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Keles A, Uyaniker ZA, Aagaard-Kienitz B, Baskaya MK. Emergency Carotid Thrombo-Endarterectomy after Failed Endovascular Recanalization for Acute Complete Carotid Occlusion: A Case Report. Brain Sci 2024; 14:882. [PMID: 39335378 PMCID: PMC11430307 DOI: 10.3390/brainsci14090882] [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: 07/26/2024] [Revised: 08/21/2024] [Accepted: 08/26/2024] [Indexed: 09/30/2024] Open
Abstract
Rapid identification of the type and origin of a stroke is crucial for prompt and appropriate treatment, which can significantly influences patient outcomes. We report a multidisciplinary management case involving a 76-year-old man who presented with left-sided weakness and mild dysarthria. Imaging revealed a completely occluded right internal carotid artery. Despite multiple endovascular recanalization attempts, adequate flow could not be achieved, leading to the decision to perform an open thrombo-endarterectomy. The patient underwent carotid endarterectomy with microsurgical techniques under general anesthesia. The atheroma plaque and central thrombus were removed, which reestablished flow. Continuous intraoperative neuromonitoring was utilized to ensure patient safety. The patient woke up without new deficits and was discharged for rehabilitation. Follow-up imaging confirmed arterial patency, and the patient eventually made an excellent recovery, including being independent over one and a half years. Emergent recanalization with carotid endarterectomy following a failed endovascular recanalization is both safe and feasible, emphasizing the need for collaboration between different treatment providers to ensure optimal patient outcomes. Our report highlights the importance of a multidisciplinary approach and the advantages of a hybrid operating room in the treatment of acute complete carotid artery occlusion.
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Affiliation(s)
- Abdullah Keles
- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53792, USA
| | - Zeynep Arzum Uyaniker
- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53792, USA
| | - Beverly Aagaard-Kienitz
- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53792, USA
| | - Mustafa K Baskaya
- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI 53792, USA
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Viticchi G, Falsetti L, Altamura C, Di Felice C, Vernieri F, Bartolini M, Silvestrini M. Impact of carotid stenosis on the outcome of stroke patients submitted to reperfusion treatments: a narrative review. Rev Neurosci 2024; 35:575-583. [PMID: 38459676 DOI: 10.1515/revneuro-2024-0002] [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: 01/04/2024] [Accepted: 02/18/2024] [Indexed: 03/10/2024]
Abstract
Intravenous thrombolysis (IT) and mechanical thrombectomy (MD) are the two interventional approaches that have changed the outcome of patients with acute ischemic stroke (AIS). Ipsilateral and contralateral carotid stenosis (ICS, CCS) play an important role in regulating cerebral hemodynamics, both in chronic and acute situations such as AIS. Several studies have explored their role in the incidence and severity of stroke, but very few have investigated the possible impact of ICS and CCS on the efficacy of interventional procedures. The purpose of this review was to I) highlight the incidence and prevalence of carotid stenosis (CS); II) assess the impact of ICS and CCS on cerebral hemodynamics; III) evaluate the effect of carotid stenosis on the efficacy of interventional therapies (IT and MT) for AIS; and IV) report therapeutic complications related to CS. We searched PubMed/Medline for case reports, reviews, and original research articles on English-language review topics during the period from January 1, 2000 to October 1, 2023. CS is associated with 15-20 % of the total number of AIS. ICS and CCS had a negative influence on both cerebral hemodynamics before AIS and outcome after interventional procedures (IT, MT alone or in bridging). Available data on cerebral hemodynamics and efficacy of interventional therapies for AIS suggest a negative role of CS. Therefore, early diagnosis of CS may be considered relevant to preventive and post-stroke treatment strategies.
