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Gomez CR, French BR, Gomez FE, Qureshi AI. Neuroendovascular Rescue 2025: Trends in Stroke Endovascular Therapy. Neurol Clin 2024; 42:717-738. [PMID: 38937038 DOI: 10.1016/j.ncl.2024.03.006] [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: 06/29/2024]
Abstract
Neuroendovascular rescue of patients with acute ischemic stroke caused by a large arterial occlusion has evolved throughout the first quarter of the present century, and continues to do so. Starting with the intra-arterial instillation of thrombolytic agents via microcatheters to dissolve occluding thromboembolic material, the current status is one that includes a variety of different techniques such as direct aspiration of thrombus, removal by stent retriever, adjuvant techniques such as balloon angioplasty, stenting, and tactical intra-arterial instillation of thrombolytic agents in smaller branches to treat no-reflow phenomenon. The results have been consistently shown to benefit these patients, irrespective of whether they had already received intravenous tissue-type plasminogen activator or not. Improved imaging methods of patient selection and tactically optimized periprocedural care measures complement this dimension of the practice of neurointervention.
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Affiliation(s)
- Camilo R Gomez
- University of Missouri Columbia School of Medicine, Columbia, MO, USA.
| | - Brandi R French
- University of Missouri Columbia School of Medicine, Columbia, MO, USA
| | - Francisco E Gomez
- University of Missouri Columbia School of Medicine, Columbia, MO, USA
| | - Adnan I Qureshi
- University of Missouri Columbia School of Medicine, Columbia, MO, USA
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2
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Wang L, Shi Q, Xue YD, Cao C, Zheng YY. Albumin levels and cerebral collateral circulation in patients with acute ischemic stroke due to intracranial arteriosclerotic: A propensity score-matched analysis. Medicine (Baltimore) 2024; 103:e38254. [PMID: 38788021 PMCID: PMC11124662 DOI: 10.1097/md.0000000000038254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 04/25/2024] [Indexed: 05/26/2024] Open
Abstract
Cerebral collateral circulation (CC) is associated with the recurrence and severity of acute ischemic stroke (AIS), and early identification of poor CC is helpful for the prevention of AIS. In this study we evaluated the association between serum albumin levels and CC in AIS using logistic regression. Propensity score (PS) matching was used to eliminate the effect of confounders, and restricted cubic splines (RCS) were employed to explore potential nonlinear associations between albumin and CC. In unadjusted logistic regression analysis, lower albumin (OR = 0.85, 95% CI = 0.79-0.92) was associated with poor CC, and after adjusting for covariates, the odds of lower albumin for poor CC compared to good CC were 0.86 (95% CI = 0.79-0.94). In the PS cohort, the association of albumin with CC was consistent with those of the original cohort. RCS results showed a linear relationship between albumin and CC (P values of .006 and .08 for overall and nonlinear associations, respectively). The results of this study suggest that lower serum albumin is independently associated with an increased risk of poor CC, which may serve as an effective predictive indicator for poor CC in patients with severe intracranial atherosclerotic stenosis.
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Affiliation(s)
- Le Wang
- Department of Neurology, Yan’an University Affiliated Hospital, Yan’an, Shaanxi, China
| | - Qiang Shi
- Department of Neurology, Yan’an University Affiliated Hospital, Yan’an, Shaanxi, China
| | - Yi-dong Xue
- Department of Neurology, Yan’an University Affiliated Hospital, Yan’an, Shaanxi, China
| | - Chan Cao
- Department of Neurology, Yan’an University Affiliated Hospital, Yan’an, Shaanxi, China
| | - Ying-Ying Zheng
- Department of Medical Laboratory, Yan’an University Affiliated Hospital, Yan’an, Shaanxi, China
- Department of Basic Medicine, Medical School of Yan’an University, Yan’an, Shaanxi, China
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Wang J, Cui Y, Kong X, Du B, Lin T, Zhang X, Lu D, Liu L, Du J. The value of cardiopulmonary comorbidity in patients with acute large vessel occlusion stroke undergoing endovascular thrombectomy: a retrospective, observational cohort study. BMC Neurol 2024; 24:155. [PMID: 38714927 PMCID: PMC11075307 DOI: 10.1186/s12883-024-03660-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2024] [Accepted: 04/30/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Chronic lung and heart diseases are more likely to lead an intensive end point after stroke onset. We aimed to investigate characteristics and outcomes of endovascular thrombectomy (EVT) in patients with acute large vessel occlusion stroke (ALVOS) and identify the role of comorbid chronic cardiopulmonary diseases in ALVOS pathogenesis. METHODS In this single-center retrospective study, 191 consecutive patients who underwent EVT due to large vessel occlusion stroke in neurological intensive care unit were included. The chronic cardiopulmonary comorbidities and several conventional stroke risk factors were assessed. The primary efficacy outcome was functional independence (defined as a mRS of 0 to 2) at day 90. The primary safety outcomes were death within 90 days and the occurrence of symptomatic intracranial hemorrhage(sICH). Univariate analysis was applied to evaluate the relationship between factors and clinical outcomes, and logistic regression model were developed to predict the prognosis of ALVOS. RESULTS Endovascular therapy in ALVOS patients with chronic cardiopulmonary diseases, as compared with those without comorbidity, was associated with an unfavorable shift in the NHISS 24 h after EVT [8(4,15.25) versus 12(7.5,18.5), P = 0.005] and the lower percentage of patients who were functionally independent at 90 days, defined as a score on the modified Rankin scale of 0 to 2 (51.6% versus 25.4%, P = 0.000). There was no significant between-group difference in the frequency of mortality (12.1% versus 14.9%, P = 0.580) and symptomatic intracranial hemorrhage (13.7% versus 19.4%, P = 0.302) or of serious adverse events. Moreover, a prediction model showed that existence of cardiopulmonary comorbidities (OR = 0.456, 95%CI 0.209 to 0.992, P = 0.048) was independently associated with functional independence at day 90. CONCLUSIONS EVT was safe in ALVOS patients with chronic cardiopulmonary diseases, whereas the unfavorable outcomes were achieved in such patients. Moreover, cardiopulmonary comorbidity had certain clinical predictive value for worse stroke prognosis.
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Affiliation(s)
- Jiarui Wang
- PLA 306 Clinical College, Anhui Medical University, Beijing, China
- The Fifth Medical college, Anhui Medical University, Beijing, China
- Department of Neurology, PLA Strategic Support Force Characteristics Medical Center, 9 Anxiangbeili Rd, Beijing, 100086, China
| | - Yongqiang Cui
- Department of Neurology, PLA Strategic Support Force Characteristics Medical Center, 9 Anxiangbeili Rd, Beijing, 100086, China
| | - Xiangkai Kong
- Department of Neurology, PLA Strategic Support Force Characteristics Medical Center, 9 Anxiangbeili Rd, Beijing, 100086, China
| | - Bin Du
- Department of Neurology, PLA Strategic Support Force Characteristics Medical Center, 9 Anxiangbeili Rd, Beijing, 100086, China
| | - Tian Lin
- Department of Neurology, PLA Strategic Support Force Characteristics Medical Center, 9 Anxiangbeili Rd, Beijing, 100086, China
| | - Xiaoyun Zhang
- Department of Neurology, PLA Strategic Support Force Characteristics Medical Center, 9 Anxiangbeili Rd, Beijing, 100086, China
| | - Dongxu Lu
- Department of Neurology, PLA Strategic Support Force Characteristics Medical Center, 9 Anxiangbeili Rd, Beijing, 100086, China
| | - Li Liu
- Department of Neurology, PLA Strategic Support Force Characteristics Medical Center, 9 Anxiangbeili Rd, Beijing, 100086, China
| | - Juan Du
- PLA 306 Clinical College, Anhui Medical University, Beijing, China.
