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van Landeghem N, Ziegenfuß C, Demircioglu A, Dammann P, Jabbarli R, Haubold J, Forsting M, Wanke I, Köhrmann M, Frank B, Deuschl C, Li Y. Impact of post-thrombectomy isolated subarachnoid hemorrhage on neurological outcomes in patients with anterior ischemic stroke - a retrospective single-center observational study. Neuroradiology 2024:10.1007/s00234-024-03424-w. [PMID: 38980345 DOI: 10.1007/s00234-024-03424-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 06/29/2024] [Indexed: 07/10/2024]
Abstract
PURPOSE We aimed to investigate the impact of post-thrombectomy isolated subarachnoid hemorrhage (i-SAH) and other types of intracranial hemorrhage (o-ICH) on patient's neurological outcomes. METHODS Stroke data from 2018 to 2022 in a tertiary care center were retrospectively analyzed. Patients with large vessel occlusion from ICA to M2 branch were included. Post-thrombectomy intracranial hemorrhages at 24 h were categorized with Heidelberg Bleeding Classification. Neurological impairment of patients was continuously assessed at admission, at 24 h, 48 h and 72 h, and at discharge. Predictors of i-SAH and o-ICH were assessed. RESULTS 297 patients were included. i-SAH and o-ICH were found in 12.1% (36/297) and 11.4% (34/297) of patients. Overall, NIHSS of i-SAH patients at discharge were comparable to o-ICH patients (median 22 vs. 21, p = 0.889) and were significantly higher than in non-ICH patients (22 vs. 7, p < 0.001). i-SAH often resulted in abrupt deterioration of patient's neurological symptoms at 24 h after thrombectomy. Compared to non-ICH patients, the occurrence of i-SAH was frequently associated with worse neurological outcome at discharge (median NIHSS increase of 4 vs. decrease of 4, p < 0.001) and higher in-hospital mortality (41.7% vs. 23.8%, p = 0.022). Regardless of successful reperfusion (TICI 2b/3), the beneficial impact of thrombectomy appeared to be outweighed by the adverse effect of i-SAH. Incomplete reperfusion and shorter time from symptom onset to admission were associated with higher probability of i-SAH, whereas longer procedure time and lower baseline ASPECTS were predictive for o-ICH occurrence. CONCLUSION Post-thrombectomy isolated subarachnoid hemorrhage is a common complication with significant negative impact on neurological outcome.
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Affiliation(s)
- Natalie van Landeghem
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany.
| | - Christoph Ziegenfuß
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Aydin Demircioglu
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Philipp Dammann
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Ramazan Jabbarli
- Department of Neurosurgery and Spine Surgery, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Johannes Haubold
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Michael Forsting
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Isabel Wanke
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
- Swiss Neuroradiology Institute, Bürglistrasse 29, Zürich, 8002, Switzerland
| | - Martin Köhrmann
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Benedikt Frank
- Department of Neurology and Center for Translational Neuro- and Behavioral Sciences (C-TNBS), University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Cornelius Deuschl
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
| | - Yan Li
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Hufelandstrasse 55, 45147, Essen, Germany
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Koo AB, Reeves BC, Renedo D, Maier IL, Al Kasab S, Jabbour P, Kim JT, Wolfe SQ, Rai A, Starke RM, Psychogios MN, Shaban A, Arthur A, Yoshimura S, Cuellar H, Grossberg JA, Alawieh A, Romano DG, Tanweer O, Mascitelli J, Fragata I, Polifka A, Osbun J, Crosa R, Park MS, Levitt MR, Brinjikji W, Moss M, Dumont T, Williamson R, Navia P, Kan P, Spiotta AM, Sheth KN, de Havenon A, Matouk CC. Impact of Procedure Time on First Pass Effect in Mechanical Thrombectomy for Anterior Circulation Acute Ischemic Stroke. Neurosurgery 2024:00006123-990000000-01086. [PMID: 38483158 DOI: 10.1227/neu.0000000000002900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2023] [Accepted: 12/13/2023] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND AND OBJECTIVES First pass effect (FPE) is a metric increasingly used to determine the success of mechanical thrombectomy (MT) procedures. However, few studies have investigated whether the duration of the procedure can modify the clinical benefit of FPE. We sought to determine whether FPE after MT for anterior circulation large vessel occlusion acute ischemic stroke is modified by procedural time (PT). METHODS A multicenter, international data set was retrospectively analyzed for anterior circulation large vessel occlusion acute ischemic stroke treated by MT who achieved excellent reperfusion (thrombolysis in cerebral infarction 2c/3). The primary outcome was good functional outcome defined by 90-day modified Rankin scale scores of 0-2. The primary study exposure was first pass success (FPS, 1 pass vs ≥2 passes) and the secondary exposure was PT. We fit-adjusted logistic regression models and used marginal effects to assess the interaction between PT (≤30 vs >30 minutes) and FPS, adjusting for potential confounders including time from stroke presentation. RESULTS A total of 1310 patients had excellent reperfusion. These patients were divided into 2 cohorts based on PT: ≤30 minutes (777 patients, 59.3%) and >30 minutes (533 patients, 40.7%). Good functional outcome was observed in 658 patients (50.2%). The interaction term between FPS and PT was significant ( P = .018). Individuals with FPS in ≤30 minutes had 11.5% higher adjusted predicted probability of good outcome compared with those who required ≥2 passes (58.2% vs 46.7%, P = .001). However, there was no significant difference in the adjusted predicted probability of good outcome in individuals with PT >30 minutes. This relationship appeared identical in models with PT treated as a continuous variable. CONCLUSION FPE is modified by PT, with the added clinical benefit lost in longer procedures greater than 30 minutes. A comprehensive metric for MT procedures, namely, FPE 30 , may better represent the ideal of fast, complete reperfusion with a single pass of a thrombectomy device.
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Affiliation(s)
- Andrew B Koo
- Department of Neurosurgery, Yale University, New Haven , Connecticut , USA
| | - Benjamin C Reeves
- Department of Neurosurgery, Yale University, New Haven , Connecticut , USA
| | - Daniela Renedo
- Department of Neurosurgery, Yale University, New Haven , Connecticut , USA
| | - Ilko L Maier
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen , Germany
| | - Sami Al Kasab
- Department of Neurology and Neurosurgery, Medical University of South Carolina, Charleston , South Carolina , USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia , Pennsylvania , USA
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju , Korea
| | - Stacey Q Wolfe
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem , North Carolina , USA
| | - Ansaar Rai
- Department of Neuroradiology, West Virginia School of Medicine, Morgantown , West Virginia , USA
| | - Robert M Starke
- Department of Neurosurgery, University of Miami Health System, Miami , Florida , USA
| | - Marios-Nikos Psychogios
- Department of Diagnostic and Interventional Neuroradiology, University of Basel, Basel , Switzerland
| | - Amir Shaban
- Department of Neurology, The University of Iowa, Iowa City , Iowa , USA
| | - Adam Arthur
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Clinic, University of Tennessee Health Science Center, Memphis , Tennessee , USA
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya , Hyogo , Japan
| | - Hugo Cuellar
- Department of Neurosurgery, Louisiana State University Health Shreveport, Shreveport , Louisiana , USA
| | | | - Ali Alawieh
- Department of Neurosurgery, Emory University, Atlanta , Georgia , USA
| | - Daniele G Romano
- Department of Radiology, Aou S. Giovanni di Dio e Ruggi d'Aragona, Salerno , Italy
| | - Omar Tanweer
- Department of Neurosurgery, Baylor College of Medicine, Houston , Texas , USA
| | - Justin Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio , Texas , USA
| | - Isabel Fragata
- Department of Neuroradiology, Centro Hospitalar Universitario de Lisboa Central, Lisbon , Portugal
| | - Adam Polifka
- Department of Neurosurgery, University of Florida, Gainesville , Florida , USA
| | - Joshua Osbun
- Department of Neurosurgery, Washington University, St. Louis , Missouri , USA
| | - Roberto Crosa
- Department of Neurosurgery, Medica Uruguaya, Montevideo , Uruguay
| | - Min S Park
- Department of Neurosurgery, University of Virginia, Charlottesville , Virginia , USA
| | - Michael R Levitt
- Department of Neurosurgery, University of Washington, Seattle , Washington , USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic in Minnesota, Rochester , Minnesota , USA
| | - Mark Moss
- Department of Interventional Neuroradiology, Washington Regional Medical Center, Fayetteville , Arkansas , USA
| | - Travis Dumont
- Department of Neurosurgery, University of Arizona, Tucson , Arizona , USA
| | - Richard Williamson
- Department of Neurosurgery, Allegheny Hospital, Pittsburgh , Pennsylvania , USA
| | - Pedro Navia
- Department of Interventional and Diagnostic Neuroradiology, Hospital Universitario La Paz, Madrid , Spain
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston , Texas , USA
| | - Alejandro M Spiotta
- Department of Neurology and Neurosurgery, Medical University of South Carolina, Charleston , South Carolina , USA
| | - Kevin N Sheth
- Department of Neurology, Yale University, New Haven , Connecticut , USA
| | - Adam de Havenon
- Department of Neurology, Yale University, New Haven , Connecticut , USA
| | - Charles C Matouk
- Department of Neurosurgery, Yale University, New Haven , Connecticut , USA
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Suzuki K, Matsumaru Y, Takeuchi M, Morimoto M, Kanazawa R, Takayama Y, Kamiya Y, Shigeta K, Okubo S, Hayakawa M, Ishii N, Koguchi Y, Takigawa T, Inoue M, Naito H, Ota T, Hirano T, Kato N, Ueda T, Iguchi Y, Akaji K, Tsuruta W, Miki K, Fujimoto S, Higashida T, Iwasaki M, Aoki J, Nishiyama Y, Otsuka T, Kimura K. The impact of SAH finding on CT to the clinical outcome after mechanical thrombectomy for large vessel occlusion. J Neurol Sci 2023; 453:120797. [PMID: 37703704 DOI: 10.1016/j.jns.2023.120797] [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: 07/02/2023] [Revised: 08/24/2023] [Accepted: 09/06/2023] [Indexed: 09/15/2023]
Abstract
BACKGROUND AND PURPOSE Whether subarachnoid haemorrhage (SAH) after mechanical thrombectomy affects the clinical outcomes of patients with acute large-vessel occlusion remains unclear. This study aimed to investigate the clinical impact of SAH on computed tomography (CT) after mechanical thrombectomy. METHODS The SKIP study was an investigator-initiated, multicentre, randomised, open-label clinical trial. This study was performed in 23 hospital networks in Japan from January 1, 2017, to July 31, 2019. Among the 204 patients, seven were excluded because they did not undergo mechanical thrombectomy (MT) and had a modified Rankin scale (mRS) score > 2. The main outcome was the association between SAH within 36 h after mechanical thrombectomy and the clinical outcome at 90 days. RESULTS Among 197 patients, the median age was 74 (67-79) years, 62.9% were male. Moreover, 26 (13.2%) patients had SAH (seven isolated SAH) on CT within 36 h. The SAH rate did not differ according to IV rt-PA administration (p = 0.4). The rate of favourable clinical outcomes tended to be lower in patients with SAH rather than patients without SAH (11 [42%] vs. 106 [62%], p = 0.08). Among the seven patients with isolated SAH, 6 showed favourable outcomes at 90 days. In the multivariate regression analysis, the presence of SAH within 36 h from onset was not associated with clinical outcome (Odd ratio, 0.59; 95% confidence interval, 0.18-1.95; p = 0.38). CONCLUSIONS Among patients with acute stroke treated with MT, SAH, especially isolated SAH findings on CT, were not associated with poor clinical outcomes after 90 days. TRIAL REGISTRATION NUMBER UMIN000021488.
