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Robbe MMQ, Pinckaers FME, Santegoeds RGC, Bos MJ, van Oostenbrugge RJ, van Zwam WH, Staals J, Postma AA. Procedural blood pressure and contrast extravasation on dual energy computed tomography after endovascular stroke treatment. J Stroke Cerebrovasc Dis 2024; 33:107673. [PMID: 38458504 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107673] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Revised: 12/11/2023] [Accepted: 03/04/2024] [Indexed: 03/10/2024] Open
Abstract
BACKGROUND Blood brain barrier disruption (BBBD) can be visualized by contrast extravasation (CE) after endovascular treatment (EVT) in patients with acute ischemic stroke. Elevated blood pressure is a risk factor for BBBD. However, the association between procedural blood pressure and CE post-EVT is unknown. METHODS In this single-center retrospective study, we analyzed 501 eligible patients who received a dual energy CT (DECT) immediately post-EVT for acute ischemic stroke. Procedural blood pressure values (SBPmean, SBPmax, SBPmax-min, and MAPmean) were collected. CE was quantified by measuring the maximum parenchymal iodine concentration on DECT iodine overlay map reconstructions. As a measure for the extent of BBBD, we created CE-ASPECTS by deducting one point per hyperdense ASPECTS region on iodine overlay maps. The association between blood pressure and CE was assessed using multivariable linear regression. RESULTS The procedural SBPmean, SBPmax, and MAPmean were 150 ± 26 mmHg, 173 ± 29 mmHg, and 101 ± 17 mmHg, respectively. The median maximum iodine concentration on post-EVT DECT was 1.2 mg/ml (IQR 0.7-2.0), and median CE-ASPECTS was 8 (IQR 5-11). The maximum iodine concentration was not associated with blood pressure. SBPmean, SBPmax, and MAPmean were significantly associated with CE-ASPECTS (per 10 mmHg, β = -0.2, 95 % CI -0.31 to -0.09, β = -0.15, 95 % CI -0.25 to -0.06, β = -0.33, 95 % CI -0.49 to -0.17, respectively). CONCLUSION In acute ischemic stroke patients undergoing EVT, particularly in patients achieving successful recanalization, SBPmean, SBPmax, and MAPmean are associated with the extent of BBBD on immediate post-EVT DECT, but not with maximum iodine concentration.
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Affiliation(s)
- M M Q Robbe
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, the Netherlands; School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, the Netherlands.
| | - F M E Pinckaers
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, the Netherlands; School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, the Netherlands
| | - R G C Santegoeds
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - M J Bos
- Departments of Anesthesiology and Pain Medicine, Maastricht University Medical Center, Maastricht, the Netherlands
| | - R J van Oostenbrugge
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, the Netherlands; Department of Neurology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - W H van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, the Netherlands; School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, the Netherlands
| | - J Staals
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, the Netherlands; Department of Neurology, Maastricht University Medical Center, Maastricht, the Netherlands
| | - A A Postma
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, the Netherlands; School for Mental Health and Sciences (MHENS), Maastricht University, Maastricht, the Netherlands
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Pinckaers FME, Robbe MMQ, Olthuis SGH, Boogaarts HD, van Zwam WH, van Oostenbrugge RJ, Postma AA. Prognostic implications of intracranial haemorrhage on dual-energy CT immediately following endovascular treatment for acute ischemic stroke. J Neuroradiol 2024; 51:101168. [PMID: 37984705 DOI: 10.1016/j.neurad.2023.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Revised: 11/15/2023] [Accepted: 11/15/2023] [Indexed: 11/22/2023]
Abstract
OBJECTIVE To describe the incidence, risk factors, and prognostic relevance of intracranial haemorrhage (ICH) immediately after endovascular treatment (EVT) for ischaemic stroke in the anterior circulation. METHODS EVT records from 2010 to 2019 were screened. Included patients underwent DECT within 3h post-EVT. Virtual native reconstructions were evaluated for ICH according to the Heidelberg criteria and grouped into Heidelberg classes (HCs): [HC1] haemorrhagic infarction (HI)1, HI2 and parenchymal haematoma (PH)1; [HC2] PH2; [HC3] i.a. intraventricular and subarachnoid haemorrhage. If ICH corresponding to multiple HCs was observed, we assumed that the (largest) parenchymal ICH would have the greatest prognostic impact. Hence, a single HC was attributed by the following order of severity: HC2, HC1, HC3. The primary outcome was the modified Rankin Scale (mRS) at 90 days. The effect of asymptomatic ICH (aICH) and symptomatic ICH (sICH) of (1) HC1 or HC2 and (2) HC3 on patient outcomes was evaluated with multivariable regression after multiple imputation. RESULTS Out of 651 records, 498 patients were included. Eighty-one (16%) patients showed ICH on post-EVT DECT, of which 19 were classified as HC1 (21% symptomatic), 6 as HC2 (100% symptomatic), and 56 as HC3 (14% symptomatic). ICH development was mainly associated with unfavourable procedural characteristics. Both aICH and sICH of HC1 or HC2 were associated with the mRS (aICH: adjusted [a]cOR 4.92, 95%CI [1.48-16.35]; sICH: acOR 12.97, 95%CI [2.39-70.26]) and mortality (aICH: aOR 10.08, 95%CI [2.48-40.88]; sICH: aOR 9.92, 95%CI [1.48-66.31]). Likewise, sICH of HC3 was associated with the mRS and mortality (acOR 19.91, 95%CI [4.03-98.35], and aOR 13.23, 95%CI [2.27-77.18], respectively). aICH of HC3 was not significantly associated with the mRS or mortality (acOR 0.87, 95%CI [0.48-1.57], and cOR 0.84, 95%CI [0.32-2.20], respectively). CONCLUSIONS Immediate post-EVT ICH is a frequent finding. Except for aICH of HC3, any ICH is associated with poor long-term clinical outcomes.