- The Fifth Medical college, Anhui Medical University, Beijing, China.
- Department of Neurology, PLA Strategic Support Force Characteristics Medical Center, 9 Anxiangbeili Rd, Beijing, 100086, China.
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Nguyen DT, Mai TD, Dao PV, Ha HT, Le AT, Nguyen TTT, Vuong TX, Tran MC. Study protocol: Early neurological deterioration in patients with minor stroke, frequency, predictors, and outcomes in Vietnam single-centre study. PLoS One 2024; 19:e0302822. [PMID: 38709783 PMCID: PMC11073673 DOI: 10.1371/journal.pone.0302822] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 04/08/2024] [Indexed: 05/08/2024] Open
Abstract
Early neurological deterioration (END) is progressive neurological deterioration with an increase in NIHSS score of 2 points or more in the first 72 hours from the onset of acute ischemic stroke. END increases the risk of poor clinical outcomes at day 90 of ischemic stroke. We will study the frequency, predictors, and outcomes of patients with END in a case-control study at a comprehensive stroke centre in Vietnam. of the design is a descriptive observational study, longitudinal follow-up of patients with minor stroke hospitalized at the Stroke Center of Bach Mai Hospital from December 1, 2023, to December 1, 2024. Minor stroke patients characterized by NIHSS score ≤ 5 hospitalized within 24 hours of symptom onset will be recruited. The estimated END rate is about 30%, relative accuracy ε = 0.11, 95% reliability, expected 5% of patients lost data or follow-up, and an estimated sample size of 779 patients. This study will help determine the END rate in patients with minor stroke and related factors, thereby building a prognostic model for END. Our study determined the END rate in patients with minor stroke in Vietnam and also proposed risk factors for minor stroke management and treatment.
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Affiliation(s)
- Dung Tien Nguyen
- BachMai Stroke Center, BachMai Hospital, Hanoi, Vietnam
- VNU University of Medicine and Pharmacy, Hanoi, Vietnam
- Hanoi Medical University, Hanoi, Vietnam
| | - Ton Duy Mai
- BachMai Stroke Center, BachMai Hospital, Hanoi, Vietnam
- VNU University of Medicine and Pharmacy, Hanoi, Vietnam
| | - Phuong Viet Dao
- BachMai Stroke Center, BachMai Hospital, Hanoi, Vietnam
- VNU University of Medicine and Pharmacy, Hanoi, Vietnam
| | | | - Anh Tuan Le
- BachMai Stroke Center, BachMai Hospital, Hanoi, Vietnam
| | | | | | - Minh Cong Tran
- Department of Clinical Neuroscience, University of Oxford, Oxford, United Kingdom
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Wang Y, Zhang J, Dai L, Kong Y, Wei Y, Wu L, Yin J. Leukocyte counts and ratios as potential predictors of large vessel occlusion in acute ischemic stroke: A retrospective cohort study. Medicine (Baltimore) 2024; 103:e37904. [PMID: 38640307 PMCID: PMC11029938 DOI: 10.1097/md.0000000000037904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 03/20/2024] [Accepted: 03/22/2024] [Indexed: 04/21/2024] Open
Abstract
Leukocyte counts and ratios are independent biomarkers to determine the severity and prognosis of acute ischemic stroke (AIS). In AIS, the connection between leukocytes and large vessel occlusion (LVO) is uncertain. This study aims to determine the relationship between the existence of LVO and leukocyte counts and ratios on admission to AIS. Patients were retrospectively evaluated within six hours of AIS starting between January 2019 and April 2023. On admission, blood specimens were collected, and leukocyte subtype counts were promptly analyzed. Computed tomography or digital subtraction angiography were utilized to verify the existence of LVO. Regression analysis and receiver operating characteristic (ROC) curves were employed to investigate the connections between the counts and ratios of leukocytes and the existence of LVO, as well as the discriminatory ability of these variables in predicting LVO. Total white blood cell (WBC) count, neutrophil count, and neutrophil-to-lymphocyte ratio (NLR) were substantially higher in the LVO existence group compared to the LVO absence group, whereas the ratio of eosinophils to neutrophils (ENR × 102) was lower (P < .001, respectively). Significant associations were observed between total WBC counts, neutrophil counts, NLR, and ENR × 102 and the existence of LVO (P < .001, respectively). Total WBC counts, neutrophil counts, NLR, and ENR × 102 had respective areas under the curves (AUC) of 0.730, 0.748, 0.704, and 0.680 for identifying LVO. Our results show that in AIS patients, the existence of LVO is independently associated with elevated total WBC and neutrophil counts, high NLR, and low ENR × 102 levels. Neutrophil and total WBC counts, as well as NLR and levels of ENR × 102, may serve as potential biomarkers for predicting LVO. Neuroinflammation, based on the existence of LVO, should be given particular attention in future investigations.
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Affiliation(s)
- Yu Wang
- Department of Neurology, Xingtai Central Hospital, Xingtai, China
| | - Jie Zhang
- Department of Neurology, Xingtai Central Hospital, Xingtai, China
| | - Lin Dai
- Physical Examination Center, Xingtai Central Hospital, Xingtai, China
| | - Yongmei Kong
- Department of Neurology, Xingtai Central Hospital, Xingtai, China
| | - Yuqing Wei
- Department of Neurology, Xingtai Central Hospital, Xingtai, China
| | - Lijuan Wu
- Department of Neurology, Xingtai Central Hospital, Xingtai, China
| | - Juntao Yin
- Department of Neurology, Xingtai Central Hospital, Xingtai, China
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Khanafer A, Henkes H, Bücke P, Hennersdorf F, Bäzner H, Forsting M, von Gottberg P. Triple platelet inhibition in intracranial thrombectomy with additional acute cervical stent angioplasty due to tandem lesion: a retrospective single-center analysis. BMC Neurol 2024; 24:99. [PMID: 38500074 PMCID: PMC10946095 DOI: 10.1186/s12883-024-03597-0] [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: 01/09/2024] [Accepted: 03/11/2024] [Indexed: 03/20/2024] Open
Abstract
BACKGROUND Acute stroke treatment with intracranial thrombectomy and treatment of ipsilateral carotid artery stenosis/occlusion ("tandem lesion", TL) in one session is considered safe. However, the risk of stent restenosis after TL treatment is high, and antiplatelet therapy (APT) preventing restenosis must be well balanced to avoid intracranial hemorrhage. We investigated the safety and 90-day outcome of patients receiving TL treatment under triple-APT, focused on stent-patency and possible disadvantageous comorbidities. METHODS Patients receiving TL treatment in the setting of acute stroke between 2013 and 2022 were analyzed regarding peri-/postprocedural safety and stent patency after 90 days. All patients received intravenous eptifibatide and acetylsalicylic acid and one of the three drugs prasugrel, clopidogrel, or ticagrelor. Duplex imaging was performed 24 h after treatment, at discharge and 90 days, and digital subtraction angiography was performed if restenosis was suspected. RESULTS 176 patients were included. Periprocedural complications occurred in 2.3% of the patients at no periprocedural death, and in-hospital death in 13.6%. Discharge mRS score was maintained or improved at the 90-day follow-up in 86%, 4.54% had an in-stent restenosis requiring treatment at 90 days. No recorded comorbidity considered disadvantageous for stent patency showed statistical significance, the duration of the endovascular procedure had no significant effect on outcome. CONCLUSION In our data, TL treatment with triple APT resulted in a low restenosis rate, low rates of sICH and a comparably high number of patients with favorable outcome. Aggressive APT in the initial phase may therefore have the potential to prevent recurrent stroke better than restrained platelet inhibition. Comorbidities did not influence stent patency.
