1
|
Yang W, Hong SA, Kim JM, Jeong HB, Nam TK, Choi HH, Kim SM, Park KY, Kim HR. The immunologic phenotype of thrombi is associated with future vascular events after cerebral infarction. J Neurointerv Surg 2024; 16:352-358. [PMID: 37197936 DOI: 10.1136/jnis-2023-020155] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2023] [Accepted: 05/04/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Thrombi retrieved from patients with acute ischemic stroke may contain prognostic information. OBJECTIVE To investigate the relationship between the immunologic phenotype of thrombi and future vascular events in patients with a stroke. METHODS This study included patients with acute ischemic stroke who underwent endovascular thrombectomy at Chung-Ang University Hospital in Seoul, Korea, between February 2017 and January 2020. Laboratory and histological variables were compared between patients with and without recurrent vascular events (RVEs). Kaplan-Meier analysis followed by the Cox proportional hazards model was used to identify factors related to RVE. Receiver operating characteristic (ROC) analysis was conducted to evaluate the performance of the immunologic score by combining immunohistochemical phenotypes to predict RVE. RESULTS A total of 46 patients were included in the study with 13 RVEs (mean±SD age, 72.8±11.3 years; 26 (56.5%) men). Thrombi with a lower percentage of programmed death ligand-1 expression (HR=11.64; 95% CI 1.60 to 84.82) and a higher number of citrullinated histone H3 positive cells (HR=4.19; 95% CI 0.81 to 21.75) were associated with RVE. The presence of high-mobility group box 1 positive cell was associated with reduced risk of RVE, but the association was lost after adjustment for stroke severity. The immunologic score, which consists of the three immunohistochemical phenotypes, showed good performance in predicting RVE (area under the ROC curve, 0.858; 95% CI 0.758 to 0.958). CONCLUSIONS The immunological phenotype of thrombi could provide prognostic information after stroke.
Collapse
Affiliation(s)
- Wookjin Yang
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Soon Auck Hong
- Department of Pathology, Chung-Ang University Hospital, Seoul, Korea
| | - Jeong-Min Kim
- Department of Neurology, Seoul National University Hospital, Seoul, Korea
| | - Hae-Bong Jeong
- Department of Neurology, Chung-Ang University Hospital, Seoul, Korea
| | - Taek-Kyun Nam
- Department of Neurosurgery, Chung-Ang University Hospital, Seoul, Korea
| | - Hyun Ho Choi
- Department of Neurosurgery, Chung-Ang University Hospital, Seoul, Korea
| | - Suh Min Kim
- Department of Surgery, Chung-Ang University College of Medicine and Graduate School of Medicine, Seoul, Korea
| | - Kwang-Yeol Park
- Department of Neurology, Chung-Ang University Hospital, Seoul, Korea
| | - Hye Ryoun Kim
- Department of Laboratory Medicine, Chung-Ang University Hospital, Seoul, Korea
| |
Collapse
|
2
|
Zhang M, Che R, Xu J, Guo W, Chen X, Zhao W, Ren C, Jia M, Ji X. Long term for patients with futile endovascular reperfusion after stroke. CNS Neurosci Ther 2024; 30:e14588. [PMID: 38475869 PMCID: PMC10933383 DOI: 10.1111/cns.14588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 12/06/2023] [Accepted: 12/20/2023] [Indexed: 03/14/2024] Open
Abstract
AIMS With the progress of thrombectomy technology, the vascular recanalization rate of patients with stroke has been continuously improved, but the proportion of futile recanalization (FR) is still quite a few. The long-term prognosis and survival of patients with FR and its influencing factors remain unclear. METHODS Consecutive patients who received endovascular treatment (EVT) for ischemic stroke were enrolled between 2013 and 2021 from a single-center prospectively registry study. We evaluated the long-term outcome of these patients by Kaplan-Meier survival analysis, and the multivariable logistic regression curve was performed to analyze influencing factors. RESULTS Among 458 patients with FR, 56.4% of patients survived at 1 year, and 50.4% at 2 years. In the multivariate regression analysis, age, premorbid modified Rankin Scale (mRS), National Institutes of Health Stroke Scale (NIHSS), posterior circulation infarct, general anesthesia, symptomatic intracerebral hemorrhage (sICH), and decompressive craniectomy were found to be related to unfavorable outcomes in long-term. Age, premorbid mRS, NIHSS, general anesthesia, and sICH were predictors of long-term mortality. CONCLUSIONS Futile recanalization accounts for a large proportion of stroke patients after thrombectomy. This study on the long-term prognosis of such patients is beneficial to the formulation of treatment plans and the prediction of therapeutic effects.
Collapse
Affiliation(s)
- Mengke Zhang
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Ruiwen Che
- Department of Neurology, Beijing ShiJiTan HospitalCapital Medical UniversityBeijingChina
| | - Jiali Xu
- Department of Rehabilitation Medicine, Beijing ShiJiTan HospitalCapital Medical UniversityBeijingChina
| | - Wenting Guo
- Department of NeurologyZhejiang Provincial People's HospitalZhejiangChina
| | - Xi Chen
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Wenbo Zhao
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Changhong Ren
- Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Milan Jia
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Xunming Ji
- Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Xuanwu HospitalCapital Medical UniversityBeijingChina
- Department of Neurosurgery, Xuanwu HospitalCapital Medical UniversityBeijingChina
| |
Collapse
|
3
|
Cheng X, Hong L, Lin L, Churilov L, Ling Y, Zhang Y, Yang L, Parsons M, Dong Q. CHinese Acute Tissue-Based Imaging Selection for Lysis In Stroke Tenecteplase II (CHABLIS-T II): rationale and design. Stroke Vasc Neurol 2024:svn-2023-002890. [PMID: 38302191 DOI: 10.1136/svn-2023-002890] [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: 10/06/2023] [Accepted: 12/12/2023] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND AND PURPOSE Tenecteplase (TNK) has demonstrated non-inferiority to alteplase in patients who had an acute ischaemic stroke presenting within 4.5 hours from symptom onset. The trial is aimed to explore the efficacy and safety of TNK in Chinese patients who had an acute ischaemic stroke with large/medium vessel occlusion in an extended time window. METHODS AND DESIGN Chinese Acute Tissue-Based Imaging Selection for Lysis In Stroke Tenecteplase II (CHABLIS-T II) is a multicentre, prospective, block-randomised, open-label, blinded-endpoint, phase IIb study. Eligible patients are 1:1 randomised into two groups: 0.25 mg/kg TNK versus best medical management (excluding TNK). The safety and efficacy of 0.25 mg/kg TNK are assessed through reperfusion status and presence of symptomatic intracranial haemorrhage (sICH). STUDY OUTCOMES The primary outcome is major reperfusion without sICH at 24-48 hours after randomisation. Major reperfusion is defined as restoration of blood flow to greater than 50% of the involved ischaemic territory assessed by catheter angiography or repeated perfusion imaging. Secondary outcomes include post-thrombolytic recanalisation, neurological improvements, change in the National Institutes of Health Stroke Scale score, haemorrhagic transformation at 24-48 hours, systematic bleeding at discharge, modified Rankin Scale (mRS) 0-1, mRS 0-2, mRS 5-6, mRS distribution and Barthel index at 90 days. DISCUSSION CHABLIS-T II will provide important evidence of intravenous thrombolysis with TNK for patients who had an acute stroke in an extended time window.
Collapse
Affiliation(s)
- Xin Cheng
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Lan Hong
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Longting Lin
- University of New South Wales South Western Sydney Clinical School, Ingham Institute for Applied Medical Research, Department of Neurology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Leonid Churilov
- Melbourne Medical School, The Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Yifeng Ling
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Yiran Zhang
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Lumeng Yang
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Mark Parsons
- University of New South Wales South Western Sydney Clinical School, Ingham Institute for Applied Medical Research, Department of Neurology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Qiang Dong
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| |
Collapse
|
4
|
Rogalewski A, Klein N, Friedrich A, Kitsiou A, Schäbitz M, Zuhorn F, Gess B, Berger B, Klingebiel R, Schäbitz WR. Functional long-term outcome following endovascular thrombectomy in patients with acute ischemic stroke. Neurol Res Pract 2024; 6:2. [PMID: 38297374 PMCID: PMC10832147 DOI: 10.1186/s42466-023-00301-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 12/11/2023] [Indexed: 02/02/2024] Open
Abstract
Endovascular thrombectomy (EVT) is the most effective treatment for acute ischemic stroke caused by large vessel occlusion (LVO). Yet, long-term outcome (LTO) and health-related quality of life (HRQoL) in these patients have rarely been addressed, as opposed to modified Rankin scale (mRS) recordings. We analysed demographic data, treatment and neuroimaging parameters in 694 consecutive stroke patients in a maximum care hospital. In 138 of these patients with respect on receipt of written informed consent, LTO and HRQoL were collected over a period of 48 months after EVT using a standardised telephone survey (median 2.1 years after EVT). Age < 70 years (OR 4.82), lower NIHSS on admission (OR 1.11), NIHSS ≤ 10 after 24 h (OR 11.23) and complete recanalisation (mTICI3) (OR 7.79) were identified as independent predictors of favourable LTO. Occurrence of an infection requiring treatment within the first 72 h was recognised as a negative predictor for good long-term outcome (OR 0.22). Patients with mRS > 2 according to the telephone survey more often had complaints regarding mobility, self-care, and usual activity domains of the HRQoL. Our results underline a sustainable positive effect of effective EVT on the quality of life in LVO stroke. Additionally, predictive parameters of outcome were identified, that may support clinical decision making in LVO stroke.
