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Kühn AL, Puri AS, Salim HA, Musmar B, Ghozy S, Siegler J, Shaikh H, Khalife J, Abdalkader M, Klein P, Nguyen TN, Heit JJ, Regenhardt RW, Diestro JDB, Cancelliere NM, Sweid A, Naamani KE, Hasan Z, Gopinathan A, Amllay A, Meyer L, Dusart A, Bellante F, Forestier G, Rouchaud A, Saleme S, Mounayer C, Fiehler J, Dyzmann C, Kan PT, Singh J, Colasurdo M, Marnat G, Berge J, Barreau X, Sibon I, Nedelcu S, Henninger N, Marotta TR, Stapleton CJ, Rabinov JD, Ota T, Dofuku S, Yeo LL, Tan BYQ, Martinez-Gutierrez JC, Salazar-Marioni S, Sheth S, Renieri L, Capirossi C, Mowla A, Tjoumakaris SI, Jabbour P, Khandelwal P, Biswas A, Clarençon F, Elhorany M, Premat K, Valente I, Pedicelli A, Filipe JP, Varela R, Quintero-Consuegra M, Gonzalez NR, Möhlenbruch MA, Jesser J, Costalat V, Ter Schiphorst A, Yedavalli V, Harker P, Chervak L, Aziz Y, Gory B, Stracke CP, Hecker C, Killer-Oberpfalzer M, Griessenauer CJ, Thomas A, Hsieh CY, Liebeskind DS, Radu RA, Alexandre AM, Fahed R, Tancredi I, Faizy TD, Weyland C, Lubicz B, Patel AB, Pereira VM, Guenego A, Dmytriw AA. Multicenter evaluation of mechanical thrombectomy for distal medium vessel occlusions with National Institute of Health Stroke Scale Scores ≥ 6 and ≤ 6. J Neurol 2024:10.1007/s00415-024-12537-4. [PMID: 38967650 DOI: 10.1007/s00415-024-12537-4] [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: 01/06/2024] [Revised: 06/21/2024] [Accepted: 06/24/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND While mechanical thrombectomy is considered standard of care for large vessel occlusions, scientific evidence to support treatment for distal and medium vessel occlusions remains scarce. PURPOSE To evaluate feasibility, safety, and outcomes in patients with low National Institute of Health Stroke Scale scores undergoing mechanical thrombectomy for treatment of distal medium vessel occlusions. MATERIALS AND METHODS Retrospective data review and analysis of prospectively maintained databases at 41 academic centers in North America, Asia, and Europe between January 2017 and January 2022. Characteristics and outcomes were compared between groups with low stroke scale score (≤ 6) versus and higher stroke scale scores (> 6). Propensity score matching using the optimal pair matching method and 1:1 ratio was performed. RESULTS Data were collected on a total of 1068 patients. After propensity score matching, there were a total of 676 patients included in the final analysis, with 338 patients in each group. High successful reperfusion rates were seen in both groups, 90.2% in ≤ 6 and 88.7% in the > 6 stroke scale groups. The frequency of excellent and good functional outcome was seen more common in low versus higher stroke scale score patients (64.5% and 81.1% versus 39.3% and 58.6%, respectively). The 90-day mortality rate observed in the ≤ 6 stroke scale group was 5.3% versus 13.3% in the > 6 stroke scale group. CONCLUSION Mechanical thrombectomy in distal and medium vessel occlusions, specifically in patients with low stroke scale scores is feasible, though it may not necessarily improve outcomes over IVT.
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Affiliation(s)
- Anna Luisa Kühn
- Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Ajit S Puri
- Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Hamza Adel Salim
- Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Los Angeles, USA.
- Brigham and Women's Hospital, Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA.
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD, USA.
| | - Basel Musmar
- Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Los Angeles, USA
| | - Sherief Ghozy
- Departments of Neurological Surgery & Radiology, Mayo Clinic, Rochester, MN, USA
| | - James Siegler
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA
| | - Hamza Shaikh
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA
| | - Jane Khalife
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA
| | - Mohamad Abdalkader
- Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA
| | - Piers Klein
- Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA
| | - Thanh N Nguyen
- Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA
| | - Jeremy J Heit
- Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, CA, USA
| | - Robert W Regenhardt
- Brigham and Women's Hospital, Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Jose Danilo Bengzon Diestro
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Nicole M Cancelliere
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Ahmad Sweid
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Kareem El Naamani
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Zuha Hasan
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Anil Gopinathan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Abdelaziz Amllay
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anne Dusart
- Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium
| | - Flavio Bellante
- Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium
| | - Géraud Forestier
- Neuroradiology Department, University Hospital of Limoges, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252, Limoges, France
| | - Aymeric Rouchaud
- Neuroradiology Department, University Hospital of Limoges, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252, Limoges, France
| | - Suzana Saleme
- Neuroradiology Department, University Hospital of Limoges, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252, Limoges, France
| | - Charbel Mounayer
- Neuroradiology Department, University Hospital of Limoges, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252, Limoges, France
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Dyzmann
- Neuroradiology Department, Sana Kliniken, Lübeck GmbH, Lübeck, Germany
| | - Peter T Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Jasmeet Singh
- Brigham and Women's Hospital, Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Marco Colasurdo
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Gaultier Marnat
- Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France
| | - Jérôme Berge
- Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France
| | - Xavier Barreau
- Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France
| | - Igor Sibon
- Neurology Department, Bordeaux University Hospital, Bordeaux, France
| | - Simona Nedelcu
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Nils Henninger
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Thomas R Marotta
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Christopher J Stapleton
- Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Los Angeles, USA
| | - James D Rabinov
- Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Los Angeles, USA
| | - Takahiro Ota
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Shogo Dofuku
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Leonard Ll Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Benjamin Y Q Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | | | - Sunil Sheth
