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Factors impacting on technical success in stroke thrombectomy: experience of a UK neuro-interventional unit. Clin Radiol 2019; 74:390-398. [PMID: 30826003 DOI: 10.1016/j.crad.2019.01.022] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2018] [Accepted: 01/24/2019] [Indexed: 11/21/2022]
Abstract
AIM To investigate factors that could impact on recanalisation and reperfusion in patients undergoing mechanical thrombectomy and to assess the technical success over time. MATERIALS AND METHODS Two hundred consecutive patients who underwent thrombectomy for a proximal anterior circulation occlusion were dichotomised into equal groups (groups 1 and 2) based on the date that immediate access to emergency general anaesthesia (GA) commenced. RESULTS Recanalisation success using thrombolysis in cerebral infarction (TICI) 2b/3 or TICI 2c/3 significantly improved in group 2 (67% versus 93%, p<0.0001; 52% versus 78%, p=0.0002). Symptomatic haemorrhage also reduced from 9% to 4%. Despite similar presentation Alberta Stroke Program Early (computed tomography) CT Scores (ASPECTS), post-procedural ASPECTS was significantly increased in group 2 (7; [interquartile range {IQR} 4-9] versus 8 [IQR 7-9]; p=0.0034). The number of patients with a post procedural ASPECTS of 8-10 increased (46% versus 64%, p=0.0155) and the difference in ASPECTS between pre- and post-thrombectomy CT was significantly lower (2 [IQR 1-4] versus 1 [IQR 0-2], p<0.0001). GA use increased from 8% to 56% (p=0.0001) as did use of distal aspiration (59% versus 87%, p=0.0001) mostly in combination with a stent-retriever. Failed access fell from 8% to 3%. When GA was used, successful recanalisation (TICI 2b/3) was achieved more frequently (90.5% versus 76.7%; OR 3.04, 1.2-7.69, p=0.0187). CONCLUSION Technical results for thrombectomy are improving over time. Technique modification, operator experience, and judicious use of GA may be contributing.
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Galovic M, Döhler N, Erdélyi-Canavese B, Felbecker A, Siebel P, Conrad J, Evers S, Winklehner M, von Oertzen TJ, Haring HP, Serafini A, Gregoraci G, Valente M, Janes F, Gigli GL, Keezer MR, Duncan JS, Sander JW, Koepp MJ, Tettenborn B. Prediction of late seizures after ischaemic stroke with a novel prognostic model (the SeLECT score): a multivariable prediction model development and validation study. Lancet Neurol 2019; 17:143-152. [PMID: 29413315 DOI: 10.1016/s1474-4422(17)30404-0] [Citation(s) in RCA: 157] [Impact Index Per Article: 31.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Revised: 10/17/2017] [Accepted: 10/18/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND Stroke is one of the leading causes of acquired epilepsy in adults. An instrument to predict whether people are at high risk of developing post-stroke seizures is not available. We aimed to develop and validate a prognostic model of late (>7 days) seizures after ischaemic stroke. METHODS In this multivariable prediction model development and validation study, we developed the SeLECT score based on five clinical predictors in 1200 participants who had an ischaemic stroke in Switzerland using backward elimination of a multivariable Cox proportional hazards model. We externally validated this score in 1169 participants from three independent international cohorts in Austria, Germany, and Italy, and assessed its performance with the concordance statistic and calibration plots. FINDINGS Data were complete for 99·2% of the predictors (99·2% for Switzerland, 100% for Austria, 97% for Germany, and 99·7% for Italy) and 100% of the outcome parameters. Overall, the risk of late seizures was 4% (95% CI 4-5) 1 year after stroke and 8% (6-9) 5 years after stroke. The final model included five variables and was named SeLECT on the basis of the first letters of the included parameters (severity of stroke, large-artery atherosclerotic aetiology, early seizures, cortical involvement, and territory of middle cerebral artery involvement). The lowest SeLECT value (0 points) was associated with a 0·7% (95% CI 0·4-1·0) risk of late seizures within 1 year after stroke (1·3% [95% CI 0·7-1·8] within 5 years), whereas the highest value (9 points) predicted a 63% (42-77) risk of late seizures within 1 year (83% [62-93] within 5 years). The model had an overall concordance statistic of 0·77 (95% CI 0·71-0·82) in the validation cohorts. Calibration plots indicated high agreement of predicted and observed outcomes. INTERPRETATION This easily applied instrument was shown to be a good predictor of the risk of late seizures after stroke in three external validation cohorts and is freely available as a smartphone app. The SeLECT score has the potential to identify individuals at high risk of seizures and is a step towards more personalised medicine. It can inform the selection of an enriched population for antiepileptogenic treatment trials and will guide the recruitment for biomarker studies of epileptogenesis. FUNDING None.
