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Hviid Hornnes A, Valentin JB, Boysen G, Groes Larsen K, Johnsen SP. Long-term risk factors of recurrent stroke, myocardial infarction and death in patients leaving hospital with a diagnosis of ischemic stroke or TIA. SCAND CARDIOVASC J 2024; 58:2373085. [PMID: 38957077 DOI: 10.1080/14017431.2024.2373085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/22/2023] [Accepted: 06/22/2024] [Indexed: 07/04/2024]
Abstract
Objectives. The prevalence of patients with prior stroke is increasing globally. Accordingly, there is a need for up-to-date evidence of patient-related prognostic factors for stroke recurrence, post stroke myocardial infarction (MI) and death based on long-term follow-up of stroke survivors. For this purpose, the RIALTO study was established in 2004. Design. A prospective cohort study in which patients diagnosed with ischemic stroke (IS) or transient ischemic attack (TIA) in three Copenhagen hospitals were included. Data were collected from medical records and by structured interview. Data on first stroke recurrence, first MI and all-cause death were extracted from the Danish National Patient Registry and the Danish Civil Registration System. Results. We included 1215 patients discharged after IS or TIA who were followed up by register data from April 2004 to end of 2018 giving a median follow-up of 3.5-6.9 years depending on the outcome. At the end of follow-up 406 (33%) patients had been admitted with a recurrent stroke, 100 (8%) had a MI and 822 (68%) had died. Long-term prognostic predictors included body mass index, diabetes, antihypertensive and lipid lowering treatment, smoking, a sedentary lifestyle as well as poor self-rated health and psychosocial problems. Conclusions. Long-term risk of recurrent stroke and MI remain high in patients discharged with IS or TIA despite substantial improvements in tertiary preventive care in recent decades. Continued attention to the patient risk profile among patients surviving the early phase of stroke, including comorbidities, lifestyle, and psychosocial challenges, is warranted.
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Affiliation(s)
| | - Jan Brink Valentin
- Department of Clinical Medicine, Danish Center for Health Services Research, Aalborg University, Gistrup, Denmark
| | - Gudrun Boysen
- Department of Neurology, Bispebjerg Hospital, Copenhagen, Denmark
| | | | - Søren Paaske Johnsen
- Department of Clinical Medicine, Danish Center for Health Services Research, Aalborg University, Gistrup, Denmark
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Liu Z, Leong MQ, Li N, Teo MM, Leong WLR, Wong SCP, Chew JS, Saffari SE, Pang YH, Chia GS. Reducing Door-to-Puncture Times for Mechanical Thrombectomy in a Large Tertiary Hospital. Neurol Clin Pract 2024; 14:e200325. [PMID: 38939047 PMCID: PMC11201277 DOI: 10.1212/cpj.0000000000200325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2024] [Accepted: 04/02/2024] [Indexed: 06/29/2024]
Abstract
Background and Objectives Endovascular therapy (EVT) for stroke has emerged as an important therapy for selected stroke patients, and shorter times to clot removal improve functional outcomes. EVT requires the close coordination of multiple departments and poses unique challenges to care coordination in large hospitals. We present the results of our quality improvement project that aimed to improve our door-to-groin puncture (DTP) times for patients who undergo EVT after direct presentation to our emergency department. Methods We conducted time-motion studies to understand the full process of an EVT activation and conducted Gemba walks in multiple hospitals. We also reviewed the literature and interviewed stakeholders to create interventions that were implemented over 4 Plan-Do-Study-Act (PDSA) cycles. We retrospectively collected data starting from baseline and during every PDSA cycle. During each cycle, we studied the impact of the interventions, adjusted the interventions, and generated further interventions. A variety of interventions were introduced targeting all aspects of the EVT process. This included parallel processing to reduce waiting time, standardization of protocols and training of staff, behavioral prompts in the form of a stroke clock, and push systems to empower staff to facilitate the forward movement of the patient. A novel role-based communication app to facilitate group communications was also used. Results Eighty-eight patients spanning across 22 months were analyzed. After the final PDSA cycle, the median DTP time was reduced by 36.5% compared with baseline (130 minutes (interquartile range [IQR] 111-140) to 82.5 minutes (IQR 74.8-100)). There were improvements in all phases of the EVT process with the largest time savings occurring in EVT decision to patient arrival at the angiosuite. Interventions that were most impactful are described. Discussion EVT is a complex process involving multiple processes and local factors. Analysis of the process from all angles and intervening on multiple small aspects can add up to significant improvements in DTP times.
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Affiliation(s)
- Zhenghong Liu
- Department of Emergency Medicine (ZL), Singapore General Hospital; Inpatient Operations (MQL), Changi General Hospital; Office of Clinical Informatics (NL), Woodlands Health; Division of Anaesthesiology and Peiroperative Medicine (MMT, W-LRL); Department of Neuroradiology (SCPW, GSC); Department of Neurology (JSC, YHP), Singapore General Hospital; and Center for Quantitative Medicine (SES), Duke-NUS Medical School, Singapore
| | - Man Qing Leong
- Department of Emergency Medicine (ZL), Singapore General Hospital; Inpatient Operations (MQL), Changi General Hospital; Office of Clinical Informatics (NL), Woodlands Health; Division of Anaesthesiology and Peiroperative Medicine (MMT, W-LRL); Department of Neuroradiology (SCPW, GSC); Department of Neurology (JSC, YHP), Singapore General Hospital; and Center for Quantitative Medicine (SES), Duke-NUS Medical School, Singapore
| | - Nanlan Li
- Department of Emergency Medicine (ZL), Singapore General Hospital; Inpatient Operations (MQL), Changi General Hospital; Office of Clinical Informatics (NL), Woodlands Health; Division of Anaesthesiology and Peiroperative Medicine (MMT, W-LRL); Department of Neuroradiology (SCPW, GSC); Department of Neurology (JSC, YHP), Singapore General Hospital; and Center for Quantitative Medicine (SES), Duke-NUS Medical School, Singapore
| | - Miqi Mavis Teo
- Department of Emergency Medicine (ZL), Singapore General Hospital; Inpatient Operations (MQL), Changi General Hospital; Office of Clinical Informatics (NL), Woodlands Health; Division of Anaesthesiology and Peiroperative Medicine (MMT, W-LRL); Department of Neuroradiology (SCPW, GSC); Department of Neurology (JSC, YHP), Singapore General Hospital; and Center for Quantitative Medicine (SES), Duke-NUS Medical School, Singapore
| | - Wei-Li Rachel Leong
- Department of Emergency Medicine (ZL), Singapore General Hospital; Inpatient Operations (MQL), Changi General Hospital; Office of Clinical Informatics (NL), Woodlands Health; Division of Anaesthesiology and Peiroperative Medicine (MMT, W-LRL); Department of Neuroradiology (SCPW, GSC); Department of Neurology (JSC, YHP), Singapore General Hospital; and Center for Quantitative Medicine (SES), Duke-NUS Medical School, Singapore
| | - Steve Chen Pong Wong
- Department of Emergency Medicine (ZL), Singapore General Hospital; Inpatient Operations (MQL), Changi General Hospital; Office of Clinical Informatics (NL), Woodlands Health; Division of Anaesthesiology and Peiroperative Medicine (MMT, W-LRL); Department of Neuroradiology (SCPW, GSC); Department of Neurology (JSC, YHP), Singapore General Hospital; and Center for Quantitative Medicine (SES), Duke-NUS Medical School, Singapore
| | - Jing Si Chew
- Department of Emergency Medicine (ZL), Singapore General Hospital; Inpatient Operations (MQL), Changi General Hospital; Office of Clinical Informatics (NL), Woodlands Health; Division of Anaesthesiology and Peiroperative Medicine (MMT, W-LRL); Department of Neuroradiology (SCPW, GSC); Department of Neurology (JSC, YHP), Singapore General Hospital; and Center for Quantitative Medicine (SES), Duke-NUS Medical School, Singapore
| | - Seyed Ehsan Saffari
- Department of Emergency Medicine (ZL), Singapore General Hospital; Inpatient Operations (MQL), Changi General Hospital; Office of Clinical Informatics (NL), Woodlands Health; Division of Anaesthesiology and Peiroperative Medicine (MMT, W-LRL); Department of Neuroradiology (SCPW, GSC); Department of Neurology (JSC, YHP), Singapore General Hospital; and Center for Quantitative Medicine (SES), Duke-NUS Medical School, Singapore
| | - Yee Hau Pang
- Department of Emergency Medicine (ZL), Singapore General Hospital; Inpatient Operations (MQL), Changi General Hospital; Office of Clinical Informatics (NL), Woodlands Health; Division of Anaesthesiology and Peiroperative Medicine (MMT, W-LRL); Department of Neuroradiology (SCPW, GSC); Department of Neurology (JSC, YHP), Singapore General Hospital; and Center for Quantitative Medicine (SES), Duke-NUS Medical School, Singapore
| | - Ghim Song Chia
- Department of Emergency Medicine (ZL), Singapore General Hospital; Inpatient Operations (MQL), Changi General Hospital; Office of Clinical Informatics (NL), Woodlands Health; Division of Anaesthesiology and Peiroperative Medicine (MMT, W-LRL); Department of Neuroradiology (SCPW, GSC); Department of Neurology (JSC, YHP), Singapore General Hospital; and Center for Quantitative Medicine (SES), Duke-NUS Medical School, Singapore
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3
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Ming J, Liao Y, Song W, Wang Z, Cui J, He L, Chen G, Xu K. Role of intracranial bone marrow mesenchymal stem cells in stroke recovery: A focus on post-stroke inflammation and mitochondrial transfer. Brain Res 2024; 1837:148964. [PMID: 38677450 DOI: 10.1016/j.brainres.2024.148964] [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: 01/24/2024] [Revised: 04/13/2024] [Accepted: 04/24/2024] [Indexed: 04/29/2024]
Abstract
Stem cell therapy has become a hot research topic in the medical field in recent years, with enormous potential for treating a variety of diseases. In particular, bone marrow mesenchymal stem cells (BMSCs) have wide-ranging applications in the treatment of ischemic stroke, autoimmune diseases, tissue repair, and difficult-to-treat diseases. BMSCs can differentiate into multiple cell types and exhibit strong immunomodulatory properties. Although BMSCs can regulate the inflammatory response activated after stroke, the mechanism by which BMSCs regulate inflammation remains unclear and requires further study. Recently, stem cell therapy has emerged as a potentially effective approach for enhancing the recovery process following an ischemic stroke. For example, by regulating post-stroke inflammation and by transferring mitochondria to exert therapeutic effects. Therefore, this article reviews the therapeutic effects of intracranial BMSCs in regulating post-stroke inflammation and mitochondrial transfer in the treatment of stroke, providing a basis for further research.
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Affiliation(s)
- Jiang Ming
- Department of Neurosurgery, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, Guizhou, China
| | - Yidong Liao
- Department of Cardio-Thoracic Surgery, The First Hospital of Guiyang, Guiyang 550002, Guizhou, China
| | - Wenxue Song
- Department of Neurosurgery, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, Guizhou, China
| | - Zili Wang
- Department of Neurosurgery, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, Guizhou, China
| | - Junshuan Cui
- Department of Neurosurgery, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, Guizhou, China
| | - Longcai He
- Department of Neurosurgery, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, Guizhou, China
| | - Guangtang Chen
- Department of Neurosurgery, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, Guizhou, China.
| | - Kaya Xu
- Department of Neurosurgery, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, Guizhou, China; Department of Hyperbaric Oxygen, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, Guizhou, China.
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4
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Biffl WL, Moore EE, Kansagra AP, Flores BCCR, Weiss JS. Diagnosis and management of blunt cerebrovascular injuries: What you need to know. J Trauma Acute Care Surg 2024:01586154-990000000-00777. [PMID: 39093622 DOI: 10.1097/ta.0000000000004439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/04/2024]
Abstract
ABSTRACT Blunt cerebrovascular injuries are not as rare as they were once thought to be-but they still have the same potential for disastrous outcomes. They may occur following any trauma, but more common with higher energy transfer mechanisms. If stroke occurs, prompt recognition and treatment offers the best chance for optimal outcome. Early diagnosis and provision of antithrombotic therapy may prevent strokes, so screening of asymptomatic patients is recommended. Herein we will present what you need to know to diagnose and manage blunt cerebrovascular injury.
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Affiliation(s)
- Walter L Biffl
- From the Division of Trauma/Acute Care Surgery (W.L.B.), Scripps Clinic/Scripps Clinic Medical Group, La Jolla, California Department of Surgery/Trauma (E.E.M.), Ernest E. Moore Shock Trauma Center at Denver Health, University of Colorado Denver, Denver, Colorado; Division of Neuroradiology, Department of Radiology (A.P.K.), Santa Clara Valley Medical Center, San Jose, California; Section of Neurosurgery and Neurointerventional Radiology (B.C.C.R.F.), Scripps Memorial Hospital La Jolla; and Division of Vascular Surgery (J.S.W.), Scripps Clinic/Scripps Clinic Medical Group, La Jolla, California
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Inoa V, Goyal N. Role of Stroke Scales and Scores in Cerebrovascular Disease. Neurol Clin 2024; 42:753-765. [PMID: 38937040 DOI: 10.1016/j.ncl.2024.03.008] [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] [Indexed: 06/29/2024]
Abstract
This article provides a comprehensive review of widely utilized stroke scales in both routine clinical settings and research. These scales are crucial for planning treatment, predicting outcomes, and helping stroke patients recover. They also play a pivotal role in planning, executing, and comprehending stroke clinical trials. Each scale presents distinct advantages and limitations, and the authors explore these aspects within the article. The authors' intention is to provide the reader with practical insights for a clear understanding of these scales, and their effective use in their clinical practice.
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Affiliation(s)
- Violiza Inoa
- Semmes Murphey Clinic; Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA; Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA.
| | - Nitin Goyal
- Semmes Murphey Clinic; Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA; Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, TN, USA
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Welle F, Stoll K, Gillmann C, Henkelmann J, Prasse G, Kaiser DPO, Kellner E, Reisert M, Schneider HR, Klingbeil J, Stockert A, Lobsien D, Hoffmann KT, Saur D, Wawrzyniak M. Tissue Outcome Prediction in Patients with Proximal Vessel Occlusion and Mechanical Thrombectomy Using Logistic Models. Transl Stroke Res 2024; 15:739-749. [PMID: 37249761 PMCID: PMC11226467 DOI: 10.1007/s12975-023-01160-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 04/28/2023] [Accepted: 05/21/2023] [Indexed: 05/31/2023]
Abstract
Perfusion CT is established to aid selection of patients with proximal intracranial vessel occlusion for thrombectomy in the extended time window. Selection is mostly based on simple thresholding of perfusion parameter maps, which, however, does not exploit the full information hidden in the high-dimensional perfusion data. We implemented a multiparametric mass-univariate logistic model to predict tissue outcome based on data from 405 stroke patients with acute proximal vessel occlusion in the anterior circulation who underwent mechanical thrombectomy. Input parameters were acute multimodal CT imaging (perfusion, angiography, and non-contrast) as well as basic demographic and clinical parameters. The model was trained with the knowledge of recanalization status and final infarct localization. We found that perfusion parameter maps (CBF, CBV, and Tmax) were sufficient for tissue outcome prediction. Compared with single-parameter thresholding-based models, our logistic model had comparable volumetric accuracy, but was superior with respect to topographical accuracy (AUC of receiver operating characteristic). We also found higher spatial accuracy (Dice index) in an independent internal but not external cross-validation. Our results highlight the value of perfusion data compared with non-contrast CT, CT angiography and clinical information for tissue outcome-prediction. Multiparametric logistic prediction has high potential to outperform the single-parameter thresholding-based approach. In the future, the combination of tissue and functional outcome prediction might provide an individual biomarker for the benefit from mechanical thrombectomy in acute stroke care.
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Affiliation(s)
- Florian Welle
- Neuroimaging Laboratory, Department of Neurology, University of Leipzig Medical Center, Leipzig, Germany
| | - Kristin Stoll
- Neuroimaging Laboratory, Department of Neurology, University of Leipzig Medical Center, Leipzig, Germany
| | - Christina Gillmann
- Signal and Image Processing Group, Institute for Informatics, University of Leipzig, Leipzig, Germany
| | - Jeanette Henkelmann
- Department of Radiology, University of Leipzig Medical Center, Leipzig, Germany
| | - Gordian Prasse
- Department of Neuroradiology, University of Leipzig Medical Center, Leipzig, Germany
| | - Daniel P O Kaiser
- Institute of Neuroradiology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Elias Kellner
- Medical Physics, Department of Diagnostic and Interventional Radiology, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Marco Reisert
- Medical Physics, Department of Diagnostic and Interventional Radiology, Medical Center - University of Freiburg, Faculty of Medicine, Freiburg, Germany
| | - Hans R Schneider
- Neuroimaging Laboratory, Department of Neurology, University of Leipzig Medical Center, Leipzig, Germany
| | - Julian Klingbeil
- Neuroimaging Laboratory, Department of Neurology, University of Leipzig Medical Center, Leipzig, Germany
| | - Anika Stockert
- Neuroimaging Laboratory, Department of Neurology, University of Leipzig Medical Center, Leipzig, Germany
| | - Donald Lobsien
- Department of Neuroradiology, University of Leipzig Medical Center, Leipzig, Germany
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, Helios Hospital Erfurt, Erfurt, Germany
| | - Karl-Titus Hoffmann
- Department of Neuroradiology, University of Leipzig Medical Center, Leipzig, Germany
| | - Dorothee Saur
- Neuroimaging Laboratory, Department of Neurology, University of Leipzig Medical Center, Leipzig, Germany
| | - Max Wawrzyniak
- Neuroimaging Laboratory, Department of Neurology, University of Leipzig Medical Center, Leipzig, Germany.
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Cramer SC, Parodi L, Moslemi Z, Braun R, Aldridge C, Shahbaba B, Rosand J, Holman EA. Genetic Variation and Stroke Recovery: The STRONG Study. Stroke 2024; 55:2094-2102. [PMID: 38979623 PMCID: PMC11262965 DOI: 10.1161/strokeaha.124.047643] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 06/12/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND Genetic association studies can reveal biology and treatment targets but have received limited attention for stroke recovery. STRONG (Stroke, Stress, Rehabilitation, and Genetics) was a prospective, longitudinal (1-year), genetic study in adults with stroke at 28 US stroke centers. The primary aim was to examine the association that candidate genetic variants have with (1) motor/functional outcomes and (2) stress-related outcomes. METHODS For motor/functional end points, 3 candidate gene variants (ApoE ε4, BDNF [brain-derived neurotrophic factor], and a dopamine polygenic score) were analyzed for associations with change in grip strength (3 months-baseline), function (3-month Stroke Impact Scale-Activities of Daily Living), mood (3-month Patient Health Questionnaire-8), and cognition (12-month telephone-Montreal Cognitive Assessment). For stress-related outcomes, 7 variants (serotonin transporter gene-linked promoter region, ACE [angiotensin-converting enzyme], oxytocin receptor, FKBP5 [FKBP prolyl isomerase 5], FAAH [fatty acid amide hydrolase], BDNF, and COMT [catechol-O-methyltransferase]) were assessed for associations with posttraumatic stress disorder ([PTSD]; PTSD Primary Care Scale) and depression (Patient Health Questionnaire-8) at 6 and 12 months; stress-related genes were examined as a function of poststroke stress level. Statistical models (linear, negative binomial, or Poisson regression) were based on response variable distribution; all included stroke severity, age, sex, and ancestry as covariates. Stroke subtype was explored secondarily. Data were Holm-Bonferroni corrected. A secondary replication analysis tested whether the rs1842681 polymorphism (identified in the GISCOME study [Genetics of Ischaemic Stroke Functional Outcome]) was related to 3-month modified Rankin Scale score in STRONG. RESULTS The 763 enrollees were 63.1±14.9 (mean±SD) years of age, with a median initial National Institutes of Health Stroke Scale score of 4 (interquartile range, 2-9); outcome data were available in n=515 at 3 months, n=500 at 6 months, and n=489 at 12 months. At 1 year poststroke, the rs6265 (BDNF) variant was associated with poorer cognition (0.9-point lower telephone-Montreal Cognitive Assessment score, P=1×10-5). For stress-related outcomes, rs4291 (ACE) and rs324420 (FAAH) were risk factors linking increased poststroke stress with higher 1-year depression and PTSD symptoms (P<0.05), while rs4680 (COMT) linked poststroke stress with lower 1-year depression and PTSD. Findings were unchanged when considering stroke subtype. STRONG replicated GISCOME: rs1842681 was associated with lower 3-month modified Rankin Scale score (P=3.2×10-5). CONCLUSIONS This study identified genetic associations with cognitive function, depression, and PTSD 1 year poststroke. Genetic susceptibility to PTSD and depressive symptoms varied according to the amount of poststroke stress, underscoring the critical role of lived experiences in recovery. Together, the results suggest that genetic association studies provide insights into the biology of stroke recovery in humans.
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Affiliation(s)
- Steven C. Cramer
- Dept. Neurology, UCLA; California Rehabilitation Institute; Los Angeles, CA
| | - Livia Parodi
- Dept. Neurology, Center for Genomic Medicine, McCance Center for Brain Health, MGH; Boston, MA
| | | | | | - Chad Aldridge
- Dept. Neurology, Univ. Virginia; Charlottesville, VA
| | | | - Jonathan Rosand
- Dept. Neurology, Center for Genomic Medicine, McCance Center for Brain Health, MGH; Boston, MA
| | - E. Alison Holman
- Sue & Bill Gross School of Nursing and Dept. Psychological Science; UC, Irvine; Irvine, CA
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Xie Y, Wu M, Li Y, Zhao Y, Chen S, Yan E, Huang Z, Xie M, Yuan K, Qin C, Zhang X. Low caveolin-1 levels and symptomatic intracranial haemorrhage risk in large-vessel occlusive stroke patients after endovascular thrombectomy. Eur J Neurol 2024; 31:e16342. [PMID: 38757755 PMCID: PMC11235756 DOI: 10.1111/ene.16342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2024] [Revised: 04/18/2024] [Accepted: 05/02/2024] [Indexed: 05/18/2024]
Abstract
BACKGROUND AND PURPOSE Caveolin-1 (Cav-1) is reported to mediate blood-brain barrier integrity after ischaemic stroke. Our purpose was to assess the role of circulating Cav-1 levels in predicting symptomatic intracranial haemorrhage (sICH) amongst ischaemic stroke patients after endovascular thrombectomy (EVT). METHODS Patients with large-vessel occlusive stroke after EVT from two stroke centres were prospectively included. Serum Cav-1 level was tested after admission. sICH was diagnosed according to the Heidelberg Bleeding Classification. RESULTS Of 325 patients (mean age 68.6 years; 207 men) included, 47 (14.5%) were diagnosed with sICH. Compared with patients without sICH, those with sICH had a lower concentration of Cav-1. After adjusting for potential confounders, multivariate regression analysis demonstrated that the increased Cav-1 level was associated with a lower sICH risk (odds ratio 0.055; 95% confidence interval 0.005-0.669; p = 0.038). Similar results were obtained when Cav-1 levels were analysed as a categorical variable. Using a logistic regression model with restricted cubic splines, a linear and negative association of Cav-1 concentration was found with sICH risk (p = 0.001 for linearity). Furthermore, the performance of the conventional risk factors model in predicting sICH was substantially improved after addition of the Cav-1 levels (integrated discrimination index 2.7%, p = 0.002; net reclassification improvement 39.7%, p = 0.007). CONCLUSIONS Our data demonstrate that decreased Cav-1 levels are related to sICH after EVT. Incorporation of Cav-1 into clinical decision-making may help to identify patients at a high risk of sICH and warrants further consideration.