- Interventistica Neurovascolare, Ospedale Careggi Di Firenze, Florence, Italy
| | - Leonardo Renieri
- Interventistica Neurovascolare, Ospedale Careggi Di Firenze, Florence, Italy
| | - Carolina Capirossi
- Interventistica Neurovascolare, Ospedale Careggi Di Firenze, Florence, Italy
| | - Ashkan Mowla
- Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), 1200 North State St, Suite 3300, Los Angeles, CA, USA
| | | | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Priyank Khandelwal
- Department of Endovascular Neurosurgery and Neuroradiology NJMS, Newark, NJ, USA
| | - Arundhati Biswas
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Frédéric Clarençon
- Department of Neuroradiology, GRC BioFast, Sorbonne University. Paris VI, Pitié-Salpêtrière Hospital, Paris, France
| | - Mahmoud Elhorany
- Department of Neuroradiology, GRC BioFast, Sorbonne University. Paris VI, Pitié-Salpêtrière Hospital, Paris, France
| | - Kevin Premat
- Department of Neuroradiology, GRC BioFast, Sorbonne University. Paris VI, Pitié-Salpêtrière Hospital, Paris, France
| | - Iacopo Valente
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy
| | - Alessandro Pedicelli
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy
| | - João Pedro Filipe
- Department of Diagnostic and Interventional Neuroradiology, Centro Hospitalar Universitário Do Porto, Porto, Portugal
| | - Ricardo Varela
- Department of Neurology, Centro Hospitalar Universitário Do Porto, Porto, Portugal
| | | | - Nestor R Gonzalez
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Markus A Möhlenbruch
- Sektion Vaskuläre Und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Jessica Jesser
- Sektion Vaskuläre Und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Vincent Costalat
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Adrien Ter Schiphorst
- Department of Neurology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Vivek Yedavalli
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD, USA
| | - Pablo Harker
- Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Lina Chervak
- Department of Neurology and Radiology, University of Cincinnati, Cincinnati, OH, USA
| | - Yasmin Aziz
- Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Benjamin Gory
- Department of Interventional Neuroradiology, Nancy University Hospital, Nancy, France
| | - Christian Paul Stracke
- Department of Radiology, Interventional Neuroradiology Section, University Medical Center, Münster, Germany
| | - Constantin Hecker
- Departments of Neurology and Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Monika Killer-Oberpfalzer
- Departments of Neurology and Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Christoph J Griessenauer
- Departments of Neurology and Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Ajith Thomas
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA
| | | | - David S Liebeskind
- UCLA Stroke Center and Department of Neurology Department, UCLA, Los Angeles, CA, USA
| | - Răzvan Alexandru Radu
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Andrea M Alexandre
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy
| | - Robert Fahed
- Department of Medicine, Division of Neurology, The Ottawa Hospital, Ottawa Hospital Research Institute and University of Ottawa, Ottawa, ON, Canada
| | - Illario Tancredi
- Department of Medicine, Division of Neurology, The Ottawa Hospital, Ottawa Hospital Research Institute and University of Ottawa, Ottawa, ON, Canada
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Charlotte Weyland
- Sektion Vaskuläre Und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Boris Lubicz
- Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Aman B Patel
- Brigham and Women's Hospital, Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Vitor Mendes Pereira
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Adrien Guenego
- Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Adam A Dmytriw
- Brigham and Women's Hospital, Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA.
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
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Zaidat OO, Ikeme S, Sheth SA, Yoshimura S, Yang XG, Brinjikji W, Kallmes DF, Brouwer P, Pederson J, Tarchand R, Steffenson A, Kallmes KM, Touchette J, Andersson T. MASTRO I: Meta-Analysis and Systematic Review of thrombectomy stent retriever outcomes: comparing functional, safety and recanalization outcomes between EmboTrap, Solitaire and Trevo in acute ischemic stroke. J Comp Eff Res 2023; 12:e230001. [PMID: 37039285 PMCID: PMC10402757 DOI: 10.57264/cer-2023-0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2023] [Accepted: 03/02/2023] [Indexed: 04/12/2023] Open
Abstract
Aim: Stent-retriever (SR) thrombectomy has demonstrated superior outcomes in patients with acute ischemic stroke compared with medical management alone, but differences among SRs remain unexplored. We conducted a Systematic Review/Meta-Analysis to compare outcomes between three SRs: EmboTrap®, Solitaire™, and Trevo®. Methods: We conducted a PRISMA-compliant Systematic Review among English-language studies published after 2014 in PubMed/MEDLINE that reported SRs in ≥25 patients. Functional and safety outcomes included 90-day modified Rankin scale (mRS 0-2), mortality, symptomatic intracranial hemorrhage (sICH), and embolization to new territory (ENT). Recanalization outcomes included modified thrombolysis in cerebral infarction (mTICI) and first-pass recanalization (FPR). We used a random effects Meta-Analysis to compare outcomes; subgroup and outlier-influencer analysis were performed to explore heterogeneity. Results: Fifty-one articles comprising 9,804 patients were included. EmboTrap had statistically significantly higher rates of mRS 0-2 (57.4%) compared with Trevo (50.0%, p = 0.013) and Solitaire (45.3%, p < 0.001). Compared with Solitaire (20.4%), EmboTrap (11.2%, p < 0.001) and Trevo (14.5%, p = 0.018) had statistically significantly lower mortality. Compared with Solitaire (7.7%), EmboTrap (3.9%, p = 0.028) and Trevo (4.6%, p = 0.049) had statistically significantly lower rates of sICH. There were no significant differences in ENT rates across all three devices (6.0% for EmboTrap, 5.3% for Trevo, and 7.7% for Solitaire, p = 0.518). EmboTrap had numerically higher rates of recanalization; however, no statistically significant differences were found. Conclusion: The results of our Systematic Review/Meta-Analysis suggest that EmboTrap may be associated with significantly improved functional outcomes compared with Solitaire and Trevo. EmboTrap and Trevo may be associated with significantly lower rates of sICH and mortality compared with Solitaire. No significant differences in recanalization and ENT rates were found. These conclusions are tempered by limitations of the analysis including variations in thrombectomy techniques in the field, highlighting the need for multi-arm RCT studies comparing different SR devices to confirm our findings.
