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Fang L, Zhou M, Mao F, Diao M, Hu W, Jin G. Development and validation of a nomogram for predicting 28-day mortality in patients with ischemic stroke. PLoS One 2024; 19:e0302227. [PMID: 38656987 PMCID: PMC11042708 DOI: 10.1371/journal.pone.0302227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Accepted: 03/25/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND/AIM We aimed to construct a validated nomogram model for predicting short-term (28-day) ischemic stroke mortality among critically ill populations. MATERIALS AND METHODS We collected raw data from the Medical Information Mart for Intensive Care IV database, a comprehensive repository renowned for its depth and breadth in critical care information. Subsequently, a rigorous analytical framework was employed, incorporating a 10-fold cross-validation procedure to ensure robustness and reliability. Leveraging advanced statistical methodologies, specifically the least absolute shrinkage and selection operator regression, variables pertinent to 28-day mortality in ischemic stroke were meticulously screened. Next, binary logistic regression was utilized to establish nomogram, then applied concordance index to evaluate discrimination of the prediction models. Predictive performance of the nomogram was assessed by integrated discrimination improvement (IDI) and net reclassification index (NRI). Additionally, we generated calibration curves to assess calibrating ability. Finally, we evaluated the nomogram's net clinical benefit using decision curve analysis (DCA), in comparison with scoring systems clinically applied under common conditions. RESULTS A total of 2089 individuals were identified and assigned into training (n = 1443) or validation (n = 646) cohorts. Various identified risk factors, including age, ethnicity, marital status, underlying metastatic solid tumor, Charlson comorbidity index, heart rate, Glasgow coma scale, glucose concentrations, white blood cells, sodium concentrations, potassium concentrations, mechanical ventilation, use of heparin and mannitol, were associated with short-term (28-day) mortality in ischemic stroke individuals. A concordance index of 0.834 was obtained in the training dataset, indicating that our nomogram had good discriminating ability. Results of IDI and NRI in both cohorts proved that our nomogram had positive improvement of predictive performance, compared to other scoring systems. The actual and predicted incidence of mortality showed favorable concordance on calibration curves (P > 0.05). DCA curves revealed that, compared with scoring systems clinically used under common conditions, the constructed nomogram yielded a greater net clinical benefit. CONCLUSIONS Utilizing a comprehensive array of fourteen readily accessible variables, a prognostic nomogram was meticulously formulated and rigorously validated to provide precise prognostication of short-term mortality within the ischemic stroke cohort.
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Affiliation(s)
- Lingyan Fang
- Department of Critical Care Medicine, Hangzhou First People’s Hospital, Hangzhou, Zhejiang, China
| | - Menglu Zhou
- Department of Neurology, Affiliated Hospital of Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Fengkai Mao
- Affiliated Hospital of Hangzhou Normal University, Hangzhou Normal University, Hangzhou, Zhejiang, China
| | - Mengyuan Diao
- Department of Critical Care Medicine, Hangzhou First People’s Hospital, Hangzhou, Zhejiang, China
| | - Wei Hu
- Department of Critical Care Medicine, Hangzhou First People’s Hospital, Hangzhou, Zhejiang, China
| | - Guangyong Jin
- Department of Critical Care Medicine, Hangzhou First People’s Hospital, Hangzhou, Zhejiang, China
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Ji X, Song B, Zhu H, Jiang Z, Hua F, Wang S, Zhou J, Li L, Dai C, Zhang M, Wei D, Zhang L, Zhang X, Zhang Q, Chen P. A study on endovascular treatment alone and bridging treatment for acute ischemic stroke. Eur J Med Res 2023; 28:12. [PMID: 36611184 PMCID: PMC9824995 DOI: 10.1186/s40001-022-00966-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 12/20/2022] [Indexed: 01/09/2023] Open
Abstract
OBJECTIVES To investigate whether intravenous thrombolysis (IVT) with alteplase (a recombinant tissue plasminogen activator, rt-PA) before endovascular treatment (EVT) is beneficial for acute ischemic stroke (AIS) patients in different periods. METHODS This study enrolled a total of 140 patients hospitalized between 2019 and 2022 with AIS from large vessel occlusion (LVO) in the anterior circulation. Those patients were divided into the EVT alone group and IVT + EVT group, in which EVT was preceded by intravenous rt-PA. According to the time from onset to femoral artery puncture, the above two groups were divided into the following subgroups: < 4.5 h, between 4.5 and 6 h, between 6 and 8 h, and between 8 and 10 h. There were 78 patients in the EVT alone group and 62 patients in the IVT + EVT group. RESULTS There was no statistically significant difference in functional independence, recanalization rate, favorable outcome rate, or mortality between the EVT and IVT + EVT groups (P > 0.05). After adjusting for confounding factors, a lower incidence of intracerebral hemorrhage was observed in the EVT group (P < 0.05). A comparison of time-dependent efficacy between the two groups showed that within 6-8 h, there were statistically significant differences between admission and postoperation in the National Institutes of Health Stroke Scale scores at 24 h (P = 0.01) or 7 days (P = 0.02). CONCLUSIONS Although there was no difference in clinical efficacy and safety between the abovementioned two groups, treatment with IVT + EVT could increase the risk of bleeding compared to EVT. Moreover, in the 6-8 h subgroup, the efficacy of EVT alone was better than that of IVT + EVT.
