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McCullough-Hicks M, Thatikunta P, Mlynash M, Albers GW, Mijalski-Sells C. Visual review of acute stroke neuroimaging prior to transfer acceptance increases likelihood of endovascular therapy. J Stroke Cerebrovasc Dis 2023; 32:107157. [PMID: 37126905 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107157] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2023] [Revised: 04/21/2023] [Accepted: 04/25/2023] [Indexed: 05/03/2023] Open
Abstract
OBJECTIVES Demand for thrombectomy, and interhospital transfer to comprehensive stroke centers (CSCs), for acute stroke is increasing. There is an urgent need to identify patients most likely to benefit from transfer. We evaluated whether CSC providers' review of neuroimaging prior to transfer acceptance improved patient selection for thrombectomy and correlated with higher rates of treatment. MATERIALS AND METHODS A retrospective database of all patients transferred to Stanford's CSC for thrombectomy between 2015-2019 was used. Pre-acceptance images, when available for visual review, were reviewed by the CSC stroke team via virtual PACS, RAPID software, or LifeImage platforms. RESULTS 525 patients met inclusion criteria. 147 (28%) had neuroimaging available for review prior to transfer. Of those who did not recanalize en route, 267 (50.8%) underwent thrombectomy. Patients with imaging available for review prior to acceptance were significantly more likely to receive thrombectomy (68% vs 54%, RR 1.26; p=0.006, 95% CI 1.09-1.48). Patient images that were reviewed via RAPID were CT-based perfusion studies; these were more likely to receive thrombectomy (70% vs 54%, RR 1.30; p=0.01, 1.09-1.56). Patients who received EVT were more likely to have had pre-transfer vessel imaging, regardless of availability for visual review (76% vs 59%, RR 1.44; p<0.001, 1.18-1.76). CONCLUSIONS Patients with concern for acute stroke transferred for consideration of thrombectomy who had neuroimaging visually reviewed prior to transfer acceptance and did not recanalize by time of arrival were significantly more likely to undergo thrombectomy. Additional prospective studies are needed to confirm our findings.
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Affiliation(s)
| | - Prateek Thatikunta
- Stanford University Department of Neurology, Stroke Division, Palo Alto, CA, USA.
| | - Michael Mlynash
- Stanford University Department of Neurology, Stroke Division, Palo Alto, CA, USA.
| | - Gregory W Albers
- Stanford University Department of Neurology, Stroke Division, Palo Alto, CA, USA.
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Quantitative analysis of thrombus migration before mechanical thrombectomy: Determinants and relationship with procedural and clinical outcomes. J Neuroradiol 2021; 49:385-391. [PMID: 34808221 DOI: 10.1016/j.neurad.2021.11.005] [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: 07/09/2021] [Revised: 11/11/2021] [Accepted: 11/13/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND PURPOSE In patients with acute ischemic stroke (AIS) and a large vessel occlusion (LVO), thrombus migration (T-Mig) is a common phenomenon before mechanical thrombectomy (MT), revealed by pre-treatment imaging. Previous works have used qualitative scales to define T-Mig. The aim of this study was to evaluate the determinants and impact of quantitatively assessed T-Mig on procedural characteristics and clinical outcome. METHODS Consecutive patients with AIS due to LVO treated by MT at a reference academic hospital were analysed. Distance between vessel origin and beginning of the thrombus on MRI (3D-time-of-flight and/or contrast-enhanced magnetic-resonance-angiography) and digital-substracted-angiography (DSA) were measured in millimeters using a curve tool. Thrombus migration was defined quantitatively as ∆TD calculated as the difference between pre-MT-DSA and MRI thrombus location. ∆TD was rated as significant if above 5mm. RESULTS A total of 267 patients were included (mean age 70±12 years; 46% females) were analyzed. Amongst them, 65 (24.3%) experienced any degree of T-Mig. T-Mig was found to be associated with iv-tPA administration prior to thrombectomy (β-estimate 2.52; 95% CI [1.25-3.79]; p<0.001), fewer device passes during thrombectomy (1.22±1.31 vs 1.66±0.99; p<0.05), and shorter pre-treatment thrombi (β-estimate -0.1millimeter; 95% CI [-0.27-0.07]; p<0.05). There was no association between T-Mig and a favourable outcome (defined by a 0-to-2 modified-Rankin-Scale at 3months, adjusted OR: 2.16 [0.93 - 5.02]; p=0.06) CONCLUSION: Thrombus migration happens in almost a fourth of our study sample, and its quantitative extent was associated with iv-tPA administration prior to MT, but not with clinical outcome.