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Affiliation(s)
| | - Shelly Ikeme
- Cardiovascular & Specialty Solutions Group, CERENOVUS, Irvine, CA 92618, USA
| | - Sunil A Sheth
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX 77030, USA
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Hyogo, 663-8131, Japan
| | - Xin-guang Yang
- Sun Yat-sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong Province, 510123, China
| | | | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, MN 55902, USA
| | - Patrick Brouwer
- Cardiovascular & Specialty Solutions Group, CERENOVUS, Irvine, CA 92618, USA
| | | | | | | | - Kevin M Kallmes
- Superior Medical Experts, St. Paul, MN 55117, USA
- Nested Knowledge, Inc., St. Paul, MN 55117, USA
| | | | - Tommy Andersson
- Medical Imaging, AZ Groeninge, 8500, Kortrijk, Belgium
- Neuroradiology, Karolinska University Hospital & Clinical Neuroscience Karolinska Institute, 171 77, Stockholm, Sweden
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Mujanovic A, Kurmann CC, Dobrocky T, Olivé-Gadea M, Maegerlein C, Pierot L, Mendes Pereira V, Costalat V, Psychogios M, Michel P, Beyeler M, Piechowiak EI, Seiffge DJ, Mordasini P, Arnold M, Gralla J, Fischer U, Kaesmacher J, Meinel TR. Bridging intravenous thrombolysis in patients with atrial fibrillation. Front Neurol 2022; 13:945338. [PMID: 35989924 PMCID: PMC9382124 DOI: 10.3389/fneur.2022.945338] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2022] [Accepted: 07/07/2022] [Indexed: 11/13/2022] Open
Abstract
Background and purpose 40% of acute ischemic stroke patients treated by mechanical thrombectomy (MT) have a clinical history of atrial fibrillation (AF). The safety of bridging intravenous thrombolysis (IVT) (MT + IVT) is currently being discussed. We aimed to analyze the interaction between oral anticoagulation (OAC) status or AF with bridging IVT, regarding the occurrence of symptomatic intracranial hemorrhage (sICH) and functional outcome. Materials and Methods Multicentric observational cohort study (BEYOND-SWIFT registry) of consecutive patients undergoing MT between 2010 and 2018 (n = 2,941). Multinomial regression models were adjusted for prespecified baseline and plausible pathophysiological covariates identified on a univariate analysis to assess the association of AF and OAC status with sICH and good outcomes (90-day modified Rankin Scale score 0–2). Results In the total cohort (median age 74, 50.6% women), 1,347 (45.8%) patients had AF. Higher admission National Institutes of Health Stroke Scale (NIHSS) score (aOR 1.04 [95% 1.02–1.06], per point of increase) and prior medication with Vitamin K antagonists (VKA) (aOR 2.19 [95% 1.27–3.66]) were associated with sICH. Neither AF itself (aOR 0.71 [95% 0.41–1.24]) nor bridging IVT (aOR 1.08 [0.67–1.75]) were significantly associated with increased sICH. Receiving bridging IVT (aOR 1.61 [95% 1.24–2.11]) was associated with good 90-day outcome, with no interaction between AF and IVT (p = 0.92). Conclusion Bridging IVT appears to be a reasonable clinical option in selected patients with AF. Given the increased sICH risk in patients with VKA, subgroup analysis of the randomized controlled trials should analyze whether patients with VKA might benefit from withholding bridging IVT. Registration clinicaltrials.gov; Unique identifier: NCT03496064.
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Affiliation(s)
- Adnan Mujanovic
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
- Department of Neurology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Christoph C. Kurmann
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Tomas Dobrocky
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Marta Olivé-Gadea
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Laurent Pierot
- Department of Neuroradiology, University Hospital Reims, Reims, France
| | - Vitor Mendes Pereira
- Joint Department of Medical Imaging, Toronto Western Hospital, Toronto, ON, Canada
| | - Vincent Costalat
- Department of Neuroradiology, University Hospital Montpellier, Montpellier, France
| | - Marios Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Patrik Michel
- Department of Neurology, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Morin Beyeler
- Department of Neurology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Eike I. Piechowiak
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - David J. Seiffge
- Department of Neurology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
- Department of Neurology, University Hospital Basel, Basel, Switzerland
| | - Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Thomas R. Meinel
- Department of Neurology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
- *Correspondence: Thomas R. Meinel
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Abbas R, Herial NA, Naamani KE, Sweid A, Weinberg JH, Habashy KJ, Tjoumakaris S, Gooch MR, Rosenwasser RH, Jabbour P. Mechanical Thrombectomy in Patients Presenting with NIHSS Score <6: A Safety and Efficacy Analysis. J Stroke Cerebrovasc Dis 2022; 31:106282. [PMID: 34998043 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106282] [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] [Received: 08/27/2021] [Revised: 10/24/2021] [Accepted: 12/19/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Groundbreaking trials have shown the tremendous efficacy of mechanical thrombectomy for large vessel occlusions. Currently, mechanical thrombectomy is limited to patients with NIHSS scores ≥6. We investigated the feasibility and safety of MT in patients presenting with NIHSS scores <6. MATERIALS AND METHODS A retrospective review of patient who presented with acute ischemic stroke due to large vessel occlusion with an NIHSS score <6 between 2015 - 2021. The patients were then divided into two groups: those who received mechanical thrombectomy and those who did not. RESULTS Among 83 patients, 41 received a mechanical thrombectomy while 42 received medical treatment only. The mean age in the mechanical thrombectomy group was 66 years versus 60 years in the medical group (p = 0.06). Risk factors for stroke did not differ significantly between both groups. 14 patients (34.1%) in the mechanical thrombectomy group and 20 (47.6%) in the medical group received tissue plasminogen activator. No significant difference in clinical improvement (NIHSS) at discharge (p=0.85) or the mRS score at 90 days (p = 0.15) was noted. Mechanical thrombectomy was associated with smaller infarct size (p=0.04) and decreased mortality (p=0.03). CONCLUSIONS Mechanical thrombectomy is safe and effective for patients who present with large vessel occlusions and low initial NIHSS scores. Therefore, the decision to offer the patient mechanical thrombectomy or not should not be decided by NIHSS score alone. Rather, the decision should be multifactorial with the aim of maximizing the patients' outcomes.
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Affiliation(s)
- Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Joshua H Weinberg
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210
| | | | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Michael R Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
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5
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Liu F, Shen H, Chen C, Bao H, Zuo L, Xu X, Yang Y, Cochrane A, Xiao Y, Li G. Mechanical Thrombectomy for Acute Stroke Due to Large-Vessel Occlusion Presenting With Mild Symptoms. Front Neurol 2021; 12:739267. [PMID: 34777207 PMCID: PMC8581036 DOI: 10.3389/fneur.2021.739267] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2021] [Accepted: 09/30/2021] [Indexed: 11/13/2022] Open
Abstract
Purpose: To evaluate the safety and efficacy of mechanical thrombectomy (MT) for acute stroke due to large vessel occlusion (LVO), presenting with mild symptoms. Methods: A prospective cohort study of patients with mild ischemic stroke and LVO was conducted. Patients were divided into two groups: MT group or best medical management (MM) group. Propensity score matching (PSM) was conducted to reduce the confounding bias between the groups. The primary outcome was functional independence at 90 days. The safety outcome was symptomatic intracranial hemorrhage (sICH). Univariate and multivariate logistic regression analyses were used to identify the independent factors associated with outcomes. Results: Among the 105 included patients, 43 were in the MT group and 62 in the MM group. Forty-three pairs of patients were generated after PSM. There were no significant differences in sICH rates between two groups (p = 1.000). The MT group had a higher proportion of independent outcomes (83.7% MT vs. 67.4% MM; OR 2.483; 95% CI 0.886–6.959; p = 0.079) and excellent outcomes (76.7% MT vs. 51.2% MM; OR 3.150; 95% CI 1.247–7.954; p = 0.013) compared to the MM group, especially in patients with stroke of the anterior circulation (p < 0.05). Multivariate logistic regression analysis showed that small infarct core volume (p = 0.015) and MT treatment (p = 0.013) were independently associated with excellent outcomes. Conclusions: Our results suggest that MT in stroke patients, presenting with mild symptoms, due to acute LVO in the anterior circulation may be associated with satisfactory clinical outcomes. Clinical Trial Registration:ClinicalTrials.gov, identifier: NCT04526756.
