1
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Ademola A, Bala F, Menon BK, Thornton J, Casetta I, Nannoni S, Goyal M, Herlihy D, Fainardi E, Power S, Saia V, Hegarty A, Pracucci G, Demchuk A, Mangiafico S, Boyle K, Michel P, Hildebrand KA, Sajobi TT, Hill MD, Toni D, Murphy S, Kim BJ, Almekhlafi MA. Workflow and Outcome of Thrombectomy in Late Time Window: A Pooled Multicenter Analysis. Can J Neurol Sci 2024:1-7. [PMID: 38639107 DOI: 10.1017/cjn.2024.60] [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: 04/20/2024]
Abstract
BACKGROUND We investigated the impact of workflow times on the outcomes of patients treated with endovascular thrombectomy (EVT) in the late time window. METHODS Individual patients' data who underwent EVT in the late time window (onset to imaging >6 hours) were pooled from seven registries and randomized clinical trials. Multiple time intervals were analyzed. Mixed-effects logistic regression was used to estimate the likelihood of functional independence at 90 days (modified Rankin Scale 0-2). Mixed-effects negative binomial regression was used to evaluate the relationship between patient characteristics and workflow time intervals. RESULTS 608 patients were included. The median age was 70 years (IQR: 58-71), 307 (50.5%) were female, and 310 (53.2%) had wake-up strokes. Successful reperfusion was achieved in 493 (81.2%) patients, and 262 (44.9%) achieved 90-day mRS 0-2. The estimated odds of functional independence decreased by 13% for every 30 minute delay from emergency department (ED) arrival to imaging time and by 7% from ED arrival to the end of EVT in the entire cohort. Also, the estimated odds of functional independence decreased by 33% for every 30 minute delay in the interval from arterial puncture to end of EVT, 16% in the interval from arrival in ED to end of EVT and 6% in the interval from stroke onset to end of EVT among patients who had a wake-up stroke. CONCLUSION Faster workflow from ED arrival to end of EVT is associated with improved functional independence among stroke patients treated in the late window.
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Affiliation(s)
- Ayoola Ademola
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- McCaig Institute of Bone and Joint, University of Calgary, Calgary, Canada
| | - Fouzi Bala
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Bijoy K Menon
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - John Thornton
- Neuroradiology Department, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ilaria Casetta
- Clinica Neurologica, University of Ferrara, Ferrara, Italy
| | - Stefania Nannoni
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
| | - Darragh Herlihy
- Neuroradiology Department, Beaumont Hospital, Dublin, Ireland
| | - Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Firenze, Italy
| | - Sarah Power
- Neuroradiology Department, Beaumont Hospital, Dublin, Ireland
| | - Valentina Saia
- Stroke Unit, Santa Corona Hospital, Pietra Ligure, Italy
| | - Aidan Hegarty
- Neuroradiology Department, Beaumont Hospital, Dublin, Ireland
| | | | - Andrew Demchuk
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
| | | | - Karl Boyle
- Department of Geriatric and Stroke Medicine, Beaumont Hospital, Dublin, Ireland
| | - Patrik Michel
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Kevin A Hildebrand
- McCaig Institute of Bone and Joint, University of Calgary, Calgary, Canada
- Department of Surgery, University of Calgary, Calgary, Canada
| | - Tolulope T Sajobi
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Michael D Hill
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
| | - Danilo Toni
- Emergency Department, Stroke Unit, Sapienza University Hospital, Rome, Italy
| | - Sean Murphy
- Department of Geriatric and Stroke Medicine, The Mater Misericordiae University Hospital, Dublin, Ireland
- School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Beom Joon Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Korea
| | - Mohammed A Almekhlafi
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
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2
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Meinel TR, Kaesmacher J, Buetikofer L, Strbian D, Eker OF, Cognard C, Mordasini P, Deppeler S, Mendes Pereira V, Albucher JF, Darcourt J, Bourcier R, Guillon B, Papagiannaki C, Costentin G, Sibolt G, Räty S, Gory B, Richard S, Liman J, Ernst M, Boulanger M, Barbier C, Mechtouff L, Zhang L, Marnat G, Sibon I, Nikoubashman O, Reich A, Consoli A, Weisenburger D, Requena M, Garcia-Tornel A, Saleme S, Moulin S, Pagano P, Saliou G, Carrera E, Janot K, Boix M, Pop R, Della Schiava L, Luft A, Piotin M, Gentric JC, Pikula A, Pfeilschifter W, Arnold M, Siddiqui A, Froehler MT, Furlan AJ, Chapot R, Wiesmann M, Machi P, Diener HC, Kulcsar Z, Bonati L, Bassetti C, Escalard S, Liebeskind D, Saver JL, Fischer U, Gralla J. Time to treatment with bridging intravenous alteplase before endovascular treatment:subanalysis of the randomized controlled SWIFT-DIRECT trial. J Neurointerv Surg 2023; 15:e102-e110. [PMID: 35902234 DOI: 