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Affiliation(s)
- Xiyang Ji
- grid.440747.40000 0001 0473 0092Department of Neurology, Xianyang Hospital of Yan’an University, No. 38 Wenlin Road, Xianyang, 712000 China
| | - Bo Song
- grid.440747.40000 0001 0473 0092Department of Neurology, Xianyang Hospital of Yan’an University, No. 38 Wenlin Road, Xianyang, 712000 China
| | - Hao Zhu
- Department of Neurology, First Hospital of Xianyang, No. 10, Biyuan Road, Xianyang, 712000 China
| | - Zhao Jiang
- grid.417295.c0000 0004 1799 374XDepartment of Neurology, Xijing Hospital, Air Force Military Medical University, No.169, Changle West Road, Xi’an, 710032 China
| | - Feng Hua
- grid.440747.40000 0001 0473 0092Department of Neurology, Xianyang Hospital of Yan’an University, No. 38 Wenlin Road, Xianyang, 712000 China
| | - Sa Wang
- grid.440747.40000 0001 0473 0092Department of Neurology, Xianyang Hospital of Yan’an University, No. 38 Wenlin Road, Xianyang, 712000 China
| | - Jianbo Zhou
- grid.440747.40000 0001 0473 0092Department of Neurology, Xianyang Hospital of Yan’an University, No. 38 Wenlin Road, Xianyang, 712000 China
| | - Lin Li
- grid.440747.40000 0001 0473 0092Department of Neurology, Xianyang Hospital of Yan’an University, No. 38 Wenlin Road, Xianyang, 712000 China
| | - Changfei Dai
- grid.440747.40000 0001 0473 0092Department of Neurology, Xianyang Hospital of Yan’an University, No. 38 Wenlin Road, Xianyang, 712000 China
| | - Mijuan Zhang
- grid.440747.40000 0001 0473 0092Department of Neurology, Xianyang Hospital of Yan’an University, No. 38 Wenlin Road, Xianyang, 712000 China
| | - Dong Wei
- grid.440747.40000 0001 0473 0092Department of Neurology, Xianyang Hospital of Yan’an University, No. 38 Wenlin Road, Xianyang, 712000 China
| | - Lele Zhang
- grid.440747.40000 0001 0473 0092Department of Neurology, Xianyang Hospital of Yan’an University, No. 38 Wenlin Road, Xianyang, 712000 China
| | - Xiaojie Zhang
- grid.440747.40000 0001 0473 0092Department of Neurology, Xianyang Hospital of Yan’an University, No. 38 Wenlin Road, Xianyang, 712000 China
| | - Qun Zhang
- grid.440747.40000 0001 0473 0092Department of Neurology, Xianyang Hospital of Yan’an University, No. 38 Wenlin Road, Xianyang, 712000 China
| | - Ping Chen
- grid.440747.40000 0001 0473 0092Department of Neurology, Xianyang Hospital of Yan’an University, No. 38 Wenlin Road, Xianyang, 712000 China
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Feng X, Hua Y, Zou J, Jia S, Ji J, Xing Y, Zhou J, Liao J. Intelligible Models for HealthCare: Predicting the Probability of 6-Month Unfavorable Outcome in Patients with Ischemic Stroke. Neuroinformatics 2022; 20:575-585. [PMID: 34435319 DOI: 10.1007/s12021-021-09535-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2021] [Indexed: 12/31/2022]
Abstract
Early prediction of unfavorable outcome after ischemic stroke is significant for clinical management. Machine learning as a novel computational modeling technique could help clinicians to address the challenge. We aim to investigate the applicability of machine learning models for individualized prediction in ischemic stroke patients and demonstrate the utility of various model-agnostic explanation techniques for machine learning predictions. A total of 499 consecutive patients with Unfavorable [modified Rankin Scale (mRS) score 3-6, n = 140] and favorable (mRS score 0-2, n = 359) outcome after 6-month from ischemic stroke were enrolled in this study. Four machine learning models, including Random Forest [RF], eXtreme Gradient Boosting [XGBoost], Adaptive Boosting [Adaboost] and Support Vector Machine [SVM] were performed with the area-under-the-curve (AUC): (90.20 ± 0.22)%, (86.91 ± 1.05)%, (86.49 ± 2.35)%, (81.89 ± 2.40)%, respectively. Three global interpretability techniques (Feature Importance shows the contribution of selected features, Partial Dependence Plot aims to visualize the average effect of a feature on the predicted probability of unfavorable outcome, Feature Interaction detects the change in the prediction that occurs by varying the features after considering the individual feature effects) and one local interpretability technique (Shapley Value indicates the probability of unfavorable outcome of different instances) have been applied to present the interpretability techniques via visualization. Thereby, the current study is important for better understanding intelligible healthcare analytics via explanations for the prediction of local and global levels, and potentially reduction of the mortality of patients with ischemic stroke by assisting clinicians in the decision-making process.
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Affiliation(s)
- Xiaobing Feng
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Yingrong Hua
- School of Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Jianjun Zou
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Shuopeng Jia
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Jiatong Ji
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China
| | - Yan Xing
- School of Science, China Pharmaceutical University, #639 Longmian Avenue, Jiangning District, Nanjing, 211198, China
| | - Junshan Zhou
- Department of Neurology, Nanjing First Hospital, Nanjing, China
| | - Jun Liao
- School of Science, China Pharmaceutical University, #639 Longmian Avenue, Jiangning District, Nanjing, 211198, China.
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Li XD, Li MM. A novel nomogram to predict mortality in patients with stroke: a survival analysis based on the MIMIC-III clinical database. BMC Med Inform Decis Mak 2022; 22:92. [PMID: 35387672 PMCID: PMC8988376 DOI: 10.1186/s12911-022-01836-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2021] [Accepted: 03/28/2022] [Indexed: 11/27/2022] Open
Abstract
Background Stroke is a disease characterized by sudden cerebral ischemia and is the second leading cause of death worldwide. We aimed to develop and validate a nomogram model to predict mortality in intensive care unit patients with stroke. Methods All data involved in this study were extracted from the Medical Information Mart for Intensive Care III database (MIMIC-III). The data were analyzed using multivariate Cox regression, and the performance of the novel nomogram, which assessed the patient’s overall survival at 30, 180, and 360 days after stroke, was evaluated using Harrell’s concordance index (C-index) and the area under the receiver operating characteristic curve. A calibration curve and decision curve were introduced to test the clinical value and effectiveness of our prediction model. Results A total of 767 patients with stroke were randomly divided into derivation (n = 536) and validation (n = 231) cohorts at a 7:3 ratio. Multivariate Cox regression showed that 12 independent predictors, including age, weight, ventilation, cardiac arrhythmia, metastatic cancer, explicit sepsis, Oxford Acute Severity of Illness Score or OASIS score, diastolic blood pressure, bicarbonate, chloride, red blood cell and white blood cell counts, played a significant role in the survival of individuals with stroke. The nomogram model was validated based on the C-indices, calibration plots, and decision curve analysis results. Conclusions The plotted nomogram accurately predicted stroke outcomes and, thus may contribute to clinical decision-making and treatment as well as consultation services for patients. Supplementary Information The online version contains supplementary material available at 10.1186/s12911-022-01836-3.