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Affiliation(s)
- Feifeng Liu
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Hao Shen
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Chen Chen
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Huan Bao
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Lian Zuo
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Xiahong Xu
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Yumei Yang
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Alexia Cochrane
- University of Edinburgh Medical School, Edinburgh, United Kingdom
| | - Yaping Xiao
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
| | - Gang Li
- Department of Neurology, Shanghai East Hospital, School of Medicine, Tongji University, Shanghai, China
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Londhe SR, Gg SK, Keshava SN, Mohan C. Indian College of Radiology and Imaging (ICRI) Consensus Guidelines for the Early Management of Patients with Acute Ischemic Stroke: Imaging and Intervention. Indian J Radiol Imaging 2021; 31:400-408. [PMID: 34556925 PMCID: PMC8448212 DOI: 10.1055/s-0041-1734346] [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] [Indexed: 11/26/2022] Open
Abstract
The medical science has witnessed significant change in the management of acute stroke patients as a result of recent advances in the field of stroke imaging and endovascular mechanical thrombectomy in addition to intravenous thrombolysis and optimization of stroke services in balance with available resources. Despite initial negative trials, we witnessed the publication of five multicenter randomized clinical trials showing superiority of the endovascular approach over standard medical management in patients with large vessel occlusion. The aim of this study is to provide comprehensive set of evidence-based recommendations regarding imaging and endovascular interventions in acute ischemic stroke patients.
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Affiliation(s)
- Shrikant R Londhe
- Department of Interventional Neuroradiology, Noble Hospital, Pune, Maharashtra, India
| | - Sharath Kumar Gg
- Department of Diagnostic and Interventional Neuroradiology, Apollo Hospitals, Bangalore, Karnataka, India
| | - Shyamkumar N Keshava
- Department of Interventional Radiology, Christian Medical College, Ida Scudder Road, Vellore, Tamil Nadu, India
| | - Chander Mohan
- Interventional Radiology, ICRI Director, Interventional Radiology, BLK Super Specialty Hospital, Pusa Road, New Delhi, India
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7
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Impact of recanalisation by mechanical thrombectomy in mild acute ischemic stroke with large anterior vessel occlusion. Rev Neurol (Paris) 2021; 177:955-963. [PMID: 33487410 DOI: 10.1016/j.neurol.2020.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/06/2020] [Accepted: 09/11/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND The net clinical benefit of mechanical thrombectomy (MT) in patients presenting acute anterior circulation ischemic stroke with large-vessel occlusion (AIS-LVO) and mild neurological deficit is uncertain. AIMS To investigate efficacy and safety of MT in patients with acute AIS-LVO and mild neurological deficit by evaluating i) the influence of recanalisation on three-month outcome and ii) mortality, symptomatic intracerebral hemorrhage (sICH) and procedural complications. METHODS We included consecutive patients with acute AIS-LVO and National Institute of Stroke Scale (NIHSS) score<8, treated by MT at Lille University Hospital. Recanalisation was graded according to modified thrombolysis in cerebral infarction (mTICI) score, mTICI 2b/2c/3 being considered successful. We recorded procedural complications and classified intra-cerebral hemorrhages (ICH) and sICH according with European Cooperative Acute Stroke Study (ECASS) and ECASS2 criteria. Three-month outcome was evaluated by modified Rankin scale (mRS). Excellent and favourable outcomes were respectively defined as mRS 0-1 and 0-2 (or similar to pre-stroke). RESULTS We included 95 patients. At three months, 56 patients (59. 0%) achieved an excellent outcome and 69 (72, 6%) a favourable outcome, both being more frequent in patients with successful recanalisation than in patients without (excellent outcome 71, 1% versus 10, 5%, P<0.001 and favourable outcome 82.9% versus 31.6%, P<0.001). The difference remained unchanged after adjustment for age and pre-MT infarct volume. Similar results were observed in patients with pre-MT NIHSS ≤5. Death occurred in five patients (5.3%), procedural complications in 12 (12.6%), any ICH in 38 (40.0%), including 3 (3.2%) sICH. CONCLUSIONS Achieving successful recanalisation appears beneficial and safe in acute AIS-LVO patients with NIHSS<8 before MT.
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8
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McCarthy DJ, Tonetti DA, Stone J, Starke RM, Narayanan S, Lang MJ, Jadhav AP, Gross BA. More expansive horizons: a review of endovascular therapy for patients with low NIHSS scores. J Neurointerv Surg 2020; 13:146-151. [PMID: 33028674 DOI: 10.1136/neurintsurg-2020-016583] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/08/2020] [Accepted: 09/13/2020] [Indexed: 11/03/2022]
Abstract
While the landmark 2015 stroke trials demonstrated that endovascular therapy (EVT) was superior to medical management for the treatment of acute ischemic stroke due to large vessel occlusion, the efficacy of EVT for patients presenting with a low NIHSS score remains undetermined. We conducted a review of the EVT low National Institutes of Health Stroke Scale (NIHSS) stroke literature, identifying 24 quantitative and six qualitative publications. Details of study designs and outcome were extracted and critically discussed.All identified qualitative studies were retrospective. There was significant study design heterogeneity, with 18 unique study designs between the 24 identified quantitative manuscripts. Study investigations included low NIHSS EVT feasibility (n=6), EVT versus best medical management (BMM; n=10), EVT versus intravenous therapy (IVT, n=3), and low NIHSS score versus high NIHSS score (n=3). From single-arm EVT feasibility studies, the reported ranges of modified Thrombolysis in Cerebral Infarction and symptomatic intracranial hemorrhage were 78-97% and 0-10%, respectively. The EVT versus BMM literature had heterogeneous results with 40% reporting benefit with EVT and 60% reporting neutral findings. None of the studies comparing EVT with IVT reported a difference between the two revascularization therapies. The four identified meta-analyses had incongruent inclusion criteria and conflicting results. Two randomized trials are currently investigating EVT in patients with a low NIHSS score. Selected meta-analyses do suggest a potential benefit of EVT over BMM; however, current and future randomized clinical trials will better elucidate the efficacy of EVT in this patient population.