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Affiliation(s)
- Ali Khanafer
- Neuroradiological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Philipp Bücke
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Florian Hennersdorf
- Department of Diagnostic and Interventional Neuroradiology, University of Tübingen, Tübingen, Germany
| | - Hansjörg Bäzner
- Neurological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany
| | - Michael Forsting
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Philipp von Gottberg
- Neuroradiological Clinic, Neurozentrum, Klinikum Stuttgart, Stuttgart, Germany.
- Klinik für Neuroradiologie, Klinikum Stuttgart, Kriegsbergstr. 60, 70174, Stuttgart, Germany.
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Valente I, Alexandre AM, Colò F, Brunetti V, Frisullo G, Camilli A, Falcou A, Scarcia L, Gigli R, Scala I, Rizzo PA, Abruzzese S, Milonia L, Piano M, Macera A, Ruggiero M, Da Ros V, Bellini L, Lazzarotti GA, Cosottini M, Caragliano AA, Vinci SL, Gabrieli JD, Causin F, Panni P, Roveri L, Limbucci N, Arba F, Renieri L, Ferretti S, Pileggi M, Bianco G, Romano DG, Frauenfelder G, Semeraro V, Ganimede MP, Lozupone E, Fasano A, Lafe E, Cavallini AM, Mazzacane F, Russo R, Bergui M, Broccolini A, Pedicelli A. Effect of General Anesthesia Versus Conscious Sedation/Local Anesthesia on the Outcome of Patients with Minor Stroke and Isolated M2 Occlusion Undergoing Immediate Thrombectomy: A Retrospective Multicenter Matched Analysis. World Neurosurg 2024; 183:e432-e439. [PMID: 38154680 DOI: 10.1016/j.wneu.2023.12.117] [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: 10/23/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 12/30/2023]
Abstract
BACKGROUND This study investigates the impact of general anesthesia (GA) versus conscious sedation/local anesthesia (CS/LA) on the outcome of patients with minor stroke and isolated M2 occlusion undergoing immediate mechanical thrombectomy (iMT). METHODS The databases of 16 comprehensive stroke centers were retrospectively screened for consecutive patients with isolated M2 occlusion and a baseline National Institutes of Health Stroke Scale score ≤5 who received iMT. Propensity score matching was used to estimate the effect of GA versus CS/LA on clinical outcomes and procedure-related adverse events. The primary outcome measure was a 90-day modified Rankin Scale (mRS) score of 0-1. Secondary outcome measures were a 90-day mRS score of 0-2 and all-cause mortality, successful reperfusion, procedural-related symptomatic subarachnoid hemorrhage, intraprocedural dissections, and new territory embolism. RESULTS Of the 172 patients who were selected, 55 received GA and 117 CS/LA. After propensity score matching, 47 pairs of patients were available for analysis. We found no significant differences in clinical outcome, rates of efficient reperfusion, and procedural-related complications between patients receiving GA or LA/CS (mRS score 0-1, P = 0.815; mRS score 0-2, P = 0.401; all-cause mortality, P = 0.408; modified Treatment in Cerebral Infarction score 2b-3, P = 0.374; symptomatic subarachnoid hemorrhage, P = 0.082; intraprocedural dissection, P = 0.408; new territory embolism, P = 0.462). CONCLUSIONS In patients with minor stroke and isolated M2 occlusion undergoing iMT, the type of anesthesia does not affect clinical outcome or the rate of procedural-related complications. Our results agree with recent data showing no benefit of one specific anesthesiologic procedure over the other and confirm their generalizability also to patients with minor baseline symptoms.
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Affiliation(s)
- Iacopo Valente
- Interventional Neuroradiology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Andrea M Alexandre
- Interventional Neuroradiology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Francesca Colò
- Department of Neuroscience, Catholic University School of Medicine, Rome, Italy
| | - Valerio Brunetti
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanni Frisullo
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Arianna Camilli
- Department of Neuroscience, Catholic University School of Medicine, Rome, Italy
| | - Anne Falcou
- Stroke Unit, University Hospital Policlinico Umberto I, Rome, Italy
| | - Luca Scarcia
- Neuroradiology Unit, Henri Mondor Hospital, Creteil, France
| | - Riccardo Gigli
- Department of Neuroscience, Catholic University School of Medicine, Rome, Italy
| | - Irene Scala
- Department of Neuroscience, Catholic University School of Medicine, Rome, Italy
| | - Pier A Rizzo
- Department of Neuroscience, Catholic University School of Medicine, Rome, Italy
| | - Serena Abruzzese
- Department of Neuroscience, Catholic University School of Medicine, Rome, Italy
| | - Luca Milonia
- Interventional Neuroradiology Unit, University Hospital Policlinico Umberto I, Rome, Italy
| | - Mariangela Piano
- Neuroradiology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | - Antonio Macera
- Neuroradiology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milano, Italy
| | | | - Valerio Da Ros
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Rome, Italy
| | - Luigi Bellini
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Rome, Italy
| | - Guido A Lazzarotti
- Neuroradiology Unit, Azienda Ospedaliero Universitaria Pisana (AOUP), Pisa, Italy
| | - Mirco Cosottini
- Neuroradiology Unit, Azienda Ospedaliero Universitaria Pisana (AOUP), Pisa, Italy
| | | | - Sergio L Vinci
- Neuroradiology Unit, AOU Policlinico G. Martino, Messina, Italy
| | - Joseph D Gabrieli
- Neuroradiology Unit, Policlinico Universitario di Padova, Padua, Italy
| | - Francesco Causin
- Neuroradiology Unit, Policlinico Universitario di Padova, Padua, Italy
| | - Pietro Panni
- Interventional Neuroradiology Unit and Neurology Unit, IRCCS San Raffaele University Hospital, Milan, Italy
| | - Luisa Roveri
- Neurology Unit, IRCCS San Raffaele University Hospital, Milan, Italy
| | - Nicola Limbucci
- Interventional Neurovascular Unit, Stroke Unit, A.O.U. Careggi, Firenze, Italy
| | | | - Leonardo Renieri
- Interventional Neurovascular Unit, Stroke Unit, A.O.U. Careggi, Firenze, Italy
| | - Simone Ferretti
- NEUROFARBA Department, University of Florence, Florence, Italy
| | - Marco Pileggi
- Neuroradiology Unit and Stroke Center, Neurocenter of Southern Switzerland-EOC, Lugano, Switzerland
| | - Giovanni Bianco
- Stroke Center, Neurocenter of Southern Switzerland-EOC, Lugano, Switzerland
| | - Daniele G Romano
- Neuroradiology Unit, AOU S Giovanni di Dio e Ruggi di Aragona, Salerno, Italy
| | - Giulia Frauenfelder
- Neuroradiology Unit, AOU S Giovanni di Dio e Ruggi di Aragona, Salerno, Italy
| | - Vittorio Semeraro
- Interventional Radiology Unit and Neuroradiology Unit, "SS Annunziata" Hospital, Taranto, Italy
| | | | - Emilio Lozupone
- Neuroradiology Unit and Neurology Unit, Vito Fazzi Hospital, Lecce, Italy
| | | | - Elvis Lafe
- Neuroradiology Unit, IRCCS Policlinico San Matteo, Pavia, Italy
| | - Anna M Cavallini
- Cerebrovascular Diseases Unit, IRCCS Fondazione Mondino, Pavia, Italy
| | | | - Riccardo Russo
- Neuroradiology Unit, Azienda Ospedaliera Città della Salute e della Scienza, Turin, Italy
| | - Mauro Bergui
- Neuroradiology Unit, Azienda Ospedaliera Città della Salute e della Scienza, Turin, Italy
| | - Aldobrando Broccolini
- Department of Neuroscience, Catholic University School of Medicine, Rome, Italy; Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
| | - Alessandro Pedicelli
- Interventional Neuroradiology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy; Department of Neuroscience, Catholic University School of Medicine, Rome, Italy
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Chen KC, Chen PH, Jhou HJ. Correspondence on the article ''Endovascular treatment versus medical management for mild stroke with acute anterior circulation large vessel occlusion: a meta-analysis''. J Neurointerv Surg 2024:jnis-2024-021514. [PMID: 38360062 DOI: 10.1136/jnis-2024-021514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 01/22/2024] [Indexed: 02/17/2024]
Affiliation(s)
- Kuan-Chih Chen
- Department of Emergency and Critical Care Medicine, Changhua Christian Hospital, Changhua, Taiwan
- School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Po-Huang Chen
- Division of Hematology and Oncology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Cente, Taipei, Taiwan
| | - Hong-Jie Jhou
- School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan
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9
