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Guo M, Yue C, Yang J, Hu J, Guo C, Peng Z, Xu R, Yang D, Kong W, Liu X, Huang J, Tian Y, Li F, Li CQ. Thrombectomy alone versus intravenous thrombolysis before thrombectomy for acute basilar artery occlusion. J Neurointerv Surg 2024; 16:794-800. [PMID: 37665653 DOI: 10.1136/jnis-2023-020361] [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: 03/23/2023] [Accepted: 07/05/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Endovascular treatment (EVT) is a well-established approach for acute ischemic stroke. Whether bridging intravenous thrombolysis (IVT) before EVT confers any benefits remains uncertain. The objective of the study was to compare the efficacy and safety of direct EVT with or without bridging IVT in patients with acute basilar artery occlusion (BAO). METHODS This multicenter cohort study enrolled 647 patients with acute BAO who underwent either bridging IVT before EVT or direct EVT from the BASILAR registry. The primary outcome was an independent functional outcome measured by the modified Rankin Scale (mRS) score of 0-2. Secondary outcomes included excellent functional outcome (mRS 0-1), favorable functional outcome (mRS 0-3), and mortality rate at 90 days, as well as symptomatic intracranial hemorrhage (sICH), and successful reperfusion between the two treatment groups. RESULTS Direct EVT and bridging IVT before EVT exhibited similar primary outcomes (27.3% vs 27.7%, respectively) and distributions of mRS scores at 90 days. Moreover, rates of sICH and 90-day mortality were not significantly different between the two groups (7.3% vs 6.0%, adjusted OR (aOR) 0.79, 95% CI 0.34 to 1.86, P=0.84 for sICH; 46.8% vs 43.7%, aOR 0.86, 95% CI 0.54 to 1.38, P=0.53 for mortality). CONCLUSIONS Among patients with acute BAO, functional outcomes were similar between those treated with bridging IVT before EVT and those treated with direct EVT, and there was no difference between the two groups in terms of sICH and mortality rates.
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Affiliation(s)
- Meng Guo
- Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, Chongqing, China
- Neurology, Army Medical University Xinqiao Hospital Department of Neurology, Chongqing, Chongqing, China
| | - Chengsong Yue
- Neurology, Army Medical University Xinqiao Hospital Department of Neurology, Chongqing, Chongqing, China
| | - Jie Yang
- Neurology, Army Medical University Xinqiao Hospital Department of Neurology, Chongqing, Chongqing, China
| | - Jinrong Hu
- Neurology, Army Medical University Xinqiao Hospital Department of Neurology, Chongqing, Chongqing, China
| | - Changwei Guo
- Neurology, Army Medical University Xinqiao Hospital Department of Neurology, Chongqing, Chongqing, China
- Department of Neurology, Guangyang Bay Laboratory, Chongqing, Chongqing, China
| | - Zhouzhou Peng
- Neurology, Army Medical University Xinqiao Hospital Department of Neurology, Chongqing, Chongqing, China
| | - Rui Xu
- Neurology, Army Medical University Xinqiao Hospital Department of Neurology, Chongqing, Chongqing, China
| | - Dahong Yang
- Neurology, Army Medical University Xinqiao Hospital Department of Neurology, Chongqing, Chongqing, China
| | - Weilin Kong
- Neurology, Army Medical University Xinqiao Hospital Department of Neurology, Chongqing, Chongqing, China
| | - Xiang Liu
- Neurology, Army Medical University Xinqiao Hospital Department of Neurology, Chongqing, Chongqing, China
| | - Jiacheng Huang
- Neurology, Army Medical University Xinqiao Hospital Department of Neurology, Chongqing, Chongqing, China
| | - Yan Tian
- Neurology, Army Medical University Xinqiao Hospital Department of Neurology, Chongqing, Chongqing, China
| | - Fengli Li
- Neurology, Army Medical University Xinqiao Hospital Department of Neurology, Chongqing, Chongqing, China
| | - Chang-Qing Li
- Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, Chongqing, China
- Neurology, Army Medical University Xinqiao Hospital Department of Neurology, Chongqing, Chongqing, China
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Han B, Raynald, Wu Y, Feng G, Liu X, Zhang P, Lu P, Liu Y, Hu W, Sun Y. Thrombectomy versus combined thrombolysis for acute basilar artery occlusion: a secondary analysis of the ATTENTION trial. J Neurointerv Surg 2024:jnis-2024-021678. [PMID: 38937086 DOI: 10.1136/jnis-2024-021678] [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: 03/04/2024] [Accepted: 05/28/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Few studies have compared the outcomes of bridging intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) with those of direct MT in patients with acute basilar artery occlusion (BAO). This study aimed to assess the efficacy and safety of direct endovascular treatment (EVT) and bridging IVT followed by EVT in Chinese patients with acute basilar artery occlusion BAO. METHODS This subanalysis derived from the prospective multicenter randomized controlled trial of the ATTENTION study, included 221 patients with acute BAO categorized into two groups based on whether they received bridging IVT before MT: MT alone or combined IVT+MT. The primary endpoint was the modified Rankin Scale (mRS) score distribution at 90 days. Secondary outcomes included mRS scores within different ranges (0-1, 0-2, and 0-3) at the 90-day point and National Institutes of Health Stroke Scale (NIHSS) scores at 24 hours and 3 days post-intervention. Safety outcomes encompassed intracranial hemorrhage incidence based on the Heidelberg classification criteria (any intracerebral hemorrhage) and mortality assessment at 90 days. RESULTS Direct and bridging IVT before EVT yielded similar primary outcomes. No significant difference in 90-day mRS scores (median, 4.5 vs 4; adjusted odds ratio (aOR), 0.95 [95% confidence interval (CI), 0.79 to 1.15]; p=0.624) was observed between the two groups. Regarding safety outcomes, no significant differences were observed between the groups in terms of death within 90 days or any intracranial hemorrhage within 24 hours. CONCLUSIONS In patients with acute BAO, those treated with bridging IVT before EVT did not demonstrate any advantages in enhanced safety and efficacy outcomes compared with those treated with direct EVT.
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Affiliation(s)
- Bin Han
- Shanxi Key Laboratory of Brain Disease Control, Department of Neurology, Shanxi Provincial People's Hospital, Taiyuan, China
| | - Raynald
- Beijing Tiantan Hospital Department of Interventional Neuroradiology, Beijing, China
| | - Yaxin Wu
- Department of Neurology, Shanxi Provincial People's Hospital, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Ganghua Feng
- Department of Neurology, Shanxi Provincial People's Hospital, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Xuehan Liu
- The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, Hefei, China
| | - Peng Zhang
- Department of Neurology, Shanxi Provincial People's Hospital, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Pengyu Lu
- Department of Neurology, Shanxi Provincial People's Hospital, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Yi Liu
- Department of Neurology, Shanxi Provincial People's Hospital, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Wei Hu
- Department of Neurology, University of Science and Technology of China, Hefei, China
| | - Yaxuan Sun
- Department of Neurology, Shanxi Provincial People's Hospital, Shanxi Medical University, Taiyuan, Shanxi, China
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Khan MO, Shah SA, Mahmood S, Aijaz A, Jatoi NN, Shakil F, Nusrat K, Siddiqui OM, Hameed I. Is endovascular treatment alone as effective and safe as that with preceding intravenous thrombolysis for acute ischemic stroke? A meta-analysis of randomized controlled trials. J Neurosurg Sci 2024; 68:338-347. [PMID: 37389453 DOI: 10.23736/s0390-5616.23.06058-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
INTRODUCTION This meta-analysis aimed to evaluate the safety and efficacy of direct endovascular therapy (EVT) and bridging therapy (EVT with preceding intravenous thrombolysis i.e. IVT), in acute anterior circulation, large vessel occlusion stroke. EVIDENCE ACQUISITION Following the PRISMA guidelines, a systematic literature review of the English language literature was conducted using PubMed, Cochrane CENTRAL, SCOPUS and ClinicalTrials.gov. Outcomes of interest were measured by the modified Rankin Scale (mRS), and included: no disability (mRS0), no significant disability despite some symptoms (mRS1), slight disability (mRS2), moderate disability (mRS3), moderately severe disability (mRS4), severe disability (mRS5), mortality (mRS6). Additionally, we inspected patients having excellent outcome, functional independence outcome, and poor outcome, along with successful reperfusion and intracranial hemorrhage. We calculated pooled risk ratios (RRs) and their corresponding 95% confidence intervals (CI). EVIDENCE SYNTHESIS A total of seven RCTs involving 2,392 patients were finally included. The chances of achieving successful reperfusion were significantly more with IVT+EVT as compared to EVT alone (RR: 0.97; 95% CI: 0.94, 1.00; P=0.03) (I2=0%). There was no significant difference in the number of patients having outcomes ranging from mRS0 to mRS6, excellent outcome, functional independence, poor outcome or incidence of intracranial hemorrhage, who underwent either EVT alone or IVT+EVT. CONCLUSIONS Additional trials are needed to determine if the absence of significant differences is due to insufficient sample size or if the combination therapy is truly not beneficial.
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Affiliation(s)
- Mohammad O Khan
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Syeda A Shah
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Samar Mahmood
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Ashnah Aijaz
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Nadia N Jatoi
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Firzah Shakil
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Khushboo Nusrat
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Omer M Siddiqui
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Ishaque Hameed
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan -
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Shafique MA, Ali SMS, Mustafa MS, Aamir A, Khuhro MS, Arbani N, Raza RA, Abbasi MB, Lucke-Wold B. Meta-analysis of direct endovascular thrombectomy vs bridging therapy in the management of acute ischemic stroke with large vessel occlusion. Clin Neurol Neurosurg 2024; 236:108070. [PMID: 38071760 DOI: 10.1016/j.clineuro.2023.108070] [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: 11/03/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND Debates persist when using intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) for acute ischemic stroke (AIS) due to large-vessel occlusion (LVO). This systematic review and meta-analysis synthesized evidence on outcomes in patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO), comparing bridging therapy (BT) with MT alone. METHOD We conducted searches of PubMed, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials from inception to July 2023 to identify pertinent clinical trials and observational studies. RESULT 76 studies, involving 37,658 patients, revealed no significant difference in 90-day functional independence between DEVT and BT. However, a trend favoring BT for achieving functional independence with a modified Rankin Scale (mRS) of 0-1 was observed, having Odds ratio (OR) of 0.75 (95% CI 0.66-0.86; p < 0.001). DEVT was associated with higher postprocedural mortality (OR 1.44;95% CI 1.25-1.65; p < 0.001), but a lower risk of symptomatic intracranial hemorrhage compared to BT (OR 0.855; 95% CI 0.621-1.177; p = 0.327). Successful recanalization rates favored BT, emphasizing the importance of individualized treatment decisions (OR 0.759; 95% CI 0.594-0.969; p = 0.027). Sensitivity analyses were conducted to identify key contributors to heterogeneity. CONCLUSION Our meta-analysis underscores the intricate equilibrium between functional efficacy and safety in the evaluation of DEVT and BT for ACS-LVO. Fundamentally, while BT appears more efficacious, concerns about safety arise due to the superior safety profile demonstrated by DEVT. Individualized treatment decisions are imperative, and further trials are warranted to enhance precision in clinical guidance.
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Affiliation(s)
| | | | | | - Ali Aamir
- Department of Medicine, Dow University of Health Sciences, Pakistan.
| | | | - Naeemullah Arbani
- Department of Medicine, Liaquat National Hospital and Medical College, Pakistan.
| | - Rana Ali Raza
- Department of Medicine, Liaquat National Hospital and Medical College, Pakistan.
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Shang K, Zhu W, Ye L, Li Y. Effect of mechanical thrombectomy with and without intravenous thrombolysis on the functional outcome of patients with different degrees of thrombus perviousness. Neuroradiology 2023; 65:1657-1663. [PMID: 37640883 DOI: 10.1007/s00234-023-03210-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 08/06/2023] [Indexed: 08/31/2023]
Abstract
PURPOSE This study aimed to investigate the long-term functional outcome of patients with different degrees of thrombus perviousness (TP) undergoing mechanical thrombectomy alone and those undergoing combined intravenous thrombolysis (IVT) plus mechanical thrombectomy. METHODS We conducted a retrospective analysis of consecutive patients with acute ischemic stroke due to large vessel occlusion who underwent mechanical thrombectomy alone or bridging therapy between January 2016 and October 2020. TP was quantified by thrombus attenuation increase (TAI) on admission computed tomography angiography compared with non-contrast computed tomography. After dichotomization of TAI as higher or lower perviousness, Fisher exact tests were performed to estimate the associations of different therapies with favorable functional outcomes [Modified Ranking Scale score at 90 days (90-day mRS) of 0 to 2]. RESULTS A total of 73 patients were included in our study. 35 (47.9%) thrombi were classified as higher-perviousness clots with TAI of ≥ 24 HU, and the other 38 thrombi were lower-perviousness clots. A favorable outcome with a 90-day mRS of 0 to 2 was observed in 32 patients. In patients with thrombi of lower perviousness, favorable outcome was more common in the bridging therapy group than in the thrombectomy-alone group (p = 0.013), whereas in patients with thrombi of higher perviousness, the long-term neurological outcome did not significantly differ between two therapy groups (p = 0.094). CONCLUSION Patients with thrombi of lower perviousness were recommended to undergo intravenous alteplase followed by endovascular thrombectomy, and those with thrombi of higher perviousness could undergo thrombectomy alone.
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Affiliation(s)
- Kai Shang
- Institute of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Xuhui District, Shanghai, 200235, China
| | - Wangshu Zhu
- Institute of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Xuhui District, Shanghai, 200235, China
| | - Lifang Ye
- Institute of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Xuhui District, Shanghai, 200235, China
| | - Yuehua Li
- Institute of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, No. 600 Yishan Road, Xuhui District, Shanghai, 200235, China.
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Bourcier R, Consoli A, Desilles JP, Labreuche J, Kyheng M, Desal H, Alias Q, Gory B, Dargazanli C, Janot K, Zhu F, Lapergue B, Marnat G. Temporal trends in results of endovascular treatment of anterior intracranial large cerebral vessel occlusion: A 7-year study. Eur Stroke J 2023; 8:655-666. [PMID: 37288701 PMCID: PMC10472952 DOI: 10.1177/23969873231180338] [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: 02/06/2023] [Accepted: 05/21/2023] [Indexed: 06/09/2023] Open
Abstract
BACKGROUND Technical improvements in devices, changes in angiographic grading scales and various confounding factors have made difficult the detection of the temporal evolution of angiographic and clinical results after endovascular treatment (EVT) for acute ischemic Stroke (AIS). We analyzed this evolution in time using the Endovascular Treatment in Ischemic Stroke (ETIS) registry. MATERIALS AND METHODS We analyzed the efficacy outcomes of EVT performed from January 2015 to January 2022, and modelized the temporal trends using mixed logistic regression models, further adjusted for age, intravenous thrombolysis prior to EVT, general anesthesia, occlusion site, balloon catheter use and the type of first-line EVT strategy. We assessed heterogeneity in temporal trends according to occlusion site, balloon catheter use, cardio embolic etiology, age (<80 years vs ⩾80 years) and first-line EVT strategy. RESULTS Among 6104 patients treated from 2015 to 2021, the rates of successful reperfusion (71.1%-89.6%) and of complete first pass effect (FPE) (4.6%-28.9%) increase, whereas the rates of patients with >3 EVT device passes (43.1%-17.5%) and favorable outcome (35.8%-28.9%) decrease significantly over time. A significant heterogeneity in temporal trends in successful reperfusion according to the first-line EVT strategy was found (p-het = 0.018). The temporal trend of increasing successful reperfusion rate was only significant in patients treated with contact aspiration in first-line (adjusted overall effect p = 0.010). CONCLUSION In this 7-year-old large registry of ischemic stroke cases treated with EVT, we observed a significant increase with time in the rate of recanalization whereas there was a tendency toward a decrease in the rate of favorable outcome over the same period.