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Alhazmi H, Bani-Sadr A, Bochaton T, Paccalet A, Da Silva CC, Buisson M, Amaz C, Ameli R, Berthezene Y, Eker OF, Ovize M, Cho TH, Nighoghossian N, Mechtouff L. Large vessel cardioembolic stroke and embolic stroke of undetermined source share a common profile of matrix metalloproteinase-9 level and susceptibility vessel sign length. Eur J Neurol 2021; 28:1977-1983. [PMID: 33682255 DOI: 10.1111/ene.14806] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Revised: 02/28/2021] [Accepted: 03/02/2021] [Indexed: 12/19/2022]
Abstract
BACKGROUND Embolic stroke of undetermined source (ESUS) accounts for up to 25% of ischemic strokes. Identification of biomarkers that could improve the prediction of stroke subtype and subsequently of stroke prevention still remains a major issue. METHODS The HIBISCUS-STROKE cohort includes ischemic stroke patients with large vessel occlusion treated with mechanical thrombectomy following admission magnetic resonance imaging. Presence and length of susceptibility vessel sign (SVS) were assessed by gradient-recalled echo T2*-weighted imaging. Matrix metalloproteinase-9 (MMP-9) was measured on sera collected at admission. A multiple logistic regression model was performed to detect independent markers distinguishing cardioembolic (CE) from large-artery atherosclerosis (LAA) subtype. RESULTS A total of 147 patients were included, of them the etiology was distributed as follows: 86 (58.5%) CE, 26 (17.7%) LAA, and 35 (23.8%) ESUS. The optimal cutoff for differentiating CE from LAA subtype was 14.5 mm for SVS length (sensitivity, 79.7%; specificity, 72.7%) and 1110 ng/ml for admission MMP-9 level (sensitivity, 85.3%; specificity, 52.2%). Multivariate analysis revealed that current smoking (odds ratio [OR] 0.07, 95% confidence interval [CI] 0.01-0.93), tandem occlusion (OR 0.01, 95% CI 0.01-0.21), SVS length (OR 0.78, 95% CI 0.63-0.97), and admission MMP-9 level (OR 0.99, 95% CI 0.99-1.00) were inversely associated with CE subtype. SVS length and MMP-9 level did not differ between ESUS and CE subtypes. CONCLUSION SVS length and admission MMP-9 level may improve the prediction of CE subtype whose profile is close to ESUS, thus suggesting a common cardiac embolic source.
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Affiliation(s)
- Hanan Alhazmi
- Stroke Center, Pierre Wertheimer Hospital, Hospices Civils de Lyon, Bron, France
| | - Alexandre Bani-Sadr
- Neuroradiology Department, Pierre Wertheimer Hospital, Hospices Civils de Lyon, Bron, France
| | - Thomas Bochaton
- Cardiac Intensive Care Unit, Louis Pradel Hospital, Hospices Civils de Lyon, Bron, France.,CarMeN, INSERM U.1060/Université Lyon1/INRA U.1397/INSA Lyon/Hospices Civils Lyon, University Lyon 1, Lyon, France
| | - Alexandre Paccalet
- CarMeN, INSERM U.1060/Université Lyon1/INRA U.1397/INSA Lyon/Hospices Civils Lyon, University Lyon 1, Lyon, France
| | - Claire Crola Da Silva
- CarMeN, INSERM U.1060/Université Lyon1/INRA U.1397/INSA Lyon/Hospices Civils Lyon, University Lyon 1, Lyon, France
| | - Marielle Buisson
- Clinical Investigation Center, INSERM 1407, Louis Pradel Hospital, Hospices Civils de Lyon, Bron, France
| | - Camille Amaz
- Clinical Investigation Center, INSERM 1407, Louis Pradel Hospital, Hospices Civils de Lyon, Bron, France
| | - Roxana Ameli
- Neuroradiology Department, Pierre Wertheimer Hospital, Hospices Civils de Lyon, Bron, France
| | - Yves Berthezene
