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van der Meij A, Holswilder G, Bernsen MLE, van Os HJ, Hofmeijer J, Spaander FH, Martens JM, van den Wijngaard IR, Lingsma HF, Konduri PR, Blm Majoie C, Schonewille WJ, Dippel DW, Kruyt ND, Nederkoorn PJ, van Walderveen MA, Wermer MJ. Sex differences in clot, vessel and tissue characteristics in patients with a large vessel occlusion treated with endovascular thrombectomy. Eur Stroke J 2024; 9:600-612. [PMID: 38420950 DOI: 10.1177/23969873241231125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
INTRODUCTION To improve our understanding of the relatively poor outcome after endovascular treatment (EVT) in women we assessed possible sex differences in baseline neuroimaging characteristics of acute ischemic stroke patients with large anterior vessel occlusion (LVO). PATIENTS AND METHODS We included all consecutive patients from the MR CLEAN Registry who underwent EVT between 2014 and 2017. On baseline non-contrast CT and CT angiography, we assessed clot location and clot burden score (CBS), vessel characteristics (presence of atherosclerosis, tortuosity, size, and collateral status), and tissue characteristics with the Alberta Stroke Program Early Computed Tomography Score (ASPECTS). Radiological outcome was assessed with the extended thrombolysis in cerebral infarction score (eTICI) and functional outcome with the modified Rankin Scale score (mRS) at 90 days. Sex-differences were assessed with multivariable regression analyses with adjustments for possible confounders. RESULTS 3180 patients were included (median age 72 years, 48% women). Clots in women were less often located in the intracranial internal carotid artery (ICA) (25%vs 28%, odds ratio (OR) 0.85;95% confidence interval: 0.73-1.00). CBS was similar between sexes (median 6, IQR 4-8). Intracranial (aOR 0.73;95% CI:0.62-0.87) and extracranial (aOR 0.64;95% CI:0.43-0.95) atherosclerosis was less prevalent in women. Vessel tortuosity was more frequent in women in the cervical ICA (aOR 1.89;95% CI:1.39-2.57) and women more often had severe elongation of the aortic arch (aOR 1.38;95% CI:1.00-1.91). ICA radius was smaller in women (2.3vs 2.5 mm, mean difference 0.22;95% CI:0.09-0.35) while M1 radius was essentially equal (1.6vs 1.7 mm, mean difference 0.09;95% CI:-0.02-0.21). Women had better collateral status (⩾50% filling in 62%vs 53% in men, aOR 1.48;95% CI:1.29-1.70). Finally, ASPECT scores were equal between women and men (median 9 in both sexes, IQR 8-10vs 9-10). Reperfusion rates were similar between women and men (acOR 0.94;95% CI:0.83-1.07). However, women less often reached functional independence than men (34%vs 46%, aOR 0.68;95% CI:0.53-0.86). DISCUSSION AND CONCLUSION On baseline imaging of this Dutch Registry, men and women with LVO mainly differ in vessel characteristics such as atherosclerotic burden, extracranial vessel tortuosity, and collateral status. These sex differences do not result in different reperfusion rates and are, therefore, not likely to explain the worse functional outcome in women after EVT.
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Affiliation(s)
- Anne van der Meij
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Ghislaine Holswilder
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marie Louise E Bernsen
- Department of Radiology and Nuclear Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Hendrikus Ja van Os
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Public Health & Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeannette Hofmeijer
- Department of Neurology, Rijnstate Hospital, Arnhem, The Netherlands
- Department of Clinical Neurophysiology, University of Twente, Enschede, The Netherlands
| | | | - Jasper M Martens
- Department of Radiology and Nuclear Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Ido R van den Wijngaard
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurology, Haaglanden Medical Center, Den Haag, The Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Praneeta R Konduri
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Charles Blm Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Diederik Wj Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Nyika D Kruyt
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Marieke Jh Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands
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Ahmed RA, Withers JR, McIntyre JA, Leslie-Mazwi TM, Das AS, Dmytriw AA, Hirsch JA, Rabinov JD, Doron O, Stapleton CJ, Patel AB, Singhal AB, Rost NS, Regenhardt RW. Impact and determinants of door in-door out time for stroke thrombectomy transfers in a large hub-and-spoke network. Interv Neuroradiol 2024:15910199241261760. [PMID: 38872477 DOI: 10.1177/15910199241261760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024] Open
Abstract
INTRODUCTION The mantra "time is brain" cannot be overstated for patients suffering from acute ischemic stroke. This is especially true for those with large vessel occlusions (LVOs) requiring transfer to an endovascular thrombectomy (EVT) capable center. We sought to evaluate the spoke hospital door in-door out (DIDO) times for patients transferred to our hub center for EVT. METHODS Individuals who first presented with LVO to a spoke hospital and were then transferred to the hub for EVT were retrospectively identified from a prospectively maintained database from January 2019 to November 2022. DIDO was defined as the time between spoke hospital door in arrival and door out exit. Baseline characteristics, treatments, and outcomes were compared, dichotomizing DIDO at 90 minutes based in the American Heart Association goal for DIDO ≤90 minutes for 50% of transfers. Multivariable regression analyses were performed for determinants of the 90-day ordinal modified Rankin Scale (mRS) and DIDO. RESULTS We identified 194 patients transferred for EVT with available DIDO. The median age was 67 years (IQR 57-80), and 46% were female. The median National Institutes of Health Stroke Scale (NIHSS) was 16 (10-20), 50% were treated with intravenous thrombolysis at a spoke, and TICI 2B-3 reperfusion was achieved in 87% at the hub. The median DIDO was 120 minutes (97-149), with DIDO ≤90 minutes achieved in 18%. DIDO was a significant determinant of 90-day ordinal mRS (B = 0.007, 95% CI = 0.001-0.012, p = 0.013), even when accounting for the last known well-to-spoke door in, spoke door out-to-hub arrival, hub arrival-to-puncture, puncture-to-first pass, age, NIHSS, intravenous thrombolysis, TICI 2B-3, and symptomatic intracranial hemorrhage. Importantly, determinants of DIDO included Black race or Hispanic ethnicity (B = 0.918, 95% CI = 0.010-1.826, p = 0.048), atrial fibrillation or heart failure (B = 0.793, 95% CI = 0.257-1.329, p = 0.004), and basilar LVO location (B = 2.528, 95% CI = 1.154-3.901, p < 0.001). CONCLUSION Spoke DIDO was the most important period of time for long-term outcomes of LVO stroke patients treated with EVT. Targets were identified to reduce DIDO and improve patient outcomes.