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Affiliation(s)
- Yi Xie
- Department of NeurologyAffiliated Jinling Hospital, Medical School of Nanjing UniversityNanjingChina
| | - Min Wu
- Department of NeurologyJinling Hospital, Nanjing Medical UniversityNanjingChina
| | - Yun Li
- Department of NeurologyAffiliated Jinling Hospital, Medical School of Nanjing UniversityNanjingChina
| | - Ying Zhao
- Department of NeurologyAffiliated Jinling Hospital, Medical School of Nanjing UniversityNanjingChina
| | - Shuaiyu Chen
- Department of NeurologyNanjing First Hospital, Nanjing Medical UniversityNanjingChina
| | - E. Yan
- Department of NeurologyNanjing First Hospital, Nanjing Medical UniversityNanjingChina
| | - Zhihang Huang
- Department of NeurologyNanjing First Hospital, Nanjing Medical UniversityNanjingChina
| | - Mengdi Xie
- Department of NeurologyAffiliated Jinling Hospital, Medical School of Nanjing UniversityNanjingChina
| | - Kang Yuan
- Department of NeurologyAffiliated Jinling Hospital, Medical School of Nanjing UniversityNanjingChina
| | - Chunhua Qin
- Department of NeurologyNanjing First Hospital, Nanjing Medical UniversityNanjingChina
| | - Xiaohao Zhang
- Department of NeurologyNanjing First Hospital, Nanjing Medical UniversityNanjingChina
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9
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Nogueira RG, Doheim MF, Jadhav AP, Aghaebrahim A, Frankel MR, Jankowitz BT, Budzik RF, Bonafe A, Bhuva P, Yavagal DR, Hanel RA, Hassan AE, Ribo M, Cognard C, Sila CA, Jenkins P, Smith WS, Saver JL, Liebeskind DS, Jovin TG, Haussen DC. Mode of Onset Modifies the Effect of Time to Endovascular Reperfusion on Clinical Outcomes after Acute Ischemic Stroke: An Analysis of the DAWN Trial. Ann Neurol 2024; 96:356-364. [PMID: 38877793 DOI: 10.1002/ana.26968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 05/01/2024] [Accepted: 05/06/2024] [Indexed: 06/16/2024]
Abstract
OBJECTIVE We aimed to assess the impact of time to endovascular thrombectomy (EVT) on clinical outcomes in the DAWN trial, while also exploring the potential effect modification of mode of stroke onset on this relationship. METHODS The association between every 1-h treatment delay with 90-day functional independence (modified Rankin Scale [mRS] score 0-2), symptomatic intracranial hemorrhage, and 90-day mortality was explored in the overall population and in three modes of onset subgroups (wake-up vs. witnessed vs. unwitnessed). RESULTS Out of the 205 patients, 98 (47.8%) and 107 (52.2%) presented in the 6 to 12 hours and 12 to 24 hours time window, respectively. Considering all three modes of onset together, there was no statistically significant association between time last seen well to randomization with either functional independence or mortality at 90 days in either the endovascular thrombectomy (mRS 0-2 1-hour delay OR 1.07; 95% CI 0.93-1.24; mRS 6 OR 0.84; 95% CI 0.65-1.03) or medical management (mRS 0-2 1-hour delay OR 0.98; 95% CI 0.80-1.14; mRS 6 1-hour delay OR 0.94; 95% CI 0.79-1.09) groups. Moreover, there was no significant interaction between treatment effect and time (p = 0.439 and p = 0.421 for mRS 0-2 and 6, respectively). However, within the thrombectomy group, the models that tested the association between time last seen well to successful reperfusion (modified Treatment in Cerebral Infarction ≥2b) and 90-day functional independence showed a significant interaction with mode of presentation (p = 0.013). This appeared to be driven by a nominally positive slope for both witnessed and unwitnessed strokes versus a significantly (p = 0.018) negative slope in wake-up patients. There was no association between treatment times and symptomatic intracranial hemorrhage. INTERPRETATION Mode of onset modifies the effect of time to reperfusion on thrombectomy outcomes, and should be considered when exploring different treatment paradigms in the extended window. ANN NEUROL 2024;96:356-364.
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Affiliation(s)
- Raul G Nogueira
- Department of Neurology and Neurosurgery, University of Pittsburgh Medical Center, UPMC Stroke Institute, Pittsburgh, PA, USA
| | - Mohamed F Doheim
- Department of Neurology and Neurosurgery, University of Pittsburgh Medical Center, UPMC Stroke Institute, Pittsburgh, PA, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | | | - Michael R Frankel
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | | | | | - Alain Bonafe
- Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France
| | - Parita Bhuva
- Division of Neurointervention, Texas Stroke Institute, Dallas-Fort Worth, Fort Worth, TX, USA
| | - Dileep R Yavagal
- Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine-Jackson Memorial Hospital, Miami, FL, USA
| | | | - Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley, Valley Baptist Hospital, Harlingen, TX, USA
| | - Marc Ribo
- Stroke Unit, Hospital Vall d'Hebrón, Barcelona, Spain
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France
| | - Cathy A Sila
- Department of Neurology, University Hospitals of Cleveland, Cleveland, OH, USA
| | | | - Wade S Smith
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - David S Liebeskind
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Tudor G Jovin
- Department of Neurology, Cooper University Hospital, Neurological Institute, Camden, NJ, USA
| | - Diogo C Haussen
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
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10
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Mistry EA, Khoury JC, Kleindorfer DO, Kissela BM, Alwell KS, Jasne AS, Ferioli S, De Los Rios La Rosa F, Coleman E, Demel SL, Walsh KB, Slavin SJ, Star M, Haverbusch M, Mackey J, Woo D, Aziz YN, Heldner MR, Fischer U, Jadhav AP, Jovin TG, Albers GW, Nogueira RG, Khatri P. Projections of Endovascular Therapy-Eligible Patients With Stroke for the US Population. Stroke 2024; 55:2011-2019. [PMID: 38934124 DOI: 10.1161/strokeaha.123.045766] [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: 12/13/2023] [Accepted: 05/08/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND As stroke endovascular thrombectomy (EVT) treatment indications expand, understanding population-based EVT eligibility becomes critical for resource planning. We aimed to project current and future population-based EVT eligibility in the United States. METHODS We conducted a post hoc analysis of the physician-adjudicated GCNKSS (Greater Cincinnati Northern Kentucky Stroke Study; 2015 epoch), a population-based, cross sectional, observational study of stroke incidence, treatment, and outcomes across a 5-county region. All hospitalized patients ≥18 years of age with acute ischemic stroke were ascertained using the International Classification of Diseases, Ninth Revision codes 430-436 and Tenth Revision codes I60-I67 and G45-G46 and extrapolated to the US adult census 2020. We determined the rate of EVT eligibility within the GCNKSS population using time from last known well to presentation (0-5 versus 5-23 hours), presenting National Institutes of Health Stroke Scale, and prestroke modified Rankin Scale. Both conservative and liberal estimates of prevalence of large vessel occlusion and large core were then applied based on literature review (unavailable within the 2015 GCNKSS). This eligibility was then extrapolated to the 2020 US population. RESULTS Of the 1 057 183 adults within GCNKSS in 2015, 2741 had an ischemic stroke and 2176 had data available for analysis. We calculated that 8659 to 17 219 patients (conservative to liberal) meet the current guideline-recommended EVT criteria (nonlarge core, no prestroke disability, and National Institutes of Health Stroke Scale score ≥6) in the United States. Estimates (conservative to liberal) for expanded EVT eligibility subpopulations include (1) 5316 to 10 635 by large core; (2) 10 635 to 21 270 by mild presenting deficits with low National Institutes of Health Stroke Scale score; (3) 13 572 to 27 089 by higher prestroke disability; and (4) 7039 to 14 180 by >1 criteria. These expanded eligibility subpopulations amount to 36 562 to 73 174 patients. CONCLUSIONS An estimated 8659 to 17 219 adult patients in the United States met strict EVT eligibility criteria in 2020. A 4-fold increase in population-based EVT eligibility can be anticipated with incremental adoption of recent or future positive trials. US stroke systems need to be rapidly optimized to handle all EVT-eligible patients with stroke.
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Affiliation(s)
- Eva A Mistry
- Department of Neurology and Rehabilitation Medicine (E.A.M., B.M.K., K.S.A., S.F., S.L.D., M.H., D.W., Y.N.A., P.K.), University of Cincinnati, OH
| | - Jane C Khoury
- Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children's Hospital, University of Cincinnati Medical Center, OH (J.C.K.)
| | | | - Brett M Kissela
- Department of Neurology and Rehabilitation Medicine (E.A.M., B.M.K., K.S.A., S.F., S.L.D., M.H., D.W., Y.N.A., P.K.), University of Cincinnati, OH
| | - Kathleen S Alwell
- Department of Neurology and Rehabilitation Medicine (E.A.M., B.M.K., K.S.A., S.F., S.L.D., M.H., D.W., Y.N.A., P.K.), University of Cincinnati, OH
| | - Adam S Jasne
- Department of Neurology, Yale University, New Haven, CT (A.S.J.)
| | - Simona Ferioli
- Department of Neurology and Rehabilitation Medicine (E.A.M., B.M.K., K.S.A., S.F., S.L.D., M.H., D.W., Y.N.A., P.K.), University of Cincinnati, OH
| | | | | | - Stacie L Demel
- Department of Neurology and Rehabilitation Medicine (E.A.M., B.M.K., K.S.A., S.F., S.L.D., M.H., D.W., Y.N.A., P.K.), University of Cincinnati, OH
| | - Kyle B Walsh
- Department of Emergency Medicine (K.B.W.), University of Cincinnati, OH
| | - Sabreena J Slavin
- Department of Neurology, University of Kansas Medical Center (S.J.S.)
| | - Michael Star
- Department of Neurology, Soroka Medical Center, Beersheva, Israel (M.S.)
| | - Mary Haverbusch
- Department of Neurology and Rehabilitation Medicine (E.A.M., B.M.K., K.S.A., S.F., S.L.D., M.H., D.W., Y.N.A., P.K.), University of Cincinnati, OH
| | - Jason Mackey
- Department of Neurology, Indiana University School of Medicine, Indianapolis (J.M.)
| | - Daniel Woo
- Department of Neurology and Rehabilitation Medicine (E.A.M., B.M.K., K.S.A., S.F., S.L.D., M.H., D.W., Y.N.A., P.K.), University of Cincinnati, OH
| | - Yasmin N Aziz
- Department of Neurology and Rehabilitation Medicine (E.A.M., B.M.K., K.S.A., S.F., S.L.D., M.H., D.W., Y.N.A., P.K.), University of Cincinnati, OH
| | - Mirjam R Heldner
- Stroke Research Center Bern, University Hospital Bern and University of Bern, Switzerland (M.R.H.)
| | - Urs Fischer
- Department of Neurology, University Hospital Basel and University of Basel, Switzerland (U.F.)
| | | | - Tudor G Jovin
- Department of Neurology, Cooper University, Camden, NJ (T.G.J.)
| | | | - Raul G Nogueira
- Department of Neurology, University of Pittsburgh, PA (R.G.N.)
| | - Pooja Khatri
- Department of Neurology and Rehabilitation Medicine (E.A.M., B.M.K., K.S.A., S.F., S.L.D., M.H., D.W., Y.N.A., P.K.), University of Cincinnati, OH
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11
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Carbonera LA, Rivillas JA, Gordon Perue G, da Luz Dorneles L, Boiani M, de Souza AC, Sampaio Silva G, Dorn M, Martins SCO. The MAPSTROKE project: A computational strategy to improve access to acute stroke care. Int J Stroke 2024; 19:747-753. [PMID: 38346937 DOI: 10.1177/17474930241234528] [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] [Indexed: 02/29/2024]
Abstract
BACKGROUND Global access to acute stroke treatment is variable worldwide, with notable gaps in low and middle-income countries (LMIC), especially in rural areas. Ensuring a standardized method for pinpointing the existing regional coverage and proposing potential sites for new stroke centers is essential to change this scenario. AIMS To create and apply computational strategies (CSs) to determine optimal locations for new acute stroke centers (ASCs), with a pilot application in nine Latin American regions/countries. METHODS Hospitals treating acute ischemic stroke (AIS) with intravenous thrombolysis (IVT) and meeting the minimum infrastructure requirements per structured protocols were categorized as ASCs. Hospitals with emergency departments, noncontrast computed tomography (NCCT) scanners, and 24/7 laboratories were identified as potential acute stroke centers (PASCs). Hospital geolocation data were collected and mapped using the OpenStreetMap data set. A 45-min drive radius was considered the ideal coverage area for each hospital based on the drive speeds from the OpenRouteService database. Population data, including demographic density, were obtained from the Kontur Population data sets. The proposed CS assessed the population covered by ASCs and proposed new ASCs or artificial points (APs) settled in densely populated areas to achieve a target population coverage (TPC) of 95%. RESULTS The observed coverage in the region presented significant disparities, ranging from 0% in the Bahamas to 73.92% in Trinidad and Tobago. No country/region reached the 95% TPC using only its current ASCs or PASCs, leading to the proposal of APs. For example, in Rio Grande do Sul, Brazil, the introduction of 132 new centers was suggested. Furthermore, it was observed that most ASCs were in major urban hubs or university hospitals, leaving rural areas largely underserved. CONCLUSIONS The MAPSTROKE project has the potential to provide a systematic approach to identify areas with limited access to stroke centers and propose solutions for increasing access to AIS treatment. DATA ACCESS STATEMENT Data used for this publication are available from the authors upon reasonable request.
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Affiliation(s)
| | - Julián Alejandro Rivillas
- Department of Neurology, Fundación Valle del Lili Hospital Universitario, Cali, Colombia
- Public Health Department, Universidad Icesi, Cali, Colombia
| | - Gillian Gordon Perue
- Department of Neurology, Miller School of Medicine, University of Miami, Miami, FL, USA
| | - Leonardo da Luz Dorneles
- Institute of Informatics and Center for Biotechnology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Mateus Boiani
- Institute of Informatics and Center for Biotechnology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Ana Cláudia de Souza
- Department of Neurology and Neurosurgery, Hospital Moinhos de Vento, Porto Alegre, Brazil
| | - Gisele Sampaio Silva
- Department of Neurology, Universidade Federal de São Paulo (UNIFESP) and Hospital Israelita Albert Einstein, São Paulo, Brazil
| | - Marcio Dorn
- Institute of Informatics and Center for Biotechnology, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
| | - Sheila Cristina Ouriques Martins
- Department of Neurology and Neurosurgery, Hospital Moinhos de Vento, Porto Alegre, Brazil
- Department of Internal Medicine, Universidade Federal do Rio Grande do Sul (UFRGS), Porto Alegre, Brazil
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12
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Shahbandi A, Holt M, Shlobin NA. The 100 highest-cited original articles in large vessel occlusions: A bibliometric analysis. Neuroradiol J 2024:19714009241269503. [PMID: 39088357 DOI: 10.1177/19714009241269503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/03/2024] Open
Abstract
BACKGROUND Large vessel occlusions (LVO) are a common etiology of morbidity and mortality. The current literature lacks a synthesis of the landscape and trends in research. OBJECTIVE We aimed to conduct a bibliometric analysis of the 100 most cited original articles on LVOs to assess the current state of research. METHODS Scopus database was queried from inception to December 2022 to identify the most cited original articles from 4506 retrieved records on LVOs. Publication year, country of origin, total and average annual citation count, and type of study were collected for each article. The journal impact factor (JIF) was obtained from the Journal Citation Reports database. RESULTS The articles were published between 1994 and 2021, with most (n = 82) published during the 2011-2020 decade. The median total citation count was 108.5, with an interquartile range (IQR) of 81-149.5. The median (IQR) average annual citation count was 15.9 (11.5-22.9). Half of the articles were published in Stroke (n = 35) and Journal of NeuroInterventional Surgery (n = 15), with JIFs ranging from 1.8 to 202.7. The USA was the leading country in contributing to LVO research (n = 45). Most studies focused on the treatment (n = 63) and diagnosis (n = 22) of LVOs. CONCLUSIONS Most articles were published during the past decade, highlighting the impact of the clinical trials of endovascular treatment on the discipline. With several ongoing clinical trials on the horizon, continued growth of the field is anticipated in the upcoming decades.
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Affiliation(s)
| | - Matthew Holt
- Department of Natural Sciences, University of South Carolina Beaufort, Bluffton, CA, USA
| | - Nathan A Shlobin
- Department of Neurological Surgery, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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13
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Ikeda H, Ishibashi R, Kinosada M, Uezato M, Hata H, Kaneko R, Osuki T, Akaike N, Tanimura M, Torimaki S, Fujiwara T, Nishi R, Wada M, Yokochi Y, Hayashi T, Takada K, Kurosaki Y, Chin M, Yamagata S. Learning Curve Effect of Combined Technique Thrombectomy as First-Line Attempt for Acute Ischemic Stroke: A Single-Center Retrospective Study. World Neurosurg 2024; 188:e467-e479. [PMID: 38810873 DOI: 10.1016/j.wneu.2024.05.138] [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: 11/12/2023] [Revised: 05/20/2024] [Accepted: 05/21/2024] [Indexed: 05/31/2024]
Abstract
OBJECTIVES We retrospectively examined the initial experience and learning curve after the introduction of thrombectomy with the combined technique using an aspiration catheter and a stent retriever as first-line attempt for acute ischemic stroke. METHODS Consecutive patients undergoing thrombectomy for acute ischemic stroke at our institution between January 2020 and December 2022 were divided into 3 groups according to the year of thrombectomy. Patient characteristics and procedural, safety, and clinical outcomes were compared between the three year periods to determine predictors of favorable clinical outcome. RESULTS In 2020, 2021, and 2022, the numbers of patients were 74, 70, and 90, respectively, with similar patient characteristics across the three years; successful recanalization rates were 79.7%, 97.1%, and 93.3%, respectively (P < 0.01 for the first 2 years); median procedure times were 67, 43, and 32 minutes, respectively (P < 0.01 for the first 2 years and P = 0.018 for the last 2 years); first pass effect rates were 20.3%, 41.4%, and 44.4%, respectively (P < 0.01 for the first 2 years); symptomatic intracranial hemorrhage rates were 14.9%, 2.9%, and 1.1%, respectively (P = 0.018 for the first 2 years); and percentages of modified Rankin Scale score 0-2 at 90 days were 24.3%, 42.9%, and 41.1%, respectively (P = 0.022 for the first 2 years). Procedure time (P = 0.038) and successful recanalization (P = 0.041) were independent predictors of favorable clinical outcome. CONCLUSIONS The learning curve effect of the combined technique may be associated with better clinical outcome due to increased successful recanalization rates, shortened procedure time, and reduced symptomatic intracranial hemorrhage.
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Affiliation(s)
- Hiroyuki Ikeda
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan.
| | - Ryota Ishibashi
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Masanori Kinosada
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Minami Uezato
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Hidenobu Hata
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Ryosuke Kaneko
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Takuya Osuki
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Natsuki Akaike
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Mai Tanimura
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Shinya Torimaki
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Toshio Fujiwara
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Ryosuke Nishi
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Makoto Wada
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Yasunori Yokochi
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Tomoko Hayashi
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Kensuke Takada
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Yoshitaka Kurosaki
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Masaki Chin
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
| | - Sen Yamagata
- Department of Neurosurgery, Kurashiki Central Hospital, Kurashiki, Japan
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14
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Morimoto T, Yoshimoto N, Kuragaichi T, Taki J, Yamada K. Mechanical thrombectomy for cerebrovascular occlusion in a patient with situs inversus. Radiol Case Rep 2024; 19:3488-3491. [PMID: 38872738 PMCID: PMC11170093 DOI: 10.1016/j.radcr.2024.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Revised: 04/24/2024] [Accepted: 05/01/2024] [Indexed: 06/15/2024] Open
Abstract
Situs inversus is a rare congenital abnormality characterized by mirror-image transposition of the major visceral organs and vessels. Few reports have discussed the use of mechanical thrombectomy in acute ischemic stroke with situs inversus. We present such a case, to raise awareness and deepen the knowledge on these cases. A 44-year-old man was admitted to our hospital with sudden-onset dysarthria and left-sided paresis. Computed tomography (CT) angiography revealed situs inversus and occlusion in the internal carotid artery. First, intravenous tissue plasminogen activator was administered, followed by immediate reperfusion with mechanical thrombectomy. We achieved thrombolysis in cerebral infarction grade 3. After the procedure, the patient fully recovered. Prompt diagnosis is crucial for rapid recanalization in patients with vascular anomalies such as situs inversus.