10.1136/jnis-2022-019207] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Accepted: 07/13/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND We hypothesized that treatment delays might be an effect modifier regarding risks and benefits of intravenous thrombolysis (IVT) before mechanical thrombectomy (MT). METHODS We used the dataset of the SWIFT-DIRECT trial, which randomized 408 patients to IVT+MT or MT alone. Potential interactions between assignment to IVT+MT and expected time from onset-to-needle (OTN) as well as expected time from door-to-needle (DTN) were included in regression models. The primary outcome was functional independence (modified Rankin Scale (mRS) 0-2) at 3 months. Secondary outcomes included mRS shift, mortality, recanalization rates, and (symptomatic) intracranial hemorrhage at 24 hours. RESULTS We included 408 patients (IVT+MT 207, MT 201, median age 72 years (IQR 64-81), 209 (51.2%) female). The expected median OTN and DTN were 142 min and 54 min in the IVT+MT group and 129 min and 51 min in the MT alone group. Overall, there was no significant interaction between OTN and bridging IVT assignment regarding either the functional (adjusted OR (aOR) 0.76, 95% CI 0.45 to 1.30) and safety outcomes or the recanalization rates. Analysis of in-hospital delays showed no significant interaction between DTN and bridging IVT assignment regarding the dichotomized functional outcome (aOR 0.48, 95% CI 0.14 to 1.62), but the shift and mortality analyses suggested a greater benefit of IVT when in-hospital delays were short. CONCLUSIONS We found no evidence that the effect of bridging IVT on functional independence is modified by overall or in-hospital treatment delays. Considering its low power, this subgroup analysis could have missed a clinically important effect, and exploratory analysis of secondary clinical outcomes indicated a potentially favorable effect of IVT with shorter in-hospital delays. Heterogeneity of the IVT effect size before MT should be further analyzed in individual patient meta-analysis of comparable trials. TRIAL REGISTRATION NUMBER URL: https://www. CLINICALTRIALS gov ; Unique identifier: NCT03192332.
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Affiliation(s)
- Thomas R Meinel
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | | | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Omer Faruk Eker
- Department of Neuroradiology, Hospices Civils de Lyon, Lyon, France
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Pasquale Mordasini
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Sandro Deppeler
- Neuro Clinical Trial Unit, Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Vitor Mendes Pereira
- Division of Neuroradiology and Division of Neurosurgery, Departments of Medical Imaging and Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
| | | | - Jean Darcourt
- Department of Neuroradiology, Hospices Civils de Lyon, Lyon, France
| | - Romain Bourcier
- Department of Diagnostic and Interventional Neuroradiology, Centre Hospitalier Universitaire de Nantes, Nantes Université, Nantes, France
| | - Benoit Guillon
- Department of Neurology, Centre Hospitalier Universitaire de Nantes, Nantes Université, Nantes, France
| | | | | | - Gerli Sibolt
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Silja Räty
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, CHRU-Nancy, Université de Lorraine, INSERM U1254, Nancy, France
| | - Sébastien Richard
- Department of Neurology, Stroke Unit, CHRU-Nancy, Université de Lorraine, INSERM U1116, Nancy, France
| | - Jan Liman
- Department of Neurology, Klinikum Nürnberg, Nürnberg, Germany
| | - Marielle Ernst
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Göttingen, Gottingen, Germany
| | - Marion Boulanger
- Deparment of Neurology, CHU Caen Normandie, University Caen Normandie, INSERM U1237, Caen, France
| | - Charlotte Barbier
- Department of Neuroradiology, CHU Caen Normandie, University Caen Normandie, INSERM U1237, Caen, France
| | - Laura Mechtouff
- Department of Vascular Neurology, Hospices Civils de Lyon, Lyon, France
| | - Liqun Zhang
- Department of Neurology, St George's University Hospital NHS Foundation Trust, London, UK
| | - Gaultier Marnat
- Department of Interventional and Diagnostic Neuroradiology, CHU Bordeaux, University of Bordeaux, Bordeaux, France
| | - Igor Sibon
- Stroke Unit, CHU Bordeaux, University of Bordeaux, Bordeaux, France
| | - Omid Nikoubashman
- Department of Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Arno Reich
- Department of Neurology, University Hospital RWTH Aachen, Aachen, Germany
| | - Arturo Consoli
- Department of Stroke and Diagnostic and Interventional Neuroradiology, Foch Hospital, Suresnes, France
| | - David Weisenburger
- Department of Stroke and Diagnostic and Interventional Neuroradiology, Foch Hospital, Suresnes, France
| | - Manuel Requena
- Stroke Unit, Department of Neurology, Hospital Vall d'Heborn, Barcelona, Spain
- Interventional Neuroradiology, Department of Radiology, Hospital Vall d'Heborn, Barcelona, Spain
| | | | - Suzana Saleme