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Affiliation(s)
- Rashid A Ahmed
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - James R Withers
- University of New England College of Osteopathic Medicine, Biddeford, ME, USA
| | - Joyce A McIntyre
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | | | - Alvin S Das
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Department of Neurology, Beth Israel Deaconess, Harvard Medical School, Boston, USA
| | - Adam A Dmytriw
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - James D Rabinov
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Omer Doron
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Christopher J Stapleton
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Aneesh B Singhal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Natalia S Rost
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Robert W Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
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Huo X, Sun D, Raynald, Jia B, Tong X, Wang A, Ma N, Gao F, Mo D, Nguyen TN, Miao Z. Sex differences in outcomes of endovascular therapy for acute vertebrobasilar occlusion: data from ANGEL-ACT Registry. J Neurol 2024; 271:1376-1384. [PMID: 37950759 DOI: 10.1007/s00415-023-12078-2] [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: 05/12/2023] [Revised: 10/17/2023] [Accepted: 10/23/2023] [Indexed: 11/13/2023]
Abstract
BACKGROUND Understanding sex disparities in stroke can identify gaps in clinical care. The objective of this study was to investigate whether sex differences could influence clinical outcomes of patients with acute vertebrobasilar artery occlusion (VBAO) who underwent endovascular therapy (EVT). METHODS Patients were selected from the ANGEL-ACT Registry. The primary outcome was favorable functional outcome (90-day modified Rankin Scale [mRS] 0-3). Secondary outcomes included 90-day mRS distribution, excellent outcome (mRS 0-1), functional independence (mRS 0-2), early neurological improvement, recanalization, intracranial hemorrhage, and mortality within 90 days. The above outcomes were compared by two adjustment models, including (1) multivariable logistics analysis adjusting for all baseline and procedural variables with a P < 0.05; (2) adjusting for the propensity score. RESULTS There were 347 acute VBAO patients treated with EVT included, of whom 72 (20.7%) were women and 275 (79.3%) were men. Women were older (72[63-76] vs. 62[53-69], P < 0.001) and had a higher rate of atrial fibrillation (31.9% vs. 8.7%, P < 0.001), lower rates of underlying intracranial atherosclerotic disease (30.6% vs. 51.3%, P = 0.007), and tandem occlusion (8.3% vs. 21.8%, P = 0.009) than men. The rate of favorable outcome (mRS 0-3) was similar between women and men (41.7% vs. 51.3%, adjusted odds ratio 1.56, 95%CI: 0.83-2.95, P = 0.171). There were no sex differences in other clinical outcomes (all P > 0.05). CONCLUSIONS In the ANGEL-ACT registry, the percentage of men with acute VBAO undergoing EVT was approximately fourfold higher than that of women with acute VBAO undergoing EVT. Sex differences did not modify the outcomes of acute VBAO after EVT.
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Affiliation(s)
- Xiaochuan Huo
- Cerebrovascular Disease Department, Neurological Disease Center, Beijing Anzhen Hospital, Capital Medical University, NO. 2 Anzhen Road, Chaoyang District, Beijing, 100029, China.
| | - Dapeng Sun
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Raynald
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Baixue Jia
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Thanh N Nguyen
- Department of Neurology, Radiology, Boston Medical Center, Boston, MA, USA.