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Affiliation(s)
- Giovanna Viticchi
- Neurological Clinic, Experimental and Clinical Medicine Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
| | - Lorenzo Falsetti
- Clinica Medica, Clinical and Molecular Sciences Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
| | - Claudia Altamura
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, via Álvaro del Portillo n.200, 00128, Rome, Italy
| | - Chiara Di Felice
- Neurological Clinic, Experimental and Clinical Medicine Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
| | - Fabrizio Vernieri
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, via Álvaro del Portillo n.200, 00128, Rome, Italy
| | - Marco Bartolini
- Neurological Clinic, Experimental and Clinical Medicine Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
| | - Mauro Silvestrini
- Neurological Clinic, Experimental and Clinical Medicine Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
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Bushnaq S, Hassan AE, Delora A, Kerro A, Datta A, Ezzeldin R, Ali Z, Anwoju T, Nejad L, Silva R, Abualnadi YD, Khalil ZM, Ezzeldin M. A Comparison of CT Perfusion Output of RapidAI and Viz.ai Software in the Evaluation of Acute Ischemic Stroke. AJNR Am J Neuroradiol 2024; 45:863-870. [PMID: 38346817 DOI: 10.3174/ajnr.a8196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Accepted: 02/06/2024] [Indexed: 02/15/2024]
Abstract
BACKGROUND AND PURPOSE Automated CTP postprocessing packages have been developed for managing acute ischemic stroke. These packages use image processing techniques to identify the ischemic core and penumbra. This study aimed to investigate the agreement of decision-making rules and output derived from RapidAI and Viz.ai software packages in early and late time windows and to identify predictors of inadequate quality CTP studies. MATERIALS AND METHODS One hundred twenty-nine patients with acute ischemic stroke who had CTP performed on presentation were analyzed by RapidAI and Viz.ai. Volumetric outputs were compared between packages by performing Spearman rank-order correlation and Wilcoxon signed-rank tests with subanalysis performed at early (<6 hours) and extended (>6 hours) time windows. The concordance of selecting patients on the basis of DAWN and DEFUSE 3 eligibility criteria was assessed using the McNemar test. RESULTS One hundred eight of 129 patients were found to have adequate-quality studies. Spearman rank-order correlation coefficients were calculated on time-to-maximum >6-second volume, time-to-maximum >10-second volume, CBF <30% volume, mismatch volume, and mismatch ratio between both software packages with correlation coefficients of 0.82, 0.65, 0.77, 0.78, 0.59, respectively. The Wilcoxon signed-rank test was also performed on time-to-maximum >6-second volume, time-to-maximum >10-second volume, CBF <30% volume, mismatch volume, and mismatch ratio with P values of .30, .016, <.001, .03, <.001, respectively. In a 1-sided test, CBF <30% was greater in Viz.ai (P < .001). Although this finding resulted in statistically significant differences, it did not cause clinically significant differences when applied to the DAWN and DEFUSE 3 criteria. A lower ejection fraction predicted an inadequate study in both software packages (P = .018; 95% CI, 0.01-0.113) and (P = .024; 95% CI, 0.008-0.109) for RapidAI and Viz.ai, respectively. CONCLUSIONS Penumbra and infarct core predictions between Rapid and Viz.ai correlated but were statistically different and resulted in equivalent triage using DAWN and DEFUSE3 criteria. Viz.ai predicted higher ischemic core volumes than RapidAI. Viz.ai predicted lower combined core and penumbra values than RapidAI at lower volumes and higher estimates than RapidAI at higher volumes. Clinicians should be cautious when using different software packages for clinical decision-making.
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Affiliation(s)
- Saif Bushnaq
- From the Department of Neurology (S.B.), Texas Tech University Health Sciences Center, Lubbock, Texas
| | - Ameer E Hassan
- Department of Neurology (A.E.H.), Valley Baptist Medical Center Harlingen (L.N., R.S., Y.D.A., Z.M.K.), Harlingten, Texas
| | - Adam Delora
- Department of Emergency Medicine (A. Delora, A. Datta), Clinical Sciences (Z.A., T.A.), and Neuroendovascular Surgery (M.E.), HCA Houston Healthcare Kingwood, Kingwood, Texas
| | - Ali Kerro
- Department of Neurology (A.K.), HCA Houston Healthcare Conroe, Conroe, Texas
| | - Anita Datta
- Department of Emergency Medicine (A. Delora, A. Datta), Clinical Sciences (Z.A., T.A.), and Neuroendovascular Surgery (M.E.), HCA Houston Healthcare Kingwood, Kingwood, Texas
| | - Rime Ezzeldin
- Jordan University of Science and Technology (R.E.), Irbid, Jordan
| | - Zuhair Ali
- Department of Emergency Medicine (A. Delora, A. Datta), Clinical Sciences (Z.A., T.A.), and Neuroendovascular Surgery (M.E.), HCA Houston Healthcare Kingwood, Kingwood, Texas