Collapse
Affiliation(s)
- Andreas Rogalewski
- Department of Neurology, Evangelisches Klinikum Bethel, University Hospital OWL of the University Bielefeld, Campus Bielefeld-Bethel, Schildescher Str. 99, 33611, Bielefeld, Germany.
- Department of Neurology, Sankt Elisabeth Hospital Gütersloh, Catholic Hospital Association of East Westfalia (KHO), Gütersloh, Germany.
| | - Nele Klein
- Department of Neurology, Evangelisches Klinikum Bethel, University Hospital OWL of the University Bielefeld, Campus Bielefeld-Bethel, Schildescher Str. 99, 33611, Bielefeld, Germany
- Department of Neurology, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Anja Friedrich
- Department of Psychology, Bielefeld University, Bielefeld, Germany
| | - Alkisti Kitsiou
- Department of Neurology, Evangelisches Klinikum Bethel, University Hospital OWL of the University Bielefeld, Campus Bielefeld-Bethel, Schildescher Str. 99, 33611, Bielefeld, Germany
| | - Marie Schäbitz
- Department of Neurology, Evangelisches Klinikum Bethel, University Hospital OWL of the University Bielefeld, Campus Bielefeld-Bethel, Schildescher Str. 99, 33611, Bielefeld, Germany
| | - Frédéric Zuhorn
- Department of Neurology, Evangelisches Klinikum Bethel, University Hospital OWL of the University Bielefeld, Campus Bielefeld-Bethel, Schildescher Str. 99, 33611, Bielefeld, Germany
| | - Burkhard Gess
- Department of Neurology, Evangelisches Klinikum Bethel, University Hospital OWL of the University Bielefeld, Campus Bielefeld-Bethel, Schildescher Str. 99, 33611, Bielefeld, Germany
- Department of Neurology, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Björn Berger
- Department of Neuroradiology, Evangelisches Klinikum Bethel EvKB, University Hospital OWL of the University Bielefeld, Campus Bielefeld-Bethel, Bielefeld, Germany
| | - Randolf Klingebiel
- Department of Neuroradiology, Evangelisches Klinikum Bethel EvKB, University Hospital OWL of the University Bielefeld, Campus Bielefeld-Bethel, Bielefeld, Germany
| | - Wolf-Rüdiger Schäbitz
- Department of Neurology, Evangelisches Klinikum Bethel, University Hospital OWL of the University Bielefeld, Campus Bielefeld-Bethel, Schildescher Str. 99, 33611, Bielefeld, Germany
| |
Collapse
|
5
|
Qiu K, Jia ZY, Cao Y, Zhao LB, Zu Q, Shi HB, Liu S. Emergency admission plasma D-dimer: a novel predictor for symptomatic intracranial hemorrhage after thrombectomy in acute ischemic stroke. J Neurointerv Surg 2023; 15:e375-e380. [PMID: 36604175 DOI: 10.1136/jnis-2022-019719] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 12/23/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Symptomatic intracranial hemorrhage (sICH) is a common and severe complication in patients with acute ischemic stroke (AIS) after treatment with thrombectomy. OBJECTIVE To explore the ability of admission plasma D-dimer levels to predict sICH after thrombectomy. METHODS Between February 2018 and August 2021, consecutive patients with AIS who underwent thrombectomy at our single comprehensive stroke center were retrospectively enrolled. sICH was defined according to the criterion of the Heidelberg Bleeding Classification. Logistic regression analysis was performed to determine the risk factors of sICH. The overall discriminative ability of D-dimer levels in predicting sICH was evaluated by adopting a receiver operating characteristic (ROC) curve. RESULTS Of the 395 enrolled patients, 48 (12.2%) had sICH. Patients with sICH were older (72.9 vs 69.3 years, P=0.037), more often female (62.5% vs 45.5%, P=0.027), had higher D-dimer levels (2.70 vs 0.74 mg/L, P<0.001), higher National Institutes of Health Stroke Scale score (20 vs 15, P<0.001), lower Alberta Stroke Program Early CT Score (8 vs 9, P<0.001), a higher proportion of internal carotid artery occlusions (56.2% vs 30.3%, P<0.001), and less commonly had large-artery atherosclerosis stroke etiology (12.5% vs 32.3%, P=0.010) than patients without sICH. After adjustment for potential confounders, D-dimer levels (adjusted OR=2.45, 95% CI 1.75 to 3.43, P<0.001) remained significantly associated with sICH. Based on the ROC, the D-dimer as a predictor for predicting sICH, presented with a specificity of 86.2%, a negative predictive value of 94.6%, and an area under the curve of 0.774. CONCLUSION Elevated admission D-dimer levels are an independent predictor of sICH in patients with AIS after thrombectomy.
Collapse
Affiliation(s)
- Kai Qiu
- Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Zhen Yu Jia
- Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Yuezhou Cao
- Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Lin-Bo Zhao
- Department of Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, JiangSu, China
| | - Qingquan Zu
- Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Hai-Bin Shi
- Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Sheng Liu
- Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| |
Collapse
|
6
|
Eriksson H, Nordanstig A, Rentzos A, Zelano J, Redfors P. Risk of poststroke epilepsy after reperfusion therapies: A national cohort study. Eur J Neurol 2023; 30:1303-1311. [PMID: 36692236 DOI: 10.1111/ene.15695] [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: 09/22/2022] [Revised: 01/13/2023] [Accepted: 01/18/2023] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND PURPOSE The risk of poststroke epilepsy (PSE) after endovascular treatment (EVT) is not well characterized. In this nationwide study, we assessed the risk of PSE after EVT and identified associated predictors. METHODS We included all individuals (n = 3319) treated with EVT (±intravenous thrombolysis [IVT]) between 2015 and 2019 in the Swedish National Quality Register for EVT. Two control groups were identified from the Swedish Stroke Register: the first treated with IVT alone (n = 3132) and the second with no treatment (n = 3184), both matched for age, sex, stroke severity, and time of stroke. RESULTS PSE developed in 7.9% (n = 410). The survival-adjusted 2-year risk was 6.5% (95% confidence interval [CI] = 5.28-7.70) after EVT, 10.0% (95% CI = 8.25-11.75) after IVT, and 12.3% after no revascularization (95% CI = 10.33-14.25). The hazard ratio (HR) of PSE after EVT was almost half compared to no treatment (HR = 0.51, 95% CI = 0.41-0.64). The risk of PSE after EVT was lower compared to no treatment in a multivariable Cox model that adjusted for age, sex, hemicraniectomy, and stroke severity (HR = 0.76, 95% CI = 0.60-0.96). Multivariable predictors of PSE after EVT were large infarction on computed tomography Day 1, high posttreatment National Institutes of Health Stroke Scale score, and need of assistance 3 months after stroke. IVT before EVT was associated with a lower risk of PSE (HR = 0.66, 95% CI = 0.46-0.94). CONCLUSIONS This nationwide study identified a reduced risk of PSE after EVT. Markers of severe infarction after EVT were associated with PSE, whereas IVT given before EVT was protective.
Collapse
Affiliation(s)
- Hanna Eriksson
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Wallenberg Center for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden
| | - Annika Nordanstig
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Alexandros Rentzos
- Department of Interventional and Diagnostic Neuroradiology, Institute of Clinical Sciences, Sahlgrenska University Hospital, Gothenburg, Sweden.,Department of Radiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Johan Zelano
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Wallenberg Center for Molecular and Translational Medicine, University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Petra Redfors
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden.,Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| |
Collapse
|
7
|
Liu F, Chen D, Fu Y, Wang H, Liu L. Incidence and association of seizures in stroke patients following endovascular treatment: A systematic review and meta-analysis. Eur J Neurol 2023; 30:134-143. [PMID: 36094786 DOI: 10.1111/ene.15564] [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: 06/14/2022] [Revised: 09/02/2022] [Accepted: 09/06/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE Post-stroke seizures (PSSs) are some of the most common complications of stroke and are associated with poor outcomes in patients. Endovascular treatment (EVT) is the standard of care for patients with acute ischaemic stroke related large-vessel occlusion. However, whether EVT increases the risk of PSSs remains controversial; the association between PSSs and EVT is poorly understood. METHODS PubMed, Embase and the Cochrane Library were searched for relevant studies published from 1995 to 6 December 2021. The overall incidence of PSSs in patients treated with EVT and the separate incidence for all included studies in each subgroup, stratified by the type of treatment or time of onset, were calculated. The pooled odds ratio and confidence interval were calculated to quantify the effects of EVT on PSS occurrence. RESULTS In all, 946 studies were screened and 16 articles were included, with a total sample size of 12,664 patients; 7836 patients received EVT, of whom 460 had PSS. The pooled incidence of PSS after EVT was 5.8%, which was similar to patients treated with mechanical thrombectomy (5.3%), intra-arterial thrombolysis (6.8%) or bridging therapy (5.4%). The cumulative incidence of post-stroke epilepsy (6.0%) was almost twice that of acute symptomatic seizures (3.6%). The pooled odds ratio for the relationship between EVT and PSS was 1.91 (95% confidence interval 0.98-3.73). CONCLUSIONS The cumulative incidence of stroke patients treated with EVT who developed seizures was 5.8%, and EVT was non-significantly associated with the occurrence of seizures after stroke.