- Neuroradiology Department, Pierre Wertheimer Hospital, Hospices Civils de Lyon, Bron, France.,CREATIS, CNRS UMR 5220, INSERM U1044, University Lyon 1, Lyon, France
| | - Omer Faruk Eker
- Neuroradiology Department, Pierre Wertheimer Hospital, Hospices Civils de Lyon, Bron, France.,CREATIS, CNRS UMR 5220, INSERM U1044, University Lyon 1, Lyon, France
| | - Michel Ovize
- CarMeN, INSERM U.1060/Université Lyon1/INRA U.1397/INSA Lyon/Hospices Civils Lyon, University Lyon 1, Lyon, France.,Clinical Investigation Center, INSERM 1407, Louis Pradel Hospital, Hospices Civils de Lyon, Bron, France
| | - Tae-Hee Cho
- Stroke Center, Pierre Wertheimer Hospital, Hospices Civils de Lyon, Bron, France.,CarMeN, INSERM U.1060/Université Lyon1/INRA U.1397/INSA Lyon/Hospices Civils Lyon, University Lyon 1, Lyon, France
| | - Norbert Nighoghossian
- Stroke Center, Pierre Wertheimer Hospital, Hospices Civils de Lyon, Bron, France.,CarMeN, INSERM U.1060/Université Lyon1/INRA U.1397/INSA Lyon/Hospices Civils Lyon, University Lyon 1, Lyon, France
| | - Laura Mechtouff
- Stroke Center, Pierre Wertheimer Hospital, Hospices Civils de Lyon, Bron, France.,CarMeN, INSERM U.1060/Université Lyon1/INRA U.1397/INSA Lyon/Hospices Civils Lyon, University Lyon 1, Lyon, France
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4
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Pan Y, Shi G. Silver Jubilee of Stroke Thrombolysis With Alteplase: Evolution of the Therapeutic Window. Front Neurol 2021; 12:593887. [PMID: 33732203 PMCID: PMC7956989 DOI: 10.3389/fneur.2021.593887] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Accepted: 02/01/2021] [Indexed: 01/01/2023] Open
Abstract
In 1995, the results of a landmark clinical trial by National Institute of Neurological Disorders and Stroke (NINDS) made a paradigm shift in managing acute cerebral ischemic stroke (AIS) patients at critical care centers. The study demonstrated the efficacy of tissue-type plasminogen activator (tPA), alteplase in improving neurological and functional outcome in AIS patients when administered within 3 h of stroke onset. After about 12 years of efforts and the results of the ECASS-III trial, it was possible to expand the therapeutic window to 4.5 h, which still represents a major logistic issue, depriving many AIS patients from the benefits of tPA therapy. Constant efforts in this regards are directed toward either speeding up the patient recruitment for tPA therapy or expanding the current tPA window. Efficient protocols to reduce the door-to-needle time and advanced technologies like telestroke services and mobile stroke units are being deployed for early management of AIS patients. Studies have demonstrated benefit of thrombolysis guided by perfusion imaging in AIS patients at up to 9 h of stroke onset, signifying “tissue window.” Several promising pharmacological and non-pharmacological approaches are being explored to mitigate the adverse effects of delayed tPA therapy, thus hoping to further expand the current tPA therapeutic window without compromising safety. With accumulation of scientific data, stroke organizations across the world are amending/updating the clinical recommendations of tPA, the only US-FDA approved drug for managing AIS patients. Alteplase has been a part of our neurocritical care and we intend to celebrate its silver jubilee by dedicating this review article discussing its journey so far and possible future evolution.
