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Sarraj A, Hill MD, Hussain MS, Abraham MG, Ortega-Gutierrez S, Chen M, Kasner SE, Churilov L, Pujara DK, Johns H, Blackburn S, Sundararajan S, Hu YC, Herial NA, Budzik RF, Hicks WJ, Arenillas JF, Tsai JP, Kozak O, Cordato DJ, Hanel RA, Wu TY, Portela PC, Gandhi CD, Al-Mufti F, Maali L, Gibson D, Pérez de la Ossa N, Schaafsma JD, Blasco J, Sangha N, Warach S, Kleinig TJ, Shaker F, Sitton CW, Nguyen T, Fifi JT, Jabbour P, Furlan A, Lansberg MG, Tsivgoulis G, Sila C, Bambakidis N, Davis S, Wechsler L, Albers GW, Grotta JC, Ribo M, Campbell BC, Hassan AE. Endovascular Thrombectomy Treatment Effect in Direct vs Transferred Patients With Large Ischemic Strokes: A Prespecified Analysis of the SELECT2 Trial. JAMA Neurol 2024:2815043. [PMID: 38363872 PMCID: PMC10853865 DOI: 10.1001/jamaneurol.2024.0206] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Accepted: 01/11/2024] [Indexed: 02/18/2024]
Abstract
Importance Patients with large ischemic core stroke have poor clinical outcomes and are frequently not considered for interfacility transfer for endovascular thrombectomy (EVT). Objective To assess EVT treatment effects in transferred vs directly presenting patients and to evaluate the association between transfer times and neuroimaging changes with EVT clinical outcomes. Design, Setting, and Participants This prespecified secondary analysis of the SELECT2 trial, which evaluated EVT vs medical management (MM) in patients with large ischemic stroke, evaluated adults aged 18 to 85 years with acute ischemic stroke due to occlusion of the internal carotid or middle cerebral artery (M1 segment) as well as an Alberta Stroke Program Early CT Score (ASPECTS) of 3 to 5, core of 50 mL or greater on imaging, or both. Patients were enrolled between October 2019 and September 2022 from 31 EVT-capable centers in the US, Canada, Europe, Australia, and New Zealand. Data were analyzed from August 2023 to January 2024. Interventions EVT vs MM. Main Outcomes and Measures Functional outcome, defined as modified Rankin Scale (mRS) score at 90 days with blinded adjudication. Results A total of 958 patients were screened and 606 patients were excluded. Of 352 enrolled patients, 145 (41.2%) were female, and the median (IQR) age was 66.5 (58-75) years. A total of 211 patients (59.9%) were transfers, while 141 (40.1%) presented directly. The median (IQR) transfer time was 178 (136-230) minutes. The median (IQR) ASPECTS decreased from the referring hospital (5 [4-7]) to an EVT-capable center (4 [3-5]). Thrombectomy treatment effect was observed in both directly presenting patients (adjusted generalized odds ratio [OR], 2.01; 95% CI, 1.42-2.86) and transferred patients (adjusted generalized OR, 1.50; 95% CI, 1.11-2.03) without heterogeneity (P for interaction = .14). Treatment effect point estimates favored EVT among 82 transferred patients with a referral hospital ASPECTS of 5 or less (44 received EVT; adjusted generalized OR, 1.52; 95% CI, 0.89-2.58). ASPECTS loss was associated with numerically worse EVT outcomes (adjusted generalized OR per 1-ASPECTS point loss, 0.89; 95% CI, 0.77-1.02). EVT treatment effect estimates were lower in patients with transfer times of 3 hours or more (adjusted generalized OR, 1.15; 95% CI, 0.73-1.80). Conclusions and Relevance Both directly presenting and transferred patients with large ischemic stroke in the SELECT2 trial benefited from EVT, including those with low ASPECTS at referring hospitals. However, the association of EVT with better functional outcomes was numerically better in patients presenting directly to EVT-capable centers. Prolonged transfer times and evolution of ischemic change were associated with worse EVT outcomes. These findings emphasize the need for rapid identification of patients suitable for transfer and expedited transport. Trial Registration ClinicalTrials.gov Identifier: NCT03876457.
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Affiliation(s)
- Amrou Sarraj
- Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Michael D. Hill
- Clinical Neuroscience, University of Calgary, Calgary, Alberta, Canada
| | - M. Shazam Hussain
- Cerebrovascular Center, Neurology, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Michael Chen
- Neurosurgery, Rush University Medical Center, Chicago, Illinois
| | | | - Leonid Churilov
- Medicine and Neurology, The Royal Melbourne Hospital, Melbourne, Australia
| | - Deep K. Pujara
- Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Hannah Johns
- Medicine and Neurology, The Royal Melbourne Hospital, Melbourne, Australia
| | - Spiros Blackburn
- Neurosurgery, McGovern Medical School at UTHealth, Houston, Texas
| | - Sophia Sundararajan
- Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Yin C. Hu
- Neurosurgery, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Nabeel A. Herial
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Ronald F. Budzik
- Neuro-Interventional Radiology, OhioHealth, Riverside Methodist Hospital, Columbus
| | | | - Juan F. Arenillas
- Internal Medicine, Hospital Clínico Universitario Valladolid, University of Valladolid, Valladolid, Spain
| | | | - Osman Kozak
- Neurosurgery, Abington Jefferson Health, Abington, Pennsylvania
| | | | - Ricardo A. Hanel
- Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, Florida
| | - Teddy Y. Wu
- Neurology, Christchurch Hospital, Christchurch, New Zealand
| | | | - Chirag D. Gandhi
- Neurosurgery, Westchester Medical Center, NY Medical College, Valhalla, New York
| | - Fawaz Al-Mufti
- Neurosurgery, Westchester Medical Center, NY Medical College, Valhalla, New York
| | - Laith Maali
- Neurology, University of Kansas Medical Center, Kansas City
| | - Daniel Gibson
- Neurointerventional Surgery, Ascension Columbia St Mary’s Hospital, Milwaukee, Wisconsin
| | | | | | - Jordi Blasco
- Stroke Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Navdeep Sangha
- Neurology, Kaiser Permanente Southern California, Los Angeles
| | - Steven Warach
- Neurology, Dell Medical School at The University of Texas at Austin, Ascension Texas, Austin
| | | | - Faris Shaker
- Neurosurgery, McGovern Medical School at UTHealth, Houston, Texas
| | - Clark W. Sitton
- Interventioal and Diagnostic Imaging, McGovern Medical School at UTHealth, Houston, Texas
| | - Thanh Nguyen
- Neurology, Boston Medical Center, Boston, Massachusetts
| | - Johanna T. Fifi
- Neurology, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Pascal Jabbour
- Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania
| | - Anthony Furlan
- Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | | | - Georgios Tsivgoulis
- Second Department of Neurology, School of Medicine, National and Kapodistrian University of Athens, “Attikon” University Hospital, Athens, Greece
| | - Cathy Sila
- Neurology, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Nicholas Bambakidis
- Neurosurgery, University Hospital Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio
| | - Stephen Davis
- Neurology, The Royal Melbourne Hospital, Melbourne, Australia
| | | | | | - James C. Grotta
- Mobile Stroke Unit, Memorial Hermann Hospital, Houston, Texas
| | - Marc Ribo
- Neurology, Hospital Vall d’Hebrón, Sabadell, Spain
| | - Bruce C. Campbell
- Medicine and Neurology, The Royal Melbourne Hospital, The Florey Institute for Neuroscience and Mental Health, Melbourne, Australia
| | - Ameer E. Hassan
- Neuroscience, Valley Baptist Medical Center, Harlingen, Texas
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Luo W, Xu Y, Liu C, Zhang H. The Influence of the Novel Computer-Aided Triage System Based on Artificial Intelligence on Endovascular Therapy in Patients with Large Vascular Occlusions: A Meta-Analysis. World Neurosurg 2024; 182:200-207.e2. [PMID: 38048961 DOI: 10.1016/j.wneu.2023.11.140] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2023] [Accepted: 11/28/2023] [Indexed: 12/06/2023]
Abstract
OBJECTIVE The integration of artificial intelligence (AI) with modern healthcare has become increasingly prominent. The purpose of this study is to explore the impact of the novel computer-aided triage system based on artificial intelligence (AI-CTS) on endovascular therapy (EVT) in patients with large vascular occlusions (LVO). This study marks the first comprehensive systematic review and meta-analysis on the subject. METHODS A comprehensive study was performed on PubMed, Medline, Embase, Cochrane Library, and Chinese databases from their establishment to September 2023, in accordance with PRISMA recommendations. RevMan 5.4 software was used for summative analysis. The outcomes included door-to-groin (DTG) time, time from CT scan initiation to EVT, time from CT scan to reperfusion, and 90-day modified Rankin Scale (mRS). RESULTS A total of 7 studies involving 752 participants were included in the meta-analysis. The pooled results demonstrated that patients in the post-AI group had less time of DTG [SMD, 0.54; 95% CI, 0.40-0.69; P < 0.00001] and CT scan to EVT [SMD, 0.57; 95% CI, 0.42-0.73; P < 0.00001], as well as less time of CTA to recanalization [SMD, 0.63; 95% CI, 0.36-0.90; P < 0.00001]. There was no significant difference between the 2 groups in terms of the mRS at 90 days [OR, 0.66; 95% CI, 0.43-1.01; P = 0.06]. CONCLUSIONS The combination of AI-CTS and EVT has improved the therapy process for LVO patients. However, the improvement in mRS at 90 days was not significant; further research is warranted.
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Affiliation(s)
- Wenmiao Luo
- Department of Neurosurgery, Susong Hospital, Xiamen, China; Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China
| | - Yonggang Xu
- Department of Neurosurgery, Susong Hospital, Xiamen, China
| | - Chao Liu
- Department of Neurosurgery, Susong Hospital, Xiamen, China
| | - Hengzhu Zhang
- Department of Neurosurgery, Clinical Medical College of Yangzhou University, Yangzhou, China.
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Worthmann H, Winzer S, Schuppner R, Gumbinger C, Barlinn J. Telestroke networks for area-wide access to endovascular stroke treatment. Neurol Res Pract 2023; 5:9. [PMID: 36864498 PMCID: PMC9983226 DOI: 10.1186/s42466-023-00237-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 02/24/2023] [Indexed: 03/04/2023] Open
Abstract
BACKGROUND Endovascular therapy (EVT) offers a highly effective therapy for patients with acute ischemic stroke due to large vessel occlusion. Comprehensive stroke centers (CSC) are required to provide permanent accessibility to EVT. However, when affected patients are not located in the immediate catchment area of a CSC, i.e. in rural or structurally weaker areas, access to EVT is not always ensured. MAIN BODY Telestroke networks play a crucial role in closing this healthcare coverage gap and thereby support specialized stroke treatment. The aim of this narrative review is to elaborate the concepts for the indication and transfer of EVT candidates via telestroke networks in acute stroke care. The targeted readership includes both comprehensive stroke centers and peripheral hospitals. The review is intended to identify ways to design care beyond those areas with narrow access to stroke unit care to provide the indicated highly effective acute therapies on a region-wide basis. Here, the two different models of care: "mothership" and "drip-and-ship" concerning rates of EVT and its complications as well as outcomes are compared. Decisively, forward-looking new model approaches such as a third model the "flying/driving interentionalists" are introduced and discussed, as far as few clinical trials have investigated these approaches. Diagnostic criteria used by the telestroke networks to enable appropriate patient selection for secondary intrahospital emergency transfers are displayed, which need to meet the criteria in terms of speed, quality and safety. CONCLUSION The few findings from the studies with telestroke networks are neutral for comparison in the drip-and-ship and mothership models. Supporting spoke centres through telestroke networks currently seems to be the best option for offering EVT to a population in structurally weaker regions without direct access to a CSC. Here, it is essential to map the individual reality of care depending on the regional circumstances.