Collapse
Affiliation(s)
- Fangzhou Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Deng Chen
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Yaoqi Fu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Haijiao Wang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| | - Ling Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, China
| |
Collapse
|
8
|
Sluis WM, Hinsenveld WH, Goldhoorn RJB, Potters LH, Bruggeman AAE, van der Hoorn A, Bot JCJ, van Oostenbrugge RJ, Lingsma HF, Hofmeijer J, van Zwam WH, BLM Majoie C, Bart van der Worp H. Timing and causes of death after endovascular thrombectomy in patients with acute ischemic stroke. Eur Stroke J 2022; 8:215-223. [PMID: 37021180 PMCID: PMC10069200 DOI: 10.1177/23969873221143210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Accepted: 11/16/2022] [Indexed: 12/15/2022] Open
Abstract
Introduction: Endovascular thrombectomy (EVT) increases the chance of good functional outcome after ischemic stroke caused by a large vessel occlusion, but the risk of death in the first 90 days is still considerable. We assessed the causes, timing and risk factors of death after EVT to aid future studies aiming to reduce mortality. Patients and methods: We used data from the MR CLEAN Registry, a prospective, multicenter, observational cohort study of patients treated with EVT in the Netherlands between March 2014, and November 2017. We assessed causes and timing of death and risk factors for death in the first 90 days after treatment. Causes and timing of death were determined by reviewing serious adverse event forms, discharge letters, or other written clinical information. Risk factors for death were determined with multivariable logistic regression. Results: Of 3180 patients treated with EVT, 863 (27.1%) died in the first 90 days. The most common causes of death were pneumonia (215 patients, 26.2%), intracranial hemorrhage (142 patients, 17.3%), withdrawal of life-sustaining treatment because of the initial stroke (110 patients, 13.4%) and space-occupying edema (101 patients, 12.3%). In total, 448 patients (52% of all deaths) died in the first week, with intracranial hemorrhage as most frequent cause. The strongest risk factors for death were hyperglycemia and functional dependency before the stroke and severe neurological deficit at 24–48 h after treatment. Discussion and conclusion: When EVT fails to decrease the initial neurological deficit, strategies to prevent complications like pneumonia and intracranial hemorrhage after EVT could improve survival, as these are often the cause of death.
Collapse
Affiliation(s)
- Wouter M Sluis
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Wouter H Hinsenveld
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Robert-Jan B Goldhoorn
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Lianne H Potters
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Agnetha AE Bruggeman
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Anouk van der Hoorn
- Department of Radiology, Medical Imaging Center (MIC), University Medical Center Groningen, Groningen, The Netherlands
| | - Joseph CJ Bot
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location VUmc, Amsterdam, The Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Hester F Lingsma
- Public Health Department, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Jeannette Hofmeijer
- Department of Neurology, Rijnstate Hospital, Arnhem, and Department of Clinical Neurophysiology, University of Twente, Enschede, The Netherlands
| | - Wim H van Zwam
- Department of Radiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Charles BLM Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| |
Collapse
|
9
|
Junttola U, Lahtinen S, Isokangas JM, Hietanen S, Vakkala M, Kaakinen T, Liisanantti J. Long-term mortality after endovascular thrombectomy for stroke. J Stroke Cerebrovasc Dis 2022; 31:106832. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 09/28/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022] Open
|
10
|
Wang X, Wang X, Ma J, Jia M, Wu L, Li W, Li C, Wu C, Ren C, Chen X, Zhao W, Ji X. Association between the time of day at stroke onset and functional outcome of acute ischemic stroke patients treated with endovascular therapy. J Cereb Blood Flow Metab 2022; 42:2191-2200. [PMID: 35791272 PMCID: PMC9670006 DOI: 10.1177/0271678x221111852] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
To investigate the association between time-of-day of stroke onset and functional outcome in patients with acute ischemic stroke(AIS) treated with endovascular thrombectomy(EVT). AIS patients treated with EVT between January 2013 and December 2018 were recruited and divided them into four 6-h interval groups according to the time-of-day of stroke onset. A total of 438 patients were enrolled, 3-month favorable outcome were achieved in 58.6%, 43.7%, 36.6%, and 30.5% of patients in the 00:00-06:00, 06:00-12:00, 12:00-18:00, and 18:00-24:00 groups, respectively (adjusted OR 0.61, 95% CI 0.40-0.93; p = 0.020). Compared with the 18:00-24:00 interval, patients in the 00:00-06:00 interval (adjusted OR 4.01, 95%CI 1.02-15.80, p = 0.047) and the 06:00-12:00 interval (adjusted OR 3.24, 95% CI 1.09-9.64, p = 0.034) were more likely to achieve favorable outcome. The time-of-day of stroke onset was not associated with 3-month mortality (adjusted p = 0.829), symptomatic intracerebral hemorrhage (sICH, adjusted p = 0.296), or early successful recanalization (adjusted p = 0.074). In conclusion, in AIS patients treated with EVT, those onsets either between 00:00 and 06:00 or between 06:00 and 12:00 appeared to be associated with a higher proportion of favorable outcomes at 3 months, but the time-of-day at stroke onset was not associated with the incidence of sICH, rate of early successful recanalization, or 3-month mortality.
Collapse
Affiliation(s)
- Xian Wang
- Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
| | - Xiaoyin Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jin Ma
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Milan Jia
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Longfei Wu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Weili Li
- Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China
| | - Chuanhui Li
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chuanjie Wu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Changhong Ren
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xin Chen
- Department of General Surgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wenbo Zhao
- Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China.,Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xunming Ji
- Beijing Institute of Brain Disorders, Laboratory of Brain Disorders, Ministry of Science and Technology, Collaborative Innovation Center for Brain Disorders, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
11
|
Ždraljević M, Pekmezović T, Stanarčević P, Vukašinović I, Berisavac I, Ercegovac M, Vitošević F, Nestorović D, Cvetić V, Padjen V, Stefanović-Budimkić M, Medjedović TŠ, Jovanović DR. Atrial fibrillation is associated with poor long-term outcome after mechanical thrombectomy for anterior large vessel occlusion stroke. J Stroke Cerebrovasc Dis 2022; 31:106755. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 08/07/2022] [Accepted: 09/04/2022] [Indexed: 11/30/2022] Open
|
12
|
Zhao W, Liu R, Yu W, Wu L, Wu C, Li C, Li S, Chen J, Song H, Hua Y, Ma Q, Ji X. Elevated pulsatility index is associated with poor functional outcome in stroke patients treated with thrombectomy: A retrospective cohort study. CNS Neurosci Ther 2022; 28:1568-1575. [PMID: 35707901 PMCID: PMC9437234 DOI: 10.1111/cns.13888] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 05/22/2022] [Accepted: 05/25/2022] [Indexed: 01/20/2023] Open
Abstract
Aims To evaluate pulsatility index (PI) in patients with acute ischemic stroke (AIS) who underwent endovascular thrombectomy (EVT). Methods Patients were retrospectively recruited if their stroke were secondary to middle cerebral artery (MCA) occlusion and achieved full recanalization after EVT. Transcranial Doppler was performed within 24‐hour post‐EVT. The primary outcome was correlation between the MCA‐PI on the affected side and 3‐month functional outcome, with modified Rankin scale (mRS) ≥5 indicated extremely poor functional outcomes. Results Totally, 170 patients were included. High MCA‐PI was positively related to the 3‐month mRS score (r = 0.288, p < 0.001). The highest quartile of the MCA‐PI was associated with a high incidence of extremely poor functional outcomes (adjusted OR, 13.33; 95% CI, 2.65–67.17; adjusted p = 0.002) after adjusting for confounding factors. The predictive capacity of the MCA‐PI for extremely poor functional outcomes was good (area under the curve, 0.755; 95% CI, 0.655–0.854; p < 0.001), and its cutoff value for predicting extremely poor outcomes was 1.04, with a sensitivity of 65.6% and specificity of 78.3%. Conclusion The MCA‐PI on the affected side is a prognostic biomarker in patients who have undergone stroke thrombectomy. An elevated MCA‐PI may be prognostically valuable for predicting extremely poor functional outcomes.