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Affiliation(s)
- Marian Galovic
- Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland; Department of Clinical and Experimental Epilepsy, National Institute for Health Research University College London Hospitals Biomedical Research Centre, Institute of Neurology, University College London, London, UK; Chalfont Centre for Epilepsy, Chalfont St Peter, UK
| | - Nico Döhler
- Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland
| | | | - Ansgar Felbecker
- Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Philip Siebel
- Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland
| | - Julian Conrad
- Department of Neurology, University of Münster, Münster, Germany; Department of Neurology and German Center for Vertigo and Balance Disorders-IFB-LMU, Ludwig Maximilian University of Munich, Munich, Germany
| | - Stefan Evers
- Department of Neurology, University of Münster, Münster, Germany; Department of Neurology, Krankenhaus Lindenbrunn, Coppenbrügge, Germany
| | - Michael Winklehner
- Department of Neurology 1, Kepler Universitätsklinikum, Neuromed Campus, Linz, Austria
| | - Tim J von Oertzen
- Department of Neurology 1, Kepler Universitätsklinikum, Neuromed Campus, Linz, Austria
| | - Hans-Peter Haring
- Department of Neurology 1, Kepler Universitätsklinikum, Neuromed Campus, Linz, Austria
| | - Anna Serafini
- Dipartimento di Aerea Medica (DAME), University of Udine, Udine, Italy
| | - Giorgia Gregoraci
- Dipartimento di Aerea Medica (DAME), University of Udine, Udine, Italy
| | - Mariarosaria Valente
- Dipartimento di Aerea Medica (DAME), University of Udine, Udine, Italy; Neurology Unit, University of Udine Academic Hospital, Udine, Italy
| | - Francesco Janes
- Neurology Unit, University of Udine Academic Hospital, Udine, Italy
| | - Gian Luigi Gigli
- Dipartimento di Aerea Medica (DAME), University of Udine, Udine, Italy; Neurology Unit, University of Udine Academic Hospital, Udine, Italy
| | - Mark R Keezer
- Department of Clinical and Experimental Epilepsy, National Institute for Health Research University College London Hospitals Biomedical Research Centre, Institute of Neurology, University College London, London, UK; Chalfont Centre for Epilepsy, Chalfont St Peter, UK; Centre Hospitalier de l'Université de Montréal (CHUM), Hôpital Notre-Dame, Montréal, QC, Canada; Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, Netherlands
| | - John S Duncan
- Department of Clinical and Experimental Epilepsy, National Institute for Health Research University College London Hospitals Biomedical Research Centre, Institute of Neurology, University College London, London, UK; Chalfont Centre for Epilepsy, Chalfont St Peter, UK
| | - Josemir W Sander
- Department of Clinical and Experimental Epilepsy, National Institute for Health Research University College London Hospitals Biomedical Research Centre, Institute of Neurology, University College London, London, UK; Chalfont Centre for Epilepsy, Chalfont St Peter, UK; Stichting Epilepsie Instellingen Nederland (SEIN), Heemstede, Netherlands
| | - Matthias J Koepp
- Department of Clinical and Experimental Epilepsy, National Institute for Health Research University College London Hospitals Biomedical Research Centre, Institute of Neurology, University College London, London, UK; Chalfont Centre for Epilepsy, Chalfont St Peter, UK
| | - Barbara Tettenborn
- Department of Neurology, Kantonsspital St Gallen, St Gallen, Switzerland.