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Affiliation(s)
- Hans Worthmann
- Klinik Für Neurologie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30623, Hannover, Germany.
| | - S. Winzer
- grid.412282.f0000 0001 1091 2917Klinik Für Neurologie, Universitätsklinikum Dresden, Dresden, Germany
| | - R. Schuppner
- grid.10423.340000 0000 9529 9877Klinik Für Neurologie, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30623 Hannover, Germany
| | - C. Gumbinger
- grid.5253.10000 0001 0328 4908Klinik Für Neurologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - J. Barlinn
- grid.412282.f0000 0001 1091 2917Klinik Für Neurologie, Universitätsklinikum Dresden, Dresden, Germany
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Ischemic Lesion Growth in Patients with a Persistent Target Mismatch After Large Vessel Occlusion. Clin Neuroradiol 2023; 33:41-48. [PMID: 35789284 PMCID: PMC10014761 DOI: 10.1007/s00062-022-01180-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2022] [Accepted: 05/11/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Failure to reperfuse a cerebral occlusion resulting in a persistent penumbral pattern has not been fully described. METHODS We retrospectively reviewed patients with anterior large vessel occlusion who did not receive reperfusion, and underwent repeated perfusion imaging, with baseline imaging < 6 h after onset and follow-up scans from 16-168 h. A persistent target mismatch (PTM) was defined as core volume of < 100 mL, mismatch ratio > 1.2, and mismatch volume > 10 mL on follow-up imaging. Patients were divided into PTM or non-PTM groups. Ischemic core and penumbral volumes were compared between baseline and follow-up imaging between the two groups, and collateral flow status assessed using CT perfusion collateral index. RESULTS A total of 25 patients (14 PTM and 11 non-PTM) were enrolled in the study. Median core volumes increased slightly in the PTM group, from 22 to 36 ml. There was a much greater increase in the non-PTM group, from 57 to 190 ml. Penumbral volumes were stable in the PTM group from a median of 79 ml at baseline to 88 ml at follow-up, whereas penumbra was reduced in the non-PTM group, from 120 to 0 ml. Collateral flow status was also better in the PTM group and the median collateral index was 33% compared with 44% in the non-PTM group (p = 0.043). CONCLUSION Multiple patients were identified with limited core growth and large penumbra (persistent target mismatch) > 16 h after stroke onset, likely due to more favorable collateral flow.
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Mueller F, Fabritius MP, Stueckelschweiger L, Kiesl S, Moench S, Tiedt S, Rémi J, Kellert L, Herzberg M, Küpper C, Dimitriadis K, Ricke J, Puhr-Westerheide D, Liebig T, Kunz WG, Reidler P. CT after interhospital transfer in acute ischemic stroke: Imaging findings and impact of prior intravenous contrast administration. Front Neurol 2022; 13:1023147. [PMID: 36570440 PMCID: PMC9767970 DOI: 10.3389/fneur.2022.1023147] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2022] [Accepted: 11/07/2022] [Indexed: 12/12/2022] Open
Abstract
Objectives Large vessel occlusion (LVO) stroke patients routinely undergo interhospital transfer to endovascular thrombectomy capable centers. Imaging is often repeated with residual intravenous (IV) iodine contrast at post-transfer assessment. We determined imaging findings and the impact of residual contrast on secondary imaging. Anterior circulation LVO stroke patients were selected out of a consecutive cohort. Directly admitted patients were contrast naïve, and transferred patients had previously received IV iodine contrast for stroke assessment at the referring hospital. Two independent readers rated the visibility of residual contrast on non-contrast computed tomography (CT) after transfer and assessed the hyperdense vessel sign. Multivariate linear regression analysis was used to investigate the association of the Alberta Stroke Program Early CT score (ASPECTS) with prior contrast administration, time from symptom onset (TFSO), and CTP ischemic core volume in both directly admitted and transferred patients. Results We included 161 patients, with 62 (39%) transferred and 99 (62%) directly admitted patients. Compared between these groups, transferred patients had a longer TFSO-to-imaging at our institution (median: 212 vs. 75 min, p < 0.001) and lower ASPECTS (median: 8 vs. 9, p < 0.001). Regression analysis presented an independent association of ASPECTS with prior contrast administration (β = -0.25, p = 0.004) but not with TFSO (β = -0.03, p = 0.65). Intergroup comparison between transferred and directly admitted patients pointed toward a stronger association between ASPECTS and CTP ischemic core volume in transferred patients (β = -0.39 vs. β = -0.58, p = 0.06). Detectability of the hyperdense vessel sign was substantially lower after transfer (66 vs. 10%, p < 0.001). Conclusion Imaging alterations due to residual IV contrast are frequent in clinical practice and render the hyperdense vessel sign largely indetectable. Larger studies are needed to clarify the influence on the association between ASPECTS and ischemic core.
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Affiliation(s)
- Franziska Mueller
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | | | | | - Sophia Kiesl
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Sebastian Moench
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research, LMU Munich, Munich, Germany
| | - Jan Rémi
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Lars Kellert
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Moriz Herzberg
- Department of Diagnostic and Interventional Radiology, University Hospital Wuerzburg, Wuerzburg, Germany
| | - Clemens Küpper
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Konstantinos Dimitriadis
- Institute for Stroke and Dementia Research, LMU Munich, Munich, Germany,Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | | | - Thomas Liebig
- Department of Neuroradiology, University Hospital, LMU Munich, Munich, Germany
| | - Wolfgang G. Kunz
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Paul Reidler
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany,*Correspondence: Paul Reidler
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Kandregula S, Savardekar A, Sharma P, Mclarty J, Kosty J, Trosclair K, Newman WC, Cuellar H, Guthikonda B. Drip and Ship versus Mothership Model in the Middle Cerebral Artery Stroke: A Propensity-Matched Real-World Analysis Through National Inpatient Sample Data. World Neurosurg 2022; 167:e1103-e1114. [PMID: 36089277 DOI: 10.1016/j.wneu.2022.08.142] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 08/28/2022] [Accepted: 08/30/2022] [Indexed: 11/18/2022]
Abstract
BACKGROUND The superiority of mechanical thrombectomy and intravenous thrombolysis versus intravenous thrombolysis alone for acute ischemic stroke caused by large vessel occlusions has been established. This treatment can be organized into 2 models: drip and ship (DS) versus mothership (MS). We analyzed the National Inpatient Sample (NIS) data to compare the outcomes between these models in real-world settings. METHODS NIS data were queried for 2017-2018 and propensity matching was used to match the differences. Outcomes for each group (disability at discharge and procedural complications) were compared. RESULTS A total of 1226 patients were included in analysis (DS, n = 540; MS, n = 686) and groups were matched with respect to age, gender, and comorbidities. A total of 930 patients were included in the final analysis after propensity matching (DS, n = 465, MS, n = 465). The mean age in the DS group was 68.9 years (standard deviation [SD], 14.7) and 69.4 years (SD, 14) in the MS group (P = 0.752). The mean National Institutes of Health Stroke Scale score was 16.75 (SD, 6.07) in the DS group and 16.54 (SD, 5.99) in the MS group (P = 0.478). At discharge, minimal disability was noted in 22.4% in the DS group versus 26.2% in the MS group (P = 0.293). In-hospital mortality was lower in the MS group (8.8% vs. 7.1%; P = 0.32). The intracerebral hemorrhage (ICH) and intraventricular hemorrhage (IVH) rates were higher in the DS group (ICH, 24.3% vs. 18.7%; IVH, 2.4% vs. 0.9%) (ICH, P = 0.038; IVH, P = 0.068). CONCLUSIONS Analyzing the efficacy and safety profile of DS versus MS models with the NIS database showed a trend toward better discharge outcomes and lower mortality for the MS group, although it did not reach statistical significance.
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Affiliation(s)
- Sandeep Kandregula
- Department of Neurosurgery, Ochsner LSU Health Shreveport, Shreveport, Louisiana, USA
| | - Amey Savardekar
- Department of Neurosurgery, Ochsner LSU Health Shreveport, Shreveport, Louisiana, USA
| | - Pankaj Sharma
- Department of Neurology, Ochsner LSU Health Shreveport, Shreveport, Louisiana, USA
| | - Jerry Mclarty
- Department of Oncology, Feist Weiller Cancer Center, LSU Health Shreveport, Shreveport, Louisiana, USA
| | - Jennifer Kosty
- Department of Neurosurgery, Ochsner LSU Health Shreveport, Shreveport, Louisiana, USA
| | - Krystle Trosclair
- Department of Neurosurgery, Ochsner LSU Health Shreveport, Shreveport, Louisiana, USA
| | | | - Hugo Cuellar
- Department of Radiology, Ochsner LSU Health Shreveport, Shreveport, Louisiana, USA
| | - Bharat Guthikonda
- Department of Neurosurgery, Ochsner LSU Health Shreveport, Shreveport, Louisiana, USA.
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He X, Lin B, Tao T, Chen Q, Wang J, Jin J. Higher serum albumin-corrected calcium levels are associated with revascularization and poor outcome after mechanical thrombectomy. BMC Neurol 2022; 22:330. [PMID: 36056314 PMCID: PMC9438214 DOI: 10.1186/s12883-022-02856-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Accepted: 08/24/2022] [Indexed: 11/13/2022] Open
Abstract
Background Serum calcium abnormalities have been determined to be associated with the risk and outcome of stroke. The aim of the present study was to examine the associations of serum calcium with vascular recanalization, symptomatic intracranial haemorrhage and functional outcome in stroke patients after mechanical thrombectomy. Methods A total of 192 patients treated with mechanical thrombectomy for anterior circulation large vessel occlusion were consecutively included from August 2017 to June 2021. Serum calcium levels were measured on admission, and albumin-corrected calcium levels were calculated for subsequent analysis. Successful arterial revascularization was defined as a modified Thrombolysis in Cerebral Infarction scale score ≥ 2b. Symptomatic intracranial haemorrhage was assessed according to the European Cooperative Acute Stroke Study (ECASS) III criteria. Poor functional outcome was defined as a modified Rankin Scale score > 2 at 3 months. Results Patients with poor outcomes had higher albumin-corrected calcium levels than patients with good outcomes before (2.20 (2.10, 2.30) mmol/L vs. 2.13 (2.04, 2.24) mmol/L, P = 0.002), and after adjusting for other factors (AOR 95% CI, 1.812 (1.253, 2.621), P = 0.002). Patients with unsuccessful recanalization had higher albumin-corrected calcium levels than those with recanalization (2.26 (2.09, 2.46) mmol/L vs. 2.17 (2.07, 2.27) mmol/L, P = 0.029), and after adjusting for other factors (AOR 95% CI, 2.068 (1.214, 3.524)), P = 0.008). No association was found between albumin-corrected calcium and symptomatic intracranial haemorrhage. Conclusions Higher serum albumin-corrected calcium levels are independently associated with revascularization and poor outcome in stroke patients after mechanical thrombectomy. Supplementary Information The online version contains supplementary material available at 10.1186/s12883-022-02856-2.
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Affiliation(s)
- Xinwei He
- Department of Neurology, Taizhou Central Hospital (Taizhou University Hospital), 999 Donghai Road, Taizhou, 318000, China
| | - Baomei Lin
- Department of Neurology, Taizhou Central Hospital (Taizhou University Hospital), 999 Donghai Road, Taizhou, 318000, China
| | - Taotao Tao
- Department of Neurology, Taizhou Central Hospital (Taizhou University Hospital), 999 Donghai Road, Taizhou, 318000, China
| | - Qiuyue Chen
- Department of Neurology, Taizhou Central Hospital (Taizhou University Hospital), 999 Donghai Road, Taizhou, 318000, China
| | - Jinhua Wang
- Department of Neurology, Huanggang Central Hospital, Huanggang, 438000, Hubei, China.
| | - Jiaolei Jin
- Department of Neurology, Taizhou Central Hospital (Taizhou University Hospital), 999 Donghai Road, Taizhou, 318000, China.
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Hassan AE, Zaidat OO, Nanda A, Atchie B, Woodward K, Doerfler A, Tomasello A, Fifi JT. Impact of interhospital transfer vs. direct admission on acute ischemic stroke patients: A subset analysis of the COMPLETE registry. Front Neurol 2022; 13:896165. [PMID: 36016541 PMCID: PMC9397115 DOI: 10.3389/fneur.2022.896165] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 07/13/2022] [Indexed: 11/18/2022] Open
Abstract
Background Efficacy of thrombectomy treatment in acute ischemic stroke large vessel occlusion (AIS-LVO) patients is time dependent. Direct admission to thrombectomy centers (vs. interhospital transfer) may reduce time to treatment and improve outcomes. In this subset analysis of the COMPLETE registry, we compared outcomes between direct to thrombectomy center (Direct) vs. transfer from another hospital to thrombectomy center (Transfer) in AIS-LVO patients treated with aspiration thrombectomy. Methods COMPLETE was a prospective, international registry that enrolled patients from July 2018 to October 2019, with a 90-day follow-up period that was completed in January 2020. Imaging findings and safety events were adjudicated by core lab and independent medical reviewers, respectively. Pre-defined primary endpoints included post-procedure angiographic revascularization (mTICI ≥2b), 90-day functional outcome (mRS 0–2), and 90-day all-cause mortality. Planned collections of procedural time metrics and outcomes were used in the present post-hoc analysis to compare outcomes between transfer and direct patient cohorts. Results Of 650 patients enrolled, 343 were transfer [52.8% female; mean (SD) age, 68.2 (13.9) years], and 307 were direct [55.4% female; 68.5 (14.5) years] admit. Median onset-to-puncture time took longer in the transfer vs. direct cohort (5.65 vs. 3.18 h: 2.33 h difference, respectively; p < 0.001). There was no significant difference in successful revascularization rate, mTICI ≥2b (88.3 and 87.3%), sICH at 24 h (3.8 and 3.9%), median length of hospital stay (7 and 6 days), and 90-day mortality (16.9 and 14.0%) between transfer vs. direct patients, respectively. However, achieving 90-day functional independence was less likely in transfer compared with direct patients (mRS 0–2 was 50.3 vs. 61.7%, p = 0.0056). Conclusions In the COMPLETE registry, direct to thrombectomy center was associated with significantly shorter onset-to-puncture times, and higher rates of good clinical outcome across different geographies. Additional research should focus on AIS-LVO detection to facilitate direct routing of patients to appropriate treatment centers. Clinical trial registration https://clinicaltrials.gov (Unique identifier: NCT03464565).
