propensity score-matched analysis. J Neurointerv Surg 2024:jnis-2024-021668. [PMID: 38782566 DOI: 10.1136/jnis-2024-021668] [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: 03/01/2024] [Accepted: 05/03/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND The optimal anesthesia modality during endovascular treatment (EVT) for distal medium vessel occlusion (DMVO) stroke is uncertain. We aimed to evaluate the association of the anesthesia modality with procedural and clinical outcomes following EVT for DMVO stroke. METHODS This is a multicenter retrospective analysis of a prospectively collected database. Patients were included if they had DMVO involving the middle cerebral artery-M3/4, anterior cerebral artery-A2/3, or posterior cerebral artery-P1/P2-3, and underwent EVT. The cohort was divided into two groups, general anesthesia (GA) and non-general anesthesia (non-GA), and compared based on the intention-to-treat principle as primary analysis. We used propensity scores to balance the two groups. The primary outcome was the shift in the degree of disability as measured by the 90-day modified Rankin Scale (mRS). Secondary outcomes included successful reperfusion, as well as excellent (mRS 0-1) and good (mRS 0-2) clinical outcomes at 90 days. Safety measures included procedural complications, symptomatic intracerebral hemorrhage (sICH), and 90-day mortality. RESULTS Among 366 DMVO thrombectomies, 61 matched pairs were eligible for analysis. Median age and National Institutes of Health Stroke Scale score as well as other baseline demographic and clinical characteristics were balanced between both groups. The GA group had no difference in the overall degree of disability (common OR 1.19, 95% CI 0.52 to 2.86, P=0.67) compared with the non-GA arm. Likewise, the GA group had comparable rates of successful reperfusion (OR 2.38, 95% CI 0.80 to 7.07, P=0.12), good/excellent clinical outcomes (OR 1.14, 95% CI 0.44 to 2.96, P=0.79/(OR 0.65, 95% CI 0.24 to 1.81, P=0.41), procedural complications (OR 1.00, 95% CI 0.19 to 5.16, P>0.99), sICH (OR 3.24, 95% CI 0.83 to 12.68, P=0.09), and 90-day mortality (OR 1.43, 95% CI 0.48 to 4.27, P=0.52) compared with the non-GA group. CONCLUSIONS In patients with DMVO, our study showed that GA and non-GA groups had similar procedural and clinical outcomes, as well as safety measures. Further larger controlled studies are warranted.
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Affiliation(s)
- Mahmoud H Mohammaden
- Neurology, Emory University, Atlanta, Georgia, USA
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, GA, USA
- Neurology, Faculty of Medicine, South Valley University, Qena, Egypt
| | | | - Hend Abdelhamid
- Neurology, Emory University, Atlanta, Georgia, USA
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, GA, USA
| | - Stavros Matsoukas
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | | | - Johanna T Fifi
- Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Okkes Kuybu
- Neurology, UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA
| | - Bradley A Gross
- Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | | | - Jaydevsinh Dolia
- Neurology, Emory University, Atlanta, Georgia, USA
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, GA, USA
| | - Jonathan A Grossberg
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, GA, USA
- Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | | | | | - Manuel Requena
- Neurology, Hospital Vall d'Hebron, Barcelona, Barcelona, Spain
| | - Andre Monteiro
- Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Siyuan Yu
- Cooper Neurological Institute, Cooper University Health Care, Camden, New Jersey, USA
| | - James E Siegler
- Cooper Neurological Institute, Cooper University Health Care, Camden, New Jersey, USA
| | | | | | - Santiago Ortega-Gutierrez
- Neurology, Neurosurgery and Radiology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Gustavo M Cortez
- Neurological Institute, Lyerley Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - Ricardo A Hanel
- Neurological Institute, Lyerley Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - Amin Aghaebrahim
- Neurological Institute, Lyerley Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley, Harlingen, Texas, USA
| | - Thanh N Nguyen
- Neurology and Radiology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Mohamad Abdalkader
- Radiology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Piers Klein
- Neurology and Radiology, Boston University Chobanian & Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Mohamed M Salem
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Jan-Karl Burkhardt
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Brian T Jankowitz
- Department of Neurosurgery, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Marco Colasurdo
- Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Peter Kan
- Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Muhammad Hafeez
- Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Omar Tanweer
- Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Sophia Peng
- Neurosurgery, University of Illinois College of Medicine at Chicago, Chicago, Illinois, USA
| | - Ali Alaraj
- Neurosurgery, University of Illinois College of Medicine at Chicago, Chicago, Illinois, USA
| | - Adnan H Siddiqui
- Neurosurgery, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
| | - Raul G Nogueira
- Neurology, UPMC Stroke Institute, Pittsburgh, Pennsylvania, USA
| | - Diogo C Haussen
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, GA, USA
- Neurology and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
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9
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Salsano G, Salsano A, Del Sette B, D’Alonzo A, Sassos D, Alexandre A, Pedicelli A, Di Iorio R, Colò F, Castellan L. Endovascular thrombectomy versus intravenous thrombolysis for primary distal, medium vessel occlusion in acute ischemic stroke. Open Med (Wars) 2024; 19:20240966. [PMID: 38756249 PMCID: PMC11097045 DOI: 10.1515/med-2024-0966] [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: 01/08/2024] [Revised: 04/17/2024] [Accepted: 04/17/2024] [Indexed: 05/18/2024] Open
Abstract
Introduction In the absence of clinical trials, the benefit of endovascular therapy (EVT) on the treatment of acute ischemic stroke (AIS) with primary distal and medium vessel occlusions (DMVO) is still not well defined. The aim of the study is to evaluate EVT with or without intravenous thrombolysis (EVT ± IVT) in primary DMVO stroke in comparison with a control cohort treated with IVT alone. Methods We analysed all consecutive AIS with proven primary DMVO. Primary endpoints were excellent outcome, functional independence at 3 months follow-up, and early neurologic improvement at 1 day after treatment. Results One hundred and fourteen patients with DMVO strokes were included between 2019 and 2023. Propensity-weighted analysis showed no significant differences in EVT ± IVT vs IVT for the excellent outcome (adjusted OR [aOR], 1.575; 95% CI, 0.706-3.513), functional independence (aOR, 2.024; 95% CI, 0.845-4.848), early neurological improvement (aOR, 2.218; 95% CI, 0.937-5.247), mortality (aOR, 0.498; 95% CI, 0.177-1.406), symptomatic intracranial haemorrhage (aOR, 0.493; 95% CI, 0.102-2.385), and subarachnoid haemorrhage (aOR, 0.560; 95% CI, 0.143-2.187). The type of revascularization did not influence the percentage of cerebral volume lost (adjusted linear regression estimate, -19.171, t value, 11.562; p = 0.104). Conclusions This study supports the hypothesis that patients with primary DMVO stroke treated with EVT (±IVT) or IVT alone have comparable outcomes.
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Affiliation(s)
- Giancarlo Salsano
- Department of Radiology and Interventional Radiology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | | | - Bruno Del Sette
- Department of Radiology and Interventional Radiology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Alessio D’Alonzo
- Department of Radiology and Interventional Radiology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Davide Sassos
- Clinica Neurologica IRCCS Azienda Ospedaliera Universitaria San Martino, IST, Genoa, Italy
| | - Andrea Alexandre
- UOSA Neuroradiology Unit, Department of Radiology, Radiotherapy and Oncology and Hematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alessandro Pedicelli
- UOSA Neuroradiology Unit, Department of Radiology, Radiotherapy and Oncology and Hematology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Riccardo Di Iorio
- Neurology Unit, Department of Aging, Neurological, Orthopedic and Head and Neck Sciences, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesca Colò
- Department of Neurosciences, Catholic University School of Medicine, Rome, Italy
| | - Lucio Castellan
- Department of Radiology and Interventional Radiology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
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10
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Marios-Nikos P, Alex B, Jens F, Isabel F, Jan G, Mira K, Ronen L, Paolo M, Marc R, Jeffrey L S, Daniel S, Adriaan VE, Claus Z, Nikki R, Luzia B, Urs F. EnDovascular Therapy Plus Best Medical Treatment (BMT) Versus BMT Alone for MedIum distal VeSsel Occlusion sTroke (DISTAL): An international, multicentre, randomized-controlled, two-arm, assessor-blinded trial. Eur Stroke J 2024:23969873241250212. [PMID: 38702876 DOI: 10.1177/23969873241250212] [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: 05/06/2024] Open
Abstract