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Affiliation(s)
- Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan.
| | - Yuji Matsumaru
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | | | - Masafumi Morimoto
- Department of Neurosurgery, Yokohama Shintoshi Neurosurgery Hospital, Kanagawa, Japan
| | | | - Yohei Takayama
- Department of Neurology, Akiyama Neurosurgical Hospital, Kanagawa, Japan
| | - Yuki Kamiya
- Department of Cerebrovascular Medicine, NTT Medical Center Tokyo, Tokyo, Japan
| | - Keigo Shigeta
- Department of Neurosurgery, National Hospital Organization Disaster Medical Center, Tokyo, Japan
| | - Seiji Okubo
- Department of Cerebrovascular Medicine, NTT Medical Center Tokyo, Tokyo, Japan
| | - Mikito Hayakawa
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, Faculty of Medicine, University of Tsukuba, Ibaraki, Japan
| | - Norihiro Ishii
- Department of Neurosurgery, New Tokyo Hospital, Chiba, Japan
| | - Yorio Koguchi
- Department of Neurology and Neurosurgery, Chiba Emergency Medical Center, Chiba, Japan
| | - Tomoji Takigawa
- Department of Neurosurgery, Dokkyo Medical University Saitama Medical Center, Saitama, Japan
| | - Masato Inoue
- Department of Neurosurgery, National Center for Global Health and Medicine, Tokyo, Japan
| | - Hiromichi Naito
- Department of Neurosurgery, Funabashi Municipal Medical Center, Chiba, Japan
| | - Takahiro Ota
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Tokyo, Japan
| | - Noriyuki Kato
- Department of Neurosurgery, Mito Medical Center, Ibaraki, Japan
| | - Toshihiro Ueda
- Department of Strokology, Stroke Center, St. Marianna University Toyoko Hospital, Kanagawa, Japan
| | - Yasuyuki Iguchi
- Department of Neurology, the Jikei University School of Medicine, Tokyo, Japan
| | - Kazunori Akaji
- Department of Neurosurgery, Mihara Memorial Hospital, Gunma, Japan
| | - Wataro Tsuruta
- Department of Endovascular Neurosurgery, Toranomon Hospital, Tokyo, Japan
| | - Kazunori Miki
- Department of Endovascular Surgery, Tokyo Medical and Dental University, Tokyo, Japan
| | - Shigeru Fujimoto
- Division of Neurology, Department of Medicine, Jichi Medical University, Tochigi, Japan
| | | | - Mitsuhiro Iwasaki
- Department of Neurosurgery, Yokohama Shintoshi Neurosurgery Hospital, Kanagawa, Japan
| | - Junya Aoki
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | | | - Toshiaki Otsuka
- Department of Hygiene and Public Health, Nippon Medical School, Tokyo, Japan
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
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Palanikumar L, Mahadevan J, Kleinig T. Oculomotor palsy and drowsiness due to post-thrombectomy subarachnoid haemorrhage falsely suggesting transtentorial herniation. BMJ Neurol Open 2023; 5:e000500. [PMID: 37808515 PMCID: PMC10551951 DOI: 10.1136/bmjno-2023-000500] [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] [Accepted: 09/05/2023] [Indexed: 10/10/2023] Open
Abstract
Introduction Post-thrombectomy subarachnoid haemorrhage (SAH) can result in oculomotor palsy and drowsiness, which may falsely suggest transtentorial herniation. Case presentation We present a case of right oculomotor nerve palsy presenting after endovascular thrombectomy (EVT) for a right middle cerebral artery (MCA) stroke. The patient presented with a significant right MCA syndrome and a National Institutes of Health Stroke Scale (NIHSS) score of 10 with CT perfusion demonstrating a large penumbral lesion and a CT angiogram confirming a right MCA M1 occlusion. After thrombectomy, the patient developed a 9mm dilated non-reactive right pupil, and a new ipsilateral near-complete oculomotor nerve palsy. Repeat code stroke imaging demonstrated perimesencephalic SAH). The patient was managed expectantly and her conscious state and oculomotor palsy gradually resolved with an excellent neurological recovery. Conclusion This case underscores the potential for post-thrombectomy perimesencephalic SAH as a rare mimic of symptomatic intracranial haemorrhage with mass effect manifesting as sudden-onset oculomotor nerve palsy.
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Affiliation(s)
- Logesh Palanikumar
- Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Joshua Mahadevan
- Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Timothy Kleinig
- Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
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Ahn S, Mummareddy N, Roth SG, Jo J, Bhamidipati A, Ko Y, DiNitto J, Chitale RV, Fusco MR, Froehler MT. The clinical utility of dual-energy CT in post-thrombectomy care: Part 1, predictors and outcomes of subarachnoid and intraparenchymal hemorrhage. J Stroke Cerebrovasc Dis 2023; 32:107217. [PMID: 37392485 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107217] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Revised: 06/08/2023] [Accepted: 06/10/2023] [Indexed: 07/03/2023] Open
Abstract
OBJECTIVES Dual-energy CT allows differentiation between blood and iodinated contrast. We aimed to determine predictors of subarachnoid and intraparenchymal hemorrhage on dual-energy CT performed immediately post-thrombectomy and the impact of these hemorrhages on 90-day outcomes. MATERIALS AND METHODS A retrospective analysis was performed on patients who underwent thrombectomy for anterior circulation large-vessel occlusion and subsequent dual-energy CT at a comprehensive stroke center from 2018-2021. The presence of contrast, subarachnoid hemorrhage, or intraparenchymal hemorrhage immediately post-thrombectomy was assessed by dual-energy CT. Univariable and multivariable analyses were performed to identify predictors of post-thrombectomy hemorrhages and 90-day outcomes. Patients with unknown 90-day mRS were excluded. RESULTS Of 196 patients, subarachnoid hemorrhage was seen in 17, and intraparenchymal hemorrhage in 23 on dual-energy CT performed immediately post-thrombectomy. On multivariable analysis, subarachnoid hemorrhage was predicted by stent retriever use in the M2 segment of MCA (OR,4.64;p=0.017;95%CI,1.49-14.35) and the number of thrombectomy passes (OR,1.79;p=0.019;95%CI,1.09-2.94;per an additional pass), while intraparenchymal hemorrhage was predicted by preprocedural non-contrast CT-based ASPECTS (OR,8.66;p=0.049;95%CI,0.92-81.55;per 1 score decrease) and preprocedural systolic blood pressure (OR,5.10;p=0.037;95%CI,1.04-24.93;per 10 mmHg increase). After adjusting for potential confounders, intraparenchymal hemorrhage was associated with worse functional outcomes (OR,0.25;p=0.021;95%CI,0.07-0.82) and mortality (OR,4.30;p=0.023,95%CI,1.20-15.36), while subarachnoid hemorrhage was associated with neither. CONCLUSIONS Intraparenchymal hemorrhage immediately post-thrombectomy was associated with worse functional outcomes and mortality and can be predicted by low ASPECTS and elevated preprocedural systolic blood pressure. Future studies focusing on management strategies for patients presenting with low ASPECTS or elevated blood pressure to prevent post-thrombectomy intraparenchymal hemorrhage are warranted.
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Affiliation(s)
- Seoiyoung Ahn
- Vanderbilt University School of Medicine, Nashville, TN.
| | - Nishit Mummareddy
- Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN.
| | - Steven G Roth
- Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN.
| | - Jacob Jo
- Vanderbilt University School of Medicine, Nashville, TN.
| | | | - Yeji Ko
- Department of Biostatistics, Vanderbilt University Medical Center, Nashville, TN.
| | - Julie DiNitto
- Siemens Medical Solutions, Malvern, PA; Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN.
| | - Rohan V Chitale
- Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN.
| | - Matthew R Fusco
- Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN.
| | - Michael T Froehler
- Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN.
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Benalia VH, Aghaebrahim A, Cortez GM, Sauvageau E, Hanel RA. Evaluation of pure subarachnoid hemorrhage after mechanical thrombectomy in a series of 781 consecutive patients. Interv Neuroradiol 2023:15910199231163046. [PMID: 36916147 DOI: 10.1177/15910199231163046] [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: 03/16/2023] Open
Abstract
INTRODUCTION Subarachnoid hyperdensity is commonly seen on postoperative computed tomography scans within 24 h after mechanical thrombectomy. The impact on patients' outcomes remains uncertain. We present a real-world experience evaluating periprocedural factors associated with the development of subarachnoid hemorrhage (SAH) and its impact on outcomes of patients with acute stroke undergoing mechanical thrombectomy. METHODS A single-center, retrospective analysis was performed between January 2016 and August 2021, including all consecutive patients who underwent thrombectomy. Our study aimed to evaluate periprocedural factors associated with subarachnoid hemorrhage within 24 h of the intervention, and the potential impact on patients' outcome. RESULTS Of 781 patients, 44 patients (5.63%) demonstrated pure SAH within 24 h of the intervention. Patients from the SAH group were more likely to have tandem occlusion (15.9% vs. 5.2%, p = .003), aspiration using reperfusion pump system (81.4% vs. 66.8%, p = .047), intraoperative complications (9.1% vs. 0.9%; p < .001), longer puncture-to-recanalization times (45 min vs 29 min, p = .042) and a higher median number of passes to achieve recanalization (1 vs. 3, p = .002). There was no statistically significant difference in the long-term functional outcome between the groups. CONCLUSION We suggest that dual-energy computed tomography could better distinguish between blood and pure contrast stagnation. Still, SAH was not associated with an unfavorable outcome in stroke patients undergoing thrombectomy.
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Affiliation(s)
- Victor Hc Benalia
- 220127Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, FL, USA.,Research Department, 4121Jacksonville University, Jacksonville, FL, USA
| | - Amin Aghaebrahim
- 220127Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, FL, USA
| | - Gustavo M Cortez
- 220127Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, FL, USA
| | - Eric Sauvageau
- 220127Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, FL, USA
| | - Ricardo A Hanel
- 220127Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, FL, USA
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Benalia VH, Cortez GM, Monteiro A, Siddiqui A, Aghaebrahim A, Sauvageau E, Hanel RA. Brain aneurysm rupture during mechanical thrombectomy for large vessel occlusion: Technical case series and complication avoidance strategies. Interv Neuroradiol 2022:15910199221138371. [PMID: 36471516 DOI: 10.1177/15910199221138371] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
Endovascular therapy became the mainstream treatment for patients with acute stroke due to emergent large vessel occlusion (LVO). With increasing number of interventions, it is not uncommon for incidental vascular pathologies to be found during mechanical thrombectomy. Overall, intracranial aneurysms can occur in up to 4% of the population, but previous studies suggest a slightly higher prevalence of intracranial aneurysms in stroke patients as they may share common risk factors. We report on three patients with acute stroke secondary to LVO undergoing mechanical thrombectomy with brain aneurysms incidentally discovered and discuss the potential implications and technical considerations of performing revascularization in these scenarios. In the first case, a patient treated with stent-retriever and aspiration developed a carotid-cavernous fistula without clinical repercussion. The second case illustrates an internal carotid artery posterior communicating segment aneurysm rupture with a massive subarachnoid hemorrhage. The third case exemplifies an unruptured middle cerebral artery bifurcation aneurysm related to an M2 occlusion managed with a different strategy, avoiding aneurysm rupture. Intraprocedural aneurysm rupture is a potential complication during mechanical thrombectomy, especially when anatomical challenges are present. Interventionalists should be aware of the potential risk and constraints in this setting in order to mitigate adverse events.