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Affiliation(s)
- Ameer E. Hassan
- Valley Baptist Medical Center, Neuroscience Department, University of Texas Rio Grande Valley, Harlingen, TX, United States
- *Correspondence: Ameer E. Hassan
| | - Osama O. Zaidat
- Endovascular Neurology and Neuroscience, Mercy Health St. Vincent Medical Center, Toledo, OH, United States
| | - Ashish Nanda
- SSM St. Clare Healthcare, Fenton, MO, United States
| | | | - Keith Woodward
- Fort Sanders Regional Medical Center, Knoxville, TN, United States
| | - Arnd Doerfler
- Department of Neuroradiology, Universitätsklinikum Erlangen, Erlangen, Germany
| | - Alejandro Tomasello
- Neurorradiologia Intervencionista, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Johanna T. Fifi
- Icahn School of Medicine at Mount Sinai, New York, NY, United States
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Sarraj A, Campbell BCV, Christensen S, Sitton CW, Khanpara S, Riascos RF, Pujara D, Shaker F, Sharma G, Lansberg MG, Albers GW. Accuracy of CT Perfusion-Based Core Estimation of Follow-up Infarction: Effects of Time Since Last Known Well. Neurology 2022; 98:e2084-e2096. [PMID: 35450966 PMCID: PMC9169942 DOI: 10.1212/wnl.0000000000200269] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 02/08/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND AND OBJECTIVES To assess the accuracy of baseline CT perfusion (CTP) ischemic core estimates. METHODS From SELECT (Optimizing Patient Selection for Endovascular Treatment in Acute Ischemic Stroke), a prospective multicenter cohort study of imaging selection, patients undergoing endovascular thrombectomy who achieved complete reperfusion (modified Thrombolysis In Cerebral Ischemia score 3) and had follow-up diffusion-weighted imaging (DWI) available were evaluated. Follow-up DWI lesions were coregistered to baseline CTP. The difference between baseline CTP core (relative cerebral blood flow [rCBF] <30%) volume and follow-up infarct volume was classified as overestimation (core ≥10 mL larger than infarct), adequate, or underestimation (core ≥25 mL smaller than infarct) and spatial overlap was evaluated. RESULTS Of 101 included patients, median time from last known well (LKW) to imaging acquisition was 138 (82-244) minutes. The median baseline ischemic core estimate was 9 (0-31.9) mL and median follow-up infarct volume was 18.4 (5.3-68.7) mL. All 6/101 (6%) patients with overestimation of the subsequent infarct volume were imaged within 90 minutes of LKW and achieved rapid reperfusion (within 120 minutes of CTP). Using rCBF <20% threshold to estimate ischemic core in patients presenting within 90 minutes eliminated overestimation. Volumetric correlation between the ischemic core estimate and follow-up imaging improved as LKW time to imaging acquisition increased: Spearman ρ <90 minutes 0.33 (p = 0.049), 90-270 minutes 0.63 (p < 0.0001), >270 minutes 0.86 (p < 0.0001). Assessment of the spatial overlap between baseline CTP ischemic core lesion and follow-up infarct demonstrated that a median of 3.2 (0.0-9.0) mL of estimated core fell outside the subsequent infarct. These regions were predominantly in white matter. DISCUSSION Significant overestimation of irreversibly injured ischemic core volume was rare, was only observed in patients who presented within 90 minutes of LKW and achieved reperfusion within 120 minutes of CTP acquisition, and occurred primarily in white matter. Use of a more conservative (rCBF <20%) threshold for estimating ischemic core in patients presenting within 90 minutes eliminated all significant overestimation cases. TRIAL REGISTRATION INFORMATION ClinicalTrials.gov: NCT03876457.
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Affiliation(s)
- Amrou Sarraj
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
| | - Bruce C V Campbell
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
| | - Soren Christensen
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
| | - Clark W Sitton
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
| | - Shekhar Khanpara
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
| | - Roy F Riascos
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
| | - Deep Pujara
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
| | - Faris Shaker
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
| | - Gagan Sharma
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
| | - Maarten G Lansberg
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
| | - Gregory W Albers
- From the Department of Neurology (A.S.), Case Western Reserve University-University Hospitals Cleveland Medical Center, OH; Department of Neurology (B.C.V.C., G.S.), The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia; Department of Neurology (S.C., M.G.L., G.W.A.), Stanford University Medical Center, CA; Departments of Diagnostic and Interventional Imaging (C.W.S., S.K., R.F.R.) and Neurology (F.S.), UTHealth McGovern Medical School, Houston, TX; and Department of Neurology (D.P.), University Hospitals Cleveland Medical Center, OH
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Jin J, Huang R, Chen Q, Ke B, Tao T, Zhao R, He X. Carotid Artery Perivascular Adipose Tissue Density Relates to Recanalization and Clinical Outcome After Mechanical Thrombectomy. Front Aging Neurosci 2021; 13:761248. [PMID: 34899273 PMCID: PMC8652413 DOI: 10.3389/fnagi.2021.761248] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2021] [Accepted: 11/01/2021] [Indexed: 12/03/2022] Open
Abstract
Background: Perivascular adipose tissue (PVAT) imaging can be used in clinical practice as a surrogate marker of vascular disease. We aimed to analyze the association between the density of carotid artery PVAT and clinical features and outcomes in stroke patients treated with mechanical thrombectomy. Methods: A total of 183 consecutive patients treated with mechanical thrombectomy due to anterior circulation large vessel occlusion were retrospectively included from January 2016 to May 2021. The density of carotid artery PVAT was evaluated by preoperative computed tomography angiography. Successful arterial recanalization was defined as a modified Thrombolysis in Cerebral Infarction score of 2b-3 on the final angiographic examination. Poor functional outcome was defined as a modified Rankin Scale (mRS) score > 2 at 3 months after stroke. We assessed the independent effect of carotid artery PVAT density on revascularization, functional outcome, and mortality using logistic regression models adjusted for relevant confounders. Results: Patients with large artery atherosclerotic stroke have higher carotid artery PVAT density than patients with other stroke etiologies (–65.82 ± 12.96 vs. –75.77 ± 13.44, P < 0.001). Higher carotid artery PVAT density was associated with unsuccessful recanalization [adjusted odds ratio (AOR) (95% CI), 2.968 (1.292, 6.819), P = 0.010], and poor outcome [AOR (95% CI), 2.704 (1.610, 4.541), P < 0.001] and mortality [AOR (95% CI), 1.894 (1.040, 3.449), P = 0.037] at 3 months in stroke patients treated with thrombectomy. Conclusion: Higher carotid artery PVAT density before mechanical thrombectomy is an indicator of worse postprocedural arterial revascularization and a worse functional outcome in acute stroke patients.
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Affiliation(s)
- Jiaolei Jin
- Department of Neurology, Taizhou Central Hospital (Taizhou University Hospital), Taizhou, China
| | - Rui Huang
- Department of Neurology, Taizhou Central Hospital (Taizhou University Hospital), Taizhou, China
| | - Qiuyue Chen
- Department of Neurology, Taizhou Central Hospital (Taizhou University Hospital), Taizhou, China
| | - Boxi Ke
- Department of Neurology, Taizhou Central Hospital (Taizhou University Hospital), Taizhou, China
| | - Taotao Tao
- Department of Neurology, Taizhou Central Hospital (Taizhou University Hospital), Taizhou, China
| | - Rong Zhao
- Department of Neurology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xinwei He
- Department of Neurology, Taizhou Central Hospital (Taizhou University Hospital), Taizhou, China
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11
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Sang HF, Yuan JJ, Qiu ZM, Zhang M, Hu XG, Liu WH, Wang N, Han HX, Tang TY, Zeng GY, Dong H, Long XM, Li LF, Li FL, Liu S, Luo WD, Huang JC, Song JX, Li LY, Chen LM, Xie DJ, Wu DP, Li FF, Zi WJ, Yang QW. Association Between Time to Endovascular Therapy and Outcomes in Patients With Acute Basilar Artery Occlusion. Neurology 2021; 97:e2152-e2163. [PMID: 34649885 DOI: 10.1212/wnl.0000000000012858] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Accepted: 08/30/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To characterize the association of onset to puncture time (OPT) with clinical outcomes among patients with acute basilar artery occlusion receiving endovascular therapy (EVT) in clinical practice. METHODS Using the EVT for Acute Basilar Artery Occlusion (BASILAR) study, we identified consecutive patients with acute basilar artery occlusion receiving EVT in 47 comprehensive stroke centers in China from January 2014 to May 2019. The primary outcome was favorable functional outcome (defined as modified Rankin Scale score [mRS] 0-3) at 90 days. Secondary outcomes included function independence (mRS 0-2), mortality, and symptomatic intracerebral hemorrhage. The associations of OPT with clinical outcomes were analyzed using multivariable logistic regression (OPT as a categorical variable) and restricted cubic spline regression (OPT as a continuous variable). RESULTS Among 639 eligible patients, the median age was 64 years, and median OPT was 328 minutes (interquartile range 220-490). Treatment within 4-8 hours and 8-12 hours was associated with lower rates of favorable outcome (adjusted odds ratio, 0.63 [95% confidence interval (CI), 0.40-0.98] and 0.47 [95% CI, 0.23-0.93], respectively) compared with treatment within 4 hours. Restricted cubic spline regression analysis showed that the OPT had L-shaped associations with favorable outcome (p nonlinearity = 0.028) and functional independence (p nonlinearity = 0.025), with significant benefit loss throughout the first 9 hours, but then appeared relatively flat. The odds of mortality increased relatively for OPT up to 9 hours, but then leveled off (p nonlinearity = 0.042). The association between symptomatic intracerebral hemorrhage and OPT was not significant. CONCLUSION Among patients with acute basilar artery occlusion in routine practice, earlier treatment with EVT was associated with better outcomes throughout the first 9 hours after onset, but benefit may sustain unchanged afterwards. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that for patients with acute ischemic stroke due to basilar artery occlusion, earlier EVT is associated with better outcomes.