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Affiliation(s)
- Xiao-Dan Li
- Department of Clinical Laboratory Medicine, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, People's Republic of China
| | - Min-Min Li
- Department of Clinical Laboratory Medicine, The First Affiliated Hospital of Jinan University, Guangzhou, 510630, People's Republic of China.
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5
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Oesch L, Arnold M, Bernasconi C, Kaesmacher J, Fischer U, Mosimann PJ, Jung S, Meinel T, Goeldlin M, Heldner M, Volbers B, Gralla J, Sarikaya H. Impact of pre-stroke dependency on outcome after endovascular therapy in acute ischemic stroke. J Neurol 2020; 268:541-548. [PMID: 32865630 PMCID: PMC7880932 DOI: 10.1007/s00415-020-10172-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 07/13/2020] [Accepted: 08/17/2020] [Indexed: 01/01/2023]
Abstract
Background and purpose Current demographic changes indicate that more people will be care-dependent due to increasing life expectancy. Little is known about impact of preexisting dependency on stroke outcome after endovascular treatment (EVT). Methods We compared prospectively collected baseline and outcome data of previously dependent vs. independent stroke patients (prestroke modified Rankin Scale score of 3–5 vs. 0–2) treated with EVT. Outcome measures were favorable 3-month outcome (mRS ≤ 3 for previously dependent and mRS ≤ 2 for independent patients, respectively), death and symptomatic intracranial hemorrhage (sICH). Results Among 1247 patients, 84 (6.7%) were dependent before stroke. They were older (81 vs. 72 years of age), more often female (61.9% vs. 46%), had a higher stroke severity at baseline (NIHSS 18 vs. 15 points), more often history of previous stroke (32.9% vs. 9.1%) and more vascular risk factors than independent patients. Favorable outcome and mortality were to the disadvantage of independent patients (26.2% vs. 44.4% and 46.4% vs. 25.5%, respectively), whereas sICH was comparable in both cohorts (4.9% vs. 5%). However, preexisting dependency was not associated with clinical outcome and mortality after adjusting for outcome predictors (OR 1.076, 95% CI 0.612–1.891; p = 0.799 and OR 1.267, 95% CI 0.758–2.119; p = 0.367, respectively). Conclusion Our study underscores the need for careful selection of care-dependent stroke patients when considering EVT, given a less favorable outcome observed in this cohort. Nonetheless, EVT should not systematically be withheld in patients with preexisting disability, since prior dependency does not significantly influence outcome.
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Affiliation(s)
- Lisa Oesch
- Department of Neurology, Bern University Hospital, Freiburgstrasse 10, 3010, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Bern University Hospital, Freiburgstrasse 10, 3010, Bern, Switzerland
| | - Corrado Bernasconi
- Department of Neurology, Bern University Hospital, Freiburgstrasse 10, 3010, Bern, Switzerland
| | - Johannes Kaesmacher
- Department of Diagnostic and Interventional Neuroradiology, Bern University Hospital, Freiburgstrasse 10, 3010, Bern, Switzerland.,Department of Diagnostic, Interventional and Pediatric Radiology, Bern University Hospital, Freiburgstrasse 10, 3010, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Bern University Hospital, Freiburgstrasse 10, 3010, Bern, Switzerland
| | - Pascal J Mosimann
- Department of Diagnostic and Interventional Neuroradiology, Bern University Hospital, Freiburgstrasse 10, 3010, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Bern University Hospital, Freiburgstrasse 10, 3010, Bern, Switzerland
| | - Thomas Meinel
- Department of Neurology, Bern University Hospital, Freiburgstrasse 10, 3010, Bern, Switzerland
| | - Martina Goeldlin
- Department of Neurology, Bern University Hospital, Freiburgstrasse 10, 3010, Bern, Switzerland.,Department of Diagnostic and Interventional Neuroradiology, Bern University Hospital, Freiburgstrasse 10, 3010, Bern, Switzerland
| | - Mirjam Heldner
- Department of Neurology, Bern University Hospital, Freiburgstrasse 10, 3010, Bern, Switzerland
| | - Bastian Volbers
- Department of Neurology, Bern University Hospital, Freiburgstrasse 10, 3010, Bern, Switzerland.,Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, Bern University Hospital, Freiburgstrasse 10, 3010, Bern, Switzerland
| | - Hakan Sarikaya
- Department of Neurology, Bern University Hospital, Freiburgstrasse 10, 3010, Bern, Switzerland.
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6
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Li X, Zou Y, Hu J, Li XM, Huang CP, Shan YJ, Nyame L, Zhao Z, Sun C, Ibrahim M, Pan XD, Liu C, Zhao ZH, Zou JJ. A NAC nomogram to predict the probability of three-month unfavorable outcome in Chinese acute ischemic stroke patients treated with mechanical thrombectomy. Int J Neurosci 2020; 131:163-169. [PMID: 32083963 DOI: 10.1080/00207454.2020.1733565] [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] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND PURPOSE Mechanical thrombectomy (MT) is a standard care for most acute ischemic stroke (AIS) patients. For AIS patients underwent MT, predicting the patients at high risk of unfavorable outcome and adjusting therapeutic strategies accordingly can greatly improve patient outcomes. We aimed to develop and validate a nomogram for individualized prediction of Chinese AIS patients underwent MT. METHODS We conducted a multicenter prospective study including 238 AIS patients who underwent MT from January 2014 to December 2018. The main outcome measure was three-month unfavorable outcome (modified Rankin Scale 3-6). A nomogram was generated based on multivariate logistic model. We assessed the discriminative performance by using the area under the receiver-operating characteristic curve and calibration of risk prediction model by using the Hosmer-Lemeshow test. RESULTS In NAC nomogram, NIHSS (National Institutes of Health Stroke Scale) score on admission (OR: 1.193, p < 0.0001), Age (OR: 1.025, p = 0.037) and Creatinine (OR: 1.028, p < 0.0001) remained independent predictors of 3-month unfavorable outcome in Chinese AIS patients treated with MT. The NAC nomogram exhibited an area under the curve of 0.816 for predicting functional impairment. Calibration was good (p = 0.560 for the Hosmer-Lemeshow test). CONCLUSIONS The NAC nomogram is the first nomogram developed and validated in Chinese AIS patients treated with MT and it may be used to predict 3 months unfavorable outcome for these patients.