| | - Zhongrong Miao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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Nome T, Enriquez B, Nome CG, Tennøe B, Lund CG, Skjelland M, Aamodt AH, Beyer M. Clinical outcome after thrombectomy in patients with MeVO stroke: importance of clinical and technical factors. J Neurol 2024; 271:877-886. [PMID: 37847291 PMCID: PMC10827971 DOI: 10.1007/s00415-023-12025-1] [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: 06/29/2023] [Revised: 09/23/2023] [Accepted: 09/25/2023] [Indexed: 10/18/2023]
Abstract
BACKGROUND AND AIMS Whereas high-level evidence has been proven for safety and efficacy of endovascular treatment (EVT) in large vessel occlusion (LVO) stroke, the evidence for EVT in medium vessel occlusion (MeVO) in both sexes and different age groupremains to be answered. The aim of this study was to evaluate the importance of clinical and technical parameters, focusing on sex, age and EVT procedural factors, on functional outcome in primary MeVO (pMeVO) strokes. METHODS 144 patients with pMeVO in the MCA territory from the Oslo Acute Reperfusion Stroke Study (OSCAR) were included. Clinical and radiological data were collected including 90-day mRS follow-up. RESULTS Successful reperfusion with modified thrombolysis in cerebral infarction (mTICI) ≥ 2b was achieved in 123 patients (84%). Good functional outcome (mRS ≤ 2) at 90-day follow-up was achieved in 84 patients (61.8%). Two or more passes with stent retriever was associated with increased risk of SAH, poor mTICI and poor functional outcome. In average, women had 62 min longer ictus to recanalization time compared to men. Age over 80 years was significantly associated with poor outcome and death. CONCLUSION In pMeVO patients, TICI score and number of passes with stent retriever were the main technical factors predicting mRS ≤ 2. Good clinical outcome occurred almost twice as often in patients under 80 years of age compared to patients over 80 years. Women with MeVO strokes had significant longer time from ictus to recanalization; however, this did not affect the clinical outcome.
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Affiliation(s)
- Terje Nome
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Brian Enriquez
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Cecilie G Nome
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
- Division of Anatomy, Department of Molecular Medicine, Institute of Basic Medical Sciences, GliaLab and Letten Centre, University of Oslo, Oslo, Norway
| | - Bjørn Tennøe
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | | | - Mona Skjelland
- Department of Neurology, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Anne Hege Aamodt
- Department of Neurology, Oslo University Hospital, Oslo, Norway.
- Department of Neuromedicine and Movement Science, The Norwegian University of Science and Technology, Trondheim, Norway.
| | - Mona Beyer
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Mbonde A, Young MJ, Dmytriw AA, Moyer QJ, Hirsch JA, Leslie-Mazwi TM, Rost NS, Patel AB, Regenhardt RW. Informed consent practices for acute stroke therapy: principles, challenges and emerging opportunities. J Neurol 2024; 271:188-197. [PMID: 37815578 DOI: 10.1007/s00415-023-12028-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2023] [Revised: 09/24/2023] [Accepted: 09/25/2023] [Indexed: 10/11/2023]
Abstract
IMPORTANCE Informed consent (IC) plays a crucial yet underexplored role in acute stroke treatment, particularly in the context of intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT). This narrative review examines data on current IC practices in acute ischemic stroke management, specifically for patients treated with IVT or EVT, with the aim of identifying areas for improvement and strategies to enhance the IC process. OBSERVATIONS IC practices for IVT vary significantly among hospitals and physicians with the frequency of always requiring consent ranging from 21 to 37%. Factors influencing IC for IVT include patient decision-making capacity, standard of care, time sensitive nature of treatments, legal and moral obligations, risk of complications, physician age and speciality, treatment delays, and hospital size. Consent requirements tend to be stricter for patients presenting within the 3-4.5-h window. The content and style of information shared as part of the IC process revealed discrepancies in the disclosure of stroke diagnosis, IVT mechanism, benefits, and risks. Research on IC practices for EVT is scarce, highlighting a concerning gap in the available evidence base. CONCLUSIONS AND RELEVANCE This review underscores the significant variability and knowledge gaps in IC for EVT and IVT. Challenges related to decision-making capacity assessment and the absence of standardised guidance substantially contributes to these gaps. Future initiatives should focus on simplifying information delivery to patients, developing formal tools for assessing capacity, standardising ethical frameworks to guide physicians when patients lack capacity and harmonizing IC standards across sites. The ultimate goal is to enhance IC practices and uphold patient autonomy, while ensuring timely treatment initiation.
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Affiliation(s)
- Amir Mbonde
- Harvard Medical School, Boston, MA, USA.
- Mayo Clinic Arizona, 13400 E Shea Blvd, Scottsdale, AZ, 85259, USA.
| | | | - Adam A Dmytriw
- Harvard Medical School, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | - Quentin J Moyer
- Harvard Medical School, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
| | | | | | | | | | - Robert W Regenhardt
- Harvard Medical School, Boston, MA, USA
- Harvard Medical School, Boston, MA, USA
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Kraft AW, Awad A, Rosenthal JA, Dmytriw AA, Vranic JE, Bonkhoff AK, Bretzner M, Hirsch JA, Rabinov JD, Stapleton CJ, Schwamm LH, Rost NS, Leslie-Mazwi TM, Patel AB, Regenhardt RW. In a hub-and-spoke network, spoke-administered thrombolysis reduces mechanical thrombectomy procedure time and number of passes. Interv Neuroradiol 2023; 29:315-320. [PMID: 35317663 PMCID: PMC10369105 DOI: 10.1177/15910199221087498] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2021] [Revised: 02/24/2022] [Accepted: 02/25/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND The utility of intravenous thrombolysis (IVT) prior to mechanical thrombectomy (MT) in large vessel occlusion stroke (LVO) is controversial. Some data suggest IVT increases MT technical difficulty. Within our hub-and-spoke telestroke network, we examined how spoke-administered IVT affected hub MT procedure time and pass number. METHODS Patients presenting to 25 spoke hospitals who were transferred to the hub and underwent MT from 2018 to 2020 were identified from a prospectively maintained database. MT procedure time, fluoroscopy time, and pass number were obtained from operative reports. RESULTS Of 107 patients, 48 received IVT at spokes. Baseline characteristics and NIHSS were similar. The last known well (LKW)-to-puncture time was shorter among IVT patients (4.3 ± 1.9 h vs. 10.5 ± 6.5 h, p < 0.0001). In patients that received IVT, mean MT procedure time was decreased by 18.8 min (50.5 ± 29.4 vs. 69.3 ± 46.7 min, p = 0.02) and mean fluoroscopy time was decreased by 11.3 min (21.7 ± 15.8 vs. 33.0 ± 30.9 min, p = 0.03). Furthermore, IVT-treated patients required fewer MT passes (median 1 pass [IQR 1.0, 1.80] vs. 2 passes [1.0, 2.3], p = 0.0002) and were more likely to achieve reperfusion in ≤2 passes (81.3% vs. 59.3%, p = 0.01). An increased proportion of IVT-treated patients achieved TICI 2b-3 reperfusion after MT (93.9% vs. 83.8%, p = 0.045). There were no associations between MT procedural characteristics and LKW-to-puncture time. CONCLUSION Within our network, hub MT following spoke-administered IVT was faster, required fewer passes, and achieved improved reperfusion. This suggests spoke-administered IVT does not impair MT, but instead may enhance it.