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Affiliation(s)
- Hong Fei Sang
- From the Department of Neurology (H.F.S., L.F.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Department of Neurology (H.F.S., J.J.Y., Z.M.Q., X.M.L., F.L.L., S.L., W.D.L., J.C.H., J.X.S., L.Y.L., L.M.C., D.J.X., D.P.W., F.F.L., W.J.Z., Q.W.Y.), Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing; Departments of Neurology (Z.M.Q.) and Cadre Health Care (H.D.), the 903rd Hospital of the People's Liberation Army, Hangzhou; Department of Neurology (M.Z.), Jiangmen Central Hospital; Department of Military Patient Management (X.G.H.), the 904th Hospital of the People's Liberation Army, Wuxi; Department of Neurology (W.H.L.), Wuhan No. 1 Hospital; Department of Neurology (N.W.), Nanyang Central Hospital; Department of Neurology (H.X.H.), Linyi People's Hospital; Department of Neurology (T.Y.T.), the Affiliated Hospital of Yangzhou University; Department of Neurology (G.Y.Z.), Ganzhou People's Hospital, China
| | - Jun Jie Yuan
- From the Department of Neurology (H.F.S., L.F.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Department of Neurology (H.F.S., J.J.Y., Z.M.Q., X.M.L., F.L.L., S.L., W.D.L., J.C.H., J.X.S., L.Y.L., L.M.C., D.J.X., D.P.W., F.F.L., W.J.Z., Q.W.Y.), Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing; Departments of Neurology (Z.M.Q.) and Cadre Health Care (H.D.), the 903rd Hospital of the People's Liberation Army, Hangzhou; Department of Neurology (M.Z.), Jiangmen Central Hospital; Department of Military Patient Management (X.G.H.), the 904th Hospital of the People's Liberation Army, Wuxi; Department of Neurology (W.H.L.), Wuhan No. 1 Hospital; Department of Neurology (N.W.), Nanyang Central Hospital; Department of Neurology (H.X.H.), Linyi People's Hospital; Department of Neurology (T.Y.T.), the Affiliated Hospital of Yangzhou University; Department of Neurology (G.Y.Z.), Ganzhou People's Hospital, China
| | - Zhong Ming Qiu
- From the Department of Neurology (H.F.S., L.F.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Department of Neurology (H.F.S., J.J.Y., Z.M.Q., X.M.L., F.L.L., S.L., W.D.L., J.C.H., J.X.S., L.Y.L., L.M.C., D.J.X., D.P.W., F.F.L., W.J.Z., Q.W.Y.), Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing; Departments of Neurology (Z.M.Q.) and Cadre Health Care (H.D.), the 903rd Hospital of the People's Liberation Army, Hangzhou; Department of Neurology (M.Z.), Jiangmen Central Hospital; Department of Military Patient Management (X.G.H.), the 904th Hospital of the People's Liberation Army, Wuxi; Department of Neurology (W.H.L.), Wuhan No. 1 Hospital; Department of Neurology (N.W.), Nanyang Central Hospital; Department of Neurology (H.X.H.), Linyi People's Hospital; Department of Neurology (T.Y.T.), the Affiliated Hospital of Yangzhou University; Department of Neurology (G.Y.Z.), Ganzhou People's Hospital, China
| | - Min Zhang
- From the Department of Neurology (H.F.S., L.F.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Department of Neurology (H.F.S., J.J.Y., Z.M.Q., X.M.L., F.L.L., S.L., W.D.L., J.C.H., J.X.S., L.Y.L., L.M.C., D.J.X., D.P.W., F.F.L., W.J.Z., Q.W.Y.), Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing; Departments of Neurology (Z.M.Q.) and Cadre Health Care (H.D.), the 903rd Hospital of the People's Liberation Army, Hangzhou; Department of Neurology (M.Z.), Jiangmen Central Hospital; Department of Military Patient Management (X.G.H.), the 904th Hospital of the People's Liberation Army, Wuxi; Department of Neurology (W.H.L.), Wuhan No. 1 Hospital; Department of Neurology (N.W.), Nanyang Central Hospital; Department of Neurology (H.X.H.), Linyi People's Hospital; Department of Neurology (T.Y.T.), the Affiliated Hospital of Yangzhou University; Department of Neurology (G.Y.Z.), Ganzhou People's Hospital, China
| | - Xiao Gang Hu
- From the Department of Neurology (H.F.S., L.F.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Department of Neurology (H.F.S., J.J.Y., Z.M.Q., X.M.L., F.L.L., S.L., W.D.L., J.C.H., J.X.S., L.Y.L., L.M.C., D.J.X., D.P.W., F.F.L., W.J.Z., Q.W.Y.), Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing; Departments of Neurology (Z.M.Q.) and Cadre Health Care (H.D.), the 903rd Hospital of the People's Liberation Army, Hangzhou; Department of Neurology (M.Z.), Jiangmen Central Hospital; Department of Military Patient Management (X.G.H.), the 904th Hospital of the People's Liberation Army, Wuxi; Department of Neurology (W.H.L.), Wuhan No. 1 Hospital; Department of Neurology (N.W.), Nanyang Central Hospital; Department of Neurology (H.X.H.), Linyi People's Hospital; Department of Neurology (T.Y.T.), the Affiliated Hospital of Yangzhou University; Department of Neurology (G.Y.Z.), Ganzhou People's Hospital, China
| | - Wen Hua Liu
- From the Department of Neurology (H.F.S., L.F.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Department of Neurology (H.F.S., J.J.Y., Z.M.Q., X.M.L., F.L.L., S.L., W.D.L., J.C.H., J.X.S., L.Y.L., L.M.C., D.J.X., D.P.W., F.F.L., W.J.Z., Q.W.Y.), Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing; Departments of Neurology (Z.M.Q.) and Cadre Health Care (H.D.), the 903rd Hospital of the People's Liberation Army, Hangzhou; Department of Neurology (M.Z.), Jiangmen Central Hospital; Department of Military Patient Management (X.G.H.), the 904th Hospital of the People's Liberation Army, Wuxi; Department of Neurology (W.H.L.), Wuhan No. 1 Hospital; Department of Neurology (N.W.), Nanyang Central Hospital; Department of Neurology (H.X.H.), Linyi People's Hospital; Department of Neurology (T.Y.T.), the Affiliated Hospital of Yangzhou University; Department of Neurology (G.Y.Z.), Ganzhou People's Hospital, China
| | - Ning Wang
- From the Department of Neurology (H.F.S., L.F.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Department of Neurology (H.F.S., J.J.Y., Z.M.Q., X.M.L., F.L.L., S.L., W.D.L., J.C.H., J.X.S., L.Y.L., L.M.C., D.J.X., D.P.W., F.F.L., W.J.Z., Q.W.Y.), Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing; Departments of Neurology (Z.M.Q.) and Cadre Health Care (H.D.), the 903rd Hospital of the People's Liberation Army, Hangzhou; Department of Neurology (M.Z.), Jiangmen Central Hospital; Department of Military Patient Management (X.G.H.), the 904th Hospital of the People's Liberation Army, Wuxi; Department of Neurology (W.H.L.), Wuhan No. 1 Hospital; Department of Neurology (N.W.), Nanyang Central Hospital; Department of Neurology (H.X.H.), Linyi People's Hospital; Department of Neurology (T.Y.T.), the Affiliated Hospital of Yangzhou University; Department of Neurology (G.Y.Z.), Ganzhou People's Hospital, China
| | - Hong Xing Han
- From the Department of Neurology (H.F.S., L.F.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Department of Neurology (H.F.S., J.J.Y., Z.M.Q., X.M.L., F.L.L., S.L., W.D.L., J.C.H., J.X.S., L.Y.L., L.M.C., D.J.X., D.P.W., F.F.L., W.J.Z., Q.W.Y.), Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing; Departments of Neurology (Z.M.Q.) and Cadre Health Care (H.D.), the 903rd Hospital of the People's Liberation Army, Hangzhou; Department of Neurology (M.Z.), Jiangmen Central Hospital; Department of Military Patient Management (X.G.H.), the 904th Hospital of the People's Liberation Army, Wuxi; Department of Neurology (W.H.L.), Wuhan No. 1 Hospital; Department of Neurology (N.W.), Nanyang Central Hospital; Department of Neurology (H.X.H.), Linyi People's Hospital; Department of Neurology (T.Y.T.), the Affiliated Hospital of Yangzhou University; Department of Neurology (G.Y.Z.), Ganzhou People's Hospital, China
| | - Tie Yu Tang
- From the Department of Neurology (H.F.S., L.F.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Department of Neurology (H.F.S., J.J.Y., Z.M.Q., X.M.L., F.L.L., S.L., W.D.L., J.C.H., J.X.S., L.Y.L., L.M.C., D.J.X., D.P.W., F.F.L., W.J.Z., Q.W.Y.), Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing; Departments of Neurology (Z.M.Q.) and Cadre Health Care (H.D.), the 903rd Hospital of the People's Liberation Army, Hangzhou; Department of Neurology (M.Z.), Jiangmen Central Hospital; Department of Military Patient Management (X.G.H.), the 904th Hospital of the People's Liberation Army, Wuxi; Department of Neurology (W.H.L.), Wuhan No. 1 Hospital; Department of Neurology (N.W.), Nanyang Central Hospital; Department of Neurology (H.X.H.), Linyi People's Hospital; Department of Neurology (T.Y.T.), the Affiliated Hospital of Yangzhou University; Department of Neurology (G.Y.Z.), Ganzhou People's Hospital, China
| | - Guo Yong Zeng
- From the Department of Neurology (H.F.S., L.F.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Department of Neurology (H.F.S., J.J.Y., Z.M.Q., X.M.L., F.L.L., S.L., W.D.L., J.C.H., J.X.S., L.Y.L., L.M.C., D.J.X., D.P.W., F.F.L., W.J.Z., Q.W.Y.), Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing; Departments of Neurology (Z.M.Q.) and Cadre Health Care (H.D.), the 903rd Hospital of the People's Liberation Army, Hangzhou; Department of Neurology (M.Z.), Jiangmen Central Hospital; Department of Military Patient Management (X.G.H.), the 904th Hospital of the People's Liberation Army, Wuxi; Department of Neurology (W.H.L.), Wuhan No. 1 Hospital; Department of Neurology (N.W.), Nanyang Central Hospital; Department of Neurology (H.X.H.), Linyi People's Hospital; Department of Neurology (T.Y.T.), the Affiliated Hospital of Yangzhou University; Department of Neurology (G.Y.Z.), Ganzhou People's Hospital, China
| | - Hui Dong
- From the Department of Neurology (H.F.S., L.F.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Department of Neurology (H.F.S., J.J.Y., Z.M.Q., X.M.L., F.L.L., S.L., W.D.L., J.C.H., J.X.S., L.Y.L., L.M.C., D.J.X., D.P.W., F.F.L., W.J.Z., Q.W.Y.), Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing; Departments of Neurology (Z.M.Q.) and Cadre Health Care (H.D.), the 903rd Hospital of the People's Liberation Army, Hangzhou; Department of Neurology (M.Z.), Jiangmen Central Hospital; Department of Military Patient Management (X.G.H.), the 904th Hospital of the People's Liberation Army, Wuxi; Department of Neurology (W.H.L.), Wuhan No. 1 Hospital; Department of Neurology (N.W.), Nanyang Central Hospital; Department of Neurology (H.X.H.), Linyi People's Hospital; Department of Neurology (T.Y.T.), the Affiliated Hospital of Yangzhou University; Department of Neurology (G.Y.Z.), Ganzhou People's Hospital, China
| | - Xing Min Long
- From the Department of Neurology (H.F.S., L.F.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Department of Neurology (H.F.S., J.J.Y., Z.M.Q., X.M.L., F.L.L., S.L., W.D.L., J.C.H., J.X.S., L.Y.L., L.M.C., D.J.X., D.P.W., F.F.L., W.J.Z., Q.W.Y.), Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing; Departments of Neurology (Z.M.Q.) and Cadre Health Care (H.D.), the 903rd Hospital of the People's Liberation Army, Hangzhou; Department of Neurology (M.Z.), Jiangmen Central Hospital; Department of Military Patient Management (X.G.H.), the 904th Hospital of the People's Liberation Army, Wuxi; Department of Neurology (W.H.L.), Wuhan No. 1 Hospital; Department of Neurology (N.W.), Nanyang Central Hospital; Department of Neurology (H.X.H.), Linyi People's Hospital; Department of Neurology (T.Y.T.), the Affiliated Hospital of Yangzhou University; Department of Neurology (G.Y.Z.), Ganzhou People's Hospital, China
| | - Ling Fei Li