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Affiliation(s)
- Romain Bourcier
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nantes, Nantes, France
| | - Arturo Consoli
- Department of Diagnostic and Therapeutic Neuroradiology, Hôpital Foch Suresnes FR, University of Versailles Saint Quentin-en-Yvelines, Saint Quentin-en-Yvelines, France
| | - Jean-Philippe Desilles
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, INSERM unit 1148, Paris-Cité University, Paris, France
| | - Julien Labreuche
- EA 2694 - Santé publique: épidémiologie et qualité des soins, University of Lille, CHU Lille, Lille, France
| | - Maeva Kyheng
- EA 2694 - Santé publique: épidémiologie et qualité des soins, University of Lille, CHU Lille, Lille, France
| | - Hubert Desal
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nantes, Nantes, France
| | - Quentin Alias
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Rennes, Rennes, France
| | - Benjamin Gory
- IADI, University of Lorraine, INSERM U1254, Nancy, France
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, Nancy, France
| | - Cyril Dargazanli
- Department of Neuroradiology, Guy de Chauliac University Hospital, Montpellier, France
| | - Kévin Janot
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Tours, Tours, France
| | - François Zhu
- IADI, University of Lorraine, INSERM U1254, Nancy, France
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, Nancy, France
| | - Bertrand Lapergue
- Department of Neurology, Hôpital Foch Suresnes FR, University of Versailles Saint Quentin-en-Yvelines, France
| | - Gaultier Marnat
- Department of Diagnostic and Interventional Neuroradiology, University Hospital, Bordeaux, France
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7
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Zheng M, Li L, Chen L, Li B, Feng C. Mechanical thrombectomy combined with intravenous thrombolysis for acute ischemic stroke: a systematic review and meta-analyses. Sci Rep 2023; 13:8597. [PMID: 37237159 DOI: 10.1038/s41598-023-35532-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 05/19/2023] [Indexed: 05/28/2023] Open
Abstract
To assess the clinical value of mechanical thrombectomy (MT) combined with intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) by comparing it with the MT alone. In this study, we conducted a comprehensive meta-analysis of both observational and randomized controlled studies (RCTs) to investigate various outcomes. Our search for relevant studies was conducted between January 2011 and June 2022 in four major databases: PubMed, Embase, WOS, and Cochrane Library. We collected data on several outcomes, including functional independence (FI; defined as modified Rankin Scale score of 0 to 2), excellent outcomes (mRS 0-1), successful recanalization (SR), symptomatic intracerebral hemorrhage (sICH), any intracerebral hemorrhage (aICH), and mortality at three months or discharge. The primary efficacy outcome and safety outcome were FI and sICH, respectively, whereas excellent outcomes and SR were considered secondary efficacy outcomes. Additionally, mortality and aICH were analyzed as secondary safety outcomes. We employed the Mantel-Haenszel fixed-effects model for RCTs when I2 < 50%, otherwise the random-effects model was utilized. For observational studies and subgroup analyses, we used the random-effects model to minimize potential bias. A total of 55 eligible studies (nine RCTs and 46 observational studies) were included. For RCTs, the MT + IVT group was superior in FI (OR: 1.27, 95% CI: 1.11-1.46), excellent outcomes (OR: 1.21, 95% CI: 1.03-1.43), SR (OR: 1.23, 95% CI: 1.05-1.45), mortality (OR: 0.72, 95% CI: 0.54-0.97) in crude analyses. In adjusted analyses, the MT + IVT group reduced the risk of mortality (OR: 0.65, 95% CI: 0.49-0.88). However, the difference in FI between the MT + IVT group and the MT alone group was not significant (OR: 1.17, 95% CI: 0.99-1.38, Fig. 3a). For observational studies, the results of FI (OR: 1.34, 95% CI: 1.16-1.33), excellent outcomes (OR: 1.30, 95% CI: 1.09-1.54), SR (OR: 1.23, 95% CI: 1.05-1.44), mortality (OR: 0.70, 95% CI: 0.64-0.77) in the MT + IVT group were better. Additionally, the MT + IVT group increased the risk of hemorrhagic transformation (HT) including sICH (OR: 1.16, 95% CI: 1.11-1.21) and aICH (OR: 1.24, 95% CI: 1.05-1.46) in crude analyses. In adjusted analyses, significant better outcomes were seen in the MT + IVT group on FI (OR: 1.36, 95% CI: 1.21-1.52), excellent outcomes (OR: 1.49, 95% CI: 1.26-1.75), and mortality (OR: 0.73, 95% CI: 0.56-0.94). The MT + IVT therapy did improve the prognosis for AIS patients and did not increase the risk of HT compared with MT alone therapy.
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Affiliation(s)
- Meiling Zheng
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100010, People's Republic of China
| | - Li Li
- Department of Radiology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, Sichuan Province, People's Republic of China.
| | - Lizhou Chen
- Department of Radiology, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan Province, People's Republic of China.
| | - Bin Li
- Department of Geriatrics, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, People's Republic of China.
| | - Cuiling Feng
- Peking University People's Hospital, Beijing, 100000, People's Republic of China.
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Kanamoto T, Tateishi Y, Yamashita K, Furuta K, Torimura D, Tomita Y, Hirayama T, Shima T, Nagaoka A, Yoshimura S, Miyazaki T, Ideguchi R, Morikawa M, Morofuji Y, Horie N, Izumo T, Tsujino A. Impact of width of susceptibility vessel sign on recanalization following endovascular therapy. J Neurol Sci 2023; 446:120583. [PMID: 36827810 DOI: 10.1016/j.jns.2023.120583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 02/05/2023] [Accepted: 02/09/2023] [Indexed: 02/14/2023]
Abstract
BACKGROUND AND PURPOSE We aimed to investigate the relationship between arterial recanalization following endovascular therapy and the susceptibility vessel sign (SVS) length and width on susceptibility-weighted imaging. METHODS We retrospectively evaluated consecutive patients with anterior circulation ischemic stroke who underwent magnetic resonance imaging preceded endovascular therapy, and measured the SVS length and width. Successful recanalization was defined as expanded thrombolysis in cerebral infarction grade of 2b to 3. Logistic regression analysis was executed to determine the independent predictors of successful recanalization and first-pass reperfusion (FPR) after endovascular therapy. RESULTS Among 100 patients, successful recanalization and FPR were observed in 77 and 34 patients, respectively. The median SVS length and width were 10.3 mm (interquartile range, 6.8-14.1 mm) and 4.2 mm (interquartile range, 3.1-5.2 mm), respectively. In multivariate logistic regression analysis, SVS width was associated with successful recanalization (odds ratio, 1.88; 95% confidence interval, 1.14-3.07; p = 0.005) and FPR (odds ratio, 1.38; 95% confidence interval, 1.01-1.89; p = 0.039). The optimal cutoff value for the SVS width to predict successful recanalization and FPR were 4.2 mm and 4.0 mm, respectively. CONCLUSIONS Larger SVS width may predict successful recanalization and FPR following endovascular therapy.
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Affiliation(s)
- Tadashi Kanamoto
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Yohei Tateishi
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Kairi Yamashita
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Kanako Furuta
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Daishi Torimura
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Yuki Tomita
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Takuro Hirayama
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Tomoaki Shima
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Atsushi Nagaoka
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Shunsuke Yoshimura
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Teiichiro Miyazaki
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Reiko Ideguchi
- Department of Radiology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Minoru Morikawa
- Department of Radiology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Yoichi Morofuji
- Department of Neurosurgery, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Nobutaka Horie
- Department of Neurosurgery, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan; Department of Neurosurgery, Hiroshima University, Kasumi 1-2-3 Minami-ku, Hiroshima 734-8551, Japan
| | - Tsuyoshi Izumo
- Department of Neurosurgery, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Akira Tsujino
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
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Direct Mechanical Thrombectomy vs. Bridging Therapy in Stroke Patients in A “Stroke Belt” Region of Southern Europe. J Pers Med 2023; 13:jpm13030440. [PMID: 36983622 PMCID: PMC10058874 DOI: 10.3390/jpm13030440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 02/25/2023] [Accepted: 02/27/2023] [Indexed: 03/03/2023] Open
Abstract
The aim of this 4-year observational study is to analyze the outcomes of stroke patients treated with direct mechanical thrombectomy (dMT) compared to bridging therapy (BT) (intravenous thrombolysis [IVT] + BT) based on 3-month outcomes, in real clinical practice in the "Stroke Belt" of Southern Europe. In total, 300 patients were included (41.3% dMT and 58.6% BT). The frequency of direct referral to the stroke center was similar in the dMT and BT group, whereas the time from onset to groin was longer in the BT group (median 210 [IQR 160–303] vs. 399 [IQR 225–675], p = 0.001). Successful recanalization (TICI 2b-3) and hemorrhagic transformation were similar in both groups. The BT group more frequently showed excellent outcomes at 3 months (32.4% vs. 15.4%, p = 0.004). Multivariate analysis showed that BT was independently associated with excellent outcomes (OR 2.7. 95% CI,1.2–5.9, p = 0.02) and lower mortality (OR 0.36. 95% CI 0.16–0.82, p = 015). Conclusions: Compared with dMT, BT was associated with excellent functional outcomes and lower 3-month mortality in this real-world clinical practice study conducted in a region belonging to the “Stroke Belt” of Southern Europe. Given the disparity of results on the benefit of BT in the current evidence, it is of vital importance to analyze the convenience of its use in each health area.
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Wang X, Zhang H, Wang Q, Li G, Shen H, Xiao Y, Xu L, Long Y, Chen C, Huang Z, Zhang Y. Effect of intravenous thrombolysis on core growth rate in patients with acute cerebral infarction. Front Neurol 2023; 14:1096605. [PMID: 36908588 PMCID: PMC9996056 DOI: 10.3389/fneur.2023.1096605] [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: 11/12/2022] [Accepted: 01/30/2023] [Indexed: 02/25/2023] Open
Abstract
Objective This study aimed to investigate the effects of recombinant tissue plasminogen activator intravenous thrombolysis (IVT) on the core growth rate of acute ischemic stroke. Methods Stroke patients with large vessel occlusion and non-recanalization from IVT treatment were retrospectively included in this study and divided into two groups: IVT and non-IVT. The core growth rate was estimated by the acute core volume on perfusion CT divided by the last known well time from stroke to CT perfusion. The primary endpoint was the core growth rate, the tissue outcome was 24 h-ASPECTS, and the clinical outcome was a 3-month modified Rankin score. Results A total of 94 patients were included with 53 in the IVT group and 41 in the non-IVT group. There was no significant difference in age, gender, hypertension, diabetes, atrial fibrillation, acute NIHSS, and last known well time from stroke to CT perfusion acquisition between the two groups. The core growth rate in the IVT group was lower than that in the non-IVT group, which was statistically significant after multivariate adjustment (coefficient: -5.20, 95% CI= [-9.85, -0.56], p = 0.028). There was a significant interaction between the IVT and the collateral index in predicting the core growth rate. The analysis was then stratified according to the collateral index, and the results suggested that IVT reduced the core growth rate more significantly after the worsening of collateral circulation (coefficient: 15.38, 95% CI= [-26.25, -4.40], p = 0.007). The 3-month modified Rankin score and 24 h-ASPECTS were not statistically significant between the two groups. Conclusion Intravenous thrombolysis reduces the core growth rate in patients with AIS, especially those with poor collateral status.
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Affiliation(s)
- Xueqi Wang
- Shanghai East Hospital, Tongji University, Shanghai, China
| | - Hao Zhang
- Shanghai East Hospital, Tongji University, Shanghai, China
| | - Qi Wang
- Shanghai East Hospital, Tongji University, Shanghai, China
| | - Gang Li
- Shanghai East Hospital, Tongji University, Shanghai, China
| | - Hao Shen
- Shanghai East Hospital, Tongji University, Shanghai, China
| | - Yaping Xiao
- Shanghai East Hospital, Tongji University, Shanghai, China
| | - Luran Xu
- Shanghai East Hospital, Tongji University, Shanghai, China
| | - Yuming Long
- Shanghai East Hospital, Tongji University, Shanghai, China
| | - Chen Chen
- Shanghai East Hospital, Tongji University, Shanghai, China
| | - Zhengyu Huang
- Shanghai East Hospital, Tongji University, Shanghai, China
| | - Yue Zhang
- Shanghai East Hospital, Tongji University, Shanghai, China
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Fang M, Xu C, Ma L, Sun Y, Zhou X, Deng J, Liu X. No sex difference was found in the safety and efficacy of intravenous alteplase before endovascular therapy. Front Neurol 2022; 13:989166. [DOI: 10.3389/fneur.2022.989166] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 09/01/2022] [Indexed: 11/11/2022] Open
Abstract
Background and purposePrior studies on sex disparities were post-hoc analyses, had limited treatment modalities, and had controversial findings. Our study aimed to examine whether sex difference modifies the effect of intravenous alteplase before endovascular therapy.MethodsWe conducted a multicenter prospective cohort study of 850 eligible patients with acute ischemic stroke who underwent endovascular therapy. A propensity score was utilized as a covariate to achieve approximate randomization of alteplase pretreatment. The baseline characteristics of women and men were compared. Logistic regression with interaction terms, adjusted for potential confounders, was used to investigate the effect of sex on the prognosis of bridging therapy.ResultsIn comparison to men, women were older [78.00 (70.00–84.00) vs. 67 (61.00–74.00), P < 0.001], had more atrial fibrillation (61.4 vs. 35.2%, P < 0.001), had a lower ASPECTS [10.00 (8.00–10.00) vs. 10 (9.00–10.00), P = 0.0047], and had a higher NIHSS score [17.00 (14.00–20.00) vs. 16 (13.00–19.00), P = 0.005]. Women tended to receive less bridging therapy (26.3 vs. 33%, P = 0.043) and more retrieval attempts [2.00 (1.00–2.00) vs. 1 (1.00–2.00), P = 0.026]. There was no sex difference in functional independence at 90 days after bridging therapy (OR 0.968, 95% CI 0.575–1.63), whereas men benefited more after EVT alone (OR 0.654, 95% CI 0.456–0.937). There were no sex-treatment interactions observed regardless of the location of the occlusion. There were no significant sex differences in all safety outcomes.ConclusionOur study could not confirm that sex modifies the treatment effect of intravenous alteplase before endovascular therapy. At the same time, we advocate for women to seek timely medical treatment.
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Intravenous thrombolysis before mechanical thrombectomy for acute ischemic stroke due to large vessel occlusion; should we cross that bridge? A systematic review and meta-analysis of 36,123 patients. Neurol Sci 2022; 43:6243-6269. [DOI: 10.1007/s10072-022-06283-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 07/09/2022] [Indexed: 10/16/2022]
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Nguyen HA, Vu DL, Nguyen QA, Mai DT, Tran AT, Le HK, Nguyen TT, Nguyen TT, Tran C, Dao VP, Pierot L. Predictive Factors for Clinical Outcome After Direct Mechanical Thrombectomy for Anterior Circulation Large Vessel Occlusion Within 4.5 h. Front Neurol 2022; 13:895182. [PMID: 35847212 PMCID: PMC9280660 DOI: 10.3389/fneur.2022.895182] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2022] [Accepted: 05/25/2022] [Indexed: 11/13/2022] Open
Abstract
BackgroundRecent trials including DIRECT-MT, DEVT, and SKIP have found that direct mechanical thrombectomy (MT) is equally effective as the combination of MT and intravenous thrombolysis. However, the results of the other trials, namely MR-CLEAN NO-IV and the SWIFT-DIRECT trial have failed to confirm the non-inferiority of direct MT vs. the combination therapy.AimWe aimed to identify prognostic factors of direct MT for anterior circulation large vessel occlusion within 4.5 h.Materials and MethodsData from January 2018 to January 2022 were retrospectively collected and analyzed. Adult patients with confirmed anterior circulation large vessel occlusion within 4.5 h of onset with baseline NIHSS of ≥6 and baseline ASPECTS of ≥6 treated using direct MT within 6 h were recruited.ResultsA total of 140 patients were enrolled in the study with a median age of 65.5 years [interquartile range (IQR), 59–76.5], median baseline NIHSS of 13.5 (IQR, 11–16), and median baseline ASPECTS of 8 (IQR, 7–8). Direct MT was feasible in all patients (100%). Successful reperfusion (mTICI 2b-3) was achieved in 124/140 patients (88.6%) with a low rate of complications (8/140, 5.7%). Any type of intracranial hemorrhage (ICH) and symptomatic ICH occurred in 44/140 (31.4%) and 5/140 (3.6%), respectively. Overall, a good outcome (mRS 0–2) was achieved in 93/140 (66.4%), and the mortality rate was 9.3% (13/140 patients). Using multivariate analysis, lower age [odds ratio (OR), 0.96; 95% CI, 0.92–1.00; P = 0.05], low baseline NIHSS (OR, 0.82; 95% CI, 0.74–0.92; P = 0.00), and absence of ICH (OR, 0.29; 95% CI, 0.10–0.81; P = 0.02) were independently associated with favorable outcome. Independent predictors of mortality were baseline NIHSS (OR, 1.21; 95% CI, 1.01–1.46; P = 0.04), successful reperfusion (OR, 0.02; 95% CI, 0.00–0.58; P = 0.02), and ICH (OR, 0.12; 95% CI, 0.02–0.75; P = 0.02). Further analysis showed that the median mRS at 90 days was significantly better in the MCA occlusion group compared to the ICA plus M1 occlusion group [1 (IQR 0–3) vs. 2 (IQR 1–4); P = 0.05].ConclusionsOur findings suggest that direct thrombectomy may be an adequate clinical option for younger patients (≤70) experiencing proximal middle artery occlusion within 4.5 h and who have low baseline NIHSS (≤14).
