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Schartz D, Singh R, Ellens N, Akkipeddi SMK, Houk C, Bhalla T, Mattingly T, Bender MT. Endovascular therapy versus medical management for ischemic stroke presenting beyond 24 hours: Systematic review and meta-analysis. Clin Neurol Neurosurg 2024; 244:108415. [PMID: 38964022 DOI: 10.1016/j.clineuro.2024.108415] [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: 08/13/2023] [Revised: 06/17/2024] [Accepted: 06/28/2024] [Indexed: 07/06/2024]
Abstract
OBJECTIVE The ideal management for ischemic stroke presenting in the very late time window, or beyond 24 hours from onset, is poorly understood. It is unknown if endovascular therapy (EVT) or best medical management (MM) is associated with superior clinical outcomes. METHODS A systematic literature and comparative meta-analysis was completed to evaluate the safety and efficacy of EVT vs. MM for stroke presenting beyond 24 hours. Outcome measures included: 90 day functional independence (mRS 0-2), 90 day mortality, and symptomatic intracranial hemorrhage (sICH) occurrence. A random effects model was used for quantitative synthesis. RESULTS From the five included studies, a total of 704 patients were included with 461 treated with EVT and 243 treated with MM alone. The proportion of patients achieving functional independence was significantly higher in patients treated with EVT (34.6 %) compared to MM alone (15.9 %) (OR: 4.24; CI: 2.61-6.88, P < 0.00001; I2 =0 %). While sICH occurred more in EVT patients (6.8 %) compared to MM (2.8 %), this was not significant (OR: 1.96; CI: 0.61-6.27, P=0.26; I2 = 67 %). Lastly, 90 day morality occurred significantly less in the EVT group (24.5 %) compared to patients treated with MM (33.1 %), and with significantly lower odds (OR: 0.51; CI: 0.35-0.73, P=0.0003; I2=0 %). CONCLUSIONS In certain patients presenting beyond 24 hours with ischemic stroke, EVT is associated with a significantly higher odds of achieving functional independence and lower odds of mortality compared with MM. While these results do not function as proof, they do encourage further research into extending the window beyond 24 hours for EVT. Randomized clinical trials are warranted to validate these findings.
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Affiliation(s)
- Derrek Schartz
- Department of Imaging Sciences, University of Rochester Medical Center, Rochester, NY, United States; Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States.
| | - Rohin Singh
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Nathaniel Ellens
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Sajal Medha K Akkipeddi
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Clifton Houk
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Tarun Bhalla
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Thomas Mattingly
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
| | - Matthew T Bender
- Department of Neurosurgery, University of Rochester Medical Center, Rochester, NY, United States
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Hofmeister J, Brina O, Bernava G, Rosi A, Reymond P, Lovblad KO, Machi P. Double Stent Retriever Technique for Mechanical Thrombectomy: A Systematic Review and Meta-Analysis. AJNR Am J Neuroradiol 2024; 45:1031-1037. [PMID: 38521091 PMCID: PMC11383395 DOI: 10.3174/ajnr.a8253] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 03/20/2024] [Indexed: 03/25/2024]
Abstract
BACKGROUND Mechanical thrombectomy using a double stent retriever technique has recently been described for the treatment of acute ischemic stroke, but its efficacy and safety are not well-established. PURPOSE The aim of this systematic review and meta-analysis was to evaluate reports of the use of a double stent retriever technique during the endovascular treatment of patients with ischemic stroke. DATA SOURCES The PubMed, EMBASE, Web of Science, and Scopus databases were searched to identify all studies (clinical trials, cohort series, and case reports) investigating the utility of a double stent retriever technique for the treatment of stroke. The study is reported in accordance with PRISMA 2020 guidelines and was prospectively registered in PROSPERO (CRD42023482691). STUDY SELECTION Seventeen studies involving a total of 128 patients with large-vessel occlusions predominantly in the anterior circulation (93.0%) were identified. DATA ANALYSIS Outcomes of interest were the prevalence of successful recanalization (modified TICI ≥2b) and a first-pass effect following the double stent retriever technique as well as complications such as iatrogenic dissections and SAH. Data were pooled using a random effects model. DATA SYNTHESIS The double stent retriever technique was used as a rescue strategy in occlusions refractory to conventional endovascular treatment in 68.7% (88/128) of patients and as a first-line strategy in 31.3% (40/128) of patients. The double stent retriever technique achieved an overall final modified TICI ≥2b in 92.6% cases, with a first-pass effect of 76.6%. The complication rate remained low, with 0.37% dissection and 1.56% SAH. LIMITATIONS Limitations of the study include the following: 1) a large number of case reports or small series, 2) a meta-analysis of proportions with no statistical comparison with a control group, and 3) the lack of access to patient-level data. CONCLUSIONS Our findings suggest that double stent retriever thrombectomy may be safe and associated with good recanalization outcomes, but prospective comparative studies are needed to determine which patients may benefit from this endovascular procedure.