- From the Department of Neurology (H.F.S., L.F.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Department of Neurology (H.F.S., J.J.Y., Z.M.Q., X.M.L., F.L.L., S.L., W.D.L., J.C.H., J.X.S., L.Y.L., L.M.C., D.J.X., D.P.W., F.F.L., W.J.Z., Q.W.Y.), Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing; Departments of Neurology (Z.M.Q.) and Cadre Health Care (H.D.), the 903rd Hospital of the People's Liberation Army, Hangzhou; Department of Neurology (M.Z.), Jiangmen Central Hospital; Department of Military Patient Management (X.G.H.), the 904th Hospital of the People's Liberation Army, Wuxi; Department of Neurology (W.H.L.), Wuhan No. 1 Hospital; Department of Neurology (N.W.), Nanyang Central Hospital; Department of Neurology (H.X.H.), Linyi People's Hospital; Department of Neurology (T.Y.T.), the Affiliated Hospital of Yangzhou University; Department of Neurology (G.Y.Z.), Ganzhou People's Hospital, China
| | - Feng Li Li
- From the Department of Neurology (H.F.S., L.F.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Department of Neurology (H.F.S., J.J.Y., Z.M.Q., X.M.L., F.L.L., S.L., W.D.L., J.C.H., J.X.S., L.Y.L., L.M.C., D.J.X., D.P.W., F.F.L., W.J.Z., Q.W.Y.), Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing; Departments of Neurology (Z.M.Q.) and Cadre Health Care (H.D.), the 903rd Hospital of the People's Liberation Army, Hangzhou; Department of Neurology (M.Z.), Jiangmen Central Hospital; Department of Military Patient Management (X.G.H.), the 904th Hospital of the People's Liberation Army, Wuxi; Department of Neurology (W.H.L.), Wuhan No. 1 Hospital; Department of Neurology (N.W.), Nanyang Central Hospital; Department of Neurology (H.X.H.), Linyi People's Hospital; Department of Neurology (T.Y.T.), the Affiliated Hospital of Yangzhou University; Department of Neurology (G.Y.Z.), Ganzhou People's Hospital, China
| | - Shuai Liu
- From the Department of Neurology (H.F.S., L.F.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Department of Neurology (H.F.S., J.J.Y., Z.M.Q., X.M.L., F.L.L., S.L., W.D.L., J.C.H., J.X.S., L.Y.L., L.M.C., D.J.X., D.P.W., F.F.L., W.J.Z., Q.W.Y.), Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing; Departments of Neurology (Z.M.Q.) and Cadre Health Care (H.D.), the 903rd Hospital of the People's Liberation Army, Hangzhou; Department of Neurology (M.Z.), Jiangmen Central Hospital; Department of Military Patient Management (X.G.H.), the 904th Hospital of the People's Liberation Army, Wuxi; Department of Neurology (W.H.L.), Wuhan No. 1 Hospital; Department of Neurology (N.W.), Nanyang Central Hospital; Department of Neurology (H.X.H.), Linyi People's Hospital; Department of Neurology (T.Y.T.), the Affiliated Hospital of Yangzhou University; Department of Neurology (G.Y.Z.), Ganzhou People's Hospital, China
| | - Wei Dong Luo
- From the Department of Neurology (H.F.S., L.F.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Department of Neurology (H.F.S., J.J.Y., Z.M.Q., X.M.L., F.L.L., S.L., W.D.L., J.C.H., J.X.S., L.Y.L., L.M.C., D.J.X., D.P.W., F.F.L., W.J.Z., Q.W.Y.), Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing; Departments of Neurology (Z.M.Q.) and Cadre Health Care (H.D.), the 903rd Hospital of the People's Liberation Army, Hangzhou; Department of Neurology (M.Z.), Jiangmen Central Hospital; Department of Military Patient Management (X.G.H.), the 904th Hospital of the People's Liberation Army, Wuxi; Department of Neurology (W.H.L.), Wuhan No. 1 Hospital; Department of Neurology (N.W.), Nanyang Central Hospital; Department of Neurology (H.X.H.), Linyi People's Hospital; Department of Neurology (T.Y.T.), the Affiliated Hospital of Yangzhou University; Department of Neurology (G.Y.Z.), Ganzhou People's Hospital, China
| | - Jia Cheng Huang
- From the Department of Neurology (H.F.S., L.F.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Department of Neurology (H.F.S., J.J.Y., Z.M.Q., X.M.L., F.L.L., S.L., W.D.L., J.C.H., J.X.S., L.Y.L., L.M.C., D.J.X., D.P.W., F.F.L., W.J.Z., Q.W.Y.), Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing; Departments of Neurology (Z.M.Q.) and Cadre Health Care (H.D.), the 903rd Hospital of the People's Liberation Army, Hangzhou; Department of Neurology (M.Z.), Jiangmen Central Hospital; Department of Military Patient Management (X.G.H.), the 904th Hospital of the People's Liberation Army, Wuxi; Department of Neurology (W.H.L.), Wuhan No. 1 Hospital; Department of Neurology (N.W.), Nanyang Central Hospital; Department of Neurology (H.X.H.), Linyi People's Hospital; Department of Neurology (T.Y.T.), the Affiliated Hospital of Yangzhou University; Department of Neurology (G.Y.Z.), Ganzhou People's Hospital, China
| | - Jia Xing Song
- From the Department of Neurology (H.F.S., L.F.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Department of Neurology (H.F.S., J.J.Y., Z.M.Q., X.M.L., F.L.L., S.L., W.D.L., J.C.H., J.X.S., L.Y.L., L.M.C., D.J.X., D.P.W., F.F.L., W.J.Z., Q.W.Y.), Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing; Departments of Neurology (Z.M.Q.) and Cadre Health Care (H.D.), the 903rd Hospital of the People's Liberation Army, Hangzhou; Department of Neurology (M.Z.), Jiangmen Central Hospital; Department of Military Patient Management (X.G.H.), the 904th Hospital of the People's Liberation Army, Wuxi; Department of Neurology (W.H.L.), Wuhan No. 1 Hospital; Department of Neurology (N.W.), Nanyang Central Hospital; Department of Neurology (H.X.H.), Linyi People's Hospital; Department of Neurology (T.Y.T.), the Affiliated Hospital of Yangzhou University; Department of Neurology (G.Y.Z.), Ganzhou People's Hospital, China
| | - Lin Yu Li
- From the Department of Neurology (H.F.S., L.F.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Department of Neurology (H.F.S., J.J.Y., Z.M.Q., X.M.L., F.L.L., S.L., W.D.L., J.C.H., J.X.S., L.Y.L., L.M.C., D.J.X., D.P.W., F.F.L., W.J.Z., Q.W.Y.), Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing; Departments of Neurology (Z.M.Q.) and Cadre Health Care (H.D.), the 903rd Hospital of the People's Liberation Army, Hangzhou; Department of Neurology (M.Z.), Jiangmen Central Hospital; Department of Military Patient Management (X.G.H.), the 904th Hospital of the People's Liberation Army, Wuxi; Department of Neurology (W.H.L.), Wuhan No. 1 Hospital; Department of Neurology (N.W.), Nanyang Central Hospital; Department of Neurology (H.X.H.), Linyi People's Hospital; Department of Neurology (T.Y.T.), the Affiliated Hospital of Yangzhou University; Department of Neurology (G.Y.Z.), Ganzhou People's Hospital, China
| | - Lu Ming Chen
- From the Department of Neurology (H.F.S., L.F.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Department of Neurology (H.F.S., J.J.Y., Z.M.Q., X.M.L., F.L.L., S.L., W.D.L., J.C.H., J.X.S., L.Y.L., L.M.C., D.J.X., D.P.W., F.F.L., W.J.Z., Q.W.Y.), Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing; Departments of Neurology (Z.M.Q.) and Cadre Health Care (H.D.), the 903rd Hospital of the People's Liberation Army, Hangzhou; Department of Neurology (M.Z.), Jiangmen Central Hospital; Department of Military Patient Management (X.G.H.), the 904th Hospital of the People's Liberation Army, Wuxi; Department of Neurology (W.H.L.), Wuhan No. 1 Hospital; Department of Neurology (N.W.), Nanyang Central Hospital; Department of Neurology (H.X.H.), Linyi People's Hospital; Department of Neurology (T.Y.T.), the Affiliated Hospital of Yangzhou University; Department of Neurology (G.Y.Z.), Ganzhou People's Hospital, China
| | - Dong Jing Xie
- From the Department of Neurology (H.F.S., L.F.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Department of Neurology (H.F.S., J.J.Y., Z.M.Q., X.M.L., F.L.L., S.L., W.D.L., J.C.H., J.X.S., L.Y.L., L.M.C., D.J.X., D.P.W., F.F.L., W.J.Z., Q.W.Y.), Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing; Departments of Neurology (Z.M.Q.) and Cadre Health Care (H.D.), the 903rd Hospital of the People's Liberation Army, Hangzhou; Department of Neurology (M.Z.), Jiangmen Central Hospital; Department of Military Patient Management (X.G.H.), the 904th Hospital of the People's Liberation Army, Wuxi; Department of Neurology (W.H.L.), Wuhan No. 1 Hospital; Department of Neurology (N.W.), Nanyang Central Hospital; Department of Neurology (H.X.H.), Linyi People's Hospital; Department of Neurology (T.Y.T.), the Affiliated Hospital of Yangzhou University; Department of Neurology (G.Y.Z.), Ganzhou People's Hospital, China
| | - De Ping Wu
- From the Department of Neurology (H.F.S., L.F.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Department of Neurology (H.F.S., J.J.Y., Z.M.Q., X.M.L., F.L.L., S.L., W.D.L., J.C.H., J.X.S., L.Y.L., L.M.C., D.J.X., D.P.W., F.F.L., W.J.Z., Q.W.Y.), Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing; Departments of Neurology (Z.M.Q.) and Cadre Health Care (H.D.), the 903rd Hospital of the People's Liberation Army, Hangzhou; Department of Neurology (M.Z.), Jiangmen Central Hospital; Department of Military Patient Management (X.G.H.), the 904th Hospital of the People's Liberation Army, Wuxi; Department of Neurology (W.H.L.), Wuhan No. 1 Hospital; Department of Neurology (N.W.), Nanyang Central Hospital; Department of Neurology (H.X.H.), Linyi People's Hospital; Department of Neurology (T.Y.T.), the Affiliated Hospital of Yangzhou University; Department of Neurology (G.Y.Z.), Ganzhou People's Hospital, China
| | - Fang Fei Li
- From the Department of Neurology (H.F.S., L.F.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Department of Neurology (H.F.S., J.J.Y., Z.M.Q., X.M.L., F.L.L., S.L., W.D.L., J.C.H., J.X.S., L.Y.L., L.M.C., D.J.X., D.P.W., F.F.L., W.J.Z., Q.W.Y.), Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing; Departments of Neurology (Z.M.Q.) and Cadre Health Care (H.D.), the 903rd Hospital of the People's Liberation Army, Hangzhou; Department of Neurology (M.Z.), Jiangmen Central Hospital; Department of Military Patient Management (X.G.H.), the 904th Hospital of the People's Liberation Army, Wuxi; Department of Neurology (W.H.L.), Wuhan No. 1 Hospital; Department of Neurology (N.W.), Nanyang Central Hospital; Department of Neurology (H.X.H.), Linyi People's Hospital; Department of Neurology (T.Y.T.), the Affiliated Hospital of Yangzhou University; Department of Neurology (G.Y.Z.), Ganzhou People's Hospital, China
| | - Wen Jie Zi
- From the Department of Neurology (H.F.S., L.F.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Department of Neurology (H.F.S., J.J.Y., Z.M.Q., X.M.L., F.L.L., S.L., W.D.L., J.C.H., J.X.S., L.Y.L., L.M.C., D.J.X., D.P.W., F.F.L., W.J.Z., Q.W.Y.), Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing; Departments of Neurology (Z.M.Q.) and Cadre Health Care (H.D.), the 903rd Hospital of the People's Liberation Army, Hangzhou; Department of Neurology (M.Z.), Jiangmen Central Hospital; Department of Military Patient Management (X.G.H.), the 904th Hospital of the People's Liberation Army, Wuxi; Department of Neurology (W.H.L.), Wuhan No. 1 Hospital; Department of Neurology (N.W.), Nanyang Central Hospital; Department of Neurology (H.X.H.), Linyi People's Hospital; Department of Neurology (T.Y.T.), the Affiliated Hospital of Yangzhou University; Department of Neurology (G.Y.Z.), Ganzhou People's Hospital, China
| | - Qing Wu Yang
- From the Department of Neurology (H.F.S., L.F.L.), Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medicine, Hangzhou; Department of Neurology (H.F.S., J.J.Y., Z.M.Q., X.M.L., F.L.L., S.L., W.D.L., J.C.H., J.X.S., L.Y.L., L.M.C., D.J.X., D.P.W., F.F.L., W.J.Z., Q.W.Y.), Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing; Departments of Neurology (Z.M.Q.) and Cadre Health Care (H.D.), the 903rd Hospital of the People's Liberation Army, Hangzhou; Department of Neurology (M.Z.), Jiangmen Central Hospital; Department of Military Patient Management (X.G.H.), the 904th Hospital of the People's Liberation Army, Wuxi; Department of Neurology (W.H.L.), Wuhan No. 1 Hospital; Department of Neurology (N.W.), Nanyang Central Hospital; Department of Neurology (H.X.H.), Linyi People's Hospital; Department of Neurology (T.Y.T.), the Affiliated Hospital of Yangzhou University; Department of Neurology (G.Y.Z.), Ganzhou People's Hospital, China.