- Department of Neuroradiology, CHU Limoges, Limoges, France
| | | | - Paolo Pagano
- Department of Neuroradiology, CHU Reims, Reims, France
| | - Guillaume Saliou
- Service of Interventional and Diagnostic Radiology, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - Emmanuel Carrera
- Department of Neurology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Kevin Janot
- Department of Diagnostic and Interventional Neuroradiology, Tours University Hospital, Tours, France
| | - Marti Boix
- Stroke Unit, Department of Neurosciences, University Hospital Germans Trias i Pujol, Barcelona, Spain
| | - Raoul Pop
- Department of Interventional Neuroradiology, Strasbourg University Hospitals, Strasbourg, France
| | | | - Andreas Luft
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
- Department of Neurology, Cereneo, Center for Neurology and Rehabilitation, Vitznau, Switzerland
| | - Michel Piotin
- Department of interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France
| | | | - Aleksandra Pikula
- Department of Neurology, University Health Network - Toronto Western Hospital - University of Toronto, Toronto, Ontario, Canada
| | | | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Adnan Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York, USA
| | - Michael T Froehler
- Vanderbilt Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Anthony J Furlan
- School of Medicine, Case Western Reserve University, Cleveland, Ohio, USA
| | - René Chapot
- Department of Intracranial Endovascular Therapy, Alfried-Krupp Krankenhaus, Essen, Germany
| | - Martin Wiesmann
- Department of Neuroradiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Paolo Machi
- Department of Neuroradiology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Hans-Christoph Diener
- Department of Neuroepidemiology, Institute for Medical Informatics, Biometry and Epidemiology (IMIBE), Essen, Germany
| | - Zsolt Kulcsar
- Department of Neuroradiology, University Hospital of Zurich, Zurich, Switzerland
| | - Leo Bonati
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Claudio Bassetti
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Simon Escalard
- Department of interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France
| | - David Liebeskind
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, UCLA, University of California, Los Angeles, California, USA
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, UCLA, University of California, Los Angeles, California, USA
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
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3
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Taschner CA, Trinks A, Bardutzky J, Brich J, Hartmann R, Urbach H, Niesen WD. Drip-and-Ship for Thrombectomy Treatment in Patients With Acute Ischemic Stroke Leads to Inferior Clinical Outcomes in a Stroke Network Covering Vast Rural Areas Compared to Direct Admission to a Comprehensive Stroke Center. Front Neurol 2021; 12:743151. [PMID: 34790162 PMCID: PMC8591070 DOI: 10.3389/fneur.2021.743151] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2021] [Accepted: 09/27/2021] [Indexed: 11/26/2022] Open
Abstract
Introduction: Organizing regional stroke care considering thrombolysis as well as mechanical thrombectomy (MTE) remains challenging in light of a wide range of regional population distribution. To compare outcomes of patients in a stroke network covering vast rural areas in southwestern Germany who underwent MTE via direct admission to a single comprehensive stroke center [CSC; mothership (MS)] with those of patients transferred from primary stroke centers [PSCs; drip-and-ship (DS)], we undertook this analysis of consecutive stroke patients with MTE. Materials and Methods: Patients who underwent MTE at the CSC between January 2013 and December 2016 were included in the analysis. The primary outcome measure was 90-day functional independence [modified Rankin score (mRS) 0–2]. Secondary outcome measures included time from stroke onset to recanalization/end of MTE, angiographic outcomes, and mortality rates. Results: Three hundred and thirty-two consecutive patients were included (MS 222 and DS 110). Median age was 74 in both arms of the study, and there was no significant difference in baseline National Institutes of Health Stroke Scale scores (median MS 15 vs. 16 DS). Intravenous (IV) thrombolysis (IVT) rates differed significantly (55% MS vs. 70% DS, p = 0.008). Time from stroke onset to recanalization/end of MTE was 112 min shorter in the MS group (median 230 vs. 342 min, p < 0.001). Successful recanalization [thrombolysis in cerebral infarction (TICI) 2b-3] was achieved in 72% of patients in the MS group and 73% in the DS group. There was a significant difference in 90-day functional independence (37% MS vs. 24% DS, p = 0.017), whereas no significant differences were observed for mortality rates at 90 days (MS 22% vs. DS 17%, p = 0.306). Discussion: Our data suggest that patients who had an acute ischemic stroke admitted directly to a CSC may have better 90-day outcomes than those transferred secondarily for thrombectomy from a PSC.