Collapse
Affiliation(s)
- Wenbo Zhao
- Department of Neurology, Xuanwu Hospital, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ran Liu
- Department of Vascular Ultrasound, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wantong Yu
- Department of Neurology, Xuanwu Hospital, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China
| | - Longfei Wu
- Department of Neurology, Xuanwu Hospital, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China
| | - Chuanjie Wu
- Department of Neurology, Xuanwu Hospital, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China
| | - Chuanhui Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Sijie Li
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jian Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Haiqing Song
- Department of Neurology, Xuanwu Hospital, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China
| | - Yang Hua
- Department of Vascular Ultrasound, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qingfeng Ma
- Department of Neurology, Xuanwu Hospital, Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China
| | - Xunming Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
13
|
Beyeler M, Weber L, Kurmann CC, Piechowiak EII, Mosimann PJ, Zibold F, Meinel TR, Branca M, Goeldlin M, Pilgram-Pastor SM, Grunder L, Arnold M, Seiffge D, Meier R, Heldner MR, Dobrocky T, Mordasini P, Gralla J, Fischer U, Kaesmacher J. Association of reperfusion success and emboli in new territories with long term mortality after mechanical thrombectomy. J Neurointerv Surg 2022; 14:326-332. [PMID: 33911015 DOI: 10.1136/neurintsurg-2021-017422] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 04/13/2021] [Accepted: 04/14/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND The degree of reperfusion is the most important modifiable predictor of 3 month functional outcome and mortality in ischemic stroke patients treated with mechanical thrombectomy. Whether the beneficial effect of reperfusion also leads to a reduction in long term mortality is unknown. METHODS Patients undergoing mechanical thrombectomy between January 2010 and December 2018 were included. The post-thrombectomy degree of reperfusion and emboli in new territories were core laboratory adjudicated. Reperfusion was evaluated according to the expanded Thrombolysis in Cerebral Infarction (eTICI) scale. Vital status was obtained from the Swiss population register. Adjusted hazard ratios (aHRs) using time split Cox regression models were calculated. Subgroup analyses were performed in patients with borderline indications. RESULTS Our study included 1264 patients (median follow-up per patient 2.5 years). Patients with successful reperfusion had longer survival times, attributable to a lower hazard of death within 0-90 days and for >90 days to 2 years (aHR 0.34, 95% CI 0.26 to 0.46; aHR 0.37, 95% CI 0.22 to 0.62). This association was homogeneous across all predefined subgroups (p for interaction >0.05). Among patients with successful reperfusion, a significant difference in the hazard of death was observed between eTICI2b50 and eTICI3 (aHR 0.51, 95% CI 0.33 to 0.79). Emboli in new territories were present in 5% of patients, and were associated with increased mortality (aHR 2.3, 95% CI 1.11 to 4.86). CONCLUSION Successful, and ideally complete, reperfusion without emboli in new territories is associated with a reduction in long term mortality in patients treated with mechanical thrombectomy, and this was evident across several subgroups.
Collapse
Affiliation(s)
- Morin Beyeler
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Loris Weber
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Christoph C Kurmann
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Eike Immo I Piechowiak
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Pascal J Mosimann
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
- Department of Diagnostic and Interventional Neuroradiology, Alfried-Krupp Krankenhaus, Essen, Nordrhein-Westfalen, Germany
| | - Felix Zibold
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Thomas Raphael Meinel
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Mattia Branca
- Institute of Social and Preventive Medicine, CTU Bern, University of Bern, Switzerland, Bern, Switzerland
| | - Martina Goeldlin
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Sara M Pilgram-Pastor
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Lorenz Grunder
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - David Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Raphael Meier
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
- Support Center for Advanced Neuroimaging, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Tomas Dobrocky
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Johannes Kaesmacher
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| |
Collapse
|
14
|
Hong L, Lin L, Li G, Yang J, Geng Y, Lou M, Parsons M, Cheng X, Dong Q. Identification of embolic stroke in patients with large vessel occlusion: The Chinese embolic stroke score, CHESS. CNS Neurosci Ther 2021; 28:531-539. [PMID: 34559949 PMCID: PMC8928917 DOI: 10.1111/cns.13729] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2021] [Revised: 08/17/2021] [Accepted: 08/29/2021] [Indexed: 11/28/2022] Open
Abstract
Aims The aim of the study was to develop a simple and objective score using clinical variables and quantified perfusion measures to identify embolic stroke with large vessel occlusions. Methods Eligible patients from five centers participating in the International Stroke Perfusion Imaging Registry were included in this study. Patients were split into a derivation cohort (n = 213) and a validation cohort (n = 116). A score was developed according to the coefficients of independent predictors of embolic stroke from stepwise logistic regression model in the derivation cohort. The performance of the score was validated by assessing its discrimination and calibration. Results The independent predictors of embolic stroke made up the Chinese Embolic Stroke Score (CHESS). There were: history of atrial fibrillation (3 points), non‐hypertension history (2 points), and delay time>6 s volume/delay time>3 s volume on perfusion imaging ≥0.23 (2 points). The AUC of CHESS in the derivation cohort and validation cohort were 0.87 and 0.79, respectively. Patients with a CHESS of 0 could be identified as low‐risk of embolic stroke, with a CHESS of 2–4 could be identified as medium‐risk and with a CHESS of 5–7 could be regarded as high‐risk. The observed rate of embolic stroke of each risk group was well‐calibrated with the predicted rate. Conclusion CHESS could reliably and independently identify embolic stroke as the cause of large vessel occlusion.
Collapse
Affiliation(s)
- Lan Hong
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Longting Lin
- South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia
| | - Gang Li
- Department of Neurology, Shanghai East Hospital, Tongji University, Shanghai, China
| | - Jianhong Yang
- Department of Neurology, Ningbo First Hospital, Ningbo, China
| | - Yu Geng
- Department of Neurology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Min Lou
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Mark Parsons
- South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia
| | - Xin Cheng
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Qiang Dong
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| |
Collapse
|
15
|
Parameshwaran B, Cordato D, Parsons M, Cheung A, Manning N, Wenderoth J, Cappelen-Smith C. The Benefit of Endovascular Thrombectomy for Stroke on Functional Outcome Is Sustained at 12 Months. Cerebrovasc Dis Extra 2021; 11:81-86. [PMID: 34469885 PMCID: PMC8460944 DOI: 10.1159/000517929] [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: 03/31/2021] [Accepted: 06/09/2021] [Indexed: 11/19/2022] Open
Abstract
Background and Purpose The short-term benefits of endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) have been widely documented, yet there is limited evidence to show that this is sustained in the long term. We aimed to determine whether the benefit of EVT on functional outcome at 3 months is maintained at 12 months and the factors correlating with functional independence and quality of life. Methods Data for analysis came from a prospective registry of consecutive patients undergoing EVT at a single Comprehensive Stroke Center (Oct 2018–Sep 2019). A phone interview was conducted for 12-month patient outcomes. Functional outcome was assessed by the modified Rankin Scale (mRS). Quality of life was determined by return to usual place of residence, work, or driving and calculation of a health utility index using the European Quality of Life-5 Dimensions questionnaire (EQ-5D-3L). Results Of the 151 patients who underwent EVT during the study period, 12-month follow-up was available for 145 (96%). At 12 months, 44% (n = 64) of patients were functionally independent (mRS 0–2) compared to 48% at 3 months. Mortality at 12 months was 26% compared to 17% at 3 months. Significant predictors of functional independence at 12 months were younger age and lower baseline National Institutes of Health Stroke Scale. Better quality of life significantly correlated with return to usual place of residence and driving. Conclusion Three-month functional independence was sustained at 12 months, indicating that EVT remains beneficial for patients with AIS in the longer term.