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Affiliation(s)
- Huu An Nguyen
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
- Radiology Center, Bach Mai Hospital, Hanoi, Vietnam
- *Correspondence: Huu An Nguyen
| | - Dang Luu Vu
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
- Radiology Center, Bach Mai Hospital, Hanoi, Vietnam
| | - Quang Anh Nguyen
- Department of Radiology, Hanoi Medical University, Hanoi, Vietnam
- Radiology Center, Bach Mai Hospital, Hanoi, Vietnam
| | - Duy Ton Mai
- Stroke Center, Bach Mai Hospital, Hanoi, Vietnam
| | | | | | | | | | - Cuong Tran
- Radiology Center, Bach Mai Hospital, Hanoi, Vietnam
| | | | - Laurent Pierot
- Department of Neuroradiology, Hôpital Maison-Blanche, Université Reims-Champagne-Ardenne, Reims, France
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Efficacy and safety of endovascular treatment with or without intravenous alteplase in acute anterior circulation large vessel occlusion stroke: a meta-analysis of randomized controlled trials. Neurol Sci 2022; 43:3551-3563. [PMID: 35314911 DOI: 10.1007/s10072-022-06017-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 03/14/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The current meta-analysis aimed to investigate the efficacy and safety of direct endovascular treatment (EVT) and bridging therapy (EVT with prior intravenous thrombolysis (IVT)) in patients with acute anterior circulation large vessel occlusion (LVO) stroke. METHODS This meta-analysis followed PRISMA guidelines. Eligible RCTs were identified through a systemic search of electronic databases (PubMed, Ovid, Web of Science, and Cochrane Library) from the inception dates to January 10, 2022. The pooled analyses were performed using RevMan 5.3 software. The primary outcome was functional outcome on the modified Rankin Scale (mRS) (range 0 to 5) at 90 days. The secondary outcomes included successful reperfusion, intracranial hemorrhage, and mortality (mRS 6) within 90 days. RESULTS A total of 4 RCTs involving 1633 patients were finally included. Findings of pooled analyses indicated that neither the primary outcomes (no disability (mRS 0), no significant disability despite some symptoms (mRS 1), slight disability (mRS 2), moderate disability (mRS 3), moderately severe disability (mRS 4), severe disability (mRS 5), excellent outcome (mRS 0-1), functional independence outcome (mRS 0-2), and poor outcome (mRS 3-5)) nor the secondary outcomes (successful reperfusion, intracranial hemorrhage, and mortality) in the EVT groups were not statistically significant compared with the IVT plus EVT groups (P > 0.05). In addition, the outcomes of sensitivity analysis implied that the findings of meta-analysis were credible. CONCLUSIONS Among patients with acute ischemic stroke due to LVO of anterior circulation, EVT alone yielded efficacy and safety outcomes similar to IVT plus EVT.
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Dicpinigaitis AJ, Gandhi CD, Shah SP, Galea VP, Cooper JB, Feldstein E, Shapiro SD, Kamal H, Kurian C, Kaur G, Tyagi R, Biswas A, Rosenberg J, Bauerschmidt A, Bowers CA, Mayer SA, Al-Mufti F. Endovascular thrombectomy with and without preceding intravenous thrombolysis for treatment of large vessel anterior circulation stroke: A cross-sectional analysis of 50,000 patients. J Neurol Sci 2022; 434:120168. [DOI: 10.1016/j.jns.2022.120168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 12/28/2021] [Accepted: 01/19/2022] [Indexed: 10/19/2022]
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Zhou Y, Xing P, Li Z, Zhang X, Zhang L, Zhang Y, Zhang Y, Hong B, Xu Y, Huang Q, Li Q, Zhao K, Zou C, Yu Y, Zuo Q, Liu S, Zhang L, Majoie CBLM, Roos YBWEM, Treurniet KM, Ye X, Peng Y, Yang P, Liu J. Effect of Occlusion Site on the Safety and Efficacy of Intravenous Alteplase Before Endovascular Thrombectomy: A Prespecified Subgroup Analysis of DIRECT-MT. Stroke 2021; 53:7-16. [PMID: 34915738 DOI: 10.1161/strokeaha.121.035267] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND AND PURPOSE Recent trials showed thrombectomy alone was comparable to bridging therapy in patients with anterior circulation large vessel occlusion eligible for both intravenous alteplase and endovascular thrombectomy. We performed this study to examine whether occlusion site modifies the effect of intravenous alteplase before thrombectomy. METHODS This is a prespecified subgroup analysis of a randomized trial evaluating risk and benefit of intravenous alteplase before thrombectomy (DIRECT-MT [Direct Intra-Arterial Thrombectomy in Order to Revascularize AIS Patients With Large Vessel Occlusion Efficiently in Chinese Tertiary Hospitals]). Among 658 randomized patients, 640 with baseline occlusion site information were included. The primary outcome was the score on the modified Rankin Scale at 90 days. Multivariable ordinal logistic regression analysis with an interaction term was used to estimate treatment effect modification by occlusion location (internal carotid artery versus M1 versus M2). We report the adjusted common odds ratio for a shift toward better outcome on the modified Rankin Scale after thrombectomy alone compared with combination treatment adjusted for age, the National Institutes of Health Stroke Scale score at baseline, the time from stroke onset to randomization, the modified Rankin Scale score before stroke onset, and collateral score per the DIRECT-MT statistical analysis plan. RESULTS The overall adjusted common odds ratio was 1.08 (95% CI, 0.82-1.43) with thrombectomy alone compared with combination treatment, and there was no significant treatment-by-occlusion site interaction (P=0.47). In subgroups based on occlusion location, we found the following adjusted common odds ratios: 0.99 (95% CI, 0.62-1.59) for internal carotid artery occlusions, 1.12 (95% CI, 0.77-1.64) for M1 occlusions, and 1.22 (95% CI, 0.53-2.79) for M2 occlusions. No treatment-by-occlusion site interactions were observed for dichotomized modified Rankin Scale distributions and successful reperfusion (extended thrombolysis in Cerebral Infarction score ≥2b) before thrombectomy. Differences in symptomatic hemorrhage rate were not significant between occlusion locations (internal carotid artery occlusion: 7.02% in bridging therapy versus 7.14% for thrombectomy alone, P=0.97; M1 occlusion: 5.06% versus 2.48%, P=0.22; M2 occlusion: 9.09% versus 4.76%; P=0.78). CONCLUSIONS In this prespecified subgroup of a randomized trial, we found no evidence that occlusion location can inform intravenous alteplase decisions in endovascular treatment eligible patients directly presenting at endovascular treatment capable centers. Future studies are needed to confirm our findings. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT03469206.
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Affiliation(s)
- Yu Zhou
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
| | - Pengfei Xing
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
| | - Zifu Li
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
| | - Xiaoxi Zhang
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
| | - Lei Zhang
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
| | - Yongxin Zhang
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
| | - Yongwei Zhang
- Department of Neurology, Naval Medical University Changhai hospital, Shanghai, China (Yongwei Zhang)
| | - Bo Hong
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
| | - Yi Xu
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
| | - Qinghai Huang
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
| | - Qiang Li
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
| | - Kaijun Zhao
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
| | - Chao Zou
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
| | - Ying Yu
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
| | - Qiao Zuo
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
| | - Shen Liu
- Department of interventional radiology, Jiangsu Provincial People's Hospital of Nanjing Medical University, Nanjing, China (S.L.)
| | - Liyong Zhang
- Department of Neurosurgery, Linyi People's Hospital of Qingdao University, Linyi, China (L.Z.)
| | - Charles B L M Majoie
- Department of Neurology, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands (C.B.L.M.M., Y.B.W.E.M.R., K.M.T.)
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands (C.B.L.M.M., Y.B.W.E.M.R., K.M.T.)
| | - K M Treurniet
- Department of Neurology, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands (C.B.L.M.M., Y.B.W.E.M.R., K.M.T.)
- Department of Radiology, Haaglanden Medical Center, The Hague, the Netherlands (K.M.T.)
| | - Xiaofei Ye
- Health Statistics Department, Naval Medical University, Shanghai, China (X.Y.)
| | - Ya Peng
- Department of Neurosurgery, Third Affiliated Hospital of Soochow University, Changzhou, China (Y.P.)
| | - Pengfei Yang
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
| | - Jianmin Liu
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China (Y. Zhou, P.X., Z.L., X.Z., L.Z., Yongxin Zhang, B.H., Y.X., Q.H., Q.L., K.Z., C.Z., Y.Y., Q.Z., P.Y., J.L.)
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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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McDonough R, Ospel J, Kashani N, Kappelhof M, Liu J, Yang P, Majoie C, Roos Y, Goyal M. Influence of recent direct-to-EVT trials on practical decision-making for the treatment of acute ischemic stroke patients. Interv Neuroradiol 2021; 28:668-674. [PMID: 34787489 DOI: 10.1177/15910199211057984] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
BACKGROUND Current guidelines recommend that eligible acute ischemic stroke (AIS) patients receive intravenous alteplase (IVT) prior to endovascular treatment (EVT). Six randomized controlled trials recently sought to determine the risks of administering IVT prior to EVT, five of which have been published/presented. It is unclear whether and how the results of these trials will change guidelines. With the DEBATE survey, we assessed the influence of the recent trials on physicians' IVT treatment strategies in the setting of EVT for large vessel occlusion (LVO) stroke. METHODS Participants were provided with 15 direct-to-mothership case-scenarios of LVO stroke patients and asked whether they would treat with IVT + EVT or EVT alone, a) before publication/presentation of the direct-to-EVT trials, and b) now (knowing the trial results). Logistic regression clustered by respondent was performed to assess factors influencing the decision to adopt an EVT-alone paradigm after publication/presentation of the trial results. RESULTS 289 participants from 37 countries provided 4335 responses, of which 13.5% (584/4335) changed from an IVT + EVT strategy to EVT alone after knowing the trial results. Very few switched from EVT alone to IVT + EVT (8/4335, 0.18%). Scenarios involving a long thrombus (RR 1.88, 95%CI:1.56-2.26), cerebral micro-hemorrhages (RR 1.78, 95%CI:1.43-2.23), and an expected short time to recanalization (RR 1.46 95%CI:1.19-1.78) had the highest chance of participants switching to an EVT-only strategy. CONCLUSION In light of the recent direct-to-EVT trials, a sizeable proportion of stroke physicians appears to be rethinking IVT treatment strategies of EVT-eligible mothership patients with AIS due to LVO in specific situations.
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Affiliation(s)
- Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, 37734University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Diagnostic Imaging, Foothills Medical Center, 2129University of Calgary, Calgary, AB, Canada
| | - Johanna Ospel
- Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, 30262University Hospital Basel, University of Basel, Basel, Switzerland
| | - Nima Kashani
- Department of Diagnostic Imaging, Foothills Medical Center, 2129University of Calgary, Calgary, AB, Canada
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Jianmin Liu
- Department of Neurosurgery, Changhai Hospital, 12521Naval Medical University, Shanghai, China
| | - Pengfei Yang
- Department of Neurosurgery, Changhai Hospital, 12521Naval Medical University, Shanghai, China
| | - Charles Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Yvo Roos
- Department of Neurology, University of Amsterdam, Amsterdam, The Netherlands
| | - Mayank Goyal
- Department of Diagnostic Imaging, Foothills Medical Center, 2129University of Calgary, Calgary, AB, Canada
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19
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Wang Q, Zhang YQ, Qiu HC, Yao YD, Liu AF, Li C, Jiang WJ. Recanalization Treatment of Acute Ischemic Stroke Caused by Large-Artery Occlusion in the Elderly: A Comparative Analysis of "the Elderly" and "the Very Elderly". DISEASE MARKERS 2021; 2021:3579074. [PMID: 34659589 PMCID: PMC8514933 DOI: 10.1155/2021/3579074] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Revised: 08/27/2021] [Accepted: 08/31/2021] [Indexed: 12/12/2022]
Abstract
OBJECTIVE To assess whether the effectiveness and safety of recanalization therapy for acute ischemic stroke (AIS) caused by large-artery occlusion (LAO) differ between patients aged 60-79 years and patients aged ≥80 years. METHODS We analyzed prospective data of patients with LAO (≥60 years) who underwent recanalization therapy at the Department of Vascular Neurosurgery, New Era Stroke Care and Research Institute, PLA Rocket Force Characteristic Medical Center, from November 2013 to July 2017. The data were compared between elderly patients (60-79 years) and very elderly patients (≥80 years). The effectiveness of recanalization therapy was evaluated using the 90-day modified Rankin scale (mRS) score, while safety was assessed by the rates of symptomatic intracranial hemorrhage (SICH) and mortality within 30 days. RESULTS A total of 151 patients with AIS induced by LAO were included in this study. Seventy-three patients (48.3% [73/151]) had an overall favorable outcome (mRS score 0-2) after treatment. A higher proportion of patients in the elderly group showed a favorable outcome compared with the very elderly group (58.6% [34/58] vs. 41.6% [39/93], respectively; P = 0.046). The incidence of SICH (12.7% vs. 16.13%, respectively; P = 0.561) and mortality (10.3% vs. 7.5%, respectively; P = 0.548) within 30 days was not significantly different between the two groups. CONCLUSION Recanalization treatment of LAO is more effective in elderly patients compared with very elderly patients, while the safety of recanalization treatment is comparable between these two groups.
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Affiliation(s)
- Qi Wang
- The PLA Rocket Force Characteristic Medical Center, The Teaching Hospital of Soochow University, Beijing, China
- Department of Vascular Neurosurgery, New Era Stroke Care and Research Institute, Department of Neurology, Beijing Rehabilitation Hospital, Capital Medical University, Beijing, China
| | - Yi-Qun Zhang
- Department of Vascular Neurosurgery, New Era Stroke Care and Research Institute, The PLA Rocket Force Characteristic Medical Center, Beijing, China
| | - Han-Cheng Qiu
- Department of Vascular Neurosurgery, New Era Stroke Care and Research Institute, The PLA Rocket Force Characteristic Medical Center, Beijing, China
| | - Yin-Dan Yao
- Department of Vascular Neurosurgery, New Era Stroke Care and Research Institute, The PLA Rocket Force Characteristic Medical Center, Beijing, China
| | - Ao-Fei Liu
- Department of Vascular Neurosurgery, New Era Stroke Care and Research Institute, The PLA Rocket Force Characteristic Medical Center, Beijing, China
| | - Chen Li
- Department of Vascular Neurosurgery, New Era Stroke Care and Research Institute, The PLA Rocket Force Characteristic Medical Center, Beijing, China
| | - Wei-Jian Jiang
- The PLA Rocket Force Characteristic Medical Center, The Teaching Hospital of Soochow University, Beijing, China
- Department of Vascular Neurosurgery, New Era Stroke Care and Research Institute, The PLA Rocket Force Characteristic Medical Center, Beijing, China
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20
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Ding HJ, Ma C, Ye FP, Zhang JF. Bridging therapy and direct mechanical thrombectomy in the treatment of cardiogenic cerebral infarction with anterior circulation macrovascular occlusion. World J Clin Cases 2021; 9:8051-8060. [PMID: 34621862 PMCID: PMC8462204 DOI: 10.12998/wjcc.v9.i27.8051] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2021] [Revised: 06/30/2021] [Accepted: 08/05/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Intravenous thrombolysis is an important treatment for cerebral infarction. However, it is difficult to achieve good results if the patient is complicated with anterior circulation macrovascular occlusion. In addition, the vascular recanalization rate is low, so mechanical thrombectomy, that is, bridging therapy, is needed
AIM To investigate the efficacy and safety of bridging therapy and direct mechanical thrombectomy in the treatment of cardiogenic cerebral infarction with anterior circulation macrovascular occlusion.
METHODS Ninety-six patients in our hospital with cardiogenic cerebral infarction with anterior circulation macrovascular occlusion from January 2017 to July 2020 were divided into a direct thrombectomy group (n = 48) and a bridging group (n = 48). Direct mechanical thrombectomy was performed in the direct thrombectomy group, and bridging therapy was used in the bridging treatment group. Comparisons were performed for the treatment data of the two groups (from admission to imaging examination, from admission to arterial puncture, from arterial puncture to vascular recanalization, and from admission to vascular recanalization), vascular recanalization rate, National Institutes of Health Stroke Scale (NIHSS) and Glasgow Coma Scale (GCS) scores before and after treatment, prognosis and incidence of adverse events.