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Affiliation(s)
- Jeremy Hofmeister
- From the Department of Diagnostics (J.H., O.B., G.B., A.R., P.R., K.-O.L., P.M.), Diagnostic and Interventional Neuroradiology, Geneva University Hospitals, Geneva, Switzerland
- Brain Endovascular Therapeutics Research and Development Lab (J.H., O.B., P.R., K.-O.L., P.M.), Radiology and Medical Informatics, University of Geneva, Geneva, Switzerland
| | - Olivier Brina
- From the Department of Diagnostics (J.H., O.B., G.B., A.R., P.R., K.-O.L., P.M.), Diagnostic and Interventional Neuroradiology, Geneva University Hospitals, Geneva, Switzerland
- Brain Endovascular Therapeutics Research and Development Lab (J.H., O.B., P.R., K.-O.L., P.M.), Radiology and Medical Informatics, University of Geneva, Geneva, Switzerland
| | - Gianmarco Bernava
- From the Department of Diagnostics (J.H., O.B., G.B., A.R., P.R., K.-O.L., P.M.), Diagnostic and Interventional Neuroradiology, Geneva University Hospitals, Geneva, Switzerland
| | - Andrea Rosi
- From the Department of Diagnostics (J.H., O.B., G.B., A.R., P.R., K.-O.L., P.M.), Diagnostic and Interventional Neuroradiology, Geneva University Hospitals, Geneva, Switzerland
| | - Philippe Reymond
- From the Department of Diagnostics (J.H., O.B., G.B., A.R., P.R., K.-O.L., P.M.), Diagnostic and Interventional Neuroradiology, Geneva University Hospitals, Geneva, Switzerland
- Brain Endovascular Therapeutics Research and Development Lab (J.H., O.B., P.R., K.-O.L., P.M.), Radiology and Medical Informatics, University of Geneva, Geneva, Switzerland
| | - Karl-Olof Lovblad
- From the Department of Diagnostics (J.H., O.B., G.B., A.R., P.R., K.-O.L., P.M.), Diagnostic and Interventional Neuroradiology, Geneva University Hospitals, Geneva, Switzerland
- Brain Endovascular Therapeutics Research and Development Lab (J.H., O.B., P.R., K.-O.L., P.M.), Radiology and Medical Informatics, University of Geneva, Geneva, Switzerland
| | - Paolo Machi
- From the Department of Diagnostics (J.H., O.B., G.B., A.R., P.R., K.-O.L., P.M.), Diagnostic and Interventional Neuroradiology, Geneva University Hospitals, Geneva, Switzerland
- Brain Endovascular Therapeutics Research and Development Lab (J.H., O.B., P.R., K.-O.L., P.M.), Radiology and Medical Informatics, University of Geneva, Geneva, Switzerland
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Sun T, Yu HY, Zhan CH, Guo HL, Luo MY. Non-contrast CT radiomics-clinical machine learning model for futile recanalization after endovascular treatment in anterior circulation acute ischemic stroke. BMC Med Imaging 2024; 24:178. [PMID: 39030494 PMCID: PMC11264869 DOI: 10.1186/s12880-024-01365-7] [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: 04/29/2024] [Accepted: 07/15/2024] [Indexed: 07/21/2024] Open
Abstract
OBJECTIVE To establish a machine learning model based on radiomics and clinical features derived from non-contrast CT to predict futile recanalization (FR) in patients with anterior circulation acute ischemic stroke (AIS) undergoing endovascular treatment. METHODS A retrospective analysis was conducted on 174 patients who underwent endovascular treatment for acute anterior circulation ischemic stroke between January 2020 and December 2023. FR was defined as successful recanalization but poor prognosis at 90 days (modified Rankin Scale, mRS 4-6). Radiomic features were extracted from non-contrast CT and selected using the least absolute shrinkage and selection operator (LASSO) regression method. Logistic regression (LR) model was used to build models based on radiomic and clinical features. A radiomics-clinical nomogram model was developed, and the predictive performance of the models was evaluated using area under the curve (AUC), accuracy, sensitivity, and specificity. RESULTS A total of 174 patients were included. 2016 radiomic features were extracted from non-contrast CT, and 9 features were selected to build the radiomics model. Univariate and stepwise multivariate analyses identified admission NIHSS score, hemorrhagic transformation, NLR, and admission blood glucose as independent factors for building the clinical model. The AUC of the radiomics-clinical nomogram model in the training and testing cohorts were 0.860 (95%CI 0.801-0.919) and 0.775 (95%CI 0.605-0.945), respectively. CONCLUSION The radiomics-clinical nomogram model based on non-contrast CT demonstrated satisfactory performance in predicting futile recanalization in patients with anterior circulation acute ischemic stroke.