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Affiliation(s)
- Andrew W Kraft
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Amine Awad
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Joseph A Rosenthal
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Adam A Dmytriw
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Justin E Vranic
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Anna K Bonkhoff
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Martin Bretzner
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Joshua A Hirsch
- Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - James D Rabinov
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | | | - Lee H Schwamm
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Natalia S Rost
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | | | - Aman B Patel
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Robert W Regenhardt
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
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Percent Insular Ribbon Infarction for Predicting Infarct Growth Rate and 90-Day Outcomes in Large-Vessel Occlusive Stroke: Secondary Analysis of Prospective Clinical Trial Data. AJR Am J Roentgenol 2023:1-11. [PMID: 36790114 DOI: 10.2214/ajr.22.28852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/16/2023]
Abstract
Background: Insight into the natural history of infarct growth could help identify patients with slowly progressing stroke who may benefit from delayed endovascular thrombectomy (EVT). Objective: To evaluate associations of percent insular ribbon infarction (PIRI) with infarct growth rate (IGR) and 90-day outcomes in patients with large-vessel occlusion (LVO) stroke. Methods: This retrospective study was a secondary analysis of a prior clinical trial that enrolled patients with acute stroke not treated with reperfusion therapies from January 2007 to June 2009. The present analysis evaluated 31 trial patients (median age, 71 years; 12 female, 19 male) with anterior-circulation LVO who underwent serial MRI examinations. Two neuroradiologists independently scored PIRI on presentation MRI examinations based on the ratio of the length of the portion of the insula showing restricted diffusion to the insula's total length using a previously described 0-4 scale; scores were categorized [mild (0-1), moderate (2), or severe (3-4)], and discrepancies were resolved by consensus. Ninety-day modified Rankin Scale (mRS) was obtained. As part of earlier clinical trial analysis, collateral pattern on CTA was classified (symmetric, malignant, other), and infarct volumes were measured on DWI during the initial 48 hours after presentation and on FLAIR at 90 days. Results: Inter-rater agreement for PIRI category was strong (K=0.890). PIRI was mild in 10, moderate in 4, and severe in 17 patients. For mild, moderate, and severe PIRI, median onset-to-presentation IGR was 1.6, 8.5, and 17.5 cc/h (p<.001); median presentation-to-48-hour IGR was 0.3, 0.2, and 1.2 cc/h (p=.005); median 90-day infarct volume was 9.4, 39.8, and 108.6 cc (p=0.01); 90-day mRS ≤2 occurred in 78%, 67%, and 6% of patients (p=.001). In multivariable models controlling for age, ICA occlusion, and collateral pattern, PIRI category independently predicted onset-to-presentation IGR (β=1.5), presentation-to-48-hour IGR (β=1.3), and 90-day mRS ≤2 (OR=0.2). For predicting 90-day mRS ≤2, mild-to-moderate PIRI had sensitivity of 90.0% and specificity of 84.2%; symmetric collateral pattern had sensitivity of 70.0% and specificity of 73.7%. Conclusion: PIRI was independently associated with IGR and 90-day outcome. Clinical Impact: PIRI may help identify patients who could benefit from late-window EVT when requiring transfer to EVT-capable centers.
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Regenhardt RW, Lev MH, He J, Dmytriw AA, Vranic JE, Rabinov JD, Stapleton CJ, Patel AB, Singhal AB, Gonzalez RG. Symmetric collateral pattern on CTA predicts favorable outcomes after endovascular thrombectomy for large vessel occlusion stroke. PLoS One 2023; 18:e0284260. [PMID: 37141234 PMCID: PMC10159158 DOI: 10.1371/journal.pone.0284260] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 03/27/2023] [Indexed: 05/05/2023] Open
Abstract
Endovascular thrombectomy (EVT) has revolutionized large vessel occlusion (LVO) stroke management, but often requires advanced imaging. The collateral pattern on CT angiograms may be an alternative because a symmetric collateral pattern correlates with a slowly growing, small ischemic core. We tested the hypothesis that such patients will have favorable outcomes after EVT. Consecutive patients (n = 74) with anterior LVOs who underwent EVT were retrospectively analyzed. Inclusion criteria were available CTA and 90-day modified Rankin Scale (mRS). CTA collateral patterns were symmetric in 36%, malignant in 24%, or other in 39%. Median NIHSS was 11 for symmetric, 18 for malignant, and 19 for other (p = 0.02). Ninety-day mRS ≤2, indicating independent living, was achieved in 67% of symmetric, 17% of malignant, and 38% of other patterns (p = 0.003). A symmetric collateral pattern was a significant determinant of 90-day mRS ≤2 (aOR = 6.62, 95%CI = 2.24,19.53; p = 0.001) in a multivariable model that included age, NIHSS, baseline mRS, thrombolysis, LVO location, and successful reperfusion. We conclude that a symmetric collateral pattern predicts favorable outcomes after EVT for LVO stroke. Because the pattern also marks slow ischemic core growth, patients with symmetric collaterals may be suitable for transfer for thrombectomy. A malignant collateral pattern is associated with poor clinical outcomes.