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Affiliation(s)
- Xiang Li
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China.,Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Yang Zou
- Faculty of Science, Melbourne University, Melbourne, Australia
| | - Jue Hu
- Department of Neurology, Changsha Central Hospital, Changsha, China
| | - Xue Mei Li
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - Chao Ping Huang
- Department of Neurology, Changsha Central Hospital, Changsha, China
| | - Ya Jie Shan
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - Linda Nyame
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China.,Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Zheng Zhao
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Chao Sun
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China.,Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Mako Ibrahim
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China.,Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xi Ding Pan
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Chao Liu
- Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Zhi Hong Zhao
- Department of Neurology, The First Affiliated Hospital (People's Hospital of Hunan Province), Hunan Normal University, Changsha, China
| | - Jian Jun Zou
- School of Basic Medicine and Clinical Pharmacy, China Pharmaceutical University, Nanjing, China.,Department of Clinical Pharmacology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
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A NADE nomogram to predict the probability of 6-month unfavorable outcome in Chinese patients with ischemic stroke. BMC Neurol 2019; 19:274. [PMID: 31699038 PMCID: PMC6839074 DOI: 10.1186/s12883-019-1464-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2019] [Accepted: 09/12/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Early prediction of unfavorable outcome after ischemic stroke is of great significance to the clinical and therapeutic management. A nomogram is a better visual tool than earlier models and prognostic scores to predict clinical outcomes, which incorporates different factors to develop a graphic continuous scoring system and calculates accurately the risk probability of poor outcome entirely based on individual characteristics. However, to date, no nomogram models have been found to predict the probability of 6-month poor outcome after ischemic stroke. We aimed to develop and validate a nomogram for individualized prediction of the probability of 6-month unfavorable outcome in Chinese patients with ischemic stroke. METHODS Based on the retrospective stroke registry, a single-center study which included 499 patients from May, 2013 to May, 2018 was conducted in Nanjing First Hospital (China) for ischemic stroke within 12 h of symptoms onset. The main outcome measure was 6-month unfavorable outcome (mRS > 2). To generate the nomogram, NIHSS score on admission, Age, previous Diabetes mellitus and crEatinine (NADE) were integrated into the model. We assessed the discriminative performance by using the area under the curve (AUC) of receiver-operating characteristic (ROC) and calibration of risk prediction model by using the Hosmer-Lemeshow test. RESULTS A visual NADE nomogram was constructed that NIHSS score on admission (OR: 1.190, 95%CI: 1.125-1.258), age (OR: 1.068, 95%CI: 1.045-1.090), previous diabetes mellitus (OR: 1.995, 95%CI: 1.236-3.221) and creatinine (OR: 1.010, 95%CI: 1.002-1.018) were found to be significant predictors of 6-month unfavorable outcome after acute ischemic stroke in Chinese patients. The AUC-ROC of nomogram was 0.791. Calibration was good (p = 0.4982 for the Hosmer-Lemeshow test). CONCLUSION The NADE is the first nomogram developed and validated in Chinese ischemic stroke patients to provide an individual, visual and precise prediction of the risk probability of 6-month unfavorable outcome.
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Association of anemia and hemoglobin decrease during acute stroke treatment with infarct growth and clinical outcome. PLoS One 2018; 13:e0203535. [PMID: 30256814 PMCID: PMC6157859 DOI: 10.1371/journal.pone.0203535] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2018] [Accepted: 08/22/2018] [Indexed: 01/29/2023] Open
Abstract
Background and purpose Anemia is associated with worse outcome in stroke, but the impact of anemia with intravenous thrombolysis or endovascular therapy has hardly been delineated. The aim of this study was to analyze the role of anemia on infarct evolution and outcome after acute stroke treatment. Methods 1158 patients from Bern and 321 from Los Angeles were included. Baseline data and 3 months outcome assessed with the modified Rankin Scale were recorded prospectively. Baseline DWI lesion volumes were measured in 345 patients and both baseline and final infarct volumes in 180 patients using CT or MRI. Multivariable and linear regression analysis were used to determine predictors of outcome and infarct growth. Results 712 patients underwent endovascular treatment and 446 intravenous thrombolysis. Lower hemoglobin at baseline, at 24h, and nadir until day 5 predicted poor outcome (OR 1.150–1.279) and higher mortality (OR 1.131–1.237) independently of treatment. Decrease of hemoglobin after hospital arrival, mainly induced by hemodilution, predicted poor outcome and had a linear association with final infarct volumes and the amount and velocity of infarct growth. Infarcts of patients with newly observed anemia were twice as large as infarcts with normal hemoglobin levels. Conclusion Anemia at hospital admission and any hemoglobin decrease during acute stroke treatment affect outcome negatively, probably by enlarging and accelerating infarct growth. Our results indicate that hemodilution has an adverse effect on penumbral evolution. Whether hemoglobin decrease in acute stroke could be avoided and whether this would improve outcome would need to be studied prospectively.
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Impact of smoking on stroke outcome after endovascular treatment. PLoS One 2018; 13:e0194652. [PMID: 29718909 PMCID: PMC5931491 DOI: 10.1371/journal.pone.0194652] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 03/07/2018] [Indexed: 12/21/2022] Open
Abstract
Background Recent studies suggest a paradoxical association between smoking status and clinical outcome after intravenous thrombolysis (IVT). Little is known about relationship between smoking and stroke outcome after endovascular treatment (EVT). Methods We analyzed data of all stroke patients treated with EVT at the tertiary stroke centre of Berne between January 2005 and December 2015. Using uni- and multivariate modeling, we assessed whether smoking was independently associated with excellent clinical outcome (modified Rankin Scale (mRS) 0–1) and mortality at 3 months. In addition, we also measured the occurrence of symptomatic intracranial hemorrhage (sICH) and recanalization. Results Of 935 patients, 204 (21.8%) were smokers. They were younger (60.5 vs. 70.1 years of age, p<0.001), more often male (60.8% vs. 52.5%, p = 0.036), had less often from hypertension (56.4% vs. 69.6%, p<0.001) and were less often treated with antithrombotics (35.3% vs. 47.7%, p = 0.004) as compared to nonsmokers. In univariate analyses, smokers had higher rates of excellent clinical outcome (39.1% vs. 23.1%, p<0.001) and arterial recanalization (85.6% vs. 79.4%, p = 0.048), whereas mortality was lower (15.6% vs. 25%, p = 0.006) and frequency of sICH similar (4.4% vs. 4.1%, p = 0.86). After correcting for confounders, smoking still independently predicted excellent clinical outcome (OR 1.758, 95% CI 1.206–2.562; p<0.001). Conclusion Smoking in stroke patients may be a predictor of excellent clinical outcome after EVT. However, these data must not be misinterpreted as beneficial effect of smoking due to the observational study design. In view of deleterious effects of cigarette smoking on cardiovascular health, cessation of smoking should still be strongly recommended for stroke prevention.