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Affiliation(s)
- Takaaki Morimoto
- Department of Neurosurgery, Hyogo Prefecture Amagasaki General Medical Center, Hyogo, Japan
| | - Naoya Yoshimoto
- Department of Neurosurgery, Hyogo Prefecture Amagasaki General Medical Center, Hyogo, Japan
| | - Takashi Kuragaichi
- Department of Cardiology, Hyogo Prefecture Amagasaki General Medical Center, Hyogo, Japan
| | - Junya Taki
- Department of Neurosurgery, Hyogo Prefecture Amagasaki General Medical Center, Hyogo, Japan
| | - Keisuke Yamada
- Department of Neurosurgery, Hyogo Prefecture Amagasaki General Medical Center, Hyogo, Japan
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15
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Tanaka K, Brown S, Goyal M, Menon BK, Campbell BCV, Mitchell PJ, Jovin TG, Saver JL, Muir KW, White PM, Bracard S, Guillemin F, Roos YBWEM, van Zwam WH, Najm M, Dowlatshahi D, Hill MD, Demchuk AM. HERMES-24 Score Derivation and Validation for Simple and Robust Outcome Prediction After Large Vessel Occlusion Treatment. Stroke 2024; 55:1982-1990. [PMID: 39038101 DOI: 10.1161/strokeaha.123.045871] [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: 11/20/2023] [Accepted: 06/04/2024] [Indexed: 07/24/2024]
Abstract
BACKGROUND Clinicians need simple and highly predictive prognostic scores to assist practical decision-making. We aimed to develop a simple outcome prediction score applied 24 hours after anterior circulation acute ischemic stroke treatment with endovascular thrombectomy and validate it in patients treated both with and without endovascular thrombectomy. METHODS Using the HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) collaboration data set (n=1764), patients in the endovascular thrombectomy arm were divided randomly into a derivation cohort (n=430) and a validation cohort (n=441). From a set of candidate predictors, logistic regression modeling using forward variable selection was used to select a model that was both parsimonious and highly predictive for modified Rankin Scale (mRS) ≤2 at 90 days. The score was validated in validation cohort, control arm (n=893), and external validation cohorts from the ESCAPE-NA1 (Efficacy and Safety of Nerinetide for the Treatment of Acute Ischaemic Stroke; n=1066) and INTERRSeCT (Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV Alteplase and Other Treatments Using Serial CT Angiography; n=614). RESULTS In the derivation cohort, we selected 2 significant predictors of mRS ≤2 (National Institutes of Health Stroke Scale score at 24 hours and age [β-coefficient, 0.34 and 0.06]) and derived the HERMES-24 score: age (years)/10+National Institutes of Health Stroke Scale score at 24 hours. The HERMES-24 score was highly predictive for mRS ≤2 (c-statistic 0.907 [95% CI, 0.879-0.935]) in the derivation cohort. In the validation cohort and the control arm, the HERMES-24 score predicts mRS ≤2 (c-statistic, 0.914 [95% CI, 0.886-0.944] and 0.909 [95% CI, 0.887-0.930]). Observed provability of mRS ≤2 ranged between 3.1% and 3.4% when HERMES-24 score ≥25, while it ranged between 90.6% and 93.0% when HERMES-24 score <10 in the derivation cohort, validation cohort, and control arm. The HERMES-24 score also showed c-statistics of 0.894 and 0.889 for mRS ≤2 in the ESCAPE-NA1 and INTERRSeCT populations. CONCLUSIONS The post-treatment HERMES-24 score is a simple validated score that predicts a 3-month outcome after anterior circulation large vessel occlusion stroke regardless of intervention, which helps prognostic discussion with families on day 2.
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Affiliation(s)
- Koji Tanaka
- Department of Clinical Neurosciences (K.T., M.G., B.K.M., M.N., M.D.H., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Scott Brown
- Altair Biostatistics, St. Louis Park, MN (S. Brown)
| | - Mayank Goyal
- Department of Clinical Neurosciences (K.T., M.G., B.K.M., M.N., M.D.H., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Radiology and Hotchkiss Brain Institute (M.G., B.K.M., M.D.H., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Bijoy K Menon
- Department of Clinical Neurosciences (K.T., M.G., B.K.M., M.N., M.D.H., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Radiology and Hotchkiss Brain Institute (M.G., B.K.M., M.D.H., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Community Health Sciences (B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre (B.C.V.C.), Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
| | - Peter J Mitchell
- Department of Radiology (P.J.M.), Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
| | - Tudor G Jovin
- Department of Neurology, Cooper University Health Care, Camden, NJ (T.G.J.)
| | - Jeffrey L Saver
- Department of Radiology and Neuroradiology, Universitätsklinikum Kiel, Schleswig-Holstein, Germany (J.L.S.)
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Scotland, United Kingdom (K.W.M.)
| | - Phil M White
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, England, United Kingdom (P.M.W.)
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, Imagerie Adaptative Diagnostique et Interventionnelle (S. Bracard), Centre Hospitalier Régional Universitaire de Nancy, Institut national de la santé et de la recherche médicale, Université de Lorraine, France
| | - Francis Guillemin
- Clinical Epidemiology Center (F.G.), Centre Hospitalier Régional Universitaire de Nancy, Institut national de la santé et de la recherche médicale, Université de Lorraine, France
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam University Medical Center, North Holland, the Netherlands (Y.B.W.E.M.R.)
| | - Wim H van Zwam
- Department of Radiology, Maastricht University Medical Center, Rotterdam, South Holland, the Netherlands (W.H.v.Z.)
| | - Mohamed Najm
- Department of Clinical Neurosciences (K.T., M.G., B.K.M., M.N., M.D.H., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Dar Dowlatshahi
- Department of Medicine and Ottawa Hospital Research Institute, University of Ottawa, ON, Canada (D.D.)
| | - Michael D Hill
- Department of Clinical Neurosciences (K.T., M.G., B.K.M., M.N., M.D.H., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Radiology and Hotchkiss Brain Institute (M.G., B.K.M., M.D.H., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Community Health Sciences (B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Medicine (M.D.H.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Andrew M Demchuk
- Department of Clinical Neurosciences (K.T., M.G., B.K.M., M.N., M.D.H., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Radiology and Hotchkiss Brain Institute (M.G., B.K.M., M.D.H., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
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16
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Ospel JM, Diprose WK, Ganesh A, Martins S, Nguyen T, Psychogios M, Mansour O, Al-Ajlan F, Yang P, Pandian J, Gopinathan A, Sandset EC, Kennedy J, Volders D, Fahed R, Tjoumakaris S, Bhogal P, Kurz M, Yavagal D, Inoa V, Hill MD, Goyal M. Challenges to Widespread Implementation of Stroke Thrombectomy. Stroke 2024; 55:2173-2183. [PMID: 38979609 DOI: 10.1161/strokeaha.124.045889] [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] [Indexed: 07/10/2024]
Abstract
Endovascular treatment (EVT) for acute ischemic stroke is one of the most efficacious and effective treatments in medicine, yet globally, its implementation remains limited. Patterns of EVT underutilization exist in virtually any health care system and range from a complete lack of access to selective undertreatment of certain patient subgroups. In this review, we outline different patterns of EVT underutilization and possible causes. We discuss common challenges and bottlenecks that are encountered by physicians, patients, and other stakeholders when trying to establish and expand EVT services in different scenarios and possible pathways to overcome these challenges. Lastly, we discuss the importance of implementation research studies, strategic partnerships, and advocacy efforts to mitigate EVT underutilization.
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Affiliation(s)
- Johanna Maria Ospel
- Department of Diagnostic Imaging (J.M.O., M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., W.K.D., A. Ganesh, M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - William K Diprose
- Department of Clinical Neurosciences (J.M.O., W.K.D., A. Ganesh, M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Aravind Ganesh
- Department of Clinical Neurosciences (J.M.O., W.K.D., A. Ganesh, M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Sheila Martins
- Neurology Department, Hospital Moinhos de Vento, Porto Alegre, Brazil (S.M.)
| | - Thanh Nguyen
- Departments of Radiology and Neurology, Boston Medical Center, MA (T.N.)
| | - Marios Psychogios
- Department of Neuroradiology, University Hospital Basel, Switzerland (M.P.)
| | - Ossama Mansour
- Alexandria Faculty of Medicine, Department of Neurology, Alexandria University, Egypt (O.M.)
| | - Fahad Al-Ajlan
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia (F.A.-A.)
| | - Pengfei Yang
- Department of Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China (P.Y.)
| | - Jeyaraj Pandian
- Department of Neurology, Christian Medical College and Hospital, Vellore, India (J.P.)
| | - Anil Gopinathan
- Division of Interventional Radiology, Department of Diagnostic Imaging, National University Health System, Singapore (A. Gopinathan)
| | | | - James Kennedy
- Oxford University Hospital NHS Foundation Trust, Oxford, United Kingdom (J.K.)
| | - David Volders
- Department of Radiology, Dalhousie University, Halifax, Canada (D.V.)
| | - Robert Fahed
- Division Neurology, Department of Medicine, The Ottawa Hospital, Ottawa Hospital Research Institute, University of Ottawa, Ontario, Canada (R.F.)
| | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA (S.T.)
| | - Pervinder Bhogal
- Department of Neuroradiology, The Royal London Hospital, Barts NHS Trust, United Kingdom (P.B.)
| | - Martin Kurz
- Department of Neurology, Stavanger University Hospital, Norway (M.K.)
| | - Dileep Yavagal
- Department of Neurology, University of Miami Miller School of Medicine, FL (D.Y.)
| | - Violiza Inoa
- Department of Neurology, University of Tennessee Health Science Center, Memphis (V.I.)
| | - Michael D Hill
- Department of Diagnostic Imaging (J.M.O., M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., W.K.D., A. Ganesh, M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
| | - Mayank Goyal
- Department of Diagnostic Imaging (J.M.O., M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
- Department of Clinical Neurosciences (J.M.O., W.K.D., A. Ganesh, M.D.H., M.G.), Cumming School of Medicine, University of Calgary, Alberta, Canada
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Jazayeri SB, Ghozy S, Hemmeda L, Bilgin C, Elfil M, Kadirvel R, Kallmes DF. Risk of Hemorrhagic Transformation after Mechanical Thrombectomy without versus with IV Thrombolysis for Acute Ischemic Stroke: A Systematic Review and Meta-analysis of Randomized Clinical Trials. AJNR Am J Neuroradiol 2024:ajnr.A8307. [PMID: 39025638 DOI: 10.3174/ajnr.a8307] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2024] [Accepted: 04/01/2024] [Indexed: 07/20/2024]
Abstract
BACKGROUND When treating acute ischemic stroke due to large-vessel occlusion, both mechanical thrombectomy and intravenous (IV) thrombolysis carry the risk of intracerebral hemorrhage. PURPOSE This study aimed to delve deeper into the risk of intracerebral hemorrhage and its subtypes associated with mechanical thrombectomy with or without IV thrombolysis to contribute to better decision-making in the treatment of acute ischemic stroke due to large-vessel occlusion. DATA SOURCES PubMed, EMBASE, and Scopus databases were searched for relevant studies from inception to September 6, 2023. STUDY SELECTION The eligibility criteria included randomized clinical trials or post hoc analysis of randomized controlled trials that focused on patients with acute ischemic stroke in the anterior circulation. After screening 4870 retrieved records, we included 9 studies (6 randomized controlled trials and 3 post hoc analyses of randomized controlled trials) with 3241 patients. DATA ANALYSIS The interventions compared were mechanical thrombectomy + IV thrombolysis versus mechanical thrombectomy alone, with the outcome of interest being any form of intracerebral hemorrhage and symptomatic intracerebral hemorrhage after intervention. A common definition for symptomatic intracerebral hemorrhage was pooled from various classification systems, and subgroup analyses were performed on the basis of different definitions and anatomic descriptions of hemorrhage. The quality of the studies was assessed using the revised version of Cochrane Risk of Bias 2 assessment tool. Meta-analysis was performed using the random effects model. DATA SYNTHESIS Eight studies had some concerns, and 1 study was considered high risk. Overall, the risk of symptomatic intracerebral hemorrhage was comparable between mechanical thrombectomy + IV thrombolysis and mechanial thrombectomy alone (risk ratio, 1.24 [95% CI, 0.89-1.72]; P = .20), with no heterogeneity across studies. Subgroup analysis of symptomatic intracerebral hemorrhage showed a non-significant difference between 2 groups based on the National Institute of Neurological Disorders and Stroke (P = .3), the Heidelberg Bleeding Classification (P = .5), the Safe Implementation of Thrombolysis in Stroke-Monitoring Study (P = .4), and the European Cooperative Acute Stroke Study III (P = .7) criteria. Subgroup analysis of different anatomic descriptions of intracerebral hemorrhage showed no difference between the 2 groups. Also, we found no difference in the risk of any intracerebral hemorrhage between two groups (risk ratio, 1.10 [95% CI, 1.00-1.21]; P = .052) with no heterogeneity across studies. LIMITATIONS There was a potential for performance bias in most studies. CONCLUSIONS In this systematic review and meta-analysis, the risk of any intracerebral hemorrhage and symptomatic intracerebral hemorrhage, including its various classifications and anatomic descriptions, was comparable between mechanical thrombectomy + IV thrombolysis and mechanical thrombectomy alone.
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Affiliation(s)
- Seyed Behnam Jazayeri
- From the Sina Trauma and Surgery Research Center (S.B.J.), Tehran University of Medical Sciences, Tehran, Iran
- Department of Radiology (S.B.J., S.G., C.B., R.K., D.F.K.), Mayo Clinic, Rochester, Minnesota
| | - Sherief Ghozy
- Department of Radiology (S.B.J., S.G., C.B., R.K., D.F.K.), Mayo Clinic, Rochester, Minnesota
- Department of Neurologic Surgery (S.G., R.K.), Mayo Clinic, Rochester, Minnesota
| | - Lina Hemmeda
- Faculty of Medicine (L.H.), University of Khartoum, Khartoum, Sudan
| | - Cem Bilgin
- Department of Radiology (S.B.J., S.G., C.B., R.K., D.F.K.), Mayo Clinic, Rochester, Minnesota
| | - Mohamed Elfil
- Department of Neurological Sciences (M.E.), University of Nebraska Medical Center, Omaha, Nebraska
| | - Ramanathan Kadirvel
- Department of Radiology (S.B.J., S.G., C.B., R.K., D.F.K.), Mayo Clinic, Rochester, Minnesota
- Department of Neurologic Surgery (S.G., R.K.), Mayo Clinic, Rochester, Minnesota
| | - David F Kallmes
- Department of Radiology (S.B.J., S.G., C.B., R.K., D.F.K.), Mayo Clinic, Rochester, Minnesota
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18
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Pei Y, Chen Y, Zhong W, He Y, Luo Z, Lou M, Chen Z. Effect of computed tomography vs. computed tomography perfusion on mechanical thrombectomy outcomes within 6 hours. Eur Radiol 2024; 34:5331-5338. [PMID: 38175220 DOI: 10.1007/s00330-023-10545-y] [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: 06/11/2023] [Revised: 11/12/2023] [Accepted: 11/25/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVES It is unclear which selection strategy, plain CT vs. CT perfusion (CTP), is more powerful in predicting outcome after mechanical thrombectomy (MT). We aimed to compare the effect of plain CT and CTP in predicting outcome after MT within 6 h. METHODS We conducted a prospective analysis of a retrospective cohort from our single-center study, which had occlusion of the internal carotid artery and middle cerebral artery up to the proximal M2 segment and received MT within 6 h. According to the Alberta Stroke Program Early CT Score (ASPECTS), patients were divided into a high-ASPECTS group (≥ 6) and a low ASPECTS group (< 6). Similarly, patients were divided into mismatch and no-mismatch groups according to the DEFUSE3 criteria for CTP. A good outcome was defined as a 90-day modified Rankin Scale (mRS) score of ≤ 3. Univariate and binary logistic regression analyses were used to investigate the association between different imaging modality and 90-day mRS score, and mortalities, respectively. RESULTS The high ASPECTS group included 307 patients (89.2%). The mismatch group included 189 (54.9%) patients meeting the DEFUSE3 criterion. Compared to the low ASPECTS group, the high ASPECTS group had a good outcome (odds ratio (OR), 2.285; [95% confidence interval (CI) (1.106, 4.723)], p = 0.026) and lower mortality (OR, 0.350; [95% CI (0.163, 0.752)], p = 0.007). However, there were no significant differences in good outcomes and mortality between the mismatch and no-mismatch groups. CONCLUSIONS Compared with plain CT, CTP does not provide additional benefits in the selection of patients suitable for MT within 6 h. CLINICAL RELEVANCE STATEMENT CT perfusion is not superior to plain CT for the prediction of clinical outcomes when selecting patients for mechanical thrombectomy in the first 6 h. In that clinical setting, plain CT may be safe in the absence of perfusion data. KEY POINTS • The advantage of CT perfusion (CTP) over CT in pre-mechanical thrombectomy (MT) screening has not been proven for patients with a large infarct core. • CTP is not better than plain CT in predicting good outcome following MT within 6 h. • Plain CT is sufficient for selecting patients suitable for MT within 6 h of large artery occlusion.
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Affiliation(s)
- Yingjian Pei
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, 310009, China
| | - Yuping Chen
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, 310009, China
| | - Wansi Zhong
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, 310009, China
| | - Yaode He
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, 310009, China
| | - Zhongyu Luo
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, 310009, China
| | - Min Lou
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, 310009, China.
| | - Zhicai Chen
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, 310009, China.
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Gao F, Tong X, Jia B, Wei M, Pan Y, Yang M, Sun D, Nguyen TN, Ren Z, Demiraj F, Yao X, Xu C, Yuan G, Wan Y, Tang J, Wang J, Jiang Y, Wang C, Luo X, Yang H, Shen R, Wu Z, Yuan Z, Wan D, Hu W, Liu Y, Jing P, Wei L, Zheng T, Wu Y, Yang X, Sun Y, Wen C, Chang M, Yin B, Li D, Duan J, Sun D, Guo Z, Xu G, Wang G, Wang L, Wang Y, Jia W, Ma G, Huo X, Mo D, Ma N, Liu L, Zhao X, Wang Y, Fiehler J, Wang Y, Miao Z. Bailout intracranial angioplasty or stenting following thrombectomy for acute large vessel occlusion in China (ANGEL-REBOOT): a multicentre, open-label, blinded-endpoint, randomised controlled trial. Lancet Neurol 2024; 23:797-806. [PMID: 38914085 DOI: 10.1016/s1474-4422(24)00186-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/29/2024] [Accepted: 05/02/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND Unsuccessful recanalisation or reocclusion after thrombectomy is associated with poor outcomes in patients with large vessel occlusion (LVO) acute ischaemic stroke (LVO-AIS). Bailout angioplasty or stenting (BAOS) could represent a promising treatment for these patients. We conducted a randomised controlled trial with the aim to investigate the safety and efficacy of BAOS following thrombectomy in patients with LVO. METHODS ANGEL-REBOOT was an investigator-initiated, multicentre, prospective, randomised, controlled, open-label, blinded-endpoint clinical trial conducted at 36 tertiary hospitals in 19 provinces in China. Participants with LVO-AIS 24 h after symptom onset were eligible if they had unsuccessful recanalisation (expanded Thrombolysis In Cerebral Infarction score of 0-2a) or risk of reocclusion (residual stenosis >70%) after thrombectomy. Eligible patients were randomly assigned by the minimisation method in a 1:1 ratio to undergo BAOS as the intervention treatment, or to receive standard therapy (continue or terminate the thrombectomy procedure) as a control group, both open-label. In both treatment groups, tirofiban could be recommended for use during and after the procedure. The primary outcome was the change in modified Rankin Scale score at 90 days, assessed in the intention-to-treat population. Safety outcomes were compared between groups. This trial was completed and registered at ClinicalTrials.gov (NCT05122286). FINDINGS From Dec 19, 2021, to March 17, 2023, 706 patients were screened, and 348 were enrolled, with 176 assigned to the intervention group and 172 to the control group. No patients withdrew from the trial or were lost to follow-up for the primary outcome. The median age of patients was 63 years (IQR 55-69), 258 patients (74%) were male, and 90 patients (26%) were female; all participants were Chinese. After random allocation, tirofiban was administered either intra-arterially, intravenously, or both in 334 [96%] of 348 participants. No between-group differences were observed in the primary outcome (common odds ratio 0·86 [95% CI 0·59-1·24], p=0·41). Mortality was similar between the two groups (19 [11%] of 176 vs 17 [10%] of 172), but the intervention group showed a higher risk of symptomatic intracranial haemorrhage (eight [5%] of 175 vs one [1%] of 169), parenchymal haemorrhage type 2 (six [3%] of 175 vs none in the control group), and procedure-related arterial dissection (24 [14%] of 176 vs five [3%] of 172). INTERPRETATION Among Chinese patients with unsuccessful recanalisation or who are at risk of reocclusion after thrombectomy, BAOS did not improve clinical outcome at 90 days, and incurred more complications compared with standard therapy. The off-label use of tirofiban might have affected our results and their generalisability, but our findings do not support the addition of BAOS for such patients with LVO-AIS. FUNDING Beijing Natural Science Foundation, National Natural Science Foundation of China, National Key R&D Program Beijing Municipal Administration of Hospitals Incubating Program, Shanghai HeartCare Medical Technology, HeMo (China) Bioengineering, Sino Medical Sciences Technology.