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Qin B, Zhang Y, Liang S, Liang H, Tang S, Liang Z. Endovascular treatment versus medical management for mild stroke with acute anterior circulation large vessel occlusion: a meta-analysis. J Neurointerv Surg 2023; 15:e475-e483. [PMID: 36813553 DOI: 10.1136/jnis-2022-019959] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/09/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND The effectiveness of endovascular treatment (EVT) in patients with mild stroke (National Institutes of Health Stroke Scale score ≤5) and acute anterior circulation large vessel occlusion (AACLVO) remains unknown. OBJECTIVE To conduct a meta-analysis to compare the efficacy and safety of EVT in patients with mild stroke and AACLVO. METHODS EMBASE, Cochrane Library, PubMed, and Clinicaltrials.gov databases were searched until October 2022. Both retrospective and prospective studies which compared the clinical outcomes between EVT and medical treatment were included. ORs and 95% confidence intervals (CIs) for excellent and favorable functional outcomes, symptomatic intracranial hemorrhage (ICH), and mortality were pooled using a random-effects model. A propensity score (PS)-based methods adjusted analysis was also performed. RESULTS 4335 patients from 14 studies were included. In patients with mild stroke and AACLVO, EVT presented no marked differences in excellent and favorable functional outcomes and mortality compared with medical treatment. A higher risk of symptomatic ICH (OR=2.79; 95% CI 1.49 to 5.24; P=0.001) was observed with EVT. Subgroup analysis revealed that EVT had potential benefit for proximal occlusions with excellent functional outcomes (OR=1.68; 95% CI 1.01 to 2.82; P=0.05). Similar results were observed when PS-based methods adjusted analysis was used. CONCLUSION EVT did not significantly benefit clinical functional outcomes in comparison with medical treatment in patients with mild stroke and AACLVO. However, it may improve functional outcomes when treating patients with proximal occlusion, despite being associated with an increased risk of symptomatic ICH. Stronger evidence from ongoing randomized controlled trials is required.
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Affiliation(s)
- Bin Qin
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yunli Zhang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Shuolin Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Huo Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Shiting Tang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Zhijian Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
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Neki H, Mochizuki Y, Kamio Y, Kurozumi K. Improving the Reachability of Contact Aspiration for Acute Ischemic Stroke Using a New Delivery Assist Catheter. World Neurosurg 2023; 179:e510-e514. [PMID: 37683918 DOI: 10.1016/j.wneu.2023.08.132] [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: 08/16/2023] [Accepted: 08/31/2023] [Indexed: 09/10/2023]
Abstract
OBJECTIVE This study aimed to improve the reachability of large lumen catheter for contact aspiration during acute ischemic stroke by a new delivery assist catheter. METHODS This study included 58 patients with large-vessel stroke treated using endovascular procedures at our institution and affiliated hospitals between July 2021 and January 2023. Contact aspiration, especially contact aspiration using nonpenetrating of thrombus (CANP) technique, was adopted as first-line thrombectomy for localized internal carotid artery, middle cerebral artery proximal (M1 segment), and basilar artery without tandem occlusion in acute stroke. The new delivery assist catheter (AXS Offset catheter, Stryker, Fremont, CA, USA) was standardized after its release. Results of this improved contact aspiration technique using the new delivery assist catheter, including reachability, procedure time, and first-pass effect, were compared with conventional catheters. RESULTS Of the 58 patients, 43 underwent only thrombectomy for acute embolic stroke. CANP technique was attempted on 25 patients (25/43, 58.1%). Of these, a normal inner catheter (inner diameter: 0.021 or 0.027 inches) and the new delivery assist catheter were used on 10 (10/25, 40%) and 15 (15/25, 60%) patients, respectively. An aspiration catheter reached the thrombus for 5 patients (5/10, 50%) and 14 patients (14/15 93.3%) in the normal and new delivery assist catheter groups, respectively (P = 0.023). There was no significant difference in the results of contact aspiration due to the delivery catheter. CONCLUSIONS The new delivery assist catheter improved the reachability of the aspiration catheter to the thrombus and is an effective device for performing CANP technique.
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Affiliation(s)
- Hiroaki Neki
- Department of Neurosurgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan.
| | - Yuichi Mochizuki
- Department of Neurosurgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Yoshinobu Kamio
- Department of Neurosurgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
| | - Kazuhiko Kurozumi
- Department of Neurosurgery, Hamamatsu University School of Medicine, Hamamatsu, Shizuoka, Japan
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11
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Alexandre AM, Pedicelli A, Broccolini A. Editorial: The role, pathophysiology, and clinical benefit of collateral circulation in acute and chronic ischemic stroke. Front Neurol 2023; 14:1281009. [PMID: 37869134 PMCID: PMC10588470 DOI: 10.3389/fneur.2023.1281009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 09/19/2023] [Indexed: 10/24/2023] Open
Affiliation(s)
- Andrea M. Alexandre
- UOSD Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alessandro Pedicelli
- UOSD Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Aldobrando Broccolini
- UOC Neurologia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
- Università Cattolica del Sacro Cuore, Rome, Italy
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12
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Safouris A, Palaiodimou L, Nardai S, Kargiotis O, Magoufis G, Psychogios K, Matusevicius M, Feil K, Ahmed N, Kellert L, Spiliopoulos S, Brountzos E, Szikora I, Sarraj A, Goyal N, Aguiar de Sousa D, Strbian D, Caso V, Alexandrov AV, Tsivgoulis G. Medical Management Versus Endovascular Treatment for Large-Vessel Occlusion Anterior Circulation Stroke With Low NIHSS. Stroke 2023; 54:2265-2275. [PMID: 37526011 DOI: 10.1161/strokeaha.123.043937] [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: 04/04/2023] [Accepted: 06/08/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Endovascular treatment (EVT) for acute ischemic stroke (AIS) patients presenting with National Institutes of Health Stroke Scale score of 0 to 5 is common in clinical practice but has not yet been proven safe and effective. Our objective is to assess whether EVT on top of best medical treatment (BMT) in AIS patients with large-vessel occlusion of the anterior circulation presenting with mild symptoms is beneficial compared with BMT. METHODS We searched MEDLINE, SCOPUS, and reference lists of retrieved articles published until December 28, 2022. A systematic literature search was conducted to identify clinical trials or observational cohort studies evaluating patients with AIS due to anterior circulation large-vessel occlusion and admission National Institutes of Health Stroke Scale score ≤5 treated with EVT versus BMT alone. The primary outcome was excellent functional outcome (modified Rankin Scale score 0-1) at 3 months. The protocol had been registered before data collection (PROSPERO). RESULTS Eleven observational eligible studies were included in the meta-analysis, comprising a total of 2019 AIS patients with National Institutes of Health Stroke Scale score ≤5 treated with EVT versus 3171 patients treated with BMT. EVT was not associated with excellent functional outcome (risk ratio, 1.10 [95% CI, 0.93-1.31]). When stratified for different study design (per-protocol versus intention-to-treat), there were no significant subgroup differences. EVT was not associated with good functional outcome (modified Rankin Scale score 0-2; risk ratio, 1.01 [95% CI, 0.89-1.16]) or reduced disability at 3 months (common odds ratio, 0.92 [95% CI, 0.60-1.41]). Symptomatic intracranial hemorrhage was more common in the patients receiving EVT (risk ratio, 3.53 [95% CI, 2.35-5.31]). No correlation was found between EVT and mortality at 3 months (risk ratio, 1.34 [95% CI, 0.83-2.18]). The same overall associations were confirmed in the sensitivity analysis of studies that performed propensity score matching. CONCLUSIONS EVT appears equivalent to BMT for patients with anterior circulation large-vessel occlusion AIS with low baseline National Institutes of Health Stroke Scale, despite the increased risk for symptomatic intracranial hemorrhage. REGISTRATION URL: https://www.crd.york.ac.uk/PROSPERO/; Unique identifier: CRD42022334417.