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Affiliation(s)
- David J McCarthy
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Daniel A Tonetti
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jeremy Stone
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami MILLER School of Medicine, Miami Beach, Florida, USA.,Department of Neurosurgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Sandra Narayanan
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael J Lang
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ashutosh P Jadhav
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Bradley A Gross
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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Kaesmacher J, Maamari B, Meinel TR, Piechowiak EI, Mosimann PJ, Mordasini P, Goeldlin M, Arnold M, Dobrocky T, Boeckh-Behrens T, Berndt M, Michel P, Requena M, Benali A, Pierot L, Mendes Pereira V, Boulouis G, Brehm A, Sporns PB, Ospel JM, Gralla J, Fischer U. Effect of Pre- and In-Hospital Delay on Reperfusion in Acute Ischemic Stroke Mechanical Thrombectomy. Stroke 2020; 51:2934-2942. [PMID: 32933420 PMCID: PMC7523579 DOI: 10.1161/strokeaha.120.030208] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose: Post hoc analyses of randomized controlled clinical trials evaluating mechanical thrombectomy have suggested that admission-to-groin-puncture (ATG) delays are associated with reduced reperfusion rates. Purpose of this analysis was to validate this association in a real-world cohort and to find associated factors and confounders for prolonged ATG intervals. Methods: Patients included into the BEYOND-SWIFT cohort (Bernese-European Registry for Ischemic Stroke Patients Treated Outside Current Guidelines With Neurothrombectomy Devices Using the Solitaire FR With the Intention for Thrombectomy; https://www.clinicaltrials.gov; Unique identifier: NCT03496064) were analyzed (n=2386). Association between baseline characteristics and ATG was evaluated using mixed linear regression analysis. The effect of increasing symptom-onset-to-admission and ATG intervals on successful reperfusion (defined as Thrombolysis in Cerebral Infarction [TICI] 2b-3) was evaluated using logistic regression analysis adjusting for potential confounders. Results: Median ATG was 73 minutes. Prolonged ATG intervals were associated with the use of magnetic resonance imaging (+19.1 [95% CI, +9.1 to +29.1] minutes), general anesthesia (+12.1 [95% CI, +3.7 to +20.4] minutes), and borderline indication criteria, such as lower National Institutes of Health Stroke Scale, late presentations, or not meeting top-tier early time window eligibility criteria (+13.8 [95% CI, +6.1 to +21.6] minutes). There was a 13% relative odds reduction for TICI 2b-3 (adjusted odds ratio [aOR], 0.87 [95% CI, 0.79–0.96]) and TICI 2c/3 (aOR, 0.87 [95% CI, 0.79–0.95]) per hour ATG delay, while the reduction of TICI 2b-3 per hour increase symptom-onset-to-admission was minor (aOR, 0.97 [95% CI, 0.94–0.99]) and inconsistent regarding TICI 2c/3 (aOR, 0.99 [95% CI, 0.97–1.02]). After adjusting for identified factors associated with prolonged ATG intervals, the association of ATG delay and lower rates of TICI 2b-3 remained tangible (aOR, 0.87 [95% CI, 0.76–0.99]). Conclusions: There is a great potential to reduce ATG, and potential targets for improvement can be deduced from observational data. The association between in-hospital delay and reduced reperfusion rates is evident in real-world clinical data, underscoring the need to optimize in-hospital workflows. Given the only minor association between symptom-onset-to-admission intervals and reperfusion rates, the causal relationship of this association warrants further research. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03496064.
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Affiliation(s)
- Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology (J.K., E.I.P., P.J.M., P. Mordasini, T.D., J.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland.,University Institute of Diagnostic and Interventional and Pediatric Radiology (J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Basel Maamari
- Department of Neurology (B.M., T.R.M., M.G., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Thomas R Meinel
- Department of Neurology (B.M., T.R.M., M.G., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Eike I Piechowiak
- University Institute of Diagnostic and Interventional Neuroradiology (J.K., E.I.P., P.J.M., P. Mordasini, T.D., J.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Pascal J Mosimann
- University Institute of Diagnostic and Interventional Neuroradiology (J.K., E.I.P., P.J.M., P. Mordasini, T.D., J.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Pasquale Mordasini
- University Institute of Diagnostic and Interventional Neuroradiology (J.K., E.I.P., P.J.M., P. Mordasini, T.D., J.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Martina Goeldlin
- Department of Neurology (B.M., T.R.M., M.G., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology (B.M., T.R.M., M.G., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Tomas Dobrocky
- University Institute of Diagnostic and Interventional Neuroradiology (J.K., E.I.P., P.J.M., P. Mordasini, T.D., J.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Tobias Boeckh-Behrens
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Germany (T.B.-B., M.B.)
| | - Maria Berndt
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Germany (T.B.-B., M.B.)
| | - Patrik Michel
- Department of Neurology, CHUV Lausanne, Switzerland (P. Michel)
| | - Manuel Requena
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain (M.R.)
| | - Amel Benali
- Department of Neuroradiology, CHU Montpellier, France (A. Benali)
| | | | - Vitor Mendes Pereira
- Joint Department of Medical Imaging and Division of Neurosurgery, Toronto Western Hospital, University of Toronto, ON, Canada (V.M.P.)
| | - Grégoire Boulouis
- Department of Neuroradiology, Université Paris Descartes, Sainte Anne Hospital, France (G.B.)
| | - Alex Brehm
- Department of Neuroradiology (A. Brehm, P.B.S.), University Hospital Basel, Switzerland
| | - Peter B Sporns
- Department of Neuroradiology (A. Brehm, P.B.S.), University Hospital Basel, Switzerland
| | - Johanna M Ospel
- Department of Radiology (J.M.O.), University Hospital Basel, Switzerland.,Department of Clinical Neuroscience, University of Calgary, Canada (J.M.O.)
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology (J.K., E.I.P., P.J.M., P. Mordasini, T.D., J.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Urs Fischer
- Department of Neurology (B.M., T.R.M., M.G., M.A., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
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Hussein O, Abd Elazim A, Sawalha K, Salam S, Saba K, Hamed M, Peng J, Hinduja A. Role of Non-Perfusion Factors in Mildly Symptomatic Large Vessel Occlusion Stroke. J Stroke Cerebrovasc Dis 2020; 29:105172. [PMID: 32912550 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 06/25/2020] [Accepted: 07/16/2020] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Uncertainty regarding reperfusion of mildly-symptomatic (minor) large vessel occlusion (LVO)-strokes exists. Recently, benefits from reperfusion were suggested. However, there is still no strong data to support this. Furthermore, a proportion of those patients don't improve even after non-hemorrhagic reperfusion. Our study evaluated whether or not non-perfusion factors account for such persistent deconditioning. METHODS Patients with identified minor LVO-strokes (NIHSS ≤ 8) from our stroke alert registry between January-2016 and May-2018 were included. Variables/ predictors of outcome were tested using univariate/multivariate logistic and linear regression analyses. Three month-modified ranking scale (mRS) was used to differentiate between favorable (mRS = 0-2) and unfavorable outcomes (mRS = 3-6). RESULTS Eighty-one patients were included. Significant differences between the two outcome groups regarding admission-NIHSS and discharge-NIHSS existed (OR = 0.47, 0.49 / p = 0.0005, <0.0001 respectively).The two groups had matching perfusion measures. In the poor outcome group, discharge-NIHSS was unchanged from the admission-NIHSS while in the good outcome group, discharge-NIHSS significantly improved. CONCLUSION Admission and discharge NIHSS are independent predictors of outcome in patients with minor-LVO strokes. Unchanged discharge-NIHSS predicts worse outcomes while improved discharge-NIHSS predicts good outcomes. Unchanged NIHSS in the poor outcome group was independent of the perfusion parameters. In literature, complement activation and pro-inflammatory responses to ischemia might account for the progression of stroke symptoms in major-strokes. Our study concludes similar phenomena might be present in minor-strokes. Therefore, discharge-NIHSS may be useful as a clinical marker for future therapies.