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Affiliation(s)
- Feng Gao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Baixue Jia
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ming Wei
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Yuesong Pan
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China; China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ming Yang
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Sun
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Thanh N Nguyen
- Department of Radiology, Boston Medical Center, Boston, MA, USA; Department of Neurology, Boston Medical Center, Boston, MA, USA
| | - Zeguang Ren
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Francis Demiraj
- Department of Neurology, Florida Atlantic University Schmidt College of Medicine, Boca Raton, FL, USA
| | - Xiaoxi Yao
- Department of Neurology, The First People's Hospital of Chenzhou, Chenzhou, China
| | - Chenghua Xu
- Department of Neurology, The First People's Hospital of Taizhou, Taizhou, China
| | - Guangxiong Yuan
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, China
| | - Yue Wan
- Department of Neurology, The Third People's Hospital of Hubei Province, Wuhan, China
| | - Jianjun Tang
- Department of Neurology, Shanghai Neuromedical Center, Shanghai, China
| | - Jing Wang
- Department of Neurointerventional Radiology, Beijing Fengtai You'anmen Hospital, Beijing, China
| | - Yuanfei Jiang
- Department of Neurology, Tai'an Hospital of Chinese Medicine, Tai'an, China
| | - Chaobin Wang
- Department of Neurology, Beijing Liangxiang Hospital, Beijing, China
| | - Xiang Luo
- Department of Neurology, Tongji Hospital, Tongji Medical College of HUST, Wuhan, China
| | - Haihua Yang
- Department of Neurology, Beijing Daxing People's Hospital, Beijing, China
| | - Ruile Shen
- Department of Neurology, The First Affiliated Hospital of Henan University of Science and Technology, Luoyang, China
| | - Zhilin Wu
- Department of Neurointerventional Radiology, YunFu People's Hospital, YunFu, China
| | - Zhengzhou Yuan
- Department of Neurology, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Dongjun Wan
- Department of Neurology, The 940th Hospital of Joint Logistics Support force of Chinese People's Liberation Army, Lanzhou, China
| | - Wei Hu
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Yan Liu
- Department of Neurology, JingJiang People's Hospital, The Seventh Affiliated Hospital of Yangzhou University, JingJiang, China
| | - Ping Jing
- Department of Neurology, Wuhan Central Hospital, Wuhan, China
| | - Liping Wei
- Department of Neurology, Luoyang Central Hospital, Luoyang, China
| | - Tuanyuan Zheng
- Department of Neurology, JiuJiang First People's Hospital, JiuJiang, China
| | - Yingchun Wu
- Department of Neurology, Ordos Central Hospital, Ordos, China
| | - Xinguang Yang
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-Sen University, Guangzhou, China
| | - Yaxuan Sun
- Department of Neurology, Shanxi Provincial People's Hospital, Taiyuan, China
| | - Changming Wen
- Department of Neurology, Nanyang Central Hospital, Nanyang, China
| | - Mingze Chang
- Department of Neurology, Xi'an Third Hospital, The Affiliated Hospital of Northwest University, Xi'an, China
| | - Bo Yin
- Department of Neurosurgery, The Second Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Di Li
- Department of Neurointerventional Radiology, Dalian Municipal Central Hospital, Dalian Medical University, Dalian, China
| | - Jixin Duan
- Department of Neurosurgery, Changsha Hospital of Traditional Chinese Medicine, Changsha, China
| | - Dianjing Sun
- Department of Neurointerventional Radiology, Yantai Mountain Hospital of Yantai City, Yantai, China
| | - Zaiyu Guo
- Center for Neurology, Tianjin TEDA Hospital, Tianjin, China
| | - Guodong Xu
- Department of Neurointerventional Radiology, Heibei Provincial People's Hospital, Shijiazhuang, China
| | - Guoqing Wang
- Department of Neurology, Binzhou People's Hospital, Binzhou, China
| | - Liyu Wang
- Department of Neurointerventional Radiology, Beijing Shunyi Hospital, Beijing, China
| | - Yang Wang
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Weihua Jia
- Department of Neurology, Beijing Shijingshan Hospital, Beijing, China
| | - Gaoting Ma
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xiaochuan Huo
- Neurological Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liping Liu
- Department of Neurology, JingJiang People's Hospital, The Seventh Affiliated Hospital of Yangzhou University, JingJiang, China
| | - Xingquan Zhao
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yilong Wang
- China National Clinical Research Center for Neurological Diseases, Beijing, China; Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Yongjun Wang
- China National Clinical Research Center for Neurological Diseases, Beijing, China; Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
| | - Zhongrong Miao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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20
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Shen Y, You H, Yang Y, Tang R, Ji Z, Liu H, Du M, Zhou M. Predicting brain edema and outcomes after thrombectomy in stroke: Frontal delta/alpha ratio as an optimal quantitative EEG index. Clin Neurophysiol 2024; 164:149-160. [PMID: 38896932 DOI: 10.1016/j.clinph.2024.05.009] [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: 11/09/2023] [Revised: 04/26/2024] [Accepted: 05/17/2024] [Indexed: 06/21/2024]
Abstract
OBJECTIVE We aimed to determine whether quantitative electroencephalography (QEEG) measures have predictive value for cerebral edema (CED) and clinical outcomes in acute ischemic stroke (AIS) patients with anterior circulation large vessel occlusion who underwent mechanical thrombectomy (MT). METHODS A total of 105 patients with AIS in the anterior circulation were enrolled in this prospective study. The occurrence and severity of CED were assessed through computed tomography conducted 24 h after MT. Clinical outcomes were evaluated based on early neurological deterioration (END) and 3-month functional status, as measured by the modified Rankin scale (mRS). Electroencephalography (EEG) recordings were performed 24 h after MT, and QEEG indices were calculated from the standard 16 electrodes and 2 frontal channels (F3-C3, F4-C4). The delta/alpha ratio (DAR), the (delta + theta) / (alpha + beta) ratio (DTABR), and relative delta power were averaged over all electrodes (global) and the F3-C3 and F4-C4 channels (frontal). The predictive effect and value of QEEG indices for CED and clinical outcomes were assessed using ordinal and logistic regression models, as well as receiver operating characteristic (ROC) curves. RESULTS Significantly, both global and frontal DAR were found to be associated with the severity of CED, END, and poor functional outcomes at 90 days, while global and frontal DTABR and relative delta power were not associated with outcomes. In ROC analysis, the best predictive effect was observed in frontal DAR, with an area under the curve of approximately 0.80. It exhibited approximately 75% sensitivity and 71% specificity for radiological and clinical outcomes when a threshold of 3.3 was used. CONCLUSIONS QEEG techniques may be considered an efficient bedside monitoring method for assessing treatment efficacy, identifying patients at higher risk of severe CED and END, and predicting long-term functional outcomes. SIGNIFICANCE QEEG can help identify patients at risk of severe neurological complications that can impact long-term functional recovery in AIS patients who underwent MT.
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Affiliation(s)
- Yeru Shen
- Department of Critical Care Medicine, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Heyang You
- Department of Critical Care Medicine, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Yanyan Yang
- Department of Critical Care Medicine, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Rui Tang
- Department of Critical Care Medicine, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Zongshu Ji
- Department of Critical Care Medicine, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Haiyan Liu
- Department of Critical Care Medicine, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Min Du
- Department of Critical Care Medicine, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Min Zhou
- Department of Critical Care Medicine, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China.
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Li W, Wang K, Zeng C, Huang K, Fu Y, Zhao Z. Safety and efficacy of tirofiban treatment in the endovascular treatment of patients with acute ischaemic stroke - A meta-analysis. Clin Neurol Neurosurg 2024; 243:108330. [PMID: 38936178 DOI: 10.1016/j.clineuro.2024.108330] [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: 09/25/2023] [Revised: 04/22/2024] [Accepted: 05/11/2024] [Indexed: 06/29/2024]
Abstract
OBJECT The use of endovascular therapy (EVT) has become a widespread strategy for the clinical management of acute ischemic stroke (AIS). However, the combination of arterial injection of tirofiban with EVT for AIS continues to be a subject of controversy. This meta-analysis was conducted to assess the safety and efficacy of this treatment approach. METHODS Relevant studies were identified through a systematic literature search in Pubmed, EMBASE, Web of Science, and Cochrane Library databases, covering articles published from January 2010 to January 2023. The efficacy outcomes included favorable functional outcomes, recanalization rates, and safety outcomes including mortality and symptomatic intracranial hemorrhage (sICH). RESULTS The meta-analysis consisted of data from 13 studies, which included 1 randomized controlled trial (RCT), 7 prospective cohort studies, and 5 retrospective cohort studies, encompassing a total of 3477 patients. The study results indicate that the intra-arterial (IA) tirofiban+EVT for AIS is associated with significant improvements in favorable functional outcomes (OR, 1.21; 95%CI, 1.05-1.40; P = 0.009) and recanalization rate (OR, 1.33; 95%CI, 1.06-1.65; P = 0.01), as well as significant reductions in mortality rates (OR, 0.65; 95%CI, 0.53-0.79; P = 0.0001). Subgroup analysis revealed that administering a maintenance dose of intravenous (IV) tirofiban post-EVT was significantly associated with improved functional outcomes and reduced mortality in patients. In addition, there was no increase in the incidence of sICH (OR, 0.92; 95%CI, 0.71-1.20; P = 0.54). CONCLUSION The administration of Intra-arterial tirofiban combined with EVT is an effective and safe treatment strategy for AIS, and postoperative maintenance doses of intravenous tirofiban may be more effective than IA only.
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Affiliation(s)
- Wei Li
- Department of Neurology,The First Affiliated Hospital of Hainan Medical University, Hainan province, China
| | - Kangmeng Wang
- Department of Neurology,The First Affiliated Hospital of Hainan Medical University, Hainan province, China
| | - Chaokun Zeng
- Department of Neurology,The First Affiliated Hospital of Hainan Medical University, Hainan province, China
| | - KaiLai Huang
- Department of Neurology,The First Affiliated Hospital of Hainan Medical University, Hainan province, China
| | - YuSi Fu
- Department of Neurology,The First Affiliated Hospital of Hainan Medical University, Hainan province, China
| | - Zhenqiang Zhao
- Department of Neurology,The First Affiliated Hospital of Hainan Medical University, Hainan province, China.
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22
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Alexandre AM, Monforte M, Brunetti V, Scarcia L, Cirillo L, Zini A, Scala I, Nardelli V, Arbia F, Arbia G, Frisullo G, Kalsoum E, Camilli A, De Leoni D, Colò F, Abruzzese S, Piano M, Rollo C, Macera A, Ruggiero M, Lafe E, Gabrieli JD, Cester G, Limbucci N, Arba F, Ferretti S, Da Ros V, Bellini L, Salsano G, Mavilio N, Russo R, Bergui M, Caragliano AA, Vinci SL, Romano DG, Frauenfelder G, Semeraro V, Ganimede MP, Lozupone E, Romi A, Cavallini A, Milonia L, Muto M, Candelaresi P, Calabresi P, Pedicelli A, Broccolini A. Baseline clinical and neuroradiological predictors of outcome in patients with large ischemic core undergoing mechanical thrombectomy: A retrospective multicenter study. Int J Stroke 2024; 19:779-788. [PMID: 38546177 DOI: 10.1177/17474930241245828] [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] [Indexed: 04/17/2024]
Abstract
BACKGROUND Recent randomized trials have shown the benefit of mechanical thrombectomy (MT) also in patients with an established large ischemic core. AIMS The purpose of this study was to define baseline predictors of clinical outcome in patients with large vessel occlusion (LVO) in the anterior circulation and an Alberta Stroke Program Early CT score (ASPECTS) ⩽ 5, undergoing MT. MATERIAL AND METHODS The databases of 16 comprehensive stroke centers were retrospectively screened for patients with LVO and ASPECTS ⩽5 that received MT. Baseline clinical and neuroradiological features, including the differential contribution of all ASPECTS regions to the composite score, were collected. Primary clinical outcome measure was a 90-day modified Rankin Scale (mRS) score of 0-2. Statistical analysis used a logistic regression model and random forest algorithm. RESULTS A total of 408 patients were available for analysis. In multivariate model, among baseline features, lower age (odd ratio (OR) = 0.962, 95% confidence interval (CI) = 0.943-0.982) and lower National Institute of Health Stroke Scale (NIHSS) score (OR = 0.911, 95% CI = 0.862-0.963) were associated with the mRS score 0-2. Involvement of the M2 (OR = 0.398, 95% CI = 0.206-0.770) or M4 (OR = 0.496, 95% CI = 0.260-0.945) ASPECTS regions was associated with an unfavorable outcome. Random forest analysis confirmed that age and baseline NIHSS score are the most important variables influencing clinical outcome, whereas involvement of cortical regions M5, M4, M2, and M1 can have a negative impact. CONCLUSION Our retrospective analysis shows that, along with age and baseline clinical impairment, presence of early ischemic changes involving cortical areas has a role in clinical outcome in patients with large ischemic core undergoing MT. DATA ACCESS STATEMENT The data that support the findings of this study are available upon reasonable request.
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Affiliation(s)
- Andrea M Alexandre
- Interventional Neuroradiology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Mauro Monforte
- Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Valerio Brunetti
- Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Luca Scarcia
- Neuroradiology Unit, Henri Mondor Hospital, Creteil, France
| | - Luigi Cirillo
- Department of Neurology and Stroke Center, IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital, Bologna, Italy
| | - Andrea Zini
- Department of Neurology and Stroke Center, IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital, Bologna, Italy
| | - Irene Scala
- Catholic University School of Medicine, Rome, Italy
| | - Vincenzo Nardelli
- Department of Statistical Sciences, Catholic University, Rome, Italy
| | - Francesco Arbia
- Department of Neuroradiology, S. Andrea Hospital, Rome, Italy
| | - Giuseppe Arbia
- Department of Statistical Sciences, Catholic University, Rome, Italy
| | - Giovanni Frisullo
- Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Erwah Kalsoum
- Neuroradiology Unit, Henri Mondor Hospital, Creteil, France
| | | | | | | | | | - Mariangela Piano
- Neuroradiology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Claudia Rollo
- Neuroradiology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Antonio Macera
- Neuroradiology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Maria Ruggiero
- Neuroradiology Unit, M. Bufalini Hospital, Cesena, Italy
| | - Elvis Lafe
- Neuroradiology Unit, M. Bufalini Hospital, Cesena, Italy
| | | | - Giacomo Cester
- Neuroradiology Unit, Padua University Hospital, Padua, Italy
| | - Nicola Limbucci
- Interventional Neurovascular Unit, A.O.U. Careggi, Florence, Italy
| | | | - Simone Ferretti
- NEUROFARBA Department, University of Florence, Florence, Italy
| | - Valerio Da Ros
- Department of Biomedicine and Prevention, "Tor Vergata" University Hospital, Rome, Italy
| | - Luigi Bellini
- Department of Biomedicine and Prevention, "Tor Vergata" University Hospital, Rome, Italy
| | | | - Nicola Mavilio
- Neuroradiology Unit, "San Martino" Hospital, Genoa, Italy
| | - Riccardo Russo
- Neuroradiology Unit, A.O. "Città della Salute e della Scienza," Turin, Italy
| | - Mauro Bergui
- Neuroradiology Unit, A.O. "Città della Salute e della Scienza," Turin, Italy
| | | | - Sergio L Vinci
- Neuroradiology Unit, "G. Martino" Hospital, Messina, Italy
| | - Daniele G Romano
- Neuroradiology Unit, AOU "S Giovanni di Dio e Ruggi di Aragona," Salerno, Italy
| | - Giulia Frauenfelder
- Neuroradiology Unit, AOU "S Giovanni di Dio e Ruggi di Aragona," Salerno, Italy
| | - Vittorio Semeraro
- Interventional Radiology Unit, "SS Annunziata" Hospital, Taranto, Italy
| | | | | | - Andrea Romi
- Neuroradiology Unit, IRCCS "San Matteo" Hospital, Pavia, Italy
| | - Anna Cavallini
- Cerebrovascular Diseases Unit, IRCCS Fondazione Mondino, Pavia, Italy
| | - Luca Milonia
- Interventional Neuroradiology Unit, "Umberto I" University Hospital, Rome, Italy
| | - Massimo Muto
- Neuroradiology Unit, A.O.R.N. "Antonio Cardarelli," Naples, Italy
| | | | - Paolo Calabresi
- Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Catholic University School of Medicine, Rome, Italy
| | - Alessandro Pedicelli
- Interventional Neuroradiology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Aldobrando Broccolini
- Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Catholic University School of Medicine, Rome, Italy
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23
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Brandel MG, McCann CP, Tucker B, Wali AR, Steinberg JA, Santiago-Dieppa DR, Khalessi AA, Pannell JS. Serial dilation to enable ulnar artery access for endovascular neurointervention: Technical report and systematic review of the literature. J Stroke Cerebrovasc Dis 2024:107900. [PMID: 39084337 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107900] [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: 12/05/2023] [Revised: 07/14/2024] [Accepted: 07/28/2024] [Indexed: 08/02/2024] Open
Abstract
BACKGROUND For rare neuro-endovascular cases in which transfemoral access is not feasible and the palmar circulation is insufficient for radial artery access, ulnar artery access may be considered. MATERIALS AND METHODS Mechanical thrombectomy via ulnar artery access was performed to preserve the dominant radial artery. The ulnar artery was serial dilated to 7-French with microdilator. Angiography was performed using a diagnostic catheter. The sheath was exchanged for a guide catheter, and a triaxial system was inserted. A mechanical thrombectomy was performed. The systematic literature review included all studies pertaining to techniques for ulnar artery access for neurointervention in the last 20 years (2003-2023) published in the PubMed, Web of Science, and Embase databases. RESULTS 67-year-old male developed left MCA syndrome in the setting of an infected abdominal aortic endograft. A transfemoral approach was ruled out due to concern for crossing the infected endograft. Allen test and ultrasound demonstrated that the right radial artery was of adequate size for access, but the ulnar artery was insufficient to support the palmar arch. Mechanical thrombectomy resulted in TICI 3 reperfusion. Systematic review of the literature yielded 2 case series and 1 case report of transulnar neurovascular procedures. Access site complications were rare and included 3 access site hematomas and 1 ulnar artery occlusion. CONCLUSION We report our technique of serial dilation of the ulnar artery for neuroendovascular procedures and provide a systematic review of the literature for complication avoidance in ulnar artery access.
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Affiliation(s)
- Michael G Brandel
- Department of Neurosurgery, University of California San Diego, San Diego, California, USA.
| | - Carson P McCann
- Department of Neurosurgery, University of California San Diego, San Diego, California, USA
| | - Brigham Tucker
- Department of Neurosurgery, University of California San Diego, San Diego, California, USA
| | - Arvin R Wali
- Department of Neurosurgery, University of California San Diego, San Diego, California, USA
| | - Jeffrey A Steinberg
- Department of Neurosurgery, University of California San Diego, San Diego, California, USA
| | | | - Alexander A Khalessi
- Department of Neurosurgery, University of California San Diego, San Diego, California, USA
| | - J Scott Pannell
- Department of Neurosurgery, University of California San Diego, San Diego, California, USA
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Li M, Zhou J, Sheng K, Guan B, Gu H, Jiang J. Radiomics of intrathrombus and perithrombus regions for Post-EVT intracranial hemorrhage risk Prediction: A multicenter CT study. Eur J Radiol 2024; 178:111653. [PMID: 39094465 DOI: 10.1016/j.ejrad.2024.111653] [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: 04/25/2024] [Revised: 07/14/2024] [Accepted: 07/25/2024] [Indexed: 08/04/2024]
Abstract
OBJECTIVES This study aimed to assess the predictive performance of radiomics derived from computed tomography (CT) images of thrombus regions in predicting the risk of intracranial hemorrhage (ICH) following endovascular thrombectomy (EVT). MATERIALS AND METHODS This retrospective multicenter study included 336 patients who underwent admission CT and EVT for acute anterior-circulation large vessel occlusion between December 2018 and December 2023. Follow-up imaging was performed 24 h post-procedure to evaluate the occurrence of ICH. 230 patients from centers A and B were randomly allocated into training and test groups in a 7:3 ratio, while the remaining 106 patients from center C comprised the validation cohort. Radiologists manually segmenting the thrombus on CT images, and the perithrombus region was defined by expanding the initial region of interest (ROI). A total of 428 radiomics features were extracted from both intrathrombus and perithrombus regions on CT images. The Mann-Whitney U test was used for feature selection, and least absolute shrinkage and selection operator (LASSO) regression was employed for model development, followed by validation using a 5-fold cross-validation approach. Model performance was assessed using the area under the curve (AUC) of the receiver operating characteristic (ROC). RESULTS Among the eligible patients, 128 (38.1 %) experienced ICH after EVT. The combined model exhibited superior performance in the training cohort (AUC: 0.913, 95 % CI: 0.861-0.965), test cohort (AUC: 0.868, 95 % CI: 0.775-0.962), and validation cohort (AUC: 0.850, 95 % CI: 0.768-0.912). Notably, in the validation group, both the perithrombus and combined models demonstrated higher predictive accuracy compared to the intrathrombus model (0.837 vs. 0.684, p = 0.02; AUC: 0.850 vs. 0.684, p = 0.01). CONCLUSIONS Radiomics features derived from the perithrombus region significantly enhance the prediction of ICH after EVT, providing valuable insights for optimizing post-procedural clinical decisions. CLINICAL RELEVANCE STATEMENT This study highlights the importance of radiomics extracted from intrathrombus and perithrombus region in predicting intracranial hemorrhagefollowing endovascular thrombectomy, which can aid in improving patient outcomes.
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Affiliation(s)
- Minda Li
- Department of Radiology, Affiliated Hospital of Nantong University, Nantong, China
| | - Jingyi Zhou
- Department of Radiology, Kunshan Second People's Hospital, Kunshan, China
| | - Kai Sheng
- Institute of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Baohui Guan
- Institute of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Hongmei Gu
- Department of Radiology, Affiliated Hospital of Nantong University, Nantong, China
| | - Jingxuan Jiang
- Department of Radiology, Affiliated Hospital of Nantong University, Nantong, China; Institute of Diagnostic and Interventional Radiology, Shanghai Sixth People's Hospital Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China.
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25
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Thomalla G, Fiehler J, Subtil F, Bonekamp S, Aamodt AH, Fuentes B, Gizewski ER, Hill MD, Krajina A, Pierot L, Simonsen CZ, Zeleňák K, Blauenfeldt RA, Cheng B, Denis A, Deutschmann H, Dorn F, Flottmann F, Gellißen S, Gerber JC, Goyal M, Haring J, Herweh C, Hopf-Jensen S, Hua VT, Jensen M, Kastrup A, Keil CF, Klepanec A, Kurča E, Mikkelsen R, Möhlenbruch M, Müller-Hülsbeck S, Münnich N, Pagano P, Papanagiotou P, Petzold GC, Pham M, Puetz V, Raupach J, Reimann G, Ringleb PA, Schell M, Schlemm E, Schönenberger S, Tennøe B, Ulfert C, Vališ K, Vítková E, Vollherbst DF, Wick W, Bendszus M. Endovascular thrombectomy for acute ischaemic stroke with established large infarct (TENSION): 12-month outcomes of a multicentre, open-label, randomised trial. Lancet Neurol 2024:S1474-4422(24)00278-3. [PMID: 39074480 DOI: 10.1016/s1474-4422(24)00278-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2024] [Revised: 06/25/2024] [Accepted: 06/26/2024] [Indexed: 07/31/2024]
Abstract
BACKGROUND Long-term data showing the benefits of endovascular thrombectomy for stroke with large infarct are scarce. The TENSION trial showed the safety and efficacy of endovascular thrombectomy in patients with ischaemic stroke and large infarct at 90 days. We aimed to investigate the safety and efficacy at 12 months of endovascular thrombectomy in patients who were enrolled in the TENSION trial. METHODS TENSION was an open-label, blinded endpoint, randomised trial done at 40 hospitals across Europe and one hospital in Canada. We included patients (aged ≥18 years) with acute ischaemic stroke due to large vessel occlusion in the anterior circulation and who had a large infarct, as indicated by an Alberta Stroke Program Early Computed Tomographic Score (ASPECTS) of 3-5 on standard-of-care stroke imaging. We randomly assigned patients (1:1) to receive either endovascular thrombectomy with medical treatment or medical treatment only up to 12 h from stroke onset. The primary outcome was functional outcome across the entire range of the modified Rankin Scale at 90 days. Here, we report the prespecified 12-month follow-up analyses for functional outcome (using the simplified modified Rankin Scale questionnaire), quality of life (using the Patient-Reported Outcomes Measurement Information System 10-item [PROMIS-10] and EQ-5D questionnaires), post-stroke anxiety and depression (using the Patient Health Questionnaire-4 [PHQ-4]), and overall survival. Outcomes (except survival) were assessed in the intention-to-treat population; the survival analysis was based on treatment received. This trial is registered with ClinicalTrials.gov, NCT03094715, and is completed. FINDINGS We enrolled patients between July 17, 2018, and Feb 21, 2023, when the trial was stopped early for efficacy. 253 patients were randomly assigned, 125 (49%) to endovascular thrombectomy and 128 (51%) to medical treatment only. Median follow-up was 8·36 months (IQR 0·02-12·00). Endovascular thrombectomy was associated with a shift in the distribution of scores on the modified Rankin Scale towards better functional outcome at 12 months (adjusted common odds ratio 2·39 [95% CI 1·47-3·90]). Endovascular thrombectomy was also associated with a better quality of life compared with medical treatment only, as reflected by median scores on the EQ-5D questionnaire index (0·7 [IQR 0·4-0·9] vs 0·4 [0·2-0·7]), median scores for health status on the EQ-5D questionnaire visual analogue scale (50 [IQR 35-70] vs 30 [5-60]), and median global physical health scores on the PROMIS-10 questionnaire (T-score 39·8 [IQR 37·4-50·8] vs 37·4 [32·4-44·9]); although there was not enough evidence to suggest a difference between groups in global mental health scores on PROMIS-10 (41·1 [IQR 36·3-48·3] vs 38·8 [31·3-44·7]) or the numbers of patients reporting anxiety (13 [22%] of 58 vs 15 [42%] of 36) and depression (18 [31%] vs 18 [50%]) on PHQ-4. Overall survival was slightly better in the endovascular thrombectomy group compared with medical treatment only (adjusted hazard ratio 0·70 [95% CI 0·50-0·99]). INTERPRETATION In patients with acute ischaemic stroke from large vessel occlusion with established large infarct, compared with medical treatment only, endovascular thrombectomy was associated at 12 months after stroke with better functional outcome, quality of life, and overall survival. These findings suggest that the benefits of endovascular thrombectomy in patients with an ischaemic stroke and a large infarct are sustained in the long term and support the use of endovascular thrombectomy in these patients. FUNDING European Union Horizon 2020 Research and Innovation Programme.