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Affiliation(s)
- Yuanmei Pan
- Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Guowen Shi
- Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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5
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Heitsch L, Ibanez L, Carrera C, Binkley MM, Strbian D, Tatlisumak T, Bustamante A, Ribó M, Molina C, Antoni DA, López-Cancio E, Muñoz-Narbona L, Soriano-Tárraga C, Giralt-Steinhauer E, Obach V, Slowik A, Pera J, Lapicka-Bodzioch K, Derbisz J, Sobrino T, Castillo J, Campos F, Rodríguez-Castro E, Arias-Rivas S, Segura T, Serrano-Heras G, Vives-Bauza C, Díaz-Navarro R, Tur S, Jimenez C, Martí-Fàbregas J, Delgado-Mederos R, Arenillas J, Krupinski J, Cullell N, Torres-Águila NP, Muiño E, Cárcel-Márquez J, Moniche F, Cabezas JA, Ford AL, Dhar R, Roquer J, Khatri P, Jiménez-Conde J, Fernandez-Cadenas I, Montaner J, Rosand J, Cruchaga C, Lee JM. Early Neurological Change After Ischemic Stroke Is Associated With 90-Day Outcome. Stroke 2021; 52:132-141. [PMID: 33317415 PMCID: PMC7769959 DOI: 10.1161/strokeaha.119.028687] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE Large-scale observational studies of acute ischemic stroke (AIS) promise to reveal mechanisms underlying cerebral ischemia. However, meaningful quantitative phenotypes attainable in large patient populations are needed. We characterize a dynamic metric of AIS instability, defined by change in National Institutes of Health Stroke Scale score (NIHSS) from baseline to 24 hours baseline to 24 hours (NIHSSbaseline - NIHSS24hours = ΔNIHSS6-24h), to examine its relevance to AIS mechanisms and long-term outcomes. METHODS Patients with NIHSS prospectively recorded within 6 hours after onset and then 24 hours later were enrolled in the GENISIS study (Genetics of Early Neurological Instability After Ischemic Stroke). Stepwise linear regression determined variables that independently influenced ΔNIHSS6-24h. In a subcohort of tPA (alteplase)-treated patients with large vessel occlusion, the influence of early sustained recanalization and hemorrhagic transformation on ΔNIHSS6-24h was examined. Finally, the association of ΔNIHSS6-24h with 90-day favorable outcomes (modified Rankin Scale score 0-2) was assessed. Independent analysis was performed using data from the 2 NINDS-tPA stroke trials (National Institute of Neurological Disorders and Stroke rt-PA). RESULTS For 2555 patients with AIS, median baseline NIHSS was 9 (interquartile range, 4-16), and median ΔNIHSS6-24h was 2 (interquartile range, 0-5). In a multivariable model, baseline NIHSS, tPA-treatment, age, glucose, site, and systolic blood pressure independently predicted ΔNIHSS6-24h (R2=0.15). In the large vessel occlusion subcohort, early sustained recanalization and hemorrhagic transformation increased the explained variance (R2=0.27), but much of the variance remained unexplained. ΔNIHSS6-24h had a significant and independent association with 90-day favorable outcome. For the subjects in the 2 NINDS-tPA trials, ΔNIHSS3-24h was similarly associated with 90-day outcomes. CONCLUSIONS The dynamic phenotype, ΔNIHSS6-24h, captures both explained and unexplained mechanisms involved in AIS and is significantly and independently associated with long-term outcomes. Thus, ΔNIHSS6-24h promises to be an easily obtainable and meaningful quantitative phenotype for large-scale genomic studies of AIS.