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Affiliation(s)
- Christian A Taschner
- Department of Neuroradiology, Freiburg University Medical Center, University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Alexandra Trinks
- Department of Neuroradiology, Freiburg University Medical Center, University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Jürgen Bardutzky
- Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Neurology and Neuroscience, Freiburg University Medical Center, Freiburg, Germany
| | - Jochen Brich
- Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Neurology and Neuroscience, Freiburg University Medical Center, Freiburg, Germany
| | - Ralph Hartmann
- Department of Neuroradiology, Freiburg University Medical Center, University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Horst Urbach
- Department of Neuroradiology, Freiburg University Medical Center, University of Freiburg, Freiburg, Germany.,Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Wolf-Dirk Niesen
- Faculty of Medicine, University of Freiburg, Freiburg, Germany.,Department of Neurology and Neuroscience, Freiburg University Medical Center, Freiburg, Germany
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4
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Almekhlafi MA, Goyal M, Dippel DWJ, Majoie CBLM, Campbell BCV, Muir KW, Demchuk AM, Bracard S, Guillemin F, Jovin TG, Mitchell P, White P, Hill MD, Brown S, Saver JL. Healthy Life-Year Costs of Treatment Speed From Arrival to Endovascular Thrombectomy in Patients With Ischemic Stroke: A Meta-analysis of Individual Patient Data From 7 Randomized Clinical Trials. JAMA Neurol 2021; 78:709-717. [PMID: 33938914 DOI: 10.1001/jamaneurol.2021.1055] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Importance The benefits of endovascular thrombectomy (EVT) are time dependent. Prior studies may have underestimated the time-benefit association because time of onset is imprecisely known. Objective To assess the lifetime outcomes associated with speed of endovascular thrombectomy in patients with acute ischemic stroke due to large-vessel occlusion (LVO). Data Sources PubMed was searched for randomized clinical trials of stent retriever thrombectomy devices vs medical therapy in patients with anterior circulation LVO within 12 hours of last known well time, and for which a peer-reviewed, complete primary results article was published by August 1, 2020. Study Selection All randomized clinical trials of stent retriever thrombectomy devices vs medical therapy in patients with anterior circulation LVO within 12 hours of last known well time were included. Data Extraction/Synthesis Patient-level data regarding presenting clinical and imaging features and functional outcomes were pooled from the 7 retrieved randomized clinical trials of stent retriever thrombectomy devices (entirely or predominantly) vs medical therapy. All 7 identified trials published in a peer-reviewed journal (by August 1, 2020) contributed data. Detailed time metrics were collected including last known well-to-door (LKWTD) time; last known well/onset-to-puncture (LKWTP) time; last known well-to-reperfusion (LKWR) time; door-to-puncture (DTP) time; and door-to-reperfusion (DTR) time. Main Outcomes and Measures Change in healthy life-years measured as disability-adjusted life-years (DALYs). DALYs were calculated as the sum of years of life lost (YLL) owing to premature mortality and years of healthy life lost because of disability (YLD). Disability weights were assigned using the utility-weighted modified Rankin Scale. Age-specific life expectancies without stroke were calculated from 2017 US National Vital Statistics. Results Among the 781 EVT-treated patients, 406 (52.0%) were early-treated (LKWTP ≤4 hours) and 375 (48.0%) were late-treated (LKWTP >4-12 hours). In early-treated patients, LKWTD was 188 minutes (interquartile range, 151.3-214.8 minutes) and DTP 105 minutes (interquartile range, 76-135 minutes). Among the 298 of 380 (78.4%) patients with substantial reperfusion, median DTR time was 145.0 minutes (interquartile range, 111.5-185.5 minutes). Care process delays were associated with worse clinical outcomes in LKW-to-intervention intervals in early-treated patients and in door-to-intervention intervals in early-treated and late-treated patients, and not associated with LKWTD intervals, eg, in early-treated patients, for each 10-minute delay, healthy life-years lost were DTP 1.8 months vs LKWTD 0.0 months; P < .001. Considering granular time increments, the amount of healthy life-time lost associated with each 1 second of delay was DTP 2.2 hours and DTR 2.4 hours. Conclusions and Relevance In this study, care delays were associated with loss of healthy life-years in patients with acute ischemic stroke treated with EVT, particularly in the postarrival time period. The finding that every 1 second of delay was associated with loss of 2.2 hours of healthy life may encourage continuous quality improvement in door-to-treatment times.