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Halvorsrud K, Flynn D, Ford GA, McMeekin P, Bhalla A, Balami J, Craig D, White P. A Delphi study and ranking exercise to support commissioning services: future delivery of Thrombectomy services in England. BMC Health Serv Res 2018; 18:135. [PMID: 29471828 PMCID: PMC5824465 DOI: 10.1186/s12913-018-2922-3] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2017] [Accepted: 02/06/2018] [Indexed: 01/19/2023] Open
Abstract
BACKGROUND Intra-arterial thrombectomy is the gold standard treatment for large artery occlusive stroke. However, the evidence of its benefits is almost entirely based on trials delivered by experienced neurointerventionists working in established teams in neuroscience centres. Those responsible for the design and prospective reconfiguration of services need access to a comprehensive and complementary array of information on which to base their decisions. This will help to ensure the demonstrated effects from trials may be realised in practice and account for regional/local variations in resources and skill-sets. One approach to elucidate the implementation preferences and considerations of key experts is a Delphi survey. In order to support commissioning decisions, we aimed using an electronic Delphi survey to establish consensus on the options for future organisation of thrombectomy services among physicians with clinical experience in managing large artery occlusive stroke. METHODS A Delphi survey was developed with 12 options for future organisation of thrombectomy services in England. A purposive sampling strategy established an expert panel of stroke physicians from the British Association of Stroke Physicians (BASP) Clinical Standards and/or Executive Membership that deliver 24/7 intravenous thrombolysis. Options with aggregate scores falling within the lowest quartile were removed from the subsequent Delphi round. Options reaching consensus following the two Delphi rounds were then ranked in a final exercise by both the wider BASP membership and the British Society of Neuroradiologists (BSNR). RESULTS Eleven stroke physicians from BASP completed the initial two Delphi rounds. Three options achieved consensus, with subsequently wider BASP (97%, n = 43) and BSNR members (86%, n = 21) assigning the highest approval rankings in the final exercise for transferring large artery occlusive stroke patients to nearest neuroscience centre for thrombectomy based on local CT/CT Angiography. CONCLUSIONS The initial Delphi rounds ensured optimal reduction of options by an expert panel of stroke physicians, while subsequent ranking exercises allowed remaining options to be ranked by a wider group of experts within stroke to reach consensus. The preferred implementation option for thrombectomy is investigating suspected acute stroke patients by CT/CT Angiography and secondary transfer of large artery occlusive stroke patients to the nearest neuroscience (thrombectomy) centre.
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Affiliation(s)
- Kristoffer Halvorsrud
- Institute of Health and Society Newcastle University, Newcastle Upon Tyne, UK
- Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Darren Flynn
- Institute of Health and Society Newcastle University, Newcastle Upon Tyne, UK
| | - Gary A. Ford
- Institute of Neuroscience, Newcastle University, 3-4, Claremont Terrace, Newcastle upon Tyne, NE2 4AX UK
- Oxford University Hospitals NHS Trust and Oxford University, Oxford, UK
| | - Peter McMeekin
- School of Health, Community and Education Studies, Northumbria University, Newcastle Upon Tyne, UK
| | - Ajay Bhalla
- Guy’s and St Thomas’ NHS Foundation Trust, London, UK
| | - Joyce Balami
- Centre for Evidence Based Medicine, University of Oxford, Oxford, UK
| | - Dawn Craig
- Institute of Health and Society Newcastle University, Newcastle Upon Tyne, UK
| | - Phil White
- Institute of Neuroscience, Newcastle University, 3-4, Claremont Terrace, Newcastle upon Tyne, NE2 4AX UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle Upon Tyne, UK
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