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Affiliation(s)
- Robert W Regenhardt
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Michael H Lev
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Julian He
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Adam A Dmytriw
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Justin E Vranic
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - James D Rabinov
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Christopher J Stapleton
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - Aneesh B Singhal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
| | - R Gilberto Gonzalez
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States of America
- Athinoula A Martinos Center for Biomedical Imaging, Boston, MA, United States of America
- Mass General Brigham Data Science Office, Boston, MA, United States of America
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9
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Kraft AW, Regenhardt RW, Awad A, Rosenthal JA, Dmytriw AA, Vranic JE, Bonkhoff AK, Bretzner M, Hirsch JA, Rabinov JD, Stapleton CJ, Schwamm LH, Singhal AB, Rost NS, Leslie-Mazwi TM, Patel AB. Spoke-administered thrombolysis improves large vessel occlusion early recanalization: the real-world experience of a large academic hub-and-spoke telestroke network. STROKE (HOBOKEN, N.J.) 2023; 3:e000427. [PMID: 36816048 PMCID: PMC9936963 DOI: 10.1161/svin.122.000427] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 08/11/2022] [Indexed: 11/16/2022]
Abstract
Introduction Intravenous thrombolysis (IVT) prior to mechanical thrombectomy (MT) for large vessel occlusion (LVO) stroke is increasingly controversial. Recent trials support MT without IVT for patients presenting directly to MT-capable "hub" centers. However, bypassing IVT has not been evaluated for patients presenting to IVT-capable "spoke" hospitals that require hub transfer for MT. A perceived lack of efficacy of IVT to result in LVO early recanalization (ER) is often cited to support bypassing IVT, but ER data for IVT in patients that require interhospital transfer is limited. Here we examined LVO ER rates after spoke-administered IVT in our hub-and-spoke stroke network. Methods Patients presenting to 25 spokes before hub transfer for MT consideration from 2018-2020 were retrospectively identified from a prospectively maintained database. Inclusion criteria were pre-transfer CTA-defined LVO, ASPECTS ≥6, and post-transfer repeat vessel imaging. Results Of 167 patients, median age was 69 and 51% were female. 76 received spoke IVT (+spokeIVT) and 91 did not (-spokeIVT). Alteplase was the only IVT used in this study. Comorbidities and NIHSS were similar between groups. ER frequency was increased 7.2-fold in +spokeIVT patients [12/76 (15.8%) vs. 2/91 (2.2%), P<0.001]. Spoke-administered IVT was independently associated with ER (aOR=11.5, 95% CI=2.2,99.6, p<0.05) after adjusting for timing of last known well, interhospital transfer, and repeat vessel imaging. Interval NIHSS was improved in patients with ER (median -2 (IQR -6.3, -0.8) vs. 0 (-2.5, 1), p<0.05). Conclusion Within our network, +spokeIVT patients had a 7.2-fold increased ER relative likelihood. This real-world analysis supports IVT use in eligible patients with LVO at spoke hospitals before hub transfer for MT.
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Affiliation(s)
- Andrew W. Kraft
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Robert W. Regenhardt
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Amine Awad
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Joseph A. Rosenthal
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Adam A. Dmytriw
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Justin E. Vranic
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Anna K. Bonkhoff
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Martin Bretzner
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Joshua A. Hirsch
- Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - James D. Rabinov
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
- Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | | | - Lee H. Schwamm
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Aneesh B. Singhal
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | - Natalia S. Rost
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, USA
| | | | - Aman B. Patel
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, USA
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10
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Regenhardt RW, Nolan NM, Rosenthal JA, McIntyre JA, Bretzner M, Bonkhoff AK, Snider SB, Das AS, Alotaibi NM, Vranic JE, Dmytriw AA, Stapleton CJ, Patel AB, Rost NS, Leslie-Mazwi TM. Understanding Delays in MRI-based Selection of Large Vessel Occlusion Stroke Patients for Endovascular Thrombectomy. Clin Neuroradiol 2022; 32:979-986. [PMID: 35486123 DOI: 10.1007/s00062-022-01165-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 03/25/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE Given the efficacy of endovascular thrombectomy (EVT), optimizing systems of delivery is crucial. Magnetic resonance imaging (MRI) is the gold standard for evaluating tissue viability but may require more time to obtain and interpret. We sought to identify determinants of arrival-to-puncture time for patients who underwent MRI-based EVT selection in a real-world setting. METHODS Patients were identified from a prospectively maintained database from 2011-2019 that included demographics, presentations, treatments, and outcomes. Process times were obtained from the medical charts. MRI times were obtained from time stamps on the first sequence. Linear and logistic regressions were used to infer explanatory variables of arrival-to-puncture times and effects of arrival-to-puncture time on functional outcomes. RESULTS In this study 192 patients (median age 70 years, 57% women, 12% non-white) underwent MRI-based EVT selection. 66% also underwent computed tomography (CT) at the hub before EVT. General anesthesia was used for 33%. Among the entire cohort, the median arrival-to-puncture was 102 min; however, among those without CT it was 77 min. Longer arrival-to-puncture times independently reduced the odds of 90-day good outcome (∆mRS ≤ 2 from pre-stroke, aOR = 0.990, 95%CI = 0.981-0.999, p = 0.040) when controlling for age, NIHSS, and good reperfusion (TICI 2b-3). Independent determinants of longer arrival-to-puncture were CT plus MRI (β = 0.205, p = 0.003), non-white race/ethnicity (β = 0.162, p = 0.012), coronary disease (β = 0.205, p = 0.001), and general anesthesia (β = 0.364, p < 0.0001). CONCLUSION Minimizing arrival-to-puncture time is important for outcomes. Real-world challenges exist in an MRI-based EVT selection protocol; avoiding double imaging is key to saving time. Racial/ethnic disparities require further study. Understanding variables associated with delay will inform protocol changes.