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Affiliation(s)
- Mohammed A Almekhlafi
- Calgary Stroke Program, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Mayank Goyal
- Calgary Stroke Program, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology, University of Calgary, Calgary, Alberta, Canada.,Department of Community Health Sciences, University of Calgary, Calgary, Alberta, Canada
| | - Diederik W J Dippel
- Erasmus MC University Medical Center Depts of Neurology, Rotterdam, the Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Amsterdam, the Netherlands
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Keith W Muir
- Institute of Neuroscience & Psychology, University of Glasgow, Glasgow, Scotland, United Kingdom
| | - Andrew M Demchuk
- Calgary Stroke Program, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, Université de Lorraine, Inserm, IADI, CHRU Nancy, Nancy, France
| | - Francis Guillemin
- CHRU-Nancy, INSERM, Université de Lorraine, CIC Clinical Epidemiology, Nancy, France
| | - Tudor G Jovin
- Department of Neurology, Cooper University Health Care, Camden, New Jersey
| | - Peter Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Philip White
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, United Kingdom
| | - Michael D Hill
- Calgary Stroke Program, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada.,Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Department of Radiology, University of Calgary, Calgary, Alberta, Canada.,Department of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Scott Brown
- Altair Biostatistics, St Louis Park, Minnesota
| | - Jeffrey L Saver
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles
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5
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Kaesmacher J, Maamari B, Meinel TR, Piechowiak EI, Mosimann PJ, Mordasini P, Goeldlin M, Arnold M, Dobrocky T, Boeckh-Behrens T, Berndt M, Michel P, Requena M, Benali A, Pierot L, Mendes Pereira V, Boulouis G, Brehm A, Sporns PB, Ospel JM, Gralla J, Fischer U. Effect of Pre- and In-Hospital Delay on Reperfusion in Acute Ischemic Stroke Mechanical Thrombectomy. Stroke 2020; 51:2934-2942. [PMID: 32933420 PMCID: PMC7523579 DOI: 10.1161/strokeaha.120.030208] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose: Post hoc analyses of randomized controlled clinical trials evaluating mechanical thrombectomy have suggested that admission-to-groin-puncture (ATG) delays are associated with reduced reperfusion rates. Purpose of this analysis was to validate this association in a real-world cohort and to find associated factors and confounders for prolonged ATG intervals. Methods: Patients included into the BEYOND-SWIFT cohort (Bernese-European Registry for Ischemic Stroke Patients Treated Outside Current Guidelines With Neurothrombectomy Devices Using the Solitaire FR With the Intention for Thrombectomy; https://www.clinicaltrials.gov; Unique identifier: NCT03496064) were analyzed (n=2386). Association between baseline characteristics and ATG was evaluated using mixed linear regression analysis. The effect of increasing symptom-onset-to-admission and ATG intervals on successful reperfusion (defined as Thrombolysis in Cerebral Infarction [TICI] 2b-3) was evaluated using logistic regression analysis adjusting for potential confounders. Results: Median ATG was 73 minutes. Prolonged ATG intervals were associated with the use of magnetic resonance imaging (+19.1 [95% CI, +9.1 to +29.1] minutes), general anesthesia (+12.1 [95% CI, +3.7 to +20.4] minutes), and borderline indication criteria, such as lower National Institutes of Health Stroke Scale, late presentations, or not meeting top-tier early time window eligibility criteria (+13.8 [95% CI, +6.1 to +21.6] minutes). There was a 13% relative odds reduction for TICI 2b-3 (adjusted odds ratio [aOR], 0.87 [95% CI, 0.79–0.96]) and TICI 2c/3 (aOR, 0.87 [95% CI, 0.79–0.95]) per hour ATG delay, while the reduction of TICI 2b-3 per hour increase symptom-onset-to-admission was minor (aOR, 0.97 [95% CI, 0.94–0.99]) and inconsistent regarding TICI 2c/3 (aOR, 0.99 [95% CI, 0.97–1.02]). After adjusting for identified factors associated with prolonged ATG intervals, the association of ATG delay and lower rates of TICI 2b-3 remained tangible (aOR, 0.87 [95% CI, 0.76–0.99]). Conclusions: There is a great potential to reduce ATG, and potential targets for improvement can be deduced from observational data. The association between in-hospital delay and reduced reperfusion rates is evident in real-world clinical data, underscoring the need to optimize in-hospital workflows. Given the only minor association between symptom-onset-to-admission intervals and reperfusion rates, the causal relationship of this association warrants further research. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03496064.