Collapse
Affiliation(s)
- Balaki Parameshwaran
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, New South Wales, Australia, .,South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia,
| | - Dennis Cordato
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Mark Parsons
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Andrew Cheung
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia.,Department of Interventional Neuroradiology, Liverpool Hospital, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Nathan Manning
- Department of Interventional Neuroradiology, Liverpool Hospital, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,The Florey Institute of Neuroscience, Melbourne, Victoria, Australia
| | - Jason Wenderoth
- Department of Interventional Neuroradiology, Liverpool Hospital, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Cecilia Cappelen-Smith
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| |
Collapse
|
16
|
Zhao W, Xu J, Li S, Liu G, Wu L, Li C, Wu C, Ren C, Chen J, Duan J, Wang R, Song H, Ma Q, Ji X. Low-dose tirofiban is associated with reduced in-hospital mortality in cardioembolic stroke patients treated with endovascular thrombectomy. J Neurol Sci 2021; 427:117539. [PMID: 34153842 DOI: 10.1016/j.jns.2021.117539] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/24/2021] [Accepted: 06/11/2021] [Indexed: 11/29/2022]
Abstract
BACKGROUND AND PURPOSE Whether tirofiban is safe and effective in cardioembolic stroke patients treated with endovascular thrombectomy (EVT) remains unknown; this study evaluated the safety and efficacy of low-dose tirofiban in this patients population. METHODS This study was a prospective registry study. Patients with cardioembolic stroke undergoing EVT from January 2013 to December 2020 were treated with EVT alone or EVT plus low-dose tirofiban. The primary outcome was symptomatic intracerebral hemorrhage (sICH) prior to discharge. The secondary outcomes included reocclusion, in-hospital mortality, and 3-month functional outcomes. RESULTS Overall, 288 patients were recruited and 117 received low-dose tirofiban; 137 patients (47.6%) experienced ICH, 42 patients (14.6%) were sICH, and 23 patients (8%) were fatal ICH. Thirteen patients (11.1%) receiving tirofiban and 29 patients (17.0%) not receiving tirofiban experienced sICH (p = 0.167). Reocclusion occurred in nine patients (7.7%) receiving tirofiban and 15 patients (8.8%) not receiving tirofiban (p = 0.745). The rates of hernia (6.8% versus 20.5%) and decompressive craniectomy (2.6% versus 11.7%) were significantly lower in patients receiving tirofiban (p < 0.01). At 3-month follow-up, functional independence was achieved in 39 patients(33.3%) receiving tirofiban and 43 patients (25.1%) not receiving tirofiban (p = 0.131). Tirofiban was associated with lower odds of in-hospital mortality (3.4% versus 12.3%; adjusted odds ratio, 0.16; 95% confidence interval, 0.03-0.81; adjusted p = 0.027). CONCLUSIONS In patients with cardioembolic stroke undergoing EVT, tirofiban is not associated with higher sICH, it seems to lead to lower odds of in-hospital death. Further investigations are needed to confirm these results and to determine the optimal treatment protocols of tirofiban.
Collapse
Affiliation(s)
- Wenbo Zhao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China; Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China; Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China.
| | - Jiali Xu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Sijie Li
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Guiyou Liu
- Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China
| | - Longfei Wu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chuanhui Li
- Clinical Stroke Research Unit, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chuanjie Wu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Changhong Ren
- Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China
| | - Jian Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jiangang Duan
- Department of Emergency, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ruixian Wang
- Department of Neurology, Tianjin Beichen Traditional Chinese Medicine Hospital, Tianjin, China
| | - Haiqing Song
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Qingfeng Ma
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China; Clinical Stroke Research Unit, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xunming Ji
- Beijing Institute for Brain Disorders, Capital Medical University, Beijing, China; Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.
| |
Collapse
|
17
|
Wu L, Zhang D, Chen J, Sun C, Ji K, Li W, Zhao W, Li C, Wu C, Li M, Wu D, Ji X. Long-term outcome of endovascular therapy for acute basilar artery occlusion. J Cereb Blood Flow Metab 2021; 41:1210-1218. [PMID: 32955959 PMCID: PMC8142131 DOI: 10.1177/0271678x20958587] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The long-term functional outcome of acute basilar artery occlusion (BAO) patients who received modern endovascular therapy (EVT) is unclear. We sought to assess the long-term functional outcome of BAO patients treated with EVT and determine the prognostic factors associated with favorable outcome. We enrolled consecutive BAO patients who received EVT between December 2012 and December 2018 in this observational study. Baseline characteristics and outcomes were presented. Multivariable logistic regression analysis was performed to identify the prognostic factors associated with long-term outcome. Among the 177 BAO patients included in this study, 80 patients (45.2%) obtained favorable outcome and 97 patients (54.8%) had unfavorable outcome at long-term follow-up with a median observation time of 12 months (interquartile range, 3-19). A total of 67 patients (37.9%) died. National Institutes of Health Stroke Scale (NIHSS), posterior circulation Alberta Stroke Program Early Computed Tomography Score (pc-ASPECTS), time from stroke onset to recanalization, and recanalization condition were identified as independent predictors for long-term outcome. Over 40% of BAO patients who were treated with modern EVT achieved favorable outcome at long-term follow-up. NIHSS, pc-ASPECTS, time from stroke onset to recanalization, and recanalization condition were identified as independent prognostic factors of long-term outcome.
Collapse
Affiliation(s)
- Longfei Wu
- Department of Neurology and China-America Institute of Neuroscience, Capital Medical University, Beijing, China
| | - Da Zhang
- Department of Radiology, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Jian Chen
- Department of Neurosurgery, Capital Medical University, Beijing, China
| | - Chenghe Sun
- Department of Neurology and China-America Institute of Neuroscience, Capital Medical University, Beijing, China
| | - Kangxiang Ji
- Department of Neurology and China-America Institute of Neuroscience, Capital Medical University, Beijing, China
| | - Weili Li
- Department of Neurology and China-America Institute of Neuroscience, Capital Medical University, Beijing, China
| | - Wenbo Zhao
- Department of Neurology and China-America Institute of Neuroscience, Capital Medical University, Beijing, China
| | - Chuanhui Li
- Department of Emergency, Capital Medical University, Beijing, China
| | - Chuanjie Wu
- Department of Neurology and China-America Institute of Neuroscience, Capital Medical University, Beijing, China
| | - Ming Li
- Department of Neurology and China-America Institute of Neuroscience, Capital Medical University, Beijing, China
| | - Di Wu
- Department of Neurology and China-America Institute of Neuroscience, Capital Medical University, Beijing, China
| | - Xunming Ji
- Department of Neurosurgery, Capital Medical University, Beijing, China
| |
Collapse
|
18
|
Wang C, Zhang X, Wu Y, Fu L, Fang Q. Clinical Predictors for Functional Independence After Tissue-Window Guided Endovascular Thrombectomy. World Neurosurg 2020; 146:e947-e954. [PMID: 33217590 DOI: 10.1016/j.wneu.2020.11.047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Revised: 11/08/2020] [Accepted: 11/09/2020] [Indexed: 11/29/2022]
Abstract
OBJECTIVE Thrombectomy increases the survival rate of acute ischemic stroke patients corresponding to large vessel occlusion. This study aimed to determine clinical predictors for good outcomes in patients subjected to tissue window guided thrombectomy. METHODS This study was performed at the stroke center of the First Affiliated Hospital of SooChow University. Baseline characteristics and outcomes were retrospectively collected, 90 days after endovascular thrombectomy. Collection was done within 6-24 hours after a patient was last seen in good condition. Binary logistic regression was used to establish the clinical predictors for functional independence. Receiver operator characteristic curve analysis was performed to determine cutoff values for outcome predictors. P value <0.05 was considered to be statistically significant. RESULTS Forty-seven patients were enrolled in this study. Among them, 13 (27.7%) had last presenting stroke, 24 (51.1%) had wake-up stroke, and 10 (21.3%) had daytime unknown stroke onset. The median initial National Institutes of Health Stroke Scale (NIHSS) score, infarct core volume, and ischemic penumbra volume were 15 (interquartile range [IQR] 11-18), 20 (IQR 8-36) mL, and 115 (IQR 81-176) mL, respectively. Multivariate regression analysis showed that patients with a lower initial NIHSS score, smaller ischemic penumbra, and no hemorrhagic transformation were more likely to have good outcomes. As shown by the receiver operator characteristic curves, the optimal thresholds of initial NIHSS score, ischemic penumbra, and infarct core were 14.5 (AUC: 0.867; P < 0.001), 109 mL (AUC: 0.841; P < 0.001), and 12.5 mL (AUC: 0.681; P = 0.036), respectively. CONCLUSIONS A lower initial NIHSS score, smaller ischemic penumbra, and lack of hemorrhagic transformation are significant independent predictors for good outcomes after a tissue-window based thrombectomy.
Collapse
Affiliation(s)
- Can Wang
- Neurology Department, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Xianxian Zhang
- Neurology Department, Yancheng Third People's Hospital, Yancheng, Jiangsu, China
| | - Yaya Wu
- Neurology Department, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Le Fu
- Neurology Department, The First Affiliated Hospital of Soochow University, Suzhou, China
| | - Qi Fang
- Neurology Department, The First Affiliated Hospital of Soochow University, Suzhou, China.
| |
Collapse
|
19
|
Lekoubou A, Fox J, Ssentongo P. Incidence and Association of Reperfusion Therapies With Poststroke Seizures: A Systematic Review and Meta-Analysis. Stroke 2020; 51:2715-2723. [PMID: 32772682 DOI: 10.1161/strokeaha.119.028899] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE We performed a systematic review and meta-analysis to assess the incidence and risk of seizures following acute stroke reperfusion therapy (intravenous thrombolysis [IVT] with r-tPA [recombinant tissue-type plasminogen activator], mechanical thrombectomy or both). METHODS We searched major databases (MEDLINE, SCOPUS, and Cochrane Library) for articles published between 1995 and October 28, 2019. The primary outcome was the overall and treatment specific pooled incidence of poststroke seizures (PSS) following acute reperfusion therapy. We also computed the pooled incidence of early poststroke seizures and late poststroke seizures separately for all studies. We derived the risk of PSS associated with IVT in the pooled cohort of patients who received only IVT. The small number of studies (<3) that reported on the risk of PSS associated with mechanical thrombectomy alone or in combination with IVT did not allow us to compute an estimate of the risk of seizures associated with this therapy. RESULTS We identified 13 753 patients with stroke, of which 592 had seizures. The pooled incidence of PSS was 5.9 % (95% CI, 4.2%-8.2%). PSS incidence rates among patients with stroke treated with IVT, mechanical thrombectomy, and both were respectively 6.1% (95% CI, 3.6%-10.2%), 5.9% (95% CI, 4.1%-8.4%), and 5.8 % (95% CI, 3.0%-10.9%). The incidence of late PSS was 6.7% (95% CI, 4.01%-11.02%) and that of early PSS was 3.14% (95% CI, 2.05%-4.76%). The pooled odds ratio for the association between IVT and PSS was 1.24 (95% CI, 0.75-2.05). CONCLUSIONS The findings of this meta-analysis suggest that about one in 15 ischemic stroke patients treated with IVT, mechanical thrombectomy, or both develop seizures independently of the specific reperfusion treatment that they received.