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Affiliation(s)
- Laura Heitsch
- Division of Emergency Medicine, Washington University School of Medicine, St. Louis, MO
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Laura Ibanez
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
| | - Caty Carrera
- Neurovascular Research Laboratory and Neurovascular Unit. Vall d’Hebron Institute of Research (VHIR), Universitat Autonoma de Barcelona, Barcelona, Spain
- Department of Neurology, Hospital Universitari Vall d”Hebron. Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Michael M Binkley
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
| | - Turgut Tatlisumak
- Department of Neurology, Helsinki University Hospital, Helsinki, Finland
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy at University of Gothenburg and Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Alejandro Bustamante
- Neurovascular Research Laboratory and Neurovascular Unit. Vall d’Hebron Institute of Research (VHIR), Universitat Autonoma de Barcelona, Barcelona, Spain
- Department of Neurology, Hospital Universitari Vall d”Hebron. Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Marc Ribó
- Department of Neurology, Hospital Universitari Vall d”Hebron. Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Carlos Molina
- Department of Neurology, Hospital Universitari Vall d”Hebron. Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Dávalos A Antoni
- Department of Neurology, Hospital Universitari Germans Trias I Pujol, Badalona, Spain
| | - Elena López-Cancio
- Department of Neurology, Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Lucia Muñoz-Narbona
- Institut Hospital del Mar d’Investigacions Mediques (IMIM), Barcelona, Spain
| | | | - Eva Giralt-Steinhauer
- Institut Hospital del Mar d’Investigacions Mediques (IMIM), Barcelona, Spain
- Department of Neurology, Hospital de Mar, Barcelona, Spain
| | - Victor Obach
- Department of Neuroscience, Hospital Clinic, University of Barcelona and August Pi I SUnyer Biomedical Research Institute (IDIBAPS), Barcelona, Spain
| | - Agnieszka Slowik
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
| | - Joanna Pera
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
| | | | - Justyna Derbisz
- Department of Neurology, Jagiellonian University Medical College, Krakow, Poland
| | - Tomás Sobrino
- Clinical Neurosciences Research Laboratory, Health Research Institute of Santiago de Compostela, Hospital Clinico Universitario, Universidade de Santiago de Compostela, Spain
| | - José Castillo
- Clinical Neurosciences Research Laboratory, Health Research Institute of Santiago de Compostela, Hospital Clinico Universitario, Universidade de Santiago de Compostela, Spain
| | - Francisco Campos
- Clinical Neurosciences Research Laboratory, Health Research Institute of Santiago de Compostela, Hospital Clinico Universitario, Universidade de Santiago de Compostela, Spain
| | - Emilio Rodríguez-Castro
- Clinical Neurosciences Research Laboratory, Health Research Institute of Santiago de Compostela, Hospital Clinico Universitario, Universidade de Santiago de Compostela, Spain
| | - Susana Arias-Rivas
- Clinical Neurosciences Research Laboratory, Health Research Institute of Santiago de Compostela, Hospital Clinico Universitario, Universidade de Santiago de Compostela, Spain
| | - Tomás Segura
- Department of Neurology, Hospital Universitario de Albacete, Albacete, Spain
| | - Gemma Serrano-Heras
- Department of Neurology, Hospital Universitario de Albacete, Albacete, Spain
| | - Cristófol Vives-Bauza
- Department of Neurology, Son Espases University Hospital, IdISBa, Palma de Mallorca, Spain
| | - Rosa Díaz-Navarro
- Department of Neurology, Son Espases University Hospital, IdISBa, Palma de Mallorca, Spain
| | - Silva Tur
- Department of Neurology, Son Espases University Hospital, IdISBa, Palma de Mallorca, Spain
| | - Carmen Jimenez
- Department of Neurology, Son Espases University Hospital, IdISBa, Palma de Mallorca, Spain
| | - Joan Martí-Fàbregas
- Department of Neurology, Hospital de la Santa Creu I Sant Pau, Barcelona, Spain
| | | | - Juan Arenillas
- Department of Neurology, Hospital Clinico Universitario de Valladolid, Valladolid, Spain
- Neurovascular research laboratory. Instituto de Biología y Genética Molecular (IBGM). Universidad de Valladolid & Consejo Superior Investigaciones Científicas. Valladolid, Spain
| | - Jerzy Krupinski
- Department of Neurology, Hospital Mutua de Terrassa, Terrassa, Spain
- School of Life Sciences, Centre for Biosciences, Manchester Met University, Manchester, UK
| | - Natalia Cullell