RESULTS In the direct thrombectomy group, the time from admission to imaging examination was 24.32 ± 8.61 min, from admission to arterial puncture was 95.56 ± 37.55 min, from arterial puncture to vascular recanalization was 54.29 ± 21.38 min, and from admission to revascularization was 156.88 ± 45.51 min, and the corresponding times in the bridging treatment group were 25.38 ± 9.33 min, 100.45 ± 39.30 min, 58.14 ± 25.56 min, and 161.23 ± 51.15 min; there were no significant differences between groups (P=0.564, 0.535, 0.426, and 0.661, respectively). There was no significant difference in the recanalization rate between the direct thrombectomy group (79.17%) and the bridging group (75.00%) (P = 0.627). There were no significant differences between the direct thrombectomy group (16.69 ± 4.91 and 12.12 ± 2.07) and the bridging group (7.13 ± 1.23 and (14.40 ± 0.59) in preoperative NIHSS score and GCS score (P = 0.200 and 0.203, respectively). After the operation, the NIHSS scores in both groups were lower than those before the operation, and the GCS scores were higher than those before the operation. There was no significant difference in NIHSS and GCS scores between the direct thrombectomy group (6.91 ± 1.10 and 14.19 ± 0.65) and the bridging group (7.13 ± 1.23 and 14.40 ± 0.59) (P = 0.358 and 0.101, respectively). There was no significant difference in the proportion of patients who achieved a good prognosis between the direct thrombectomy group (52.08%) and the bridging group (50.008%) (P = 0.838). There was no significant difference in the incidence of adverse events between the direct thrombectomy group (6.25%) and the bridging group (8.33%) (P = 0.913).
CONCLUSION Bridging therapy and direct mechanical thrombectomy can safely treat cardiogenic cerebral infarction with anterior circulation macrovascular occlusion, achieve good vascular recanalization effects and prognoses, and improve the neurological function of patients.
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Affiliation(s)
- Hong-Ju Ding
- Department of Emergency, Qingdao Jiaozhou Central Hospital, Qingdao 266300, Shandong Province, China
| | - Cong Ma
- Department of Neurology, Qingdao Jiaozhou Central Hospital, Qingdao 266300, Shandong Province, China
| | - Fu-Ping Ye
- Department of Gastrointestinal Surgery, Qingdao Jiaozhou Central Hospital, Qingdao 266300, Shandong Province, China
| | - Ji-Fang Zhang
- Department of Neurosurgery, Qingdao Municipal Hospital, School of Medicine, Qingdao University, Qingdao 266071, Shandong Province, China
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21
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Mishra NK, Leigh R, Campbell BCV. Editorial: Intracranial Bleeding After Reperfusion Therapy in Acute Ischemic Stroke. Front Neurol 2021; 12:745993. [PMID: 34531820 PMCID: PMC8438163 DOI: 10.3389/fneur.2021.745993] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 07/23/2021] [Indexed: 01/19/2023] Open
Affiliation(s)
- Nishant K Mishra
- Department of Neurology, Division of Stroke and Vascular Neurology, Yale University, New Haven, CT, United States
| | - Richard Leigh
- Department of Neurology, Johns Hopkins University, Baltimore, MD, United States
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
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22
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Maier IL, Leha A, Badr M, Allam I, Bähr M, Jamous A, Hesse A, Psychogios MN, Behme D, Liman J. Inhouse Bridging Thrombolysis Is Associated With Improved Functional Outcome in Patients With Large Vessel Occlusion Stroke: Findings From the German Stroke Registry. Front Neurol 2021; 12:649108. [PMID: 34177759 PMCID: PMC8222775 DOI: 10.3389/fneur.2021.649108] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 04/20/2021] [Indexed: 01/17/2023] Open
Abstract
Background: Endovascular treatment (EVT) for large vessel occlusion stroke (LVOS) is highly effective. To date, it remains controversial if intravenous thrombolysis (IVT) prior to EVT is superior compared with EVT alone. The aim of our study was to specifically address the question, whether bridging IVT directly prior to EVT has additional positive effects on reperfusion times, successful reperfusion, and functional outcomes compared with EVT alone. Methods: Patients with LVOS in the anterior circulation eligible for EVT with and without prior IVT and direct admission to endovascular centers (mothership) were included in this multicentric, retrospective study. Patient data was derived from the German Stroke Registry (an open, multicenter, and prospective observational study). Outcome parameters included groin-to-reperfusion time, successful reperfusion [defined as a Thrombolysis in Cerebral Infarction (TICI) scale 2b-3], change in National Institute of Health Stroke Scale (NIHSS), modified Rankin Scale (mRS), and mortality at 90 days. Results: Of the 881 included mothership patients with anterior circulation LVOS, 486 (55.2%) received bridging therapy with i.v.-rtPA prior to EVT, and 395 (44.8%) received EVT alone. Adjusted, multivariate linear mixed effect models revealed no difference in groin-to-reperfusion time between the groups (48 ± 36 vs. 49 ± 34 min; p = 0.299). Rates of successful reperfusion (TICI ≥ 2b) were higher in patients with bridging IVT (fixed effects estimate 0.410, 95% CI, 0.070; 0.750, p = 0.018). There was a trend toward a higher improvement in the NIHSS during hospitalization [ΔNIHSS: bridging-IVT group 8 (IQR, 9.8) vs. 4 (IQR 11) points in the EVT alone group; fixed effects estimate 1.370, 95% CI, −0.490; 3.240, p = 0.149]. mRS at 90 days follow-up was lower in the bridging IVT group [3 (IQR, 4) vs. 4 (IQR, 4); fixed effects estimate −0.350, 95% CI, −0.680; −0.010, p = 0.041]. There was a non-significantly lower 90 day mortality in the bridging IVT group compared with the EVT alone group (22.4% vs. 33.6%; fixed effects estimate 0.980, 95% CI −0.610; 2.580, p = 0.351). Rates of any intracerebral hemorrhage did not differ between both groups (4.1% vs. 3.8%, p = 0.864). Conclusions: This study provides evidence that bridging IVT might improve rates of successful reperfusion and long-term functional outcome in mothership patients with anterior circulation LVOS eligible for EVT.
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Affiliation(s)
- Ilko L Maier
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Andreas Leha
- Department of Medical Statistics, University Medical Center Göttingen, Göttingen, Germany
| | - Mostafa Badr
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Ibrahim Allam
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Mathias Bähr
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Ala Jamous
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - Amelie Hesse
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | | | - Daniel Behme
- Department of Neuroradiology, University Hospital Magdeburg, Magdeburg, Germany
| | - Jan Liman
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
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23
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Riederer I, Fingerle AA, Zimmer C, Noël PB, Makowski MR, Pfeiffer D. Potential of dual-layer spectral CT for the differentiation between hemorrhage and iodinated contrast medium in the brain after endovascular treatment of ischemic stroke patients. Clin Imaging 2021; 79:158-164. [PMID: 33962188 DOI: 10.1016/j.clinimag.2021.04.020] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 04/01/2021] [Accepted: 04/25/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND One possible complication after mechanical thrombectomy is hemorrhage. In conventional CT it is often difficult to differ between extravasation of iodinated contrast medium and blood. This differentiation, however, is essential for treatments with anticoagulants and antiplatelets. PURPOSE To evaluate dual-layer spectral Computed Tomography (DLSCT) for the differentiation between intracranial hemorrhage and iodinated contrast medium in ischemic stroke patients after mechanical thrombectomy. MATERIALS AND METHODS First, in vitro experiments were performed. Then, head CT images of 47 patients after mechanical thrombectomy were analyzed. Virtual non-contrast (VNC) images and iodine density maps (IDM) were calculated and evaluated. Region of interests (ROIs) analyses were performed. Sensitivity and specificity as well as ROC curves were calculated. RESULTS IDM and VNC images enabled clear differentiation between blood and iodine and reliable quantification of different iodine concentrations in vitro. A total of 23 hyperdense areas were detected in 13 patients, classified as hemorrhage (n = 7), iodinated contrast medium (n = 4) and a mixture of both (n = 12). Sensitivity and specificity for the detection of blood was 100%. CONCLUSION DLSCT enables differentiation between intracranial hemorrhage and iodinated contrast medium in patients after mechanical thrombectomy and might improve diagnostic imaging in post-interventional stroke patients.
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Affiliation(s)
- Isabelle Riederer
- Department of Diagnostic and Interventional Neuroradiology, Technical University of Munich, Munich, Germany.
| | - Alexander A Fingerle
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, Munich, Germany
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, Technical University of Munich, Munich, Germany
| | - Peter B Noël
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, Munich, Germany; Department of Radiology, Perelman School of Medicine, University of Pennsylvania, 3400 Spruce Street, One Silverstein, Philadelphia, PA 19104, USA
| | - Marcus R Makowski
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, Munich, Germany
| | - Daniela Pfeiffer
- Department of Diagnostic and Interventional Radiology, Technical University of Munich, Munich, Germany
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24
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Cabrera-Maqueda JM, Alba-Isasi MT, Díaz-Pérez J, Albert-Lacal L, Morales A, Parrilla G. Bridging Therapy and Occlusion Site Influence Symptomatic Hemorrhage Rate after Thrombectomy: A Daily Practice Study in 623 Stroke Patients. Cerebrovasc Dis 2021; 50:279-287. [PMID: 33706319 DOI: 10.1159/000512604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 10/21/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Comparison of symptomatic intracranial hemorrhage (SICH) rates between stroke patients treated with bridging therapy (BT) and primary mechanical thrombectomy (PMT) are scarce and difficult to interpret due to baseline differences between both populations. METHODS Retrospective analysis of patients with acute ischemic stroke treated with endovascular therapy (BT or PMT) was performed at our center between January 2010 and June 2017. RESULTS Six hundred twenty-three patients were included. Global SICH rate was 9% overall: 6.8% in the PMT group and 12.6% in the BT group. The following factors significantly associated with SICH after multivariate analysis: MCA occlusion (p: 0.047), stroke of unknown origin (p: 0.025), BT (p: 0.024), and procedural time over 65 min (p: 0.027). The following variables presented a statistically significant higher frequency in patients treated with PMT: atrial fibrillation (p: 0.005), anticoagulant medication (p < 0.001), wake-up strokes (p < 0.001), atherothrombotic etiology (p < 0.05), combined thrombectomy technique (p: 0.008), longer procedural times (p: 0.025), and favorable outcome at 3 months (p: 0.011). The following variables presented a statistically significant higher frequency in patients treated with BT: antiplatelet medication (p: 0.048), MCA occlusions (p: 0.017), cardioembolic etiology (p < 0.05), stent retriever/aspiration technique (p: 0.008), and SICH (p: 0.013). Patients with MCA occlusions had twice the risk of SICH after BT than after PMT (16.4 and 8.6%, p: 0.038). CONCLUSIONS In this clinical series, the SICH rate was higher in patients treated with BT than in those treated with PMT. Relevant differences in baseline (related to IVT contraindications) were found between both groups. Randomized studies of BT versus PMT in populations with similar baseline characteristics might be of interest.
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Affiliation(s)
- Jose María Cabrera-Maqueda
- Department of Neurology, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain.,Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Group of Experimental Opththalmology, Murcia, Spain
| | - Maria Teresa Alba-Isasi
- Department of Neurology, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain,
| | - Jose Díaz-Pérez
- Department of Neurointerventional Surgery, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Laura Albert-Lacal
- Department of Neurology, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Ana Morales
- Department of Neurology, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Guillermo Parrilla
- Department of Neurointerventional Surgery, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
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25
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Zi W, Qiu Z, Li F, Sang H, Wu D, Luo W, Liu S, Yuan J, Song J, Shi Z, Huang W, Zhang M, Liu W, Guo Z, Qiu T, Shi Q, Zhou P, Wang L, Fu X, Liu S, Yang S, Zhang S, Zhou Z, Huang X, Wang Y, Luo J, Bai Y, Zhang M, Wu Y, Zeng G, Wan Y, Wen C, Wen H, Ling W, Chen Z, Peng M, Ai Z, Guo F, Li H, Guo J, Guan H, Wang Z, Liu Y, Pu J, Wang Z, Liu H, Chen L, Huang J, Yang G, Gong Z, Shuai J, Nogueira RG, Yang Q. Effect of Endovascular Treatment Alone vs Intravenous Alteplase Plus Endovascular Treatment on Functional Independence in Patients With Acute Ischemic Stroke: The DEVT Randomized Clinical Trial. JAMA 2021; 325:234-243. [PMID: 33464335 PMCID: PMC7816099 DOI: 10.1001/jama.2020.23523] [Citation(s) in RCA: 307] [Impact Index Per Article: 102.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
IMPORTANCE For patients with large vessel occlusion strokes, it is unknown whether endovascular treatment alone compared with intravenous thrombolysis plus endovascular treatment (standard treatment) can achieve similar functional outcomes. OBJECTIVE To investigate whether endovascular thrombectomy alone is noninferior to intravenous alteplase followed by endovascular thrombectomy for achieving functional independence at 90 days among patients with large vessel occlusion stroke. DESIGN, SETTING, AND PARTICIPANTS Multicenter, randomized, noninferiority trial conducted at 33 stroke centers in China. Patients (n = 234) were 18 years or older with proximal anterior circulation intracranial occlusion strokes within 4.5 hours from symptoms onset and eligible for intravenous thrombolysis. Enrollment took place from May 20, 2018, to May 2, 2020. Patients were enrolled and followed up for 90 days (final follow-up was July 22, 2020). INTERVENTIONS A total of 116 patients were randomized to the endovascular thrombectomy alone group and 118 patients to combined intravenous thrombolysis and endovascular thrombectomy group. MAIN OUTCOMES AND MEASURES The primary end point was the proportion of patients achieving functional independence at 90 days (defined as score 0-2 on the modified Rankin Scale; range, 0 [no symptoms] to 6 [death]). The noninferiority margin was -10%. Safety outcomes included the incidence of symptomatic intracerebral hemorrhage within 48 hours and 90-day mortality. RESULTS The trial was stopped early because of efficacy when 234 of a planned 970 patients had undergone randomization. All 234 patients who were randomized (mean age, 68 years; 102 women [43.6%]) completed the trial. At the 90-day follow-up, 63 patients (54.3%) in the endovascular thrombectomy alone group vs 55 (46.6%) in the combined treatment group achieved functional independence at the 90-day follow-up (difference, 7.7%, 1-sided 97.5% CI, -5.1% to ∞)P for noninferiority = .003). No significant between-group differences were detected in symptomatic intracerebral hemorrhage (6.1% vs 6.8%; difference, -0.8%; 95% CI, -7.1% to 5.6%) and 90-day mortality (17.2% vs 17.8%; difference, -0.5%; 95% CI, -10.3% to 9.2%). CONCLUSIONS AND RELEVANCE Among patients with ischemic stroke due to proximal anterior circulation occlusion within 4.5 hours from onset, endovascular treatment alone, compared with intravenous alteplase plus endovascular treatment, met the prespecified statistical threshold for noninferiority for the outcome of 90-day functional independence. These findings should be interpreted in the context of the clinical acceptability of the selected noninferiority threshold. TRIAL REGISTRATION Chinese Clinical Trial Registry: ChiCTR-IOR-17013568.