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Affiliation(s)
- Robert W Regenhardt
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA, 02114.
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, 02114.
| | - Neal M Nolan
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, 02114
| | - Joseph A Rosenthal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, 02114
| | - Joyce A McIntyre
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, 02114
| | - Martin Bretzner
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, 02114
| | - Anna K Bonkhoff
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, 02114
| | - Samuel B Snider
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, 02114
| | - Alvin S Das
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, 02114
| | - Naif M Alotaibi
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA, 02114
| | - Justin E Vranic
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA, 02114
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, 02114
| | - Adam A Dmytriw
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA, 02114
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, 02114
| | - Christopher J Stapleton
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA, 02114
| | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA, 02114
| | - Natalia S Rost
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, 02114
| | - Thabele M Leslie-Mazwi
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School, 55 Fruit St, Boston, MA, USA, 02114
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA, 02114
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11
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Regenhardt RW, Rosenthal JA, Dmytriw AA, Vranic JE, Bonkhoff AK, Bretzner M, Hirsch JA, Rabinov JD, Stapleton CJ, Patel AB, Singhal AB, Rost NS, Leslie-Mazwi TM, Etherton MR. Direct to angio-suite large vessel occlusion transfers achieve faster arrival-to-puncture times and improved outcomes. STROKE (HOBOKEN, N.J.) 2022; 2:e000327. [PMID: 36571077 PMCID: PMC9787192 DOI: 10.1161/svin.121.000327] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Accepted: 05/16/2022] [Indexed: 12/30/2022]
Abstract
Introduction For patients with large vessel occlusion (LVO) stroke, time to treatment with endovascular thrombectomy (EVT) is crucial to prevent infarction and improve outcomes. We sought to evaluate the hub arrival-to-puncture times and outcomes for transferred patients accepted directly to the angio-suite (LVO2OR) versus those accepted through the emergency department (ED) in a hub-and-spoke telestroke network. Methods Consecutive patients transferred for EVT with spoke CTA-confirmed LVO, spoke ASPECTS >6, and LKW-to-hub arrival <6 hours were identified. Our LVO2OR protocol began implementation in January 2017. The LVO2OR cohort includes patients who underwent EVT from July 2017 to October 2020; the ED cohort includes those from January 2011 to December 2016. Hub arrival-to-puncture time and 90-day modified Rankin Scale (mRS) were prospectively recorded. Results The LVO2OR cohort was comprised of 91 patients and the ED cohort 90. LVO2OR patients had more atrial fibrillation (AF, 51% vs 32%, p=0.02) and more M2 occlusions (27% vs 10%, p=0.01). LVO2OR patients had faster median hub arrival-to-puncture time (11 vs 92 minutes, p<0.001), faster median telestroke consult-to-puncture time (2.4 vs 3.6 hours, p<0.001), greater TICI 2b-3 reperfusion (92% vs 69%, p<0.001), and greater 90-day mRS <2 (35% vs 21%, p=0.04). In a multivariable model, LVO2OR significantly increased the odds of 90-day mRS <2 (aOR 2.77, 95%CI 1.07,7.20; p=0.04) even when controlling for age, baseline mRS, AF, NIHSS, M2 location, and TICI 2b-3. Conclusion In a hub-and-spoke telestroke network, accepting transferred patients directly to the angio-suite was associated with dramatically reduced hub arrival-to-puncture time and may lead to improved 90-day outcomes. Direct-to-angio-suite protocols should continue to be evaluated in other regions and telestroke models.