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Meisterernst J, Klinger-Gratz PP, Leidolt L, Lang MF, Schroth G, Mordasini P, Heldner MR, Mono ML, Kurmann R, Buehlmann M, Fischer U, Arnold M, Gralla J, Mattle HP, El-Koussy M, Jung S. Focal T2 and FLAIR hyperintensities within the infarcted area: A suitable marker for patient selection for treatment? PLoS One 2017; 12:e0185158. [PMID: 28957339 PMCID: PMC5619762 DOI: 10.1371/journal.pone.0185158] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2017] [Accepted: 09/07/2017] [Indexed: 12/03/2022] Open
Abstract
Background and purpose Some authors use FLAIR imaging to select patients for stroke treatment. However, the effect of hyperintensity on FLAIR images on outcome and bleeding has been addressed in only few studies with conflicting results. Methods 466 patients with anterior circulation strokes were included in this study. They all were examined with MRI before intravenous or endovascular treatment. Baseline data and 3 months outcome were recorded prospectively. Focal T2 and FLAIR hyperintensities within the ischemic lesion were evaluated by two raters, and the PROACT II classification was applied to assess bleeding complications on follow up imaging. Logistic regression analysis was used to determine predictors of bleeding complications and outcome and to analyze the influence of T2 or FLAIR hyperintensity on outcome. Results Focal hyperintensities were found in 142 of 307 (46.3%) patients with T2 weighted imaging and in 89 of 159 (56%) patients with FLAIR imaging. Hyperintensity in the basal ganglia, especially in the lentiform nucleus, on T2 weighted imaging was the only independent predictor of any bleeding after reperfusion treatment (33.8% in patients with vs. 18.2% in those without; p = 0.003) and there was a non-significant trend for more bleedings in patients with FLAIR hyperintensity within the basal ganglia (p = 0.069). However, there was no association of hyperintensity on T2 weighted or FLAIR images and symptomatic bleeding or worse outcome. Conclusion Our results question the assumption that T2 or FLAIR hyperintensities within the ischemic lesion should be used to exclude patients from reperfusion therapy, especially not from endovascular treatment.
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Affiliation(s)
- Julia Meisterernst
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Pascal P. Klinger-Gratz
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
- Department of Radiology, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Lars Leidolt
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Matthias F. Lang
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Gerhard Schroth
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Mirjam R. Heldner
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Marie-Luise Mono
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Rebekka Kurmann
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Monika Buehlmann
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Heinrich P. Mattle
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Marwan El-Koussy
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
- * E-mail:
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11
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Mueller L, Pult F, Meisterernst J, Heldner MR, Mono ML, Kurmann R, Buehlmann M, Fischer U, Mattle HP, Arnold M, Mordasini P, Gralla J, Schroth G, El-Koussy M, Jung S. Impact of intravenous thrombolysis on recanalization rates in patients with stroke treated with bridging therapy. Eur J Neurol 2017. [DOI: 10.1111/ene.13330] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- L. Mueller
- Department of Neurology; Inselspital; University Hospital Bern, Bern and University of Bern; Bern
| | - F. Pult
- Department of Diagnostic and Interventional Neuroradiology; Inselspital; University Hospital Bern and University of Bern; Bern Switzerland
| | - J. Meisterernst
- Department of Neurology; Inselspital; University Hospital Bern, Bern and University of Bern; Bern
| | - M. R. Heldner
- Department of Neurology; Inselspital; University Hospital Bern, Bern and University of Bern; Bern
| | - M.-L. Mono
- Department of Neurology; Inselspital; University Hospital Bern, Bern and University of Bern; Bern
| | - R. Kurmann
- Department of Neurology; Inselspital; University Hospital Bern, Bern and University of Bern; Bern
| | - M. Buehlmann
- Department of Neurology; Inselspital; University Hospital Bern, Bern and University of Bern; Bern
| | - U. Fischer
- Department of Neurology; Inselspital; University Hospital Bern, Bern and University of Bern; Bern
| | - H. P. Mattle
- Department of Neurology; Inselspital; University Hospital Bern, Bern and University of Bern; Bern
| | - M. Arnold
- Department of Neurology; Inselspital; University Hospital Bern, Bern and University of Bern; Bern
| | - P. Mordasini
- Department of Diagnostic and Interventional Neuroradiology; Inselspital; University Hospital Bern and University of Bern; Bern Switzerland
| | - J. Gralla
- Department of Diagnostic and Interventional Neuroradiology; Inselspital; University Hospital Bern and University of Bern; Bern Switzerland
| | - G. Schroth
- Department of Diagnostic and Interventional Neuroradiology; Inselspital; University Hospital Bern and University of Bern; Bern Switzerland
| | - M. El-Koussy
- Department of Diagnostic and Interventional Neuroradiology; Inselspital; University Hospital Bern and University of Bern; Bern Switzerland
| | - S. Jung
- Department of Neurology; Inselspital; University Hospital Bern, Bern and University of Bern; Bern
- Department of Diagnostic and Interventional Neuroradiology; Inselspital; University Hospital Bern and University of Bern; Bern Switzerland
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12
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Broeg-Morvay A, Mordasini P, Slezak A, Liesirova K, Meisterernst J, Schroth G, Arnold M, Jung S, Mattle HP, Gralla J, Fischer U. Does Antiplatelet Therapy during Bridging Thrombolysis Increase Rates of Intracerebral Hemorrhage in Stroke Patients? PLoS One 2017; 12:e0170045. [PMID: 28095449 PMCID: PMC5240999 DOI: 10.1371/journal.pone.0170045] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2016] [Accepted: 12/28/2016] [Indexed: 11/18/2022] Open
Abstract
Background Symptomatic intracerebral hemorrhage (sICH) after bridging thrombolysis for acute ischemic stroke is a devastating complication. We aimed to assess whether the additional administration of aspirin during endovascular intervention increases bleeding rates. Methods We retrospectively compared bleeding complications and outcome in stroke patients who received bridging thrombolysis with (tPA+ASA) and without (tPA-ASA) aspirin during endovascular intervention between November 2008 and March 2014. Furthermore, we analyzed bleeding complications and outcome in antiplatelet naïve patients with those with prior or acute antiplatelet therapy. Results Baseline characteristics, previous medication, and dosage of rtPA did not differ between 50 tPA+ASA (39 aspirin naïve, 11 preloaded) and 181 tPA-ASA patients (p>0.05). tPA+ASA patients had more often internal carotid artery (ICA) occlusion (p<0.001), large artery disease (p<0.001) and received more often acute stenting of the ICA (p<0.001). 10/180 (5.6%) tPA-ASA patients and 3/49 (6.1%) tPA+ASA patients suffered a sICH (p = 1.0). Rates of asymptomatic intracerebral hemorrhage, systemic bleeding complications and outcome did not differ between both groups (p>0.1). There were no differences in bleeding complications and mortality among 112 bridging patients with antiplatelet therapy (62 preloaded, 39 acute administration, 11 both) and 117 antiplatelet naïve patients. In a logistic regression analysis, aspirin administration during endovascular procedure was not a predictor of sICH. Conclusion Antiplatelet therapy before or during bridging thrombolysis in patients with acute ischemic stroke did not increase the risk of bleeding complications and had no impact on outcome. This finding has to be confirmed in larger studies.