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Affiliation(s)
- Florentina M E Pinckaers
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands; School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, the Netherlands.
| | - Magretha M Q Robbe
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands; School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, the Netherlands
| | - Susanne G H Olthuis
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, the Netherlands; Department of Neurology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | | | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands; School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, the Netherlands
| | - Robert J van Oostenbrugge
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, the Netherlands; Department of Neurology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Alida A Postma
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, the Netherlands; School for Mental Health and Neuroscience (MHENS), Maastricht University, Maastricht, the Netherlands
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Samuels N, van de Graaf RA, Roos YBWM, Dippel D, van der Lugt A. Advancements in diagnostic and interventional radiology for stroke treatment: the path from trial to bedside through the pre-MR CLEAN, MR CLEAN, and MR CLEAN II eras. Insights Imaging 2024; 15:30. [PMID: 38289430 PMCID: PMC10828318 DOI: 10.1186/s13244-023-01597-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2023] [Accepted: 11/20/2023] [Indexed: 02/02/2024] Open
Abstract
The stroke field is inevitably connected with imaging in which radiologists fulfill a central role. Our landmark MR CLEAN trial led to the implementation of baseline computed tomography angiography or magnetic resonance angiography in the acute stroke workup and subsequent endovascular treatment (EVT) for ischemic stroke patients with a large vessel occlusion in the anterior circulation, resulting in numerous patients worldwide currently being treated often successfully. A reversal of the pathophysiologic process behind an acute cerebrovascular event was made possible. Subsequently, in the MR CLEAN II trials, the clinical impact of both diagnostic and interventional radiologists remained a cornerstone of our research, which means value-based radiology. Within these MR CLEAN II trials, we proved that aspirin and heparin during EVT should be avoided due to increased symptomatic intracranial hemorrhage risk (MR CLEAN-MED). We concluded there is additional benefit of EVT in the 6-to-24-h window after stroke in the presence of good collaterals on baseline CTA (MR CLEAN-LATE). The impactful success of our stroke trials that changed many guidelines was mainly attributable to (1) the societal burden of the disease, with two thirds of patients dying or being independent at 3 months; (2) the fact that stroke is a common disease, (3) the relatively simple and pragmatic approach of the trials resembling real-world setting; (4) the acceleration of implementation in clinical practice facilitated by a structured approach to guideline development and conditional funding; and foremost (5) the excellent collaboration on a professional level between-disciplines, i.e., diagnostic radiologists, interventionalists, and neurologists.Critical relevance statement The MR CLEAN and MR CLEAN II trials have had tremendous impact on clinical practice, directly by more patients being treated with an effective intervention and indirectly through adoption of evidence-based guidelines. It is in this setting of stroke treatment that diagnostic and interventional radiologists have played a crucial role and created clinical impact.
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Affiliation(s)
- Noor Samuels
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Rob A van de Graaf
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands.
| | - Yvo B W M Roos
- Department of Neurology, Amsterdam University Medical Center, Location AMC, Amsterdam, the Netherlands
| | - Diederik Dippel
- Department of Neurology, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center Rotterdam, Rotterdam, the Netherlands
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Huijberts I, Pinckaers FME, van Zwam WH, Boogaarts HD, van Oostenbrugge RJ, Postma AA. Cerebral arterial air emboli on immediate post-endovascular treatment CT are associated with poor short- and long-term clinical outcomes in acute ischaemic stroke patients. J Neuroradiol 2023; 50:530-536. [PMID: 37331695 DOI: 10.1016/j.neurad.2023.06.001] [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: 03/21/2023] [Revised: 05/30/2023] [Accepted: 06/11/2023] [Indexed: 06/20/2023]
Abstract
PURPOSE To determine the incidence and predictors of cerebral arterial air emboli (CAAE) on immediate post-endovascular treatment (EVT) dual-energy CT (DECT) in acute ischaemic stroke (AIS) patients, and describe their association with clinical outcomes. METHODS EVT records from 2010 to 2019 were screened. Exclusion criteria included intracerebral haemorrhage on post-EVT DECT. In the affected middle cerebral artery (MCA)-territory, circular and linear (length ≥ 1.5*width) CAAE were counted. Clinical data were collected from prospective records. The modified Rankin Scale (mRS) at 90 days was the primary outcome. Multivariable linear, logistic, and ordinal regression were used to analyse the effect of (1) linear CAAE and (2) isolated circular CAAE. RESULTS Out of 651 EVT-records, 402 patients were included. In 65 patients (16%), at least one linear CAAE was found in the affected MCA-territory. 17 patients (4%) showed isolated circular CAAE. Multivariable regression showed an association between both the presence and the number of linear CAAE and the mRS at 90 days (presence: adjusted (a)cOR 3.10, 95%CI 1.75-5.50; number: acOR 1.28, 95%CI 1.13-1.44), NIHSS at 24-48 h (presence: aβ 4.15, 95%CI 1.87-6.43; number: aβ 0.88, 95%CI 0.42-1.34), mortality at 90 days (presence: aOR 3.34, 95%CI 1.51-7.40; number: aOR 1.24, 95%CI 1.08-1.43) and stroke progression (presence: aOR 4.01, 95%CI 1.96-8.18; number: aOR 1.31, 95%CI 1.15-1.50). Isolated circular CAAE were not significantly associated with any outcome measure. CONCLUSION CAAE were found frequently on post-EVT CT imaging. The presence and the number of linear CAAE, but not circular CAAE, are associated with unfavourable short- and long-term clinical outcomes.
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Affiliation(s)
- Ilse Huijberts
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, the Netherlands; Faculty of Health, Medicine and Life Sciences (FHML), Maastricht University, Maastricht, the Netherlands
| | - Florentina M E Pinckaers
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, the Netherlands; School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, the Netherlands.