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Affiliation(s)
- Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf, und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.
| | - Jens Fiehler
- Universitätsklinikum Hamburg-Eppendorf, Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Hamburg, Germany; eppdata, Hamburg, Germany
| | - Fabien Subtil
- Service de Biostatistique, Hospices Civils de Lyon, Lyon, France; Laboratoire de Biométrie et Biologie Évolutive, Université de Lyon, Villeurbanne, France; Université Lyon 1, CNRS, Laboratoire de Biométrie et Biologie Évolutive UMR 5558, Villeurbanne, France
| | - Susanne Bonekamp
- Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Anne Hege Aamodt
- Department of Neurology, Oslo University Hospital, Rikshospitalet Oslo, Norway
| | - Blanca Fuentes
- Department of Neurology and Stroke Center, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital-Universidad Autonoma de Madrid), Madrid, Spain
| | - Elke R Gizewski
- Department of Neuroradiology, Medical University Innsbruck, Innsbruck, Austria
| | - Michael D Hill
- University of Calgary & Foothills Medical Centre, Department of Clinical Neurosciences, Hotchkiss Brain Institute, HBA 2939, Health Science Centre, Calgary, AB, Canada
| | - Antonin Krajina
- Department of Radiology, Charles University, Faculty of Medicine, Hradec Kralove, Czech Republic
| | - Laurent Pierot
- Department of Neuroradiology, Hôpital Maison-Blanche, Université Reims-Champagne-Ardenne, Reims, France
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Department of Neurology, Aarhus, Denmark
| | - Kamil Zeleňák
- Clinic of Radiology, Jessenius Faculty of Medicine, Comenius University of Bratislava, Martin, Slovakia
| | - Rolf A Blauenfeldt
- Department of Neurology, Aarhus University Hospital, Department of Neurology, Aarhus, Denmark
| | - Bastian Cheng
- Klinik und Poliklinik für Neurologie, Kopf, und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Angélique Denis
- Service de Biostatistique, Hospices Civils de Lyon, Lyon, France; Laboratoire de Biométrie et Biologie Évolutive, Université de Lyon, Villeurbanne, France; Université Lyon 1, CNRS, Laboratoire de Biométrie et Biologie Évolutive UMR 5558, Villeurbanne, France
| | - Hannes Deutschmann
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University Graz, Graz, Austria
| | - Franziska Dorn
- Klinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum Bonn, Bonn, Germany
| | - Fabian Flottmann
- Universitätsklinikum Hamburg-Eppendorf, Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Hamburg, Germany
| | - Susanne Gellißen
- Universitätsklinikum Hamburg-Eppendorf, Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Hamburg, Germany
| | - Johannes C Gerber
- Institute of Neuroradiology, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany; Dresden Neurovascular Center, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Mayank Goyal
- University of Calgary & Foothills Medical Centre, Department of Clinical Neurosciences, Hotchkiss Brain Institute, HBA 2939, Health Science Centre, Calgary, AB, Canada
| | - Jozef Haring
- Faculty Hospital Trnava, Department of Neurology, Trnava, Slovakia
| | - Christian Herweh
- Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Silke Hopf-Jensen
- DIAKO Krankenhaus, Institut für Diagnostische und Interventionelle Radiologie und Neuroradiologie, Flensburg, Germany
| | - Vi Tuan Hua
- Department of Neuroradiology, Hôpital Maison-Blanche, Université Reims-Champagne-Ardenne, Reims, France
| | - Märit Jensen
- Klinik und Poliklinik für Neurologie, Kopf, und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Kastrup
- Klinik für Neurologie, Klinikum Bremen Mitte, Bremen, Germany
| | - Christiane Fee Keil
- Universitätsklinikum Frankfurt, Institut für Neuroradiologie, Frankfurt am Main, Germany
| | - Andrej Klepanec
- Faculty Hospital Trnava, Department of Neurology, Trnava, Slovakia
| | - Egon Kurča
- Clinic of Neurology, Jessenius Faculty of Medicine, Comenius University of Bratislava, Martin, Slovakia
| | - Ronni Mikkelsen
- Department of Neuroradiology, Aarhus University Hospital, Department of Neurology, Aarhus, Denmark
| | | | - Stefan Müller-Hülsbeck
- DIAKO Krankenhaus, Institut für Diagnostische und Interventionelle Radiologie und Neuroradiologie, Flensburg, Germany
| | - Nico Münnich
- Klinikum Dortmund, Klinikum der Universität Witten/Herdecke, Dortmund, Germany
| | - Paolo Pagano
- Department of Neuroradiology, Hôpital Maison-Blanche, Université Reims-Champagne-Ardenne, Reims, France
| | - Panagiotis Papanagiotou
- Klinik für Diagnostische und Interventionelle Neuroradiologie, Klinikum Bremen Mitte, Bremen, Germany; Department of Radiology, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Gabor C Petzold
- Department of Vascular Neurology, Universitätsklinikum Bonn, Bonn, Germany
| | - Mirko Pham
- Universitätsklinikum Würzburg, Institut für Diagnostische und Interventionelle Neuroradiologie, Würzburg, Germany
| | - Volker Puetz
- Dresden Neurovascular Center, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany; Department of Neurology, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Jan Raupach
- Department of Radiology, Charles University, Faculty of Medicine, Hradec Kralove, Czech Republic
| | - Gernot Reimann
- Klinikum Dortmund, Klinikum der Universität Witten/Herdecke, Dortmund, Germany
| | | | - Maximilian Schell
- Klinik und Poliklinik für Neurologie, Kopf, und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Eckhard Schlemm
- Klinik und Poliklinik für Neurologie, Kopf, und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | - Bjørn Tennøe
- Department of Neuroradiology, Oslo University Hospital, Rikshospitalet Oslo, Norway
| | - Christian Ulfert
- Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Kateřina Vališ
- Department of Medical Imaging, St Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Eva Vítková
- Department of Neurology, Charles University, Faculty of Medicine, Hradec Kralove, Czech Republic
| | | | - Wolfgang Wick
- Neurologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Martin Bendszus
- Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
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Tao M, Li Y, Peng Y, Zhang X, Liu S, Tang T, Xu T, Ke K. Blood Pressure Fluctuation During 72 Hours After Endovascular Therapy and Prognosis in Acute Ischemic Stroke Patients. J Endovasc Ther 2024:15266028241266235. [PMID: 39058276 DOI: 10.1177/15266028241266235] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/28/2024]
Abstract
PURPOSE Our study aimed to investigate the relationship between fluctuations in different blood pressure (BP) components within 72 hours following endovascular therapy (EVT) and the prognosis of acute ischemic stroke (AIS) patients. METHODS This prospective multicenter study included 283 AIS patients who underwent EVT and had available BP data. The primary outcome was the ordinal modified Rankin Scale (mRS) score evaluated at 90 days. The secondary outcome was a combination of death and major disability, defined as an mRS score of 3 to 6 within 3 months. RESULTS After adjusting for imbalanced variables, the highest tertile of systolic blood pressure (SBP) fluctuation had an odds ratio (OR) of 1.747 (95% confidence interval [CI]=1.031-2.961; p for trend=0.035) for the primary outcome and 1.889 (95% CI=1.015-3.516; p for trend=0.039) for the secondary outcome, respectively. Fluctuations in diastolic blood pressure (DBP) (OR=1.914, 95% CI=1.134-3.230, p for trend=0.015) and mean arterial pressure (MAP) (OR=1.759, 95% CI=1.026-3.015, p for trend=0.039) were only associated with the primary outcome. The multivariate-adjusted restricted cubic spline analyses supported these findings. Furthermore, the fluctuations in both SBP and MAP exhibited the significant discriminatory capability in predicting the prognosis, comparable to their mean values. CONCLUSION Our study revealed that larger fluctuations in SBP, DBP, and MAP within 72 hours after EVT were associated with a higher risk of poor clinical outcomes within 3 months in AIS patients. Controlling BP fluctuations may be valuable for improving the prognosis in patients undergoing EVT. CLINICAL IMPACT How will this change clinical practice?It provides physicians a new approach to directly monitor BP fluctuations over an extended observation period in AIS patients after EVT in routine clinical practice.What does it mean for the clinicians?These results underscore the importance of giving equal attention to controlling long-term BP fluctuations, in addition to managing mean BP, as a means to improve the prognosis of AIS patients after EVT.What is the innovation behind the study?This study systematically evaluated the association between fluctuations in different blood pressure components and clinical outcomes in AIS patients over an extended period following EVT.
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Affiliation(s)
- Mingfeng Tao
- Department of Neurology, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong, China
| | - Yongxin Li
- Department of Neurology, Affiliated Hospital of Nantong University, Medical School of Nantong University, Nantong, China
| | - Ya Peng
- Department of Neurosurgery, The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Xin Zhang
- Department of Neurology, Nanjing Drum Tower Hospital, Nanjing, China
| | - Sheng Liu
- Department of Radiology, Jiangsu Provincial People's Hospital, Nanjing Medical University, Nanjing, China
| | - Tieyu Tang
- Department of Neurology, Affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Tian Xu
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong, China
| | - Kaifu Ke
- Department of Neurology, Affiliated Hospital of Nantong University, Nantong, China
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Sembill JA, Sprügel MI, Haupenthal D, Kremer S, Knott M, Mühlen I, Kallmünzer B, Kuramatsu JB. Endovascular thrombectomy in patients with anterior circulation stroke: an emulated real-world comparison. Neurol Res Pract 2024; 6:37. [PMID: 39049127 PMCID: PMC11270839 DOI: 10.1186/s42466-024-00331-6] [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: 04/09/2024] [Accepted: 06/21/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Endovascular thrombectomy (EVT) has been proven effective in anterior circulation stroke due to large vessel occlusion (LVO). However, translation from randomized clinical trials (RCTs) with highly selected patients to real-world requires confirmation, particularly to identify associations outside of strict selection criteria. AIMS This study aims to compare functional outcomes after EVT in real-world with those reported in RCTs, and to identify associations with functional outcome after EVT outside RCT-criteria. METHODS This study analyzed longitudinal German real-world data from the Stroke Research Consortium in Northern Bavaria (STAMINA) cohort from January, 2015 to June, 2019. We conducted a trial emulation, comparing patients with anterior circulation stroke and LVO meeting selection criteria for RCTs investigating EVT (1) predominantly within 6 hours with those from HERMES meta-analysis, and (2) within 6-24 hours with those from AURORA meta-analysis. We (3) analyzed treatment effects of EVT and association with functional outcome in patients treated outside RCT criteria. RESULTS Of 598 patients, 281 (47.0%) met RCT-criteria for treatment within 6 hours (hereinafter STAMINA-HERMES), 74 (12.4%) met RCT-criteria for treatment within 6-24 hours (STAMINA-AURORA), and 277 (46.3%) patients received EVT outside RCT-criteria. We observed no difference in rates of functional independence or mortality, comparing STAMINA-HERMES with HERMES meta-analysis (mRS 0-1: n=120/281 [43%] vs. 291/633 [46%], p=0.36; mortality: n=34/281 [12%] vs. 97/633 [15%], p=0.20), and STAMINA-AURORA with AURORA meta-analysis (mRS 0-1: n=26/74 [35%] vs. 122/266 [46%], p=0.10, mortality: n=10/74 [14%] vs. 45/266 [17%], p=0.48). Patients treated outside RCT-criteria had worse outcome (mRS 0-1: n=38/277 [14%], mortality: n=90/277 [32%], both p<0.001); possibly driven by pre-existing functional dependence (n=172/277 [62%]). Compared to matched controls, EVT outside of RCT-criteria was associated with lower mortality (absolute treatment effect: -14%, 95% Confidence Interval [CI] -23 to -5, p<0.01), but not with recovery to functional independence or premorbid functional status (treatment effect: 4%, CI -4 to 11, p=0.34), which was associated with lower NIHSS (Odds ratio [OR] 0.86, CI 0.80-0.92, p<0.001) and age (OR 0.95, CI 0.93-0.98, p=0.002). CONCLUSIONS Translation of EVT outcomes reported in RCTs into real-world is possible, however, almost half of patients did not meet trial criteria. Identification of patients who functionally benefit from frequently performed EVT outside RCT-criteria requires further investigation. TRIAL REGISTRATION Clinicaltrials.gov, NCT04357899.
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Affiliation(s)
- Jochen A Sembill
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany.
| | - Maximilian I Sprügel
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - David Haupenthal
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Svenja Kremer
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Michael Knott
- Department of Neuroradiology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Iris Mühlen
- Department of Neuroradiology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Bernd Kallmünzer
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Joji B Kuramatsu
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
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Roy JM, Majmundar S, Patel S, Fuleihan A, Musmar B, El Naamani K, Tjoumakaris SI, Gooch MR, Rosenwasser RH, Jabbour PM. Extended Length of Stay After Mechanical Thrombectomy for Stroke: A Single-Center Analysis of 703 Patients. Neurosurgery 2024:00006123-990000000-01295. [PMID: 39041803 DOI: 10.1227/neu.0000000000003128] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Accepted: 06/25/2024] [Indexed: 07/24/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Mechanical thrombectomy (MT) is crucial for improving functional outcomes for acute ischemic stroke. Length of stay (LOS) is a reimbursement metric implemented to incentivize value-based care. Our study aims to identify predictors of LOS in patients undergoing MT at a high-volume center in the United States. METHODS This was a retrospective study of patients who underwent MT at a single institution from 2017 to 2023. Patients who experienced mortality during their course of hospital stay were excluded from this study. Extended LOS (eLOS) was defined as the upper quartile (≥75th) of the median duration of hospital stay. Univariate and multivariate analyses were performed, with P values < .05 denoting statistical significance. RESULTS Seven hundred three patients met criteria for inclusion. The median age of the cohort was 72 years (IQR: 61-82), and 57.2% was female. The median LOS was 6, IQR: 4-10. A total of 28.9% of the cohort (n = 203) patients experienced eLOS. The multivariate regression model identified age (odds ratio [OR]: 0.98, 95% CI: 0.97-0.99), diabetes mellitus (OR: 1.68, 95% CI: 1.15-2.44), and hemorrhagic transformation of stroke (OR: 2.89, 95% CI: 0.39-0.90) as predictors of eLOS, whereas antiplatelet use before admission (OR: 0.55, 95% CI: 0.34-0.89) and higher baseline modified Rankin Scale before stroke were associated with lower odds (OR: 0.59 [0.39-0.90]; P < .05) of eLOS. CONCLUSION By identifying predictors of eLOS, we provide a foundation for targeted interventions aimed at optimizing post-thrombectomy care pathways and improving patient outcomes. The implications of our study extend beyond clinical practice, offering insights into healthcare resource utilization, reimbursement strategies, and value-based care initiatives.
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Affiliation(s)
- Joanna M Roy
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
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29
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Dippel DW, van Klaveren D. The Dilemma of Incomplete Reperfusion After Thrombectomy for Ischemic Stroke: Proceed With Caution. Neurology 2024; 103:e209646. [PMID: 38896811 DOI: 10.1212/wnl.0000000000209646] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/21/2024] Open
Affiliation(s)
- Diederik W Dippel
- From the Departments of Neuroloy and Public Health, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
| | - David van Klaveren
- From the Departments of Neuroloy and Public Health, Erasmus MC, University Medical Center, Rotterdam, the Netherlands
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Mierzwa AT, Prologo-Richardson P, Kasab SA, Nelson A, Gutierrez SO, Vivanco-Suarez J, Farooqui M, Jadhav AP, Desai S, Toth G, Alrohimi A, Nguyen TN, Klein P, Abdalkader M, Salahuddin H, Wilseck Z, Pandey A, Koduri S, Vora N, Aladamat N, Gharaibeh K, Afreen E, Zaidi S, Jumaa M. Control-matched octo/nonagenarian outcomes in acute basilar artery occlusions treated with mechanical thrombectomy-analysis of the PC-SEARCH thrombectomy registry. Interv Neuroradiol 2024:15910199241265397. [PMID: 39043366 DOI: 10.1177/15910199241265397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/25/2024] Open
Abstract
INTRODUCTION Age is often used as a predictor in determining outcomes in large vessel occlusions treated with mechanical thrombectomy. However, limited data exist for octo/nonagenarian outcomes compared to younger individuals in acute basilar artery occlusions treated with thrombectomy. METHODS Patient data were obtained from the PC-SEARCH Thrombectomy Registry which consists of 444 acute basilar artery occlusions treated with mechanical thrombectomy. Individuals were dichotomized based on age (>80 and ≤80 years old). Primary outcome was defined as modified Rankin Scale of 0-3 at 90 days. Logistic and multivariate regression, as well as control-matched analysis, were performed. RESULTS There were 373 and 71 patients in the younger and older cohorts, respectively. Gender, ethnicity, smoking status, atrial fibrillation, and coronary artery disease were noted to be significantly different between cohorts. At 90 days, 178 (47.7%) and 23 (32.4%) patients achieved primary outcome at 90 days (p = 0.02), however, after controlling for potentially confounding factors this association lost significance (OR 0.50 95% CI 0.24-1.05; p = 0.07). There were 84 patients included in the control matched analysis and demonstrated no significant differences on multivariate analysis between cohorts (OR 0.68 95% CI 0.25-1.84; p = 0.45). INTERPRETATION Octa/nonagenarians presenting with an acute basilar artery occlusion treated with mechanical thrombectomy can achieve acceptable rates of favorable functional outcomes compared to younger individuals with similar baseline demographic and stroke characteristics.
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Affiliation(s)
- Adam T Mierzwa
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
- Department of Neurology, Promedica Stroke Network, Toledo, OH, USA
| | - Paige Prologo-Richardson
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Sami Al Kasab
- Department of Neurology and Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Ashley Nelson
- Department of Neurology and Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | | | - Juan Vivanco-Suarez
- Department of Cerebrovascular and Neurointerventional Lab, University of Iowa, Iowa City, IA, USA
| | - Mudassir Farooqui
- Department of Cerebrovascular and Neurointerventional Lab, University of Iowa, Iowa City, IA, USA
| | - Ashutosh P Jadhav
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Shashvat Desai
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Gabor Toth
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Anas Alrohimi
- Department of Neurosurgery, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Thanh N Nguyen
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, MA, USA
| | - Piers Klein
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, MA, USA
| | - Mohamad Abdalkader
- Department of Neurology, Boston University Chobanian & Avedisian School of Medicine, MA, USA
| | - Hisham Salahuddin
- Department of Neurology, Antelope Valley Hospital, Los Angeles, CA, USA
| | - Zachary Wilseck
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Aditya Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Sravanthi Koduri
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Nirav Vora
- Department of Neurology, Ohio Health Riverside Methodist Hospital, Columbus, OH, USA
| | - Nameer Aladamat
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Khaled Gharaibeh
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Ehad Afreen
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
- Department of Neurology, Promedica Stroke Network, Toledo, OH, USA
| | - Syed Zaidi
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
- Department of Neurology, Promedica Stroke Network, Toledo, OH, USA
| | - Mouhammad Jumaa
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
- Department of Neurology, Promedica Stroke Network, Toledo, OH, USA
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Salim HA, Yedavalli V, Musmar B, Adeeb N, E L Naamani K, Henninger N, Sundararajan SH, Kühn AL, Khalife J, Ghozy S, Scarcia L, Tan BYQ, Heit JJ, Regenhardt RW, Cancelliere NM, Bernstock JD, Rouchaud A, Fiehler J, Essibayi MA, Sheth SA, Puri AS, Barreau X, Colasurdo M, Renieri L, Dyzmann C, Marotta T, Spears J, Mowla A, Jabbour P, Filipe JP, Biswas A, Harker P, Clarençon F, Radu RA, Siegler JE, Nguyen TN, Varela R, Ota T, Gonzalez N, Moehlenbruch MA, Altschul D, Gory B, Costalat V, Stracke CP, Aziz-Sultan MA, Hecker C, Shaikh H, Liebeskind DS, Baker A, Pedicelli A, Alexandre A, Faizy TD, Tancredi I, Kalsoum E, Lubicz B, Patel AB, Mendes Pereira V, Guenego A, Dmytriw AA. Endovascular therapy versus best medical management in distal medium middle cerebral artery acute ischaemic stroke: a multinational multicentre propensity score-matched study. J Neurol Neurosurg Psychiatry 2024:jnnp-2024-333669. [PMID: 39043567 DOI: 10.1136/jnnp-2024-333669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 06/24/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND The efficacy of endovascular treatment (EVT) in acute ischaemic stroke due to distal medium vessel occlusion (DMVO) remains uncertain. Our study aimed to evaluate the safety and efficacy of EVT compared with the best medical management (BMM) in DMVO. METHODS In this prospectively collected, retrospectively reviewed, multicentre cohort study, we analysed data from the Multicentre Analysis of primary Distal medium vessel occlusions: effect of Mechanical Thrombectomy registry. Patients with acute ischaemic stroke due to DMVO in the M2, M3 and M4 segments who underwent EVT or received BMM were included. Primary outcome measures comprised 10 co-primary endpoints, including functional independence (mRS 0-2), excellent outcome (mRS 0-1), mortality (mRS 6) and haemorrhagic complications. Propensity score matching was employed to balance the cohorts. RESULTS Among 2125 patients included in the primary analysis, 1713 received EVT and 412 received BMM. After propensity score matching, each group comprised 391 patients. At 90 days, no significant difference was observed in achieving mRS 0-2 between EVT and BMM (adjusted OR 1.00, 95% CI 0.67 to 1.50, p>0.99). However, EVT was associated with higher rates of symptomatic intracerebral haemorrhage (8.4% vs 3.0%, adjusted OR 3.56, 95% CI 1.69 to 7.48, p<0.001) and any intracranial haemorrhage (37% vs 19%, adjusted OR 2.61, 95% CI 1.81 to 3.78, p<0.001). Mortality rates were similar between groups (13% in both, adjusted OR 1.48, 95% CI 0.87 to 2.51, p=0.15). CONCLUSION Our findings suggest that while EVT does not significantly improve functional outcomes compared with BMM in DMVO, it is associated with higher risks of haemorrhagic complications. These results support a cautious approach to the use of EVT in DMVO and highlight the need for further prospective randomised trials to refine treatment strategies.