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Affiliation(s)
- Tao Sun
- First Clinical Medical College, Gannan Medical University, Ganzhou, Jiangxi, China
| | - Hai-Yun Yu
- First Clinical Medical College, Gannan Medical University, Ganzhou, Jiangxi, China
| | - Chun-Hua Zhan
- Department of Medical Ultrasonics, The Third Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
| | - Han-Long Guo
- First Clinical Medical College, Gannan Medical University, Ganzhou, Jiangxi, China
| | - Mu-Yun Luo
- Department of Neurosurgery, The First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China.
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Kits A, Al-Saadi J, De Luca F, Janzon F, Mazya MV, Lundberg J, Sprenger T, Skare S, Delgado AF. 2.5-Minute Fast Brain MRI with Multiple Contrasts in Acute Ischemic Stroke. Neuroradiology 2024; 66:737-747. [PMID: 38462584 PMCID: PMC11031482 DOI: 10.1007/s00234-024-03331-0] [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: 01/07/2024] [Accepted: 03/04/2024] [Indexed: 03/12/2024]
Abstract
PURPOSE To assess the performance of a 2.5-minute multi-contrast brain MRI sequence (NeuroMix) in diagnosing acute cerebral infarctions. METHODS Adult patients with a clinical suspicion of acute ischemic stroke were retrospectively included. Brain MRI at 3 T included NeuroMix and routine clinical MRI (cMRI) sequences, with DWI/ADC, T2-FLAIR, T2-weighted, T2*, SWI-EPI, and T1-weighted contrasts. Three radiologists (R1-3) independently assessed NeuroMix and cMRI for the presence of acute infarcts (DWI ↑, ADC = or ↓) and infarct-associated abnormalities on other image contrasts. Sensitivity, specificity, and the area under the receiver operating characteristic curve (AUC) were calculated and compared using DeLong's test. Inter- and intra-rater agreements were studied with kappa statistics. Relative DWI (rDWI) and T2-FLAIR (rT2-FLAIR) signal intensity for infarctions were semi-automatically rendered, and the correlation between methods was evaluated. RESULTS According to the reference standard, acute infarction was present in 34 out of 44 (77%) patients (63 ± 17 years, 31 men). Other infarct-associated signal abnormalities were reported in similar frequencies on NeuroMix and cMRI (p > .08). Sensitivity for infarction detection was 94%, 100%, and 94% evaluated by R1, R2, R3, for NeuroMix and 94%, 100%, and 100% for cMRI. Specificity was 100%, 90%, and 100% for NeuroMix and 100%, 100%, and 100% for cMRI. AUC for NeuroMix was .97, .95, and .97 and .97, 1, and 1 for cMRI (DeLong p = 1, .32, .15), respectively. Inter- and intra-rater agreement was κ = .88-1. The correlation between NeuroMix and cMRI was R = .73 for rDWI and R = .83 for rT2-FLAIR. CONCLUSION Fast multi-contrast MRI NeuroMix has high diagnostic performance for detecting acute cerebral infarctions.