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Affiliation(s)
- Anne Broeg-Morvay
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Agnieszka Slezak
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Kai Liesirova
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Julia Meisterernst
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Gerhard Schroth
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Heinrich P. Mattle
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, University Hospital Bern and University of Bern, Bern, Switzerland
- * E-mail:
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13
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Broeg-Morvay A, Mordasini P, Bernasconi C, Bühlmann M, Pult F, Arnold M, Schroth G, Jung S, Mattle HP, Gralla J, Fischer U. Direct Mechanical Intervention Versus Combined Intravenous and Mechanical Intervention in Large Artery Anterior Circulation Stroke: A Matched-Pairs Analysis. Stroke 2016; 47:1037-44. [PMID: 26906917 DOI: 10.1161/strokeaha.115.011134] [Citation(s) in RCA: 108] [Impact Index Per Article: 13.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 01/27/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Five randomized controlled trials have consistently shown that mechanical thrombectomy (MT) in addition to best medical treatment (±intravenous tissue-type plasminogen activator) improves outcome after acute ischemic stroke in patients with large artery anterior circulation stroke. Whether direct MT is equally effective as combined intravenous thrombolysis with MT (ie, bridging thrombolysis) remains unclear. METHODS We retrospectively compared clinical and radiological outcomes in 167 bridging patients with 255 patients receiving direct MT because of large artery anterior circulation stroke. We matched all patients from the direct MT group who would have qualified for intravenous tissue-type plasminogen activator with controls from the bridging group, using multivariate and propensity score analyses. Functional independence was defined as modified Rankin Scale score of 0 to 2. RESULTS From February 2009 to August 2014, 40 patients from the direct MT group would have qualified for bridging thrombolysis but were treated with MT only. Clinical and radiological characteristics did not differ from the bridging cohort, except for higher rates of hypercholesterolemia (P=0.019), coronary heart disease (P=0.039), and shorter intervals from symptom onset to endovascular intervention (P=0.01) in the direct MT group. Functional independence, mortality, and intracerebral hemorrhage rates did not differ (P>0.1). After multivariate matching analysis outcome in both groups did not differ, except for lower rates of asymptomatic intracerebral hemorrhage (P=0.023) and lower mortality (P=0.007) in the direct MT group. CONCLUSIONS In patients with large anterior circulation stroke, direct mechanical intervention seems to be equally effective as bridging thrombolysis. A randomized trial comparing direct MT with bridging therapy is warranted.
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Affiliation(s)
- Anne Broeg-Morvay
- From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Corrado Bernasconi
- From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Monika Bühlmann
- From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Frauke Pult
- From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Marcel Arnold
- From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Gerhard Schroth
- From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Simon Jung
- From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Heinrich P Mattle
- From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Jan Gralla
- From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Urs Fischer
- From the Departments of Neurology (A.B.-M., C.B., M.B., M.A., S.J., H.P.M., U.F.) and Diagnostic and Interventional Neuroradiology (P.M., F.P., G.S., S.J., J.G.), Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland.
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14
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Slater LA, Coutinho JM, Gralla J, Nogueira RG, Bonafé A, Dávalos A, Jahan R, Levy E, Baxter BJ, Saver JL, Pereira VM. TICI and Age: What's the Score? AJNR Am J Neuroradiol 2015; 37:838-43. [PMID: 26611995 DOI: 10.3174/ajnr.a4618] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2015] [Accepted: 09/07/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE Previous studies have suggested that advanced age predicts worse outcome following mechanical thrombectomy. We assessed outcomes from 2 recent large prospective studies to determine the association among TICI, age, and outcome. MATERIALS AND METHODS Data from the Solitaire FR Thrombectomy for Acute Revascularization (STAR) trial, an international multicenter prospective single-arm thrombectomy study and the Solitaire arm of the Solitaire FR With the Intention For Thrombectomy (SWIFT) trial were pooled. TICI was determined by core laboratory review. Good outcome was defined as an mRS score of 0-2 at 90 days. We analyzed the association among clinical outcome, successful-versus-unsuccessful reperfusion (TICI 2b-3 versus TICI 0-2a), and age (dichotomized across the median). RESULTS Two hundred sixty-nine of 291 patients treated with Solitaire in the STAR and SWIFT data bases for whom TICI and 90-day outcome data were available were included. The median age was 70 years (interquartile range, 60-76 years) with an age range of 25-88 years. The mean age of patients 70 years of age or younger was 59 years, and it was 77 years for patients older than 70 years. There was no significant difference between baseline NIHSS scores or procedure time metrics. Hemorrhage and device-related complications were more common in the younger age group but did not reach statistical significance. In absolute terms, the rate of good outcome was higher in the younger population (64% versus 44%, P < .001). However, the magnitude of benefit from successful reperfusion was higher in the 70 years of age and older group (OR, 4.82; 95% CI, 1.32-17.63 versus OR 7.32; 95% CI, 1.73-30.99). CONCLUSIONS Successful reperfusion is the strongest predictor of good outcome following mechanical thrombectomy, and the magnitude of benefit is highest in the patient population older than 70 years of age.