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Affiliation(s)
- Victor Hc Benalia
- 220127Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, FL, USA
- Research Department, 4121Jacksonville University, Jacksonville, FL, USA
| | - Gustavo M Cortez
- 220127Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, FL, USA
| | - Andre Monteiro
- Departments of Neurosurgery and Radiology, 12291University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Adnan Siddiqui
- Departments of Neurosurgery and Radiology, 12291University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, NY, USA
| | - Amin Aghaebrahim
- 220127Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, FL, USA
| | - Eric Sauvageau
- 220127Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, FL, USA
| | - Ricardo A Hanel
- 220127Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, FL, USA
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Kim DY, Baik SH, Jung C, Kim JY, Han SG, Kim BJ, Kang J, Bae HJ, Kim JH. Predictors and Impact of Sulcal SAH after Mechanical Thrombectomy in Patients with Isolated M2 Occlusion. AJNR Am J Neuroradiol 2022; 43:1292-1298. [PMID: 35902120 PMCID: PMC9451639 DOI: 10.3174/ajnr.a7594] [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: 04/07/2022] [Accepted: 06/17/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Data on SAH after M2 mechanical thrombectomy are limited. We aimed to determine the prevalence of sulcal SAH after mechanical thrombectomy for M2 occlusion, its associated predictors, and the resulting clinical outcome. MATERIALS AND METHODS The study retrospectively reviewed the data of patients with acute ischemic stroke who underwent mechanical thrombectomy for isolated M2 occlusion. The patients were divided into 2 groups according to the presence of sulcal SAH after M2 mechanical thrombectomy. Angiographic and clinical outcomes were compared. Multivariable analysis was performed to identify independent predictors of sulcal SAH and unfavorable outcome (90-day mRS, 3-6). RESULTS Of the 209 enrolled patients, sulcal SAH was observed in 33 (15.8%) patients. The sulcal SAH group showed a higher rate of distal M2 occlusion (69.7% versus 22.7%), a higher of rate of superior division occlusion (63.6% versus 43.8%), and a higher M2 angulation (median, 128° versus 106°) than the non-sulcal SAH group. Of the 33 sulcal SAH cases, 23 (66.7%) were covert without visible intraprocedural contrast extravasation. Distal M2 occlusion (OR, 12.04; 95% CI, 4.56-35.67; P < .001), superior division (OR, 3.83; 95% CI, 1.43-11.26; P = .010), M2 angulation (OR, 1.02; 95% CI, 1.01-1.04; P < .001), and the number of passes (OR, 1.58; 95% CI, 1.22-2.09; P < .001) were independent predictors of sulcal SAH. However, covert sulcal SAH was not associated with an unfavorable outcome (P = .830). CONCLUSIONS After mechanical thrombectomy for M2 occlusion, sulcal SAH was not uncommon and occurred more frequently with distal M2 occlusion, superior division, acute M2 angulation, and multiple thrombectomy passes (≥3). The impact of covert sulcal SAH was mostly benign and was not associated with an unfavorable outcome.
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Affiliation(s)
- D Y Kim
- From the Departments of Radiology (D.Y.K., S.H.B., C.J., J.H.K.)
- Neurology (D.Y.K, J.Y.K, S.-G.H., B.J.K, J.K., H-.J.B), Seoul National University Bundang Hospital, Seongnam, South Korea
| | - S H Baik
- From the Departments of Radiology (D.Y.K., S.H.B., C.J., J.H.K.)
| | - C Jung
- From the Departments of Radiology (D.Y.K., S.H.B., C.J., J.H.K.)
| | - J Y Kim
- Neurology (D.Y.K, J.Y.K, S.-G.H., B.J.K, J.K., H-.J.B), Seoul National University Bundang Hospital, Seongnam, South Korea
| | - S-G Han
- Neurology (D.Y.K, J.Y.K, S.-G.H., B.J.K, J.K., H-.J.B), Seoul National University Bundang Hospital, Seongnam, South Korea
| | - B J Kim
- Neurology (D.Y.K, J.Y.K, S.-G.H., B.J.K, J.K., H-.J.B), Seoul National University Bundang Hospital, Seongnam, South Korea
| | - J Kang
- Neurology (D.Y.K, J.Y.K, S.-G.H., B.J.K, J.K., H-.J.B), Seoul National University Bundang Hospital, Seongnam, South Korea
| | - H-J Bae
- Neurology (D.Y.K, J.Y.K, S.-G.H., B.J.K, J.K., H-.J.B), Seoul National University Bundang Hospital, Seongnam, South Korea
| | - J H Kim
- From the Departments of Radiology (D.Y.K., S.H.B., C.J., J.H.K.)
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9
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ADC measurement relevance to predict hemorrhage transformation after mechanical thrombectomy. J Neurol Sci 2022; 441:120370. [DOI: 10.1016/j.jns.2022.120370] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 07/11/2022] [Accepted: 07/27/2022] [Indexed: 11/20/2022]
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10
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Renú A, Laredo C, Rodríguez-Vázquez A, Santana D, Werner M, Llull L, Lopez-Rueda A, Urra X, Rudilosso S, Obach V, Amaro S, Chamorro Á. Characterization of Subarachnoid Hyperdensities After Thrombectomy for Acute Stroke Using Dual-Energy CT. Neurology 2021; 98:e601-e611. [PMID: 34921104 DOI: 10.1212/wnl.0000000000013198] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Accepted: 11/30/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The presence of post-interventional subarachnoid hyperdensities (SA-HD) is a relatively common finding after mechanical thrombectomy (MT). We aimed to assess the incidence, characteristics, clinical relevance and predictors of SA-HD after MT as categorized through the use of post-interventional Dual Energy-CT (DE-CT). METHODS A single-center consecutive series of acute stroke patients treated with MT were retrospectively reviewed. Post-treatment SA-HD were defined as incident extra-axial hyperdensities in a follow-up DE-CT performed within a median of 8 hours after MT. SA-HD were further classified according to their content (isolated contrast extravasation versus blood extravasation) and extension [diffuse (hyperdensities in more than one extraparenchymal compartments) versus non-diffuse]. Adjusted logistic regression models assessed the association of SA-HD with pretreatment and procedural variables and with bad clinical outcome (shift towards worse categories in the ordinal Rankin Scale at 90 days). RESULTS SA-HD were observed in 120 (28%) of the 424 included patients (isolated contrast extravasation n=22, blood extravasation n=98). In this group, SA-HD were diffuse in 72 (60%) patients (isolated contrast extravasation n=7, blood extravasation n=65) and non-diffuse in 48 (40%) patients (isolated contrast extravasation n=15, blood extravasation n=33). Diffuse SA-HD were significantly associated with worse clinical outcome in adjusted models (cOR=2.3, 95%CI=1.36-4.00, p=0.002), unlike the specific SA-HD content alone. In contrast with the absence of SA-HD, only the diffuse pattern with blood extravasation was significantly associated with worse clinical outcome (cOR=2.4, 95%CI=1.36-4.15, p=0.002). Diffuse SA-HD patterns were predicted by M2 occlusions, more thrombectomy passes and concurrent parenchymal hematomas. DISCUSSION In our cohort of patients imaged within a median of 8 hours after MT, post-interventional SA-HD showed a diffuse pattern in 17% of thrombectomies and were associated with more arduous procedures. Diffuse SA-HD but not local collections of blood or contrast extravasations were associated with an increased risk of poor outcome and death. These findings reinforce the need for improvement in reperfusion strategies. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that in individuals with proximal carotid artery territory occlusions treated with mechanical thrombectomy, diffuse post-interventional subarachnoid hyperdensities on imaging 8 hours post-procedure are associated with worse clinical outcomes at 90 days.
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Affiliation(s)
- Arturo Renú
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Carlos Laredo
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Alejandro Rodríguez-Vázquez
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Daniel Santana
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | | | - Laura Llull
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | | | - Xabier Urra
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Salvatore Rudilosso
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Víctor Obach
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Sergi Amaro
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Ángel Chamorro
- Comprehensive Stroke Center, Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi i Sunyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
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11
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Xu T, Wang Y, Yuan J, Chen Y, Luo H. Contrast extravasation and outcome of endovascular therapy in acute ischaemic stroke: a systematic review and meta-analysis. BMJ Open 2021; 11:e044917. [PMID: 34233968 PMCID: PMC8264910 DOI: 10.1136/bmjopen-2020-044917] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE Contrast extravasation (CE) after endovascular therapy (EVT) is commonly present in acute ischaemic stroke (AIS) patients. Substantial uncertainties remain about the relationship between CE and the outcomes of EVT in patients with AIS. Therefore, we aimed to evaluate this association. DESIGN A systematic review and meta-analysis of published studies were performed. DATA SOURCE We systematically searched the Medline and Embase databases for relevant clinical studies. The last literature search in databases was performed in June 2020. ELIGIBILITY CRITERIA FOR STUDY SELECTION We included studies exploring the associations between CE and the outcomes of EVT in patients with AIS undergoing EVT. DATA EXTRACTION AND SYNTHESIS Two reviewers extracted relevant information and data from each article independently. We pooled ORs with CIs using a random-effects meta-analysis to calculate the associations between CE and outcomes of EVT. The magnitude of heterogeneity between estimates was quantified with the I2 statistic with 95% CIs. RESULTS Fifteen observational studies that enrolled 1897 patients were included. Patients with CE had higher risks of poor functional outcome at discharge (2.38, 95% CI 1.45 to 3.89 p=0.001; n=545) and poor functional outcome at 90 days (OR 2.16, 95% CI 1.20 to 3.90; n=1194). We found no association between CE and in-hospital mortality (OR 0.95, 95% CI 0.27 to 3.30; n=376) or 90-day mortality (OR 1.38, 95% CI 0.81 to 2.36; n=697) after EVT. Moreover, CE was associated with higher risks of post-EVT intracranial haemorrhage (ICH) (OR 6.68, 95% CI 3.51 to 12.70; n=1721) and symptomatic ICH (OR 3.26, 95% CI 1.97 to 5.40; n=1092). CONCLUSIONS This systematic review and meta-analysis indicates that in patients with AIS undergoing EVT, CE is associated with higher risks of unfavourable functional outcomes and ICH. Thus, we should pay more attention to CE in patients with AIS undergoing EVT.