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12
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Reidler P, Stueckelschweiger L, Puhr-Westerheide D, Feil K, Kellert L, Dimitriadis K, Tiedt S, Herzberg M, Rémi J, Liebig T, Fabritius MP, Kunz WG. Performance of Automated Attenuation Measurements at Identifying Large Vessel Occlusion Stroke on CT Angiography. Clin Neuroradiol 2021; 31:763-772. [PMID: 32939563 PMCID: PMC8463515 DOI: 10.1007/s00062-020-00956-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 08/17/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE Computed tomography angiography (CTA) is routinely used to detect large-vessel occlusion (LVO) in patients with suspected acute ischemic stroke; however, visual analysis is time consuming and prone to error. To evaluate solutions to support imaging triage, we tested performance of automated analysis of CTA source images (CTASI) at identifying patients with LVO. METHODS Stroke patients with LVO were selected from a prospectively acquired cohort. A control group was selected from consecutive patients with clinically suspected stroke without signs of ischemia on CT perfusion (CTP) or infarct on follow-up. Software-based automated segmentation and Hounsfield unit (HU) measurements were performed on CTASI for all regions of the Alberta Stroke Program Early CT score (ASPECTS). We derived different parameters from raw measurements and analyzed their performance to identify patients with LVO using receiver operating characteristic curve analysis. RESULTS The retrospective analysis included 145 patients, 79 patients with LVO stroke and 66 patients without stroke. The parameters hemispheric asymmetry ratio (AR), ratio between highest and lowest regional AR and M2-territory AR produced area under the curve (AUC) values from 0.95-0.97 (all p < 0.001) for detecting presence of LVO in the total population. Resulting sensitivity (sens)/specificity (spec) defined by the Youden index were 0.87/0.97-0.99. Maximum sens/spec defined by the specificity threshold ≥0.70 were 0.91-0.96/0.77-0.83. Performance in a small number of patients with isolated M2 occlusion was lower (AUC: 0.72-0.85). CONCLUSION Automated attenuation measurements on CTASI identify proximal LVO stroke patients with high sensitivity and specificity. This technique can aid in accurate and timely patient selection for thrombectomy, especially in primary stroke centers without CTP capacity.
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Affiliation(s)
- Paul Reidler
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
| | - Lena Stueckelschweiger
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Daniel Puhr-Westerheide
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Katharina Feil
- Department of Neurology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
- German Center for Vertigo and Balance Disorders, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Lars Kellert
- Department of Neurology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Konstantinos Dimitriadis
- Department of Neurology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
- Institute for Stroke and Dementia Research, LMU Munich, Feodor-Lynen-Str. 17, 81377, Munich, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research, LMU Munich, Feodor-Lynen-Str. 17, 81377, Munich, Germany
| | - Moriz Herzberg
- Department of Neuroradiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Jan Rémi
- Department of Neurology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Thomas Liebig
- Department of Neuroradiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Matthias P Fabritius
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Wolfgang G Kunz
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
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13
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Sarraj A, Goyal N, Chen M, Grotta JC, Blackburn S, Requena M, Kamal H, Abraham MG, Elijovich L, Dannenbaum M, Mir O, Tekle WG, Pujara D, Shaker F, Cai C, Maali L, Radaideh Y, Reddy ST, Parsha KN, Alenzi B, Abdulrazzak MA, Greco J, Hoit D, Martin-Schild SB, Song S, Sitton C, Tsivgoulis GK, Alexandrov AV, Arthur AS, Day AL, Hassan AE, Ribo M. Direct to Angiography vs Repeated Imaging Approaches in Transferred Patients Undergoing Endovascular Thrombectomy. JAMA Neurol 2021; 78:916-926. [PMID: 34125153 DOI: 10.1001/jamaneurol.2021.1707] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Importance A direct to angiography (DTA) treatment paradigm without repeated imaging for transferred patients with large vessel occlusion (LVO) may reduce time to endovascular thrombectomy (EVT). Whether DTA is safe and associated with better outcomes in the late (>6 hours) window is unknown. Also, DTA feasibility and effectiveness in reducing time to EVT during on-call vs regular-work hours and the association of interfacility transfer times with DTA outcomes have not been established. Objective To evaluate the functional and safety outcomes of DTA vs repeated imaging in the different treatment windows and on-call hours vs regular hours. Design, Setting, and Participants This pooled retrospective cohort study at 6 US and European comprehensive stroke centers enrolled adults (aged ≥18 years) with anterior circulation LVO (internal cerebral artery or middle cerebral artery subdivisions M1/M2) and transferred for EVT within 24 hours of the last-known-well time from January 1, 2014, to February 29, 2020. Exposures Repeated imaging (computed tomography with or without computed tomographic angiography or computed tomography perfusion) before EVT vs DTA. Main Outcomes and Measures Functional independence (90-day modified Rankin Scale score, 0-2) was the primary outcome. Symptomatic intracerebral hemorrhage, mortality, and time metrics were also compared between the DTA and repeated imaging groups. Results A total of 1140 patients with LVO received EVT after transfer, including 327 (28.7%) in the DTA group and 813 (71.3%) in the repeated imaging group. The median age was 69 (interquartile range [IQR], 59-78) years; 529 were female (46.4%) and 609 (53.4%) were male. Patients undergoing DTA had greater use of intravenous alteplase (200 of 327 [61.2%] vs 412 of 808 [51.0%]; P = .002), but otherwise groups were similar. Median time from EVT center arrival to groin puncture was faster with DTA (34 [IQR, 20-62] vs 60 [IQR, 37-95] minutes; P < .001), overall and in both regular and on-call hours. Three-month functional independence was higher with DTA overall (164 of 312 [52.6%] vs 282 of 763 [37.0%]; adjusted odds ratio [aOR], 1.85 [95% CI, 1.33-2.57]; P < .001) and during regular (77 of 143 [53.8%] vs 118 of 292 [40.4%]; P = .008) and on-call (87 of 169 [51.5%] vs 164 of 471 [34.8%]; P < .001) hours. The results did not vary by time window (0-6 vs >6 to 24 hours; P = .88 for interaction). Three-month mortality was lower with DTA (53 of 312 [17.0%] vs 186 of 763 [24.4%]; P = .008). A 10-minute increase in EVT-center arrival to groin puncture in the repeated imaging group correlated with 5% reduction in the functional independence odds (aOR, 0.95 [95% CI, 0.91-0.99]; P = .01). The rates of modified Rankin Scale score of 0 to 2 decreased with interfacility transfer times of greater than 3 hours in the DTA group (96 of 161 [59.6%] vs 15 of 42 [35.7%]; P = .006), but not in the repeated imaging group (75 of 208 [36.1%] vs 71 of 192 [37.0%]; P = .85). Conclusions and Relevance The DTA approach may be associated with faster treatment and better functional outcomes during all hours and treatment windows, and repeated imaging may be reasonable with prolonged transfer times. Optimal EVT workflow in transfers may be associated with faster, safe reperfusion with improved outcomes.
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Affiliation(s)
- Amrou Sarraj
- Department of Neurology, The University of Texas McGovern Medical School, Houston
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis.,Department of Neurology, Semmes Murphy Clinic, Memphis, Tennessee
| | - Michael Chen
- Department of Neurology, Rush University Medical Center, Chicago, Illinois
| | - James C Grotta
- Memorial Hermann Hospital Texas Medical Center, Clinical Institute for Research and Innovation, Houston
| | - Spiros Blackburn
- Department of Neurosurgery, The University of Texas McGovern Medical School, Houston
| | - Manuel Requena
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Haris Kamal
- Department of Neurosurgery, Westchester Medical Center, New York, New York
| | - Michael G Abraham
- Department of Neurology, University of Kansas Medical Center, Kansas City
| | - Lucas Elijovich
- Department of Neurology, University of Tennessee Health Science Center, Memphis.,Department of Neurology, Semmes Murphy Clinic, Memphis, Tennessee
| | - Mark Dannenbaum
- Department of Neurosurgery, The University of Texas McGovern Medical School, Houston
| | - Osman Mir
- Department of Radiology, New York University, New York
| | - Wondwossen G Tekle
- Department of Neurology, The University of Texas Rio Grande Valley, Harlingen
| | - Deep Pujara
- Department of Neurology, The University of Texas McGovern Medical School, Houston
| | - Faris Shaker
- Department of Neurology, The University of Texas McGovern Medical School, Houston
| | - Chunyan Cai
- Center for Clinical and Translational Science, The University of Texas at Houston
| | - Laith Maali
- Department of Neurology, University of Kansas Medical Center, Kansas City
| | - Yazan Radaideh
- Department of Neurology, Rush University Medical Center, Chicago, Illinois
| | | | | | - Bader Alenzi
- Department of Neurology, St Vincent Mercy Health Medical Center, Toledo, Ohio
| | | | - Jonathan Greco
- Department of Neurology, The University of Texas McGovern Medical School, Houston
| | - Daniel Hoit
- Department of Neurology, Semmes Murphy Clinic, Memphis, Tennessee
| | - Sheryl B Martin-Schild
- Department of Neurology, Touro Infirmary and New Orleans East Hospital, Metairie, Louisiana
| | - Sarah Song
- Department of Neurology, Rush University Medical Center, Chicago, Illinois
| | - Clark Sitton
- Department of Radiology, The University of Texas McGovern Medical School, Houston
| | - Georgios K Tsivgoulis
- Department of Neurology, University of Tennessee Health Science Center, Memphis.,Second Department of Neurology, National and Kapodistrian University of Athens, Athens, Greece
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis
| | - Adam S Arthur
- Department of Neurology, University of Tennessee Health Science Center, Memphis.,Department of Neurology, Semmes Murphy Clinic, Memphis, Tennessee
| | - Arthur L Day
- Department of Neurosurgery, The University of Texas McGovern Medical School, Houston
| | - Ameer E Hassan
- Department of Neurology, The University of Texas Rio Grande Valley, Harlingen
| | - Marc Ribo
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
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Natera-Villalba E, Cruz-Culebras A, García-Madrona S, Vera-Lechuga R, de Felipe-Mimbrera A, Matute-Lozano C, Gómez-López A, Ros-Castelló V, Sánchez-Sánchez A, Martínez-Poles J, Nedkova-Hristova V, Escribano-Paredes JB, García-Bermúdez I, Méndez J, Fandiño E, Masjuan J. Mechanical thrombectomy beyond 6 hours in acute ischaemic stroke with large vessel occlusion in the carotid artery territory: experience at a tertiary hospital. NEUROLOGÍA (ENGLISH EDITION) 2021; 38:236-245. [PMID: 34092537 DOI: 10.1016/j.nrleng.2020.08.013] [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: 02/04/2020] [Accepted: 08/04/2020] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Thrombectomy in the carotid artery territory was recently shown to be effective up to 24 hours after symptoms onset. METHODS We conducted a retrospective review of a prospective registry of patients treated at our stroke reference centre between November 2016 and April 2019 in order to assess the safety and effectiveness of mechanical thrombectomy performed beyond 6 hours after symptoms onset in patients with acute ischaemic stroke and large vessel occlusion in the carotid artery territory. RESULTS Data were gathered from 59 patients (55.9% women; median age, 71 years). In 33 cases, stroke was detected upon awakening; 57.6% of patients were transferred from another hospital. Median baseline NIHSS score was 16, and median ASPECTS score was 8, with 94.9% of patients presenting > 50% of salvageable tissue. Satisfactory recanalisation was achieved in 88.1% of patients, beyond 24 hours after onset in 5 cases. At 90 days of follow-up, 67.8% were functionally independent; those who were not were older and presented higher prevalence of atrial fibrillation, greater puncture-to-recanalisation time, and higher NIHSS scores, both at baseline and at discharge. CONCLUSION In our experience, mechanical thrombectomy beyond 6 hours was associated with good 90-day functional outcomes. Age, NIHSS score, puncture-to-recanalisation time, and presence of atrial fibrillation affected functional prognosis. The efficacy of the treatment beyond 24 hours after onset merits study.