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Affiliation(s)
- Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology (J.K., E.I.P., P.J.M., P. Mordasini, T.D., J.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland.,University Institute of Diagnostic and Interventional and Pediatric Radiology (J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Basel Maamari
- Department of Neurology (B.M., T.R.M., M.G., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Thomas R Meinel
- Department of Neurology (B.M., T.R.M., M.G., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Eike I Piechowiak
- University Institute of Diagnostic and Interventional Neuroradiology (J.K., E.I.P., P.J.M., P. Mordasini, T.D., J.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Pascal J Mosimann
- University Institute of Diagnostic and Interventional Neuroradiology (J.K., E.I.P., P.J.M., P. Mordasini, T.D., J.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Pasquale Mordasini
- University Institute of Diagnostic and Interventional Neuroradiology (J.K., E.I.P., P.J.M., P. Mordasini, T.D., J.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Martina Goeldlin
- Department of Neurology (B.M., T.R.M., M.G., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology (B.M., T.R.M., M.G., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Tomas Dobrocky
- University Institute of Diagnostic and Interventional Neuroradiology (J.K., E.I.P., P.J.M., P. Mordasini, T.D., J.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Tobias Boeckh-Behrens
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Germany (T.B.-B., M.B.)
| | - Maria Berndt
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Germany (T.B.-B., M.B.)
| | - Patrik Michel
- Department of Neurology, CHUV Lausanne, Switzerland (P. Michel)
| | - Manuel Requena
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain (M.R.)
| | - Amel Benali
- Department of Neuroradiology, CHU Montpellier, France (A. Benali)
| | | | - Vitor Mendes Pereira
- Joint Department of Medical Imaging and Division of Neurosurgery, Toronto Western Hospital, University of Toronto, ON, Canada (V.M.P.)
| | - Grégoire Boulouis
- Department of Neuroradiology, Université Paris Descartes, Sainte Anne Hospital, France (G.B.)
| | - Alex Brehm
- Department of Neuroradiology (A. Brehm, P.B.S.), University Hospital Basel, Switzerland
| | - Peter B Sporns
- Department of Neuroradiology (A. Brehm, P.B.S.), University Hospital Basel, Switzerland
| | - Johanna M Ospel
- Department of Radiology (J.M.O.), University Hospital Basel, Switzerland.,Department of Clinical Neuroscience, University of Calgary, Canada (J.M.O.)
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology (J.K., E.I.P., P.J.M., P. Mordasini, T.D., J.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Urs Fischer
- Department of Neurology (B.M., T.R.M., M.G., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
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Meinel TR, Kaesmacher J, Mordasini P, Mosimann PJ, Jung S, Arnold M, Heldner MR, Michel P, Hajdu SD, Ribo M, Requena M, Maegerlein C, Friedrich B, Costalat V, Benali A, Pierot L, Gawlitza M, Schaafsma J, Pereira VM, Gralla J, Fischer U. Outcome, efficacy and safety of endovascular thrombectomy in ischaemic stroke according to time to reperfusion: data from a multicentre registry. Ther Adv Neurol Disord 2019; 12:1756286419835708. [PMID: 30944585 PMCID: PMC6437320 DOI: 10.1177/1756286419835708] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 02/03/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND PURPOSE In acute ischaemic stroke (AIS) of the anterior circulation (AC) treated with mechanical thrombectomy (MT), data point to a decline of treatment effect with increasing time from symptom onset to treatment. However, the magnitude of the decline will depend on the clinical setting and imaging selection used. The aims of this study were (1) to evaluate the clinical effect of time to reperfusion (TTR); and (2) to assess the safety and technical efficacy of MT according to strata of TTR. METHODS Using the retrospective multicentre BEYOND-SWIFT registry data (ClinicalTrials.gov identifier: NCT03496064), we compared safety and efficacy of MT in 1461 patients between TTR strata of 0-180 min (n = 192), 180-360 min (n = 876) and >360 min (n = 393). Clinical effect of TTR was evaluated using multivariable logistic regression analyses adjusting for pre-specified confounders [adjusted odds ratios (aOR) and 95% confidence intervals (95% CI)]. Primary outcome was good functional outcome (modified Rankin Scale: mRS 0-2) at day 90. RESULTS Every hour delay in TTR was a significant factor related to mRS 0-2 (aOR 0.933, 95% CI 0.887-0.981) with an estimated 1.5% decreased probability of good functional outcome per hour delay of reperfusion, and mRS 0-1 (aOR 0.929, 95% CI 0.877-0.985). Patients with late TTR had lower rates of successful and excellent reperfusion, higher complication rates and number of passes. CONCLUSIONS TTR is an independent factor related to long-term functional outcome. With increasing TTR, interventional procedures become technically less effective. Efforts should be made to shorten TTR through optimized prehospital and in-hospital pathways.