RATIONALE Whether endovascular therapy (EVT) in addition to best medical treatment (BMT) in people with acute ischemic stroke (AIS) due to a medium distal vessel occlusion (MDVO) is beneficial remains unclear. AIM To determine if people experiencing an AIS due to an isolated MDVO (defined as the co- or non-dominant M2 segment, the M3 or M4 segment of the middle cerebral artery, the A1, A2, or A3 segment of the anterior cerebral artery or the P1, P2 or P3 segment of the posterior cerebral artery) will have superior outcome if treated with EVT in addition to BMT compared to BMT alone. SAMPLE SIZE To randomize 526 participants 1:1 to EVT plus BMT or BMT alone. METHODS AND DESIGN A multicentre, international, prospective, randomized, open-label, blinded-endpoint (PROBE) superiority trial. OUTCOMES The primary efficacy endpoint is the distribution of disability levels on the modified Rankin Scale at 90 days. Secondary clinical efficacy outcomes include normalized change in National Institutes of Health Stroke Scale score from baseline to day 1, cognitive outcome at 90 days, and health-related quality of life at 90 days. Safety outcomes include all serious adverse events, symptomatic intracranial hemorrhage within 24 h, and all-cause mortality up to 90 days. Secondary imaging outcomes include successful reperfusion at end of EVT procedure and recanalization of target artery at 24 h. DISCUSSION DISTAL will inform physicians whether EVT in addition to BMT in people with AIS due to a MDVO is more efficacious than BMT alone.
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Affiliation(s)
| | - Brehm Alex
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Fiehler Jens
- Clinic of Diagnostic and Interventional Neuroradiology, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | - Fragata Isabel
- Department of Neuroradiology, Centro Hospitalar Universitário Lisboa Central, Lisboa, Portugal
- NOVA Medical School, Universidade NOVA de Lisboa, Lisbon, Portugal
| | - Gralla Jan
- Clinic of Diagnostic and Interventional Neuroradiology, Inselspital Bern, Bern, Switzerland
| | - Katan Mira
- Clinic of Neurology, University Hospital Basel, Basel, Switzerland
| | - Leker Ronen
- Department of Neurology, Stroke Center, Hadassah Medical Center, Jerusalem, Israel
| | - Machi Paolo
- Clinic of Diagnostic and Interventional Neuroradiology, Hôpitaux universitaires de Genève, Genève, Switzerland
| | - Ribo Marc
- Department of Neurology, Hospital Vall d'Hebron, Barcelona, Spain
| | - Saver Jeffrey L
- Comprehensive Stroke Center and Department of Neurology, David Geffen School of Medicine of UCLA, Los Angeles, CA, USA
| | - Strbian Daniel
- Division of Emergency Neurology and Neurocritical care, HUS, Helsinki, Finland
| | - van Es Adriaan
- Department of Radiology and Nuclear Medicine, Leiden University Medical Center, Leiden, The Netherlands
| | - Zimmer Claus
- Clinic of Diagnostic and Interventional Neuroradiology, Technical University of Munich, Munich, Germany
| | - Rommers Nikki
- Department of Clinical Research, University Hospital Basel, Basel, Switzerland
| | - Balmer Luzia
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Fischer Urs
- Clinic of Diagnostic and Interventional Neuroradiology, Inselspital Bern, Bern, Switzerland
- Clinic of Neurology, Inselspital Bern, Bern, Switzerland
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11
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Nogueira RG, Doheim MF, Al-Bayati AR, Lee JS, Haussen DC, Mohammaden M, Lang M, Starr M, Rocha M, da Câmara CP, Gross BA, Bhatt NR. Distal Medium Vessel Occlusion Strokes: Understanding the Present and Paving the Way for a Better Future. J Stroke 2024; 26:190-202. [PMID: 38836268 PMCID: PMC11164590 DOI: 10.5853/jos.2023.02649] [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: 08/12/2023] [Revised: 02/02/2024] [Accepted: 02/06/2024] [Indexed: 06/06/2024] Open
Abstract
Distal medium vessel occlusions (DMVOs) are thought to cause as many as 25% to 40% of all acute ischemic strokes and may result in substantial disability amongst survivors. Although intravenous thrombolysis (IVT) is more effective for distal than proximal vessel occlusions, the overall efficacy of IVT remains limited in DMVO with less than 50% of patients achieving reperfusion and about 1/3 to 1/4 of the patients failing to achieve functional independence. Data regarding mechanical thrombectomy (MT) among these patients remains limited. The smaller, thinner, and more tortuous vessels involved in DMVO are presumably associated with higher procedural risks whereas a lower benefit might be expected given the smaller amount of tissue territory at risk. Recent advances in technology have shown promising results in endovascular treatment of DMVOs with room for future improvement. In this review, we discuss some of the key technical and clinical considerations in DMVO treatment including the anatomical and clinical terminology, diagnostic modalities, the role of IVT and MT, existing technology, and technical challenges as well as the contemporary evidence and future treatment directions.