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Affiliation(s)
- E Natera-Villalba
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain.
| | - A Cruz-Culebras
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - S García-Madrona
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - R Vera-Lechuga
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - A de Felipe-Mimbrera
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - C Matute-Lozano
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - A Gómez-López
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - V Ros-Castelló
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - A Sánchez-Sánchez
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - J Martínez-Poles
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - V Nedkova-Hristova
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - J B Escribano-Paredes
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - I García-Bermúdez
- Servicio de Radiología, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - J Méndez
- Servicio de Radiología, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - E Fandiño
- Servicio de Radiología, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - J Masjuan
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, Spain; Servicio de Neurología, Hospital Ramón y Cajal, Departamento de Medicina, Facultad de Medicina, Universidad de Alcalá, IRYCIS, Madrid, Spain
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MacKenzie IER, Arusoo T, Sigounas D. Impact of Direct Admission Versus Interfacility Transfer on Endovascular Treatment Outcomes for Acute Ischemic Stroke: Systematic Review and Meta-Analysis. World Neurosurg 2021; 152:e387-e397. [PMID: 34087463 DOI: 10.1016/j.wneu.2021.05.106] [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: 04/15/2021] [Revised: 05/22/2021] [Accepted: 05/24/2021] [Indexed: 10/21/2022]
Abstract
BACKGROUND Mechanical thrombectomy is a proven treatment for large-vessel ischemic stroke with improved functional outcomes compared with intravenous thrombolytics. Access to thrombectomy-capable sites varies greatly by geography, often necessitating interhospital transfer of patients who first present to hospitals unable to provide thrombectomy. The purpose of this meta-analysis was to examine the impact of interhospital transportation on patient outcomes to better inform recommendations for prehospital protocols. METHODS A meta-analysis was performed following systematic literature searches. Outcomes of interest included successful reperfusion, symptomatic intracranial hemorrhage, 90-day modified Rankin Scale score 0-2, 90-day mortality, onset-to-puncture times, and door-to-puncture times. RESULTS Pooled analysis comprised >27,000 patients. Door-to-puncture time was 35.6 minutes shorter among transferred patients; however, symptom onset-to-puncture time was 91.6 minutes longer. Rate of reperfusion or symptomatic intracranial hemorrhage as well as 90-day mortality did not differ significantly between transferred and directly admitted patients. While the proportion of patients achieving good functional outcome at 90 days with modified Rankin Scale score 0-2 did not differ by admission type, when modified Rankin Scale score was narrowed to 0-1, direct transport showed 20% greater probability of achieving excellent functional outcome (P < 0.001). CONCLUSIONS This meta-analysis represents the largest pooled population examined to date to assess how interfacility transportation to thrombectomy-capable sites affects patient outcomes. Our results indicate that direct admission is a significant predictor of excellent functional outcome. The findings presented here can be used to better inform quality improvement projects to streamline access to facilities providing endovascular mechanical thrombectomy capabilities.
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Affiliation(s)
- Isobel E R MacKenzie
- George Washington University School of Medicine & Health Sciences, Washington, DC, USA
| | - Toomas Arusoo
- Department of Radiology, George Washington University, Washington, DC, USA
| | - Dimitri Sigounas
- Department of Neurosurgery, George Washington University, Washington, DC, USA.
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16
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Natera-Villalba E, Cruz-Culebras A, García-Madrona S, Vera-Lechuga R, de Felipe-Mimbrera A, Matute-Lozano C, Gómez-López A, Ros-Castelló V, Sánchez-Sánchez A, Martínez-Poles J, Nedkova-Hristova V, Escribano-Paredes JB, García-Bermúdez I, Méndez J, Fandiño E, Masjuan J. Mechanical thrombectomy beyond 6hours in acute ischaemic stroke with large vessel occlusion in the carotid artery territory: Experience at a tertiary hospital. Neurologia 2021; 38:S0213-4853(20)30298-X. [PMID: 33551125 DOI: 10.1016/j.nrl.2020.08.019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Revised: 07/06/2020] [Accepted: 08/04/2020] [Indexed: 11/29/2022] Open
Abstract
INTRODUCTION Thrombectomy in the carotid artery territory was recently shown to be effective up to 24hours after symptoms onset. METHODS We conducted a retrospective review of a prospective registry of patients treated at our stroke reference centre between November 2016 and April 2019 in order to assess the safety and effectiveness of mechanical thrombectomy performed beyond 6hours after symptoms onset in patients with acute ischaemic stroke and large vessel occlusion in the carotid artery territory. RESULTS Data were gathered from 59 patients (55.9% women; median age, 71 years). In 33 cases, stroke was detected upon awakening; 57.6% of patients were transferred from another hospital. Median baseline NIHSS score was 16, and median ASPECTS score was 8, with 94.9% of patients presenting>50% of salvageable tissue. Satisfactory recanalisation was achieved in 88.1% of patients, beyond 24hours after onset in 5 cases. At 90 days of follow-up, 67.8% were functionally independent; those who were not were older and presented higher prevalence of atrial fibrillation, greater puncture-to-recanalisation time, and higher NIHSS scores, both at baseline and at discharge. CONCLUSION In our experience, mechanical thrombectomy beyond 6hours was associated with good 90-day functional outcomes. Age, NIHSS score, puncture-to-recanalisation time, and presence of atrial fibrillation affected functional prognosis. The efficacy of the treatment beyond 24hours after onset merits study.
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Affiliation(s)
- E Natera-Villalba
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España.
| | - A Cruz-Culebras
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - S García-Madrona
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - R Vera-Lechuga
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - A de Felipe-Mimbrera
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - C Matute-Lozano
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - A Gómez-López
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - V Ros-Castelló
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - A Sánchez-Sánchez
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - J Martínez-Poles
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - V Nedkova-Hristova
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - J B Escribano-Paredes
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España
| | - I García-Bermúdez
- Servicio de Radiología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - J Méndez
- Servicio de Radiología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - E Fandiño
- Servicio de Radiología, Hospital Universitario Ramón y Cajal, Madrid, España
| | - J Masjuan
- Servicio de Neurología, Unidad de Ictus, Hospital Universitario Ramón y Cajal, Madrid, España; Servicio de Neurología, Hospital Ramón y Cajal, Departamento de Medicina, Facultad de Medicina, Universidad de Alcalá, IRYCIS, Madrid, España
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Shigeta K, Ota T, Kaneko J, Sato K, Aoki R, Jimbo H, Sato Y, Kuroshima Y, Shiokawa Y, Hirano T. Negative impact of Interhospital Transfer on Clinical Outcomes of Mechanical Thrombectomy for Fast Progressive Stroke. J Stroke Cerebrovasc Dis 2021; 30:105633. [PMID: 33517031 DOI: 10.1016/j.jstrokecerebrovasdis.2021.105633] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Revised: 11/04/2020] [Accepted: 01/16/2021] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES The time-dependence of the clinical outcome of mechanical thrombectomy is higher in the "fast progressor" in whom cerebral ischemia progresses rapidly. The impact of time-consuming interhospital transfer (IT) on the clinical outcome of such patients is unknown. The effect on clinical outcomes of IT of fast progressors was investigated. METHODS Among the patients enrolled in the Tokyo/Tama REgistry of Acute endovascular Thrombectomy, fast progressor cerebral ischemia cases were retrospectively investigated. In this study, a fast progressor was defined as a case with an Alberta Stroke Program Early CT Score less than 6 and last known well (LKW) to arterial puncture within 6 h. Patients' background characteristics, treatment progress, and the modified Rankin Scale (mRS) score at 3 months were examined. RESULTS Of a total of 1182 patients, 92 (7.8%) were included, with 76 patients in the direct transfer (DT) group, and 16 patients in the IT group. Median LKW to reperfusion was 190 min and 272 min, respectively (P<.001). The number of patients with mRS scores 0-2 at three months was 22 (28.9%) in the DT group and 1 (6.2%) in the IT group. Interhospital transfer was an independent factor associated with worse outcomes (odds ratio 0.08, 95% confidence interval 0.01-0.87, P=.038). CONCLUSION This study showed that, among fast progressor patients, the IT group had a worse prognosis than the DT group. To provide good clinical outcomes for fast progressor patients, those who are likely to undergo mechanical thrombectomy should be sent directly to a thrombectomy-capable center.
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Affiliation(s)
- Keigo Shigeta
- Department of Neurosurgery, National Hospital Organization Disaster Medical Center, 3256, Midorhicho, Tachikawa, Tokyo 190-0014, Japan.
| | - Takahiro Ota
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, 2-8-29, Musashidai, Fuchu, Tokyo 183-8524, Japan.
| | - Junya Kaneko
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, 1-7-1 Nagayama, Tama, Tokyo 206-8512, Japan
| | - Katsuya Sato
- Department of Neurosurgery, Showa General Hospital, 8-1-1 Hanakoganei, Kodaira, Tokyo 187-8510, Japan.
| | - Rie Aoki
- Department of Neurosurgery, Tokai University Hachioji Hospital, 1838 Ishikawamachi, Hachioji, Tokyo 192-0032, Japan.
| | - Hiroyuki Jimbo
- Department of Neurosurgery, Tokyo Medical University Hachioji Medical Center, 1163 Tatemachi, Hachioji, Tokyo 193-0998, Japan.
| | - Yohei Sato
- Department of Neurosurgery, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonancho, Musashino, Tokyo 180-8610, Japan.
| | - Yoshiaki Kuroshima
- Department of Neurosurgery, Hino Municipal Hospital, 4-3-1 Tamadaira, Hino, Tokyo 191-0062, Japan
| | - Yoshiaki Shiokawa
- Department of Neurosurgery, Kyorin University, 6-20-2, Shinkawa, Mitaka, Tokyo 181-8611, Japan.
| | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, 6-20-2, Shinkawa, Mitaka, Tokyo 181-8611, Japan.
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18
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Candelario-Jalil E, Paul S. Impact of aging and comorbidities on ischemic stroke outcomes in preclinical animal models: A translational perspective. Exp Neurol 2021; 335:113494. [PMID: 33035516 PMCID: PMC7874968 DOI: 10.1016/j.expneurol.2020.113494] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2020] [Revised: 09/25/2020] [Accepted: 10/02/2020] [Indexed: 12/16/2022]
Abstract
Ischemic stroke is a highly complex and devastating neurological disease. The sudden loss of blood flow to a brain region due to an ischemic insult leads to severe damage to that area resulting in the formation of an infarcted tissue, also known as the ischemic core. This is surrounded by the peri-infarct region or penumbra that denotes the functionally impaired but potentially salvageable tissue. Thus, the penumbral tissue is the main target for the development of neuroprotective strategies to minimize the extent of ischemic brain damage by timely therapeutic intervention. Given the limitations of reperfusion therapies with recombinant tissue plasminogen activator or mechanical thrombectomy, there is high enthusiasm to combine reperfusion therapy with neuroprotective strategies to further reduce the progression of ischemic brain injury. Till date, a large number of candidate neuroprotective drugs have been identified as potential therapies based on highly promising results from studies in rodent ischemic stroke models. However, none of these interventions have shown therapeutic benefits in stroke patients in clinical trials. In this review article, we discussed the urgent need to utilize preclinical models of ischemic stroke that more accurately mimic the clinical conditions in stroke patients by incorporating aged animals and animal stroke models with comorbidities. We also outlined the recent findings that highlight the significant differences in stroke outcome between young and aged animals, and how major comorbid conditions such as hypertension, diabetes, obesity and hyperlipidemia dramatically increase the vulnerability of the brain to ischemic damage that eventually results in worse functional outcomes. It is evident from these earlier studies that including animal models of aging and comorbidities during the early stages of drug development could facilitate the identification of neuroprotective strategies with high likelihood of success in stroke clinical trials.
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Affiliation(s)
- Eduardo Candelario-Jalil
- Department of Neuroscience, McKnight Brain Institute, University of Florida, Gainesville, FL 32610, USA.
| | - Surojit Paul
- Department of Neurology, University of New Mexico Health Sciences Center, Albuquerque, NM 87131, USA
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19
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Abstract
BACKGROUND AND PURPOSE Severity-based assessment tools may assist in prehospital triage of patients to comprehensive stroke centers (CSCs) for endovascular thrombectomy (EVT), but criticisms regarding diagnostic inaccuracy have not been adequately addressed. This study aimed to quantify the benefits and disadvantages of severity-based triage in a large real-world paramedic validation of the Ambulance Clinical Triage for Acute Stroke Treatment (ACT-FAST) algorithm. METHODS Ambulance Victoria paramedics assessed the prehospital ACT-FAST algorithm in patients with suspected stroke from November 2017 to July 2019 following an 8-minute training video. All patients were transported to the nearest stroke center as per current guidelines. ACT-FAST diagnostic accuracy was compared with hospital imaging for the presence of large vessel occlusion (LVO) and need for CSC-level care (LVO, intracranial hemorrhage, and tumor). Patient-level time saving to EVT was modeled using a validated Google Maps algorithm. Disadvantages of CSC bypass examined potential thrombolysis delays in non-LVO infarcts, proportion of patients with false-negative EVT, and CSC overburdening. RESULTS Of 517 prehospital assessments, 168/517 (32.5%) were ACT-FAST positive and 132/517 (25.5%) had LVO. ACT-FAST sensitivity and specificity for LVO was 75.8% and 81.8%, respectively. Positive predictive value was 58.8% for LVO and 80.0% when intracranial hemorrhage and tumor (CSC-level care) were included. Within the metropolitan region, 29/55 (52.7%) of ACT-FAST-positive patients requiring EVT underwent a secondary interhospital transfer. Prehospital bypass with avoidance of secondary transfers was modeled to save 52 minutes (95% CI, 40.0-61.5) to EVT commencement. ACT-FAST was false-positive in 8 patients receiving thrombolysis (8.1% of 99 non-LVO infarcts) and false-negative in 4 patients with EVT requiring secondary transfer (5.4% of 74 EVT cases). CSC bypass was estimated to over-triage 1.1 patients-per-CSC-per-week in our region. CONCLUSIONS The overall benefits of an ACT-FAST algorithm bypass strategy in expediting EVT and avoiding secondary transfers are estimated to substantially outweigh the disadvantages of potentially delayed thrombolysis and over-triage, with only a small proportion of EVT patients missed.