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Affiliation(s)
- Thomas Raphael Meinel
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Pascal J. Mosimann
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Mirjam Rachel Heldner
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Patrik Michel
- Department of Neurology, CHUV Lausanne, Lausanne, Switzerland
| | - Steven D. Hajdu
- Department of Radiology, CHUV Lausanne, Lausanne, Switzerland
| | - Marc Ribo
- Department of Neurology, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Manuel Requena
- Department of Neurology, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Benjamin Friedrich
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Vincent Costalat
- Department of Neuroradiology, CHU Montpellier, Montpellier, France
| | - Amel Benali
- Department of Neuroradiology, CHU Montpellier, Montpellier, France
| | - Laurent Pierot
- Department of Neurology, Toronto Western Hospital, Toronto, Canada
| | | | - Joanna Schaafsma
- Department of Neurology, Toronto Western Hospital, Toronto, Canada
| | | | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Freiburgstrasse 8, CH-3010, Switzerland
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Single-Centre Experience with Patients Selection for Mechanical Thrombectomy Based on Automated Computed Tomography Perfusion Analysis-A Comparison with Computed TomographyCT Perfusion Thrombectomy Trials. J Stroke Cerebrovasc Dis 2019; 28:1085-1092. [PMID: 30655040 DOI: 10.1016/j.jstrokecerebrovasdis.2018.12.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 12/20/2018] [Accepted: 12/26/2018] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND In randomized clinical trials, mechanical thrombectomy (MT) was proved to be a highly effective treatment of acute ischemic stroke which improved clinical outcomes. Some of the trials used automated computed tomography perfusion (CTP) analysis for selection of participants. We present a single-center experience with CTP selection and comparison with CTP trials. METHODS Data of consecutive MT patients (from January 2016 to December 2017) were retrospectively reviewed. All patients with multiphase CT angiography confirmed the presence of anterior circulation large vessel occlusion/s in the intracranial internal carotid artery and/or middle cerebral artery (M1 or M2) and with admission brain CTP analyzed by RAPID software were included into the analysis. RESULTS Sixty-two patients fulfilled the inclusion criteria (mean age was 70.1 ± 13.6 years, females 48.5%). At baseline, National Institutes of Health Stroke Scale score was 16 (IQR = 13-20), Alberta Stroke Program Early CT Score (ASPECTS) was 8 (IQR = 7-9), CTP core volume was 20 mL (IQR = 2-36), and CTP penumbra volume was 145.5 mL (IQR = 107-184). Time from stroke onset to imaging was 1 hour 32 minutes, time from stroke onset to reperfusion was 3 hours 50 minutes, and median time from CT to reperfusion was 1 hour 56 minutes. Modified thrombolysis in cerebral infarction 2b/3 was achieved in 42 patients (67.7%). Twenty-three patients (37%) had modified Rankin scale 0-2 at 90 days. CONCLUSIONS Our analysis of CTP-selected patients for MT supports clinical applicability of automated CTP analysis into everyday clinical practice.
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Broocks G, Rajput F, Hanning U, Faizy TD, Leischner H, Schön G, Gellißen S, Sporns P, Deb-Chatterji M, Thomalla G, Kemmling A, Fiehler J, Flottmann F. Highest Lesion Growth Rates in Patients With Hyperacute Stroke: When Time Is Brain Particularly Matters. Stroke 2019; 50:189-192. [PMID: 30580711 DOI: 10.1161/strokeaha.118.023457] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- The early growth of ischemic lesions has been described as being nonlinear, with lesion growth rates at their highest during the earliest period after stroke onset. We hypothesized that the time gap from imaging to revascularization results in higher lesion growth in patients with hyperacute presentation. Methods- Fifty-one patients with ischemic stroke with initial multimodal computed tomography (CT), follow-up CT after 24 hours, and successful endovascular recanalization were included and separated into 2 groups according to their median time from symptom onset to imaging (eg, hyperacute versus acute). The difference in Alberta Stroke Program Early CT Score (ASPECTS) between initial CT and follow-up CT was assessed, as well as volumetric lesion growth from early ischemic core in admission perfusion CT and total lesion volume in follow-up CT. Results- The median time from onset to imaging was 1.85 hours. There was no significant difference in admission ASPECTS (mean, 8.5 versus 8.2) or time from imaging to recanalization in both groups (median, 2.7 versus 2.4 hours; P=0.4). The mean (SD) lesion growth assessed by ASPECTS difference was 2.7 (2.3) in the hyperacute group and 1.6 (1.3) in the acute group (P=0.03). The mean (SD) volumetric difference in the hyperacute group was 26.6 mL (43.2 mL) and 17.2 mL (26.3 mL; P=0.36) in the acute group, respectively. For every passing hour after onset, ASPECTS lesion growth was reduced by 0.4. Conclusions- Patients in the hyperacute phase showed increased ASPECTS lesion growth from imaging to recanalization suggesting a particular benefit of faster recanalization times in this group of patients with stroke.