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Affiliation(s)
- Hamza Adel Salim
- Radiology, Johns Hopkins Medicine, Baltimore, Maryland, USA
- Neuroendovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
- Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
| | | | - Basel Musmar
- Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
| | - Nimer Adeeb
- Neurosurgery, BIDMC, Shreveport, Louisiana, USA
| | | | - Nils Henninger
- Neurology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Sri Hari Sundararajan
- New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | | | - Jane Khalife
- Cooper Hospital University Medical Center, Camden, New Jersey, USA
| | - Sherief Ghozy
- Radiology Neuroradiology Department, Mayo Clinic, Rochester, Minnesota, USA
| | - Luca Scarcia
- Policlinico Universitario Agostino Gemelli, Roma, Lazio, Italy
| | | | | | - Robert W Regenhardt
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston MA, Boston, Massachusetts, USA
| | | | | | - Aymeric Rouchaud
- Interventional Neuroradiology, Hopital Bicetre, Paris Kremlin Bicêtre, France
- Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jens Fiehler
- Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | - Sunil A Sheth
- Neurology, University of Texas - Houston, Houston, Texas, USA
| | - Ajit S Puri
- Radiology and Neurosurgery, Univ Massachusetts, Worcester, Massachusetts, USA
| | | | | | - Leonardo Renieri
- Interventional Neurovascular Unit, Azienda Ospedaliero Universitaria Careggi, Firenze, Italy
| | | | | | - Julian Spears
- Department of Medical Imaging, Division of Diagnostic and Therapeutic Neuroradiology, St. Michael's Hospital, University of Toronto, Department of Medical Imaging, Division of Diagnostic and Therapeutic Neuroradiology, St. Michael's Hospital, University of Toronto, Pessac, France
- Department of Surgery, Division of Neurosurgery, University of Toronto, Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Askan Mowla
- USC Keck School of Medicine, Los Angeles, California, USA
| | - Pascal Jabbour
- Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Arundhati Biswas
- Neurosurgery, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Frédéric Clarençon
- Interventional Neuroradiology, University Hospital Pitié Salpêtrière, Paris, France
| | | | - James E Siegler
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thanh N Nguyen
- Neurology, Neurosurgery, Radiology, Boston University Medical Center, Boston, Massachusetts, USA
| | - Ricardo Varela
- Neurology, University of California, Los Angeles, Los Angeles, California, USA
| | - Takahiro Ota
- Radiological Sciences, Catholic University of Sacred Heart, "A. Gemelli" Hospital, Rome, Italy
| | - Nestor Gonzalez
- Radiology and Neuroradiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Benjamin Gory
- Hôpital Civil Marie Curie à Lodelinsart, Charleroi, Belgium
| | | | | | | | - Constantin Hecker
- Institute of Neurointervention, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Hamza Shaikh
- Interventional Neuroradiology Department, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - David S Liebeskind
- Neurology, University of California, Los Angeles, Los Angeles, California, USA
| | - Amanda Baker
- Montefiore Medical Center, New York, New York, USA
| | - Alessandro Pedicelli
- Radiological Sciences, Catholic University of Sacred Heart, "A. Gemelli" Hospital, Rome, Italy
| | - Andrea Alexandre
- Radiology and Neuroradiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Erwah Kalsoum
- Neuroradiology, Henri Mondor Hospital, Créteil, France
| | - Boris Lubicz
- Centre Universitair Bruxelles Hôpital Erasme, Bruxelles, Belgium
| | - Aman B Patel
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Adrien Guenego
- Interventional Neuroradiology Department, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
- Neurovascular Centre, Divisions of Therapeutic Neuroradiology and Neurosurgery, St. Michael Hospital, University of Toronto, Toronto, ON, Canada
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Strbian D, Tsivgoulis G, Ospel J, Räty S, Cimflova P, Georgiopoulos G, Ullberg T, Arquizan C, Gralla J, Zelenak K, Hussain S, Fiehler J, Michel P, Turc G, van Zwam WH. European Stroke Organisation (ESO) and European Society for Minimally Invasive Neurological Therapy (ESMINT) guideline on acute management of basilar artery occlusion. J Neurointerv Surg 2024:jnis-2024-022053. [PMID: 39043395 DOI: 10.1136/jnis-2024-022053] [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: 05/28/2024] [Accepted: 06/11/2024] [Indexed: 07/25/2024]
Abstract
The aim of the present European Stroke Organisation (ESO) guideline is to provide evidence-based recommendations on the acute management of patients with basilar artery occlusion (BAO). These guidelines were prepared following the Standard Operational Procedure of the ESO and according to the GRADE methodology.Although BAO accounts for only 1-2% of all strokes, it has very poor natural outcome. We identified 10 relevant clinical situations and formulated the corresponding Population Intervention Comparator Outcomes (PICO) questions, based on which a systematic literature search and review was performed. The working group consisted of 10 voting members (five representing ESO and five representing the European Society of Minimally Invasive Neurological Therapy (ESMINT)) and three non-voting junior members. The certainty of evidence was generally very low. In many PICOs, available data were scarce or lacking, hence, we provided expert consensus statements.First, we compared intravenous thrombolysis (IVT) to no IVT, but specific BAO-related data do not exist. Yet, historically, IVT was standard of care for BAO patients who were also included (although in small numbers) in IVT trials. Non-randomized studies of IVT-only cohorts showed a high proportion of favorable outcomes. Expert Consensus suggests using IVT up to 24 hours unless otherwise contraindicated. We further suggest IVT plus endovascular treatment (EVT) over direct EVT. EVT on top of best medical treatment (BMT) was compared with BMT alone within 6 and 6-24 hours from last seen well. In both time windows, we observed a different effect of treatment depending on a) the region where the patients were treated (Europe vs Asia), b) on the proportion of IVT in the BMT arm, and c) on the initial stroke severity. In case of high proportion of IVT in the BMT group and in patients with a National Institutes of Health Stroke Scale (NIHSS) score below 10, EVT plus BMT was not found better than BMT alone. Based on very low certainty of evidence, we suggest EVT+BMT over BMT alone (this is based on results of patients with at least 10 NIHSS points and a low proportion of IVT in BMT). For patients with an NIHSS score below 10, we found no evidence to recommend EVT over BMT. In fact, BMT was non-significantly better and safer than EVT. Furthermore, we found a stronger treatment effect of EVT+BMT over BMT alone in proximal and middle locations of BAO compared with distal location. While recommendations for patients without extensive early ischemic changes in the posterior fossa can, in general, follow those of other PICOs, we formulated an Expert Consensus Statement suggesting against reperfusion therapy in those with extensive bilateral and/or brainstem ischemic changes. Another Expert Consensus suggests reperfusion therapy regardless of collateral scores. Based on limited evidence, we suggest direct aspiration over stent retriever as the first-line strategy of mechanical thrombectomy. As an Expert Consensus, we suggest rescue percutaneous transluminal angioplasty and/or stenting after a failed EVT procedure. Finally, based on very low certainty of evidence, we suggest add-on antithrombotic treatment during EVT or within 24 hours after EVT in patients with no concomitant IVT and in whom EVT was complicated (defined as failed or imminent re-occlusion, or need for additional stenting or angioplasty).
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Affiliation(s)
- Daniel Strbian
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Georgios Tsivgoulis
- Second Department of Neurology, 'Attikon' University Hospital of Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - Johanna Ospel
- Neuroradiology, Department of Diagnostic Imaging, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - Silja Räty
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Petra Cimflova
- Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - Georgios Georgiopoulos
- Department of Physiology, School of Medicine, University of Patras, Patras, Greece
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Teresa Ullberg
- Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund and Malmö, Sweden
| | - Caroline Arquizan
- Department of Neurology, Hôpital Gui de Chauliac, INSERM U1266, Montpellier, France
| | - Jan Gralla
- Neuroradiology, Inselspital, University of Bern, Bern, Switzerland
| | - Kamil Zelenak
- Clinic of Radiology, Jessenius Faculty of Medicine, Comenius University, Martin, Slovakia
| | | | | | - Patrik Michel
- Department of Clinical Neuroscience, Lausanne University Hospital and University of Lausanne, Bâtiment Hospitalier Principal, Lausanne, Switzerland
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, INSERM U1266, Université Paris Cité, FHU NeuroVasc, Paris, France
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, Netherlands
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33
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Strbian D, Tsivgoulis G, Ospel J, Räty S, Cimflova P, Georgiopoulos G, Ullberg T, Arquizan C, Gralla J, Zeleňák K, Hussain S, Fiehler J, Michel P, Turc G, Van Zwam W. European stroke organisation and European society for minimally invasive neurological therapy guideline on acute management of basilar artery occlusion. Eur Stroke J 2024:23969873241257223. [PMID: 38752743 DOI: 10.1177/23969873241257223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/24/2024] Open
Abstract
The aim of the present European Stroke Organisation (ESO) guideline is to provide evidence-based recommendations on the acute management of patients with basilar artery occlusion (BAO). These guidelines were prepared following the Standard Operational Procedure of the ESO and according to the GRADE methodology. Although BAO accounts for only 1%-2% of all strokes, it has very poor natural outcome. We identified 10 relevant clinical situations and formulated the corresponding Population Intervention Comparator Outcomes (PICO) questions, based on which a systematic literature search and review was performed. The working group consisted of 10 voting members (five representing ESO and five ESMINT) and three non-voting junior members. The certainty of evidence was generally very low. In many PICOs, available data were scarce or lacking, hence, we provided expert consensus statements. First, we compared intravenous thrombolysis (IVT) to no IVT, but specific BAO-related data do not exist. Yet, historically, IVT was standard of care for BAO patients who were also included (albeit in small numbers) in IVT trials. Non-randomised studies of IVT-only cohorts showed high proportion of favourable outcomes. Expert Consensus suggests using IVT up to 24 h unless otherwise contraindicated. We further suggest IVT plus endovascular treatment (EVT) over direct EVT. EVT on top of best medical treatment (BMT) was compared to BMT alone within 6 and 6-24 h from last seen well. In both time windows, we observed a different effect of treatment depending on (a) the region where the patients were treated (Europe vs. Asia), (b) on the proportion of IVT in the BMT arm, and (c) on the initial stroke severity. In case of high proportion of IVT in the BMT group and in patients with NIHSS below 10, EVT plus BMT was not found better than BMT alone. Based on very low certainty of evidence, we suggest EVT + BMT over BMT alone (i.e. based on results of patients with at least 10 NIHSS points and a low proportion of IVT in BMT). For patients with an NIHSS below 10, we found no evidence to recommend EVT over BMT. In fact, BMT was non-significantly better and safer than EVT. Furthermore, we found a stronger treatment effect of EVT + BMT over BMT alone in proximal and middle locations of BAO compared to distal location. While recommendations for patients without extensive early ischaemic changes in the posterior fossa can, in general, follow those of other PICOs, we formulated an Expert Consensus Statement suggesting against reperfusion therapy in those with extensive bilateral and/or brainstem ischaemic changes. Another Expert Consensus suggests reperfusion therapy regardless of collateral scores. Based on limited evidence, we suggest direct aspiration over stent retriever as the first-line strategy of mechanical thrombectomy. As an Expert Consensus, we suggest rescue percutaneous transluminal angioplasty and/or stenting after a failed EVT procedure. Finally, based on very low certainty of evidence, we suggest add-on antithrombotic treatment during EVT or within 24 h after EVT in patients with no concomitant IVT and in whom EVT was complicated (defined as failed or imminent re-occlusion, or need for additional stenting or angioplasty).
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Affiliation(s)
- Daniel Strbian
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Georgios Tsivgoulis
- Second Department of Neurology, 'Attikon' University Hospital of Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - Johanna Ospel
- Neuroradiology, Department of Diagnostic Imaging, Foothills Medical Center, University of Calgary, Calgary, AB, Canada
| | - Silja Räty
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Petra Cimflova
- Foothills Medical Center, University of Calgary, Calgary, AB, Canada
| | - Georgios Georgiopoulos
- Department of Physiology, School of Medicine, University of Patras, Greece
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Teresa Ullberg
- Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund and Malmö, Malmö, Sweden
| | - Caroline Arquizan
- Department of Neurology, Hôpital Gui de Chauliac, INSERM U1266, Montpellier, France
| | - Jan Gralla
- Neuroradiology, Inselspital, University of Bern, Bern, Switzerland
| | - Kamil Zeleňák
- Clinic of Radiology, Jessenius Faculty of Medicine, Comenius University, Martin, Slovakia
| | | | | | - Patrik Michel
- Department of Clinical Neuroscience, Lausanne University Hospital and University of Lausanne, Bâtiment Hospitalier Principal, Lausanne, Switzerland
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, INSERM U1266, Université Paris Cité, FHU NeuroVasc, Paris, France
| | - Wim Van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
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Ghozy S, Kobeissi H, Amoukhteh M, Kadirvel R, Brinjikji W, Rabinstein AA, Carpenter CR, Kallmes DF. The Utilization of Systematic Reviews and Meta-Analyses in Stroke Guidelines. Brain Sci 2024; 14:728. [PMID: 39061468 PMCID: PMC11274449 DOI: 10.3390/brainsci14070728] [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: 05/18/2024] [Revised: 06/13/2024] [Accepted: 07/18/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND Stroke guideline statements are important references for clinicians due to the rapidly evolving nature of treatments. Guideline statements should be informed by up-to-date systematic reviews (SRs) and meta-analyses (MAs) because they provide the highest level of evidence. To investigate the utilization of SRs/MAs in stroke management guidelines, we conducted a literature review of guidelines and extracted relevant information regarding SRs/MAs. METHODS A literature review was conducted in PubMed with supplementation using the Trip medical database with the term "stroke" as the target population, followed by using the filter "guidelines". We extracted the number of included SRs/MAs, the years of publication, the country of origin, and other characteristics of interest. Descriptive statistics were generated using the R software version 4.2.1. RESULTS We included 27 guideline statements. The median number of overall SRs or MAs within the guidelines was 4.0 (interquartile range [IQR] = 2-9). For MAs only, the median number included in the guidelines was 3.0 (IQR = 2.0-5.5). Canadian guidelines had the oldest citations, with a median gap of 12.0 (IQR = 5.2-18.0) years for the oldest citation, followed by European (median = 12; IQR = 9.5-13.5) and US (median = 10.0; IQR = 5.2-16) guidelines. CONCLUSIONS Stroke guideline writing groups and issuing bodies should devote greater effort to the inclusion of up-to-date SRs/MAs in their guideline statements so that clinicians can reference recent data with the highest level of evidence.
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Affiliation(s)
- Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA; (H.K.); (M.A.); (R.K.); (W.B.); (D.F.K.)
| | - Hassan Kobeissi
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA; (H.K.); (M.A.); (R.K.); (W.B.); (D.F.K.)
| | - Melika Amoukhteh
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA; (H.K.); (M.A.); (R.K.); (W.B.); (D.F.K.)
| | - Ramanathan Kadirvel
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA; (H.K.); (M.A.); (R.K.); (W.B.); (D.F.K.)
- Department of Neurologic Surgery, Mayo Clinic, Rochester, MN 55905, USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA; (H.K.); (M.A.); (R.K.); (W.B.); (D.F.K.)
| | | | | | - David F. Kallmes
- Department of Radiology, Mayo Clinic, Rochester, MN 55905, USA; (H.K.); (M.A.); (R.K.); (W.B.); (D.F.K.)
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Masouris I, Kellert L, Müller R, Fuhry L, Hamann GF, Rémi JM, Schöberl F. Performance and clinical outcomes in telestroke remain robust during the COVID-pandemic: insight into the NEVAS network. J Neurol 2024:10.1007/s00415-024-12578-9. [PMID: 39033262 DOI: 10.1007/s00415-024-12578-9] [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: 05/06/2024] [Revised: 07/09/2024] [Accepted: 07/12/2024] [Indexed: 07/23/2024]
Abstract
BACKGROUND The COVID-19 pandemic had significant impact on global healthcare, including stroke management. Telemedical stroke networks have emerged with positive results for patient outcome in rural areas without stroke expertise. However, telestroke faced enormous on-site challenges during the pandemic. So far, data on performance and clinical outcomes in telestroke settings during the COVID-pandemic are scarce. METHODS We retrospectively analyzed data from stroke patients treated in four spoke hospitals of the Bavarian telestroke network NEVAS in 2020-2021 and 2019 as reference year and compared the 3 years for various parameters. Primary outcome was functional outcome according to the modified Rankin scale (mRS). Secondary outcome parameters included time intervals, periprocedural intracranial hemorrhage rates, and mortality. RESULTS In 2019-2021, 2820 patients were treated for acute ischemic stroke with an admission decrease of 10% during the pandemic. Of those, 241 received only IVT and 204 were transferred to our center for MT. Door-to-imaging, door-to-needle, and symptom-onset-to-groin times remained comparable in the 3 years. Complication rates remained at a low level. Good clinical outcome rates (mRS 0-2) at discharge remained stable for all stroke patients (82-84%) and for those treated with IVT (64-77%). Good clinical outcome rates at 3 month follow-up for MT patients declined in 2020 (23% vs. 35% in 2019) but recovered again in 2021 (42%). Mortality rates did not increase for all patient groups analyzed. CONCLUSIONS Stroke care remained robust during the COVID-pandemic within our network, indicating that well-established telestroke networks can overcome unexpected critical challenges such as a pandemic, guaranteeing best practice stroke care in rural areas.
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Affiliation(s)
- Ilias Masouris
- Department of Neurology, LMU University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany.
| | - L Kellert
- Department of Neurology, LMU University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany
| | - R Müller
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Guenzburg, Guenzburg, Germany
| | - L Fuhry
- Department of Neurology, Klinikum Ingolstadt, Ingolstadt, Germany
| | - G F Hamann
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Guenzburg, Guenzburg, Germany
| | - J M Rémi
- Department of Neurology, LMU University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany
| | - F Schöberl
- Department of Neurology, LMU University Hospital, LMU, Marchioninistr. 15, 81377, Munich, Germany
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Su S, Bai X, Li Q, Yue C, Yang J, Huang J, Kong W, Guo C, Hu J, Liu S, Yang D, Song J, Peng Z, Li L, Tian Y, Li F, Zi W, Liu X. Safety and efficacy of tirofiban combined with intravenous thrombolysis and endovascular treatment in acute large vessel occlusion stroke. Clin Neurol Neurosurg 2024; 244:108463. [PMID: 39053321 DOI: 10.1016/j.clineuro.2024.108463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 07/14/2024] [Accepted: 07/20/2024] [Indexed: 07/27/2024]
Abstract
OBJECTIVE This study assesses the safety and efficacy of tirofiban for patients with large vessel occlusion stroke after intravenous thrombolysis. METHODS This study data was from SUSTAIN, DEVT, and RESCUE BT trials. According to whether the use of tirofiban who underwent endovascular treatment and preceding intravenous thrombolysis was divided into the tirofiban group and the no-tirofiban group. The safety outcomes were symptomatic intracranial hemorrhage, any intracranial hemorrhage within 48 h, and 3-month mortality. The efficacy outcome was defined as a score of 0-2 on the modified Rankin Scale scores at 3 months. RESULTS A total of 372 patients with intravenous thrombolysis were included in these SUSTAIN, DEVT, and RESCUE BT trials. Adjusted multivariate analysis showed that tirofiban with intravenous thrombolysis was not associated with symptomatic intracranial hemorrhage (aOR, 0.87; 95 % CI, 0.49-1.57; P=0.65), any intracranial hemorrhage within 48 h (aOR, 1.00; 95 % CI, 0.60-1.66; P=1.00), 3-month mortality (aOR, 1.10; 95 % CI, 0.56-2.19; P=0.78) and 3-month modified Rankin Scale scores 0-2 (aOR, 0.72; 95 % CI, 0.42-1.25; P=0.25) in patients with acute large vessel occlusion. In the subgroup analysis, we found that tirofiban was not recommended for females (aOR, 0.34; 95 % CI, 0.12-0.93), baseline Alberta Stroke Program Early CT Score≤9 (aOR, 0.37; 95 % CI, 0.18-0.76), and cardiogenic embolism (aOR, 0.36; 95 % CI, 0.14-0.97). CONCLUSION Tirofiban combined with intravenous thrombolysis in patients with acute large vessel occlusion may be safe. Further studies need to confirm the effectiveness of tirofiban after intravenous thrombolysis in different stroke etiology.
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Affiliation(s)
- Shixing Su
- Neurosurgery Center, Department of Cerebrovascular Surgery, Engineering Technology Research Center of Education Ministry of China on Diagnosis and Treatment of Cerebrovascular Disease, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong 510280, China
| | - Xiubin Bai
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Qin Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Chengsong Yue
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jie Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jiacheng Huang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Weilin Kong
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Changwei Guo
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jinrong Hu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Shuai Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Dahong Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jiaxing Song
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Zhouzhou Peng
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Linyu Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Yan Tian
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China.
| | - Xiang Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China.