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Affiliation(s)
- Wenjie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
| | - Zhongming Qiu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
- Department of Neurology, The 903rd Hospital of The Chinese People’s Liberation Army, Xihu District, Hangzhou, China
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
| | - Hongfei Sang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
- Department of Neurology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Deping Wu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
- Huaian Medical District of Jingling Hospital, Medical School of Nanjing University, Huaian, China
| | - Weidong Luo
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
| | - Shuai Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
| | - Junjie Yuan
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
| | - Jiaxing Song
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
| | - Zhonghua Shi
- Department of Neurosurgery, The 904th Hospital of The Chinese People’s Liberation Army, Wuxi, China
| | - Wenguo Huang
- Department of Neurology, Maoming Traditional Chinese Medicine Hospital, Maonan District, Maoming, China
| | - Min Zhang
- Department of Neurology, Maoming Traditional Chinese Medicine Hospital, Maonan District, Maoming, China
| | - Wenhua Liu
- Department of Neurology, Wuhan No. 1 Hospital, Qiaokou District, Wuhan, China
| | - Zhangbao Guo
- Department of Neurology, Wuhan No. 1 Hospital, Qiaokou District, Wuhan, China
| | - Tao Qiu
- Department of Neurology, The First People’s Hospital of Zigong, Da'an District, Zigong, China
| | - Qiang Shi
- Department of Neurology, The First People’s Hospital of Zigong, Da'an District, Zigong, China
| | - Peiyang Zhou
- Department of Neurology, The First People’s Hospital of Xiangyang, Fancheng District, Xiangyang, China
| | - Li Wang
- Department of Neurology, The Third People’s Hospital of Zigong, Gongjing District, Zigong, China
| | - Xinmin Fu
- Department of Neurology, Xuzhou Central Hospital, Quanshan District, Xuzhou, China
| | - Shudong Liu
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing Key Laboratory of Cerebrovascular Disease Research, Yongchuan District, Chongqing, China
| | - Shiquan Yang
- Department of Neurology, The 902nd Hospital of The Chinese People’s Liberation Army, Yuhui District, Bengbu, China
| | - Shuai Zhang
- Department of Neurology, The Affiliated Hospital of Yangzhou University, Guangling District, Yangzhou, China
| | - Zhiming Zhou
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Xianjun Huang
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Yan Wang
- Department of Neurology, The Fifth People’s Hospital of Chengdu, Wenjiang District, Chengdu, China
| | - Jun Luo
- Department of Neurology, Sichuan Mianyang 404 Hospital, Fucheng District, Mianyang, China
| | - Yongjie Bai
- Department of Neurology, The First Affiliated Hospital of Henan Science and Technology University, Jianxi District, Luoyang, China
| | - Min Zhang
- Department of Neurology, Jiangmen Central Hospital, Pengjiang District, Jiangmen, China
| | - Youlin Wu
- Department of Neurology, Chongzhou People's Hospital, Chongzhou, China
| | - Guoyong Zeng
- Department of Neurology, Ganzhou People's Hospital, Zhanggong District, Ganzhou, China
| | - Yue Wan
- Department of Neurology, Yangluo District of Hubei Zhongshan Hospital, Qiaokou District, Wuhan, China
| | - Changming Wen
- Department of Neurology, Nanyang Central Hospital, Wolong District, Nanyang, China
| | - Hongbin Wen
- Department of Neurology, Xiangyang Central Hospital, Xiangcheng District, Xiangyang, China
| | - Wentong Ling
- Department of Neurology, Zhongshan People's Hospital, Zhongshan, China
| | - Zhuo Chen
- Department of Neurology, Mianzhu People's Hospital, Mianzhu, China
| | - Miao Peng
- Department of Neurology, Deyang People’s Hospital, Jingyang District, Deyang, China
| | - Zhibing Ai
- Department of Neurology, Taihe Affiliated Hospital of Shiyan, Shiyan, China
| | - Fuqiang Guo
- Department of Neurology, Sichuan Provincial People’s Hospital, Qingyang District, Chengdu, China
| | - Huagang Li
- Department of Neurology, Zhongnan Hospital of Wuhan University, Wuchang District, Wuhan, China
| | - Jing Guo
- Department of Neurology, Chongqing Three Gorges Central Hospital, Wanzhou District, Chongqing, China
| | - Haitao Guan
- Department of Neurology, The Third Affiliated Hospital of Guangzhou Medical University, Liwan District, Guangzhou, China
| | - Zhiyi Wang
- Department of Neurology, Huazhou People’s Hospital, Hexi District, Huazhou, China
| | - Yong Liu
- Department of Neurology, Lu'an People’s Hospital, Jin'an District, Lu'an, China
| | - Jie Pu
- Department of Neurology, Hubei Provincial People's Hospital, Wuchang District, Wuhan, China
| | - Zhen Wang
- Department of Neurology, Changsha Central Hospital, Yuhua District, Changsha, China
| | - Hansheng Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
| | - Luming Chen
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
| | - Jiacheng Huang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
| | - Guoqiang Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
| | - Zili Gong
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
| | - Jie Shuai
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
| | - Raul G. Nogueira
- Department of Neurology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia
| | - Qingwu Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
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Chang A, Beheshtian E, Llinas EJ, Idowu OR, Marsh EB. Intravenous Tissue Plasminogen Activator in Combination With Mechanical Thrombectomy: Clot Migration, Intracranial Bleeding, and the Impact of "Drip and Ship" on Effectiveness and Outcomes. Front Neurol 2020; 11:585929. [PMID: 33424741 PMCID: PMC7794010 DOI: 10.3389/fneur.2020.585929] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 11/16/2020] [Indexed: 01/19/2023] Open
Abstract
Purpose: Intravenous tissue plasminogen activator (tPA) is indicated prior to mechanical thrombectomy (MT) to treat large vessel occlusion (LVO). However, administration takes time, and rates of clot migration complicating successful retrieval and hemorrhagic transformation may be higher. Given time-to-effectiveness, the benefit of tPA may vary significantly based on whether administration occurs at a thrombectomy-capable center or transferring hospital. Methods: We prospectively evaluated 170 individuals with LVO involving the anterior circulation who underwent MT at our Comprehensive Stroke Center over a 3.5 year period. Two thirds (n = 114) of patients were admitted through our Emergency Department (ED). The other 33% were transferred from outside hospitals (OSH). Patients meeting criteria were bridged with IV tPA; the others were treated with MT alone. Clot migration, recanalization times, TICI scores, and hemorrhage rates were compared for those bridged vs. treated with MT alone, along with modified Rankin scores (mRS) at discharge and 90-day follow-up. Multivariable regression was used to determine the relationship between site of presentation and effect of tPA on outcomes. Results: Patients presenting to an OSH had longer mean discovery to puncture/recanalization times, but were actually more likely to receive IV tPA prior to MT (70 vs. 42%). The rate of clot migration was low (11%) and similar between groups, though slightly higher for those receiving IV tPA. There was no difference in symptomatic ICH rate after tPA. TICI scores were also not significantly different; however, more patients achieved TICI 2b or higher reperfusion (83 vs. 67%, p = 0.027) after tPA, and TICI 0 reperfusion was seen almost exclusively in patients who were not treated with tPA. Those bridged at an OSH required fewer passes before successful recanalization (2.4 vs. 1.6, p = 0.037). Overall, mean mRS scores on discharge and at 90 days were significantly better for those receiving IV tPA (3.9 vs. 4.6, 3.4 vs. 4.4 respectively, p ~ 0.01) and differences persisted when comparing only patients recanalized in under 6 h. Conclusion: Independent of site of presentation, IV tPA before MT appears to lead to better radiographic outcomes, without increased rates of clot migration or higher intracranial hemorrhage risk, and overall better functional outcomes.
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Affiliation(s)
- Adam Chang
- Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Elham Beheshtian
- Department of Radiology, The Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Edward J. Llinas
- Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Oluwatoyin R. Idowu
- Department of Radiology, The Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Elisabeth B. Marsh
- Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD, United States
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Ko CC, Liu HM, Chen TY, Wu TC, Tsai LK, Tang SC, Tsui YK, Jeng JS. Prediction of mTICI 3 recanalization and clinical outcomes in endovascular thrombectomy for acute ischemic stroke: a retrospective study in the Taiwan registry. Neurol Sci 2020; 42:2325-2335. [PMID: 33037513 DOI: 10.1007/s10072-020-04800-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2020] [Accepted: 10/05/2020] [Indexed: 11/25/2022]
Abstract
PURPOSE Early recanalization for acute ischemic stroke (AIS) due to large vessel occlusion (LVO) by endovascular thrombectomy (EVT) is strongly related to improved functional outcomes. With data obtained from the Taiwan registry, the factors associated with mTICI 3 recanalization and clinical outcomes in EVT are investigated. METHODS From January 2014 to September 2016, 108 patients who underwent EVT for AIS due to LVO in 11 medical centers throughout Taiwan were included. Complete recanalization is defined as achieving modified thrombolysis in cerebral infarction (mTICI) grade 3. Good clinical outcomes are defined by the modified Rankin scale (mRS) 0-2 at 3 months after EVT. Clinical and imaging parameters for predicting mTICI 3 recanalization and good clinical outcomes are analyzed. RESULTS Of the 108 patients who received EVT, 54 (50%) patients had mTICI 3 recanalization. Having received aspiration only and the use of IV-tPA are shown to be significant predictors for mTICI 3 recanalization with odds ratios of 2.61 and 2.53 respectively. Forty-six (42.6%) patients experienced good 3-month clinical outcomes (mRS 0-2). Pretreatment collateral statuses, NIHSS scores, time lapses between symptoms to needle, and the occurrence of hemorrhage at 24 h are all significant predictors for good outcomes with odds ratios of 2.88, 0.91, 0.99, and 0.31 respectively. CONCLUSIONS Prediction of mTICI 3 recanalization and clinical outcomes offer valuable clinical information for treatment planning in EVT.
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Affiliation(s)
- Ching-Chung Ko
- Department of Medical Imaging, Chi Mei Medical Center, No.901, Zhonghua Rd., Yongkang District, Tainan City, 71004, Taiwan, Republic of China
- Department of Health and Nutrition, Chia Nan University of Pharmacy and Science, Tainan, Taiwan
| | - Hon-Man Liu
- Department of Medical Imaging, Fu Jen Catholic University Hospital, Fu Jen Catholic University, No.69, Guizi Rd., Taishan Dist, New Taipei City, 24352, Taiwan, Republic of China
- Department of Medical Imaging, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei City, Taiwan
| | - Tai-Yuan Chen
- Department of Medical Imaging, Chi Mei Medical Center, No.901, Zhonghua Rd., Yongkang District, Tainan City, 71004, Taiwan, Republic of China
- Graduate Institute of Medical Sciences, Chang Jung Christian University, Tainan, Taiwan
| | - Te-Chang Wu
- Department of Medical Imaging, Chi Mei Medical Center, No.901, Zhonghua Rd., Yongkang District, Tainan City, 71004, Taiwan, Republic of China
- Graduate Institute of Medical Sciences, Chang Jung Christian University, Tainan, Taiwan
- Department of Biomedical Imaging and Radiological Sciences, National Yang-Ming University, Taipei, Taiwan
| | - Li-Kai Tsai
- Stroke Center and Department of Neurology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei City, 100, Taiwan, Republic of China
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei City, 100, Taiwan, Republic of China
| | - Yu-Kun Tsui
- Department of Medical Imaging, Chi Mei Medical Center, No.901, Zhonghua Rd., Yongkang District, Tainan City, 71004, Taiwan, Republic of China.
| | - Jiann-Shing Jeng
- Stroke Center and Department of Neurology, National Taiwan University Hospital, No. 7, Chung-Shan South Road, Taipei City, 100, Taiwan, Republic of China
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Siegler JE, Jovin TG. Thrombolysis Before Thrombectomy in Acute Large Vessel Occlusion: a Risk/Benefit Assessment and Review of the Evidence. Curr Treat Options Neurol 2020. [DOI: 10.1007/s11940-020-00633-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Yi HJ, Sung JH, Lee DH. Bridging Intravenous Thrombolysis Before Mechanical Thrombectomy for Large Artery Occlusion May be Detrimental with Thrombus Fragmentation. Curr Neurovasc Res 2020; 17:18-26. [DOI: 10.2174/1567202617666191223143831] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Revised: 11/15/2019] [Accepted: 11/20/2019] [Indexed: 11/22/2022]
Abstract
Objective:
We investigated whether intravenous thrombolysis (IVT) affected the outcomes
and complications of mechanical thrombectomy (MT), specifically focusing on thrombus
fragmentation.
Methods:
The patients who underwent MT for large artery occlusion (LAO) were classified into
two groups: MT with prior IVT (MT+IVT) group and MT without prior IVT (MT-IVT) group.
The clinical outcome, successful recanalization with other radiological outcomes, and complications
were compared, between two groups. Subgroup analysis was also performed for patients with
simultaneous application of stent retriever and aspiration.
Results:
There were no significant differences in clinical outcome and successful recanalization
rate, between both groups. However, the ratio of pre- to peri-procedural thrombus fragmentation
was significantly higher in the MT+IVT group (14.6% and 16.2%, respectively; P=0.004) compared
to the MT-IVT group (5.1% and 6.8%, respectively; P=0.008). The MT+IVT group required
more second stent retriever (16.2%), more stent passages (median value = 2), and more occurrence
of distal emboli (3.9%) than the MT-IVT group (7.9%, median value = 1, and 8.1%, respectively)
(P=0.004, 0.008 and 0.018, respectively). In subgroup analysis, the results were similar to those of
the entire patients.
Conclusion:
Thrombus fragmentation of IVT with t-PA before MT resulted in an increased need
for additional rescue therapies, and it could induce more distal emboli. The use of IVT prior to MT
does not affect the clinical outcome and successful recanalization, compared with MT without
prior IVT. Therefore, we need to reconsider the need for IVT before MT.
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Affiliation(s)
- Ho Jun Yi
- Department of Neurosurgery, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Jae Hoon Sung
- Department of Neurosurgery, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong Hoon Lee
- Department of Neurosurgery, St. Vincent’s Hospital, College of Medicine, The Catholic University of Korea, Seoul, Korea
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30
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Styczen H, Maus V, Hesse AC, Goertz L, Fischer S, Riedel C, Forsting M, Radbruch A, Behme D. Impact of early division of the middle cerebral artery on outcome following mechanical thrombectomy. Interv Neuroradiol 2020; 26:389-395. [PMID: 32340515 DOI: 10.1177/1591019920920987] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Mechanical thrombectomy has become the standard care for acute ischemic stroke caused by large vessel occlusion. However, complete reperfusion cannot be achieved in all cases, and several factors influencing the results of mechanical thrombectomy have been investigated. Among others, a tortuous anatomy is associated with lower rates of complete reperfusion. We aimed to investigate whether an early division of the middle cerebral artery has an impact on reperfusion results in mechanical thrombectomy. METHODS Retrospective review of consecutive patients with M1 occlusion treated endovascularly between January 2016 and December 2019 at three tertiary care centers. The study group was dichotomized based on the length of the M1 segment. Early division of the middle cerebral artery was defined as a maximum length of 10 mm of the M1 segment. Primary endpoints were first-pass mTICI scores of 3, ≥2c, and ≥2b. Secondary endpoints contained final reperfusion, number of device-passes, time interval from groin puncture to reperfusion, rate of postinterventional symptomatic intracranial hemorrhage, and frequency of emboli of new territory. RESULTS Among 284 included patients, 70 presented with an early division of the M1 segment (25%). Reperfusion results did not differ significantly between early and late division of M1. A higher rate of symptomatic intracranial hemorrhage was found in the group with an early M1 division treated with aspiration only (14.3% vs. 0%; p = 0.013). Patients with late M1 division had a significantly higher rate of large artery sclerosis (19.2% vs. 8.6%, p = 0.039). CONCLUSION The anatomic variant of an early division of the middle cerebral artery was not a predictor for incomplete reperfusion.
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Affiliation(s)
- Hanna Styczen
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Volker Maus
- Department of Radiology, Neuroradiology and Nuclear Medicine, Ruhr-University Bochum, University Medical Center Langendreer, Bochum, Germany
| | - Amélie C Hesse
- Institute for Diagnostic and Interventional Neuroradiology, University Hospital Goettingen, Goettingen, Germany
| | - Lukas Goertz
- Center for Neurosurgery, Medical Faculty and University Hospital, University of Cologne, Cologne, Germany
| | - Sebastian Fischer
- Department of Radiology, Neuroradiology and Nuclear Medicine, Ruhr-University Bochum, University Medical Center Langendreer, Bochum, Germany
| | - Christian Riedel
- Institute for Diagnostic and Interventional Neuroradiology, University Hospital Goettingen, Goettingen, Germany
| | - Michael Forsting
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Alexander Radbruch
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Daniel Behme
- Institute for Diagnostic and Interventional Neuroradiology, University Hospital Goettingen, Goettingen, Germany
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Bourcier R, Goyal M, Liebeskind DS, Muir KW, Desal H, Siddiqui AH, Dippel DWJ, Majoie CB, van Zwam WH, Jovin TG, Levy EI, Mitchell PJ, Berkhemer OA, Davis SM, Derraz I, Donnan GA, Demchuk AM, van Oostenbrugge RJ, Kelly M, Roos YB, Jahan R, van der Lugt A, Sprengers M, Velasco S, Lycklama À Nijeholt GJ, Ben Hassen W, Burns P, Brown S, Chabert E, Krings T, Choe H, Weimar C, Campbell BCV, Ford GA, Ribo M, White P, Cloud GC, San Roman L, Davalos A, Naggara O, Hill MD, Bracard S. Association of Time From Stroke Onset to Groin Puncture With Quality of Reperfusion After Mechanical Thrombectomy: A Meta-analysis of Individual Patient Data From 7 Randomized Clinical Trials. JAMA Neurol 2020; 76:405-411. [PMID: 30667465 DOI: 10.1001/jamaneurol.2018.4510] [Citation(s) in RCA: 112] [Impact Index Per Article: 28.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Importance Reperfusion is a key factor for clinical outcome in patients with acute ischemic stroke (AIS) treated with endovascular thrombectomy (EVT) for large-vessel intracranial occlusion. However, data are scarce on the association between the time from onset and reperfusion results. Objective To analyze the rate of reperfusion after EVT started at different intervals after symptom onset in patients with AIS. Design, Setting, and Participants We conducted a meta-analysis of individual patient data from 7 randomized trials of the Highly Effective Reperfusion Using Multiple Endovascular Devices (HERMES) group. This is a multicenter cohort study of the intervention arm of randomized clinical trials included in the HERMES group. Patients with anterior circulation AIS who underwent EVT for M1/M2 or intracranial carotid artery occlusion were included. Each trial enrolled patients according to its specific inclusion and exclusion criteria. Data on patients eligible but not enrolled (eg, refusals or exclusions) were not available. All analyses were performed by the HERMES biostatistical core laboratory using the pooled database. Data were analyzed between December 2010 and April 2015. Main Outcomes and Measures Successful reperfusion was defined as a modified thrombolysis in cerebral infarction score of 2b/3 at the end of the EVT procedure adjusted for age, occlusion location, pretreatment intravenous thrombolysis, and clot burden score and was analyzed in relation to different intervals (onset, emergency department arrival, imaging, and puncture) using mixed-methods logistic regression. Results Among the 728 included patients, with a mean (SD) age of 65.4 (13.5) years and of whom 345 were female (47.4%), decreases in rates of successful reperfusion defined as a thrombolysis in cerebral infarction score of 2b/3 were observed with increasing time from admission or first imaging to groin puncture. The magnitude of effect was a 22% relative reduction (odds ratio, 0.78; 95% CI, 0.64-0.95) per additional hour between admission and puncture and a 26% relative reduction (odds ratio, 0.74; 95% CI, 0.59-0.93) per additional hour between imaging and puncture. Conclusions and Relevance Because the probability of reperfusion declined significantly with time between hospital arrival and groin puncture, we provide additional arguments for minimizing the intervals after symptom onset in anterior circulation acute ischemic stroke.