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, the Netherlands; School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, the Netherlands
| | | | - Robert J van Oostenbrugge
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, the Netherlands; Department of Neurology, Maastricht University Medical Centre+, Maastricht, the Netherlands
| | - Alida A Postma
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre+, the Netherlands; School for Mental Health and Neuroscience (MHENS), Maastricht University, Maastricht, the Netherlands
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Wang J, Wang Y, Xiaohalati X, Su Q, Liu J, Cai B, Yang W, Wang Z, Wang L. A Bioinspired Manganese-Organic Framework Ameliorates Ischemic Stroke through its Intrinsic Nanozyme Activity and Upregulating Endogenous Antioxidant Enzymes. ADVANCED SCIENCE (WEINHEIM, BADEN-WURTTEMBERG, GERMANY) 2023; 10:e2206854. [PMID: 37129343 PMCID: PMC10369237 DOI: 10.1002/advs.202206854] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/22/2022] [Revised: 03/21/2023] [Indexed: 05/03/2023]
Abstract
Following stroke, oxidative stress induced by reactive oxygen species (ROS) aggravates neuronal damage and enlarges ischemic penumbra, which is devastating to stroke patients. Nanozyme-based antioxidants are emerging to treat stroke through scavenging excessive ROS. However, most of nanozymes cannot efficiently scavenge ROS in neuronal cytosol and mitochondria, due to low-uptake abilities of neurons and barriers of organelle membranes, significantly limiting nanozymes' neuroprotective effects. To overcome this limitation, a manganese-organic framework modified with polydopamine (pDA-MNOF), capable of not only mimicking catalytic activities of natural SOD2's catalytic domain but also upregulating two endogenous antioxidant enzymes in neurons is fabricated. With such a dual anti-ROS effect, this nanozyme robustly decreases cellular ROS and effectively protects them from ROS-induced injury. STAT-3 signaling is found to play a vital role in pDA-MNOF activating the two antioxidant enzymes, HO1 and SOD2. In vivo pDA-MNOF treatment significantly improves the survival of middle cerebral artery occlusion (MCAo) mice by reducing infarct volume and more importantly, promotes animal behavioral recovery. Further, pDA-MNOF activates vascular endothelial growth factor expression, a downstream target of STAT3 signaling, thus enhancing angiogenesis. Taken together, the biochemical, cell-biological, and animal-level behavioral data demonstrate the potentiality of pDA-MNOF as a dual ROS-scavenging agent for stroke treatment.
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Affiliation(s)
- Jian Wang
- Department of Clinical LaboratoryUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022P. R. China
- Hubei Key Laboratory of Regenerative Medicine and Multi‐disciplinary Translational ResearchResearch Center for Tissue Engineering and Regenerative MedicineUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022P. R. China
| | - Yang Wang
- Department of Clinical LaboratoryUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022P. R. China
- Hubei Key Laboratory of Regenerative Medicine and Multi‐disciplinary Translational ResearchResearch Center for Tissue Engineering and Regenerative MedicineUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022P. R. China
| | - Xiakeerzhati Xiaohalati
- Hubei Key Laboratory of Regenerative Medicine and Multi‐disciplinary Translational ResearchResearch Center for Tissue Engineering and Regenerative MedicineUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022P. R. China
| | - Qiangfei Su
- Department of Clinical LaboratoryUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022P. R. China
- Hubei Key Laboratory of Regenerative Medicine and Multi‐disciplinary Translational ResearchResearch Center for Tissue Engineering and Regenerative MedicineUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022P. R. China
| | - Jingwei Liu
- Hubei Key Laboratory of Regenerative Medicine and Multi‐disciplinary Translational ResearchResearch Center for Tissue Engineering and Regenerative MedicineUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022P. R. China
| | - Bo Cai
- Hubei Key Laboratory of Regenerative Medicine and Multi‐disciplinary Translational ResearchResearch Center for Tissue Engineering and Regenerative MedicineUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022P. R. China
| | - Wen Yang
- Hubei Key Laboratory of Regenerative Medicine and Multi‐disciplinary Translational ResearchResearch Center for Tissue Engineering and Regenerative MedicineUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022P. R. China
| | - Zheng Wang
- Hubei Key Laboratory of Regenerative Medicine and Multi‐disciplinary Translational ResearchResearch Center for Tissue Engineering and Regenerative MedicineUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022P. R. China
- Department of Gastrointestinal SurgeryUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022P. R. China
| | - Lin Wang
- Department of Clinical LaboratoryUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022P. R. China
- Hubei Key Laboratory of Regenerative Medicine and Multi‐disciplinary Translational ResearchResearch Center for Tissue Engineering and Regenerative MedicineUnion HospitalTongji Medical CollegeHuazhong University of Science and TechnologyWuhan430022P. R. China
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Pinckaers FME, Mentink MMG, Boogaarts HD, van Zwam WH, van Oostenbrugge RJ, Postma AA. Early post-endovascular treatment contrast extravasation on dual-energy CT is associated with clinical and radiological stroke outcomes: A 10-year single-centre experience. Eur Stroke J 2023; 8:508-516. [PMID: 37231689 PMCID: PMC10334176 DOI: 10.1177/23969873231157901] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 01/31/2023] [Indexed: 11/22/2023] Open
Abstract
OBJECTIVE To determine the association between early post-endovascular treatment (EVT) contrast extravasation (CE) on dual-energy CT (DECT) and stroke outcomes. METHODS EVT records in 2010-2019 were screened. Exclusion criteria included the occurrence of immediate post-procedural intracranial haemorrhage (ICH). Hyperdense areas on iodine overlay maps were scored according to the Alberta Stroke Programme Early CT Score (ASPECTS), thus forming a CE-ASPECTS. Maximum parenchymal iodine concentration and maximum iodine concentration relative to the torcula were recorded. Follow-up imaging was reviewed for ICH. The primary outcome measure was the modified Rankin Scale (mRS) at 90 days. RESULTS Out of 651 records, 402 patients were included. CE was found in 318 patients (79%). Thirty-five patients developed ICH on follow-up imaging. Fourteen ICHs were symptomatic. Stroke progression occurred in 59 patients. Multivariable regression showed a significant association between decreasing CE-ASPECTS and the mRS at 90 days (adjusted (a)cOR: 1.10, 95% CI: 1.03-1.18), NIHSS at 24-48 h (aβ: 0.57, 95% CI: 0.29-0.84), stroke progression (aOR: 1.14, 95% CI: 1.03-1.26) and ICH (aOR: 1.21, 95% CI: 1.06-1.39), but not symptomatic ICH (aOR 1.19, 95% CI: 0.95-1.38). Iodine concentration was significantly associated with the mRS (acOR: 1.18, 95% CI: 1.06-1.32), NIHSS (aβ: 0.68, 95% CI: 0.30-1.06), ICH (aOR: 1.37, 95% CI: 1.04-1.81) and symptomatic ICH (aOR: 1.19, 95% CI: 1.02-1.38), but not stroke progression (aOR: 0.99, 95% CI: 0.86-1.15). Results of the analyses with relative iodine concentration were similar and did not improve prediction. CONCLUSIONS CE-ASPECTS and iodine concentration are both associated with short- and long-term stroke outcomes. CE-ASPECTS is likely a better predictor for stroke progression.