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Affiliation(s)
- Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece (A. Safouris, O.K., K.P.)
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (A. Safouris, L.P., G.T.)
- Department of Neurosurgery, National Institute of Mental Health, Neurology and Neurosurgery, Department Section of Neurointervention, Semmelweis University, Budapest, Hungary (A. Safouris, S.N., I.S.)
| | - Lina Palaiodimou
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (A. Safouris, L.P., G.T.)
| | - Sándor Nardai
- Department of Neurosurgery, National Institute of Mental Health, Neurology and Neurosurgery, Department Section of Neurointervention, Semmelweis University, Budapest, Hungary (A. Safouris, S.N., I.S.)
| | - Odysseas Kargiotis
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece (A. Safouris, O.K., K.P.)
| | - George Magoufis
- Neuroradiology Department, Metropolitan Hospital, Piraeus, Greece (G.M.)
- Interventional Radiology Department, "Attikon" University Hospital, Athens, Greece (G.M., S.S., E.B.)
| | | | - Marius Matusevicius
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (M.M., N.A.)
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (M.M., N.A.)
| | - Katharina Feil
- Department of Neurology, Ludwig-Maximilians-Universitaet (LMU) Munich, Germany (K.F., L.K.)
- Department of Neurology and Stroke, Eberhard-Karls University Tuebingen/Universitaetsklinikum Tuebingen (UKT), Germany (K.F.)
| | - Niaz Ahmed
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (M.M., N.A.)
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (M.M., N.A.)
| | - Lars Kellert
- Department of Neurology, Ludwig-Maximilians-Universitaet (LMU) Munich, Germany (K.F., L.K.)
| | - Stavros Spiliopoulos
- Interventional Radiology Department, "Attikon" University Hospital, Athens, Greece (G.M., S.S., E.B.)
| | - Elias Brountzos
- Interventional Radiology Department, "Attikon" University Hospital, Athens, Greece (G.M., S.S., E.B.)
| | - István Szikora
- Department of Neurosurgery, National Institute of Mental Health, Neurology and Neurosurgery, Department Section of Neurointervention, Semmelweis University, Budapest, Hungary (A. Safouris, S.N., I.S.)
| | - Amrou Sarraj
- Department of Neurology, University Hospitals Cleveland Medical Center, OH (A. Sarraj)
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH (A. Sarraj)
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis (N.G., A.V.A., G.T.)
- Department of Neurosurgery, University of Tennessee Health Science Center and Semmes Murphey Neurologic and Spine Clinic, Memphis (N.G.)
| | - Diana Aguiar de Sousa
- Stroke Center, Lisbon Central University Hospital, and Faculty of Medicine, University of Lisbon, Portugal (D.A.D.S.)
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Finland (D.S.)
| | - Valeria Caso
- Stroke Unit, Santa Maria Della Misericordia Hospital, University of Perugia, Italy (V.C.)
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis (N.G., A.V.A., G.T.)
- Department of Neurology, Banner University Hospital, University of Arizona, Phoenix (A.V.A.)
| | - Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Greece (A. Safouris, L.P., G.T.)
- Department of Neurology, University of Tennessee Health Science Center, Memphis (N.G., A.V.A., G.T.)
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13
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Piano M, Romi A, Cervo A, Gatti A, Macera A, Pero G, Motto C, Agostoni EC, Lozupone E. Endovascular Treatment of Cerebral Vein Thrombosis: Safety and Effectiveness in the Thrombectomy Era. Diagnostics (Basel) 2023; 13:2248. [PMID: 37443641 DOI: 10.3390/diagnostics13132248] [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: 06/11/2023] [Revised: 06/25/2023] [Accepted: 06/27/2023] [Indexed: 07/15/2023] Open
Abstract
Cerebral venous thrombosis (CVT) is a rare cause of stroke that tends to affect young people. Endovascular treatment (EVT) has not yet shown to be beneficial in CVT and is therefore actually only indicated as rescue therapy in severe and refractory cases for medical treatment. Clinical, neuroimaging, procedural and follow-up data were evaluated in order to define the safety and efficacy of EVT in the management of CVT between January 2016 and December 2022. Safety was assessed on the basis of recording adverse events. Functional outcomes (NIHSS, mRS) and neuroimaging were recorded at onset, at discharge and at a 6-month follow-up. Efficacy was assessed evaluating the recanalization rate at the end of the procedure. Twenty-one patients (17 female, 4 male, range 16-84 years) with CVT underwent EVT. Overall morbidity and mortality were both at 4.7%. Median NIHSS at the onset and at the discharge were, respectively, 10 and 2. Successful recanalization was achieved in 21/23 procedures (91.3%). Imaging follow-up (FUP) showed stable recanalization in all but one patient with successful recanalization. In 18/21 patients, a good clinical independence (mRS 0-2) was recorded at 6 months. Our study adds evidence on the safety and efficacy of endovascular techniques in the treatment of CVT.