- Stroke Pharmacogenomics and Genetics, Fundacio Docencia I Recerca Mutua de Terrassa, Terassa, Spain
- Stroke Pharmacogenomics and Genetics, Sant Pau Institute of Research, Sant Pau Hospital, Barcelona, Spain
| | - Nuria P Torres-Águila
- Stroke Pharmacogenomics and Genetics, Sant Pau Institute of Research, Sant Pau Hospital, Barcelona, Spain
| | - Elena Muiño
- Stroke Pharmacogenomics and Genetics, Fundacio Docencia I Recerca Mutua de Terrassa, Terassa, Spain
- Stroke Pharmacogenomics and Genetics, Sant Pau Institute of Research, Sant Pau Hospital, Barcelona, Spain
| | - Jara Cárcel-Márquez
- Stroke Pharmacogenomics and Genetics, Fundacio Docencia I Recerca Mutua de Terrassa, Terassa, Spain
- Stroke Pharmacogenomics and Genetics, Sant Pau Institute of Research, Sant Pau Hospital, Barcelona, Spain
| | - Francisco Moniche
- Department of Neurology, Hospital Universitario Virgen del Rocio, Sevilla, Spain
| | - Juan A Cabezas
- Department of Neurology, Hospital Universitario Virgen del Rocio, Sevilla, Spain
| | - Andria L Ford
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Rajat Dhar
- Department of Neurology, Washington University School of Medicine, St. Louis, MO
| | - Jaume Roquer
- Institut Hospital del Mar d’Investigacions Mediques (IMIM), Barcelona, Spain
- Department of Neurology, Hospital de Mar, Barcelona, Spain
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati, Cincinnati, OH
| | - Jordi Jiménez-Conde
- Institut Hospital del Mar d’Investigacions Mediques (IMIM), Barcelona, Spain
- Department of Neurology, Hospital de Mar, Barcelona, Spain
| | - Israel Fernandez-Cadenas
- Neurovascular Research Laboratory and Neurovascular Unit. Vall d’Hebron Institute of Research (VHIR), Universitat Autonoma de Barcelona, Barcelona, Spain
- Department of Neurology, Hospital Mutua de Terrassa, Terrassa, Spain
- Stroke Pharmacogenomics and Genetics, Fundacio Docencia I Recerca Mutua de Terrassa, Terassa, Spain
| | - Joan Montaner
- Neurovascular Research Laboratory and Neurovascular Unit. Vall d’Hebron Institute of Research (VHIR), Universitat Autonoma de Barcelona, Barcelona, Spain
- Institute de Biomedicine of Seville, IBiS/Hospital Universitario Virgen del Rocío/CSIC/University of Seville & Department of Neurology, Hospital Universitario Virgen Macarena, Seville
| | - Jonathan Rosand
- Henry and Alison Center for Brain Health, Center for Genomic Medicine, Division of Neurocritical Care and Emergency Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Carlos Cruchaga
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
| | - Jin-Moo Lee
- Department of Psychiatry, Washington University School of Medicine, St. Louis, MO
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Staessens S, Denorme F, Francois O, Desender L, Dewaele T, Vanacker P, Deckmyn H, Vanhoorelbeke K, Andersson T, De Meyer SF. Structural analysis of ischemic stroke thrombi: histological indications for therapy resistance. Haematologica 2020; 105:498-507. [PMID: 31048352 PMCID: PMC7012484 DOI: 10.3324/haematol.2019.219881] [Citation(s) in RCA: 155] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2019] [Accepted: 04/24/2019] [Indexed: 11/28/2022] Open
Abstract
Ischemic stroke is caused by a thromboembolic occlusion of cerebral arteries. Treatment is focused on fast and efficient removal of the occluding thrombus, either via intravenous thrombolysis or via endovascular thrombectomy. Recanalization, however, is not always successful and factors contributing to failure are not completely understood. Although the occluding thrombus is the primary target of acute treatment, little is known about its internal organization and composition. The aim of this study, therefore, was to better understand the internal organization of ischemic stroke thrombi on a molecular and cellular level. A total of 188 thrombi were collected from endovascularly treated ischemic stroke patients and analyzed histologically for fibrin, red blood cells (RBC), von Willebrand factor (vWF), platelets, leukocytes and DNA, using bright field and fluorescence microscopy. Our results show that stroke thrombi are composed of two main types of areas: RBC-rich areas and platelet-rich areas. RBC-rich areas have limited complexity as they consist of RBC that are entangled in a meshwork of thin fibrin. In contrast, platelet-rich areas are characterized by dense fibrin structures aligned with vWF and abundant amounts of leukocytes and DNA that accumulate around and in these platelet-rich areas. These findings are important to better understand why platelet-rich thrombi are resistant to thrombolysis and difficult to retrieve via thrombectomy, and can guide further improvements of acute ischemic stroke therapy.