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Affiliation(s)
- Florentina ME Pinckaers
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Max MG Mentink
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
| | | | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Robert J van Oostenbrugge
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
- Department of Neurology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Alida A Postma
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
- School for Mental Health and Neuroscience (MHENS), Maastricht University, Maastricht, The Netherlands
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Olthuis SGH, den Hartog SJ, van Kuijk SMJ, Staals J, Benali F, van der Leij C, Beumer D, Lycklama à Nijeholt GJ, Uyttenboogaart M, Martens JM, van Doormaal PJ, Vos JA, Emmer BJ, Dippel DWJ, van Zwam WH, van Oostenbrugge RJ, de Ridder IR. Influence of the interventionist's experience on outcomes of endovascular thrombectomy in acute ischemic stroke: results from the MR CLEAN Registry. J Neurointerv Surg 2023; 15:113-119. [PMID: 35058316 PMCID: PMC9872238 DOI: 10.1136/neurintsurg-2021-018295] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2021] [Accepted: 12/23/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND The relationship between the interventionist's experience and outcomes of endovascular thrombectomy (EVT) for acute ischemic stroke of the anterior circulation, is unclear. OBJECTIVE To assess the effect of the interventionist's level of experience on clinical, imaging, and workflow outcomes. Secondly, to determine which of the three experience definitions is most strongly associated with these outcome measures. METHODS We analysed data from 2700 patients, included in the MR CLEAN Registry. We defined interventionist's experience as the number of procedures performed in the year preceding the intervention (EXPfreq), total number of procedures performed (EXPno), and years of experience (EXPyears). Our outcomes were the baseline-adjusted National Institutes of Health Stroke Scale (NIHSS) score at 24-48 hours post-EVT, recanalization (extended Thrombolysis in Cerebral Infarction (eTICI) score ≥2B), and procedural duration. We used multilevel regression models with interventionists as random intercept. For EXPfreq and EXPno results were expressed per 10 procedures. RESULTS Increased EXPfreq was associated with lower 24-48 hour NIHSS scores (adjusted (a)β:-0.46, 95% CI -0.70 to -0.21). EXPno and EXPyears were not associated with short-term neurological outcomes. Increased EXPfreq and EXPno were both associated with recanalization (aOR=1.20, 95% CI 1.11 to 1.31 and aOR=1.08, 95% CI 1.04 to 1.12, respectively), and increased EXPfreq, EXPno, and EXPyears were all associated with shorter procedure times (aβ:-3.08, 95% CI-4.32 to -1.84; aβ:-1.34, 95% CI-1.84 to -0.85; and aβ:-0.79, 95% CI-1.45 to -0.13, respectively). CONCLUSIONS Higher levels of interventionist's experience are associated with better outcomes after EVT, in particular when experience is defined as the number of patients treated in the preceding year. Every 20 procedures more per year is associated with approximately one NIHSS score point decrease, an increased probability for recanalization (aOR=1.44), and a 6-minute shorter procedure time.
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Affiliation(s)
- Susanne G H Olthuis
- Department of Neurology, Maastricht University Medical Center+, Maastricht, The Netherlands,Maastricht University CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Sanne J den Hartog
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands,Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands,Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Julie Staals
- Department of Neurology, Maastricht University Medical Center+, Maastricht, The Netherlands,Maastricht University CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Faysal Benali
- Maastricht University CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Christiaan van der Leij
- Maastricht University CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Debbie Beumer
- Department of Neurology, Maastricht University Medical Center+, Maastricht, The Netherlands,Maastricht University CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | | | - Maarten Uyttenboogaart
- Department of Neurology and Medical Imaging Center, University Medical Center Groningen, Groningen, The Netherlands
| | - Jasper M Martens
- Department of Radiology, Rijnstate Hospital, Arnhem, The Netherlands
| | - Pieter-Jan van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Jan Albert Vos
- Department of Radiology, Sint Antonius Hospital, Nieuwegein, The Netherlands
| | - Bart J Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC, University Medical Center, Rotterdam, The Netherlands
| | - Wim H van Zwam
- Maastricht University CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands,Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, Maastricht University Medical Center+, Maastricht, The Netherlands,Maastricht University CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
| | - Inger R de Ridder
- Department of Neurology, Maastricht University Medical Center+, Maastricht, The Netherlands,Maastricht University CARIM School for Cardiovascular Diseases, Maastricht, The Netherlands
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Khan NR, Elarjani T, Jamshidi AM, Lu VM, Silva MA, Richardson A, Harrington T, Valdes T, Campo N, Krementz N, Asdaghi N, Sur N, Londono EM, Malik AM, Koch S, Romano J, Morcos JJ. Direct Bypass Surgery for Moyamoya and Steno-occlusive Vasculopathy: Clinical Outcomes, Intraoperative Blood Flow Analysis, Long-term Follow-up, and Long-term Bypass Patency in a Single Surgeon Case Series of 162 Procedures. World Neurosurg 2022; 168:e500-e517. [DOI: 10.1016/j.wneu.2022.10.015] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Revised: 10/04/2022] [Accepted: 10/05/2022] [Indexed: 11/06/2022]
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9
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The Association between Hypoxia-Induced Low Activity and Apoptosis Strongly Resembles That between TTX-Induced Silencing and Apoptosis. Int J Mol Sci 2022; 23:ijms23052754. [PMID: 35269895 PMCID: PMC8911517 DOI: 10.3390/ijms23052754] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2022] [Revised: 02/16/2022] [Accepted: 02/26/2022] [Indexed: 01/27/2023] Open
Abstract
In the penumbra of a brain infarct, neurons initially remain structurally intact, but perfusion is insufficient to maintain neuronal activity at physiological levels. Improving neuronal recovery in the penumbra has large potential to advance recovery of stroke patients, but penumbral pathology is incompletely understood, and treatments are scarce. We hypothesize that low activity in the penumbra is associated with apoptosis and thus contributes to irreversible neuronal damage. We explored the putative relationship between low neuronal activity and apoptosis in cultured neurons exposed to variable durations of hypoxia or TTX. We combined electrophysiology and live apoptosis staining in 42 cultures, and compared effects of hypoxia and TTX silencing in terms of network activity and apoptosis. Hypoxia rapidly reduced network activity, but cultures showed limited apoptosis during the first 12 h. After 24 h, widespread apoptosis had occurred. This was associated with full activity recovery observed upon reoxygenation within 12 h, but not after 24 h. Similarly, TTX exposure strongly reduced activity, with full recovery upon washout within 12 h, but not after 24 h. Mean temporal evolution of apoptosis in TTX-treated cultures was the same as in hypoxic cultures. These results suggest that prolonged low activity may be a common factor in the pathways towards apoptosis.