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Affiliation(s)
- Romain Bourcier
- Centre Hospitalier Universitaire de Nantes, Nantes Cedex, France
| | | | | | | | - Hubert Desal
- Centre Hospitalier Universitaire de Nantes, Nantes Cedex, France
| | | | | | | | - Wim H van Zwam
- Maastricht University Medical Center, Maastricht, the Netherlands
| | - Tudor G Jovin
- University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | | | | | | | | | - Imad Derraz
- University Hospital of Montpellier, Montpellier, France
| | - Geoffrey A Donnan
- The Florey Institute of Neuroscience and Mental Health, Parkville, Australia
| | | | | | - Michael Kelly
- Division of Neurosurgery, Department of Surgery, University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Yvo B Roos
- Academic Medical Center Amsterdam, Amsterdam, the Netherlands
| | - Reza Jahan
- University of California, Los Angeles Medical Center, Los Angeles
| | - Aad van der Lugt
- Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | | | | | | | | | - Paul Burns
- Department of Neuroradiology, Royal Victoria Hospital, Belfast, Belfast, Ireland
| | - Scott Brown
- Altair Biostatistics, Mooresville, North Carolina
| | - Emmanuel Chabert
- Centre Hospitalier Universitaire Clermont-Ferrand, Clermont-Ferrand, France
| | - Timo Krings
- University of Toronto, Toronto Western Hospital, Toronto, Ontario, Canada
| | - Hana Choe
- Abington and Jefferson Health, Abington, Pennsylvania
| | | | | | - Gary A Ford
- Oxford University Hospitals National Health Services Foundation trust and University of Oxford, Oxford, England
| | - Marc Ribo
- Hospital Vall d'Hebron, Barcelona, Spain
| | - Phil White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, England
| | - Geoffrey C Cloud
- Department of Clinical Neuroscience, Central Clinical School, Monash University and The Alfred Hospital, Melbourne, Australia
| | | | - Antoni Davalos
- Hospital Germans Trias i Pujol, Badalona, Barcelona, Spain
| | - Olivier Naggara
- Hopital Saint Anne, University Paris-Descartes, Paris, France
| | | | - Serge Bracard
- University of Lorraine, and University Hospital of Nancy, Nancy, France
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Sinha K, Bettermann K. Clinical outcomes of moderate to severe acute ischemic stroke in a telemedicine network. J Clin Neurosci 2019; 69:160-165. [PMID: 31471078 DOI: 10.1016/j.jocn.2019.08.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2019] [Accepted: 08/05/2019] [Indexed: 10/26/2022]
Abstract
Acute ischemic strokes (AIS) with severe neurologic deficits are associated with poor short- and long-term prognosis. Thrombectomy alone or in combination with thrombolysis is used for reperfusion in patients with moderate-to-severe AIS. However, the best therapeutic approach within the setting of telemedicine networks needs to be elucidated further. The objective of this study was to analyze clinical and imaging based outcomes of moderate to severe stroke following treatment with thrombolysis, thrombectomy or a combination of both in a telemedicine network. Data of this retrospective study was abstracted from the institutional telestroke database. Patients with a National Institute of Health Stroke Scale score (NIH-SS ≥ 10) were included into the study. Primary outcome measure was the difference in NIH-SS at admission compared to discharge from the hospital. Secondary outcome measure was the discharge disposition defined as favorable (discharge to home or rehabilitation) versus unfavorable disposition (discharge to hospice/death). Furthermore, outcome was analyzed based on reperfusion status following thrombectomy using the Thrombolysis in Cerebral Infarction (TICI) scale. The NIH-SS improved in all three groups, independent of treatment subtype, with a trend towards best outcomes following thrombolysis and combined treatment therapy compared to thrombectomy alone. In addition, reperfusion rates were higher in the combination group compared to the thrombectomy only group. The number of favorable discharges was similar in all three groups. The present study stresses the benefits of tele-stroke networks in allowing to early identify and treat even patients with severe strokes and benefit from different treatment modalities.
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Affiliation(s)
- Kusum Sinha
- Department of Neurology, Penn State College of Medicine, Hershey, PA, USA
| | - Kerstin Bettermann
- Department of Neurology, Penn State College of Medicine, Hershey, PA, USA.
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Is intravenous thrombolysis still necessary in patients who undergo mechanical thrombectomy? Curr Opin Neurol 2019; 32:3-12. [PMID: 30461464 DOI: 10.1097/wco.0000000000000633] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW To summarize available evidence on the potential utility of pretreatment with intravenous thrombolysis (IVT) using recombinant tissue-plasminogen activator (rt-PA) in acute ischemic stroke (AIS) patients with large vessel occlusions (LVO) who are treated with mechanical thrombectomy. RECENT FINDINGS Despite theoretical concerns of a higher bleeding risk with IVT pretreatment, there are no data showing increased risk of symptomatic intracerebral hemorrhage (sICH) in patients with LVO receiving bridging therapy (IVT and mechanical thrombectomy) compared with direct mechanical thrombectomy (dMT). Additionally, evidence from observational studies suggest lower rates of infarctions in previously unaffected territories and higher rates of successful reperfusion, with lower number of device passes, in patients receiving bridging therapy. There are substantial discrepancies in studies comparing clinical outcomes between dMT and bridging therapy that are directly related to the inclusion of patients with contraindications to IVT in the dMT group. Ongoing clinical trials will provide definitive answers on the potential additional benefit of IVT in LVO patients receiving mechanical thrombectomy. SUMMARY IVT and mechanical thrombectomy are two effective reperfusion therapies that should be used in a swift and noncompeting fashion in AIS patients. AIS patients with LVO and no contraindications for IVT should receive promptly rt-PA bolus followed by immediate initiation of mechanical thrombectomy as indicated by current international recommendations, unless future randomized controlled trials provide evidence to proceed differently.
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34
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Nicastro N, Eger AF, Boukrid II, Mueller HFG, Machi P, Vargas MI, Poletti PA, Platon A, Sztajzel RF. Earlier IV thrombolysis and mechanical thrombectomy in acute ischemic stroke are associated with a better recanalization. CLINICAL AND TRANSLATIONAL NEUROSCIENCE 2019. [DOI: 10.1177/2514183x19855602] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Introduction: Combined intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) are the recommended treatment options for acute ischemic stroke (AIS). It is unclear whether earlier IVT and MT management can predict complete vessel recanalization. Methods: In this single-center retrospective observational study, we included 81 consecutive subjects with proximal middle cerebral artery AIS (age 70.5 ± 14.2 years, 53% female) who had both IVT and MT. We assessed recanalization after mechanical procedure according to modified thrombolysis in cerebral infarction (TICI) score as well as the National Institute of Health Stroke Scale (NIHSS) score at 24 h. Outcomes were modified Rankin Scale (mRS) at discharge, mRS at 3 months, death at 3 months, and prevalence of intracerebral hemorrhage during hospitalization. Results: Multinomial logistic regression ( χ 2 = 49.4, p = 0.0075, pseudo- R 2 = 0.26) showed that complete recanalization (TICI score = 3) was predicted by lower door-to-MT time ( p = 0.014, 95% confidence interval (CI) = −0.09 to −0.01) and lower symptoms-to-IVT time ( p = 0.045, 95% CI = −0.038 to −0.0004). An NIHSS score ≥10 at 24 h was predicted by higher baseline NIHSS ( p < 0.0001) and lower TICI score ( p = 0.009). Lower NIHSS at 24 h predicted a good outcome according to mRS at 3 months ( p = 0.006). Similarly, higher NIHSS at 24 h was a predictor of death at 3 months ( p = 0.013). Conclusions: The present study suggests that bridging therapy may improve vascular recanalization when both IVT and MT are performed earlier.
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Affiliation(s)
- Nicolas Nicastro
- Department of Psychiatry, University of Cambridge, Cambridge, UK
- Division of Neurorehabilitation, Geneva University Hospitals, Geneva, Switzerland
| | - Antoine F Eger
- Division of Neurology, Geneva University Hospitals, Geneva, Switzerland
| | - Iman I Boukrid
- Division of Neurology, Geneva University Hospitals, Geneva, Switzerland
| | | | - Paolo Machi
- Division of Neuroradiology, Geneva University Hospitals, Geneva, Switzerland
| | - Maria Isabel Vargas
- Division of Neuroradiology, Geneva University Hospitals, Geneva, Switzerland
| | | | - Alexandra Platon
- Department of Radiology, Geneva University Hospitals, Geneva, Switzerland
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Casetta I, Pracucci G, Saletti A, Saia V, Padroni M, De Vito A, Inzitari D, Zini A, Vallone S, Bergui M, Cerrato P, Bracco S, Tassi R, Gandini R, Sallustio F, Piano M, Motto C, Spina PL, Vinci SL, Causin F, Baracchini C, Gasparotti R, Magoni M, Castellan L, Serrati C, Mangiafico S, Toni D. Combined intravenous and endovascular treatment versus primary mechanical thrombectomy. The Italian Registry of Endovascular Treatment in Acute Stroke. Int J Stroke 2019; 14:898-907. [DOI: 10.1177/1747493019851279] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Whether mechanical thrombectomy alone may achieve better or at least equal clinical outcome than mechanical thrombectomy combined with intravenous thrombolysis is a matter of debate. Methods From the Italian Registry of Endovascular Stroke Treatment, we extracted all cases treated with intravenous thrombolysis followed by mechanical thrombectomy or with primary mechanical thrombectomy for anterior circulation stroke due to proximal vessel occlusion. We included only patients who would have qualified for intravenous thrombolysis. We compared outcomes of the two groups by using multivariate regression analysis and propensity score method. Results We included 1148 patients, treated with combined intravenous thrombolysis and mechanical thrombectomy therapy (n = 635; 55.3%), or with mechanical thrombectomy alone (n = 513; 44.7%). Demographic and baseline clinical characteristics did not differ between the two groups, except for a shorter onset to groin puncture time (p < 0.05) in the mechanical thrombectomy group. A shift in the 90-day modified Rankin Scale distributions toward a better outcome was found in favor of the combined treatment (adjusted common odds ratio = 1.3; 95% confidence interval: 1.04–1.66). Multivariate analyses on binary outcome show that subjects who underwent combined treatment had higher probability to survive with modified Rankin Scale 0–3 (odds ratio = 1.42; 95% confidence interval: 1.04–1.95) and lower case fatality rate (odds ratio = 0.6; 95% confidence interval: 0.44–0.9). Hemorrhagic transformation did not differ between the two groups. Conclusion These data seem to indicate that combined intravenous thrombolysis and mechanical thrombectomy could be associated with lower probability of death or severe dependency after three months from stroke due to large vessel occlusion, supporting the current guidelines of treating eligible patients with intravenous thrombolysis before mechanical thrombectomy.
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Affiliation(s)
- Ilaria Casetta
- Neurological Clinic, S. Anna University Hospital of Ferrara, Italy
| | | | - Andrea Saletti
- Interventional Neuroradiology, S. Anna University Hospital of Ferrara, Italy
| | - Valentina Saia
- Neurology and Stroke Unit, Santa Corona Hospital, Pietra Ligure
| | - Marina Padroni
- Stroke Unit, S. Anna University Hospital of Ferrara, Italy
| | | | | | - Andrea Zini
- Stroke Unit, Ospedale Civile “S.Agostino-Estense”, Modena
| | - Stefano Vallone
- Neuroradiological Unit, Ospedale Civile “S.Agostino-Estense”, Modena
| | - Mauro Bergui
- Interventional Neuroradiology Unit, Ospedale “Molinette”, Torino
| | - Paolo Cerrato
- Stroke Unit, Ospedale “Molinette”, Torino
- Ospedale “Molinette”, Torino
| | - Sandra Bracco
- Interventional Neuroradiology Unit, Siena University Hospital
| | | | - Roberto Gandini
- Interventional Neuroradiology Unit, Policlinico Tor Vergata, Rome
| | | | - Mariangela Piano
- NEUROFARBA Department, Neuroscience Section, University of Florence
- Interventional Neuroradiology Unit, Niguarda Cà Granda” Hospital, Milan
| | | | | | - Sergio L Vinci
- Interventional Neuroradiology Unit, Policlinico G. Martino, Messina
| | | | | | | | | | - Lucio Castellan
- Interventional Neuroradiology Unit, IRCCS S. Martino-IST, Genova
| | | | | | - Danilo Toni
- Stroke Unit, University Hospital “Umberto I”, Rome
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Kawabata Y, Nakajima N, Miyake H, Fukuda S, Tsukahara T. Endovascular treatment of acute ischaemic stroke in octogenarians and nonagenarians compared with younger patients. Neuroradiol J 2019; 32:303-308. [PMID: 30987508 DOI: 10.1177/1971400919840847] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Purpose: Endovascular therapy for emergent large vessel occlusion has been established as the standard approach for acute ischaemic stroke. However, the effectiveness and safety of endovascular therapy in the very elderly population has not been proved. Objective: To determine the safety and effectiveness of endovascular therapy in octogenarians and nonagenarians. Methods: We retrospectively reviewed all patients who underwent endovascular therapy at two stroke centres between April 2012 and July 2018. Functional outcome was assessed using the modified Rankin scale at 90 days after stroke or at discharge. A favourable outcome was defined as a modified Rankin scale score of 0-2 or not worsening of the modified Rankin scale score before stroke. Outcome was compared between younger patients (aged 46-79 years, n = 40) and octogenarians and nonagenarians (aged 80-97 years, n = 19). Results: Octogenarian and nonagenarian patients had pre-stroke functional deficit (modified Rankin scale score >1) more frequently than younger patients (57.9% vs. 20.0%, respectively, P = 0.0059). No difference was observed between very elderly and younger patients in the rate of successful reperfusion (89.5% vs. 67.5%, respectively, P = 0.11), favourable functional outcome (47.4% vs. 45.0%, respectively, P = 1.00) and mortality (21.1% vs. 27.5%, respectively, P = 1.00). On multiple regression analysis, successful reperfusion, concomitant use of intravenous thrombolysis, and out-of-hospital onset were independent predictors of favourable outcome (P = 0.0003, 0.015 and 0.028, respectively). Conclusions: Successful reperfusion, concomitant use of intravenous thrombolysis, and out-of-hospital onset were clinical predictors of favourable outcome. However, we did not observe an age-dependent effect of clinical outcome after endovascular therapy.
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Affiliation(s)
- Yasuhiro Kawabata
- 1 Department of Neurosurgery, Kyoto Katsura Hospital, Japan.,2 Department of Neurosurgery, National Hospital Organization Kyoto Medical Center, Japan
| | - Norio Nakajima
- 1 Department of Neurosurgery, Kyoto Katsura Hospital, Japan
| | | | - Shunichi Fukuda
- 2 Department of Neurosurgery, National Hospital Organization Kyoto Medical Center, Japan
| | - Tetsuya Tsukahara
- 2 Department of Neurosurgery, National Hospital Organization Kyoto Medical Center, Japan
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Pan X, Liu G, Wu B, Liu X, Fang Y. Comparative efficacy and safety of bridging strategies with direct mechanical thrombectomy in large vessel occlusion: A systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e14956. [PMID: 30946319 PMCID: PMC6456029 DOI: 10.1097/md.0000000000014956] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Whether bridging strategies[intravenous thrombolysis (IVT) + mechanical thrombectomy (MT)] are superior to mechanical thrombectomy alone for large vessel occlusion(LVO) is still uncertain. A systematic review and meta-analysis was conducted to investigate and evaluate comparative efficacy and safety of bridging strategies vs direct MT in patients with LVO. METHODS The PubMed, EMBASE and Cochrane library databases were searched to evaluate the efficacy and safety of bridging strategies with direct MT in LVO. Functional independence, mortality, symptomatic intracranial hemorrhage (sICH) and successful recanalization were assessed. The risk ratio (RR) and its 95% confidence interval (CI) were calculated. RESULTS The proportion of patients who received MT + IVT was significantly higher in functional independence and successful recanalization rate than MT alone patients. However, pooled results showed that the mortality of patients who received MT + IVT was significantly lower than that of MT alone patients. Moreover, no significant differences were observed in the incidence of sICH between the 2 groups. CONCLUSION The findings of our meta-analysis confirmed that bridging strategies improved functional outcomes, successful recanalization rate and reduced mortality rates. Moreover, the incidence of sICH showed no differences between the bridging strategies and MT alone treatments. However, the conduct of high-quality randomized clinical trials that directly compare both strategies is warranted.