Collapse
Affiliation(s)
- Alain Lekoubou
- Department of Neurology (A.L.), Penn State University, Hershey, PA.,Division of Epidemiology, Department of Public Health Sciences (A.L., P.S.), Penn State University, Hershey, PA
| | - Jonah Fox
- Department of Neurology, Medical University of South Carolina, Charleston (J.F.)
| | - Paddy Ssentongo
- Division of Epidemiology, Department of Public Health Sciences (A.L., P.S.), Penn State University, Hershey, PA
| |
Collapse
|
20
|
Ota T, Shigeta K, Inoue M, Matsumaru Y, Shiokawa Y, Hirano T. Long-Term Outcomes of Acute Endovascular Thrombectomy: Tokyo/tama-Registry of Acute Endovascular Thrombectomy (TREAT). World Neurosurg 2020; 142:e271-e277. [PMID: 32622064 DOI: 10.1016/j.wneu.2020.06.209] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2020] [Revised: 06/24/2020] [Accepted: 06/25/2020] [Indexed: 11/16/2022]
Abstract
OBJECTIVE Mechanical thrombectomy (MT) is the recommended treatment for patients with acute ischemic stroke due to large cerebral vessel occlusion (LVO). However, few studies have investigated long-term outcomes after MT. The aim of this study was to investigate functional outcomes at long-term follow-up (1 year after MT) in patients undergoing MT for anterior circulation LVO in real-world clinical practice. METHODS This was a retrospective and prospective observational study using data from TREAT (Tokyo/tama-Registry of Acute Endovascular Thrombectomy), a multicenter registry of MT for acute LVO in the Tokyo metropolitan area. All subjects emergently transferred and treated with MT from January 2015 to December 2018 were selected. Patients' baseline characteristics and stroke-related parameters were evaluated. The primary outcome was the modified Rankin Scale (mRS) score 1 year after MT. The secondary outcomes were risk factors for long-term good outcomes (mRS score 0-2); transfer system (stroke bypass vs. secondary transfer) was also evaluated as a potential factor associated with good long-term outcomes. RESULTS A total of 162 cases (mean age 73.0 years, age range 30-97 years; 59.9% male) whose mRS scores at 1 year were obtained were analyzed. The median admission National Institutes of Health Stroke Scale (NIHSS) score was 17. Overall, 42.6% of the patients achieved functional independence at 1-year follow-up. Lower initial NIHSS score and mRS score 0-2 at 90 days were the independent predictors for good long-term outcomes. Stroke bypass was associated with a higher initial NIHSS score and mRS score 0 at 1 year. CONCLUSIONS A significant number of patients experience a good long-term outcome after MT.
Collapse
Affiliation(s)
- Takahiro Ota
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Fuchu, Japan.
| | - Keigo Shigeta
- Department of Neurosurgery, National Hospital Organization Disaster Medical Center, Tachikawa, Japan
| | - Masato Inoue
- Department of Neurosurgery, Center Hospital of the National Center for Global Health and Medicine, Shinjuku, Japan
| | - Yuji Matsumaru
- Division of Stroke Prevention and Treatment, Department of Neurosurgery, University of Tsukuba, Ibaraki, Japan
| | | | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Mitaka, Japan
| |
Collapse
|
21
|
Li W, Ding J, Sui X, Qi Z, Wu L, Sun C, Ji K, Ma Q, Ji X, Liu KJ. Prognosis and risk factors for reocclusion after mechanical thrombectomy. Ann Clin Transl Neurol 2020; 7:420-428. [PMID: 32154677 PMCID: PMC7187702 DOI: 10.1002/acn3.50999] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2019] [Revised: 12/29/2019] [Accepted: 01/31/2020] [Indexed: 11/12/2022] Open
Abstract
Objective This study evaluates reocclusion prognostic outcomes and explores reocclusion risk factors after mechanical thrombectomy (MT) in Chinese stroke patients. Methods Altogether, 614 patients with AIS with successful recanalization after MT were recruited in this study and divided into the reocclusion and the non‐reocclusion group depending on the 24‐h imaging results after MT. Differences between the two groups were compared including 24‐h and 7‐day National Institutes of Health Stroke Scale (NIHSS) scores, 90‐day modified Rankin scale(mRS) scores, good prognosis (mRS:0–2) rates, incidence of intracranial hemorrhage, and 90‐day mortality. Results Forty‐four (7.2%) patients experienced reocclusion within 24 h. Compared with the non‐reocclusion group, patients in the reocclusion group had higher 24‐h (15 vs. 13) and 7‐day (15 vs. 9) NIHSS scores, 90‐day mRS scores (4 vs. 3), and 90‐day mortality rates (34.1% vs. 18.6%); lower rates of good prognosis (13.6% vs. 9.3%); and a higher incidence of early neurological deterioration (36.4% vs. 14.7%). Age, internal carotid artery occlusion (ICA), intravenous thrombolysis (IVT), number of thrombectomy passes, stent implantation, and levels of D‐dimer (adjusted odds ratio and 95% confidence interval: 0.97, 0.94–0.99; 2.40, 1.10–5.23; 2.21, 1.05–4.66; 2.60, 1.04–6.47; 0.25, 0.09–0.67; and 1.06, 1.01–1.12, respectively) were independently associated with 24‐h reocclusion. Interpretation The prognosis of reocclusion after MT was poor. Timely evaluation of these factors including age, D‐dimer, ICA occlusion, IVT, number of passes, and stent implantation and appropriate intervention could reduce the incidence of reocclusion for Chinese stroke patients.
Collapse
Affiliation(s)
- Weili Li
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Jiayue Ding
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Xueqin Sui
- Department of General Medicine, Affiliated Hospital of Weifang Medical University, Weifang, Shandong Province, China
| | - Zhifeng Qi
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Longfei Wu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Chenghe Sun
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Kangxiang Ji
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Qingfeng Ma
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Xunming Ji
- Cerebrovascular Diseases Research Institute, Xuanwu Hospital, Capital Medical University, Beijing, China.,Advanced Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ke Jian Liu
- Department of Pharmaceutical Sciences, College of Pharmacy, University of New Mexico Health Sciences Center, Albuquerque, New Mexico
| |
Collapse
|
22
|
Intra- and extra-hospital improvement in ischemic stroke patients: influence of reperfusion therapy and molecular mechanisms. Sci Rep 2020; 10:3513. [PMID: 32103074 PMCID: PMC7044227 DOI: 10.1038/s41598-020-60216-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Accepted: 01/31/2020] [Indexed: 12/31/2022] Open
Abstract
Neuroprotective treatments in ischemic stroke are focused to reduce the pernicious effect of excitotoxicity, oxidative stress and inflammation. However, those cellular and molecular mechanisms may also have beneficial effects, especially during the late stages of the ischemic stroke. The objective of this study was to investigate the relationship between the clinical improvement of ischemic stroke patients and the time-dependent excitotoxicity and inflammation. We included 4295 ischemic stroke patients in a retrospective study. The main outcomes were intra and extra-hospital improvement. High glutamate and IL-6 levels at 24 hours were associated with a worse intra-hospital improvement (OR:0.993, 95%CI: 0.990–0.996 and OR:0.990, 95%CI: 0.985–0.995). High glutamate and IL-6 levels at 24 hours were associated with better extra-hospital improvement (OR:1.13 95%CI, 1.07–1.12 and OR:1.14, 95%CI, 1.09–1.18). Effective reperfusion after recanalization showed the best clinical outcome. However, the long term recovery is less marked in patients with an effective reperfusion. The variations of glutamate and IL6 levels in the first 24 hours clearly showed a relationship between the molecular components of the ischemic cascade and the clinical outcome of patients. Our findings suggest that the rapid reperfusion after recanalization treatment blocks the molecular response to ischemia that is associated with restorative processes.