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10
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Wang J, Su Q, Lv Q, Cai B, Xiaohalati X, Wang G, Wang Z, Wang L. Oxygen-Generating Cyanobacteria Powered by Upconversion-Nanoparticles-Converted Near-Infrared Light for Ischemic Stroke Treatment. NANO LETTERS 2021; 21:4654-4665. [PMID: 34008994 DOI: 10.1021/acs.nanolett.1c00719] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/12/2023]
Abstract
Stroke is one of most common causes of death and disability. Most of neuroprotective agents fail to rescue neurons from cerebral ischemic insults, mainly because of targeting downstream cascading events, such as excitotoxicity, oxidative and nitrosative stress, and inflammation, rather than improving hypoxia that initially occurs. Here, we report a near-infrared light (NIR)-driven nanophotosynthesis biosystem capable of generating oxygen and absorbing carbon dioxide, thus rescuing neurons from ischemia toward treating stroke. Through cerebral delivery of S. elongatus that spontaneously photosynthesize and upconversion nanoparticles (UCNPs), NIR with excellent tissue penetrating capability is converted to visible light by UCNPs to activate S. elongatus generating oxygen in vivo, enhancing angiogenesis, reducing infarction, and facilitating repair of brain tissues, thus improving neuronal function recovery. The combination of cell-biological, biochemical, and animal-level behavioral data provides compelling evidence demonstrating that this oxygen-generating biosystem through jointly utilizing microorganism and nanotechnology represents a novel approach to stroke treatment.
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Affiliation(s)
- Jian Wang
- Department of Clinical Laboratory, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Research Center for Tissue Engineering and Regenerative Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Qiangfei Su
- Research Center for Tissue Engineering and Regenerative Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Qiying Lv
- Research Center for Tissue Engineering and Regenerative Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Bo Cai
- Research Center for Tissue Engineering and Regenerative Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Xiakeerzhati Xiaohalati
- Research Center for Tissue Engineering and Regenerative Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Guobin Wang
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Zheng Wang
- Research Center for Tissue Engineering and Regenerative Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Department of Gastrointestinal Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
| | - Lin Wang
- Department of Clinical Laboratory, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
- Research Center for Tissue Engineering and Regenerative Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430022, China
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11
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Wiegers EJA, Compagne KCJ, Janssen PM, Venema E, Deckers JW, Schonewille WJ, Albert Vos J, Lycklama À Nijeholt GJ, Roozenbeek B, Martens JM, Hofmeijer J, van Oostenbrugge RJ, van Zwam WH, Majoie CBLM, van der Lugt A, Lingsma HF, Roos YBWEM, Dippel DWJ. Path From Clinical Research to Implementation: Endovascular Treatment of Ischemic Stroke in the Netherlands. Stroke 2020; 51:1941-1950. [PMID: 32568637 DOI: 10.1161/strokeaha.119.026731] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Before 2015, endovascular treatment (EVT) for acute ischemic stroke was considered a promising treatment option. Based on limited evidence, it was performed in several dedicated stroke centers worldwide on selected patients. Since 2015, EVT for patients with intracranial large vessel occlusion has quickly been implemented as standard treatment in many countries worldwide, supported by the revised international guidelines based on solid evidence from multiple clinical trials. We describe the development in use of EVT in the Netherlands before, during, and after the pivotal EVT trials. We used data from all patients who were treated with EVT in the Netherlands from January 2002 until December 2018. We undertook a time-series analysis to examine trends in the use of EVT using Poisson regression analysis. Incidence rate ratios per year with 95% CIs were obtained to demonstrate the impact and implementation after the publication of the EVT trial results. We made regional observation plots, adjusted for stroke incidence, to assess the availability and use of the treatment in the country. In the buildup to the MR CLEAN (Multicenter Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands), a slow increase of EVT patients was observed, with 0.2% of all ischemic stroke patients receiving EVT. Before the trial results were formally announced, a statistically significant increase in EVT-treated patients per year was observed (incidence rate ratio, 1.72 [95% CI, 1.46-2.04]), and after the trial publication, an immediate steep increase was seen, followed by a more gradual increase (incidence rate ratio, 2.14 [95% CI, 1.77-2.59]). In 2018, the percentage of ischemic stroke patients receiving EVT increased to 5.8%. A well-developed infrastructure, a pragmatic approach toward the use of EVT in clinical practice, in combination with a strict adherence by the regulatory authorities to national evidence-based guidelines has led to successful implementation of EVT in the Netherlands. Ongoing efforts are directed at further increasing the proportion of stroke patients with EVT in all regions of the country.