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Affiliation(s)
- Annika Kits
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
- Department of Neuroradiology, Karolinska University Hospital, Solna, 17176, Stockholm, Sweden.
| | - Jonathan Al-Saadi
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neuroradiology, Karolinska University Hospital, Solna, 17176, Stockholm, Sweden
| | - Francesca De Luca
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neuroradiology, Karolinska University Hospital, Solna, 17176, Stockholm, Sweden
- Department of Radiology, Karolinska University Hospital, Stockholm, Sweden
| | - Fredrik Janzon
- Department of Neuroradiology, Karolinska University Hospital, Solna, 17176, Stockholm, Sweden
- Department of Radiology, Danderyd Hospital, Stockholm, Sweden
| | - Michael V Mazya
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Johan Lundberg
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neuroradiology, Karolinska University Hospital, Solna, 17176, Stockholm, Sweden
| | - Tim Sprenger
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- MR Applied Science Laboratory Europe, GE Healthcare, Stockholm, Sweden
| | - Stefan Skare
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neuroradiology, Karolinska University Hospital, Solna, 17176, Stockholm, Sweden
| | - Anna Falk Delgado
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neuroradiology, Karolinska University Hospital, Solna, 17176, Stockholm, Sweden
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Gomez CR, Cardonell B, Pfeiffer K, Pond D, Ingebritson D, French BR, Siddiq F, Qureshi AI. Optimizing workflow of urgent stroke endovascular intervention: A focused lean six sigma project. J Stroke Cerebrovasc Dis 2024; 33:107559. [PMID: 38214242 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 12/21/2023] [Accepted: 01/04/2024] [Indexed: 01/13/2024] Open
Abstract
INTRODUCTION Urgent endovascular intervention is currently accepted as the primary and critical therapeutic approach to patients whose acute ischemic stroke results from a large arterial occlusion (LAO). In this context, one of the quality metrics most widely applied to the assessment of emergency systems performance is the "door-to-puncture" (D-P) time. We undertook a project to identify the subinterval of the D-P metric causing the most impact on workflow delays and created a narrowly focused project on improving such subinterval. METHODS Using the DMAIC (i.e., define, measure, analyze, improve and control) approach, we retrospectively reviewed our quality stroke data for calendar year (CY) 2021 (i.e., baseline population), completed a statistical process control assessment, defined the various subintervals of the D-P interval, and completed a Pareto analysis of their duration and their proportional contribution to the D-P interval. We retooled our workflow based on these analyses and analyzed the data resulting from its implementation between May and December 2022 (i.e., outcome population). RESULTS The baseline population included 87 patients (44 men; mean age = 67.2 years). Their D-P process was uncontrolled, and times varied between 35-235 minutes (Mean = 97; SD = 38.40). Their door to angiography arrival (D-AA) subinterval was significantly slower than their arrival to puncture (AA-P) (73.4 v. 23.5 minutes; p < 0.01), accounted for 73% of the average length of the D-P interval. The group page activation to angiography arrival (GP-AA) subinterval accounted for 41.5% of the entire D-AA duration, making it the target of our project. The outcome population originally consisted of 38 patients (15 men; mean age = 70.3 years). Their D-P process was controlled, its times varying between 43-177 minutes (Mean = 85.8; SD = 34.46), but not significantly difference than the baseline population (p = 0.127). Their target subinterval GP-AA varied between 0-37 minutes and was significantly improved from the baseline population (Mean = 13.21 v. 29.68; p < 0.001). CONCLUSIONS It seems feasible and reasonable to analyze the subinterval components of complex quality metrics such as the D-P time and carry out more focused quality improvement projects. Care must be exercised when interpreting the impact on overall system performance, due to unexpected variations within interdependent subprocesses. The application of a robust and comprehensive LSS continuous quality improvement process in any CSC will have to include individualized focused projects that simultaneously control the different components of overall system performance.
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Affiliation(s)
- Camilo R Gomez
- The Comprehensive Stroke Center, The Departments of Neurology, School of Medicine, University of Missouri Columbia, 548 CS&E Building - One Hospital Drive, Columbia, MO 65212, USA.