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Affiliation(s)
- L A Slater
- From the Division of Neuroradiology (L.A.S., J.M.C., V.M.P.), Joint Department of Medical Imaging, Department of Medical Imaging
| | - J M Coutinho
- From the Division of Neuroradiology (L.A.S., J.M.C., V.M.P.), Joint Department of Medical Imaging, Department of Medical Imaging
| | - J Gralla
- Service of Neuroradiology (J.G.), Inselspital, University of Bern, Bern, Switzerland
| | - R G Nogueira
- Marcus Stroke and Neuroscience Center (R.G.N.), Department of Neurology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia
| | - A Bonafé
- Department of Neuroradiology (A.B.), Hôpital Gui-de-Chauliac, Montpellier, France
| | - A Dávalos
- Department of Neurosciences (A.D.), Hospital Universitario Germans Trias i Pujol, Barcelona, Spain
| | - R Jahan
- Division of Interventional Neuroradiology (R.J.)
| | - E Levy
- Toshiba Stroke and Vascular Research Center (E.L.), State University of New York at Buffalo, Buffalo, New York
| | - B J Baxter
- Department of Radiology (B.J.B.), Erlanger Hospital at the University of Tennessee, Chattanooga, Tennessee
| | - J L Saver
- Department of Neurology and Comprehensive Stroke Center (J.L.S.), David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California
| | - V M Pereira
- From the Division of Neuroradiology (L.A.S., J.M.C., V.M.P.), Joint Department of Medical Imaging, Department of Medical Imaging Division of Neurosurgery (V.M.P.), Department of Surgery, Toronto Western Hospital, University Health Network, University of Toronto, Toronto, Ontario, Canada
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15
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Broussalis E, Weymayr F, Hitzl W, Unterrainer AF, Trinka E, Killer M. Endovascular mechanical recanalization of acute ischaemic stroke in octogenarians. Eur Radiol 2015; 26:1742-50. [PMID: 26370945 DOI: 10.1007/s00330-015-3969-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2015] [Revised: 07/13/2015] [Accepted: 08/05/2015] [Indexed: 01/19/2023]
Abstract
BACKGROUND Multiple studies have shown a clinical benefit of thrombectomy in acute ischaemic stroke, but most of them excluded octogenarians. The purpose of this study was to compare the outcomes between octogenarians and younger patients after thrombectomy. MATERIALS AND METHODS One hundred and sixty-six patients with large cerebral artery occlusion and consecutive thrombectomy were evaluated and divided into two patient age groups: younger than 80 years and older than 80 years. We compared recanalization rates, complications experienced, disability, death after discharge and at a 90-day follow-up between these age groups. RESULTS Sixty-eight percent of octogenarians and 72 % of younger patients were registered with successful recanalization (p = 1.0). There was no significant difference in symptomatic intracerebral haemorrhage between the groups (p = 0.32). However, octogenarians had a significantly lower rate of good clinical outcome (24 % vs. 48 %; p = 0.008) and a higher mortality rate (36 % vs. 12 %; p = 0.0013). CONCLUSION Octogenarians have a lower chance of good clinical outcome and a higher mortality rate despite successful recanalization. Nevertheless, 24 % of octogenarians were documented with mRS ≤2. As this age group of octogenarians will grow prospectively, careful patient selection should be mandatory when considering octogenarians for thrombectomy. KEY POINTS • Careful patient selection for thrombectomy should be mandatory in octogenarians. • Octogenarians have a higher mortality rate despite successful recanalization. • Nearly one-third of octogenarians were documented with a good clinical outcome.
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Affiliation(s)
- Erasmia Broussalis
- Department of Neuroradiology, Paracelsus Medical University Salzburg, Salzburg, Austria. .,Research Institute of Neurointervention, Paracelsus Medical University Salzburg, Salzburg, Austria. .,Department of Neurology, Paracelsus Medical University Salzburg, Salzburg, Austria. .,Department of Neuroradiology and Neurorology, Research Institute for Neurointervention, Paracelsus Medical University Salzburg, Ignaz-Harrerstrasse 79, 5020, Salzburg, Austria.
| | - F Weymayr
- Department of Neuroradiology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - W Hitzl
- Research Office, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - A F Unterrainer
- Department of Neuroanesthesiology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - E Trinka
- Department of Neurology, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - M Killer
- Research Institute of Neurointervention, Paracelsus Medical University Salzburg, Salzburg, Austria.,Department of Neurology, Paracelsus Medical University Salzburg, Salzburg, Austria
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16
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Gilgen MD, Klimek D, Liesirova KT, Meisterernst J, Klinger-Gratz PP, Schroth G, Mordasini P, Hsieh K, Slotboom J, Heldner MR, Broeg-Morvay A, Mono ML, Fischer U, Mattle HP, Arnold M, Gralla J, El-Koussy M, Jung S. Younger Stroke Patients With Large Pretreatment Diffusion-Weighted Imaging Lesions May Benefit From Endovascular Treatment. Stroke 2015; 46:2510-6. [PMID: 26251252 DOI: 10.1161/strokeaha.115.010250] [Citation(s) in RCA: 71] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 06/23/2015] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND PURPOSE Lesion volume on diffusion-weighted magnetic resonance imaging (DWI) before acute stroke therapy is a predictor of outcome. Therefore, patients with large volumes are often excluded from therapy. The aim of this study was to analyze the impact of endovascular treatment in patients with large DWI lesion volumes (>70 mL). METHODS Three hundred seventy-two patients with middle cerebral or internal carotid artery occlusions examined with magnetic resonance imaging before treatment since 2004 were included. Baseline data and 3 months outcome were recorded prospectively. DWI lesion volumes were measured semiautomatically. RESULTS One hundred five patients had lesions >70 mL. Overall, the volume of DWI lesions was an independent predictor of unfavorable outcome, survival, and symptomatic intracerebral hemorrhage (P<0.001 each). In patients with DWI lesions >70 mL, 11 of 31 (35.5%) reached favorable outcome (modified Rankin scale score, 0-2) after thrombolysis in cerebral infarction 2b-3 reperfusion in contrast to 3 of 35 (8.6%) after thrombolysis in cerebral infarction 0-2a reperfusion (P=0.014). Reperfusion success, patient age, and DWI lesion volume were independent predictors of outcome in patients with DWI lesions >70 mL. Thirteen of 66 (19.7%) patients with lesions >70 mL had symptomatic intracerebral hemorrhage with a trend for reduced risk with avoidance of thrombolytic agents. CONCLUSIONS There was a growing risk for poor outcome and symptomatic intracerebral hemorrhage with increasing pretreatment DWI lesion volumes. Nevertheless, favorable outcome was achieved in every third patient with DWI lesions >70 mL after successful endovascular reperfusion, whereas after poor or failed reperfusion, outcome was favorable in only every 12th patient. Therefore, endovascular treatment might be considered in patients with large DWI lesions, especially in younger patients.
