1
|
Goyal M, Hill MD, Ospel JM. Designing clinical trials for bridging cerebroprotection in the era of mechanical thrombectomy: are we missing the point? J Neurointerv Surg 2024:jnis-2024-022009. [PMID: 38937085 DOI: 10.1136/jnis-2024-022009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2024] [Indexed: 06/29/2024]
Affiliation(s)
- Mayank Goyal
- Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| | - Michael D Hill
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Clinical Neurosciences, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Johanna M Ospel
- Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
2
|
Ospel JM, Rex N, Oueidat K, McDonough R, Rinkel L, Baird G, Collins S, Jindal G, Alvin MD, Boxerman J, Barber P, Jayaraman M, Smith W, Amirault-Capuano A, Hill MD, Goyal M, McTaggart R. Infarcts Due to Large Vessel Occlusions Continue to Grow Despite Near-Complete Reperfusion After Endovascular Treatment. J Stroke 2024; 26:260-268. [PMID: 38836273 PMCID: PMC11164585 DOI: 10.5853/jos.2023.02621] [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: 08/11/2023] [Revised: 01/09/2024] [Accepted: 02/01/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND AND PURPOSE Infarcts in acute ischemic stroke (AIS) patients may continue to grow even after reperfusion, due to mechanisms such as microvascular obstruction and reperfusion injury. We investigated whether and how much infarcts grow in AIS patients after near-complete (expanded Thrombolysis in Cerebral Infarction [eTICI] 2c/3) reperfusion following endovascular treatment (EVT), and to assess the association of post-reperfusion infarct growth with clinical outcomes. METHODS Data are from a single-center retrospective observational cohort study that included AIS patients undergoing EVT with near-complete reperfusion who received diffusion-weighted magnetic resonance imaging (MRI) within 2 hours post-EVT and 24 hours after EVT. Association of infarct growth between 2 and 24 hours post-EVT and 24-hour National Institutes of Health Stroke Scale (NIHSS) as well as 90-day modified Rankin Scale score was assessed using multivariable logistic regression. RESULTS Ninety-four of 155 (60.6%) patients achieved eTICI 2c/3 and were included in the analysis. Eighty of these 94 (85.1%) patients showed infarct growth between 2 and 24 hours post-reperfusion. Infarct growth ≥5 mL was seen in 39/94 (41.5%) patients, and infarct growth ≥10 mL was seen in 20/94 (21.3%) patients. Median infarct growth between 2 and 24 hours post-reperfusion was 4.5 mL (interquartile range: 0.4-9.2 mL). Post-reperfusion infarct growth was associated with the 24-hour NIHSS in multivariable analysis (odds ratio: 1.16 [95% confidence interval 1.09-1.24], P<0.01). CONCLUSION Infarcts continue to grow after EVT, even if near-complete reperfusion is achieved. Investigating the underlying mechanisms may inform future therapeutic approaches for mitigating the process and help improve patient outcome.
Collapse
Affiliation(s)
- Johanna M. Ospel
- Department of Radiology, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Nathaniel Rex
- Department of Radiology, University of Calgary, Calgary, AB, Canada
- Department of Diagnostic Imaging, Brown University, Providence, RI, USA
| | - Karim Oueidat
- Department of Diagnostic Imaging, Brown University, Providence, RI, USA
| | | | - Leon Rinkel
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Grayson Baird
- Department of Diagnostic Imaging, Brown University, Providence, RI, USA
| | - Scott Collins
- Department of Diagnostic Imaging, Brown University, Providence, RI, USA
| | - Gaurav Jindal
- Department of Diagnostic Imaging, Brown University, Providence, RI, USA
| | - Matthew D. Alvin
- Department of Diagnostic Imaging, Brown University, Providence, RI, USA
| | - Jerrold Boxerman
- Department of Diagnostic Imaging, Brown University, Providence, RI, USA
| | - Phil Barber
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Mahesh Jayaraman
- Department of Diagnostic Imaging, Brown University, Providence, RI, USA
| | - Wendy Smith
- Department of Diagnostic Imaging, Brown University, Providence, RI, USA
| | | | - Michael D. Hill
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Mayank Goyal
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Ryan McTaggart