| | - Bradford Cardonell
- Anesthesiology, School of Medicine, University of Missouri Columbia, Columbia, MO, USA
| | - Kimberley Pfeiffer
- The Comprehensive Stroke Center, The Departments of Neurology, School of Medicine, University of Missouri Columbia, 548 CS&E Building - One Hospital Drive, Columbia, MO 65212, USA
| | - Donna Pond
- The Comprehensive Stroke Center, The Departments of Neurology, School of Medicine, University of Missouri Columbia, 548 CS&E Building - One Hospital Drive, Columbia, MO 65212, USA
| | - Daphne Ingebritson
- The Comprehensive Stroke Center, The Departments of Neurology, School of Medicine, University of Missouri Columbia, 548 CS&E Building - One Hospital Drive, Columbia, MO 65212, USA
| | - Brandi R French
- The Comprehensive Stroke Center, The Departments of Neurology, School of Medicine, University of Missouri Columbia, 548 CS&E Building - One Hospital Drive, Columbia, MO 65212, USA
| | - Farhan Siddiq
- Neurosurgery, School of Medicine, University of Missouri Columbia, Columbia, MO, USA
| | - Adnan I Qureshi
- The Comprehensive Stroke Center, The Departments of Neurology, School of Medicine, University of Missouri Columbia, 548 CS&E Building - One Hospital Drive, Columbia, MO 65212, USA
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Nguyen TQ, Tran MH, Phung HN, Nguyen KV, Tran HTM, Walter S, Hoang DCB, Pham BN, Truong ALT, Tran VT, Nguyen TN, Pham AL, Nguyen HT. Endovascular treatment for acute ischemic stroke beyond the 24-h time window: Selection by target mismatch profile. Int J Stroke 2024; 19:305-313. [PMID: 37807200 DOI: 10.1177/17474930231208817] [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] [Indexed: 10/10/2023]
Abstract
INTRODUCTION Endovascular treatment for acute ischemic stroke patients with large vessel occlusion (LVO) has been established as a promising clinical intervention within a late time window of 6-24 h after symptom onset. Patients with slow progression, however, may still benefit from endovascular treatment beyond the 24-h time window (very late window). AIM The aim of this study is to report insight into the potential clinical benefits of endovascular treatment for acute ischemic stroke beyond 24 h from symptom onset. METHODS A retrospective analysis was performed on consecutive patients undergoing endovascular treatment for acute anterior circulation LVO ischemic stroke beyond 24 h. Participants were recruited between July 2019 and November 2020. Patients were selected based on the DAWN/DEFUSE 3 criteria (Perfusion-RAPID, iSchemaView) and patients receiving treatment beyond 24 h were compared to a group of patients receiving endovascular treatment between 6 and 24 h after symptom onset. The primary outcome was the proportion of patients with functional independence at 90 days (modified Rankin Scale score of 0-2). The secondary outcomes were shift modified Rankin Scale (mRS) analysis and successful reperfusion was defined by thrombolysis in cerebral infarction (TICI) 2b-3 on the final procedure. Safety outcomes were symptomatic intracranial hemorrhage and death at the 90-day follow-up. Propensity score (PS)-matched analyses were employed to rectify the imbalanced baseline characteristics between the two groups. RESULTS A total of 166 patients were recruited with a median age of 63.0 (56.0-69.0) and 28.9% of all patients were females. Patients in the beyond 24-h group had a longer onset-to-groin time (median = 27.2 vs 14.3 h, p < 0.001) than those in the 6- to 24-h group. There were no statistically significant differences between the two groups in National Institutes of Health Stroke Scale (NIHSS) (median = 12.0 vs 15.0, p = 0.37), perfusion imaging characteristics (core: median = 11.0 vs 9.0 mL, p = 0.86; mismatch volume: median = 106.0 vs 96.0, p = 0.44; mismatch ratio = 6.46 vs 7.24, p = 0.91), and perfusion-to-groin time (median = 72.5 vs 76.0 min, p = 0.77). No significant differences were noted among patients between the two groups in the primary endpoint functional independence analysis (50.0% vs 46.6%, p = 0.77) and in the safety endpoint analysis: mortality (15.0% vs 11.0%, p = 0.71) or symptomatic hemorrhage (0% vs 3.42%, p > 0.999). In PS-matched analyses, there were no significant differences among patients between the two groups in functional independence (50.0% vs 54.8%, p = 0.74), mortality (16.7% vs 9.68%, p = 0.50), or symptomatic hemorrhage (0% vs 6.45%, p = 0.53). CONCLUSION Endovascular treatment can be performed safely and effectively in LVO patients beyond 24 h from symptom onset when selected by target mismatch profile. The clinical outcome of these patients was comparable to those treated in the 6- to 24-h window. Larger studies are needed to confirm these findings.