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Affiliation(s)
- Senna Staessens
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk,Belgium
| | - Frederik Denorme
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk,Belgium
| | | | - Linda Desender
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk,Belgium
| | - Tom Dewaele
- Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
| | - Peter Vanacker
- Department of Neurology, AZ Groeninge, Kortrijk, Belgium.,Department of Neurology, University Hospitals Antwerp, Antwerp, Belgium.,Department of Translational Neuroscience, University of Antwerp, Antwerp, Belgium
| | - Hans Deckmyn
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk,Belgium
| | - Karen Vanhoorelbeke
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk,Belgium
| | - Tommy Andersson
- Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium.,Department of Neuroradiology, Karolinska University Hospital and Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Simon F De Meyer
- Laboratory for Thrombosis Research, KU Leuven Campus Kulak Kortrijk, Kortrijk,Belgium
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7
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Impact of smoking on stroke outcome after endovascular treatment. PLoS One 2018; 13:e0194652. [PMID: 29718909 PMCID: PMC5931491 DOI: 10.1371/journal.pone.0194652] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 03/07/2018] [Indexed: 12/21/2022] Open
Abstract
Background Recent studies suggest a paradoxical association between smoking status and clinical outcome after intravenous thrombolysis (IVT). Little is known about relationship between smoking and stroke outcome after endovascular treatment (EVT). Methods We analyzed data of all stroke patients treated with EVT at the tertiary stroke centre of Berne between January 2005 and December 2015. Using uni- and multivariate modeling, we assessed whether smoking was independently associated with excellent clinical outcome (modified Rankin Scale (mRS) 0–1) and mortality at 3 months. In addition, we also measured the occurrence of symptomatic intracranial hemorrhage (sICH) and recanalization. Results Of 935 patients, 204 (21.8%) were smokers. They were younger (60.5 vs. 70.1 years of age, p<0.001), more often male (60.8% vs. 52.5%, p = 0.036), had less often from hypertension (56.4% vs. 69.6%, p<0.001) and were less often treated with antithrombotics (35.3% vs. 47.7%, p = 0.004) as compared to nonsmokers. In univariate analyses, smokers had higher rates of excellent clinical outcome (39.1% vs. 23.1%, p<0.001) and arterial recanalization (85.6% vs. 79.4%, p = 0.048), whereas mortality was lower (15.6% vs. 25%, p = 0.006) and frequency of sICH similar (4.4% vs. 4.1%, p = 0.86). After correcting for confounders, smoking still independently predicted excellent clinical outcome (OR 1.758, 95% CI 1.206–2.562; p<0.001). Conclusion Smoking in stroke patients may be a predictor of excellent clinical outcome after EVT. However, these data must not be misinterpreted as beneficial effect of smoking due to the observational study design. In view of deleterious effects of cigarette smoking on cardiovascular health, cessation of smoking should still be strongly recommended for stroke prevention.