Collapse
|
23
|
Zhao W, Wu C, Dornbos D, Li S, Song H, Wang Y, Ding Y, Ji X. Multiphase adjuvant neuroprotection: A novel paradigm for improving acute ischemic stroke outcomes. Brain Circ 2020; 6:11-18. [PMID: 32166195 PMCID: PMC7045534 DOI: 10.4103/bc.bc_58_19] [Citation(s) in RCA: 42] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2019] [Revised: 11/29/2019] [Accepted: 01/17/2020] [Indexed: 12/24/2022] Open
Abstract
While several large pivotal clinical trials recently revealed a substantial benefit of endovascular thrombectomy for acute ischemic stroke (AIS) caused by large-vessel occlusion, many patients still experience mediocre prognosis. Enlargement of the ischemic core, failed revascularization, incomplete reperfusion, distal embolization, and secondary reperfusion injury substantially impact the salvaging of brain tissue and the functional outcomes of AIS. Here, we propose novel concept of “Multiphase Adjuvant Neuroprotection” as a new paradigm that may help guide our search for adjunctive treatments to be used together with thrombectomy. The premise of multiphase adjuvant neuroprotection is based on the diverse and potentially nonoverlapping pathophysiologic mechanisms that are triggered before, during, and after thrombectomy therapies. Before thrombectomy, strategies should focus on preventing the growth of the ischemic core; during thrombectomy, improving recanalization while reducing distal embolization and maximizing reperfusion are of significant importance; after reperfusion, strategies should focus on seeking targets to reduce secondary reperfusion injury. The concept of multiphase adjuvant neuroprotection, wherein different strategies are employed throughout the various phases of clinical care, might provide a paradigm to minimize the final infarct size and improve functional outcome in AIS patients treated with thrombectomy. With the success of thrombectomy in selected AIS patients, there is now an opportunity to revisit stroke neuroprotection. Notably, if the underlying mechanisms of these neuroprotective strategies are identified, their role in the distinct phases will provide further avenues to improve patient outcomes of AIS.
Collapse
Affiliation(s)
- Wenbo Zhao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chuanjie Wu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - David Dornbos
- Department of Neurological Surgery, Semmes-Murphey Clinic and University of Tennessee Health Science Center, Memphis, TN, USA
| | - Sijie Li
- Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Haiqing Song
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuping Wang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuchuan Ding
- China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xunming Ji
- Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China.,China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
24
|
Endovascular Treatment of Acute Ischemic Stroke Due to Intracranial Atherosclerotic Large Vessel Occlusion : A Systematic Review. Clin Neuroradiol 2019; 30:777-787. [PMID: 31616958 DOI: 10.1007/s00062-019-00839-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 09/16/2019] [Indexed: 10/25/2022]
Abstract
OBJECTIVE To evaluate the efficacy and safety of endovascular treatment (ET) of acute ischemic stroke (AIS) caused by intracranial atherosclerotic large vessel occlusion (ICAS-LVO). METHODS A systemic review and meta-analysis were conducted on studies published between July 2005 and October 2018 on the outcomes of ET in patients with AIS due to ICAS-LVO. The outcomes of the ICAS-LVO and embolic LVO groups were also compared. RESULTS A total of 17 studies including 1315 subjects with ICAS-LVO were included. In the single-arm meta-analysis, the pooled estimates of successful recanalization rate, favorable outcomes, symptomatic intracranial hemorrhage and mortality were 88% (95% CI (95% confidence interval), 84-92%), 52% (95% CI, 47-56%), 5% (95% CI, 3-7%) and 15% (95% CI, 12-19%) respectively. The preferred primary treatment was stent-retriever thrombectomy (84.1%) and the preferred rescue treatment was stent implantation with or without percutaneous transluminal angioplasty (PTA, 32.7%). In the double-arm meta-analysis, the incidence of symptomatic intracranial hemorrhage was lower in the ICAS-LVO compared to the embolic-LVO group (OR (odds ratio) = 0.60, 95% CI, 0.46-0.77, p < 0.01), whereas the implementation of rescue treatment (OR = 5.94, 95% CI, 3.15-11.19, p < 0.01) and stenting rate (OR = 10.06, 95%CI, 4.43-22.85, p < 0.01) were higher in the ICAS-LVO group. Other parameters were similar in both groups. CONCLUSION The use of ET is a safe and effective therapeutic option for AIS due to ICAS-LVO. Stent-retriever thrombectomy and stent-implement are the preferred primary and rescue therapies respectively for ICAS-LVO. Less symptomatic intracranial hemorrhage and higher stenting were observed in the ICAS-LVO compared to the embolic-LVO group.
Collapse
|
25
|
An H, Zhao W, Wang J, Wright JC, Elmadhoun O, Wu D, Shang S, Wu C, Li C, Wu L, Chen J, Duan J, Zhang H, Song H, Ding Y, Ji X. Contrast Staining may be Associated with Intracerebral Hemorrhage but Not Functional Outcome in Acute Ischemic Stroke Patients Treated with Endovascular Thrombectomy. Aging Dis 2019; 10:784-792. [PMID: 31440384 PMCID: PMC6675522 DOI: 10.14336/ad.2018.0807] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2018] [Accepted: 08/07/2018] [Indexed: 12/17/2022] Open
Abstract
To evaluate the incidence of post-interventional contrast staining (PICS) in acute ischemic stroke (AIS) Chinese patients who were treated with endovascular thrombectomy (ET) and investigate potential association of PICS with functional outcome and intracerebral hemorrhage (ICH). This observational study was based on a single-center prospective registry study. AIS patients who underwent ET from January 2013 to February 2017 were recruited into this study. All patients had dual-energy CT (DECT) scan of the head at 12 to 24 hours post-ET. The primary outcome was the incidence of PICS. Secondary outcomes were total ICH, symptomatic ICH (sICH), 3-month functional outcome, and long-term functional outcome. One hundred and eighty patients were enrolled in this study. PICS was detected in 50 patients (28%) based on the post-interventional CT scan. We first used basic statistical analyses, showing that the incidence of both total ICH (60% vs. 25%, p<0.001) and sICH (18% vs. 8%, p=0.044) were higher in patients with PICS than those without, and fewer patients achieved no disability (mRS≤1) in the PICS group compared to the control group at both 3-month and long-term follow-up (p<0.01 each). However, multivariate regression analysis further revealed that PICS only increased total (adjusted odds ratio, 7.38; 95% confidence interval 1.66 to 32.9; p=0.009) but not sICH risk. Furthermore, the logistic regression analyses did not show statistical difference in good clinical outcomes or mortality between the two groups. PICS is a common phenomenon in Chinese AIS patients. It is associated with total ICH after ET, but it seems to have no effect on functional outcome and sICH. Further large-scale studies are warranted to validate these results.
Collapse
Affiliation(s)
- Hong An
- 1Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,2China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wenbo Zhao
- 1Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jianguo Wang
- 3Department of Rehabilitation, Beijing Tongren Hospital, Capital Medical University, Beijing, China
| | - Joshua C Wright
- 4Wayne State University School of Medicine, Detroit, MI, USA
| | - Omar Elmadhoun
- 5Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA.,6Department of Anesthesiology, Critical Care, and Pain Medicine, Beth Israel Deaconess Medical Center/Harvard Medical School, Massachusetts, USA
| | - Di Wu
- 2China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Shuyi Shang
- 1Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chuanjie Wu
- 1Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chuanhui Li
- 7Department of Emergency, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Longfei Wu
- 1Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China.,2China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jian Chen
- 8Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jiangang Duan
- 7Department of Emergency, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Hongqi Zhang
- 8Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Haiqing Song
- 1Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Yuchuan Ding
- 2China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,5Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, USA
| | - Xunming Ji
- 2China-America Institute of Neuroscience, Xuanwu Hospital, Capital Medical University, Beijing, China.,8Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
26
|
Jiang F, Zhao W, Wu C, Zhang Z, Li C, Che R, Chen J, Hu W, Song H, Duan J, Ji X. Asymptomatic Intracerebral Hemorrhage May Worsen Clinical Outcomes in Acute Ischemic Stroke Patients Undergoing Thrombectomy. J Stroke Cerebrovasc Dis 2019; 28:1752-1758. [PMID: 30926220 DOI: 10.1016/j.jstrokecerebrovasdis.2019.02.006] [Citation(s) in RCA: 31] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2018] [Revised: 01/28/2019] [Accepted: 02/11/2019] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Asymptomatic intracerebral hemorrhage (AICH) is a common phenomenon in patients with acute ischemic stroke (AIS) who were treated with endovascular thrombectomy (ET). This study aimed to evaluate the clinical effects of AICH and its risk factors in this patient population. METHODS This observational study was based on a prospective registry study. AIS patients with large-vessel occlusion in the anterior circulation and treated with ET were recruited. During thrombectomy procedures, intra-arterial infusion of thrombolytics or antiplatelet and permanent stenting were used as remedial therapies. The primary outcome was the overall distribution of modified Rankin scale (mRS) 90 days after ET. RESULTS This study included 102 patients (61.1 ± 12.7 years old), in whom 39 patients (38.2%) experienced AICH. At 90-day follow-up, the median mRS was 2 (interquartile range [IQR] 0-3) for patients without AICH and 4 (IQR 2-6) for those with AICH (adjusted P = .005). Fourteen patients with AICH and 7 patients without AICH died, which was significantly different (35.9% versus 11.1%, adjusted P = .015). Thirty-nine patients (61.9%) without AICH and 14 patients (35.9%) with AICH achieved functional independence at 3-month follow-up (adjusted P = .117). The length of intensive care unit staying was 5 days (IQR 2-10) in patients without AICH and 8 days (IQR 3-19) in those with AICH (adjusted P = .840). In multivariate analysis, lower Alberta Stroke Program Early CT Score (ASPECTS) (adjusted P = .003) and adjunctively intra-arterial thrombolysis (adjusted P = .016) were independently associated with AICH. CONCLUSIONS In AIS patients treated with ET AICH appears to be associated with worse functional outcomes and high mortality. Lower ASPECTS and adjectively intra-arterial thrombolysis were independent risk factors of AICH.