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Affiliation(s)
- Trung Quoc Nguyen
- Department of Cerebrovascular Disease, 115 People's Hospital, Ho Chi Minh City, Vietnam
- University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Mai Hoang Tran
- School of Public Health, Griffith University, Gold Coast, QLD, Australia
| | - Hai Ngoc Phung
- School of Medicine and Dentistry, Griffith University, Gold Coast, QLD, Australia
| | - Khang Vinh Nguyen
- Department of Neurology, University Medical Center, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Hang T Minh Tran
- Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Silke Walter
- Department of Neurology, Saarland University Hospital, Homburg, Germany
| | - Dinh C Bao Hoang
- Department of Neurology, Tam Anh Hospital, Ho Chi Minh City, Vietnam
| | - Binh Nguyen Pham
- Department of Cerebrovascular Disease, 115 People's Hospital, Ho Chi Minh City, Vietnam
| | - Anh Le Tuan Truong
- Department of Cerebrovascular Disease, 115 People's Hospital, Ho Chi Minh City, Vietnam
| | - Vu Thanh Tran
- Department of Neurointervention, 115 People's Hospital, Ho Chi Minh City, Vietnam
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - An Le Pham
- University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Huy-Thang Nguyen
- Department of Cerebrovascular Disease, 115 People's Hospital, Ho Chi Minh City, Vietnam
- Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
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Kalinin MN, Khasanova DR. Heterogeneous treatment effects of Cerebrolysin as an early add-on to reperfusion therapy: post hoc analysis of the CEREHETIS trial. Front Pharmacol 2024; 14:1288718. [PMID: 38249342 PMCID: PMC10796496 DOI: 10.3389/fphar.2023.1288718] [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: 09/11/2023] [Accepted: 12/11/2023] [Indexed: 01/23/2024] Open
Abstract
Background: There has been intensive research into enhancing the effects of reperfusion therapy to mitigate hemorrhagic transformation (HT) in stroke patients. Using neuroprotective agents alongside intravenous thrombolysis (IVT) appears a promising approach. Cerebrolysin is one of the candidates since it consists of neuropeptides mimicking the action of neurotrophic factors on brain protection and repair. Objectives: We looked at treatment effects of Cerebrolysin as an early add-on to IVT in stroke patients with varying HT risk. Methods: It was post hoc analysis of the CEREHETIS trial (ISRCTN87656744). Patients with middle cerebral artery infarction (n = 238) were selected from the intention-to-treat population. To stratify participants according to their HT risk, the DRAGON, SEDAN and HTI scores were computed for each eligible subject using on-admission data. The study endpoints were any and symptomatic HT, and functional outcome measured with the modified Rankin Scale (mRS) on day 90. Favorable functional outcome (FFO) was defined as an mRS ≤2. The performance of each stratification tool was estimated with regression approaches. Heterogeneous treatment effect analysis was conducted using techniques of meta-analysis and the matching-smoothing method. Results: The HTI score outperformed other tools in terms of HT risk stratification. Heterogeneity of Cerebrolysin treatment effects was moderate (I2, 35.8%-56.7%; H2, 1.56-2.31) and mild (I2, 10.9%; H2, 1.12) for symptomatic and any HT, respectively. A significant positive impact of Cerebrolysin on HT and functional outcome was observed in the moderate (HTI = 1) and high (HTI ≥2) HT risk patients, but it was neutral in those with the low (HTI = 0) risk. In particular, there was a steady decline in the rate of symptomatic (HTI = 0 vs. HTI = 4: by 4.3%, p = 0.077 vs. 21.1%, p < 0.001) and any HT (HTI = 0 vs. HTI = 4: by 1.2%, p = 0.737 vs. 32.7%, p < 0.001). Likewise, an mRS score reduction (HTI = 0 vs. HTI = 4: by 1.8%, p = 0.903 vs. 126%, p < 0.001) with a reciprocal increase of the fraction of FFO patients (HTI = 0 vs. HTI = 4: by 1.2% p = 0.757 vs. 35.5%, p < 0.001) was found. Conclusion: Clinically meaningful heterogeneity of Cerebrolysin treatment effects on HT and functional outcome was established in stroke patients. The beneficial effects were significant in those whose estimated on-admission HT risk was either moderate or high.