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Affiliation(s)
- Eveline J A Wiegers
- Department of Public Health (E.J.A.W., E.V., H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Kars C J Compagne
- Department of Radiology and Nuclear Medicine (K.C.J.C., A.v.d.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Neurology (K.C.J.C., P.M.J., E.V., B.R., D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Paula M Janssen
- Department of Neurology (K.C.J.C., P.M.J., E.V., B.R., D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Esmee Venema
- Department of Public Health (E.J.A.W., E.V., H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Neurology (K.C.J.C., P.M.J., E.V., B.R., D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Jaap W Deckers
- Department of Cardiology, Thoraxcenter, Erasmus MC, Rotterdam, the Netherlands (J.W.D.)
| | - Wouter J Schonewille
- Department of Neurology (W.J.S.), St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Jan Albert Vos
- Department of Radiology (J.A.V.), St. Antonius Hospital, Nieuwegein, the Netherlands
| | | | - Bob Roozenbeek
- Department of Neurology (K.C.J.C., P.M.J., E.V., B.R., D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Jasper M Martens
- Department of Radiology, Rijnstate Hospital, Arnhem, the Netherlands (J.M.M.)
| | - Jeannette Hofmeijer
- Department of Clinical Neurophysiology, Clinical Neurophysiology, University of Twente, Enschede, the Netherlands (J.H.)
| | - Robert-Jan van Oostenbrugge
- Cardiovascular Research Institute Maastricht, Maastricht University, the Netherlands (R.-J.v.O., W.H.v.Z.).,Department of Neurology (R.-J.v.O.), Maastricht University Medical Center, the Netherlands
| | - Wim H van Zwam
- Cardiovascular Research Institute Maastricht, Maastricht University, the Netherlands (R.-J.v.O., W.H.v.Z.).,Department of Radiology (W.H.v.Z.), Maastricht University Medical Center, the Netherlands
| | | | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine (K.C.J.C., A.v.d.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - H F Lingsma
- Department of Public Health (E.J.A.W., E.V., H.F.L.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Yvo B W E M Roos
- Department of Neurology (Y.B.W.E.M.R.), Amsterdam UMC, the Netherlands
| | - Diederik W J Dippel
- Department of Neurology (K.C.J.C., P.M.J., E.V., B.R., D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
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12
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Link TW, Santillan A, Patsalides A. Intra-arterial neuroprotective therapy as an adjunct to endovascular intervention in acute ischemic stroke: A review of the literature and future directions. Interv Neuroradiol 2020; 26:405-415. [PMID: 32423272 DOI: 10.1177/1591019920925677] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
Mechanical thrombectomy for acute ischemic stroke due to large vessel occlusion has been shown to significantly improve outcomes. However, despite efficient rates of recanalization (60-90%), the rates of functional independence remain suboptimal (14-58%), most likely due to pathways of cell death in the brain that have already committed despite successful reperfusion. Pharmacologic neuroprotection provides a potential means of preventing this inevitable damage through targeting excitotoxicity, reactive oxygen species, cellular apoptosis, and inflammation. Numerous clinical trials using various neuroprotective agents have failed, but the majority of these trials did not include endovascular reperfusion, and thus the drugs were not reaching the therapeutic target. Intra-arterial delivery of neuroprotective agents via the guide catheter already in place for mechanical thrombectomy could provide a way to deliver high doses directly to the affected territory while limiting systemic exposure. Agents that have shown promise via the intra-arterial route in preclinical as well as some clinical models include magnesium sulfate, verapamil, cold saline, stem cells, and various combined approaches. Targeted hypothermia, achieved with intra-carotid infusion of cold saline, may provide an effective means of achieving hypothermia of the ischemic tissue while avoiding the systemic effects that have limited its use previously. Combination therapy of targeted hypothermia and a cocktail of drugs that provide anti-excitotoxic, anti-oxidant, anti-apopototic, and anti-inflammatory effects may provide an ideal approach that deserves further study in clinical trials.
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Affiliation(s)
- Thomas W Link
- Department of Neurosurgery, Weill Cornell Medical Institution New York Presbyterian Hospital, New York, NY, USA
| | - Alejandro Santillan
- Department of Neurosurgery, Weill Cornell Medical Institution New York Presbyterian Hospital, New York, NY, USA
| | - Athos Patsalides
- Department of Neurology, Weill Cornell Medical Institution New York Presbyterian Hospital, New York, NY, USA
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13
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Pirson FAV, van Oostenbrugge RJ, van Zwam WH, Remmers MJ, Dippel DW, van Es AC, van den Wijngaard IR, Schonewille WJ, Staals J. Repeated Endovascular Thrombectomy in Patients With Acute Ischemic Stroke. Stroke 2020; 51:526-532. [DOI: 10.1161/strokeaha.119.027525] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Patients with acute ischemic stroke treated with endovascular thrombectomy may be treated with repeat endovascular thrombectomy (rEVT) in case of recurrent large vessel occlusion. Data on safety and efficacy of these interventions is scarce. Our aim is to report on frequency, timing, and outcome of rEVT in a large nation-wide multicenter registry.
Methods—
In the Netherlands, all patients with endovascular thrombectomy have been registered since 2002 (MR CLEAN Pretrial registry, MR CLEAN Trial [Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands], and MR CLEAN Registry). We retrospectively reviewed these databases for anterior circulation rEVT cases. Patient characteristics, procedural data, and functional outcome (modified Rankin Scale at 90 days) were analyzed.
Results—
Of 3928 patients treated between 2002 and 2017, 27 (0.7%) underwent rEVT. Median time between first and second procedure was 78 (1–1122) days; 11/27 patients were re-treated within 30 days. Cardioembolism was the most common etiology (18 patients [67%]). In 19 patients (70%), recurrent occlusion occurred ipsilateral to previous occlusion. At 90 days after rEVT procedure, 44% of the patients had achieved functional independence (modified Rankin Scale score of 0–2), and 33% had died. Adverse events were 2/27 (7.4%) intracranial hemorrhage, 1/27 (3.7%) stroke progression, and 1/27 (3.7%) pneumonia.
Conclusions—
In this large nationwide cohort of patients with acute ischemic stroke treated with endovascular thrombectomy, rEVT was rare. Stroke cause was mainly cardio-embolic, and most recurrent large vessel occlusions in which rEVT was performed occurred ipsilateral. Although there probably is a selection bias on repeated treatment in case of recurrent large vessel occlusion, rEVT appears safe, with similar outcome as in single-treated cases.