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Affiliation(s)
- Xiaohua Pan
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan
- Department of Neurology, Baotou Central Hospital, Baotou, Inner Mongolia, China
| | - Guorong Liu
- Department of Neurology, Baotou Central Hospital, Baotou, Inner Mongolia, China
| | - Bo Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan
| | - Xiuzhen Liu
- Department of Neurology, Baotou Central Hospital, Baotou, Inner Mongolia, China
| | - Yong Fang
- Department of Neurology, Baotou Central Hospital, Baotou, Inner Mongolia, China
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Gong L, Zheng X, Feng L, Zhang X, Dong Q, Zhou X, Wang H, Zhang X, Shu Z, Zhao Y, Liu X. Bridging Therapy Versus Direct Mechanical Thrombectomy in Patients with Acute Ischemic Stroke due to Middle Cerebral Artery Occlusion: A Clinical- Histological Analysis of Retrieved Thrombi. Cell Transplant 2019; 28:684-690. [PMID: 30654640 PMCID: PMC6686432 DOI: 10.1177/0963689718823206] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Mechanical thrombectomy (MT) is effective in managing patients with acute ischemic stroke (AIS) caused by large-vessel occlusions and allows for valuable histological analysis of thrombi. However, whether bridging therapy (pretreatment with intravenous thrombolysis before MT) provides additional benefits in patients with middle cerebral artery (MCA) occlusion remains unclear. Therefore, this study aimed to compare the effects of direct MT and bridging therapy, and to elucidate the correlation between thrombus composition and stroke subtypes. Seventy-three patients with acute ischemic stroke who received MT, were eligible for intravenous thrombolysis, and had MCA occlusion were included. We matched 21 direct MT patients with 21 bridging therapy patients using propensity score matching and compared their 3rd-month clinical outcomes. All MCA thrombi (n = 45) were histologically analyzed, and the red blood cell (RBC) and fibrin percentages were quantified. We compared the clot composition according to stroke etiology (large-artery atherosclerosis and cardioembolism) and intravenous thrombolysis application. The baseline characteristics showed no difference between groups except for a higher atrial fibrillation rate and NIHSS score on admission in the direct MT group. We performed a supportive analysis using propensity score matching but could not find any differences in the functional outcome, mortality, and intracerebral hemorrhage. In the histological clot analysis, the cardioembolic clots without intravenous thrombolysis pretreatment had higher RBC (P = 0.042) and lower fibrin (P = 0.042) percentages than the large-artery atherosclerosis thrombi. Similar findings were observed in the thrombi treated with recombinant tissue plasminogen activator (P = 0.012). In conclusion, there was no difference in the functional outcomes between the direct MT and bridging therapy groups. However, randomized trials are needed to elucidate the high ratio of cardioembolism subtype in our group of patients. The histological MCA thrombus composition differed between cardioembolism and large-artery atherosclerosis, and this finding provides valuable information on the underlying pathogenesis and thrombus origin.
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Affiliation(s)
- Li Gong
- 1 Department of Neurology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Xiaoran Zheng
- 1 Department of Neurology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Lijin Feng
- 2 Department of Pathology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Xiang Zhang
- 3 Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Qiong Dong
- 1 Department of Neurology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Xiaoyu Zhou
- 1 Department of Neurology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Haichao Wang
- 1 Department of Neurology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Xiaojun Zhang
- 4 Department of Intervention, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Zhongwen Shu
- 3 Department of Neurosurgery, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Yanxin Zhao
- 1 Department of Neurology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
| | - Xueyuan Liu
- 1 Department of Neurology, Shanghai Tenth People's Hospital, Tongji University, Shanghai, China
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Kaesmacher J, Mordasini P, Arnold M, López-Cancio E, Cerdá N, Boeckh-Behrens T, Kleine JF, Goyal M, Hill MD, Pereira VM, Saver JL, Gralla J, Fischer U. Direct mechanical thrombectomy in tPA-ineligible and -eligible patients versus the bridging approach: a meta-analysis. J Neurointerv Surg 2019; 11:20-27. [PMID: 29705773 PMCID: PMC6327861 DOI: 10.1136/neurintsurg-2018-013834] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 03/26/2018] [Accepted: 04/03/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Whether pretreatment with intravenous thrombolysis prior to mechanical thrombectomy (IVT+MTE) adds additional benefit over direct mechanical thrombectomy (dMTE) in patients with large vessel occlusions (LVO) is a matter of debate. METHODS This study-level meta-analysis was presented in accord with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pooled effect sizes were calculated using the inverse variance heterogeneity model and displayed as summary Odds Ratio (sOR) and corresponding 95% confidence interval (95% CI). Sensitivity analysis was performed by distinguishing between studies including dMTE patients eligible for IVT (IVT-E) or ineligible for IVT (IVT-IN). Primary outcome measures were functional independence (modified Rankin Scale≤2) and mortality at day 90, successful reperfusion, and symptomatic intracerebral hemorrhage. RESULTS Twenty studies, incorporating 5279 patients, were included. There was no evidence that rates of successful reperfusion differed in dMTE and IVT+MTE patients (sOR 0.93, 95% CI 0.68 to 1.28). In studies including IVT-IN dMTE patients, patients undergoing dMTE tended to have lower rates of functional independence and had higher odds for a fatal outcome as compared with IVT+MTE patients (sOR 0.78, 95% CI 0.61 to 1.01 and sOR 1.45, 95% CI 1.22 to 1.73). However, no such treatment group effect was found when analyses were confined to cohorts with a lower risk of selection bias (including IVT-E dMTE patients). CONCLUSION The quality of evidence regarding the relative merits of IVT+MTE versus dMTE is low. When considering studies with lower selection bias, the data suggest that dMTE may offer comparable safety and efficacy as compared with IVT+MTE. The conduct of randomized-controlled clinical trials seems justified.
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Affiliation(s)
- Johannes Kaesmacher
- Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Elena López-Cancio
- Department of Neurology, Stroke Unit Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Neus Cerdá
- Biostatistics Unit, Bioclever CRO, Barcelona, Spain
| | - Tobias Boeckh-Behrens
- Institute of Diagnostic and Interventional Neuroradiology, Technical University Munich, Klinikum rechts der Isar, München, Germany
| | | | - Mayank Goyal
- Department of Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Vitor Mendes Pereira
- Division of Neuroradiology, Department of Medical Imaging and Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Jeffrey L Saver
- Comprehensive Stroke Center, Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
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Liu M, Li G. Is Direct Endovascular Treatment as an Alternative of Bridging Therapy in Acute Stroke Patients with Large Vessel Occlusion? J Stroke Cerebrovasc Dis 2018; 28:531-541. [PMID: 30595512 DOI: 10.1016/j.jstrokecerebrovasdis.2018.10.007] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2018] [Revised: 09/24/2018] [Accepted: 10/05/2018] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Although endovascular treatment (EVT) is very effective for acute ischemia stroke (AIS) patients with proximal large vessels occlusion (LVO), whether bridging rPA before EVT in stroke patients of LVO is of any benefit and is currently one of the most urgent unanswered questions. We aim to comprehensively determine the efficacy and safety of direct EVT (DEVT) in AIS patients with LVO versus bridging therapy (BT). METHODS Clinical researches published in the Embase, PubMed, and Cochrane Library electronic databases up to May 2017 were identified for analysis. Two reviewers extracted data and conducted quality assessment independently. Statistical tests were performed to check for heterogeneity and publication bias. Subgroup and sensitivity analysis were also conducted to evaluate the robustness of the conclusions. RESULTS Overall, 13 studies involving 3302 patients met the inclusion criteria. The AIS patients with DEVT had a similar likelihood to achieve good functional outcome at 3 months (risk ratio [RR] = .93, 95% confidence interval [CI] = .85-1.01, P = .094), mortality at 3 months (RR = 1.10, 95% CI = .91-1.33, P = .33), and symptomatic intracranial hemorrhage (RR = 1.06, 95% CI = .74-1.51, P = .75) versus BT; furthermore, the risk of intracranial hemorrhage was lower in DEVT group (RR = .76, 95% CI = .60-.95, P = .02). No significant difference in recanalization rate existed between the 2 groups (RR = .97, 95% CI = .92-1.02, P = .22); however, in the subgroup analysis, it had a rise trend after DEVT than BT in IVT-eligible group (RR = 1.45, 95% CI = .95-2.22, P = .09). CONCLUSIONS DEVT appears to have equally effectiveness to BT with a low risk of intracranial hemorrhage in AIS patients with LVO, especially for anterior circulation, which offered a practical information to select appropriate therapeutic strategies for patients with LVO, though the level of evidence seems to be quite shaky.
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Affiliation(s)
- Mingsu Liu
- Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Chongqing Key Laboratory of Neurobiology, Chongqing, China.
| | - Guangqin Li
- Department of Neurology, the First Affiliated Hospital of Chongqing Medical University, Chongqing, China; Chongqing Key Laboratory of Neurobiology, Chongqing, China.
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Soize S, Fabre G, Gawlitza M, Serre I, Bakchine S, Manceau PF, Pierot L. Can early neurological improvement after mechanical thrombectomy be used as a surrogate for final stroke outcome? J Neurointerv Surg 2018; 11:450-454. [DOI: 10.1136/neurintsurg-2018-014332] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2018] [Revised: 10/24/2018] [Accepted: 10/29/2018] [Indexed: 11/04/2022]
Abstract
Background and purposeWe aimed to identify the best definition of early neurological improvement (ENI) at 2 and 24 hours after mechanical thrombectomy (MT) and determine its ability to predict a good functional outcome at 3 months.MethodsThis retrospective analysis was based on a prospectively collected registry of patients treated by MT for ischemic stroke from May 2010 to March 2017. We included patients treated with stent-retrievers with National Institute of Health Stroke Scale (NIHSS) score before treatment and at 2 and/or 24 hours after treatment and modified Rankin Score (mRS) at 3 months. Receiver operating characteristic curve analysis was performed to estimate optimal thresholds for ENI at 2 and 24 hours. The relationship between optimal ENI definitions and good outcome at 3 months (mRS 0–2) was assessed by logistic regression.ResultsThe analysis included 246 patients. At 2 hours, the optimal threshold to predict a good outcome at 3 months was improvementin the NIHSS score of >1 point (AUC 0.83,95% CI 0.77 to 0.87), with sensitivity and specificity 78.3% (62.2–85.7%) and 84.6% (77.2–90.3%), respectively, and OR 12.67 (95% CI 4.69 to 31.10, p<0.0001). At 24 hours, the optimal threshold was an improvementin the NIHSS score of >4 points (AUC 0.93, 95% CI 0.89 to 0.96), with sensitivity and specificity 93.8% (87.7–97.5%) and 83.2% (75.7–89.2%), respectively, and OR 391.32 (95% CI 44.43 to 3448.35, p<0.0001).ConclusionsENI 24 hours after thrombectomy appears to be a straightforward surrogate of long-term endpoints and may have value in future research.
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Ferrigno M, Bricout N, Leys D, Estrade L, Cordonnier C, Personnic T, Kyheng M, Henon H. Intravenous Recombinant Tissue-Type Plasminogen Activator: Influence on Outcome in Anterior Circulation Ischemic Stroke Treated by Mechanical Thrombectomy. Stroke 2018; 49:1377-1385. [PMID: 29748424 DOI: 10.1161/strokeaha.118.020490] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 03/24/2018] [Accepted: 04/17/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE Intravenous thrombolysis (IVT) followed by mechanical thrombectomy (MT) improves functional outcome in patients with ischemic stroke related to proximal-vessel occlusion in the anterior circulation. Whether MT alone is as effective as IVT/MT remains controversial. We aimed at evaluating the influence of IVT in patients with large anterior circulation artery occlusion treated with MT. METHODS We did a prospective observational cohort study in patients with stroke related to large anterior circulation artery occlusion treated by MT who were admitted to Lille University Hospital, Lille, France. We evaluated the influence of IVT on favorable functional outcome (defined as a modified Rankin Scale score 0-2 or similar to the prestroke modified Rankin Scale) and on mortality at month 3. Between-group comparisons in outcomes were adjusted for prespecified confoundors by using a propensity score-adjusted approach. RESULTS From January 2012 to January 2017, we included 485 patients (median age, 68 years; 46% men; 348 [72%] in the IVT/MT group; 137 [28%] in the MT group). In MT group, 22% of patients had a favorable outcome versus 35% in IVT/MT group (adjusted relative risk, 1.76; 95% confidence interval, 1.23-2.55). Mortality within 3 months occurred less frequently in IVT/MT group (14% versus 32%; adjusted relative risk, 0.46; 95% confidence interval, 0.31-0.70). Successful reperfusion (Thrombolysis in Cerebral Infarction scale 2b-3) was more frequent in IVT/MT group (75% versus 60%; adjusted relative risk, 1.30; 95% confidence interval, 1.11-1.53). There was no difference between groups on hemorrhagic complications. CONCLUSIONS In this population, previous IVT improved functional outcome and survival at 3 months in patients treated by MT. While waiting for randomized controlled trials, this result encourages not to avoid IVT before MT.
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Affiliation(s)
- Marc Ferrigno
- From the Stroke Unit, Department of Neurology, CHU Lille, INSERM, U1171-Degenerative and Vascular Cognitive Disorders (M.F., D.L., C.C., H.H.)
| | - Nicolas Bricout
- Department of Neuroradiology, Lille University Hospital, France (N.B., L.E., T.P.)
| | - Didier Leys
- From the Stroke Unit, Department of Neurology, CHU Lille, INSERM, U1171-Degenerative and Vascular Cognitive Disorders (M.F., D.L., C.C., H.H.)
| | - Laurent Estrade
- Department of Neuroradiology, Lille University Hospital, France (N.B., L.E., T.P.)
| | - Charlotte Cordonnier
- From the Stroke Unit, Department of Neurology, CHU Lille, INSERM, U1171-Degenerative and Vascular Cognitive Disorders (M.F., D.L., C.C., H.H.)
| | - Thomas Personnic
- Department of Neuroradiology, Lille University Hospital, France (N.B., L.E., T.P.)
| | - Maeva Kyheng
- Department of Biostatistics, CHRU Lille (M.K.), University of Lille, France
| | - Hilde Henon
- From the Stroke Unit, Department of Neurology, CHU Lille, INSERM, U1171-Degenerative and Vascular Cognitive Disorders (M.F., D.L., C.C., H.H.)