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Lu ZJ, Lai JX, Huang JR, Xie SH, Lai ZH. Predictive value of intracranial high-density areas in neurological function. World J Psychiatry 2024; 14:1080-1086. [PMID: 39050205 PMCID: PMC11262925 DOI: 10.5498/wjp.v14.i7.1080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/21/2024] [Accepted: 06/05/2024] [Indexed: 07/12/2024] Open
Abstract
BACKGROUND Intracranial high-density areas (HDAs) have attracted considerable attention for predicting clinical outcomes; however, whether HDAs predict worse neurological function and mental health remains controversial and unclear, which requires further investigation. AIM To investigate the predictive value of intracranial HDAs for neurological function and mental health after endovascular treatment. METHODS In this prospective study, 96 patients with acute ischemic stroke (AIS) who accepted endovascular mechanical thrombectomy (EMT) were included. The enrolled patients underwent cranial computed tomography (CT) examination within 24 hours after EMT. Clinical data in terms of National Institutes of Health Stroke Scale (NIHSS), the 3-month modified Rankin Scale (mRS), self-rating depression scale (SDS), and self-rating anxiety scale (SAS) scores were collected and compared between patients with HDAs and non-HDAs and between patients with good and poor clinical prognosis. RESULTS Compared to patients without HDAs, patients with HDAs presented severe neurological deficits (admission NIHSS score: 18 ± 3 vs 19 ± 4), were more likely to have post-stroke disabilities (mRS < 3: 35% vs 62%), and suffered more severe depression (SDS score: 58 ± 16 vs 64 ± 13) and anxiety disorder (SAS score: 52 ± 8 vs 59 ± 10). Compared to patients with a good prognosis, patients with a poor prognosis presented severe neurological deficits (admission NIHSS score: 17 ± 4 vs 20 ± 3), were more likely to have HDAs on CT images (64% vs 33%), and suffered more severe depression (SDS score: 55 ± 19 vs 65 ± 11) and anxiety (SAS score: 50 ± 8 vs 58 ± 12). Multivariate analysis revealed that HDAs were independent negative prognostic factors. CONCLUSION In conclusion, HDAs on CT images predicted poor prognosis and severe depressive and anxiety symptoms in patients with AIS who underwent EMT.
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Affiliation(s)
- Zhi-Juan Lu
- Department of Neurology, Ganzhou People’s Hospital, Ganzhou 341000, Jiangxi Province, China
| | - Jin-Xing Lai
- Department of Neurology, Ganzhou People’s Hospital, Ganzhou 341000, Jiangxi Province, China
| | - Jing-Ru Huang
- Department of Neurology, Ganzhou People’s Hospital, Ganzhou 341000, Jiangxi Province, China
| | - Shu-Hua Xie
- Department of Neurology, Ganzhou People’s Hospital, Ganzhou 341000, Jiangxi Province, China
| | - Zhao-Hui Lai
- Department of Neurology, Ganzhou People’s Hospital, Ganzhou 341000, Jiangxi Province, China
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Sun T, Yu HY, Zhan CH, Guo HL, Luo MY. Non-contrast CT radiomics-clinical machine learning model for futile recanalization after endovascular treatment in anterior circulation acute ischemic stroke. BMC Med Imaging 2024; 24:178. [PMID: 39030494 PMCID: PMC11264869 DOI: 10.1186/s12880-024-01365-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/29/2024] [Accepted: 07/15/2024] [Indexed: 07/21/2024] Open
Abstract
OBJECTIVE To establish a machine learning model based on radiomics and clinical features derived from non-contrast CT to predict futile recanalization (FR) in patients with anterior circulation acute ischemic stroke (AIS) undergoing endovascular treatment. METHODS A retrospective analysis was conducted on 174 patients who underwent endovascular treatment for acute anterior circulation ischemic stroke between January 2020 and December 2023. FR was defined as successful recanalization but poor prognosis at 90 days (modified Rankin Scale, mRS 4-6). Radiomic features were extracted from non-contrast CT and selected using the least absolute shrinkage and selection operator (LASSO) regression method. Logistic regression (LR) model was used to build models based on radiomic and clinical features. A radiomics-clinical nomogram model was developed, and the predictive performance of the models was evaluated using area under the curve (AUC), accuracy, sensitivity, and specificity. RESULTS A total of 174 patients were included. 2016 radiomic features were extracted from non-contrast CT, and 9 features were selected to build the radiomics model. Univariate and stepwise multivariate analyses identified admission NIHSS score, hemorrhagic transformation, NLR, and admission blood glucose as independent factors for building the clinical model. The AUC of the radiomics-clinical nomogram model in the training and testing cohorts were 0.860 (95%CI 0.801-0.919) and 0.775 (95%CI 0.605-0.945), respectively. CONCLUSION The radiomics-clinical nomogram model based on non-contrast CT demonstrated satisfactory performance in predicting futile recanalization in patients with anterior circulation acute ischemic stroke.
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Affiliation(s)
- Tao Sun
- First Clinical Medical College, Gannan Medical University, Ganzhou, Jiangxi, China
| | - Hai-Yun Yu
- First Clinical Medical College, Gannan Medical University, Ganzhou, Jiangxi, China
| | - Chun-Hua Zhan
- Department of Medical Ultrasonics, The Third Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China
| | - Han-Long Guo
- First Clinical Medical College, Gannan Medical University, Ganzhou, Jiangxi, China
| | - Mu-Yun Luo
- Department of Neurosurgery, The First Affiliated Hospital of Gannan Medical University, Ganzhou, Jiangxi, China.
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Rotaru-Zăvăleanu AD, Dinescu VC, Aldea M, Gresita A. Hydrogel-Based Therapies for Ischemic and Hemorrhagic Stroke: A Comprehensive Review. Gels 2024; 10:476. [PMID: 39057499 PMCID: PMC11276304 DOI: 10.3390/gels10070476] [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: 06/07/2024] [Revised: 07/12/2024] [Accepted: 07/16/2024] [Indexed: 07/28/2024] Open
Abstract
Stroke remains the second leading cause of death and a major cause of disability worldwide, significantly impacting individuals, families, and healthcare systems. This neurological emergency can be triggered by ischemic events, including small vessel arteriolosclerosis, cardioembolism, and large artery atherothromboembolism, as well as hemorrhagic incidents resulting from macrovascular lesions, venous sinus thrombosis, or vascular malformations, leading to significant neuronal damage. The resultant motor impairment, cognitive dysfunction, and emotional disturbances underscore the urgent need for effective therapeutic interventions. Recent advancements in biomaterials, particularly hydrogels, offer promising new avenues for stroke management. Hydrogels, composed of three-dimensional networks of hydrophilic polymers, are notable for their ability to absorb and retain substantial amounts of water. Commonly used polymers in hydrogel formulations include natural polymers like alginate, chitosan, and collagen, as well as synthetic polymers such as polyethylene glycol (PEG), polyvinyl alcohol (PVA), and polyacrylamide. Their customizable characteristics-such as their porosity, swelling behavior, mechanical strength, and degradation rates-make hydrogels ideal for biomedical applications, including drug delivery, cell delivery, tissue engineering, and the controlled release of therapeutic agents. This review comprehensively explores hydrogel-based approaches to both ischemic and hemorrhagic stroke therapy, elucidating the mechanisms by which hydrogels provide neuroprotection. It covers their application in drug delivery systems, their role in reducing inflammation and secondary injury, and their potential to support neurogenesis and angiogenesis. It also discusses current advancements in hydrogel technology and the significant challenges in translating these innovations from research into clinical practice. Additionally, it emphasizes the limited number of clinical trials utilizing hydrogel therapies for stroke and addresses the associated limitations and constraints, underscoring the need for further research in this field.
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Affiliation(s)
- Alexandra-Daniela Rotaru-Zăvăleanu
- Department of Epidemiology, University of Medicine and Pharmacy of Craiova, 2-4 Petru Rares Str., 200349 Craiova, Romania;
- Experimental Research Centre for Normal and Pathological Aging, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
| | - Venera Cristina Dinescu
- Department of Health Promotion and Occupational Medicine, University of Medicine and Pharmacy of Craiova, 2–4 Petru Rares Str., 200349 Craiova, Romania
| | - Madalina Aldea
- Psychiatry Department, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Andrei Gresita
- Experimental Research Centre for Normal and Pathological Aging, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania;
- Department of Biomedical Sciences, New York Institute of Technology, College of Osteopathic Medicine, Old Westbury, NY 115680, USA
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Han M, Joo H, Lee H, Heo J, Jung JW, Kim YD, Park E, Nam HS. Arterial Stiffness Predicts the Outcome of Endovascular Treatment in Patients with Acute Ischemic Stroke. J Clin Med 2024; 13:4198. [PMID: 39064237 PMCID: PMC11278379 DOI: 10.3390/jcm13144198] [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: 06/21/2024] [Revised: 07/12/2024] [Accepted: 07/17/2024] [Indexed: 07/28/2024] Open
Abstract
Background: The association between arterial stiffness and outcome after endovascular treatment (EVT) is unknown. This study investigated whether arterial stiffness predicts post-EVT outcome in patients with acute ischemic stroke. Methods: This retrospective and observational cohort study included consecutive patients treated with EVT for acute ischemic stroke from June 2020 to November 2022. Arterial stiffness was assessed by brachial-ankle pulse wave velocity. Poor functional outcome was defined as a modified Rankin Scale score ≥3 at 3 months. Results: The mean age of patients included in this study was 71.9 ± 11.8 years, and 57.3% were men. Poor functional outcome was present in 46.8%. Multivariable logistic regression analysis showed that arterial stiffness was independently associated with poor functional outcome (odds ratio 8.640, 95% confidence interval [CI] 1.581-47.228) after adjusting for age, initial stroke severity, hypertension, atrial fibrillation, device pass number, and successful recanalization. A nomogram based on the multivariable statistic model showed a better prediction of poor functional outcome compared to classic risk factor models without arterial stiffness (net reclassification improvement 0.529, 95% CI 0.186-0.873; integrated discrimination improvement 0.046, 95% CI 0.009-0.083). Conclusions: We found that arterial stiffness was an independent predictor of poor functional outcome in patients treated with EVT following acute ischemic stroke.
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Affiliation(s)
- Minho Han
- Department of Neurology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (M.H.); (H.L.); (J.H.); (J.W.J.); (Y.D.K.); (E.P.)
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Haram Joo
- Department of Neurology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (M.H.); (H.L.); (J.H.); (J.W.J.); (Y.D.K.); (E.P.)
| | - Hyungwoo Lee
- Department of Neurology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (M.H.); (H.L.); (J.H.); (J.W.J.); (Y.D.K.); (E.P.)
| | - JoonNyung Heo
- Department of Neurology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (M.H.); (H.L.); (J.H.); (J.W.J.); (Y.D.K.); (E.P.)
| | - Jae Wook Jung
- Department of Neurology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (M.H.); (H.L.); (J.H.); (J.W.J.); (Y.D.K.); (E.P.)
| | - Young Dae Kim
- Department of Neurology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (M.H.); (H.L.); (J.H.); (J.W.J.); (Y.D.K.); (E.P.)
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Eunjeong Park
- Department of Neurology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (M.H.); (H.L.); (J.H.); (J.W.J.); (Y.D.K.); (E.P.)
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
| | - Hyo Suk Nam
- Department of Neurology, Yonsei University College of Medicine, Seoul 03722, Republic of Korea; (M.H.); (H.L.); (J.H.); (J.W.J.); (Y.D.K.); (E.P.)
- Integrative Research Center for Cerebrovascular and Cardiovascular Diseases, Yonsei University College of Medicine, Seoul 03722, Republic of Korea
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Beckonert NM, Weller JM, Alegiani AC, Boeckh-Behrens T, Deb-Chatterji M, Hamann GF, Krause LU, Lehnen NC, Nitsch L, Poli S, Riedel C, Tiedt S, Zweynert S, Petzold GC, Dorn F, Bode FJ. Endovascular treatment of primary M3 occlusion stroke in clinical practice: analysis of the German Stroke Registry. Neurol Res Pract 2024; 6:36. [PMID: 39020409 PMCID: PMC11256396 DOI: 10.1186/s42466-024-00330-7] [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: 03/28/2024] [Accepted: 06/10/2024] [Indexed: 07/19/2024] Open
Abstract
BACKGROUND Endovascular treatment (ET) options for acute stroke due to distal middle cerebral artery occlusions are rapidly evolving, but data on outcome and safety are sparse. We therefore performed an analysis of patients undergoing ET for primary M3 occlusions in routine clinical practice in a nationwide registry. METHODS Patients enrolled between 01/20 and 12/21 in the prospective, multicenter German Stroke Registry-Endovascular Treatment (GSR-ET) were screened for mechanical thrombectomy performed for primary M3 occlusion. We analyzed neurological deficit as measured by the National Institute of Health Stroke Scale (NIHSS), symptomatic intracranial hemorrhage (sICH), thrombectomy technique, successful reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] score of 2b-3) and functional outcome as measured by the modified Rankin Scale (mRS) at discharge and 90 days. RESULTS Out of 5574 patients, 11 patients (0.2%, median age 80 years, 54.5% female) underwent ET for primary M3 occlusion. All patients had pre-admission mRS ≤ 1, median NIHSS on admission was 8, and successful reperfusion was achieved in 6/11 patients (54.5%). While no vasospasm, dissection or perforation was reported, symptomatic intracranial hemorrhage occurred in 2 patients (18.2%). Favorable outcome (mRS ≤ 2) was achieved in 6/11 patients (54.5%) at 90-day follow-up. CONCLUSIONS ET for primary M3 occlusions is rarely performed. While technically feasible, the procedure's potential benefits must be carefully weighed against its associated risks, including clinically relevant complications. Caution and further research is needed to optimize patient selection for this intervention. TRIAL REGISTRATION GSR-ET; ClinicalTrials.gov Identifier: NCT03356392; Trial Registration Date: 11/29/2017.
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Affiliation(s)
- Niklas M Beckonert
- Department of Vascular Neurology, University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany.
- Vascular Neurology Research Group, German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany.
| | - Johannes M Weller
- Department of Vascular Neurology, University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Anna C Alegiani
- Department of Neurology, Asklepios Klinik Altona, Hamburg, Germany
| | - Tobias Boeckh-Behrens
- Department of Diagnostic and Interventional Neuroradiology, Klinikum Rechts Der Isar, Technical University Munich, Munich, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Hospital Schleswig Holstein Campus Kiel, Kiel, Germany
| | - Gerhard F Hamann
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Günzburg, Günzburg, Germany
| | - Lars U Krause
- Department of Neurology, Klinikum Osnabrück, Osnabrück, Germany
| | - Nils C Lehnen
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Louisa Nitsch
- Department of Vascular Neurology, University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Sven Poli
- Department of Vascular Neurology, Eberhard-Karls University, Tuebingen, Germany
| | - Christian Riedel
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research, Klinikum Der Universität München, Ludwig-Maximilians-Universität LMU, Munich, Germany
| | - Sarah Zweynert
- Department of Neurology, University Hospital Berlin Charité, Berlin, Germany
| | - Gabor C Petzold
- Department of Vascular Neurology, University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
- Vascular Neurology Research Group, German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - Franziska Dorn
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Felix J Bode
- Department of Vascular Neurology, University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
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Petrović I, Broggi S, Killer-Oberpfalzer M, Pfaff JAR, Griessenauer CJ, Milosavljević I, Balenović A, Mutzenbach JS, Pikija S. Predictors of In-Hospital Mortality after Thrombectomy in Anterior Circulation Large Vessel Occlusion: A Retrospective, Machine Learning Study. Diagnostics (Basel) 2024; 14:1531. [PMID: 39061668 PMCID: PMC11275350 DOI: 10.3390/diagnostics14141531] [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: 06/18/2024] [Revised: 07/08/2024] [Accepted: 07/14/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND Despite the increased use of mechanical thrombectomy (MT) in recent years, there remains a lack of research on in-hospital mortality rates following the procedure, the primary factors influencing these rates, and the potential for predicting them. This study aimed to utilize interpretable machine learning (ML) to help clarify these uncertainties. METHODS This retrospective study involved patients with anterior circulation large vessel occlusion (LVO)-related ischemic stroke who underwent MT. The patient division was made into two groups: (I) the in-hospital death group, referred to as miserable outcome, and (II) the in-hospital survival group, or favorable outcome. Python 3.10.9 was utilized to develop the machine learning models, which consisted of two types based on input features: (I) the Pre-MT model, incorporating baseline features, and (II) the Post-MT model, which included both baseline and MT-related features. After a feature selection process, the models were trained, internally evaluated, and tested, after which interpretation frameworks were employed to clarify the decision-making processes. RESULTS This study included 602 patients with a median age of 76 years (interquartile range (IQR) 65-83), out of which 54% (n = 328) were female, and 22% (n = 133) had miserable outcomes. Selected baseline features were age, baseline National Institutes of Health Stroke Scale (NIHSS) value, neutrophil-to-lymphocyte ratio (NLR), international normalized ratio (INR), the type of the affected vessel ('Vessel type'), peripheral arterial disease (PAD), baseline glycemia, and premorbid modified Rankin scale (pre-mRS). The highest odds ratio of 4.504 was observed with the presence of peripheral arterial disease (95% confidence interval (CI), 2.120-9.569). The Pre-MT model achieved an area under the curve (AUC) value of around 79% utilizing these features, and the interpretable framework discovered the baseline NIHSS value as the most influential factor. In the second data set, selected features were the same, excluding pre-mRS and including puncture-to-procedure-end time (PET) and onset-to-puncture time (OPT). The AUC value of the Post-MT model was around 84% with age being the highest-ranked feature. CONCLUSIONS This study demonstrates the moderate to strong effectiveness of interpretable machine learning models in predicting in-hospital mortality following mechanical thrombectomy for ischemic stroke, with AUCs of 0.792 for the Pre-MT model and 0.837 for the Post-MT model. Key predictors included patient age, baseline NIHSS, NLR, INR, occluded vessel type, PAD, baseline glycemia, pre-mRS, PET, and OPT. These findings provide valuable insights into risk factors and could improve post-procedural patient management.
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Affiliation(s)
- Ivan Petrović
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia; (I.M.); (A.B.)
| | - Serena Broggi
- Neurology and Stroke Unit, ASST dei Sette Laghi, 21100 Varese, Italy;
| | - Monika Killer-Oberpfalzer
- Department of Neurology, University Hospital Salzburg, Christian Doppler Klinik, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; (M.K.-O.); (J.S.M.)
- Institute of Neurointervention, Christian Doppler Klinik, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria
| | - Johannes A. R. Pfaff
- Department of Neuroradiology, University Hospital Salzburg, Christian Doppler Klinik, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria;
| | - Christoph J. Griessenauer
- Department of Neurosurgery, University Hospital Salzburg, Christian Doppler Klinik, Paracelsus Medical University, 5020 Salzburg, Austria;
| | | | - Ana Balenović
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia; (I.M.); (A.B.)
| | - Johannes S. Mutzenbach
- Department of Neurology, University Hospital Salzburg, Christian Doppler Klinik, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; (M.K.-O.); (J.S.M.)
| | - Slaven Pikija
- Department of Neurology, University Hospital Salzburg, Christian Doppler Klinik, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; (M.K.-O.); (J.S.M.)
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Karimian-Jazi K, Vollherbst DF, Schwarz D, Fischer M, Schregel K, Bauer G, Kocharyan A, Sturm V, Neuberger U, Jesser J, Herweh C, Ulfert C, Hilgenfeld T, Seker F, Preisner F, Schmitt N, Charlet T, Hamelmann S, Sahm F, Heiland S, Wick W, Ringleb PA, Schirmer L, Bendszus M, Möhlenbruch MA, Breckwoldt MO. MR microscopy to assess clot composition following mechanical thrombectomy predicts recanalization and clinical outcome. J Neurointerv Surg 2024; 16:830-837. [PMID: 37527928 DOI: 10.1136/jnis-2023-020594] [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: 05/17/2023] [Accepted: 07/16/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND Mechanical thrombectomy (MT) is the standard of care for patients with a stroke and large vessel occlusion. Clot composition is not routinely assessed in clinical practice as no specific diagnostic value is attributed to it, and MT is performed in a standardized 'non-personalized' approach. Whether different clot compositions are associated with intrinsic likelihoods of recanalization success or treatment outcome is unknown. METHODS We performed a prospective, non-randomized, single-center study and analyzed the clot composition in 60 consecutive patients with ischemic stroke undergoing MT. Clots were assessed by ex vivo multiparametric MRI at 9.4 T (MR microscopy), cone beam CT, and histopathology. Clot imaging was correlated with preinterventional CT and clinical data. RESULTS MR microscopy showed red blood cell (RBC)-rich (21.7%), platelet-rich (white,38.3%) or mixed clots (40.0%) as distinct morphological entities, and MR microscopy had high accuracy of 95.4% to differentiate clots. Clot composition could be further stratified on preinterventional non-contrast head CT by quantification of the hyperdense artery sign. During MT, white clots required more passes to achieve final recanalization and were not amenable to contact aspiration compared with mixed and RBC-rich clots (maneuvers: 4.7 vs 3.1 and 1.2 passes, P<0.05 and P<0.001, respectively), whereas RBC-rich clots showed higher probability of first pass recanalization (76.9%) compared with white clots (17.4%). White clots were associated with poorer clinical outcome at discharge and 90 days after MT. CONCLUSION Our study introduces MR microscopy to show that the hyperdense artery sign or MR relaxometry could guide interventional strategy. This could enable a personalized treatment approach to improve outcome of patients undergoing MT.