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Affiliation(s)
- Gabriel Broocks
- From the Department of Diagnostic and Interventional Neuroradiology (G.B., F.R., U.H., T.D.F., H.L., S.G., J.F., F.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Furqan Rajput
- From the Department of Diagnostic and Interventional Neuroradiology (G.B., F.R., U.H., T.D.F., H.L., S.G., J.F., F.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Uta Hanning
- From the Department of Diagnostic and Interventional Neuroradiology (G.B., F.R., U.H., T.D.F., H.L., S.G., J.F., F.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Tobias Djamsched Faizy
- From the Department of Diagnostic and Interventional Neuroradiology (G.B., F.R., U.H., T.D.F., H.L., S.G., J.F., F.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Hannes Leischner
- From the Department of Diagnostic and Interventional Neuroradiology (G.B., F.R., U.H., T.D.F., H.L., S.G., J.F., F.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany
| | - Susanne Gellißen
- From the Department of Diagnostic and Interventional Neuroradiology (G.B., F.R., U.H., T.D.F., H.L., S.G., J.F., F.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Peter Sporns
- Department of Clinical Radiology, University Hospital Münster, Germany (P.S., A.K.)
| | - Milani Deb-Chatterji
- Department of Neurology (M.D.-C., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Götz Thomalla
- Department of Neurology (M.D.-C., G.T.), University Medical Center Hamburg-Eppendorf, Germany
| | - Andre Kemmling
- Department of Clinical Radiology, University Hospital Münster, Germany (P.S., A.K.)
| | - Jens Fiehler
- From the Department of Diagnostic and Interventional Neuroradiology (G.B., F.R., U.H., T.D.F., H.L., S.G., J.F., F.F.), University Medical Center Hamburg-Eppendorf, Germany
| | - Fabian Flottmann
- From the Department of Diagnostic and Interventional Neuroradiology (G.B., F.R., U.H., T.D.F., H.L., S.G., J.F., F.F.), University Medical Center Hamburg-Eppendorf, Germany
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Egger K, Strecker C, Kellner E, Urbach H. [Imaging in acute ischemic stroke using automated postprocessing algorithms]. DER NERVENARZT 2018; 89:885-894. [PMID: 29947938 DOI: 10.1007/s00115-018-0535-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
There are several automated analytical methods to detect thromboembolic vascular occlusions, the infarct core and the potential infarct-endangered tissue (tissue at risk) by means of multimodal computed tomography (CT) and magnetic resonance imaging (MRI). The infarct core is more reliably visualized by diffusion-weighted imaging (DWI) MRI or CT perfusion than by native CT. The extent of tissue at risk and endangerment can only be estimated; however, it seems essential whether "tissue at risk" actually exists. To ensure consistent patient care, uniform imaging protocols should be acquired in the referring hospital and thrombectomy center and the collected data should be standardized and automatically evaluated and presented. Whether patients with a large infarct core and with or without tissue at risk or patients with large vessel occlusion (LVO) but low NIHSS benefit from thrombectomy has to be evaluated in controlled clinical trials using standardized imaging protocols. A promising, potentially time-saving approach is also native CT and CT angiography using a flat-panel detector angiography system for assessment of vessel occlusion and leptomeningeal collaterals.
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Affiliation(s)
- K Egger
- Neurozentrum, Klinik für Neuroradiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Breisacher Str. 64, 79106, Freiburg, Deutschland.
| | - C Strecker
- Klinik für Neurologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
| | - E Kellner
- Abteilung Medizinische Physik Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
| | - H Urbach
- Neurozentrum, Klinik für Neuroradiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Breisacher Str. 64, 79106, Freiburg, Deutschland
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Galinovic I, Dicken V, Heitz J, Klein J, Puig J, Guibernau J, Kemmling A, Gellissen S, Villringer K, Neeb L, Gregori J, Weiler F, Pedraza S, Thomalla G, Fiehler J, Gerloff C, Fiebach JB. Homogeneous application of imaging criteria in a multicenter trial supported by investigator training: A report from the WAKE-UP study. Eur J Radiol 2018; 104:115-119. [DOI: 10.1016/j.ejrad.2018.05.011] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Revised: 03/27/2018] [Accepted: 05/10/2018] [Indexed: 10/16/2022]
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