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Affiliation(s)
- Raul G. Nogueira
- UPMC Stroke Institute, Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Mohamed F. Doheim
- UPMC Stroke Institute, Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alhamza R. Al-Bayati
- UPMC Stroke Institute, Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Jin Soo Lee
- Department of Neurology, Ajou University Medical Center, Ajou University School of Medicine, Suwon, Korea
| | - Diogo C. Haussen
- Department of Neurology, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | - Mahmoud Mohammaden
- Department of Neurology, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | - Michael Lang
- UPMC Stroke Institute, Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Matthew Starr
- UPMC Stroke Institute, Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Marcelo Rocha
- UPMC Stroke Institute, Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Bradley A. Gross
- UPMC Stroke Institute, Department of Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Nirav R. Bhatt
- UPMC Stroke Institute, Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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12
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Nome T, Enriquez B, Nome CG, Tennøe B, Lund CG, Skjelland M, Aamodt AH, Beyer M. Clinical outcome after thrombectomy in patients with MeVO stroke: importance of clinical and technical factors. J Neurol 2024; 271:877-886. [PMID: 37847291 PMCID: PMC10827971 DOI: 10.1007/s00415-023-12025-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 09/23/2023] [Accepted: 09/25/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND AND AIMS Whereas high-level evidence has been proven for safety and efficacy of endovascular treatment (EVT) in large vessel occlusion (LVO) stroke, the evidence for EVT in medium vessel occlusion (MeVO) in both sexes and different age groupremains to be answered. The aim of this study was to evaluate the importance of clinical and technical parameters, focusing on sex, age and EVT procedural factors, on functional outcome in primary MeVO (pMeVO) strokes. METHODS 144 patients with pMeVO in the MCA territory from the Oslo Acute Reperfusion Stroke Study (OSCAR) were included. Clinical and radiological data were collected including 90-day mRS follow-up. RESULTS Successful reperfusion with modified thrombolysis in cerebral infarction (mTICI) ≥ 2b was achieved in 123 patients (84%). Good functional outcome (mRS ≤ 2) at 90-day follow-up was achieved in 84 patients (61.8%). Two or more passes with stent retriever was associated with increased risk of SAH, poor mTICI and poor functional outcome. In average, women had 62 min longer ictus to recanalization time compared to men. Age over 80 years was significantly associated with poor outcome and death. CONCLUSION In pMeVO patients, TICI score and number of passes with stent retriever were the main technical factors predicting mRS ≤ 2. Good clinical outcome occurred almost twice as often in patients under 80 years of age compared to patients over 80 years. Women with MeVO strokes had significant longer time from ictus to recanalization; however, this did not affect the clinical outcome.
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Affiliation(s)
- Terje Nome
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Brian Enriquez
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Cecilie G Nome
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
- Division of Anatomy, Department of Molecular Medicine, Institute of Basic Medical Sciences, GliaLab and Letten Centre, University of Oslo, Oslo, Norway
| | - Bjørn Tennøe
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Mona Skjelland
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Anne Hege Aamodt
- Department of Neurology, Oslo University Hospital, Oslo, Norway.