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Affiliation(s)
- Tao Xu
- Department of Neurology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - You Wang
- Department of Neurology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Jinxian Yuan
- Department of Neurology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yangmei Chen
- Department of Neurology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Haiyan Luo
- Department of Neurology, the Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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12
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Lee H, Qureshi AM, Mueller-Kronast NH, Zaidat OO, Froehler MT, Liebeskind DS, Pereira VM. Subarachnoid Hemorrhage in Mechanical Thrombectomy for Acute Ischemic Stroke: Analysis of the STRATIS Registry, Systematic Review, and Meta-Analysis. Front Neurol 2021; 12:663058. [PMID: 34113310 PMCID: PMC8185211 DOI: 10.3389/fneur.2021.663058] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Accepted: 04/13/2021] [Indexed: 11/13/2022] Open
Abstract
Background: The indications for mechanical thrombectomy in acute ischemic stroke continue to broaden, leading neurointerventionalists to treat vessel occlusions at increasingly distal locations farther in time from stroke onset. Accessing these smaller vessels raises the concern of iatrogenic subarachnoid hemorrhage (SAH) owing to increasing complexity in device navigation and retrieval. This study aims to determine the prevalence of SAH following mechanical thrombectomy, associated predictors, and resulting functional outcomes using a multicenter registry and compare this with a systematic review and meta-analysis of the literature. Methods: Data from STRATIS (The Systematic Evaluation of Patients Treated with Neurothrombectomy Devices for Acute Ischemic Stroke) registry were analyzed dichotomized by the presence or absence of SAH after thrombectomy. Only patients with 24-h post-procedural neuroimaging were included (n = 841). Multivariable logistic regression was performed to identify significant predictors of SAH. A systematic review and random-effects meta-analysis was also conducted in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analysis) protocol. Results: The prevalence of post-thrombectomy SAH was 5.23% in STRATIS with 15.9% (1.84% overall) experiencing neurological decline. Distal location of vessel occlusion (OR 3.41 [95% CI: 1.75-6.63], p < 0.001) and more than 3 device passes (OR 1.34 [95% CI: 1.09-1.64], p = 0.01) were associated with a higher probability of SAH in contrast to a reduction with administration of intravenous tissue plasminogen activator (tPA) (OR 0.48 [95% CI: 0.26-0.89], p = 0.02). There was a trend toward a higher discharge NIHSS (8.3 ± 8.7 vs. 5.3 ± 6.6, p = 0.07) with a significantly reduced proportion achieving functional independence at 90 days (modified Rankin Score 0-2: 32.5% vs. 57.8%, p = 0.002) in SAH patients. Pooled analysis of 10,126 patients from 6 randomized controlled trials and 64 observational studies demonstrated a prevalence of 5.85% [95% CI: 4.51-7.34%, I 2: 85.2%]. Only location of vessel occlusion was significant for increased odds of SAH at distal sites (OR 2.89 [95% CI: 1.14, 7.35]). Conclusions: Iatrogenic SAH related to mechanical thrombectomy is more common with treatment of distally-situated occlusions and multiple device passes. While low in overall prevalence, its effect is not benign with fewer patients reaching post-procedural functional independence, particularly if symptomatic.
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Affiliation(s)
- Hubert Lee
- Division of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, Toronto, ON, Canada.,Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, United States
| | - Ayman M Qureshi
- Division of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, Toronto, ON, Canada.,Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, UCLH NHS Foundation Trust, London, United Kingdom
| | | | - Osama O Zaidat
- Neuroscience Institute, St Vincent Mercy Medical Center, Toledo, OH, United States
| | - Michael T Froehler
- Department of Neurology, Vanderbilt University Medical Center, Nashville, TN, United States
| | - David S Liebeskind
- Department of Neurology, University of California, Los Angeles, Los Angeles, CA, United States
| | - Vitor M Pereira
- Division of Neuroradiology, Joint Department of Medical Imaging, Toronto Western Hospital, Toronto, ON, Canada.,Therapeutic Neuroradiology & Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
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13
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Memon MZ, Daniel D, Chaudhry MRA, Grewal M, Saini V, Lukas J, Siddu M, Algahtani R, Nisar T, Majidi S, Leon Guerrero CR, Burger KM, Greenberg E, Khandelwal P, Malik AM, Starke RM, Koch S, Yavagal DR. Clinical impact of the first pass effect on clinical outcomes in patients with near or complete recanalization during mechanical thrombectomy for large vessel ischemic stroke. J Neuroimaging 2021; 31:743-750. [PMID: 33930218 DOI: 10.1111/jon.12864] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 03/22/2021] [Accepted: 03/23/2021] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND AND PURPOSE The first pass effect has been reported as a mechanical thrombectomy (MT) success metric in patients with large vessel occlusive stroke. We aimed to compare the clinical and neuroimagign outcomes of patients who had favorable recanalization (mTICI 2c or mTICI 3) achieved in one pass versus those requiring multiple passes. METHODS In this "real-world" multicenter study, patients with mTICI 2c or 3 recanalization were identified from three prospectively collected stroke databases from January 2016 to December 2019. Clinical outcomes were a favorable functional outcome at 90 days (modified Rankin Scale score 0-2), and the rate of symptomatic intracranial hemorrhage (ICH) any ICH, and 90-day mortality. RESULTS Favorable recanalization was achieved in 390/664 (59%) of consecutive patients who underwent MT (age 71.2 ± 13.2 years, 188 [48.2%] women). This was achieved after a single thrombectomy pass (n = 290) or multiple thrombectomy passes (n = 100). The rate of favorable clinical outcome was higher (41% vs. 28 %, p = .02) in the first pass group with a continued trend on multivariate analysis that did not reaching statistical significance (OR 1.68 95% confidence interval [CI] 1.0-2.95, p = .07). Similarly, the odds of any ICH were significantly lower (OR 0.56 CI 0.32-0.97, p = .03). A similar trend of favorable clinical outcomes was noticed on subgroup analysis of patients with M1 occlusion (OR 1.81 CI 1.01-3.61, p = .08). CONCLUSION The first-pass reperfusion was associated with a trend toward favorable clinical outcome and lower rates of ICH. These data suggest that the first-pass effect should be the mechanical thrombectomy procedure goal.
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Affiliation(s)
- Muhammad Zeeshan Memon
- Department of Neurology, University of Miami, Miami, Florida, USA.,Department of Neurosurgery Rutgers, The State University of New Jersey, Newark, New Jersey, USA
| | - David Daniel
- Department of Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Neurology, George Washington University, Washington, DC, USA
| | | | - Manjot Grewal
- Department of Neurology, George Washington University, Washington, DC, USA
| | - Vasu Saini
- Department of Neurology, University of Miami, Miami, Florida, USA.,Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - Joshua Lukas
- Department of Neurology, University of Miami, Miami, Florida, USA
| | - Mithilesh Siddu
- Department of Neurology, University of Miami, Miami, Florida, USA.,Department of Neurology, George Washington University, Washington, DC, USA
| | - Rami Algahtani
- Department of Neurology, University of Miami, Miami, Florida, USA.,Department of Neurology, George Washington University, Washington, DC, USA.,Department of Medicine, Umm Alqura University, Makkah, Saudi Arabia
| | - Taha Nisar
- Department of Neurosurgery Rutgers, The State University of New Jersey, Newark, New Jersey, USA
| | - Shahram Majidi
- Department of Neurology and Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA.,Department of Neurology, George Washington University, Washington, DC, USA
| | | | - Kathleen M Burger
- Department of Neurology, George Washington University, Washington, DC, USA
| | | | - Priyank Khandelwal
- Department of Neurology, University of Miami, Miami, Florida, USA.,Department of Neurosurgery Rutgers, The State University of New Jersey, Newark, New Jersey, USA
| | - Amer M Malik
- Department of Neurology, University of Miami, Miami, Florida, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami, Miami, Florida, USA
| | - Sebastian Koch
- Department of Neurology, University of Miami, Miami, Florida, USA
| | - Dileep R Yavagal
- Department of Neurology, University of Miami, Miami, Florida, USA.,Department of Neurological Surgery, University of Miami, Miami, Florida, USA
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14
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Watershed subarachnoid hemorrhage after middle cerebral artery rescue stenting in patients with acute ischemic stroke. Neuroradiology 2021; 63:1383-1388. [PMID: 33760956 PMCID: PMC8295148 DOI: 10.1007/s00234-021-02692-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 03/15/2021] [Indexed: 11/24/2022]
Abstract
Cortical subarachnoid hemorrhage is an infrequent subtype of non-aneurysmal subarachnoid hemorrhage, rarely reported in watershed territories (wSAH) after carotid stenting. It has never been reported after treatment of middle cerebral artery stenosis (MCAS) that is increasingly used in selected patients, as rescue treatment of failed mechanical thrombectomy, due to recent advancements in endovascular interventions. We present a series of patients with MCAS that developed a wSAH after stenting.
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15
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den Hartog SJ, Zaidat O, Roozenbeek B, van Es ACGM, Bruggeman AAE, Emmer BJ, Majoie CBLM, van Zwam WH, van den Wijngaard IR, van Doormaal PJ, Lingsma HF, Burke JF, Dippel DWJ. Effect of First-Pass Reperfusion on Outcome After Endovascular Treatment for Ischemic Stroke. J Am Heart Assoc 2021; 10:e019988. [PMID: 33739141 PMCID: PMC8174317 DOI: 10.1161/jaha.120.019988] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background First‐pass reperfusion (FPR) is associated with favorable outcome after endovascular treatment. It is unknown whether this effect is independent of patient characteristics and whether FPR has better outcomes compared with excellent reperfusion (Expanded Thrombolysis in Cerebral Infarction [eTICI] 2C‐3) after multiple‐passes reperfusion. We aimed to evaluate the association between FPR and outcome with adjustment for patient, imaging, and treatment characteristics to single out the contribution of FPR. Methods and Results FPR was defined as eTICI 2C‐3 after 1 pass. Multivariable regression models were used to investigate characteristics associated with FPR and to investigate the effect of FPR on outcomes. We included 2686 patients of the MR CLEAN (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) Registry. Factors associated with FPR were as follows: history of hyperlipidemia (adjusted odds ratio [OR], 1.05; 95% CI, 1.01–1.10), middle cerebral artery versus intracranial carotid artery occlusion (adjusted OR, 1.11; 95% CI, 1.06–1.16), and aspiration versus stent thrombectomy (adjusted OR, 1.07; 95% CI, 1.03–1.11). Interventionist experience increased the likelihood of FPR (adjusted OR, 1.03 per 50 patients previously treated; 95% CI, 1.01–1.06). Adjusted for patient, imaging, and treatment characteristics, FPR remained associated with a better 24‐hour National Institutes of Health Stroke Scale (NIHSS) score (−37%; 95% CI, −43% to −31%) and a better modified Rankin Scale (mRS) score at 3 months (adjusted common OR, 2.16; 95% CI, 1.83–2.54) compared with no FPR (multiple‐passes reperfusion+no excellent reperfusion), and compared with multiple‐passes reperfusion alone (24‐hour NIHSS score, (−23%; 95% CI, −31% to −14%), and mRS score (adjusted common OR, 1.45; 95% CI, 1.19–1.78)). Conclusions FPR compared with multiple‐passes reperfusion is associated with favorable outcome, independently of patient, imaging, and treatment characteristics. Factors associated with FPR were the experience of the interventionist, history of hyperlipidemia, location of occluded artery, and use of an aspiration device compared with stent thrombectomy.