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Affiliation(s)
| | - Dominik F Vollherbst
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Daniel Schwarz
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Manuel Fischer
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Katharina Schregel
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Gregor Bauer
- Neurology Clinic, University Hospital Heidelberg, Heidelberg, Germany
| | - Anna Kocharyan
- Department of Neurology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Volker Sturm
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Ulf Neuberger
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Jessica Jesser
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christian Herweh
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Christian Ulfert
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Tim Hilgenfeld
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Fatih Seker
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Fabian Preisner
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Niclas Schmitt
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Tobias Charlet
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Stefan Hamelmann
- Department of Neuropathology, University of Heidelberg, Heidelberg, Germany
- Clinical Cooperation Unit Neuropathology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Felix Sahm
- Department of Neuropathology, University of Heidelberg, Heidelberg, Germany
- Clinical Cooperation Unit Neuropathology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Sabine Heiland
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Wolfgang Wick
- Neurology Clinic and National Center for Tumor Diseases, University Hospital Heidelberg, Heidelberg, Germany
- Clinical Cooperation Unit Neurooncology, German Cancer Consortium (DKTK), German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Peter A Ringleb
- Neurology Clinic, University Hospital Heidelberg, Heidelberg, Germany
| | - Lucas Schirmer
- Department of Neurology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Martin Bendszus
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
| | - Michael O Breckwoldt
- Department of Neuroradiology, University Hospital Heidelberg, Heidelberg, Germany
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Schulze-Zachau V, Brehm A, Ntoulias N, Krug N, Tsogkas I, Blackham KA, Möhlenbruch MA, Jesser J, Cervo A, Kreiser K, Althaus K, Maslias E, Michel P, Saliou G, Riegler C, Nolte CH, Maier I, Jamous A, Rautio R, Ylikotila P, Fargen KM, Wolfe SQ, Castellano D, Boghi A, Kaiser DPO, Cuberi A, Kirschke JS, Schwarting J, Limbucci N, Renieri L, Al Kasab S, Spiotta AM, Fragata I, Rodriquez-Ares T, Maurer CJ, Berlis A, Moreu M, López-Frías A, Pérez-García C, Commodaro C, Pileggi M, Mascitelli J, Giordano F, Casagrande W, Purves CP, Bester M, Flottmann F, Kan PT, Edhayan G, Hofmeister J, Machi P, Kaschner M, Weiss D, Katan M, Fischer U, Psychogios MN. Incidence and outcome of perforations during medium vessel occlusion compared with large vessel occlusion thrombectomy. J Neurointerv Surg 2024; 16:775-780. [PMID: 37524518 DOI: 10.1136/jnis-2023-020531] [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: 05/04/2023] [Accepted: 07/19/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Vessel perforation during thrombectomy is a severe complication and is hypothesized to be more frequent during medium vessel occlusion (MeVO) thrombectomy. The aim of this study was to compare the incidence and outcome of patients with perforation during MeVO and large vessel occlusion (LVO) thrombectomy and to report on the procedural steps that led to perforation. METHODS In this multicenter retrospective cohort study, data of consecutive patients with vessel perforation during thrombectomy between January 1, 2015 and September 30, 2022 were collected. The primary outcomes were independent functional outcome (ie, modified Rankin Scale 0-2) and all-cause mortality at 90 days. Binomial test, chi-squared test and t-test for unpaired samples were used for statistical analysis. RESULTS During 25 769 thrombectomies (5124 MeVO, 20 645 LVO) in 25 stroke centers, perforation occurred in 335 patients (1.3%; mean age 72 years, 62% female). Perforation occurred more often in MeVO thrombectomy (2.4%) than in LVO thrombectomy (1.0%, p<0.001). More MeVO than LVO patients with perforation achieved functional independence at 3 months (25.7% vs 10.9%, p=0.001). All-cause mortality did not differ between groups (overall 51.6%). Navigation beyond the occlusion and retraction of stent retriever/aspiration catheter were the two most common procedural steps that led to perforation. CONCLUSIONS In our cohort, perforation was approximately twice as frequent in MeVO than in LVO thrombectomy. Efforts to optimize the procedure may focus on navigation beyond the occlusion site and retraction of stent retriever/aspiration catheter. Further research is necessary in order to identify thrombectomy candidates at high risk of intraprocedural perforation and to provide data on the effectiveness of endovascular countermeasures.
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Affiliation(s)
- Victor Schulze-Zachau
- Diagnostic and Interventional Neuroradiology Department, Radiology and Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
| | - Alex Brehm
- Diagnostic and Interventional Neuroradiology Department, Radiology and Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
| | - Nikolaos Ntoulias
- Diagnostic and Interventional Neuroradiology Department, Radiology and Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
| | - Nadja Krug
- Diagnostic and Interventional Neuroradiology Department, Radiology and Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
| | - Ioannis Tsogkas
- Diagnostic and Interventional Neuroradiology Department, Radiology and Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
| | - Kristine Ann Blackham
- Diagnostic and Interventional Neuroradiology Department, Radiology and Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
| | - Markus A Möhlenbruch
- Vascular & Interventional Neuroradiology Section, Minimal Invasive NeuroTherapy Center, University Hospital Heidelberg, Heidelberg, Germany
| | - Jessica Jesser
- Vascular & Interventional Neuroradiology Section, Minimal Invasive NeuroTherapy Center, University Hospital Heidelberg, Heidelberg, Germany
| | - Amedeo Cervo
- Neuroradiology Department, Niguarda Hospital, Milan, Italy
| | - Kornelia Kreiser
- Radiology and Neuroradiology Clinic, RKU - Universitäts- und Rehabilitationskliniken Ulm gGmbH, Ulm, Germany
| | | | - Errikos Maslias
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
- UNIL - Université de Lausanne, Lausanne, Switzerland
| | - Patrik Michel
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
- UNIL - Université de Lausanne, Lausanne, Switzerland
| | - Guillaume Saliou
- UNIL - Université de Lausanne, Lausanne, Switzerland
- Diagnostic and Interventional Radiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Christoph Riegler
- Department of Neurology with Experimental Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology with Experimental Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ilko Maier
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Ala Jamous
- Department of Diagnostic & Interventional Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - Riitta Rautio
- Department of Radiology, Turku University Hospital, Turku, Finland
| | | | - Kyle M Fargen
- Neurological Surgery and Radiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Stacey Q Wolfe
- Neurological Surgery and Radiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Davide Castellano
- Department of Interventional Radiology and Neuroradiology, Ospedale San Giovanni Bosco, Turin, Italy
| | - Andrea Boghi
- Department of Interventional Radiology and Neuroradiology, Ospedale San Giovanni Bosco, Turin, Italy
| | - Daniel P O Kaiser
- Department of Neuroradiology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Ani Cuberi
- Department of Radiology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Jan S Kirschke
- Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Julian Schwarting
- Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Nicola Limbucci
- Department of Neurovascular Intervention, Azienda Ospedaliero Universitaria Careggio, Florence, Italy
| | - Leonardo Renieri
- Department of Neurovascular Intervention, Azienda Ospedaliero Universitaria Careggio, Florence, Italy
| | - Sami Al Kasab
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Isabel Fragata
- Department of Neuroradiology, Centro Hospitalar Universitario de Lisboa Central EPE, Lisbon, Portugal
- NOVA Medical School, Lisbon, Portugal
| | - Tania Rodriquez-Ares
- Department of Neuroradiology, Centro Hospitalar Universitario de Lisboa Central EPE, Lisbon, Portugal
| | - Christoph Johannes Maurer
- Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Germany
| | - Ansgar Berlis
- Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Germany
| | - Manuel Moreu
- Neurointerventional Unit, Radiology Department, Hospital Clinico Universitario San Carlos, Madrid, Spain
| | - Alfonso López-Frías
- Neurointerventional Unit, Radiology Department, Hospital Clinico Universitario San Carlos, Madrid, Spain
| | - Carlos Pérez-García
- Neurointerventional Unit, Radiology Department, Hospital Clinico Universitario San Carlos, Madrid, Spain
| | - Christian Commodaro
- Diagnostic and Interventional Neuroradiology Department, Neurocenter of Southern Switzerland EOC, Lugano, Switzerland
| | - Marco Pileggi
- Diagnostic and Interventional Neuroradiology Department, Neurocenter of Southern Switzerland EOC, Lugano, Switzerland
| | - Justin Mascitelli
- Department of Neurosurgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Flavio Giordano
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, Azienda Ospedaliera di Rilievo Nazionale Antonio Cardarelli, Naples, Italy
| | - Walter Casagrande
- Neurosurgery Department, Hospital General de Agudos Juan A Fernandez, Buenos Aires, Argentina
| | - Cynthia P Purves
- Neurosurgery Department, Hospital General de Agudos Juan A Fernandez, Buenos Aires, Argentina
| | - Maxim Bester
- Diagnostic and Interventional Neuroradiology Department, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Diagnostic and Interventional Neuroradiology Department, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter T Kan
- Department of Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Gautam Edhayan
- Department of Radiology, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Jeremy Hofmeister
- Department of Radiology and Medical Informatics, Geneva University Hospitals, Geneva, Switzerland
| | - Paolo Machi
- Department of Radiology and Medical Informatics, Geneva University Hospitals, Geneva, Switzerland
| | - Marius Kaschner
- Department of Diagnostic and Interventional Radiology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Daniel Weiss
- Department of Diagnostic and Interventional Radiology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Mira Katan
- Neurology Clinic, University Hospital Basel, Basel, Switzerland
| | - Urs Fischer
- Neurology Clinic, University Hospital Basel, Basel, Switzerland
| | - Marios-Nikos Psychogios
- Diagnostic and Interventional Neuroradiology Department, Radiology and Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
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Dabhi N, Kumar J, Kellogg RT, Park MS. Mechanical thrombectomy for treatment of acute ischemic stroke in frail patients: a systematic review of the literature. J Neurointerv Surg 2024; 16:788-793. [PMID: 37487691 DOI: 10.1136/jnis-2023-020476] [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: 04/21/2023] [Accepted: 07/07/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND The overall safety and efficacy of mechanical thrombectomy (MT) for acute ischemic stroke (AIS) in frail patients is not well delineated. This systematic review aims to summarize and compare outcomes in frail and non-frail patients who underwent MT for AIS. METHODS A systematic review of the literature was performed using PubMed, Ovid Medline, and Web of Science to identify studies with outcomes-related data for frail patients with MT-treated AIS. The recanalization rate, procedural complications, and clinical outcome at 90-day follow-up were collected. RESULTS In the four included studies there were 642 frail patients and 499 non-frail patients. Frail patients had reduced rates of good functional outcomes (29% vs 42%; χ2=22, p<0.01) and increased 90-day mortality (51% vs 25%; χ2=38, p<0.01) compared with non-frail patients. CONCLUSION MT for treatment of AIS in frail patients may be associated with worse rates of morbidity and mortality along with reduced efficacy. Given that no studies to date directly compare conservative measures with endovascular management for AIS in frail patients, more studies are required to further evaluate and identify characteristics that may improve outcomes in these patients.
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Affiliation(s)
- Nisha Dabhi
- Department of Neurosurgery, Univerisity of Virginia, Charlottesville, Virginia, USA
| | - Jeyan Kumar
- Department of Neurosurgery, Univerisity of Virginia, Charlottesville, Virginia, USA
| | - Ryan T Kellogg
- Department of Neurosurgery, Univerisity of Virginia, Charlottesville, Virginia, USA
| | - Min S Park
- Department of Neurosurgery, Univerisity of Virginia, Charlottesville, Virginia, USA
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Duan H, Cheng Z, Geng X, Rajah GB, Gao J, Guo Y, Cai L, Tong Y, Li F, Jiang Q, Han Z, Ding Y. Prospective randomized controlled trial on the safety and neuroprotective efficacy of remote administration of hypothermia over spleen during acute ischemic stroke with mechanical thrombectomy: rationale, design, and protocol. Front Neurol 2024; 15:1382365. [PMID: 39081338 PMCID: PMC11286455 DOI: 10.3389/fneur.2024.1382365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2024] [Accepted: 07/01/2024] [Indexed: 08/02/2024] Open
Abstract
Background Brain inflammation plays a key role in ischemia/reperfusion (I/R) injury and is the main cause of "ineffective or futile recanalization" after successful mechanical thrombectomy (MT) in acute ischemic stroke (AIS). One of the primary sources of inflammatory cells after AIS are derived from the spleen. As an innovative and potential neuroprotective strategy after stroke, Remote Administration of Hypothermia (RAH) temporarily suppresses immune activities in the spleen, reduces the release of inflammatory cells and cytokines into blood, and thus reversibly diminishes inflammatory injury in the brain. Methods This single-center, prospective, randomized controlled study (RCT) is proposed for AIS patients with anterior circulation large vessel occlusion (LVO). Subjects will be randomly assigned to either the control or intervention groups in a 1:1 ratio (n = 40). Participants allocated to the intervention group will receive RAH on the abdomen above the spleen prior to recanalization until 6 h after thrombectomy. All enrolled patients will receive standard stroke Guideline care. The main adverse events associated with RAH are focal cold intolerance and abdominal pain. The primary outcome will assess safety as it pertains to RAH application. The secondary outcomes include the efficacy of RAH on spleen, determined by spleen volumes, blood inflammatory factor (cells and cytokines), and on brain injury, determined by infarction volumes and poststroke functional outcomes. Discussion This study aims to examine the safety and preliminary effectiveness of RAH over the spleen during endovascular therapy in AIS patients. The results of this study are expected to facilitate larger randomized clinical trials and hopefully prove RAH administration confers adjuvant neuroprotective properties in AIS treated with MT. Clinical trial registration https://www.chictr.org.cn/. Identifier ChiCTR 2300077052.
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Affiliation(s)
- Honglian Duan
- Department of Neurology and Stroke Center, Beijing Luhe Hospital, Capital Medical University, Beijing, China
- Luhe Institute of Neuroscience, Capital Medical University, Beijing, China
| | - Zhe Cheng
- Department of Neurology and Stroke Center, Beijing Luhe Hospital, Capital Medical University, Beijing, China
- Luhe Institute of Neuroscience, Capital Medical University, Beijing, China
| | - Xiaokun Geng
- Department of Neurology and Stroke Center, Beijing Luhe Hospital, Capital Medical University, Beijing, China
- Luhe Institute of Neuroscience, Capital Medical University, Beijing, China
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, United States
| | - Gary B. Rajah
- Department of Neurosurgery, Munson Medical Center, Traverse City, MI, United States
| | - Jie Gao
- Department of Neurology and Stroke Center, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Yang Guo
- Department of Neurology and Stroke Center, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Lipeng Cai
- Department of Neurology and Stroke Center, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Yanna Tong
- Department of Neurology and Stroke Center, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Fengwu Li
- Luhe Institute of Neuroscience, Capital Medical University, Beijing, China
| | - Qian Jiang
- Luhe Institute of Neuroscience, Capital Medical University, Beijing, China
| | - Zhenzhen Han
- Department of Neurology and Stroke Center, Beijing Luhe Hospital, Capital Medical University, Beijing, China
| | - Yuchuan Ding
- Department of Neurosurgery, Wayne State University School of Medicine, Detroit, MI, United States
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47
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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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48
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van der Sluijs PM, Su R, Cornelissen S, van Es ACGM, Lycklama A Nijeholt GJ, van Doormaal PJ, van Zwam WH, Dippel DWJ, van Walsum T, van der Lugt A. Assessment of automated TICI scoring during endovascular treatment in patients with an ischemic stroke. J Neurointerv Surg 2024:jnis-2024-021892. [PMID: 39019506 DOI: 10.1136/jnis-2024-021892] [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: 04/24/2024] [Accepted: 06/18/2024] [Indexed: 07/19/2024]
Abstract
BACKGROUND The extended Thrombolysis in Cerebral Infarction (eTICI) score is used in digital subtraction angiography (DSA) to quantify reperfusion grade in patients with an ischemic stroke who undergo endovascular thrombectomy (EVT). A previously developed automatic TICI score (autoTICI), which quantifies the ratio of reperfused pixels after EVT, demonstrates good correlation with eTICI. OBJECTIVE To evaluate the autoTICI model in a large multicenter registry of patients with an ischemic stroke, investigate the association with visual eTICI, and compare prediction of functional outcome between autoTICI and eTICI. METHODS Patients in the MR CLEAN Registry with an internal carotid artery, M1, and M2 occlusion were selected if both anteroposterior and lateral views were present in pre- and post-EVT DSA scans. The autoTICI score was compared with eTICI in predicting favorable functional outcome (modified Rankin Scale score 0-2), using area under the receiver operating characteristics curve (AUC) with a multivariable logistic regression model including known prognostic characteristics. RESULTS In total 421 of 3637 patients were included. AutoTICI was significantly associated with eTICI non-linearly (below 70% cOR=2.3 (95% CI 2.1 to 2.5), above 70% cOR=1.6 (95% CI 1.6 to 1.7) per 10% increment). The AUC of the model predicting favorable functional outcome was similar for autoTICI and eTICI (0.86, 95% CI 0.82 to 0.92 vs 0.86, 95% CI 0.83 to 0.90, P=0.73) and was higher than for a model with prognostic patient characteristics alone (0.86 vs 0.84, P=0.01). CONCLUSION Automatic quantitative assessment of reperfusion after EVT is associated with eTICI, and prediction of functional outcome is similar to that with visual eTICI. Therefore, autoTICI could be used as an alternative or additional review for visual reperfusion assessment to facilitate reproducible and uniform reporting.
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Affiliation(s)
| | - Ruisheng Su
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - Sandra Cornelissen
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - Adriaan C G M van Es
- Department of Radiology, Leiden Universitair Medisch Centrum, Leiden, Zuid-Holland, The Netherlands
| | | | - Pieter Jan van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - Wim H van Zwam
- Department of Radiology, Maastricht UMC+, Maastricht, Limburg, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - T van Walsum
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC, Rotterdam, Zuid-Holland, The Netherlands
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49
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Fruhwirth V, Berger L, Gattringer T, Fandler-Höfler S, Kneihsl M, Eppinger S, Ropele S, Fink A, Deutschmann H, Reishofer G, Enzinger C, Pinter D. White matter integrity and functional connectivity of the default mode network in acute stroke are associated with cognitive outcome three months post-stroke. J Neurol Sci 2024; 462:123071. [PMID: 38850772 DOI: 10.1016/j.jns.2024.123071] [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: 03/21/2024] [Revised: 05/27/2024] [Accepted: 05/29/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND Knowledge about factors that are associated with post-stroke cognitive outcome is important to identify patients with high risk for impairment. We therefore investigated the associations of white matter integrity and functional connectivity (FC) within the brain's default-mode network (DMN) in acute stroke patients with cognitive outcome three months post-stroke. METHODS Patients aged between 18 and 85 years with an acute symptomatic MRI-proven unilateral ischemic middle cerebral artery infarction, who had received reperfusion therapy, were invited to participate in this longitudinal study. All patients underwent brain MRI within 24-72 h after symptom onset, and participated in a neuropsychological assessment three months post-stroke. We performed hierarchical regression analyses to explore the incremental value of baseline white matter integrity and FC beyond demographic, clinical, and macrostructural information for cognitive outcome. RESULTS The study cohort comprised 34 patients (mean age: 64 ± 12 years, 35% female). The initial median National Institutes of Health Stroke Scale (NIHSS) score was 10, and significantly improved three months post-stroke to a median NIHSS = 1 (p < .001). Nonetheless, 50% of patients showed cognitive impairment three months post-stroke. FC of the non-lesioned anterior cingulate cortex of the affected hemisphere explained 15% of incremental variance for processing speed (p = .007), and fractional anisotropy of the non-lesioned cingulum of the affected hemisphere explained 13% of incremental variance for cognitive flexibility (p = .033). CONCLUSIONS White matter integrity and functional MRI markers of the DMN in acute stroke explain incremental variance for post-stroke cognitive outcome beyond demographic, clinical, and macrostructural information.
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Affiliation(s)
- Viktoria Fruhwirth
- Department of Neurology, Medical University of Graz, Graz, Austria; Department of Neurology, Research Unit for Neuronal Plasticity and Repair, Medical University of Graz, Graz, Austria; Institute of Psychology, Department of Biological Psychology, University of Graz, Graz, Austria
| | - Lisa Berger
- Institute of Psychology, Department of Neuropsychology - Neuroimaging, University of Graz, Graz, Austria
| | - Thomas Gattringer
- Department of Neurology, Medical University of Graz, Graz, Austria; Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | | | - Markus Kneihsl
- Department of Neurology, Medical University of Graz, Graz, Austria
| | | | - Stefan Ropele
- Department of Neurology, Medical University of Graz, Graz, Austria
| | - Andreas Fink
- Institute of Psychology, Department of Biological Psychology, University of Graz, Graz, Austria
| | - Hannes Deutschmann
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Gernot Reishofer
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Christian Enzinger
- Department of Neurology, Medical University of Graz, Graz, Austria; Department of Neurology, Research Unit for Neuronal Plasticity and Repair, Medical University of Graz, Graz, Austria; Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University of Graz, Graz, Austria
| | - Daniela Pinter
- Department of Neurology, Medical University of Graz, Graz, Austria; Department of Neurology, Research Unit for Neuronal Plasticity and Repair, Medical University of Graz, Graz, Austria.
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50
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Mannismäki L, Martinez-Majander N, Suomalainen O, Sibolt G, Girfanova M, Nybondas M, Nissinen H, Curtze S. Comparison of functional and safety outcomes between the extended versus early time window after intravenous thrombolysis and endovascular thrombectomy. J Neurol Sci 2024; 462:123107. [PMID: 38925068 DOI: 10.1016/j.jns.2024.123107] [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: 03/09/2024] [Revised: 06/02/2024] [Accepted: 06/20/2024] [Indexed: 06/28/2024]
Abstract
INTRODUCTION Based on recent trials regarding the early time window, omitting intravenous thrombolysis (IVT) before endovascular thrombectomy (EVT) in eligible patients seems unjustified. Whether this also concerns the extended time window, 4.5 to 9 h from last seen well, is yet unclear. PATIENTS AND METHODS All consecutive patients treated with IVT, EVT, or IVT plus EVT in the extended time window at Helsinki University Hospital (HUS) between 1/2021 and 12/2022 were compared with matched controls treated in the early time window between 1/2016 and 12/2020. Regression analysis was applied on functional outcome at 90 days, evaluated on modified Rankin Scale (mRS), and on the occurrence of symptomatic intracerebral hemorrhage (sICH), adjusted for potential confounders. RESULTS Altogether 134 patients and 134 matching controls were included. Functional outcomes did not significantly differ between the extended versus early time window. Among patients with IVT plus EVT, the adjusted odds ratio (aOR) for a favorable outcome shift on mRS was 1.15, 95% confidence interval (CI) 0.54-2.43. Although sICH occurred more frequently (2.2% versus 3.0%) in the extended time window, regression analysis did not show a significant difference, aOR 0.96, 95% CI 0.14-6.87. DISCUSSION AND CONCLUSION We found no significant differences in the functional or safety outcomes between the extended versus early time window among patients with either IVT, EVT, or IVT plus EVT. There were no signals indicating, that IVT or EVT should be avoided in eligible patients in the extended time window which aligns with the current clinical treatment guidelines of HUS.
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Affiliation(s)
- Laura Mannismäki
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland.
| | - Nicolas Martinez-Majander
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Olli Suomalainen
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Gerli Sibolt
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Maria Girfanova
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Miranda Nybondas
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Hanna Nissinen
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Sami Curtze
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
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