- Department of Diagnostic Imaging, Brown University, Providence, RI, USA
| |
Collapse
|
3
|
Rex N, Oueidat K, Ospel J, McDonough R, Rinkel L, Baird GL, Collins S, Jindal G, Alvin MD, Boxerman J, Barber P, Jayaraman M, Smith W, Amirault-Capuano A, Hill M, Goyal M, McTaggart R. Modeling diffusion-weighted imaging lesion expansion between 2 and 24 h after endovascular thrombectomy in acute ischemic stroke. Neuroradiology 2024; 66:621-629. [PMID: 38277008 DOI: 10.1007/s00234-024-03294-2] [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: 08/11/2023] [Accepted: 01/10/2024] [Indexed: 01/27/2024]
Abstract
PURPOSE Diffusion-weighted imaging (DWI) lesion expansion after endovascular thrombectomy (EVT) is not well characterized. We used serial diffusion-weighted magnetic resonance imaging (MRI) to measure lesion expansion between 2 and 24 h after EVT. METHODS In this single-center observational analysis of patients with acute ischemic stroke due to large vessel occlusion, DWI was performed post-EVT (< 2 h after closure) and 24-h later. DWI lesion expansion was evaluated using multivariate generalized linear mixed modeling with various clinical moderators. RESULTS We included 151 patients, of which 133 (88%) had DWI lesion expansion, defined as a positive change in lesion volume between 2 and 24 h. In an unadjusted analysis, median baseline DWI lesion volume immediately post-EVT was 15.0 mL (IQR: 6.6-36.8) and median DWI lesion volume 24 h post-EVT was 20.8 mL (IQR: 9.4-66.6), representing a median change of 6.1 mL (IQR: 1.5-17.7), or a 39% increase. There were no significant associations among univariable models of lesion expansion. Adjusted models of DWI lesion expansion demonstrated that relative lesion expansion (defined as final/initial DWI lesion volume) was consistent across eTICI scores (0-2a, 0.52%; 2b, 0.49%; 2c-3, 0.42%, p = 0.69). For every 1 mL increase in lesion volume, there was 2% odds of an increase in 90-day mRS (OR: 1.021, 95%CI [1.009, 1.034], p < 0.001). CONCLUSION We observed substantial lesion expansion post-EVT whereby relative lesion expansion was consistent across eTICI categories, and greater absolute lesion expansion was associated with worse clinical outcome. Our findings suggest that alternate endpoints for cerebroprotectant trials may be feasible.
Collapse
Affiliation(s)
- Nathaniel Rex
- Department of Diagnostic Imaging, Brown University, 593 Eddy Street Providence, Providence, RI, 02903, USA
- Department of Radiology, University of Calgary, Calgary, Canada
| | - Karim Oueidat
- Department of Diagnostic Imaging, Brown University, 593 Eddy Street Providence, Providence, RI, 02903, USA
| | - Johanna Ospel
- Department of Radiology, University of Calgary, Calgary, Canada
| | | | - Leon Rinkel
- Department of Radiology, University of Calgary, Calgary, Canada
| | - Grayson L Baird
- Department of Diagnostic Imaging, Brown University, 593 Eddy Street Providence, Providence, RI, 02903, USA
| | - Scott Collins
- Department of Diagnostic Imaging, Brown University, 593 Eddy Street Providence, Providence, RI, 02903, USA
| | - Gaurav Jindal
- Department of Diagnostic Imaging, Brown University, 593 Eddy Street Providence, Providence, RI, 02903, USA
| | - Matthew D Alvin
- Department of Diagnostic Imaging, Brown University, 593 Eddy Street Providence, Providence, RI, 02903, USA
| | - Jerrold Boxerman
- Department of Diagnostic Imaging, Brown University, 593 Eddy Street Providence, Providence, RI, 02903, USA
| | - Phil Barber
- Department of Radiology, University of Calgary, Calgary, Canada
| | - Mahesh Jayaraman
- Department of Diagnostic Imaging, Brown University, 593 Eddy Street Providence, Providence, RI, 02903, USA
| | - Wendy Smith
- Department of Diagnostic Imaging, Brown University, 593 Eddy Street Providence, Providence, RI, 02903, USA
| | - Amanda Amirault-Capuano
- Department of Diagnostic Imaging, Brown University, 593 Eddy Street Providence, Providence, RI, 02903, USA
| | - Michael Hill
- Department of Clinical Neuroscience, University of Calgary, Calgary, Canada
| | - Mayank Goyal
- Department of Radiology, University of Calgary, Calgary, Canada
| | - Ryan McTaggart
- Department of Diagnostic Imaging, Brown University, 593 Eddy Street Providence, Providence, RI, 02903, USA.