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Affiliation(s)
- Robert W Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School
| | - Joseph A Rosenthal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School
| | - Adam A Dmytriw
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School
| | - Justin E Vranic
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School
| | - Anna K Bonkhoff
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School
| | - Martin Bretzner
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School
| | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School
| | - James D Rabinov
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School
| | | | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School
| | - Aneesh B Singhal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School
| | - Natalia S Rost
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School
| | - Thabele M Leslie-Mazwi
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School
| | - Mark R Etherton
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School
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12
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Regenhardt RW, Bonkhoff AK, Bretzner M, Etherton MR, Das AS, Hong S, Alotaibi NM, Vranic JE, Dmytriw AA, Stapleton CJ, Patel AB, Leslie-Mazwi TM, Rost NS. Association of Infarct Topography and Outcome After Endovascular Thrombectomy in Patients With Acute Ischemic Stroke. Neurology 2022; 98:e1094-e1103. [PMID: 35101908 PMCID: PMC8935439 DOI: 10.1212/wnl.0000000000200034] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 01/03/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The care of patients with large vessel occlusion (LVO) stroke has been revolutionized by endovascular thrombectomy (EVT). While EVT has a large effect size, most patients treated with EVT remain disabled or die within 90 days. A better understanding of outcomes may influence EVT selection criteria, novel therapies, and prognostication. We sought to identify associations between outcomes and brain regions involved in ischemic lesions. METHODS For this cohort study, consecutive patients with LVO who were treated with EVT and underwent post-EVT MRI were identified from a tertiary referral center (2011-2019). Acute ischemic lesions were manually segmented from diffusion-weighted imaging and spatially normalized. Individual lesions were parcellated (atlas-defined 94 cortical regions, 14 subcortical nuclei, 20 white matter tracts) and reduced to 10 essential lesion patterns with the use of unsupervised dimensionality reduction techniques. Ninety-day modified Rankin Scale (mRS) score (>2) was modeled via bayesian regression, taking the 10 lesion patterns as inputs and controlling for lesion size, age, sex, acute NIH Stroke Scale (NIHSS) score, alteplase, prior stroke, intracerebral hemorrhage, and good reperfusion (Thrombolysis in Cerebral Infarction 2b-3). In comparative analyses, 90-day mRS score was modeled considering covariates only, and compartment-wise relevances for acute stroke severity and 90-day mRS score were evaluated. RESULTS There were 151 patients with LVO identified (age 68 ± 15 years, 52% female). The median NIHSS score was 16 (interquartile range 13-20); 56% had mRS score >2. Lesion locations predictive of 90-day mRS score involved bilateral but left hemispherically more pronounced precentral and postcentral gyri, insular and opercular cortex, and left putamen and caudate (area under the curve 0.91, highest probability density interval [HPDI] covering 90% certainty 0.90-0.92). The lesion location model outperformed the simpler model relying on covariates only (bayesian model comparison of 97% weight to the model with vs 3% weight to the model without lesion location). While lesions affecting subcortical nuclei had the highest relevance for stroke severity (posterior distribution mean 0.75, 90% HPDI 0.256-1.31), lesions affecting white matter tracts had the highest relevance for 90-day mRS score (0.656, 90% HPDI 0.0864-1.12). DISCUSSION These data describe the significance for outcomes of specific brain regions involved in ischemic lesions on MRI after EVT. Future work in additional datasets is needed to confirm these granular findings.
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Affiliation(s)
- Robert W Regenhardt
- From the Departments of Neurology (R.W.R., A.K.B., M.B., M.R.E., A.S.D., S.H., T.M.L.-M., N.S.R.), Neurosurgery (R.W.R., N.M.A., J.E.V., A.A.D., C.J.S., A.B.P., T.M.L.-M.), and Radiology (J.E.V., A.A.D.), Massachusetts General Hospital, Harvard Medical School, Boston.
| | - Anna K Bonkhoff
- From the Departments of Neurology (R.W.R., A.K.B., M.B., M.R.E., A.S.D., S.H., T.M.L.-M., N.S.R.), Neurosurgery (R.W.R., N.M.A., J.E.V., A.A.D., C.J.S., A.B.P., T.M.L.-M.), and Radiology (J.E.V., A.A.D.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Martin Bretzner
- From the Departments of Neurology (R.W.R., A.K.B., M.B., M.R.E., A.S.D., S.H., T.M.L.-M., N.S.R.), Neurosurgery (R.W.R., N.M.A., J.E.V., A.A.D., C.J.S., A.B.P., T.M.L.-M.), and Radiology (J.E.V., A.A.D.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Mark R Etherton
- From the Departments of Neurology (R.W.R., A.K.B., M.B., M.R.E., A.S.D., S.H., T.M.L.-M., N.S.R.), Neurosurgery (R.W.R., N.M.A., J.E.V., A.A.D., C.J.S., A.B.P., T.M.L.-M.), and Radiology (J.E.V., A.A.D.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Alvin S Das
- From the Departments of Neurology (R.W.R., A.K.B., M.B., M.R.E., A.S.D., S.H., T.M.L.-M., N.S.R.), Neurosurgery (R.W.R., N.M.A., J.E.V., A.A.D., C.J.S., A.B.P., T.M.L.-M.), and Radiology (J.E.V., A.A.D.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Sungmin Hong
- From the Departments of Neurology (R.W.R., A.K.B., M.B., M.R.E., A.S.D., S.H., T.M.L.-M., N.S.R.), Neurosurgery (R.W.R., N.M.A., J.E.V., A.A.D., C.J.S., A.B.P., T.M.L.-M.), and Radiology (J.E.V., A.A.D.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Naif M Alotaibi