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20
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Menon BK, Ospel JM, McTaggart RA, Nogueira RG, Demchuk AM, Poppe A, Rempel JL, Zerna C, Joshi M, Almekhlafi MA, Field TS, Dowlatshahi D, van Adel BA, Sauvageau E, Tarpley J, Moreira T, Bang OY, Heck D, Psychogios MN, Tymianski M, Hill MD, Goyal M. Imaging criteria across pivotal randomized controlled trials for late window thrombectomy patient selection. J Neurointerv Surg 2020; 13:neurintsurg-2020-016902. [PMID: 33239306 DOI: 10.1136/neurintsurg-2020-016902] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Revised: 10/29/2020] [Accepted: 10/30/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND The DAWN and DEFUSE-3 trials showed the benefit of endovascular treatment (EVT) in acute ischemic stroke patients presenting beyond 6 hours from last known well (LKW) and selected by perfusion imaging criteria. The ESCAPE NA1-trial selected patients based on non-contrast CT (NCCT) Alberta Stroke Program Early CT Score (ASPECTS) and multiphase CT angiography (CTA) collateral status. This study compares baseline characteristics, workflow, and outcomes in the EVT arms of DAWN and DEFUSE-3 with late-window patients from the EVT-only arm of ESCAPE-NA1. METHODS Aggregate data on baseline characteristics, workflow, reperfusion quality, final infarct volume, and clinical outcomes (modified Rankin Score [mRS] at 90 days) in subjects enrolled in the DAWN and DEFUSE-3 EVT arms were compared with similar data from the ESCAPE-NA1 control arm (EVT-only arm) presenting beyond 6 hours from LKW using descriptive statistics. RESULTS Baseline characteristics among late-window patients in the ESCAPE NA1 trial were similar to those in the DAWN and DEFUSE-3 EVT arms. Median time from LKW-to-puncture in subjects enrolled in the ESCAPE NA1 trial was 9 hrs (IQR: 7.5-11 hours) when compared with DAWN (n=107; 12.8 hours, IQR: 10.6-16.7 hours) and DEFUSE-3 (n=92; 11.5 hours, IQR: 9.2-12.8 hours). Median post-treatment infarct-volume was largest in the ESCAPE NA1-patients (47 mL [IQR: 19-146] vs median 8 mL [IQR: 0-48] in the DAWN group and 35 mL [IQR: 18-82] in DEFUSE-3), while % mRS 0-2 at 90 days were similar across the three trials (ESCAPE NA1: 50/111 [45%], DAWN: 52/107 [49%], DEFUSE-3: 41/92 [45%]). CONCLUSION Patients enrolled beyond 6 hours from LKW in the ESCAPE-NA1 trial based on NCCT-ASPECTS and mCTA had similar clinical outcomes when compared with patients selected by perfusion imaging in the DAWN and DEFUSE-3 trials.
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Affiliation(s)
- Bijoy K Menon
- Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Johanna Maria Ospel
- Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Ryan A McTaggart
- Warren Alpert School of Medicine & Brown University, Providence, Rhode Island, USA
| | - Raul G Nogueira
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Andrew M Demchuk
- Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Alexandre Poppe
- Department of Neurology/ Neurosciences, Universite de Montreal, Montreal, Quebec, Canada
| | - Jeremy L Rempel
- Department of Radiology, University of Alberta, Edmonton, Alberta, Canada
| | - Charlotte Zerna
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Manish Joshi
- Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| | - Mohammed A Almekhlafi
- Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Thalia S Field
- Neurology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Dariush Dowlatshahi
- Neurology, University of Ottawa Faculty of Medicine, Ottawa, Ontario, Canada
| | | | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Hospital, Jacksonville, Florida, USA
| | - Jason Tarpley
- Vascular Neurology, Providence Saint John's Health Center and The Pacific Neuroscience Institute, Torrance, California, USA
| | - Tiago Moreira
- Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Oh Young Bang
- Department of Neurology, Samsung Medical Center, Seoul, Republic of Korea
| | - Don Heck
- Radiology, Forsyth Medical Center, Winston Salem, North Carolina, USA
| | - Marios N Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | | | - Michael D Hill
- Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Mayank Goyal
- Calgary Stroke Program, University of Calgary, Calgary, Alberta, Canada
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
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21
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Gangadharan S, Lillicrap T, Miteff F, Garcia-Bermejo P, Wellings T, O'Brien B, Evans J, Alanati K, Levi C, Parsons MW, Bivard A, Garcia-Esperon C, Spratt NJ. Air vs. Road Decision for Endovascular Clot Retrieval in a Rural Telestroke Network. Front Neurol 2020; 11:628. [PMID: 32765396 PMCID: PMC7380106 DOI: 10.3389/fneur.2020.00628] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2020] [Accepted: 05/28/2020] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: Telestroke aims to increase access to endovascular clot retrieval (ECR) for rural areas. There is limited information on transfer workflow for ECR in rural settings. We sought to describe the transfer metrics for ECR in a rural telestroke network with respect to decision making. Methods: A retrospective cohort study was employed on consecutive patients transferred to the comprehensive stroke center (CSC) for ECR in a rural hub-and-spoke telestroke network between April 2013 and October 2019, by road or air. Key time-based metrics were analyzed. Results: Sixty-two patients were included. Mean age was 66 years [standard deviation (SD), 14] and median National Institutes of Health Stroke Scale 13 [interquartile range (IQR), 8–18]. Median rural-hospital-door-to-CSC-door (D2D) was 308 min (IQR, 254–351), of which 68% was spent at rural hospitals [door-in-door-out (DIDO); 214 min; IQR, 171–247]. DIDO was longer for air transfers than road (P = 0.004), primarily because of a median 87 min greater decision-to-departure time (Decision-DO, P < 0.001). In multiple linear regression analysis, intubation but not thrombolysis was associated with significantly longer DIDO. The distance at which the extra speed of an aircraft made up for the delays involved in booking an aircraft was 299 km from the CSC. Conclusions: DIDO is longer for air retrievals compared with road. Decision-DO represents the most important component of DIDO, being longer for air transfers. Systems for rapid transportation of rural ECR candidates need optimization for best patient outcomes, with decision support seen as a potential tool to achieve this.
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Affiliation(s)
- Shyam Gangadharan
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Thomas Lillicrap
- Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Ferdinand Miteff
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia.,Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Pablo Garcia-Bermejo
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Thomas Wellings
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Billy O'Brien
- Department of Neurology, Gosford Hospital, Gosford, NSW, Australia
| | - James Evans
- Department of Neurology, Gosford Hospital, Gosford, NSW, Australia
| | - Khaled Alanati
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Christopher Levi
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia.,Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Mark W Parsons
- Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia.,Department of Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Andrew Bivard
- Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia.,Department of Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Carlos Garcia-Esperon
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia.,Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Neil J Spratt
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia.,Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
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Zhao W, Ma P, Chen J, Yue X. Direct admission versus secondary transfer for acute ischemic stroke patients treated with thrombectomy: a systematic review and meta-analysis. J Neurol 2020; 268:3601-3609. [PMID: 32494852 DOI: 10.1007/s00415-020-09877-2] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2020] [Revised: 04/28/2020] [Accepted: 04/29/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND AND PURPOSE Randomized controlled trials have demonstrated that mechanical thrombectomy (MT) could provide more benefit than standard medical care for acute ischemic stroke (AIS) patients due to emergent large vessel occlusion. However, most primary stroke centers (PSCs) are unable to perform MT, and MT can only be performed in comprehensive stroke centers (CSCs) with on-site interventional neuroradiologic services. Therefore, there is an ongoing debate regarding whether patients with suspected AIS should be directly admitted to CSCs or secondarily transferred to CSCs from PSCs. This meta-analysis was aimed to investigate the two transportation paradigms of direct admission and secondary transfer, which one could provide more benefit for AIS patients treated with MT. METHODS We conducted a systematic review and meta-analysis through searching PubMed, Embase and the Cochrane Library database up to March 2020. Primary outcomes are as follows: symptomatic intracerebral hemorrhage (sICH) within 7 days; favorable functional outcome at 3 months; mortality in hospital; mortality at 3 months; and successful recanalization rate. RESULTS Our pooled results showed that patients directly admitted to CSCs had higher chances of achieving a favorable functional outcome at 3 months than those secondarily transferred to CSCs (OR = 1.26; 95% CI, 1.12-1.42; P < 0.001). In addition, no significant difference was found between the two transportation paradigms in the rate of sICH (OR = 0.86; 95% CI, 0.62-1.18; P = 0.35), mortality in hospital (OR = 0.84; 95% CI, 0.51-1.39; P = 0.51), mortality at 3 months (OR = 1.01; 95% CI, 0.85-1.21; P = 0.91), and successful recanalization (OR = 1.03; 95% CI, 0.88-1.20; P = 0.74). However, in the 100% bridging thrombolysis usage rate subgroup, our subgroup analysis indicated that no difference was found in any outcome between the two transportation paradigms. CONCLUSION Patients with AIS directly admitted to CSCs for MT may be a feasible transportation paradigm for AIS patients. However, more large-scale randomized prospective trials are required to further investigate this issue.
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Affiliation(s)
- Weisong Zhao
- Department of Pediatrics, The First Clinic College of Xinxiang Medical University, Xinxiang, 453000, Henan, China
| | - Pengju Ma
- Department of Neurosurgery, The First Affiliated Hospital of Xinxiang Medical University, Xinxiang, 453000, Henan, China
| | - Jinbao Chen
- Department of Pediatrics, The First Clinic College of Xinxiang Medical University, Xinxiang, 453000, Henan, China
| | - Xuejing Yue
- School of Basic Medicine, Xinxiang Medical University, No.601 Jinsui Avenue, Xinxiang, 453000, China.
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Delayed Thrombectomy Center Arrival is Associated with Decreased Treatment Probability. Can J Neurol Sci 2020; 47:770-774. [PMID: 32418553 DOI: 10.1017/cjn.2020.95] [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: 11/07/2022]
Abstract
BACKGROUND Endovascular thrombectomy (EVT) is effective in reducing disability in selected patients with stroke and large vessel occlusion (LVO), but access to this treatment is suboptimal. AIM We examined the proportion of patients with LVO who did not receive EVT, the reasons for non-treatment, and the association between time from onset and probability of treatment. METHODS We conducted a retrospective cohort study of consecutive patients with acute stroke and LVO presenting between January 2017 and June 2018. We used multivariable log-binomial models to determine the association between time and probability of treatment with and without adjustment for age, sex, dementia, active cancer, baseline disability, stroke severity, and evidence of ischemia on computerized tomography. RESULTS We identified 256 patients (51% female, median age 74 [interquartile range, IQR 63.5, 82.5]), of whom 59% did not receive EVT. The main reasons for not treating with EVT were related to occlusion characteristics or infarct size. The median time from onset to EVT center arrival was longer among non-treated patients (218 minutes [142, 302]) than those who were treated (180 minutes [104, 265], p = 0.03). Among patients presenting within 6 hours of onset, the relative risk (RR) of receiving EVT decreased by 3% with every 10-minute delay in arrival to EVT center (adjusted RR 0.97 CI95 [0.95, 0.99]). This association was not found in the overall cohort. CONCLUSIONS The proportion of patients with acute stroke and confirmed LVO who do not undergo EVT is substantial. Minimizing delays in arrival to EVT center may optimize the delivery of this treatment.
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