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Affiliation(s)
- Sanne J den Hartog
- Department of Neurology Erasmus MC, University Medical Center Rotterdam the Netherlands.,Department of Radiology and Nuclear Medicine Erasmus MC, University Medical Center Rotterdam the Netherlands.,Department of Public Health Erasmus MC, University Medical Center Rotterdam the Netherlands
| | - Osama Zaidat
- Department of Neurology Mercy St. Vincent Medical Center Toledo OH United States of America
| | - Bob Roozenbeek
- Department of Neurology Erasmus MC, University Medical Center Rotterdam the Netherlands.,Department of Radiology and Nuclear Medicine Erasmus MC, University Medical Center Rotterdam the Netherlands
| | - Adriaan C G M van Es
- Department of Radiology and Nuclear Medicine Leiden University Medical Center Leiden the Netherlands
| | - Agnetha A E Bruggeman
- Department of Radiology and Nuclear Medicine Amsterdam University Medical Centers, location AMC Amsterdam the Netherlands
| | - Bart J Emmer
- Department of Radiology and Nuclear Medicine Amsterdam University Medical Centers, location AMC Amsterdam the Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine Amsterdam University Medical Centers, location AMC Amsterdam the Netherlands
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine Cardiovascular Research Institute MaastrichtMaastricht University Medical Center Maastricht the Netherlands
| | | | - Pieter Jan van Doormaal
- Department of Radiology and Nuclear Medicine Erasmus MC, University Medical Center Rotterdam the Netherlands
| | - Hester F Lingsma
- Department of Public Health Erasmus MC, University Medical Center Rotterdam the Netherlands
| | - James F Burke
- Department of Neurology University of Michigan Ann Arbor MI United States of America
| | - Diederik W J Dippel
- Department of Neurology Erasmus MC, University Medical Center Rotterdam the Netherlands
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16
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Is the detectability of the spot sign on CT angiography depending on slice thickness and reconstruction type? Clin Neurol Neurosurg 2021; 203:106559. [PMID: 33618171 DOI: 10.1016/j.clineuro.2021.106559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 02/08/2021] [Accepted: 02/09/2021] [Indexed: 10/22/2022]
Abstract
OBJECTIVE The spot sign is a validated imaging marker widely used in CT angiography (CTA) to detect active bleeding and a higher risk of hematoma expansion in patients with intracerebral hemorrhage (ICH). The aim of this study was to investigate the detectability of spot signs on thin multiplanar projection reconstruction (MPR) images compared to thicker maximum intensity projection (MIP) images. METHODS In this retrospective analysis, we assessed imaging data of 146 patients with primary hypertensive/microangiopathic ICH who received emergency non-contrast computed tomography (NCCT) and CTA. Two experienced radiologists, blinded to each other, evaluated images of thin (1 mm) MPR images and thick (3 mm) MIP images on the presence of spot signs and performed a consensus reading. Kappa tests were used for data comparison. RESULTS In total, spot signs were observed in 27 cases (=18.5 %) in both thin MPR and thick MIP slices. Detectability of the spot sign did not differ in 1 mm MPR images and 3 mm MIP images (Cohen's kappa, 1.0; p = 0.00). Also, when the readings of the two radiologists were analyzed separately, results for MPR and MIP slices were similar (MPR: Cohen's kappa, 0.81, p = 0.00; MIP: Cohen's kappa, 0.74; p = 0.00). CONCLUSION No significant difference in the detectability of the spot sign could be demonstrated when comparing 1 mm MPR images with 3 mm MIP images.
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17
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Kitano T, Sakaguchi M, Yamagami H, Ishikawa T, Ishibashi-Ueda H, Tanaka K, Okazaki S, Sasaki T, Kadono Y, Takagaki M, Nishida T, Nakamura H, Yanase M, Fukushima N, Shiozawa M, Toyoda K, Takahashi JC, Funatsu T, Ryu B, Yoshioka D, Toda K, Murayama S, Kawamata T, Kishima H, Sawa Y, Mochizuki H, Todo K. Mechanical thrombectomy in acute ischemic stroke patients with left ventricular assist device. J Neurol Sci 2020; 418:117142. [PMID: 32977225 DOI: 10.1016/j.jns.2020.117142] [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: 06/18/2020] [Revised: 08/24/2020] [Accepted: 09/14/2020] [Indexed: 01/27/2023]
Abstract
OBJECTIVES As the number of patients with left ventricular assist device (LVAD) implantation has been increasing, treatment of LVAD-related ischemic stroke is becoming a critical issue. We sought to clarify the features of mechanical thrombectomy in LVAD-related stroke with large vessel occlusion. METHODS In a multi-center, retrospective case-control study, we compared 20 LVAD-related strokes with 33 non-LVAD strokes, all of which had large vessel occlusion in the anterior circulation treated with mechanical thrombectomy. A comparative histopathological examination of the retrieved thrombi was also performed. RESULTS Successful reperfusion was achieved in 75% of the LVAD-related strokes. The time from onset to reperfusion was similar to that of non-LVAD strokes, but the total number of device passes required for reperfusion (median, 2.5 versus 1, P = 0.01) and the incidences of post-procedural parenchymal and subarachnoid hemorrhage (25% versus 3%, P = 0.02 and 55% versus 15%, P = 0.01, respectively) were higher in LVAD-related strokes. Symptomatic intracranial hemorrhage occurred in 4 patients (20%) with LVAD-related strokes. The histopathological analysis revealed that the ratio of erythrocyte components was significantly lower in thrombi retrieved from patients with LVAD-related stroke than in those with non-LVAD stroke (19 ± 6% versus 41 ± 17%, P = 0.01). CONCLUSIONS Mechanical thrombectomy is feasible in patients with LVAD-related stroke. However, repetitive device passes are needed to achieve successful reperfusion mainly because of the structurally organized thrombi, and the higher risk of hemorrhagic complications should be considered, while offering this therapeutic alternative.
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Affiliation(s)
- Takaya Kitano
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Manabu Sakaguchi
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hiroshi Yamagami
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Tatsuya Ishikawa
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | | | - Kanta Tanaka
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Shuhei Okazaki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tsutomu Sasaki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshinori Kadono
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Masatoshi Takagaki
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takeo Nishida
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hajime Nakamura
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Masanobu Yanase
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Norihide Fukushima
- Department of Transplant Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Jun C Takahashi
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Osaka, Japan
| | - Takayuki Funatsu
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Bikei Ryu
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Daisuke Yoshioka
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Koichi Toda
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shigeo Murayama
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Takakazu Kawamata
- Department of Neurosurgery, Tokyo Women's Medical University, Tokyo, Japan
| | - Haruhiko Kishima
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yoshiki Sawa
- Department of Cardiovascular Surgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hideki Mochizuki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kenichi Todo
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan.
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Enomoto M, Shigeta K, Ota T, Amano T, Ueda M, Matsumaru Y, Shiokawa Y, Hirano T. Predictors of intracranial hemorrhage in acute ischemic stroke after endovascular thrombectomy. Interv Neuroradiol 2020; 26:368-375. [PMID: 32475194 DOI: 10.1177/1591019920926335] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Limited data are available regarding the predictors, clinical relevance, and bleeding rate by surgical devices of intracranial hemorrhage after endovascular thrombectomy. This is partially explained by the difference in the classification and definition of hemorrhage among studies. The purpose of this study was to identify the predictors of hemorrhagic transformation and isolated subarachnoid hemorrhage after endovascular thrombectomy. METHODS This was a retrospective, multicenter observational cohort study of consecutive patients who underwent endovascular thrombectomy between January 2015 and December 2018. Univariate and logistic regression analyses were performed to determine the predictors, the impact on clinical outcomes, and the bleeding rate by surgical devices of hemorrhagic transformation and isolated subarachnoid hemorrhage. RESULTS Among 610 eligible patients, hemorrhagic transformations occurred in 93 (15.2%). Fourteen patients (2.3%) were classified as having symptomatic intracranial hemorrhage. Isolated subarachnoid hemorrhage was found in 60 (9.8%) patients. In the logistic regression analyses, diabetes mellitus (odds ratio: 1.92; 95% confidence interval: 1.06-3.49) was associated with hemorrhagic transformation, and the number of device passes (odds ratio: 1.33; 95% confidence interval: 1.11-1.59) was associated with isolated subarachnoid hemorrhage. Both hemorrhagic transformation and isolated subarachnoid hemorrhage were associated with poor 90-day functional outcomes. There was a significant correlation between treatment with stent retrievers and isolated subarachnoid hemorrhage. CONCLUSIONS Patients with diabetes mellitus were vulnerable to hemorrhagic transformation, whereas those who underwent several attempts of thrombectomy were susceptible to isolated subarachnoid hemorrhage. Both hemorrhage types worsened the functional outcome. Treatment with the stent retriever was significantly associated with postprocedural isolated subarachnoid hemorrhage.
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Affiliation(s)
- Masaya Enomoto
- Department of Neurosurgery, National Hospital Organization Disaster Medical Center, Tokyo, Japan
| | - Keigo Shigeta
- Department of Neurosurgery, National Hospital Organization Disaster Medical Center, Tokyo, Japan
| | - Takahiro Ota
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Tatsuo Amano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Tokyo, Japan
| | - Masayuki Ueda
- Department of Neurology and Stroke Medicine, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Yuji Matsumaru
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | | | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Tokyo, Japan
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Sun Y, Su Y, Chen Z, He Y, Zhang Y, Chen H. Contrast Extravasation After Endovascular Treatment in Posterior Circulation Stroke. World Neurosurg 2019; 130:e583-e587. [PMID: 31254696 DOI: 10.1016/j.wneu.2019.06.156] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2019] [Revised: 06/17/2019] [Accepted: 06/19/2019] [Indexed: 01/01/2023]
Abstract
OBJECTIVE Endovascular treatment (EVT) is a promising clinical technology. However, some patients with posterior circulation stroke might not experience neurological function recovery after EVT. We reviewed the recent experience with EVT to clarify the clinical and radiographic factors that contribute to optimal neurological outcomes. METHODS We analyzed the data from 108 consecutive patients with acute posterior circulation stroke who had undergone EVT from January 2016 to December 2018. A favorable outcome was defined as a modified Rankin scale score of 0-3 at 3 months. We evaluated the association and predictive value of the clinical and radiographic factors that contribute to good neurological outcomes. RESULTS Of the 108 included patients, 43 had a favorable clinical outcome at day 90. Univariate analysis revealed a significant association between the 90-day favorable outcome and the baseline values of systolic blood pressure, time of stroke onset, contrast extravasation, symptomatic intracranial hemorrhage, general anesthesia, Alberta stroke program early computed tomography score for the posterior circulation, and the National Institutes of Health stroke scale (NIHSS) score. Contrast extravasation (odds ratio [OR], 5.094; 95% confidence interval [CI], 1.22-21.261), symptomatic intracranial hemorrhage (OR, 11.24; 95% CI, 1.309-96.517), general anesthesia (OR, 5.094; 95% CI, 1.22-21.26), and baseline NIHSS score (OR, 1.087; 95% CI, 1.023-1.309) were found to be independent predictors of a favorable outcome at day 90. Contrast extravasation alone predicted for unfavorable clinical outcomes and mortality with high specificity. CONCLUSION In the present retrospective case series, contrast extravasation, symptomatic intracranial hemorrhage, the use of general anesthesia, and baseline NIHSS score were related to a favorable prognosis for patients with posterior circulation stroke after EVT. Contrast extravasation was an independent and strong predictor of unfavorable clinical outcomes.