- Department of Neuromedicine and Movement Science, The Norwegian University of Science and Technology, Trondheim, Norway.
| | - Mona Beyer
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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13
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Cascio Rizzo A, Schwarz G, Cervo A, Giussani G, Ceresa C, Gatti A, De Angeli F, Motto C, Guccione A, Tortorella R, Granata G, Rollo C, Macera A, Piano M, Pero G, Agostoni EC. Safety and efficacy of endovascular thrombectomy for primary and secondary MeVO. J Stroke Cerebrovasc Dis 2024; 33:107492. [PMID: 37988832 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107492] [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: 06/15/2023] [Revised: 09/17/2023] [Accepted: 11/15/2023] [Indexed: 11/23/2023] Open
Abstract
BACKGROUND Medium-vessel occlusions (MeVO) are emerging as a new target for endovascular treatment (EVT). Primary MeVO occur de novo, while secondary MeVO arise from large vessel occlusion (LVO) through clot migration or fragmentation - spontaneously, following intravenous thrombolysis or EVT. We aimed to evaluate efficacy and safety of EVT in primary and EVT-induced secondary MeVO. METHODS Retrospective single-center study on consecutive EVT-treated acute ischemic stroke, from 2019-to-2021. We considered: (1) exclusive-LVO, patients with LVO and - in case of residual distal occlusion - no rescue endovascular procedure; (2) primary MeVO: initial A2, A3, M2 non-dominant, M3, P2, P3 occlusions; (3) EVT-induced secondary MeVO, presenting LVO with subsequent (treated) EVT-induced MeVO. We compared (univariable/multivariable logistic regression) EVT efficacy (eTICI≥2b, 3-month modified Rankin Scale [mRS] 0-2) and safety (EVT-complications [vessel dissection, perforation, persistent-SAH], symptomatic ICH) in all MeVO versus exclusive-LVO, primary MeVO versus exclusive-LVO, EVT-induced secondary MeVO versus exclusive-LVO and EVT-induced secondary MeVO versus primary MeVO. RESULTS We included 335 patients: 221 (66.0 %) exclusive-LVO and 114 (34.0 %) MeVO (55 [48.2 %] primary, 59 [51.8 %] secondary). Compared to exclusive-LVO, primary MeVO had higher rates of EVT complications (aOR 3.77 [95%CI 1.58-9.00],p=0.003), lower rates of eTICI≥2b (aOR 0.32 [95%CI 0.12-0.88],p=0.027) and mRS 0-2 (aOR 0.28 [95%CI 0.13-0.63],p=0.002). EVT-induced secondary MeVO had no major differences in efficacy and safety outcomes compared to exclusive-LVO, but a better mRS 0-2 (aOR 8.00 [95%CI 2.12-30.17],p=0.002) compared to primary MeVO. CONCLUSIONS Primary and EVT-induced secondary MeVO showed different safety/efficacy EVT-related profiles. Dedicated randomized data are needed to identify the best acute reperfusion strategy in the two categories.
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Affiliation(s)
- Angelo Cascio Rizzo
- Department of Neurology and Stroke Unit - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy.