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Affiliation(s)
- Mikhail N. Kalinin
- Department of Neurology, Kazan State Medical University, Kazan, Russia
- Department of Neurology, Interregional Clinical Diagnostic Center, Kazan, Russia
| | - Dina R. Khasanova
- Department of Neurology, Kazan State Medical University, Kazan, Russia
- Department of Neurology, Interregional Clinical Diagnostic Center, Kazan, Russia
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Jiang X, Wang J, Hu Y, Lang H, Bao J, Chen N, He L. Is endovascular treatment still good for acute ischemic stroke in the elderly? A meta-analysis of observational studies in the last decade. Front Neurosci 2024; 17:1308216. [PMID: 38249587 PMCID: PMC10796798 DOI: 10.3389/fnins.2023.1308216] [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: 10/06/2023] [Accepted: 12/11/2023] [Indexed: 01/23/2024] Open
Abstract
Background The lack of randomized evidence makes it difficult to establish reliable treatment recommendations for endovascular treatment (EVT) in elderly patients. This meta-analysis aims to evaluate the therapeutic effects of endovascular treatment for acute ischemic stroke in the elderly compared with younger patients. Methods Comprehensive literature retrieval was conducted to identify studies that directly compared the outcomes of EVT in elderly patients and those aged <80 years. The primary outcome was functional independence, defined as mRS 0-2 at 90 days after EVT. The secondary outcomes were the rate of successful recanalization, symptomatic intracranial hemorrhage (sICH) and mortality. Odds ratios (ORs) were estimated using a random effects model. Results In total, twenty-six studies with 9,492 enrolled participants were identified. Our results showed that, compared with patients aged <80 years undergoing EVT, EVT was associated with a lower rate of functional independence at 90 days (OR = 0.38; 95% CI, 0.33-0.45; p < 0.00001) and a higher mortality rate (OR = 2.51; 95% CI, 1.98-3.18; p < 0.00001) in the elderly. Furthermore, even without a significantly observed increase in sICH (OR = 1.19; 95% CI, 0.96-1.47; p = 0.11), EVT appeared to be associated with a lower rate of successful recanalization (OR = 0.81; 95% CI, 0.68-0.96; p = 0.02). Conclusion Evidence from observational studies revealed that EVT has less functional outcomes in elderly patients with acute ischemic stroke. Further studies are needed to better identify patients aged ≥80 years who could potentially benefit from EVT.
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Affiliation(s)
| | | | | | | | | | - Ning Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Li He
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan, China
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Koch PJ, Rudolf LF, Schramm P, Frontzkowski L, Marburg M, Matthis C, Schacht H, Fiehler J, Thomalla G, Hummel FC, Neumann A, Münte TF, Royl G, Machner B, Schulz R. Preserved Corticospinal Tract Revealed by Acute Perfusion Imaging Relates to Better Outcome After Thrombectomy in Stroke. Stroke 2023; 54:3081-3089. [PMID: 38011237 DOI: 10.1161/strokeaha.123.044221] [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] [Accepted: 10/04/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND The indication for mechanical thrombectomy (MT) in stroke patients with large vessel occlusion has been constantly expanded over the past years. Despite remarkable treatment effects at the group level in clinical trials, many patients remain severely disabled even after successful recanalization. A better understanding of this outcome variability will help to improve clinical decision-making on MT in the acute stage. Here, we test whether current outcome models can be refined by integrating information on the preservation of the corticospinal tract as a functionally crucial white matter tract derived from acute perfusion imaging. METHODS We retrospectively analyzed 162 patients with stroke and large vessel occlusion of the anterior circulation who were admitted to the University Medical Center Lübeck between 2014 and 2020 and underwent MT. The ischemic core was defined as fully automatized based on the acute computed tomography perfusion with cerebral blood volume data using outlier detection and clustering algorithms. Normative whole-brain structural connectivity data were used to infer whether the corticospinal tract was affected by the ischemic core or preserved. Ordinal logistic regression models were used to correlate this information with the modified Rankin Scale after 90 days. RESULTS The preservation of the corticospinal tract was associated with a reduced risk of a worse functional outcome in large vessel occlusion-stroke patients undergoing MT, with an odds ratio of 0.28 (95% CI, 0.15-0.53). This association was still significant after adjusting for multiple confounding covariables, such as age, lesion load, initial symptom severity, sex, stroke side, and recanalization status. CONCLUSIONS A preinterventional computed tomography perfusion-based surrogate of corticospinal tract preservation or disconnectivity is strongly associated with functional outcomes after MT. If validated in independent samples this concept could serve as a novel tool to improve current outcome models to better understand intersubject variability after MT in large vessel occlusion stroke.