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Gory B, Haussen DC, Piotin M, Steglich-Arnholm H, Holtmannspötter M, Labreuche J, Kyheng M, Taschner C, Eiden S, Nogueira RG, Papanagiotou P, Boutchakova M, Siddiqui AH, Lapergue B, Dorn F, Cognard C, Killer M, Mangiafico S, Ribo M, Psychogios MN, Spiotta AM, Labeyrie MA, Biondi A, Mazighi M, Turjman F. Impact of intravenous thrombolysis and emergent carotid stenting on reperfusion and clinical outcomes in patients with acute stroke with tandem lesion treated with thrombectomy: a collaborative pooled analysis. Eur J Neurol 2018; 25:1115-1120. [DOI: 10.1111/ene.13633] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2017] [Accepted: 02/26/2018] [Indexed: 11/29/2022]
Affiliation(s)
- B. Gory
- Department of Diagnostic and Interventional Neuroradiology; INSERM U947; University Hospital of Nancy; Nancy France
| | - D. C. Haussen
- Department of Neurology; Emory University/Grady Memorial Hospital; Atlanta GA USA
| | - M. Piotin
- Department of Interventional Neuroradiology; Rothschild Foundation; Paris France
| | | | | | - J. Labreuche
- Department of Biostatistics; EA2694-Santé Publique: Epidémiologie et Qualité Des Soins; Lille University; Lille France
| | - M. Kyheng
- Department of Biostatistics; EA2694-Santé Publique: Epidémiologie et Qualité Des Soins; Lille University; Lille France
| | - C. Taschner
- Department of Neuroradiology; Medical Center-University of Freiburg; Freiburg
| | - S. Eiden
- Department of Neuroradiology; Medical Center-University of Freiburg; Freiburg
| | - R. G. Nogueira
- Department of Neurology; Emory University/Grady Memorial Hospital; Atlanta GA USA
| | - P. Papanagiotou
- Department of Diagnostic and Interventional Neuroradiology; Klinikum Bremen-Mitte/Bremen-Ost; Bremen Germany
| | - M. Boutchakova
- Department of Diagnostic and Interventional Neuroradiology; Klinikum Bremen-Mitte/Bremen-Ost; Bremen Germany
| | - A. H. Siddiqui
- Department of Neurosurgery; University at Buffalo; State University of New York; Buffalo NY USA
| | - B. Lapergue
- Department of Neurology; Stroke Center; Foch Hospital; Suresnes France
| | - F. Dorn
- Department of Neuroradiology; University Hospital of Munich; Munich Germany
| | - C. Cognard
- Department of Neuroradiology; University Hospital of Toulouse; Toulouse France
| | - M. Killer
- Department of Neuroradiology; Christian Doppler Clinic; Research Institute for Neurointervention; Paracelsus Medical University; Salzburg Austria
| | - S. Mangiafico
- Department of Interventional Neuroradiology; Careggi University Hospital; Florence Italy
| | - M. Ribo
- Department of Neurology; Hospital Vall D'Hebron; Barcelona Spain
| | - M. N. Psychogios
- Department of Neuroradiology; University Medical Center Göttingen; Göttingen Germany
| | - A. M. Spiotta
- Department of Neurosurgery; Medical University of South Carolina; Charleston SC USA
| | - M. A. Labeyrie
- Department of Interventional Neuroradiology; Lariboisière Hospital; Paris
| | - A. Biondi
- Department of Neuroradiology and Endovascular Therapeutic; University Hospital of Besançon; Besançon
| | - M. Mazighi
- Department of Interventional Neuroradiology; Rothschild Foundation; Paris France
| | - F. Turjman
- Department of Interventional Neuroradiology; Hospices Civils de Lyon; Lyon France
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Short and long-term outcomes after combined intravenous thrombolysis and mechanical thrombectomy versus direct mechanical thrombectomy: a prospective single-center study. J Thromb Thrombolysis 2018; 44:203-209. [PMID: 28702769 DOI: 10.1007/s11239-017-1527-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Recent clinical trials demonstrated that mechanical thrombectomy (MT) using second-generation endovascular devices has beneficial effects in acute ischemic stroke (AIS) due to large vessel occlusion (LVO). However, it remains controversial if intravenous thrombolysis (IVT) prior to MT is superior compared to direct mechanical thrombectomy (DMT). The aims of this study were to compare short and long-term outcomes between IVT + MT and DMT patients. We prospectively recruited AIS patients with LVO in the anterior or posterior circulation eligible for MT with and without prior IVT. Modified Rankin Scale (mRS) and mortality were assessed at baseline, at discharge, 90-days and 1-year after stroke. Favorable outcome was defined as a mRS score ≤2. Of the 66 patients included, 33 (50%) were in IVT + MT group and 33 (50%) were in DMT group. Except for a higher prevalence of patients using anticoagulants at admission in DMT group, baseline characteristics did not differ in the two groups. Procedural characteristics were similar in IVT + MT and DMT group. Rate of favorable outcome was significantly higher in IVT + MT patients than DMT ones both 90-days (51.5 vs. 18.2%; p = 0.004) and 1-year (51.5 vs. 15.2%; p = 0.002) after stroke. DMT patients were six times more likely to die during the 1-year follow-up compared to IVT + MT patients. This study suggests that bridging therapy may improve short and long-term outcomes in patients eligible for endovascular treatment. Further studies with larger patient numbers and randomized design are needed to confirm our findings.
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45
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Choi JH, Im SH, Lee KJ, Koo JS, Kim BS, Shin YS. Comparison of Outcomes After Mechanical Thrombectomy Alone or Combined with Intravenous Thrombolysis and Mechanical Thrombectomy for Patients with Acute Ischemic Stroke due to Large Vessel Occlusion. World Neurosurg 2018; 114:e165-e172. [PMID: 29510288 DOI: 10.1016/j.wneu.2018.02.126] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Revised: 02/20/2018] [Accepted: 02/22/2018] [Indexed: 12/19/2022]
Abstract
BACKGROUND Whether intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) provides additional benefits remains controversial. We aimed to compare clinical and radiologic outcomes between IVT+MT and MT alone groups. METHODS We retrospectively reviewed the clinical and radiological features of patients from the prospectively collected database who sustained anterior circulation stroke due to large vessel occlusion (LVO) and were treated with MT within 8 hours of symptom onset. We compared rates of successful reperfusion, functional independence and mortality at 90 days, and symptomatic intracranial hemorrhage (sICH) as clinical endpoints between the 2 groups. RESULTS The 81 patients included in this study included 38 (46.9%) in the MT alone group (mean age, 72.6 ± 14.1 years; 17 males [44.7%]) and 43 in the IVT+MT group (mean age, 68.9 ± 12.8 years; 29 males [67.4%]). There were no significant differences in patient baseline characteristics between the 2 groups except for a male predominance in the IVT+MT group. The mean interval from onset to groin puncture (221.6 ± 110.5 minutes vs. 204.7 ± 63.7 minutes; P = 0.472) and the rate of successful reperfusion rate (thrombolysis in cerebral infarction 2b/3, 60.5% vs. 58.1%; P = 0.827) did not differ significantly between the MT and IVT+MT groups. The rate of favorable functional outcome, as determined by a modified Rankin Scale score 0-2 (36.8% vs. 51.2%; P = 0.263) and mortality at 90 days (18.4% vs. 9.3%; P = 0.332), and the rate of sICH (5.3% vs. 4.6%; P = 1.000) were also not significantly different between the 2 groups. CONCLUSIONS This study suggests that previous IVT might not facilitate successful reperfusion and favorable functional outcomes in patients with anterior circulation stroke treated with MT. MT alone can be a safe and effective treatment modality in patients who are ineligible for IVT for various reasons.
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Affiliation(s)
- Jai Ho Choi
- Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Republic of Korea
| | - Sang Hyuk Im
- Department of Radiology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Republic of Korea
| | - Ki Jeong Lee
- Department of Neurology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Republic of Korea
| | - Ja Seong Koo
- Department of Neurology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Republic of Korea
| | - Bum Soo Kim
- Department of Radiology, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Republic of Korea
| | - Yong Sam Shin
- Department of Neurosurgery, Seoul St. Mary's Hospital, The Catholic University of Korea College of Medicine, Seoul, Republic of Korea.
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Heinrichs A, Nikoubashman O, Schürmann K, Tauber SC, Wiesmann M, Schulz JB, Reich A. Relevance of standard intravenous thrombolysis in endovascular stroke therapy of a tertiary stroke center. Acta Neurol Belg 2018; 118:105-111. [PMID: 29435828 DOI: 10.1007/s13760-018-0892-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2017] [Accepted: 02/01/2018] [Indexed: 11/26/2022]
Abstract
The majority of patients undergoing endovascular stroke treatment (EST) in randomized controlled trials received additional systemic thrombolysis ("combination or bridging therapy (C/BT)"). Nevertheless, its usefulness in this subtype of acute ischemic stroke (AIS) is discussed controversially. Of all consecutive AIS patients, who received any kind of reperfusion therapy in a tertiary university stroke center between January 2015 and March 2016, those with large vessel occlusions (LVO) and EST with or without additional C/BT, were compared primarily regarding procedural aspects. Data were extracted from an investigator-initiated, single-center, prospective and blinded end-point study. 70 AIS patients with EST alone and 118 with C/BT were identified. Significant baseline differences existed in pre-existing cardiovascular disease (52.9% (EST alone) vs. 35.6% (C/BT), p = 0.023), use of anticoagulation (30.6% vs. 5.9%, p < 0.001), and frequency of unknown time of symptom onset (65.7% vs. 32.2%, p < 0.001), in-hospital stroke (18.6% vs. 1.7%, p < 0.001), pre-treatment ASPECT scores (7.9 vs. 8.9, p = 0.004), and frequency of occlusion in the posterior circulation (18.6% vs. 5.1%, p = 0.003). Pre-interventional procedural time intervals tended to be shorter in the C/BT group, reaching statistical significance in door-to-image time (30.3 (EST alone) vs. 22.2 min (C/BT), p < 0.001). Good clinical outcome (mRS d90) was reached more often in the C/BT group (24.5% vs. 11.8%, p = 0.064). Rates of symptomatic intracranial hemorrhages (sICH) were comparable (4.3% (EST alone) vs. 6.8% (C/BT), p = 0.481). Additional systemic thrombolysis did not delay EST. On the contrary, application of IVRTPA seemed to be a positive indicator for faster EST without increased side effects.
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Affiliation(s)
- Annette Heinrichs
- Department of Neurology, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Omid Nikoubashman
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, 52074, Aachen, Germany
| | - Kolja Schürmann
- Department of Neurology, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Simone C Tauber
- Department of Neurology, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
| | - Martin Wiesmann
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, 52074, Aachen, Germany
| | - Jörg B Schulz
- Department of Neurology, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany
- JARA-BRAIN Institute Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH and RWTH Aachen University, Aachen, Germany
| | - Arno Reich
- Department of Neurology, RWTH Aachen University, Pauwelsstrasse 30, 52074, Aachen, Germany.
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Jeon JP, Kim SE, Kim CH. Primary suction thrombectomy for acute ischemic stroke: A meta-analysis of the current literature. Clin Neurol Neurosurg 2017; 163:46-52. [DOI: 10.1016/j.clineuro.2017.09.014] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Revised: 09/28/2017] [Accepted: 09/30/2017] [Indexed: 01/19/2023]
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48
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Bourcier R, Alexandre PL, Eugène F, Delasalle-Guyomarch B, Guillon B, Kerleroux B, Saleme S, Marnat G, Boucebci S, Mirza M, Ferré JC, Papagiannaki C, Desal H. Is bridging therapy still required in stroke due to carotid artery terminus occlusions? J Neurointerv Surg 2017; 10:625-628. [PMID: 29146829 DOI: 10.1136/neurintsurg-2017-013398] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/15/2017] [Revised: 10/04/2017] [Accepted: 10/05/2017] [Indexed: 11/04/2022]
Abstract
INTRODUCTION Studies comparing endovascular stroke treatment using mechanical thrombectomy (MT) with or without prior IV tissue plasminogen activator (tPa) have included only 30% of internal carotid artery terminus occlusions (ICA-O), a known predictor of recanalization failure with IV tPa. OBJECTIVE To carry out a retrospective multicenter analysis of prospectively collected data of consecutive patients to investigate the impact of intravenous thrombolysis on ICA-O by comparing patients treated with MT alone or bridging therapy (BT). MATERIAL AND METHODS Patients with ICA-O treated with MT alone or BT were retrospectively examined and compared. Demographic data, vascular risk factors, treatment modalities, complications, technical and clinical outcomes were recorded. A propensity score (PS) analysis was used to compare modified Rankin Scale (mRS) score at 3 months and intracerebral hemorrhage (ICH) between groups. RESULTS 141 consecutive patients (60% BT/40% MT) were included between January 2014 and June 2016. Baseline characteristics did not differ between the groups. There was no significant difference in the rate of Thrombolysis in Cerebral Infarction 2b/3, distal emboli, and median number of passes between the groups. There was a significant difference between BT and MT groups in the median time between imaging and groin puncture (median 97 min vs 75, p=0.007), the rate of ICH (44% vs 27%, p=0.05), but not for symptomatic ICH (18% vs 13%, p=0.49). With PS, there was a trend towards a higher rate of ICH (OR=2.3, 95% CI 0.9 to 5.9, p=0.09) in the BT group compared with the MT alone group, with no difference in mRS score ≤2 at 3 months (OR=1.6, 95% CI 0.7 to 3.7, p=0.29). CONCLUSION There was no significant difference in clinical outcomes between patients receiving bridging therapy versus direct thrombectomy. Bridging therapy delayed time to groin puncture and increased ICH rate.
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Affiliation(s)
- Romain Bourcier
- Department of Neuroradiology, University Hospital of Nantes, Nantes, France
| | | | - François Eugène
- Department of Neuroradiology, University Hospital of Rennes, Rennes, France
| | | | - Benoit Guillon
- Stroke Unit, University Hospital of Nantes, Nantes, France
| | | | - Suzana Saleme
- Interventional Neuroradiology, CHU Limoges, Limoges, France
| | - Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, Bordeaux University Hospital, Bordeaux, France
| | - Samy Boucebci
- Department of Neuroradiology, University Hospital of Poitiers, Poitiers, France
| | | | | | | | - Hubert Desal
- Department of Neuroradiology, University Hospital of Nantes, Nantes, France
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49
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Bellwald S, Weber R, Dobrocky T, Nordmeyer H, Jung S, Hadisurya J, Mordasini P, Mono ML, Stracke CP, Sarikaya H, Bernasconi C, Berger K, Arnold M, Chapot R, Gralla J, Fischer U. Direct Mechanical Intervention Versus Bridging Therapy in Stroke Patients Eligible for Intravenous Thrombolysis: A Pooled Analysis of 2 Registries. Stroke 2017; 48:3282-3288. [PMID: 29114095 DOI: 10.1161/strokeaha.117.018459] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 09/11/2017] [Accepted: 09/15/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Randomized controlled trials have shown that mechanical thrombectomy (MT) plus best medical treatment improves outcome in stroke patients with large-vessel occlusion in the anterior circulation. Whether direct MT is equally effective as bridging thrombolysis (intravenous thrombolysis plus MT) in intravenous thrombolysis eligible patients remains unclear. METHODS We compared clinical and radiological outcomes at 3 months in 249 bridging patients with 111 patients receiving direct MT for large-vessel occlusion anterior circulation stroke from 2 prospective registries (study period Essen: June 2012 to August 2013, Bern February 2009 to August 2014). We matched all patients from the direct MT group who would have qualified for intravenous thrombolysis with controls from the bridging group, using multivariate and propensity score methods. Subgroup analyses for internal carotid artery occlusions were performed. RESULTS Baseline characteristics did not differ between the direct MT group and bridging cohort, except for higher rates of coronary heart disease (P=0.029) and shorter intervals from onset to endovascular therapy (P<0.001) in the MT group. Functional outcome, mortality, and intracerebral hemorrhage did not differ, neither in univariate nor after multivariate and propensity score matching. However, in patients with internal carotid artery occlusion, mortality in the direct cohort was significantly lower. CONCLUSIONS In this matched-pair analysis, there was no difference in outcome in patients with large-vessel occlusion anterior circulation stroke treated with direct MT compared with those treated with bridging thrombolysis; however, mortality in patients with internal carotid artery occlusion treated with direct MT was significantly lower than after bridging thrombolysis. Randomized trials comparing direct MT with bridging therapy are needed.
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Affiliation(s)
- Sebastian Bellwald
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.)
| | - Ralph Weber
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.)
| | - Tomas Dobrocky
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.)
| | - Hannes Nordmeyer
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.)
| | - Simon Jung
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.)
| | - Jeffrie Hadisurya
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.)
| | - Pasquale Mordasini
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.)
| | - Marie-Luise Mono
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.)
| | - Christian P Stracke
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.)
| | - Hakan Sarikaya
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.)
| | - Corrado Bernasconi
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.)
| | - Klaus Berger
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.)
| | - Marcel Arnold
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.)
| | - René Chapot
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.)
| | - Jan Gralla
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.)
| | - Urs Fischer
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.).
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50
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Manceau PF, Soize S, Gawlitza M, Fabre G, Bakchine S, Durot C, Serre I, Metaxas GE, Pierot L. Is there a benefit of mechanical thrombectomy in patients with large stroke (DWI-ASPECTS ≤ 5)? Eur J Neurol 2017; 25:105-110. [DOI: 10.1111/ene.13460] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2017] [Accepted: 09/06/2017] [Indexed: 12/17/2022]
Affiliation(s)
- P. -F. Manceau
- Department of Neuroradiology; CHU Reims; Hôpital Maison Blanche; Université Reims-Champagne Ardenne; Reims France
| | - S. Soize
- Department of Neuroradiology; CHU Reims; Hôpital Maison Blanche; Université Reims-Champagne Ardenne; Reims France
| | - M. Gawlitza
- Department of Neuroradiology; CHU Reims; Hôpital Maison Blanche; Université Reims-Champagne Ardenne; Reims France
| | - G. Fabre
- Department of Neuroradiology; CHU Reims; Hôpital Maison Blanche; Université Reims-Champagne Ardenne; Reims France
| | - S. Bakchine
- Department of Neurology; CHU Reims; Hôpital Maison Blanche; Université Reims-Champagne Ardenne; Reims France
| | - C. Durot
- Department of Neuroradiology; CHU Reims; Hôpital Maison Blanche; Université Reims-Champagne Ardenne; Reims France
| | - I. Serre
- Department of Neurology; CHU Reims; Hôpital Maison Blanche; Université Reims-Champagne Ardenne; Reims France
| | - G. -E. Metaxas
- Department of Neuroradiology; CHU Reims; Hôpital Maison Blanche; Université Reims-Champagne Ardenne; Reims France
| | - L. Pierot
- Department of Neuroradiology; CHU Reims; Hôpital Maison Blanche; Université Reims-Champagne Ardenne; Reims France
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