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Affiliation(s)
- Mariangela Piano
- Department of Neuroradiology, Ospedale Niguarda Ca' Granda, Piazza Ospedale Maggiore, 3, 20162 Milano, Italy
| | - Andrea Romi
- Neuroradiology Unit, IRCCS Policlinico San Matteo, 27100 Pavia, Italy
| | - Amedeo Cervo
- Department of Neuroradiology, Ospedale Niguarda Ca' Granda, Piazza Ospedale Maggiore, 3, 20162 Milano, Italy
| | - Antonella Gatti
- Neurology and Stroke Unit, Department of Neuroscience, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162 Milano, Italy
| | - Antonio Macera
- Department of Neuroradiology, Ospedale Niguarda Ca' Granda, Piazza Ospedale Maggiore, 3, 20162 Milano, Italy
| | - Guglielmo Pero
- Department of Neuroradiology, Ospedale Niguarda Ca' Granda, Piazza Ospedale Maggiore, 3, 20162 Milano, Italy
| | - Cristina Motto
- Neurology and Stroke Unit, Department of Neuroscience, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162 Milano, Italy
| | - Elio Clemente Agostoni
- Neurology and Stroke Unit, Department of Neuroscience, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore, 3, 20162 Milano, Italy
| | - Emilio Lozupone
- Department of Neuroradiology, Vito-Fazzi Hospital, 73100 Lecce, Italy
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14
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Sepp D, Hernandez Petzsche MR, Zarth T, Wunderlich S, Ikenberg B, Maegerlein C, Zimmer C, Berndt MT, Boeckh-Behrens T, Kirschke JS. Mechanical thrombectomy of distal cerebral vessel occlusions of the anterior circulation. Sci Rep 2023; 13:5730. [PMID: 37029202 PMCID: PMC10082188 DOI: 10.1038/s41598-023-32634-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2022] [Accepted: 03/30/2023] [Indexed: 04/09/2023] Open
Abstract
Mechanical thrombectomy (MT) is frequently performed for distal medium vessel occlusions (DMVO) of the anterior circulation in acute stroke patients. However, evidence for its clinical benefit remains scarce. In this study, we aim to investigate clinical course and safety outcomes of MT in comparison to standard medical therapy (SMT) in DMVO. This single-center retrospective observational study included 138 consecutive patients treated for DMVO of the anterior circulation between 2015 and 2021. To reduce the risk of selection bias, propensity score matching (PSM) of patients with MT versus SMT was performed for the covariates NIHSS and mRS at admission. Out of all 138 patients, 48 (34.8%) received MT and 90 (65.2%) received SMT only. Overall, patients treated with MT showed significantly higher NIHSS and mRS scores at admission. Post 1:1 PSM, there was a trend toward a better NIHSS improvement in patients with MT (median 4 vs. 1, P = 0.1). No significant differences were observed in the occurrence of symptomatic intracranial hemorrhage or mortality between the groups before and after PSM. A subgroup analysis showed significantly higher NIHSS improvement (median 5 versus 1, P = 0.01) for patients with successful MT (≥ mTICI 2b). Mechanical thrombectomy for distal medium vessel occlusions (DMVO) in the anterior circulation appeared safe and feasible. Successful recanalization was associated with clinical improvement. Larger, multi-center, randomized-controlled trials are required to corroborate these findings.
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Affiliation(s)
- Dominik Sepp
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, München, Germany.
| | - Moritz Roman Hernandez Petzsche
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, München, Germany
| | - Teresa Zarth
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, München, Germany
| | - Silke Wunderlich
- Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Straße 22, 81675, München, Germany
| | - Benno Ikenberg
- Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Ismaninger Straße 22, 81675, München, Germany
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, München, Germany
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, München, Germany
| | - Maria Teresa Berndt
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, München, Germany
| | - Tobias Boeckh-Behrens
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, München, Germany
| | - Jan Stefan Kirschke
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, München, Germany
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15
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Yuksen C, Tienpratarn W, Treerasoradaj T, Jenpanitpong C, Termkijwanich P. The Clinical Predictive Score for Prehospital Large Vessel Occlusion Stroke: A Retrospective Cohort Study in the Asian Country. Open Access Emerg Med 2023; 15:53-60. [PMID: 36798910 PMCID: PMC9925388 DOI: 10.2147/oaem.s398061] [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] [Received: 11/30/2022] [Accepted: 01/27/2023] [Indexed: 02/11/2023] Open
Abstract
Background Large vessel occlusive (LVO) stroke causes severe disabilities and occurs in more than 37% of strokes. Reperfusion therapy is the gold standard of treatment. Studies proved that endovascular thrombectomy (EVT) is more beneficial and decreases mortality. This study aimed to evaluate the factor associated with LVO stroke in an Asian population and to develop the scores to predict LVO in a prehospital setting. The score will hugely contribute to the future of stroke care in prehospital settings in the aspect of transferal suspected LVO stroke patients to appropriate EVT-capable stroke centers. Methods This study was a retrospective cohort study using an exploratory model at the emergency department of Ramathibodi Hospital, Bangkok, Thailand, between January 2018 and December 2020. We included the stroke patients aged >18 who visit ED and an available radiologic report representing LVO. Those whose stroke onset was >24 hours and no radiologic report were excluded. Multivariable logistic regression analysis developed the prediction model and score for LVO stroke. Results A total of 252 patients met the inclusion criteria; 61 cases (24%) had LVO stroke. Six independent factors were significantly predictive: comorbidity with atrial fibrillation, clinical hemineglect, gaze deviation, facial palsy, aphasia, and cerebellar sign abnormality. The predicted score had an accuracy of 92.5%. The LVO risk score was categorized into three groups: low risk (LVO score <3), moderate risk (LVO score 3-6), and high risk (LVO score >6). The positive likelihood ratio to predicting LVO stroke were 0.12 (95% CI 0.06-0.26), 2.33 (95% CI 1.53-3.53) and 45.40 (95% CI 11.16-184.78), respectively. Conclusion The Large Vessel Occlusion (LVO) Risk Score provides a screening tool for predicting LVO stroke. A clinical predictive score of ≥3 appears to be associated with LVO stroke.
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Affiliation(s)
- Chaiyaporn Yuksen
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Welawat Tienpratarn
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand,Correspondence: Welawat Tienpratarn, Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, 10400, Thailand, Email
| | - Thitibud Treerasoradaj
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Chetsadakon Jenpanitpong
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
| | - Phatcha Termkijwanich
- Department of Emergency Medicine, Faculty of Medicine, Ramathibodi Hospital, Mahidol University, Bangkok, Thailand
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16
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Yedavalli VS, Hamam O, Gudenkauf J, Wang R, Llinas R, Marsh EB, Caplan J, Nael K, Urrutia V. Assessing the Efficacy of Mechanical Thrombectomy in Patients with an NIHSS < 6 Presenting with Proximal Middle Cerebral Artery Vessel Occlusion as Compared to Best Medical Management. Brain Sci 2023; 13:brainsci13020214. [PMID: 36831757 PMCID: PMC9953866 DOI: 10.3390/brainsci13020214] [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: 01/13/2023] [Revised: 01/23/2023] [Accepted: 01/25/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND AND PURPOSE Minor acute ischemic stroke (AIS) patients-defined by an NIHSS score < 6-presenting with proximal middle cerebral artery large vessel occlusions (MCA-LVO) is a subgroup for which treatment is still debated. Although these patients present with minor symptoms initially, studies have shown that several patients afflicted with MCA-LVO in this subgroup experience cognitive and functional decline. Although mechanical thrombectomy (MT) is the standard of care for patients with an NIHSS score of 6 or higher, treatment in the minor stroke subgroup is still being explored. The purpose of this preliminary study is to report our center's experience in evaluating the potential benefit of mechanical thrombectomy (MT) in minor stroke patients when compared to medical management (MM). METHODS We performed a retrospective study with two comprehensive stroke centers within our hospital enterprise of consecutive patients presenting with minor AIS secondary to MCA-LVO (defined as M1 or proximal M2 segments of MCA). We subsequently evaluated patients who received MT versus those who received MM. RESULTS Between January 2017 and July 2021, we identified 46 AIS patients (11 treated with MT and 35 treated with MM) who presented with an NIHSS score < 6 secondary to MCA-LVO (47.8% 22/46 female, mean age 62.3 years, range 49-75 years). MT was associated with a significantly lower mRS at 90 days (median: 1.0 [IQR 0.0-2.0] versus 3.0 [IQR 1.0-4.0], p = <0.001), a favorable NIHSS shift (-4.0 [IQR -10.0--2.0] versus 0.0 [IQR -2.0-1.0], p = 0.002), favorable NIHSS shift dichotomization (5/11, 45.5% versus 3/35, 8.6%, p = 0.003) and favorable mRS dichotomization (7/11, 63.6% versus 14/35, 40.0%, p = 0.024). CONCLUSIONS In our center's preliminary experience, for AIS patients presenting with an NIHSS score < 6 secondary to MCA-LVO, MT may be associated with improved clinical outcomes when compared to MM only.