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Affiliation(s)
- Omar Hussein
- University of New Mexico Health Sciences Center, Department of Neurology, Albuquerque, New Mexico, USA.
| | - Ahmed Abd Elazim
- University of New Mexico Health Sciences Center, Department of Neurology, Albuquerque, New Mexico, USA
| | - Khalid Sawalha
- University of Massachusetts-Baystate Medical Center - Department of Internal-Medicine, 3601 Main St, Springfield, MA 01107, USA
| | - Smeer Salam
- The Ohio State University Wexner Medical Center, Department of Neurology, 410 W 10th Ave, Columbus, USA
| | - Kasser Saba
- Atrium Health, Department of Neurology, Charlotte, North Carolina, USA
| | - Mohammad Hamed
- The Ohio State University Wexner Medical Center, Department of Neurology, 410 W 10th Ave, Columbus, USA
| | - Juan Peng
- The Ohio State University, Department of Biostatistics, 410 W 10th Ave, Columbus, USA
| | - Archana Hinduja
- The Ohio State University Wexner Medical Center, Department of Neurology, 410 W 10th Ave, Columbus, USA
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11
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Meinel TR, Kaesmacher J, Mosimann PJ, Seiffge D, Jung S, Mordasini P, Arnold M, Goeldlin M, Hajdu SD, Olivé-Gadea M, Maegerlein C, Costalat V, Pierot L, Schaafsma JD, Fischer U, Gralla J. Association of initial imaging modality and futile recanalization after thrombectomy. Neurology 2020; 95:e2331-e2342. [PMID: 32847948 PMCID: PMC7682915 DOI: 10.1212/wnl.0000000000010614] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2020] [Accepted: 05/18/2020] [Indexed: 12/12/2022] Open
Abstract
Objective To test the hypothesis that selection by initial imaging modality (MRI vs CT) is associated with rate of futile recanalizations (FRs) after mechanical thrombectomy (MT), we assessed this association in a multicenter, retrospective observational registry (BEYOND-SWIFT [Registry for Evaluating Outcome of Acute Ischemic Stroke Patients Treated With Mechanical Thrombectomy], NCT03496064). Methods In 2,011 patients (49.7% female, median age 73 years [61–81]) included between 2009 and 2017, we performed univariate and multivariate analyses regarding the occurrence of FR. FRs were defined as 90-day modified Rankin Scale (mRS) score 4–6 despite successful recanalization in patients selected by MRI (n = 690) and CT (n = 1,321) with a sensitivity analysis considering only patients with mRS 5–6 as futile. Results MRI as compared to CT resulted in similar rates of subsequent MT (adjusted odds ratio [aOR] 1.048, 95% confidence interval [CI] 0.677–1.624). Rates of FR were as follows: 571/1,489 (38%) FR mRS 4–6 including 393/1,489 (26%) FR mRS 5–6. CT-based selection was associated with increased rates of FRs compared to MRI (44% [41%–47%] vs 29% [25%–32%], p < 0.001; aOR 1.77 [95% CI 1.25–2.51]). These findings were robust in sensitivity analysis. MRI-selected patients had a delay of approximately 30 minutes in workflow metrics in real-world university comprehensive stroke centers. However, functional outcome and mortality were more favorable in patients selected by MRI compared to patients selected with CT. Conclusions CT selection for MT was associated with an increased risk of FRs as compared to MRI selection. Efforts are needed to shorten workflow delays in MRI patients. Further research is needed to clarify the role of the initial imaging modality on FR occurrence and to develop a reliable FR prediction algorithm.
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Affiliation(s)
- Thomas Raphael Meinel
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Johannes Kaesmacher
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Pascal John Mosimann
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - David Seiffge
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Simon Jung
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Pasquale Mordasini
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Marcel Arnold
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Martina Goeldlin
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Steven D Hajdu
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Marta Olivé-Gadea
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Christian Maegerlein
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Vincent Costalat
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Laurent Pierot
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Joanna D Schaafsma
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
| | - Urs Fischer
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada.
| | - Jan Gralla
- From the Departments of Neurology (T.R.M., D.S., S.J., M.A., M.G., U.F.) and Neuroradiology (P.J.M., P.M., J.G.) and Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Institute of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, Bern University Hospital, University of Bern; Department of Radiology (S.D.H.), Lausanne University Hospital, Switzerland; Department of Neurology (M.-O.G.), Vall d'Hebron University Hospital, Barcelona, Spain; Department of Diagnostic and Interventional Neuroradiology (C.M.), Klinikum rechts der Isar, Technical University Munich, Germany; Department of Neuroradiology (V.C.), CHU Montpellier; Department of Neuroradiology (L.P.), CHU Reims, France; and Department of Neurology Medicine (J.D.S.), Division of Neurology, Toronto Western Hospital, Canada
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12
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Meinel TR, Kniepert JU, Seiffge DJ, Gralla J, Jung S, Auer E, Frey S, Goeldlin M, Mordasini P, Mosimann PJ, Nogueira RG, Haussen DC, Rodrigues GM, Uphaus T, L'Allinec V, Krajíčková D, Alonso A, Costalat V, Hajdu SD, Olivé-Gadea M, Maegerlein C, Pierot L, Schaafsma J, Suzuki K, Arnold M, Heldner MR, Fischer U, Kaesmacher J. Endovascular Stroke Treatment and Risk of Intracranial Hemorrhage in Anticoagulated Patients. Stroke 2020; 51:892-898. [PMID: 31992179 DOI: 10.1161/strokeaha.119.026606] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Background and Purpose- We aimed to determine the safety and mortality after mechanical thrombectomy in patients taking vitamin K antagonists (VKAs) or direct oral anticoagulants (DOACs). Methods- In a multicenter observational cohort study, we used multiple logistic regression analysis to evaluate associations of symptomatic intracranial hemorrhage (sICH) with VKA or DOAC prescription before thrombectomy as compared with no anticoagulation. The primary outcomes were the rate of sICH and all-cause mortality at 90 days, incorporating sensitivity analysis regarding confirmed therapeutic anticoagulation. Additionally, we performed a systematic review and meta-analysis of literature on this topic. Results- Altogether, 1932 patients were included (VKA, n=222; DOAC, n=98; no anticoagulation, n=1612); median age, 74 years (interquartile range, 62-82); 49.6% women. VKA prescription was associated with increased odds for sICH and mortality (adjusted odds ratio [aOR], 2.55 [95% CI, 1.35-4.84] and 1.64 [95% CI, 1.09-2.47]) as compared with the control group, whereas no association with DOAC intake was observed (aOR, 0.98 [95% CI, 0.29-3.35] and 1.35 [95% CI, 0.72-2.53]). Sensitivity analyses considering only patients within the confirmed therapeutic anticoagulation range did not alter the findings. A study-level meta-analysis incorporating data from 7462 patients (855 VKAs, 318 DOACs, and 6289 controls) from 15 observational cohorts corroborated these observations, yielding an increased rate of sICH in VKA patients (aOR, 1.62 [95% CI, 1.22-2.17]) but not in DOAC patients (aOR, 1.03 [95% CI, 0.60-1.80]). Conclusions- Patients taking VKA have an increased risk of sICH and mortality after mechanical thrombectomy. The lower risk of sICH associated with DOAC may also be noticeable in the acute setting. Improved selection might be advisable in VKA-treated patients. Registration- URL: https://www.clinicaltrials.gov. Unique identifier: NCT03496064. Systematic Review and Meta-Analysis: CRD42019127464.