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Affiliation(s)
- France Anne Victoire Pirson
- From the Department of Neurology (F.A.V.P., R.J.v.O., J.S.), Maastricht University Medical Center, the Netherlands
| | - Robert J. van Oostenbrugge
- From the Department of Neurology (F.A.V.P., R.J.v.O., J.S.), Maastricht University Medical Center, the Netherlands
| | - Wim H. van Zwam
- Department of Radiology (W.H.v.Z.), Maastricht University Medical Center, the Netherlands
| | | | - Diederik W.J. Dippel
- Department of Neurology (D.W.J.D.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Adriaan C.G.M. van Es
- Department of Radiology and Nuclear Medicine (A.C.G.M.v.E.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | - Wouter J. Schonewille
- Department of Neurology, St. Antonius Hospital, Nieuwegein, the Netherlands (W.J.S.)
| | - Julie Staals
- From the Department of Neurology (F.A.V.P., R.J.v.O., J.S.), Maastricht University Medical Center, the Netherlands
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14
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Behme D, Tsogkas I, Colla R, Gera RG, Schregel K, Hesse AC, Maier IL, Liman J, Liebeskind DS, Psychogios MN. Validation of the extended thrombolysis in cerebral infarction score in a real world cohort. PLoS One 2019; 14:e0210334. [PMID: 30629664 PMCID: PMC6328192 DOI: 10.1371/journal.pone.0210334] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/17/2018] [Accepted: 12/20/2018] [Indexed: 11/19/2022] Open
Abstract
Background A thrombolysis in cerebral infarction (TICI) score of 2b is defined as a good recanalization result although the reperfusion may only cover 50% of the affected territory. An additional mTICI2c category was introduced to further differentiate between mTICI scores. Despite the new mTICI2c category, mTICI2b still covers a range of 50–90% reperfusion which might be too imprecise to predict neurological improvement after therapy. Aim To compare the 7-point “expanded TICI” (eTICI) scale with the traditional mTICI in regard to predict functional independence at 90 days. Methods Retrospective review of 225 patients with large artery occlusion. Angiograms were graded by 2 readers according the 7-point eTICI score (0% = eTICI0; reduced clot = eTICI1; 1–49% = eTICI2a, 50–66% = eTICI2b50; 67–89% = eTICI2b67, 90–99% = eTICI2c and complete reperfusion = eTICI3) and the conventional mTICI score. The ability of e- and mTICI to predict favorable outcome at 90days was compared. Results Given the ROC analysis eTICI was the better predictor of favorable outcome (p-value 0.047). Additionally, eTICI scores 2b50, 2b67 and 2c (former mTICI2b) were significantly superior at predicting the probability of a favorable outcome at 90 days after endovascular therapy with a p-value of 0.033 (probabilities of 17% for mTICI2b50, 24% for mTICI2b67 and 54% for mTICI2c vs. 36% for mTICI2b). Conclusions The 7-point eTICI allows for a more accurate outcome prediction compared to the mTICI score because it refines the broad range of former mTICI2b results.
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Affiliation(s)
- Daniel Behme
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - Ioannis Tsogkas
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - Ruben Colla
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - Roland G. Gera
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Katharina Schregel
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - Amélie C. Hesse
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - Ilko L. Maier
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Jan Liman
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - David S. Liebeskind
- Neurovascular Imaging Research Core and Stroke Center, Department of Neurology, UCLA, Los Angeles, CA, United States of America
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
- * E-mail:
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15
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Fraser JF, Maniskas M, Trout A, Lukins D, Parker L, Stafford WL, Alhajeri A, Roberts J, Bix GJ. Intra-arterial verapamil post-thrombectomy is feasible, safe, and neuroprotective in stroke. J Cereb Blood Flow Metab 2017; 37:3531-3543. [PMID: 28429604 PMCID: PMC5669346 DOI: 10.1177/0271678x17705259] [Citation(s) in RCA: 40] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Large vessel ischemic stroke represents the most disabling subtype. While t-PA and endovascular thrombectomy can recanalize the occluded vessel, good clinical outcomes are not uniformly achieved. We propose that supplementing endovascular thrombectomy with superselective intra-arterial (IA) verapamil immediately following recanalization could be safe and effective. Verapamil, a calcium channel blocker, has been shown to be an effective IA adjunct in a pre-clinical mouse focal ischemia model. To demonstrate translational efficacy, mechanism, feasibility, and safety, we conducted a group of translational experiments. We performed in vivo IA dose-response evaluation in our animal stroke model with C57/Bl6 mice. We evaluated neuroprotective mechanism through in vitro primary cortical neuron (PCN) cultures. Finally, we performed a Phase I trial, SAVER-I, to evaluate feasibility and safety of administration in the human condition. IA verapamil has a likely plateau or inverted-U dose-response with a defined toxicity level in mice (LD50 16-17.5 mg/kg). Verapamil significantly prevented PCN death and deleterious ischemic effects. Finally, the SAVER-I clinical trial showed no evidence that IA verapamil increased the risk of intracranial hemorrhage or other adverse effect/procedural complication in human subjects. We conclude that superselective IA verapamil administration immediately following thrombectomy is safe and feasible, and has direct, dose-response-related benefits in ischemia.