| |
Collapse
|
4
|
Tanashyan M, Morozova S, Raskurazhev A, Kuznetsova P. A prospective randomized, double-blind placebo-controlled study to evaluate the effectiveness of neuroprotective therapy using functional brain MRI in patients with post-covid chronic fatigue syndrome. Biomed Pharmacother 2023; 168:115723. [PMID: 37862966 DOI: 10.1016/j.biopha.2023.115723] [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: 09/01/2023] [Revised: 10/12/2023] [Accepted: 10/13/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND AND PURPOSE to assess executive network using resting-state fMRI and patterns of brain activation using task fMRI with a cognitive paradigm, against the background of taking the drug in comparison with placebo in patients with post-COVID asthenic syndrome. METHODS The study employed a prospective, randomized, double-blind, placebo-controlled trial approach to assess the efficacy of utilizing functional MRI of the brain as a neuroprotective therapy for treating patients with chronic fatigue syndrome following COVID-19. The study included 30 patients matched by sex and age with post-COVID asthenic syndrome. All patients were examined with MFI-20, MoCA, FAS-10 scales, MRI using a Siemens MAGNETOM Prisma 3 T scanner before and after a course of therapy with coordination complex with succinate acid anion (CCSA) or placebo (15 patients each) using resting state fMRI and with cognitive paradigm. RESULTS The changes obtained as a result of the treatment of post-Covid asthenic syndrome demonstrated clinical superiority in the reduction of asthenic symptoms for the group of patients treated with CCSA (MFI-20 scores: -20·0 points in the CCSA group compared to -12 points in the placebo group, p = 0·043). The data obtained also correlate with the analysis of task fMRI and resting state fMRI may indicate an increase in the functional cognitive status after a course of therapy with CCSA. Clinically, this correlates with a statistically significant improvement in the MoCA score (2 points in the CCSA group compared to 1 point in the placebo group, p < 0·05). CONCLUSIONS the study demonstrates the potential effectiveness of CCSA therapy in relation to a wide range of symptoms (chronic fatigue syndrome/ asthenic syndrome and cognitive impairment) in patients with post-COVID syndrome. The first time demonstrated the effectiveness of neuroprotective therapy after post-COVID asthenic syndrome with the use of high-tech neuroimaging techniques.
Collapse
Affiliation(s)
- M Tanashyan
- Research Center of Neurology, Moscow, Russia.
| | - S Morozova
- Research Center of Neurology, Moscow, Russia.
| | | | | |
Collapse
|
5
|
Rex NB, McDonough RV, Ospel JM, Kashani N, Sehgal A, Fladt JC, McTaggart RA, Nogueira R, Menon B, Demchuk AM, Tymianski M, Hill MD, Goyal M. CT Perfusion Does Not Modify the Effect of Reperfusion in Patients with Acute Ischemic Stroke Undergoing Endovascular Treatment in the ESCAPE-NA1 Trial. AJNR Am J Neuroradiol 2023; 44:1045-1049. [PMID: 37620153 PMCID: PMC10494951 DOI: 10.3174/ajnr.a7954] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2023] [Accepted: 06/27/2023] [Indexed: 08/26/2023]
Abstract
BACKGROUND AND PURPOSE Although reperfusion is associated with improved outcomes in patients with acute ischemic stroke undergoing endovascular treatment, many patients still do poorly. We investigated whether CTP modifies the effect of near-complete reperfusion on clinical outcomes, ie, whether poor clinical outcomes despite near-complete reperfusion can be partly or fully explained by CTP findings. MATERIALS AND METHODS Data are from the Safety and Efficacy of Nerinetide in Subjects Undergoing Endovascular Thrombectomy for Stroke (ESCAPE-NA1) trial. Admission CTP was processed using RAPID software, generating relative CBF and CBV volume maps at standard thresholds. CTP lesion volumes were compared in patients with-versus-without near-complete reperfusion. Associations between each CTP metric and clinical outcome (90-day mRS) were tested using multivariable logistic regression, adjusted for baseline imaging and clinical variables. Treatment-effect modification was assessed by introducing CTP lesion volume × reperfusion interaction terms in the models. RESULTS CTP lesion volumes and reperfusion status were available in 410/1105 patients. CTP lesion volumes were overall larger in patients without near-complete reperfusion, albeit not always statistically significant. Increased CBF <34%, CBV <34%, CBV <38%, and CBV <42% lesion volumes were associated with worse clinical outcome (ordinal mRS) at 90 days. CTP core lesion volumes did not modify the treatment effect of near-complete recanalization on clinical outcome. CONCLUSIONS CTP did not modify the effect of near-complete reperfusion on clinical outcomes. Thus, CTP cannot explain why some patients with near-complete reperfusion have poor clinical outcomes.