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Affiliation(s)
- Thomas R Meinel
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Joachim U Kniepert
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - David J Seiffge
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.G., M.G., P.M., P.J.M.)
| | - Simon Jung
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Elias Auer
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Sebastién Frey
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Martina Goeldlin
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.).,University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.G., M.G., P.M., P.J.M.)
| | - Pasquale Mordasini
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.G., M.G., P.M., P.J.M.)
| | - Pascal J Mosimann
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.G., M.G., P.M., P.J.M.)
| | - Raul G Nogueira
- Emory University/Marcus Stroke and Neuroscience Center-Grady Memorial Hospital, Atlanta, GA (R.G.N., D.C.H., G.M.R.)
| | - Diogo C Haussen
- Emory University/Marcus Stroke and Neuroscience Center-Grady Memorial Hospital, Atlanta, GA (R.G.N., D.C.H., G.M.R.)
| | - Gabriel M Rodrigues
- Emory University/Marcus Stroke and Neuroscience Center-Grady Memorial Hospital, Atlanta, GA (R.G.N., D.C.H., G.M.R.)
| | - Timo Uphaus
- Department of Neurology, University Medical Center of the Johannes Gutenberg University Mainz, Germany, on behalf of the ENDOSTROKE Study Group (T.U.)
| | - Vincent L'Allinec
- Neuroradiology Department, Nantes University Hospital, France (V.L.)
| | - Dagmar Krajíčková
- Department of Neurology, Comprehensive Stroke Center, Faculty of Medicine in Hradec Králové, Charles University and University Hospital Hradec Králové, Czech Republic (D.K.)
| | - Angelika Alonso
- Department of Neurology, Universitätsmedizin Mannheim, Medical Faculty Mannheim, University of Heidelberg, Germany (A.A.)
| | | | - Steven D Hajdu
- Department of Radiology, CHUV Lausanne, Switzerland (S.D.H.)
| | - Marta Olivé-Gadea
- Department of Neurology, Hospital Universitario Vall d'Hebron, Barcelona, Spain (M.O.-G.)
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Germany (C.M.)
| | | | - Joanna Schaafsma
- Division of Neurology, University Health Network, University of Toronto, Canada (J.S.)
| | - Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan (K.S.)
| | - Marcel Arnold
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Mirjam R Heldner
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Urs Fischer
- From the Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (T.R.M., J.U.K., D.J.S., S.J., E.A., S.F., M.G., M.A., M.R.H., U.F.)
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.K.).,Institute of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.K.).,Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Switzerland (J.K.)
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13
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Williams MM, Leslie-Mazwi T, Hirsch JA, Kittel C, Spiotta A, De Leacy R, Mocco J, Albuquerque FC, Ducruet AF, Goyal N, Arthur AS, Kan P, Mokin M, Dumont TM, Reeves A, Wolfe SQ, Fargen K. Real-world effects of late window neurothrombectomy: procedure rates increase without night-time bias. J Neurointerv Surg 2019; 12:460-464. [PMID: 31723049 DOI: 10.1136/neurintsurg-2019-015223] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 09/23/2019] [Accepted: 10/01/2019] [Indexed: 01/13/2023]
Abstract
INTRODUCTION With the expansion of the interventional time window for stroke from emergent large vessel occlusion (ELVO), the rate of mechanical thrombectomy (MT) is expected to rise, potentially causing higher burnout rates and requiring hospitals to develop strategies for adequate coverage of these procedures. METHODS Neurointerventional physicians at 10 participating stroke centers prospectively recorded time requirements for all MT consultations over 30 consecutive 24-hour call periods, including both false positive consultations and MT procedures, during mid to late 2018. Consult start time, procedure start and end time, and data regarding commute to the hospital and delay in scheduled procedures were collected and compared with those from an identical prospective study performed in 2017. RESULTS Data were collected from a total of 300 days of call. A total of 166 procedures were performed (mean 0.55 per day), an increase from 0.32 per day in 2017. Overall mean MT direct time burden during each 24-hour call was 124 min (compared with 85 min in 2017). The percentage of consultations for thrombectomy varied based on time of day, with 87% of consults between the hours of midnight and 04:00 proceeding to thrombectomy compared with 37% between the hours of 16:00 and 20:00. CONCLUSIONS MT procedural volumes have increased from one every 5 days in 2016 to one every 2 days in 2018. The highest percentage of consults leading to thrombectomy occur in the early morning hours after midnight. Compared with similar data from 2016 and 2017, call demands continue to escalate, representing a significant demand on neurointerventional teams.