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Affiliation(s)
- Vivek Srikar Yedavalli
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Hospital, 600 N Wolfe Street, Baltimore, MD 21287, USA
| | - Omar Hamam
- Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD 21205, USA
| | - Julie Gudenkauf
- Department Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Richard Wang
- Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD 21205, USA
| | - Rafael Llinas
- Department Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Elisabeth Breese Marsh
- Department Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Justin Caplan
- Department Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Kambiz Nael
- Department of Radiology, University of California, Los Angeles, CA 90095, USA
| | - Victor Urrutia
- Department Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, MD 21287, USA
- Correspondence:
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Development and Internal Validation of a Model Predicting the Risk of Recurrent Stroke for Middle-Aged and Elderly Patients: A Retrospective Cohort Study. World Neurosurg 2022; 168:e418-e431. [DOI: 10.1016/j.wneu.2022.10.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2022] [Revised: 10/12/2022] [Accepted: 10/13/2022] [Indexed: 11/06/2022]
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18
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Kim BJ, Menon BK, Yoo J, Han JH, Kim BJ, Kim CK, Kim JG, Kim JT, Park H, Baik SH, Han MK, Kang J, Kim JY, Lee KJ, Park JM, Kang K, Lee SJ, Cha JK, Kim DH, Jeong JH, Park TH, Park SS, Lee KB, Lee J, Hong KS, Cho YJ, Park HK, Lee BC, Yu KH, Oh MS, Kim DE, Ryu WS, Choi KH, Choi JC, Kim JG, Kwon JH, Kim WJ, Shin DI, Yum KS, Sohn SI, Hong JH, Kim C, Lee SH, Lee J, Almekhlafi MA, Demchuk A, Bae HJ. Effectiveness and safety of EVT in patients with acute LVO and low NIHSS. Front Neurol 2022; 13:955725. [PMID: 35989920 PMCID: PMC9389111 DOI: 10.3389/fneur.2022.955725] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2022] [Accepted: 07/12/2022] [Indexed: 11/13/2022] Open
Abstract
Background and purposeThere is much uncertainty in endovascular treatment (EVT) decisions in patients with acute large vessel occlusion (LVO) and mild neurological deficits.MethodsFrom a prospective, nationwide stroke registry, all patients with LVO and baseline NIHSS <6 presenting within 24 h from the time last known well (LKW) were included. Early neurological deterioration (END) developed before EVT was prospectively collected as an increasing total NIHSS score ≥2 or any worsening of the NIHSS consciousness or motor subscores during hospitalization not related to EVT. Significant hemorrhage was defined as PH2 hemorrhagic transformation or hemorrhage at a remote site. The modified Rankin Scale (mRS) was prospectively collected at 3 months.ResultsAmong 1,083 patients, 149 (14%) patients received EVT after a median of 5.9 [3.6–12.3] h after LKW. In propensity score-matched analyses, EVT was not associated with mRS 0-1 (matched OR 0.99 [0.63–1.54]) but increased the risk of a significant hemorrhage (matched OR, 4.51 [1.59–12.80]). Extraneous END occurred in 207 (19%) patients after a median of 24.5 h [IQR, 13.5–41.9 h] after LKW (incidence rate, 1.41 [95% CI, 1.23–1.62] per 100 person-hours). END unrelated to EVT showed a tendency to modify the effectiveness of EVT (P-for-interaction, 0.08), which decreased the odds of having mRS 0–1 in mild LVO patients without END (adjusted OR, 0.63 [0.40–0.99]).ConclusionsThe use of EVT in patients with acute LVO and low NIHSS scores may require the assessment of individual risks of early deterioration, hemorrhagic complications and expected benefit.
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Affiliation(s)
- Beom Joon Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
- *Correspondence: Beom Joon Kim
| | - Bijoy K. Menon
- Calgary Stroke Program, Department of Clinical Neuroscience, Radiology and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Joonsang Yoo
- Department of Neurology, Yongin Severance Hospital, Yongin-si, South Korea
| | - Jung Hoon Han
- Department of Neurology, Korea University Guro Hospital, Seoul, South Korea
| | - Bum Joon Kim
- Department of Neurology, Asan Medical Center, Seoul, South Korea
| | - Chi Kyung Kim
- Department of Neurology, Korea University Guro Hospital, Seoul, South Korea
| | - Jae Guk Kim
- Department of Neurology, Eulji University Hospital, Daejeon, South Korea
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Hospital, Gwangju, South Korea
| | - Hyungjong Park
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Sung Hyun Baik
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Moon-Ku Han
- Department of Neurology and Cerebrovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Jihoon Kang
- Department of Neurology and Cerebrovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Jun Yup Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Keon-Joo Lee
- Department of Neurology and Cerebrovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
| | - Jong-Moo Park
- Department of Neurology, Uijeongbu Eulji Medical Center, Eulji University School of Medicine, Uijeongbu-si, South Korea
| | - Kyusik Kang
- Department of Neurology, Nowon Eulji Medical Center, Eulji University School of Medicine, Seoul, South Korea
| | - Soo Joo Lee
- Department of Neurology, Eulji University Hospital, Daejeon, South Korea
| | - Jae-Kwan Cha
- Department of Neurology, Dong-A University Hospital, Busan, South Korea
| | - Dae-Hyun Kim
- Department of Neurology, Dong-A University Hospital, Busan, South Korea
| | - Jin-Heon Jeong
- Department of Neurology, Dong-A University Hospital, Busan, South Korea
| | - Tai Hwan Park
- Department of Neurology, Seoul Medical Center, Seoul, South Korea
| | - Sang-Soon Park
- Department of Neurology, Seoul Medical Center, Seoul, South Korea
| | - Kyung Bok Lee
- Department of Neurology, Soonchunhyang University Hospital, Seoul, South Korea
| | - Jun Lee
- Department of Neurology, Yeungnam University Medical Center, Daegu, South Korea
| | - Keun-Sik Hong
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang-si, South Korea
| | - Yong-Jin Cho
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang-si, South Korea
| | - Hong-Kyun Park
- Department of Neurology, Inje University Ilsan Paik Hospital, Goyang-si, South Korea
| | - Byung-Chul Lee
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang-si, South Korea
| | - Kyung-Ho Yu
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang-si, South Korea
| | - Mi-Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, Anyang-si, South Korea
| | - Dong-Eog Kim
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang-si, South Korea
| | - Wi-Sun Ryu
- Department of Neurology, Dongguk University Ilsan Hospital, Goyang-si, South Korea
| | - Kang-Ho Choi
- Department of Neurology, Chonnam National University Hospital, Gwangju, South Korea
| | - Jay Chol Choi
- Department of Neurology, Jeju National University Hospital, Jeju, South Korea
| | - Joong-Goo Kim
- Department of Neurology, Jeju National University Hospital, Jeju, South Korea
| | - Jee-Hyun Kwon
- Department of Neurology, Ulsan University Hospital, Ulsan, South Korea
| | - Wook-Joo Kim
- Department of Neurology, Ulsan University Hospital, Ulsan, South Korea
| | - Dong-Ick Shin
- Department of Neurology, Chungbuk National University Hospital, Cheongju-si, South Korea
| | - Kyu Sun Yum
- Department of Neurology, Chungbuk National University Hospital, Cheongju-si, South Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University Dongsan Medical Center, Daegu, South Korea
| | - Chulho Kim
- Department of Neurology, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon-si, South Korea
| | - Sang-Hwa Lee
- Department of Neurology, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon-si, South Korea
| | - Juneyoung Lee
- Department of Biostatistics, Korea University, Seoul, South Korea
| | - Mohammed A. Almekhlafi