Collapse
Affiliation(s)
- N B Rex
- From the Department of Diagnostic Imaging (N.B.R., R.A.M.), Brown University, Providence, Rhode Island
- Department of Diagnostic Imaging (N.B.R., R.V.M., J.M.O., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - R V McDonough
- Department of Diagnostic Imaging (N.B.R., R.V.M., J.M.O., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - J M Ospel
- Department of Diagnostic Imaging (N.B.R., R.V.M., J.M.O., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., A.S., J.C.F., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - N Kashani
- Department of Neurosurgery (N.K.), University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - A Sehgal
- Department of Clinical Neurosciences (J.M.O., A.S., J.C.F., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - J C Fladt
- Department of Clinical Neurosciences (J.M.O., A.S., J.C.F., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
- Department of Neurology and Stroke Center (J.C.F.), University Hospital Basel, Basel, Switzerland
| | - R A McTaggart
- From the Department of Diagnostic Imaging (N.B.R., R.A.M.), Brown University, Providence, Rhode Island
| | - R Nogueira
- Department of Neurology and Neurosurgery (R.N.), University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - B Menon
- Department of Diagnostic Imaging (N.B.R., R.V.M., J.M.O., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., A.S., J.C.F., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
| | - A M Demchuk
- Department of Diagnostic Imaging (N.B.R., R.V.M., J.M.O., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., A.S., J.C.F., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
| | | | - M D Hill
- Department of Diagnostic Imaging (N.B.R., R.V.M., J.M.O., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., A.S., J.C.F., B.M., A.M.D., M.D.H., M.G.), University of Calgary, Calgary, Alberta, Canada
| | | |
Collapse
|
6
|
Rex N, Ospel JM, Brown SB, McDonough RV, Kashani N, Hill MD, Dippel DWJ, Campbell B, Muir KW, Demchuk AM, Bracard S, Guillemin F, Jovin TG, Mitchell PJ, White P, Majoie CBLM, Saver JL, Goyal M. Endovascular therapy in acute ischemic stroke with poor reperfusion is associated with worse outcomes compared with best medical management: a HERMES substudy. J Neurointerv Surg 2023:jnis-2023-020411. [PMID: 37532454 DOI: 10.1136/jnis-2023-020411] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2023] [Accepted: 07/21/2023] [Indexed: 08/04/2023]
Abstract
BACKGROUND Functional outcomes in patients with acute ischemic stroke (AIS) with large vessel occlusion (LVO) undergoing endovascular treatment (EVT) with poor reperfusion were compared with patients with AIS-LVO treated with best medical management only. METHODS Data are from the HERMES collaboration, a patient-level meta-analysis of seven randomized EVT trials. Baseline characteristics and functional outcomes (modified Rankin Scale (mRS) score at 90 days) were compared between patients with poor reperfusion (defined as modified Thrombolysis in Cerebral Infarction Score 0-1 on the final intracranial angiography run as assessed by the central imaging core laboratory) and patients in the control arm with multivariable logistic ordinal logistic regression adjusted for pre-specified baseline variables. RESULTS 972 of 1764 patients from the HERMES collaboration were included in the analysis: 893 in the control arm and 79 in the EVT arm with final mTICI 0-1. Patients with poor reperfusion who underwent EVT had higher baseline National Institutes of Health Stroke Scale than controls (median 19 (IQR 15.5-21) vs 17 (13-21), P=0.011). They also had worse mRS at 90 days compared with those in the control arm in adjusted analysis (median 4 (IQR 3-6) vs median 4 (IQR 2-5), adjusted common OR 0.59 (95% CI 0.38 to 0.91)). Symptomatic intracranial hemorrhage was not different between the two groups (3.9% vs 3.5%, P=0.75, adjusted OR 0.94 (95% CI 0.23 to 3.88)). CONCLUSION Poor reperfusion after EVT was associated with worse outcomes than best medical management, although no difference in symptomatic intracranial hemorrhage was seen. These results emphasize the need for additional efforts to further improve technical EVT success rates.