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Affiliation(s)
- Michelle Marie Williams
- Neurological Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Thabele Leslie-Mazwi
- Interventional Neuroradiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joshua A Hirsch
- Interventional Neuroradiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Carol Kittel
- Neurological Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Alejandro Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Reade De Leacy
- Neurosurgery, Mount Sinai Hospital, New York City, New York, USA
| | - J Mocco
- Neurosurgery, Mount Sinai Hospital, New York City, New York, USA
| | | | - Andrew F Ducruet
- Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Nitin Goyal
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
| | - Adam S Arthur
- UT Dept Neurosurgery/Semmes-Murphey Clinic, Memphis, Tennessee, USA
| | - Peter Kan
- Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Maxim Mokin
- Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Travis M Dumont
- Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
| | - Alan Reeves
- Neuroendovascular Division, Department of Radiology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Stacey Q Wolfe
- Neurological Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Kyle Fargen
- Neurological Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
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14
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Meinel TR, Kaesmacher J, Chaloulos-Iakovidis P, Panos L, Mordasini P, Mosimann PJ, Michel P, Hajdu S, Ribo M, Requena M, Maegerlein C, Friedrich B, Costalat V, Benali A, Pierot L, Gawlitza M, Schaafsma J, Pereira VM, Gralla J, Fischer U. Mechanical thrombectomy for basilar artery occlusion: efficacy, outcomes, and futile recanalization in comparison with the anterior circulation. J Neurointerv Surg 2019; 11:1174-1180. [PMID: 31239331 PMCID: PMC6902072 DOI: 10.1136/neurintsurg-2018-014516] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2018] [Revised: 04/03/2019] [Accepted: 04/11/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND Performing mechanical thrombectomy (MT) in patients with basilar artery occlusion (BAO) is currently not evidence-based. OBJECTIVE To compare patients' outcome, relative merits of achieving recanalization, and predictors of futile recanalization (FR) between BAO and anterior circulation large vessel occlusion (ACLVO) MT. METHODS In the multicenter BEYOND-SWIFT registry (NCT03496064), univariate and multivariate (displayed as adjusted Odds Ratios, aOR and 95% confidence intervals, 95%-CI) outcome comparisons between BAO (N=165) and ACLVO (N=1574) were performed. The primary outcome was favorable outcome at 90 days (modified Rankin Scale, mRS 0-2). Secondary outcome included mortality, symptomatic intracranial hemorrhage (sICH) and FR. The relative merits of achieving successful recanalization between ACLVO and BAO were evaluated with interaction terms. RESULTS MT in BAO was more often technically effective and equally safe in regards to mortality and sICH when compared to ACLVO. When adjusting for baseline differences, there was no significant difference between BAO vs ACLVO regarding rates of favorable outcome (aOR 0.986, 95%-CI 0.553 - 1.758). However, BAO were associated with increased rates of FR (aOR 2.146, 95%-CI 1.267 - 3.633). Predictors for FR were age, stroke severity, maneuver count and intracranial stenting. No significant heterogeneity on the relative merits of achieving successful recanalization on several outcome parameters were observed when comparing BAO and ACLVO. CONCLUSIONS In selected patients, similar outcomes can be achieved in BAO and ACLVO patients treated with MT. Randomized controlled trials comparing patient selection and interventional strategies seem warranted to avoid FR. TRIAL REGISTRATION NUMBER NCT03496064.
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Affiliation(s)
- Thomas Raphael Meinel
- Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | | | - Leonidas Panos
- Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- Department for Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Pascal J Mosimann
- Department for Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Patrik Michel
- Department of Neurology, CHUV Lausanne, Lausanne, Switzerland
| | - Steven Hajdu
- Department of Interventional and Diagnostic Neuroradiology, University Hospital of Lausanne, CHUV, Lausanne, Switzerland
| | - Marc Ribo
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Manuel Requena
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technische Universität, Munich, Germany
| | - Benjamin Friedrich
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technische Universität, Munich, Germany
| | - Vincent Costalat
- Department of Neuroradiology, Centre Hospitalier Regional Universitaire de Montpellier, Montpellier, France
| | - Amel Benali
- Department of Neuroradiology, Centre Hospitalier Regional Universitaire de Montpellier, Montpellier, France
| | - Laurent Pierot
- Department of Neuroradiology, Centre Hospitalier Universitaire de Reims, Reims, France
| | - Matthias Gawlitza
- Department of Neuroradiology, Centre Hospitalier Universitaire de Reims, Reims, France
| | | | - Vitor M Pereira
- Joint Department of Medical Imaging, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Jan Gralla
- Department for Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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15
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Meinel TR, Kaesmacher J, Mordasini P, Mosimann PJ, Jung S, Arnold M, Heldner MR, Michel P, Hajdu SD, Ribo M, Requena M, Maegerlein C, Friedrich B, Costalat V, Benali A, Pierot L, Gawlitza M, Schaafsma J, Pereira VM, Gralla J, Fischer U. Outcome, efficacy and safety of endovascular thrombectomy in ischaemic stroke according to time to reperfusion: data from a multicentre registry. Ther Adv Neurol Disord 2019; 12:1756286419835708. [PMID: 30944585 PMCID: PMC6437320 DOI: 10.1177/1756286419835708] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Accepted: 02/03/2019] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND AND PURPOSE In acute ischaemic stroke (AIS) of the anterior circulation (AC) treated with mechanical thrombectomy (MT), data point to a decline of treatment effect with increasing time from symptom onset to treatment. However, the magnitude of the decline will depend on the clinical setting and imaging selection used. The aims of this study were (1) to evaluate the clinical effect of time to reperfusion (TTR); and (2) to assess the safety and technical efficacy of MT according to strata of TTR. METHODS Using the retrospective multicentre BEYOND-SWIFT registry data (ClinicalTrials.gov identifier: NCT03496064), we compared safety and efficacy of MT in 1461 patients between TTR strata of 0-180 min (n = 192), 180-360 min (n = 876) and >360 min (n = 393). Clinical effect of TTR was evaluated using multivariable logistic regression analyses adjusting for pre-specified confounders [adjusted odds ratios (aOR) and 95% confidence intervals (95% CI)]. Primary outcome was good functional outcome (modified Rankin Scale: mRS 0-2) at day 90. RESULTS Every hour delay in TTR was a significant factor related to mRS 0-2 (aOR 0.933, 95% CI 0.887-0.981) with an estimated 1.5% decreased probability of good functional outcome per hour delay of reperfusion, and mRS 0-1 (aOR 0.929, 95% CI 0.877-0.985). Patients with late TTR had lower rates of successful and excellent reperfusion, higher complication rates and number of passes. CONCLUSIONS TTR is an independent factor related to long-term functional outcome. With increasing TTR, interventional procedures become technically less effective. Efforts should be made to shorten TTR through optimized prehospital and in-hospital pathways.
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Affiliation(s)
- Thomas Raphael Meinel
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Institute of Diagnostic, Interventional and Pediatric Radiology and Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Pascal J. Mosimann
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Mirjam Rachel Heldner
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Patrik Michel
- Department of Neurology, CHUV Lausanne, Lausanne, Switzerland
| | - Steven D. Hajdu
- Department of Radiology, CHUV Lausanne, Lausanne, Switzerland
| | - Marc Ribo
- Department of Neurology, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Manuel Requena
- Department of Neurology, Vall d’Hebron University Hospital, Barcelona, Spain
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Benjamin Friedrich
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Vincent Costalat
- Department of Neuroradiology, CHU Montpellier, Montpellier, France
| | - Amel Benali
- Department of Neuroradiology, CHU Montpellier, Montpellier, France
| | - Laurent Pierot
- Department of Neurology, Toronto Western Hospital, Toronto, Canada
| | | | - Joanna Schaafsma
- Department of Neurology, Toronto Western Hospital, Toronto, Canada
| | | | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Freiburgstrasse 8, CH-3010, Switzerland
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