Collapse
Affiliation(s)
- Fang Jiang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wenbo Zhao
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chuanjie Wu
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Zhen Zhang
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Chuanhui Li
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Ruiwen Che
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jian Chen
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Weiming Hu
- Department of Molecular Biosciences, The University of Texas (Austin), Austin, Texas
| | - Haiqing Song
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jiangang Duan
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xunming Ji
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.
| |
Collapse
|
27
|
Pego-Pérez ER, Fernández-Rodríguez I, Pumar-Cebreiro JM. National Institutes of Health Stroke Scale, modified Rankin Scale, and modified Thrombolysis in Cerebral Infarction as autonomy predictive tools for stroke patients. Rev Neurosci 2019; 30:701-708. [PMID: 30849051 DOI: 10.1515/revneuro-2019-0011] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2019] [Accepted: 01/19/2019] [Indexed: 01/19/2023]
Abstract
Whereas mortality from ischemic stroke is decreasing in all age groups, the prevalence of stroke continues to increase. Its increasing incidence in the younger population adds to the large number of survivors who will live many years with their disabilities related to stroke. Thus, the objectives of this study are to determine the National Institutes of Health Stroke Scale (NIHSS), the modified Rankin Scale (mRS), and the modified Thrombolysis in Cerebral Infarction (mTICI) as adequate prognostic functionality tools for stroke patients and to analyze the relation between stroke and rehabilitation. This study involved a systematic review. We obtained articles found on Google Scholar and MEDLINE and published from January 2008 to May 2018. The functionality of the patient after a stroke is associated with the likelihood of a hospital readmission, which should be taken into account during the diagnosis. Patients with poor functionality at discharge are also more likely to need long-term care and intensive rehabilitation plans. The severity of the initial stroke is a primary determinant of the clinical outcome. The NIHSS, mRS, and mTICI appear to be predictive tools of the functionality of the patient with ischemic stroke, especially in the acute phase. Rehabilitation demonstrates better results in reducing disability and greater participation of affected people.
Collapse
Affiliation(s)
- Emilio Rubén Pego-Pérez
- Department of Psychiatry, Radiology, Public Health, Nursing and Medicine, University of Santiago de Compostela, E-15782 Santiago de Compostela, Spain
| | | | - José Manuel Pumar-Cebreiro
- Department of Psychiatry, Radiology, Public Health, Nursing and Medicine, University of Santiago de Compostela, E-15782 Santiago de Compostela, Spain
| |
Collapse
|
28
|
Zhao W, Li S, Ren C, Meng R, Jin K, Ji X. Remote ischemic conditioning for stroke: clinical data, challenges, and future directions. Ann Clin Transl Neurol 2018; 6:186-196. [PMID: 30656197 PMCID: PMC6331204 DOI: 10.1002/acn3.691] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 10/11/2018] [Accepted: 10/15/2018] [Indexed: 12/25/2022] Open
Abstract
Despite great improvement during the past several decades, the management of stroke is still far from satisfactory, which warrants alternative or adjunctive strategies. Remote ischemic conditioning (RIC), an easy‐to‐use and noninvasive therapy, can be performed in various clinical scenarios (e.g., prehospital transportation, intrahospital, and at home), and it has been widely investigated for stroke management. RIC has been demonstrated to be well tolerated in patients with acute ischemic stroke and aneurysm subarachnoid hemorrhage, and it may benefit these patients by improving clinical outcomes; in patients with intracranial atherosclerosis, long‐term repeated RIC could be safely performed and benefit patients by reducing recurrent ischemic stroke and transient ischemic attack, as well as improving cerebral perfusion status; long‐term repeated RIC may also benefit patients with cerebral small vessel disease by slowing cognitive decline and reducing volume of white matter hyperintensities on brain MRI; in patients with severe carotid atherosclerotic stenosis undergoing stenting, preprocedural RIC could reduce the odds of new brain lesions on postprocedural MRI. Previous clinical studies suggest broad future prospects of RIC in the field of cerebrovascular diseases. However, the optimal RIC protocol and the mechanisms that RIC protects the brain is not fully clear, and there is lack of sensitive and specific biomarkers of RIC, all these dilemmas prevent RIC from entering clinical practice. This review focuses on recent advances in clinical studies of RIC in stroke management, its challenges, and the potential directions of future studies.
Collapse
Affiliation(s)
- Wenbo Zhao
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China
| | - Sijie Li
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine Xuanwu Hospital Capital Medical University Beijing China
| | - Changhong Ren
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine Xuanwu Hospital Capital Medical University Beijing China
| | - Ran Meng
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China
| | - Kunlin Jin
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine Xuanwu Hospital Capital Medical University Beijing China.,Center for Neuroscience Discovery Institute for Healthy Aging University of North Texas Health Science Center Fort Worth Texas
| | - Xunming Ji
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine Xuanwu Hospital Capital Medical University Beijing China.,Department of Neurosurgery Xuanwu Hospital Capital Medical University Beijing China
| |
Collapse
|
29
|
Zhao W, Che R, Li S, Ren C, Li C, Wu C, Lu H, Chen J, Duan J, Meng R, Ji X. Remote ischemic conditioning for acute stroke patients treated with thrombectomy. Ann Clin Transl Neurol 2018; 5:850-856. [PMID: 30009202 PMCID: PMC6043766 DOI: 10.1002/acn3.588] [Citation(s) in RCA: 42] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2018] [Revised: 04/27/2018] [Accepted: 05/08/2018] [Indexed: 01/01/2023] Open
Abstract
Objective Remote ischemic conditioning (RIC) has been demonstrated to be safe and feasible for patients with acute ischemic stroke (AIS), as well as for those receiving intravenous thrombolysis. We assessed the safety and feasibility of RIC for AIS patients undergoing endovascular treatment (ET). Methods We conducted a pilot study with patients with AIS who were suspected of having an emergent large‐vessel occlusion in the anterior circulation and who were scheduled for ET within 6 hours of ictus. Four cycles of RIC were performed before recanalization, immediately following recanalization, and once daily for the subsequent 7 days. The primary outcome was any serious RIC‐related adverse events. Results Twenty subjects, aged 66.1 ± 12.1 years, were recruited. No subject experienced serious RIC‐related adverse events. The intracranial pressure, cranial perfusion pressure, mean arterial pressure, heart rate, middle cerebral artery peak systolic flow velocity, and pulsatility index did not change significantly before, during, or after the limb ischemia (P > 0.1 for all). Of 80 cycles, 71 (89%) were completed before recanalization and 80 (100%) were completed immediately after recanalization; 444 of 560 cycles (78%) were completed within 7 days posttreatment. No patients had to stop RIC because it affected routine clinical managements. Six subjects (30%) experienced intracerebral hemorrhage, which was symptomatic in one case (5%). At the 3‐month follow‐up, 11 subjects (55%) had achieved functional independence, and two subjects (10%) died. Interpretation RIC appears to be safe and feasible for patients with AIS undergoing ET. Investigations are urgently needed to determine the efficacy of RIC in this patient population.
Collapse
Affiliation(s)
- Wenbo Zhao
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China.,Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine Xuanwu Hospital Capital Medical University Beijing China
| | - Ruiwen Che
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China
| | - Sijie Li
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine Xuanwu Hospital Capital Medical University Beijing China
| | - Changhong Ren
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine Xuanwu Hospital Capital Medical University Beijing China
| | - Chuanhui Li
- Department of Neurosurgery Xuanwu Hospital Capital Medical University Beijing China
| | - Chuanjie Wu
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China
| | - Hui Lu
- Department of Neurology Brain Hospital of Cangzhou Central Hospital Hebei China
| | - Jian Chen
- Department of Neurosurgery Xuanwu Hospital Capital Medical University Beijing China
| | - Jiangang Duan
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China
| | - Ran Meng
- Department of Neurology Xuanwu Hospital Capital Medical University Beijing China
| | - Xunming Ji
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine Xuanwu Hospital Capital Medical University Beijing China.,Department of Neurosurgery Xuanwu Hospital Capital Medical University Beijing China
| |
Collapse
|