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Affiliation(s)
- Yijia Sun
- Department of Neurology, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Yingying Su
- Department of Neurology, Xuan Wu Hospital, Capital Medical University, Beijing, China.
| | - Zhongyun Chen
- Department of Neurology, Xuan Wu Hospital, Capital Medical University, Beijing, China
| | - Yanbo He
- Department of Neurology, Beijing Moslem People Hospital, Beijing, China
| | - Yingbo Zhang
- Department of Neurology, Beijing Tsinghua Changgung Hospital, Affiliated With Tsinghua University, Beijing, China
| | - Hongbo Chen
- Department of Neurology, Liangxiang Hospital of Beijing, Beijing, China
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20
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Raychev R, Saver JL, Jahan R, Nogueira RG, Goyal M, Pereira VM, Gralla J, Levy EI, Yavagal DR, Cognard C, Liebeskind DS. The impact of general anesthesia, baseline ASPECTS, time to treatment, and IV tPA on intracranial hemorrhage after neurothrombectomy: pooled analysis of the SWIFT PRIME, SWIFT, and STAR trials. J Neurointerv Surg 2019; 12:2-6. [PMID: 31239326 DOI: 10.1136/neurintsurg-2019-014898] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/08/2019] [Accepted: 05/12/2019] [Indexed: 01/16/2023]
Abstract
BACKGROUND Despite the proven benefit of neurothrombectomy, intracranial hemorrhage (ICH) remains the most serious procedural complication. The aim of this analysis was to identify predictors of different hemorrhage subtypes and evaluate their individual impact on clinical outcome. METHODS Pooled individual patient-level data from three large prospective multicenter studies were analyzed for the incidence of different ICH subtypes, including any ICH, hemorrhagic transformation (HT), parenchymal hematoma (PH), subarachnoid hemorrhage (SAH), and symptomatic intracranial hemorrhage (sICH). All patients (n=389) treated with the Solitaire device were included in the analysis. A multivariate stepwise logistic regression model was used to identify predictors of each hemorrhage subtype. RESULTS General anesthesia and higher baseline Alberta Stroke Program Early CT score (ASPECTS) were associated with a lower probability of any ICH (OR 0.36, p=0.003), (OR 0.80, p=0.032) and HT (OR 0.54, p=0.023), (OR 0.78, p=0.001), respectively. Longer time from onset to treatment was associated with a higher likelihood of HT (OR 1.08, p=0.001) and PH (OR 1.11, p=0.015). Intravenous tissue plasminogen activator (IV-tPA) was also a strong predictor of PH (OR 7.63, p=0.013). Functional independence at 90 days (modified Rankin Scale (mRS) 0-2) was observed significantly less frequently in all hemorrhage subtypes except SAH. None of the patients who achieved functional independence at 90 days had sICH. CONCLUSIONS General anesthesia and smaller baseline ischemic core are associated with a lower probability of HT whereas IV-tPA and prolonged time to treatment increase the risk of PH after neurothrombectomy. TRIAL REGISTRATION NUMBERS SWIFT-NCT01054560; post results, SWIFT PRIME-NCT01657461; post results, STAR-NCT01327989; post results.
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Affiliation(s)
- Radoslav Raychev
- Department of Neurology and Comprehensive Stroke Center, University of California Los Angeles David Geffen School of Medicine, Los Angeles, California, USA
| | - Jeffrey L Saver
- Division of Interventional Neuroradiology, University of California Los Angeles Medical Center, Los Angeles, California, USA
| | - Reza Jahan
- Grady Memorial Hospital Marcus Stroke & Neuroscience Center, Atlanta, Georgia, USA
| | - Raul G Nogueira
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Mayank Goyal
- Departments of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Vitor M Pereira
- Division of Neuroradiology, Medical Imaging, University Health Network - Toronto Western Hospital, Toronto, Ontario, Canada
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Elad I Levy
- Department of Neurosurgery, State University of New York, Buffalo, New York, USA
| | - Dileep R Yavagal
- University of Miami and Jackson Memorial Hospitals, Miami, Florida, USA
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France
| | - David S Liebeskind
- Department of Neurology, University of California Los Angeles, Neurovascular Imaging Research Core, Los Angeles, California, USA
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Nikoubashman O, Dekeyzer S, Riabikin A, Keulers A, Reich A, Mpotsaris A, Wiesmann M. True First-Pass Effect. Stroke 2019; 50:2140-2146. [PMID: 31216965 DOI: 10.1161/strokeaha.119.025148] [Citation(s) in RCA: 135] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Background and Purpose- It has been hypothesized that in stroke patients, complete reperfusion (modified Thrombolysis in Cerebral Infarction; mTICI 3) after a single thrombectomy pass is a predictor for favorable outcome (modified Rankin Scale score, 0-2), but a true first-pass effect defined as improved clinical outcome after complete reperfusion with one versus multiple passes has not yet been specifically addressed in the literature. Methods- We compared clinical outcome of 164 consecutive patients with occlusions in the anterior circulation and known symptom onset, in whom we achieved complete reperfusion (mTICI 3), depending on whether complete reperfusion was achieved after a single thrombectomy pass (n=62) or multiple thrombectomy passes (n=102). To adjust for confounding factors such as prolonged time spans between symptom onset and reperfusion, additional administration of intra-arterial thrombolysis, and clot localization, we also compared clinical outcome of our first-pass group with a matched cohort (n=54) and a superselective subgroup of first-pass patients (only M1 occlusions, no additional intra-arterial thrombolysis; n=46) with its matched cohort (n=24). Results- Multivariable analysis of our cohort of 164 nonmatched patients revealed that there was a significant association between first-pass complete reperfusion and favorable clinical outcome (P=0.013). This was confirmed in our case-control analyses (P=0.010 and P=0.042). In our matched cohorts, favorable clinical outcome was seen almost twice as often if complete reperfusion was achieved after one pass (62% and 67% versus 36% and 37%), and odds for favorable outcome were 2.4 to 3.2× higher (CIs, 1.1-4.8 and 1.0-9.9). Conclusions- First-pass complete reperfusion is an independent factor for favorable outcome and should be aimed for in mechanical thrombectomy.
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Affiliation(s)
- Omid Nikoubashman
- From the Department of Neuroradiology (O.N., S.D., A. Riabikin, A.K., A.M., M.W.), University Hospital RWTH Aachen, Germany
| | - Sven Dekeyzer
- From the Department of Neuroradiology (O.N., S.D., A. Riabikin, A.K., A.M., M.W.), University Hospital RWTH Aachen, Germany
| | - Alexander Riabikin
- From the Department of Neuroradiology (O.N., S.D., A. Riabikin, A.K., A.M., M.W.), University Hospital RWTH Aachen, Germany
| | - Annika Keulers
- From the Department of Neuroradiology (O.N., S.D., A. Riabikin, A.K., A.M., M.W.), University Hospital RWTH Aachen, Germany
| | - Arno Reich
- Department of Neurology (A. Reich), University Hospital RWTH Aachen, Germany
| | - Anastasios Mpotsaris
- From the Department of Neuroradiology (O.N., S.D., A. Riabikin, A.K., A.M., M.W.), University Hospital RWTH Aachen, Germany
| | - Martin Wiesmann
- From the Department of Neuroradiology (O.N., S.D., A. Riabikin, A.K., A.M., M.W.), University Hospital RWTH Aachen, Germany
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22
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Puntonet J, Richard ME, Edjlali M, Ben Hassen W, Legrand L, Benzakoun J, Rodriguez-Régent C, Trystram D, Naggara O, Méder JF, Boulouis G, Oppenheim C. Imaging Findings After Mechanical Thrombectomy in Acute Ischemic Stroke. Stroke 2019; 50:1618-1625. [PMID: 31060439 DOI: 10.1161/strokeaha.118.024754] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Julien Puntonet
- From the Imaging Department, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266 INSERM, Sainte-Anne Hospital, Paris Descartes University, France
| | - Marie-Edith Richard
- From the Imaging Department, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266 INSERM, Sainte-Anne Hospital, Paris Descartes University, France
| | - Myriam Edjlali
- From the Imaging Department, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266 INSERM, Sainte-Anne Hospital, Paris Descartes University, France
| | - Wagih Ben Hassen
- From the Imaging Department, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266 INSERM, Sainte-Anne Hospital, Paris Descartes University, France
| | - Laurence Legrand
- From the Imaging Department, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266 INSERM, Sainte-Anne Hospital, Paris Descartes University, France
| | - Joseph Benzakoun
- From the Imaging Department, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266 INSERM, Sainte-Anne Hospital, Paris Descartes University, France
| | - Christine Rodriguez-Régent
- From the Imaging Department, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266 INSERM, Sainte-Anne Hospital, Paris Descartes University, France
| | - Denis Trystram
- From the Imaging Department, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266 INSERM, Sainte-Anne Hospital, Paris Descartes University, France
| | - Olivier Naggara
- From the Imaging Department, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266 INSERM, Sainte-Anne Hospital, Paris Descartes University, France
| | - Jean-Francois Méder
- From the Imaging Department, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266 INSERM, Sainte-Anne Hospital, Paris Descartes University, France
| | - Grégoire Boulouis
- From the Imaging Department, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266 INSERM, Sainte-Anne Hospital, Paris Descartes University, France
| | - Catherine Oppenheim
- From the Imaging Department, Institut de Psychiatrie et Neurosciences de Paris (IPNP), UMR_S1266 INSERM, Sainte-Anne Hospital, Paris Descartes University, France
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23
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Kadono Y, Nakamura H, Saito S, Nishida T, Takagaki M, Shigematsu T, Asai K, Murakami T, Todo K, Fujinaka T, Sakaguchi M, Toda K, Sawa Y, Kishima H. Endovascular treatment for large vessel occlusion stroke in patients with ventricular assist devices. J Neurointerv Surg 2019; 11:1205-1209. [DOI: 10.1136/neurintsurg-2018-014645] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2019] [Revised: 04/11/2019] [Accepted: 04/18/2019] [Indexed: 11/04/2022]
Abstract
BackgroundEmbolic stroke with large vessel occlusion (LVO) is a major adverse event during ventricular assist device (VAD) support. In this study we aimed to clarify the efficacy of, and problems associated with, endovascular treatment (EVT) of LVO in patients with VAD support.MethodsWe retrospectively reviewed EVT for LVO in patients with VAD support between 2006 and 2017 at our institute and evaluated baseline characteristics, treatment variables, outcomes, and complications.ResultsThe study cohort comprised 12 consecutive patients (age 35.4±20.4 years), with 15 LVO events involving 20 arterial occlusions, who had undergone EVT. The median Alberta Stroke Program Early CT score was 10 and good collaterals were observed in 10 of 17 occluded middle cerebral artery areas. No study patients had received intravenous thrombolysis therapy. EVT was performed on 18 of the 20 occluded arteries and mechanical thrombectomy on 13 vessels. The successful reperfusion (modified Thrombolysis in Cerebral Infarction grade ≥2 b) rate was 67% in all EVTs and 85% with mechanical thrombectomy. Histological analysis showed fibrin-rich thrombi in four of five samples. Seven of 12 patients (58%) maintained their neurological function (modified Rankin Scale score ≤2 or equal to pre-stroke score) at 90 days. Periprocedural complications comprised two symptomatic intracranial hemorrhages and the 90-day mortality rate was 13%. Seven of 10 cardiac transplant candidates (70%) returned to the waiting list and three of them received transplants.ConclusionsEndovascular therapy for acute LVO stroke is feasible even in patients with VAD support.