| | - Ghil Schwarz
- Department of Neurology and Stroke Unit - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Amedeo Cervo
- Department of Neuroradiology - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giuditta Giussani
- Department of Neurology and Stroke Unit - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Chiara Ceresa
- Department of Neurology and Stroke Unit - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Antonella Gatti
- Department of Neurology and Stroke Unit - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Fausto De Angeli
- Department of Neurology and Stroke Unit - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Cristina Motto
- Department of Neurology and Stroke Unit - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Angelo Guccione
- Department of Neurology and Stroke Unit - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Rachele Tortorella
- Department of Neurology and Stroke Unit - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Giuseppe Granata
- Department of Neuroradiology - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Claudia Rollo
- Department of Neuroradiology - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Antonio Macera
- Department of Neuroradiology - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Mariangela Piano
- Department of Neuroradiology - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Guglielmo Pero
- Department of Neuroradiology - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Elio Clemente Agostoni
- Department of Neurology and Stroke Unit - ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
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14
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Rodriguez-Calienes A, Vivanco-Suarez J, Sequeiros JM, Galecio-Castillo M, Zevallos CB, Farooqui M, Ortega-Gutierrez S. Mechanical thrombectomy for the treatment of primary and secondary distal medium-vessel occlusion stroke: systematic review and meta-analysis. J Neurointerv Surg 2023; 15:e460-e467. [PMID: 36797050 DOI: 10.1136/jnis-2022-019975] [Citation(s) in RCA: 14] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 02/05/2023] [Indexed: 02/18/2023]
Abstract
BACKGROUND There is limited evidence on the indication and role of mechanical thrombectomy (MT) in patients with distal medium-vessel occlusions (DMVOs). The aim of this systematic review and meta-analysis was to evaluate all the evidence available on the efficacy and safety of MT techniques (stent retriever, aspiration) in primary and secondary DMVOs. METHODS Five databases were searched from inception to January 2023 for studies of MT in primary and secondary DMVOs. Outcomes of interest included favorable functional outcome (90-day modified Rankin scale (mRS) 0-2), successful reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 2b-3), symptomatic intracerebral hemorrhage (sICH), and 90-day mortality. Prespecified subgroup meta-analyses according to the specific MT technique and to the vascular territory (distal M2-M5, A2-A5, P2-P5) were also performed. RESULTS A total of 29 studies with 1262 patients were included. For primary DMVOs (n=971 patients), pooled rates of successful reperfusion, favorable outcome, 90-day mortality and sICH were 84% (95% confidence interval (CI) 76 to 90%), 64% (95% CI 54 to 72%), 12% (95% CI 8 to 18%), and 6% (95% CI 4 to 10%), respectively. For secondary DMVOs (n=291 patients), pooled rates of successful reperfusion, favorable outcome, 90-day mortality and sICH were 82% (95% CI 73 to 88%), 54% (95% CI 39 to 69%), 11% (95% CI 5 to 20%), and 3% (95% CI 1 to 9%), respectively. Subgroup analyses by MT technique and by vascular territory showed no differences in primary and secondary DMVOs. CONCLUSION Our findings suggest that MT using aspiration or stent retriever techniques appears to be effective and safe in primary and secondary DMVOs. However, given the level of evidence of our results, further confirmation in well-designed randomized controlled trials is needed.
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Affiliation(s)
- Aaron Rodriguez-Calienes
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
- Neuroscience, Clinical Effectiveness and Public Health Research Group, Universidad Cientifica del Sur, Lima, Peru
| | - Juan Vivanco-Suarez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Joel M Sequeiros
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | - Cynthia B Zevallos
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Mudassir Farooqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Santiago Ortega-Gutierrez
- Department of Neuroloy, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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15
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Kobeissi H, Bilgin C, Ghozy S, Kadirvel R, Kallmes DF, Brinjikji W. A review of acute ischemic stroke caused by distal, medium vessel occlusions. Interv Neuroradiol 2023:15910199231197616. [PMID: 37644821 DOI: 10.1177/15910199231197616] [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: 08/31/2023] Open
Abstract
Acute ischemic stroke (AIS) due to distal, medium vessel occlusion (DMVO) is increasingly recognized as the next frontier for mechanical thrombectomy. Distal, medium vessel occlusions are typically defined as an occlusion in the following arteries: anterior cerebral artery, M2-M4 segments of the middle cerebral artery, posterior cerebral artery, posterior inferior cerebellar artery, anterior inferior cerebellar artery, and superior cerebellar artery. It is estimated that 25-40% of all AIS is due to DMVO. Because of the large burden of DMVO, the frequency of literature published regarding these occlusions has greatly increased in recent years. Furthermore, treatment modalities have been created specifically for DMVOs. Due to the rapidly evolving literature on this topic, remaining up to date on DMVO definitions, anatomy, management, imaging, and clinical course is difficult. In this review article, we synthesized existing literature regarding the aforementioned topics and discussed future directions.
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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
| | - Ramanathan Kadirvel
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
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