Collapse
Affiliation(s)
- Nathaniel Rex
- Diagnostic Imaging, Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
- Department of Radiology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Johanna M Ospel
- Department of Radiology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | | | - Rosalie V McDonough
- Department of Radiology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Nima Kashani
- Neuroradiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Michael D Hill
- Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | | | - Bruce Campbell
- Department of Neurology, The Royal Melbourne Hospital, Melbourne, Victoria, Australia
| | - Keith W Muir
- Department of Neurology, University of Glasgow, Glasgow, UK
| | - Andrew M Demchuk
- Clinical Neurosciences, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| | - Serge Bracard
- Neuroradiology, Université de Lorraine, Nancy, France
| | - Francis Guillemin
- Clinical Investigation Centre-Clinical Epidemiology INSERM 1433, University of Lorraine, Nancy, France
| | - Tudor G Jovin
- Neurology, Cooper University Hospital, Camden, New Jersey, USA
| | - Peter J Mitchell
- Radiology, The Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Phil White
- Newcastle University Faculty of Medical Sciences, Newcastle upon Tyne, UK
| | - Charles B L M Majoie
- Radiology and Nuclear Medicine, Amsterdam UMC - Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Jeffrey L Saver
- Comprehensive Stroke Center and Neurology, David Geffen School of Medicine, Los Angeles, California, USA
| | - Mayank Goyal
- Department of Radiology, University of Calgary Cumming School of Medicine, Calgary, Alberta, Canada
| |
Collapse
|
7
|
Goyal M, Rinkel LA, Ospel JM. A Review on Adjunctive Therapies for Endovascular Treatment in Acute Ischemic Stroke. JOURNAL OF NEUROENDOVASCULAR THERAPY 2023; 17:263-271. [PMID: 38025256 PMCID: PMC10657729 DOI: 10.5797/jnet.ra.2023-0035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 05/24/2023] [Indexed: 12/01/2023]
Abstract
Endovascular treatment (EVT) has revolutionized the management of acute ischemic stroke (AIS), but almost half of patients undergoing EVT do not achieve a good outcome. Adjunctive therapies have been proposed to improve the outcomes of EVT in AIS. This review aims to summarize the current evidence on the use of adjunctive therapies in EVT for AIS, including antithrombotic agents, intra-arterial thrombolytics, cerebroprotective agents, normobaric oxygen, and hypothermia. Several adjunctive therapies have shown promise in improving the outcomes of EVT in AIS, but phase 3 clinical trials are needed to establish clinical efficacy. We summarize the advantages and disadvantages of adjunctive EVT treatments and outline the challenges that each of these therapies will face before being adopted in clinical practice.
Collapse
Affiliation(s)
- Mayank Goyal
- Department of Diagnostic Imaging and Clinical Neurosciences, Foothills Medical Center, University of Calgary, Calgary, AB, Canada
| | - Leon A Rinkel
- Department of Diagnostic Imaging and Clinical Neurosciences, Foothills Medical Center, University of Calgary, Calgary, AB, Canada
- Department of Neurology, Amsterdam University Medical Center, Amsterdam, the Netherlands
| | - Johanna M Ospel
- Department of Diagnostic Imaging and Clinical Neurosciences, Foothills Medical Center, University of Calgary, Calgary, AB, Canada
| |
Collapse
|