- From the Departments of Neurology (R.W.R., A.K.B., M.B., M.R.E., A.S.D., S.H., T.M.L.-M., N.S.R.), Neurosurgery (R.W.R., N.M.A., J.E.V., A.A.D., C.J.S., A.B.P., T.M.L.-M.), and Radiology (J.E.V., A.A.D.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Justin E Vranic
- From the Departments of Neurology (R.W.R., A.K.B., M.B., M.R.E., A.S.D., S.H., T.M.L.-M., N.S.R.), Neurosurgery (R.W.R., N.M.A., J.E.V., A.A.D., C.J.S., A.B.P., T.M.L.-M.), and Radiology (J.E.V., A.A.D.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Adam A Dmytriw
- From the Departments of Neurology (R.W.R., A.K.B., M.B., M.R.E., A.S.D., S.H., T.M.L.-M., N.S.R.), Neurosurgery (R.W.R., N.M.A., J.E.V., A.A.D., C.J.S., A.B.P., T.M.L.-M.), and Radiology (J.E.V., A.A.D.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Christopher J Stapleton
- From the Departments of Neurology (R.W.R., A.K.B., M.B., M.R.E., A.S.D., S.H., T.M.L.-M., N.S.R.), Neurosurgery (R.W.R., N.M.A., J.E.V., A.A.D., C.J.S., A.B.P., T.M.L.-M.), and Radiology (J.E.V., A.A.D.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Aman B Patel
- From the Departments of Neurology (R.W.R., A.K.B., M.B., M.R.E., A.S.D., S.H., T.M.L.-M., N.S.R.), Neurosurgery (R.W.R., N.M.A., J.E.V., A.A.D., C.J.S., A.B.P., T.M.L.-M.), and Radiology (J.E.V., A.A.D.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Thabele M Leslie-Mazwi
- From the Departments of Neurology (R.W.R., A.K.B., M.B., M.R.E., A.S.D., S.H., T.M.L.-M., N.S.R.), Neurosurgery (R.W.R., N.M.A., J.E.V., A.A.D., C.J.S., A.B.P., T.M.L.-M.), and Radiology (J.E.V., A.A.D.), Massachusetts General Hospital, Harvard Medical School, Boston
| | - Natalia S Rost
- From the Departments of Neurology (R.W.R., A.K.B., M.B., M.R.E., A.S.D., S.H., T.M.L.-M., N.S.R.), Neurosurgery (R.W.R., N.M.A., J.E.V., A.A.D., C.J.S., A.B.P., T.M.L.-M.), and Radiology (J.E.V., A.A.D.), Massachusetts General Hospital, Harvard Medical School, Boston
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13
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Regenhardt RW, Rosenthal JA, Awad A, Martinez-Gutierrez JC, Nolan NM, McIntyre JA, Whitney C, Alotaibi NM, Dmytriw AA, Vranic JE, Stapleton CJ, Patel AB, Rost NS, Schwamm LH, Leslie-Mazwi TM. 'Drip-and-ship' intravenous thrombolysis and outcomes for large vessel occlusion thrombectomy candidates in a hub-and-spoke telestroke model. J Neurointerv Surg 2021; 14:650-653. [PMID: 34326197 DOI: 10.1136/neurintsurg-2021-017819] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 07/11/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Randomized trials have not demonstrated benefit from intravenous thrombolysis among patients undergoing endovascular thrombectomy (EVT). However, these trials included primarily patients presenting directly to an EVT capable hub center. We sought to study outcomes for EVT candidates who presented to spoke hospitals and were subsequently transferred for EVT consideration, comparing those administered alteplase at spokes (i.e., 'drip-and-ship' model) versus those not. METHODS Consecutive EVT candidates presenting to 25 spokes from 2018 to 2020 with pre-transfer CT angiography defined emergent large vessel occlusion and Alberta Stroke Program CT score ≥6 were identified from a prospectively maintained Telestroke database. Outcomes of interest included adequate reperfusion (Thrombolysis in Cerebral Infarction (TICI) 2b-3), intracerebral hemorrhage (ICH), discharge functional independence (modified Rankin Scale (mRS) ≤2), and 90 day functional independence. RESULTS Among 258 patients, median age was 70 years (IQR 60-81), median National Institutes of Health Stroke Scale (NIHSS) score was 13 (6-19), and 50% were women. Ninety-eight (38%) were treated with alteplase at spokes and 113 (44%) underwent EVT at the hub. Spoke alteplase use independently increased the odds of discharge mRS ≤2 (adjusted OR 2.43, 95% CI 1.08 to 5.46, p=0.03) and 90 day mRS ≤2 (adjusted OR 3.45, 95% CI 1.65 to 7.22, p=0.001), even when controlling for last known well, NIHSS, and EVT; it was not associated with an increased risk of ICH (OR 1.04, 95% CI 0.39 to 2.78, p=0.94), and there was a trend toward association with greater TICI 2b-3 (OR 3.59, 95% CI 0.94 to 13.70, p=0.06). CONCLUSIONS Intravenous alteplase at spoke hospitals may improve discharge and 90 day mRS and should not be withheld from EVT eligible patients who first present at alteplase capable spoke hospitals that do not perform EVT. Additional studies are warranted to confirm and further explore these benefits.
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Affiliation(s)
- Robert W Regenhardt
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA .,Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joseph A Rosenthal
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Amine Awad
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Neal M Nolan
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Joyce A McIntyre
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Cynthia Whitney
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Naif M Alotaibi
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Adam A Dmytriw
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Neuroradiology, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Justin E Vranic
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Neuroradiology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Christopher J Stapleton
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aman B Patel
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Natalia S Rost
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Lee H Schwamm
- Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Thabele M Leslie-Mazwi
- Neurosurgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA.,Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
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