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Affiliation(s)
- Philipp J Koch
- Department of Neurology (P.J.K., M.M., G.R., B.M.), University Hospital Schleswig-Holstein, Campus Lübeck, Germany
- Center of Brain, Behavior and Metabolism (CBBM), University of Lübeck, Germany (P.J.K., T.F.M., G.R., B.M.)
| | - Linda F Rudolf
- Department of Neuroradiology (L.F.R., P.S., H.S., A.N.), University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Peter Schramm
- Department of Neuroradiology (L.F.R., P.S., H.S., A.N.), University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Lukas Frontzkowski
- Department of Neurology (L.F., G.T., R.S.) University Medical Center Hamburg Eppendorf, Germany
| | - Maria Marburg
- Department of Neurology (P.J.K., M.M., G.R., B.M.), University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Christine Matthis
- Department of Social Medicine and Epidemiology (C.M.), University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Hannes Schacht
- Department of Neuroradiology (L.F.R., P.S., H.S., A.N.), University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Jens Fiehler
- Department of Neuroradiology (J.F.) University Medical Center Hamburg Eppendorf, Germany
| | - Götz Thomalla
- Department of Neurology (L.F., G.T., R.S.) University Medical Center Hamburg Eppendorf, Germany
| | - Friedhelm C Hummel
- Neuro-X Institute and Brain Mind Institute, Swiss Federal Institute of Technology, Geneva, Switzerland (F.C.H.)
- Neuro-X Institute and Brain Mind Institute, Swiss Federal Institute of Technology (EPFL Valais), Clinique Romande de Réadaptation, Sion, Switzerland (F.C.H.)
- Clinical Neuroscience, University of Geneva Medical School, Switzerland (F.C.H.)
| | - Alexander Neumann
- Department of Neuroradiology (L.F.R., P.S., H.S., A.N.), University Hospital Schleswig-Holstein, Campus Lübeck, Germany
| | - Thomas F Münte
- Center of Brain, Behavior and Metabolism (CBBM), University of Lübeck, Germany (P.J.K., T.F.M., G.R., B.M.)
| | - Georg Royl
- Department of Neurology (P.J.K., M.M., G.R., B.M.), University Hospital Schleswig-Holstein, Campus Lübeck, Germany
- Center of Brain, Behavior and Metabolism (CBBM), University of Lübeck, Germany (P.J.K., T.F.M., G.R., B.M.)
| | - Björn Machner
- Department of Neurology (P.J.K., M.M., G.R., B.M.), University Hospital Schleswig-Holstein, Campus Lübeck, Germany
- Center of Brain, Behavior and Metabolism (CBBM), University of Lübeck, Germany (P.J.K., T.F.M., G.R., B.M.)
- Department of Neurology, Schoen Clinic Neustadt, Holstein, Germany (B.M.)
| | - Robert Schulz
- Department of Neurology (L.F., G.T., R.S.) University Medical Center Hamburg Eppendorf, Germany
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Michalski D, Jungk C, Beynon C, Brenner T, Nusshag C, Reuß CJ, Fiedler MO, Bernhard M, Hecker A, Weigand MA, Dietrich M. [Focus on neurological intensive care medicine 2022/2023 : Summary of selected intensive medical care studies]. DIE ANAESTHESIOLOGIE 2023; 72:894-906. [PMID: 37857724 DOI: 10.1007/s00101-023-01352-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Accepted: 09/27/2023] [Indexed: 10/21/2023]
Affiliation(s)
- Dominik Michalski
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig, Liebigstraße 20, 04103, Leipzig, Deutschland.
| | - Christine Jungk
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Christopher Beynon
- Neurochirurgische Klinik, Universitätsklinikum Mannheim, Mannheim, Deutschland
| | - Thorsten Brenner
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Universität Duisburg-Essen, Essen, Deutschland
| | - Christian Nusshag
- Klinik für Endokrinologie, Stoffwechsel und klinische Chemie, Sektion Nephrologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Christopher J Reuß
- Klinik für Anästhesiologie und operative Intensivmedizin, Klinikum Stuttgart, Stuttgart, Deutschland
| | - Mascha O Fiedler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Michael Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Düsseldorf, Deutschland
| | - Andreas Hecker
- Klinik für Allgemein‑, Viszeral‑, Thorax‑, Transplantations- und Kinderchirurgie, Universitätsklinikum Gießen, Gießen, Deutschland
| | - Markus A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Maximilian Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
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