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Affiliation(s)
- Justin F Fraser
- 1 Department of Neurological Surgery, University of Kentucky, Lexington, KY, USA.,2 Department of Neurology, University of Kentucky, Lexington, KY, USA.,3 Department of Radiology, University of Kentucky, Lexington, KY, USA.,4 Department of Anatomy & Neurobiology, University of Kentucky, Lexington, KY, USA
| | - Michael Maniskas
- 1 Department of Neurological Surgery, University of Kentucky, Lexington, KY, USA.,4 Department of Anatomy & Neurobiology, University of Kentucky, Lexington, KY, USA
| | - Amanda Trout
- 4 Department of Anatomy & Neurobiology, University of Kentucky, Lexington, KY, USA
| | - Doug Lukins
- 3 Department of Radiology, University of Kentucky, Lexington, KY, USA
| | - Lindsey Parker
- 1 Department of Neurological Surgery, University of Kentucky, Lexington, KY, USA
| | - W Lane Stafford
- 3 Department of Radiology, University of Kentucky, Lexington, KY, USA
| | - Abdulnasser Alhajeri
- 1 Department of Neurological Surgery, University of Kentucky, Lexington, KY, USA.,2 Department of Neurology, University of Kentucky, Lexington, KY, USA.,3 Department of Radiology, University of Kentucky, Lexington, KY, USA
| | - Jill Roberts
- 4 Department of Anatomy & Neurobiology, University of Kentucky, Lexington, KY, USA.,5 Sanders Brown Center on Aging, University of Kentucky, Lexington, KY, USA
| | - Gregory J Bix
- 1 Department of Neurological Surgery, University of Kentucky, Lexington, KY, USA.,2 Department of Neurology, University of Kentucky, Lexington, KY, USA.,4 Department of Anatomy & Neurobiology, University of Kentucky, Lexington, KY, USA.,5 Sanders Brown Center on Aging, University of Kentucky, Lexington, KY, USA
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16
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Neuhaus AA, Couch Y, Hadley G, Buchan AM. Neuroprotection in stroke: the importance of collaboration and reproducibility. Brain 2017. [DOI: 10.1093/brain/awx126] [Citation(s) in RCA: 124] [Impact Index Per Article: 17.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Affiliation(s)
- Ain A Neuhaus
- Acute Stroke Programme, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Yvonne Couch
- Acute Stroke Programme, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Gina Hadley
- Acute Stroke Programme, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
| | - Alastair M Buchan
- Acute Stroke Programme, Radcliffe Department of Medicine, University of Oxford, Oxford, UK
- Medical Sciences Division, University of Oxford, Oxford, UK
- Acute Vascular Imaging Centre, University of Oxford, Oxford University Hospitals, Oxford, UK
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17
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Protective roles of intra-arterial mild hypothermia and arterial thrombolysis in acute cerebral infarction. SPRINGERPLUS 2016; 5:1988. [PMID: 27917359 PMCID: PMC5114217 DOI: 10.1186/s40064-016-3654-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Accepted: 11/04/2016] [Indexed: 11/24/2022]
Abstract
Objective
Herein, we evaluated the efficacy and safety of intra-arterial mild hypothermia in combination with arterial thrombolysis to treat acute cerebral infarction due to middle cerebral artery occlusion. Methods A total of 26 patients with acute middle cerebral artery occlusion were divided into a normothermia group (n = 15) and a mild hypothermia group (n = 11). The infarct volumes at 24 h and 7 days after the operation were compared between the normothermia group and the mild hypothermia group. Additionally, we compared neurological deficit scores between the two groups at 24 h, 7 days, and 1 mo after the operation. Results The infarct volumes and neurological deficit scores of the mild hypothermia group were significantly reduced compared to those in the normothermia group (p < 0.05). Furthermore, no adverse reactions or complications occurred in the mild hypothermia group. Conclusion Intra-arterial mild hypothermia reduced infarct volume after ischemia–reperfusion injury in the arterial thrombolysis of an acute cerebral infarction. Additionally, it improved the prognosis of patients with an acute middle cerebral artery occlusion, suggesting that this procedure is safe and effective for treating acute cerebral infarction.
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18
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Beumer D, Rozeman AD, Lycklama À Nijeholt GJ, Brouwer PA, Jenniskens SFM, Algra A, Boiten J, Schonewille W, van Oostenbrugge RJ, Dippel DWJ, van Zwam WH. The effect of age on outcome after intra-arterial treatment in acute ischemic stroke: a MR CLEAN pretrial study. BMC Neurol 2016; 16:68. [PMID: 27185043 PMCID: PMC4869391 DOI: 10.1186/s12883-016-0592-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2015] [Accepted: 05/09/2016] [Indexed: 11/12/2022] Open
Abstract
Background In recent randomized controlled trials (RCTs) intra-arterial treatment (IAT) has been proven effective and safe for patients with acute ischemic stroke (AIS). So far, there seemed to be no interaction between older age (>80) and main treatment effect. We studied the association of older age with outcome and adverse events after IAT in a cohort of intra arterially treated patients. Methods and findings Data from all AIS patients with proven proximal anterior circulation cerebral artery occlusion who were intra arterially treated between 2002 until the start of the MR CLEAN trial were studied retrospectively. Duration of the procedure, recanalization (Thrombolysis In Cerebral Infarction score (TICI)), early neurological recovery (i.e. decrease on NIHSS of ≥ 8 points) after one week or at discharge, good functional outcome at discharge by modified Rankin Scale (mRS ≤ 2) and the occurrence of neurological and non-neurological adverse events were assessed and the association with age was investigated. In total 315 patients met our inclusion criteria. Median age was 63 years (range 22–93) and 17 patients (5.4 %) were over 80. Age was inversely associated with good functional outcome (adjusted Odds Ratio (aOR) 0.80, 95 % CI: 0.66–0.98) for every 10 years increase of age. Age was not associated with longer duration of the procedure, lower recanalization rate or less early neurological recovery. The risk of all adverse events (aOR 1.27; 95 % CI: 1.08–1.50) and non-neurological adverse events (aOR 1.34; 95 % CI: 1.11–1.61) increased, but that of peri-procedural adverse events (aOR 0.79; 95 % CI: 0.66–0.94) decreased with age. Conclusion Higher age is inversely associated with good functional outcome after IAT in patients with AIS. However, treatment related adverse events are not related to age. These findings may help decision making when considering treatment of older patients with AIS.
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Affiliation(s)
- Debbie Beumer
- Department of Neurology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Oxfordlaan 10, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands. .,Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands.
| | - Anouk D Rozeman
- Department of Neurology, MC Haaglanden, The Hague, The Netherlands
| | | | - Patrick A Brouwer
- Department of Radiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Sjoerd F M Jenniskens
- Department of Radiology, Nijmegen University Medical Center, Nijmegen, The Netherlands
| | - Ale Algra
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, Utrecht University Medical Center, Utrecht, The Netherlands.,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Jelis Boiten
- Department of Neurology, MC Haaglanden, The Hague, The Netherlands
| | - Wouter Schonewille
- Department of Neurology, St. Antonius hospital, Nieuwegein, The Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology and Cardiovascular Research Institute Maastricht (CARIM), Maastricht University Medical Center, Oxfordlaan 10, P.O. Box 5800, 6202 AZ, Maastricht, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, Rotterdam, The Netherlands
| | - Wim H van Zwam
- Department of Radiology, Maastricht University Medical Center, Maastricht, The Netherlands
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