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24
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Keulers A, Nikoubashman O, Mpotsaris A, Wilson SD, Wiesmann M. Preventing vessel perforations in endovascular thrombectomy: feasibility and safety of passing the clot with a microcatheter without microwire: the wireless microcatheter technique. J Neurointerv Surg 2018; 11:653-658. [PMID: 30530771 DOI: 10.1136/neurintsurg-2018-014267] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2018] [Revised: 11/09/2018] [Accepted: 11/12/2018] [Indexed: 11/04/2022]
Abstract
BACKGROUND To place a stent retriever for thrombectomy in acute ischemic stroke, the clot has to be passed first. A microwire is usually used for this maneuver. As an alternative, a wireless microcatheter can be used to pass the clot. OBJECTIVE To analyze the feasibility and complication rates of passing the clot using either a microwire or a wireless microcatheter. METHODS A retrospective non-randomized analysis of 110 consecutive patients with acute ischemic stroke in the anterior circulation was performed, in whom video recordings of mechanical thrombectomies were available. In total, 203 attempts at mechanical recanalization were performed. RESULTS Successful recanalization (TICI 2b-3) was achieved in 97.3% of patients. In 71.8% of attempts the clot was successfully passed using a wireless microcatheter only. When a microwire was used initially, clot passage was successful in 95.3% of attempts. Complication rates for angiographically detectable subarachnoid hemorrhage were 6.1% when a microwire was used to pass the clot compared with 0% when a wireless microcatheter was used (p<0.001). Complication rates for angiographically occult circumscribed subarachnoid contrast extravasation observed on post-interventional CT scans were 18.2% when a microwire was used to pass the clot and 4.5% when a wireless microcatheter was used (p<0.001). CONCLUSIONS In most cases of mechanical recanalization the clot can be passed with a wireless microcatheter instead of a microwire. In our study this method significantly reduced the risk for vessel perforation and subarachnoid hemorrhage. We therefore recommend the use of this technique whenever possible.
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Affiliation(s)
- Annika Keulers
- Department of Neuroradiology, University Hospital Aachen, Aachen, Germany
| | - Omid Nikoubashman
- Department of Neuroradiology, University Hospital Aachen, Aachen, Germany
| | | | | | - Martin Wiesmann
- Department of Neuroradiology, University Hospital Aachen, Aachen, Germany
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25
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Heinrichs A, Nikoubashman O, Schürmann K, Tauber SC, Wiesmann M, Schulz JB, Reich A. Relevance of standard intravenous thrombolysis in endovascular stroke therapy of a tertiary stroke center. Acta Neurol Belg 2018; 118:105-111. [PMID: 29435828 DOI: 10.1007/s13760-018-0892-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 02/01/2018] [Indexed: 11/26/2022]
Abstract
The majority of patients undergoing endovascular stroke treatment (EST) in randomized controlled trials received additional systemic thrombolysis ("combination or bridging therapy (C/BT)"). Nevertheless, its usefulness in this subtype of acute ischemic stroke (AIS) is discussed controversially. Of all consecutive AIS patients, who received any kind of reperfusion therapy in a tertiary university stroke center between January 2015 and March 2016, those with large vessel occlusions (LVO) and EST with or without additional C/BT, were compared primarily regarding procedural aspects. Data were extracted from an investigator-initiated, single-center, prospective and blinded end-point study. 70 AIS patients with EST alone and 118 with C/BT were identified. Significant baseline differences existed in pre-existing cardiovascular disease (52.9% (EST alone) vs. 35.6% (C/BT), p = 0.023), use of anticoagulation (30.6% vs. 5.9%, p < 0.001), and frequency of unknown time of symptom onset (65.7% vs. 32.2%, p < 0.001), in-hospital stroke (18.6% vs. 1.7%, p < 0.001), pre-treatment ASPECT scores (7.9 vs. 8.9, p = 0.004), and frequency of occlusion in the posterior circulation (18.6% vs. 5.1%, p = 0.003). Pre-interventional procedural time intervals tended to be shorter in the C/BT group, reaching statistical significance in door-to-image time (30.3 (EST alone) vs. 22.2 min (C/BT), p < 0.001). Good clinical outcome (mRS d90) was reached more often in the C/BT group (24.5% vs. 11.8%, p = 0.064). Rates of symptomatic intracranial hemorrhages (sICH) were comparable (4.3% (EST alone) vs. 6.8% (C/BT), p = 0.481). Additional systemic thrombolysis did not delay EST. On the contrary, application of IVRTPA seemed to be a positive indicator for faster EST without increased side effects.
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Affiliation(s)
- Annette Heinrichs
- Department of Neurology, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Omid Nikoubashman
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, 52074, Aachen, Germany
| | - Kolja Schürmann
- Department of Neurology, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Simone C Tauber
- Department of Neurology, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, 52074, Aachen, Germany
| | - Jörg B Schulz
- Department of Neurology, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
- JARA-BRAIN Institute Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH and RWTH Aachen University, Aachen, Germany
| | - Arno Reich
- Department of Neurology, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany.
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Improvement of Endovascular Stroke Treatment: A 24-Hour Neuroradiological On-Site Service Is Not Enough. BIOMED RESEARCH INTERNATIONAL 2018. [PMID: 29516015 PMCID: PMC5817218 DOI: 10.1155/2018/9548743] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background and Purpose With the advent of endovascular stroke treatment (EST) with mechanical thrombectomy, stroke treatment has also become more challenging. Purpose of this study was to investigate whether a fulltime neuroradiological on-site service and workflow optimization with a structured documentation of the interdisciplinary stroke workflow resulted in improved procedural times. Material and Methods Procedural times of 322 consecutive patients, who received EST (1) before (n = 96) and (2) after (n = 126) establishing a 24-hour neuroradiological on-site service as well as (3) after implementation of a structured interdisciplinary workflow documentation (“Stroke Check”) (n = 100), were analysed. Results A fulltime neuroradiological on-site service resulted in a nonsignificant improvement of procedural times during out-of-hours admissions (p ≥ 0.204). Working hours and out-of-hours procedural times improved significantly, if additional workflow optimization was realized (p ≤ 0.026). Conclusions A 24-hour interventional on-site service is a major prerequisite to adequately provide modern reperfusion therapies in patients with acute ischemic stroke. However, simple measures like standardized and focused documentation that affect the entire interdisciplinary pre- and intrahospital stroke rescue chain seem to be important.
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Nikoubashman O, Nikoubashman A, Büsen M, Wiesmann M. Necessary Catheter Diameters for Mechanical Thrombectomy with ADAPT. AJNR Am J Neuroradiol 2017; 38:2277-2281. [PMID: 29025728 DOI: 10.3174/ajnr.a5401] [Citation(s) in RCA: 41] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2017] [Accepted: 08/07/2017] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Large-bore catheters allow mechanical thrombectomy in ischemic stroke by engaging and retrieving clots without additional devices (direct aspiration first-pass technique [ADAPT]). The purpose of this study was to establish a model for minimal catheter diameters needed for ADAPT. MATERIALS AND METHODS We established a theoretic model for the calculation of minimal catheter diameters needed for ADAPT. We then verified its validity in 28 ADAPT maneuvers in a porcine in vivo model. To account for different mechanical thrombectomy techniques, we factored in ADAPT with/without a hypothetic 0.021-inch microcatheter or 0.014-inch microwire inside the lumen of the aspiration catheter and aspiration with a 60-mL syringe versus an aspiration pump. RESULTS According to our calculations, catheters with an inner diameter of >0.040 inch and >0.064 inch, respectively, are needed to be effective in the middle cerebral artery (2.5-mm diameter) or in the internal carotid artery (4 mm) in an average patient. There was a significant correlation between predicted and actual thrombectomy results (P = .010). Our theoretic model had a positive and negative predictive value of 78% and 79%, respectively. Sensitivity and specificity were 88% and 64%, respectively. CONCLUSIONS Our theoretic model allows estimating the minimal catheter diameters needed for successful mechanical thrombectomy with ADAPT, as demonstrated by the good agreement with our animal experiments. Our model will be helpful to interventionalists in avoiding selecting catheters that are likely too small to be effective.
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Affiliation(s)
- O Nikoubashman
- From the Department of Diagnostic and Interventional Neuroradiology (O.N., M.W.), University Hospital, RWTH Aachen University, Aachen, Germany
| | - A Nikoubashman
- Institute of Physics (A.N.), Johannes Gutenberg University Mainz, Mainz, Germany
| | - M Büsen
- Institute of Applied Medical Engineering (M.B.), RWTH Aachen University, Aachen, Germany
| | - M Wiesmann
- From the Department of Diagnostic and Interventional Neuroradiology (O.N., M.W.), University Hospital, RWTH Aachen University, Aachen, Germany
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Qureshi AI, Saleem MA, Aytac E. Postprocedure Subarachnoid Hemorrhage after Endovascular Treatment for Acute Ischemic Stroke. J Neuroimaging 2017; 27:493-498. [DOI: 10.1111/jon.12430] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2016] [Revised: 12/25/2016] [Accepted: 01/11/2017] [Indexed: 11/30/2022] Open
Affiliation(s)
| | | | - Emrah Aytac
- Zeenat Qureshi Stroke Institute; St. Cloud MN
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Kurre W, Bäzner H, Henkes H. [Mechanical thrombectomy: Acute complications and delayed sequelae]. Radiologe 2016; 56:32-41. [PMID: 26631170 DOI: 10.1007/s00117-015-0050-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Due to the positive evidence for mechanical thrombectomy (mTE), it will be increasingly used in future. Profound knowledge of potential complications, prevention and management of complications is necessary to safely implement mTE into clinical practice. AIM Description of specific complications of mTE and their clinical relevance, measures for prevention and management. Summary of the current knowledge on long-term side effects of mTE. MATERIAL AND METHODS Analysis of current trial results and selected case series to address specific topics. Summary of own practical clinical experience. RESULTS Vascular injury (1-5%) and emboli (5-9%) are the most relevant intraprocedural complications but the clinical outcome is variable. Measures for prevention and management are described in detail. Vasospasms frequently occur (20-26%) but rarely need specific treatment and do not affect the clinical course. In the case of restrictive indications the frequency of symptomatic hemorrhage is similar to that for medicinal treatment (up to 8%). Contrast medium enhancement in the area of the infarction on post-treatment imaging should not be mistaken for hemorrhages. Focal subarachnoid contrast medium enhancement or hemorrhage occurs in up to 24% of cases and is predominantly benign. In follow-up imaging stenoses or occlusions can be detected in 4-10% of the treated vessels, most of which are asymptomatic. They are considered to be caused by microtrauma to the vascular wall. CONCLUSION Clinically relevant complications of mTE are rare. Preventive measures and effective management of complications may even increase safety. Stenoses occasionally occur as a long-term side effect but are asymptomatic in the majority of cases.