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Affiliation(s)
- Marc D Gilgen
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Dariusz Klimek
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Kai T Liesirova
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Julia Meisterernst
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Pascal P Klinger-Gratz
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Gerhard Schroth
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.).
| | - Pasquale Mordasini
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Kety Hsieh
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Johannes Slotboom
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Mirjam R Heldner
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Anne Broeg-Morvay
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Marie-Luise Mono
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Urs Fischer
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Heinrich P Mattle
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Marcel Arnold
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Jan Gralla
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Marwan El-Koussy
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
| | - Simon Jung
- From the Department of Diagnostic and Interventional Neuroradiology (M.D.G., D.K., P.P.K.-G., G.S., P.M., K.H., J.S., J.G., M.E.-K., S.J.) and Department of Neurology, Inselspital (M.D.G., K.T.L., J.M., M.R.H., A.B.-M., M.-L.M., U.F., H.P.M., M.A., S.J.), University Hospital Bern and University of Bern, Bern, Switzerland; and Department of Radiology, University of Basel, Basel (P.P.K.-G.)
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Kleine JF, Boeckh-Behrens T, Prothmann S, Zimmer C, Liebig T. Discrepancy between early neurological course and mid-term outcome in older stroke patients after mechanical thrombectomy. J Neurointerv Surg 2015; 8:671-6. [DOI: 10.1136/neurintsurg-2015-011702] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 05/11/2015] [Indexed: 11/03/2022]
Abstract
BackgroundStroke in aged patients has a relatively poor prognosis, even after recanalizing therapy. Potential reasons include mechanisms that relate directly to the extent of brain tissue damage, but also age-dependent factors which are not, or only indirectly, stroke-related, such as pre-existing functional deficits, comorbidities, and post-stroke complications (eg, infections).ObjectiveTo compare early neurological course with subsequent functional outcome in older (≥80 years) and younger stroke patients in order to estimate the relative impact of these factors. Specifically, to examine if the strong age-dependency of modified Rankin Scale (mRS) outcome scores in stroke patients after mechanical thrombectomy is paralleled by a similar age dependency of early postinterventional National Institute of Health Stroke Scale (NIHSS) scores—a more specific measure of stroke-induced brain damage.MethodsWe evaluated technical results, pre- and postinterventional NIHSS scores, mid-term mRS scores and early and overall mortality and their relation to age in 125 patients, 40 of them ≥80 years, with acute middle cerebral artery occlusion, treated by mechanical thrombectomy.ResultsTechnical success, pre- and postinterventional NIHSS scores and early mortality were age-independent. Early neurological improvement depended on successful recanalization, but not on age. Nevertheless, good mRS outcome (mRS 0–2) was much rarer, and overall mortality almost threefold higher in aged patients.ConclusionsOlder patients exhibit a similar early neurological course and responsiveness to mechanical thrombectomy as younger patients, but this is not reflected in mid-term functional outcome scores. This indicates that post-stroke complications and other factors that are not, or only indirectly, related to the brain tissue damage induced by the incident stroke have a dominant role in their poor prognosis.
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18
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Demchuk AM, Goyal M, Menon BK, Eesa M, Ryckborst KJ, Kamal N, Patil S, Mishra S, Almekhlafi M, Randhawa PA, Roy D, Willinsky R, Montanera W, Silver FL, Shuaib A, Rempel J, Jovin T, Frei D, Sapkota B, Thornton JM, Poppe A, Tampieri D, Lum C, Weill A, Sajobi TT, Hill MD. Endovascular treatment for Small Core and Anterior circulation Proximal occlusion with Emphasis on minimizing CT to recanalization times (ESCAPE) trial: methodology. Int J Stroke 2014; 10:429-38. [PMID: 25546514 DOI: 10.1111/ijs.12424] [Citation(s) in RCA: 97] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Accepted: 11/12/2014] [Indexed: 01/21/2023]
Abstract
ESCAPE is a prospective, multicenter, randomized clinical trial that will enroll subjects with the following main inclusion criteria: less than 12 h from symptom onset, age > 18, baseline NIHSS >5, ASPECTS score of >5 and CTA evidence of carotid T/L or M1 segment MCA occlusion, and at least moderate collaterals by CTA. The trial will determine if endovascular treatment will result in higher rates of favorable outcome compared with standard medical therapy alone. Patient populations that are eligible include those receiving IV tPA, tPA ineligible and unwitnessed onset or wake up strokes with 12 h of last seen normal. The primary end-point, based on intention-to-treat criteria is the distribution of modified Rankin Scale scores at 90 days assessed using a proportional odds model. The projected maximum sample size is 500 subjects. Randomization is stratified under a minimization process using age, gender, baseline NIHSS, baseline ASPECTS (8-10 vs. 6-7), IV tPA treatment and occlusion location (ICA vs. MCA) as covariates. The study will have one formal interim analysis after 300 subjects have been accrued. Secondary end-points at 90 days include the following: mRS 0-1; mRS 0-2; Barthel 95-100, EuroQOL and a cognitive battery. Safety outcomes are symptomatic ICH, major bleeding, contrast nephropathy, total radiation dose, malignant MCA infarction, hemicraniectomy and mortality at 90 days.
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Affiliation(s)
- Andrew M Demchuk
- Departments of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada; Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
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