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Rotzinger DC, Mosimann PJ, Meuli RA, Maeder P, Michel P. Site and Rate of Occlusive Disease in Cervicocerebral Arteries: A CT Angiography Study of 2209 Patients with Acute Ischemic Stroke. AJNR Am J Neuroradiol 2017; 38:868-874. [PMID: 28302611 DOI: 10.3174/ajnr.a5123] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 12/13/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE CTA can rapidly and accurately detect and localize occlusive disease in patients with ischemic stroke. We have used CTA to assess arterial stenosis and occlusion in an ischemic stroke population arriving at a tertiary stroke center within 24 hours of symptom onset in order to obtain a comprehensive picture of occlusive disease pattern, and to determine the proportion of eligible candidates for endovascular treatment. MATERIALS AND METHODS Data from consecutive patients with acute ischemic stroke admitted to a single center between 2003 and 2012, collected in the Acute Stroke Registry and Analysis of Lausanne data base, were retrospectively analyzed. Patients with a diagnostic CTA within 24 hours of symptom onset were selected. Relevant extra- and intracranial pathology, defined as stenosis of ≥50% and occlusions, were registered and classified into 21 prespecified segments. RESULTS Of the 2209 included patients (42.1% women; median age, 72 years), 1075 (48.7%) had pathology in and 308 (13.9%) had pathology outside the ischemic territory. In the 50,807 arterial segments available for revision, 1851 (3.6%) abnormal segments were in the ischemic (symptomatic) territory and another 408 (0.8%) were outside it (asymptomatic). In the 1211 patients with ischemic stroke imaged within 6 hours of symptom onset, 40.7% had symptomatic large, proximal occlusions potentially amenable to endovascular therapy. CONCLUSIONS CTA in patients with acute ischemic stroke shows large individual variations of occlusion sites and degrees. Approximately half of such patients have no visible occlusive disease, and 40% imaged within 6 hours show large, proximal segment occlusions amenable to endovascular therapy. These findings show the importance of early noninvasive imaging of extra- and intracranial arteries for identifying occlusive disease, planning recanalization strategies, and designing interventional trials.
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Affiliation(s)
- D C Rotzinger
- From the Department of Diagnostic and Interventional Radiology (D.C.R., P.J.M., R.A.M., P. Maeder)
| | - P J Mosimann
- From the Department of Diagnostic and Interventional Radiology (D.C.R., P.J.M., R.A.M., P. Maeder)
| | - R A Meuli
- From the Department of Diagnostic and Interventional Radiology (D.C.R., P.J.M., R.A.M., P. Maeder)
| | - P Maeder
- From the Department of Diagnostic and Interventional Radiology (D.C.R., P.J.M., R.A.M., P. Maeder)
| | - P Michel
- Neurology Service (P. Michel), Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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van Ginneken V, Gierhake D, Audebert HJ, Fiebach JB. Distal Middle Cerebral Artery Branch Recanalization Does Not Affect Final Lesion Volume in Ischemic Stroke. Cerebrovasc Dis 2017; 43:200-205. [DOI: 10.1159/000457811] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2016] [Accepted: 01/16/2017] [Indexed: 11/19/2022] Open
Abstract
Background: Early recanalization in ischemic stroke is associated with favorable outcome. However, limited data are available on the effect of recanalization on infarct growth and functional outcome in stroke with distal middle cerebral artery (MCA) pathology. This study was aimed at determining the effect of recanalization in acute stroke patients with perfusion-diffusion mismatch and occlusion or high-grade stenosis of a distal MCA branch. Methods: We prospectively examined 34 consecutive stroke patients with perfusion-diffusion mismatch and M3 or M4 pathology within 24 h of symptom onset. The MRI protocol consisted of diffusion-weighted images (DWI), fluid-attenuated inversion recovery (FLAIR), T2*, perfusion-weighted imaging, time-of-flight magnetic resonance angiography at days 0, 1, and 4-6. Volume measurements were performed with MRIcron. Infarct growth was defined as the difference between lesion volumes on FLAIR at days 4-6 and DWI at day 0. Certified raters assessed modified Rankin Scale scores at discharge and day 90. Results: Twenty-four patients (71%) showed recanalization at day 1. Infarct growth was modest (median 2.4 mL, 95% CI 0.8-6.7) and not significantly different between patients with and without recanalization (p = 0.87). Functional outcome at discharge was good with 70% of patients suffering no significant disabilities. There was no association between functional outcome at discharge and recanalization (OR 2.1, 95% CI 0.4-13.0, p = 0.40) or infarct volume at days 4-6 (p = 0.40). Conclusions: The high rate of spontaneous recanalization and good functional outcome in patients with distal MCA pathology might obscure a potential benefit from recanalization in this population.
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Yan S, Xu M, Han Q, Ye K, Lai Y, Liu K, Liebeskind DS, Lou M. Late recanalisation beyond 24 hours is associated with worse outcome: an observational study. Eur Radiol 2017; 27:24-31. [DOI: 10.1007/s00330-016-4366-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 03/14/2016] [Accepted: 04/11/2016] [Indexed: 11/30/2022]
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