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Affiliation(s)
- W Kurre
- Neuroradiologische Klinik, Klinikum Stuttgart, Kriegsbergstrasse 60, 70174, Stuttgart, Deutschand.
| | - H Bäzner
- Neurologische Klinik, Klinikum Stuttgart, Kriegsbergstrasse 60, 70174, Stuttgart, Deutschland
| | - H Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, Kriegsbergstrasse 60, 70174, Stuttgart, Deutschand
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Nikoubashman O, Schürmann K, Probst T, Müller M, Alt JP, Othman AE, Tauber S, Wiesmann M, Reich A. Clinical Impact of Ventilation Duration in Patients with Stroke Undergoing Interventional Treatment under General Anesthesia: The Shorter the Better? AJNR Am J Neuroradiol 2016; 37:1074-9. [PMID: 26822729 DOI: 10.3174/ajnr.a4680] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2015] [Accepted: 11/18/2015] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND PURPOSE Whether general anesthesia for neurothrombectomy in patients with ischemic stroke has a negative impact on clinical outcome is currently under discussion. We investigated the impact of early extubation and ventilation duration in a cohort that underwent thrombectomy under general anesthesia. MATERIALS AND METHODS We analyzed 103 consecutive patients from a prospective stroke registry. They met the following criteria: CTA-proved large-vessel occlusion in the anterior circulation, ASPECTS above 6 on presenting cranial CT, revascularization by thrombectomy with the patient under general anesthesia within 6 hours after onset of symptoms, and available functional outcome (mRS) 90 days after onset. RESULTS The mean ventilation time was 128.07 ± 265.51 hours (median, 18.5 hours; range, 1-1244.7 hours). Prolonged ventilation was associated with pneumonia during hospitalization and unfavorable functional outcome (mRS ≥3) and death at follow-up (Mann-Whitney U test; P ≤ .001). According to receiver operating characteristic analysis, a cutoff after 24 hours predicted unfavorable functional outcome with a sensitivity and specificity of 60% and 78%, respectively. Our results imply that delayed extubation was not associated with a less favorable clinical outcome compared with immediate extubation after the procedure. CONCLUSIONS Short ventilation times are associated with a lower pneumonia rate and more favorable clinical outcome. Cautious interpretation of our data implies that whether patients are extubated immediately after the procedure is irrelevant for clinical outcome as long as ventilation does not exceed 24 hours.
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Affiliation(s)
- O Nikoubashman
- From the Departments of Neuroradiology (O.N., T.P., M.M., J.P.A., M.W.) Institute of Neuroscience and Medicine 4 (O.N.), Forschungszentrum Jülich, Jülich, Germany
| | - K Schürmann
- Neurology (K.S., S.T., A.R.), University Hospital Aachen, Aachen, Germany
| | - T Probst
- From the Departments of Neuroradiology (O.N., T.P., M.M., J.P.A., M.W.)
| | - M Müller
- From the Departments of Neuroradiology (O.N., T.P., M.M., J.P.A., M.W.)
| | - J P Alt
- From the Departments of Neuroradiology (O.N., T.P., M.M., J.P.A., M.W.)
| | - A E Othman
- Department of Radiology (A.E.O.), University Hospital Tübingen, Tübingen, Germany
| | - S Tauber
- Neurology (K.S., S.T., A.R.), University Hospital Aachen, Aachen, Germany
| | - M Wiesmann
- From the Departments of Neuroradiology (O.N., T.P., M.M., J.P.A., M.W.)
| | - A Reich
- Neurology (K.S., S.T., A.R.), University Hospital Aachen, Aachen, Germany
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Nikoubashman O, Probst T, Schürmann K, Othman AE, Matz O, Brockmann MA, Müller M, Wiesmann M, Reich A. Weekend effect in endovascular stroke treatment: do treatment decisions, procedural times, and outcome depend on time of admission? J Neurointerv Surg 2016; 9:336-339. [DOI: 10.1136/neurintsurg-2015-012220] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2015] [Revised: 02/24/2016] [Accepted: 02/26/2016] [Indexed: 11/04/2022]
Abstract
BackgroundEpidemiologic studies identified a ‘weekend effect’ or ‘out-of-hours effect’, which implies that procedural and clinical outcomes of patients with stroke, who are admitted out-of-hours, are less favorable than for patients admitted during working-hours.ObjectiveTo determine (1) whether our procedural times and clinical outcome were affected by an out-of-hours effect and (2) whether the decision in favor of, or against, endovascular stroke treatment (EST) depends on the time of admission.MethodsBetween February 2010 and January 2015, 6412 consecutive patients presenting with symptoms of acute ischemic stroke were evaluated for EST eligibility according to established local protocols and generally accepted consensus criteria, and dichotomized into working-hours and out-of-hours cohorts according to admission times. Within both groups, patients given EST were identified and the rate of treatment decision, procedural times, and clinical outcome were compared and analyzed.ResultsClinical and radiological features of patients admitted in working-hours and out-of-hours did not differ significantly. Procedural times and clinical outcome were not affected by an out-of-hours effect (p≥0.054). 221/240 (92.1%) out-of-hours patients and 154/166 (92.8%) working-hours patients who were eligible for EST were transferred to the angiography suite for EST (p=0.798). The rationale not to treat patients who were eligible for EST did not differ between working-hours and out-of-hours admission (p=0.756).ConclusionsIt is possible to produce competitive procedural times regardless of the time of admission and to prevent a treatment decision bias when standard operating procedures are applied consistently.
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Stent Retriever Thrombectomy of Small Caliber Intracranial Vessels Using pREset LITE: Safety and Efficacy. Clin Neuroradiol 2016; 27:351-360. [PMID: 26795038 PMCID: PMC5577062 DOI: 10.1007/s00062-016-0497-0] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2015] [Accepted: 01/04/2016] [Indexed: 11/26/2022]
Abstract
Purpose Few devices are approved for thrombectomy of distal vessel branches, and clinical experience is limited. Here we report our experience with pREset LITE for thrombectomy of small intracranial vessels. Methods From an institutional database we selected consecutive patients treated with pREset LITE for an occlusion of small (≤ 2 mm), intracranial target vessels. Recanalization success was measured by applying the modified Thrombolysis In Cerebral Infarction (mTICI) score. To assess safety, we recorded device-related procedural events and potentially device-related hemorrhages on follow-up imaging. Infarcts in the dependent territory served as a measure for efficacy. Results Of 536 patients treated between August 2013 and March 2015, 76 met the inclusion criteria. pREset LITE was used in 90 branches with an average diameter of 1.6 mm (1.3–2.0 mm). An mTICI score ≥ 2b was achieved in 70.0 %. Procedural events consisted of 5.6 % significant vasospasm, 2.2 % suspected dissections, 2.2 % downstream emboli, and 1.1 % self-limiting extravasations. On posttreatment imaging 2.2 % parenchymal hemorrhages type I (PHI) and 13.3 % focal subarachnoid hemorrhage (SAH) were potentially device related, but all of these events remained asymptomatic. After successful recanalization, 33.3 % developed no ischemia in the dependent territory while 41.7 % developed a partial infarct, and 25 % developed a complete infarct. Successful recanalization significantly increased the chance to develop no or only partial infarct compared with a complete infarction (p = 0.003, p = 0.013). Conclusions Thrombectomy of small vessels with pREset LITE is feasible with good recanalization and reasonable safety margins. Successful recanalization significantly reduces the risk of infarction in the dependent territory. The impact on the overall clinical outcome remains to be determined.
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Wahlgren N, Moreira T, Michel P, Steiner T, Jansen O, Cognard C, Mattle HP, van Zwam W, Holmin S, Tatlisumak T, Petersson J, Caso V, Hacke W, Mazighi M, Arnold M, Fischer U, Szikora I, Pierot L, Fiehler J, Gralla J, Fazekas F, Lees KR. Mechanical thrombectomy in acute ischemic stroke: Consensus statement by ESO-Karolinska Stroke Update 2014/2015, supported by ESO, ESMINT, ESNR and EAN. Int J Stroke 2015; 11:134-47. [DOI: 10.1177/1747493015609778] [Citation(s) in RCA: 271] [Impact Index Per Article: 30.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
The original version of this consensus statement on mechanical thrombectomy was approved at the European Stroke Organisation (ESO)-Karolinska Stroke Update conference in Stockholm, 16–18 November 2014. The statement has later, during 2015, been updated with new clinical trials data in accordance with a decision made at the conference. Revisions have been made at a face-to-face meeting during the ESO Winter School in Berne in February, through email exchanges and the final version has then been approved by each society. The recommendations are identical to the original version with evidence level upgraded by 20 February 2015 and confirmed by 15 May 2015. The purpose of the ESO-Karolinska Stroke Update meetings is to provide updates on recent stroke therapy research and to discuss how the results may be implemented into clinical routine. Selected topics are discussed at consensus sessions, for which a consensus statement is prepared and discussed by the participants at the meeting. The statements are advisory to the ESO guidelines committee. This consensus statement includes recommendations on mechanical thrombectomy after acute stroke. The statement is supported by ESO, European Society of Minimally Invasive Neurological Therapy (ESMINT), European Society of Neuroradiology (ESNR), and European Academy of Neurology (EAN).
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Affiliation(s)
- Nils Wahlgren
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Tiago Moreira
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Patrik Michel
- Département des Neurosciences Cliniques, Lausanne, Switzerland
| | - Thorsten Steiner
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
- Department of Neurology, Klinikum Frankfurt Höchst, Frankfurt, Germany
| | - Olav Jansen
- Department of Radiology and Neuroradiology, UKSH, Kiel, Germany
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France
| | - Heinrich P Mattle
- Department of Neurology, Inselspital, Bern University Hospital, Bern, Switzerland
- University of Bern, Bern, Switzerland
| | - Wim van Zwam
- Department of Radiology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Staffan Holmin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden
| | - Turgut Tatlisumak
- Institute of Neuroscience and Physiology, Sahlgrenska Academy of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Jesper Petersson
- Department of Neurology, Skåne University Hospital, Malmö, Sweden
- Department of Neurology, Lund University, Lund, Sweden
| | - Valeria Caso
- Stroke Unit, Santa Maria Hospital, University of Perugia, Perugia, Italy
| | - Werner Hacke
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Mikael Mazighi
- Pole Neurosensoriel Tête et Cou, Hôpital Lariboisière, Paris, France
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, Bern, Switzerland
- University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, Bern, Switzerland
- University of Bern, Bern, Switzerland
| | - Istvan Szikora
- Department of Neurointerventions, National Institute of Clinical Neurosciences, Budapest, Hungary
| | - Laurent Pierot
- Service de Radiologie, Hôpital Maison-Blanche, Reims, France
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, Bern, Switzerland
| | - Franz Fazekas
- Department of Neurology, Medical University Graz, Graz, Austria
| | - Kennedy R Lees
- Department of Cerebrovascular Medicine, University of Glasgow, Glasgow, Scotland, UK
- Acute Stroke Unit, Western Infirmary, Glasgow, Scotland, UK
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