- Calgary Stroke Program, Department of Clinical Neuroscience, Radiology and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Andrew Demchuk
- Calgary Stroke Program, Department of Clinical Neuroscience, Radiology and Community Health Sciences, University of Calgary, Calgary, AB, Canada
| | - Hee-Joon Bae
- Department of Neurology and Cerebrovascular Center, Seoul National University College of Medicine, Seoul National University Bundang Hospital, Seongnam-si, South Korea
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19
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Miethe K, Iordanishvili E, Habib P, Panse J, Krämer S, Wiesmann M, Schulz JB, Nikoubashman O, Reich A, Pinho J. Imaging patterns of cerebral ischemia in hypereosinophilic syndrome: case report and systematic review. Neurol Sci 2022; 43:5091-5094. [PMID: 35590001 PMCID: PMC9349058 DOI: 10.1007/s10072-022-06134-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2022] [Accepted: 05/09/2022] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Ischemic stroke is a potential complication of hypereosinophilic syndromes (HES), and little is known about underlying pathophysiological mechanisms. We aimed to describe the imaging patterns of cerebral ischemia in patients with HES. METHODS An individual case is reported. A systematic PubMed review of all records reporting adult patients with HES who suffered ischemic stroke and for whom neuroimaging details of ischemic lesions were available was performed. RESULTS A 60-year-old man presented with progressive subacute gait difficulty and psychomotor slowing as well as an absolute eosinophilia (2.2 × 109/L) at admission. Brain magnetic resonance tomography revealed multiple acute and subacute internal and external border zone infarcts. Cardiac diagnostic suggested the presence of endomyocarditis. After extensive diagnostic workup, idiopathic HES was diagnosed. The systematic review yielded 183 studies, of which 40 fulfilled the inclusion criteria: a total of 64 patients (31.3% female), with mean age 51.1 years and a median absolute eosinophile count at diagnosis of 10.2 × 109/L were included in the analyses. A border zone pattern of cerebral ischemic lesions was reported in 41 patients (64.1%). Isolated peripheral infarcts were reported in 7 patients (10.9%). Sixteen patients had multiple acute infarcts with no border zone distribution (25.0%). An intracardiac thrombus was reported in 15/60 patients (25%), and findings suggestive of endomyocarditis or endomyocardial fibrosis were found in 31/60 patients (51.7%). CONCLUSIONS Border zone distribution of cerebral ischemia without hemodynamic compromise is the most frequent imaging pattern in patients with HES, occurring in 2/3 of patients who develop ischemic stroke.
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Affiliation(s)
- Kathrin Miethe
- Department of Neurology, University Hospital, RTWH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - Elene Iordanishvili
- Department of Diagnostic and Interventional Neuroradiology, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Pardes Habib
- Department of Neurology, University Hospital, RTWH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
- JARA-BRAIN Institute Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH and RWTH Aachen University, Aachen, Germany
| | - Jens Panse
- Department of Hematology, Oncology, Hemostaseology, and Stem Cell Transplantation, University Hospital, RTWH Aachen University, Aachen, Germany
- Center for Integrated Oncology, Aachen Bonn Cologne Düsseldorf (CIO ABCD), Aachen, Germany
| | - Stefan Krämer
- Department of Nephrology and Clinical Immunology, University Hospital, RTWH Aachen University, Aachen, Germany
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Jörg B Schulz
- Department of Neurology, University Hospital, RTWH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
- JARA-BRAIN Institute Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH and RWTH Aachen University, Aachen, Germany
| | - Omid Nikoubashman
- Department of Diagnostic and Interventional Neuroradiology, University Hospital, RWTH Aachen University, Aachen, Germany
| | - Arno Reich
- Department of Neurology, University Hospital, RTWH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany
| | - João Pinho
- Department of Neurology, University Hospital, RTWH Aachen University, Pauwelsstr. 30, 52074, Aachen, Germany.
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Guo Z, Hou J, Yu S, Zhang H, Yu S, Wang H, Xu J, You S, Huang Z, Xiao G, Cao Y, Liu CF. Eosinophils, Stroke-Associated Pneumonia, and Outcome After Mechanical Thrombectomy for Acute Ischemic Stroke. Front Aging Neurosci 2022; 14:830858. [PMID: 35677203 PMCID: PMC9168221 DOI: 10.3389/fnagi.2022.830858] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/25/2022] [Indexed: 11/23/2022] Open
Abstract
Background Eosinophils contribute to antibacterial defense by releasing mitochondrial DNA, which are decreased in patients with acute ischemic stroke (AIS). However, the impact of eosinophils on stroke-associated pneumonia (SAP) among patients with AIS remains unclear. Moreover, whether SAP is in the path of the association between eosinophils and clinical outcomes also remains unclear. We aimed to assess the relationships between eosinophils, SAP, and clinical outcome after mechanical thrombectomy in patients with AIS. Methods A total of 328 consecutive patients with AIS who underwent mechanical thrombectomy between May 2017 and March 2021 were analyzed. Their baseline data and peripheral eosinophil counts were recorded on admission. Regression analysis was used to assess the effect of eosinophils on SAP, and its effect on poor outcome is defined as a modified Rankin Scale score of 3–6 at month 3 after admission. Mediation analysis was utilized to assess the proportion of the total effect of SAP on the association between eosinophils and poor outcomes. Results Multivariate analysis revealed that eosinophils was independently associated with SAP after adjusting for potential confounders (odds ratio, 0.00; 95% CI, 0.00–0.38; P = 0.0267), which are consistent with the result of eosinophils (dichotomous) as a categorical variable (odds ratio, 0.54; 95% CI, 0.31–0.96; P = 0.0342). A non-linear relationship was detected between eosinophils and SAP, whose inflection point was 0.06. Subgroup analyses further confirmed these associations. Eosinophils were also associated with poor outcomes (odds ratio, 0.00; 95% CI, 0.00–0.14; P = 0.0124). Additionally, mediation analysis found that SAP partially mediated the negative relationship between eosinophils and poor outcome (indirect effect = −0.169; 95% CI:−0.339 –−0.040, P < 0.001). Conclusion Our findings suggested that a lower eosinophil level was associated with higher SAP and poorer outcome, and SAP might play an important effect in the association between eosinophils and poor outcomes.
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Affiliation(s)
- Zhiliang Guo
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Jie Hou
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Shuai Yu
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Hang Zhang
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Shuhong Yu
- Department of Encephalopathy, Suzhou Integrated Traditional Chinese and Western Medicine Hospital, Suzhou, China
| | - Huaishun Wang
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Jiaping Xu
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Shoujiang You
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Zhichao Huang
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
| | - Guodong Xiao
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
- *Correspondence: Guodong Xiao
| | - Yongjun Cao
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
- Yongjun Cao
| | - Chun-Feng Liu
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, The Second Affiliated Hospital of Soochow University, Suzhou, China
- Chun-Feng Liu
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