| | - Tunmi Anwoju
- Department of Emergency Medicine (A. Delora, A. Datta), Clinical Sciences (Z.A., T.A.), and Neuroendovascular Surgery (M.E.), HCA Houston Healthcare Kingwood, Kingwood, Texas
| | - Layla Nejad
- Department of Neurology (A.E.H.), Valley Baptist Medical Center Harlingen (L.N., R.S., Y.D.A., Z.M.K.), Harlingten, Texas
| | - Rene Silva
- Department of Neurology (A.E.H.), Valley Baptist Medical Center Harlingen (L.N., R.S., Y.D.A., Z.M.K.), Harlingten, Texas
| | - Yazan Diya Abualnadi
- Department of Neurology (A.E.H.), Valley Baptist Medical Center Harlingen (L.N., R.S., Y.D.A., Z.M.K.), Harlingten, Texas
| | - Zorain Mustafa Khalil
- Department of Neurology (A.E.H.), Valley Baptist Medical Center Harlingen (L.N., R.S., Y.D.A., Z.M.K.), Harlingten, Texas
| | - Mohamad Ezzeldin
- Department of Emergency Medicine (A. Delora, A. Datta), Clinical Sciences (Z.A., T.A.), and Neuroendovascular Surgery (M.E.), HCA Houston Healthcare Kingwood, Kingwood, Texas
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Chen KS, Khawaja A, Xu E, Mekary RA, Vaitkevicius H, Aziz-Sultan A, Du R, Patel NJ. Changes in inpatient brain arteriovenous malformation management in the United States following the ARUBA trial: analysis of an interrupted time series design. Clin Neurol Neurosurg 2024; 242:108293. [PMID: 38728853 DOI: 10.1016/j.clineuro.2024.108293] [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: 11/07/2023] [Revised: 01/31/2024] [Accepted: 04/18/2024] [Indexed: 05/12/2024]
Abstract
The November 2013 online publication of ARUBA, the first multi-institutional randomized controlled trial for unruptured brain arteriovenous malformations (AVMs), has sparked over 100 publications in protracted debates METHODS: This study sought to examine inpatient management patterns of brain AVMs from 2009 to 2016 and observe if changes in U.S. inpatient management were attributable to the ARUBA publication using interrupted time series of brain AVM studies from the National Inpatient Sample data 2009-2016. Outcomes of interest were use of embolization, surgery, combined embolization and microsurgery, radiotherapy, and observation during that admission. An interrupted time series design compared management trends before and after ARUBA. Segmented linear regression analysis tested for immediate and long-term impacts of ARUBA on management. RESULTS: Elective and asymptomatic patient admissions declined 2009-2016. In keeping with the ARUBA findings, observation for unruptured brain AVMs increased and microsurgery decreased. However, embolization, radiosurgery, and combined embolization and microsurgery also increased. For ruptured brain AVMs, treatment modality trends remained positive with even greater rates of observation, embolization, and combined embolization and microsurgery occurring after ARUBA (data on radiosurgery were scarce). None of the estimates for the change in trends were statistically significant. CONCLUSIONS: The publication of ARUBA was associated with a decrease in microsurgery and increase in observation for unruptured brain AVMs in the US. However, inpatient radiotherapy, embolization, and combined embolization and surgery also increased, suggesting trends moved counter to ARUBA's conclusions. This analysis suggested that ARUBA had a small impact as clinicians rejected ARUBA's findings in managing unruptured brain AVMs.
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Affiliation(s)
- Karen S Chen
- Department of Radiology and Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin St, Suite 470, Houston, TX 77030, USA
| | - Ayaz Khawaja
- Department of Neurology, New York University Health and Hospitals, Bellevue, 462 First Ave, New York, NY 10016, USA
| | - Edward Xu
- Department of Radiology and Neurosurgery, Texas Children's Hospital, Baylor College of Medicine, 6701 Fannin St, Suite 470, Houston, TX 77030, USA
| | - Rania A Mekary
- Department of Social and Administrative Sciences, School of Pharmacy, MCPHS University, 179 Longwood Ave, Boston, MA 02115, USA; Computational Neuroscience Outcomes Center at Harvard, Department of Neurosurgery, Brigham and Women's Hospital, 75 Francis St, Boston, MA 02115, USA
| | - Henri Vaitkevicius
- Marinus Pharmaceuticals, 5 Radnor Corporate Center, 100 Matsonford Rd, Suite 500, Radnor, PA 19087, USA
| | - Ali Aziz-Sultan
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Rose Du
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA
| | - Nirav J Patel
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis St, Boston, MA 02115, USA.
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Chausson N, Olindo S, Laborne FX, Aghasaryan M, Renou P, Soumah D, Debruxelles S, Altarcha T, Poli M, L'Hermitte Y, Sagnier S, Toudou-Daouda M, Aminou-Tassiou NR, Bentamra L, Benmoussa N, Alecu C, Imbernon C, Smadja L, Ouanounou G, Rouanet F, Sibon I, Smadja D. Second-dose intravenous thrombolysis with tenecteplase in alteplase-resistant medium-vessel-occlusion strokes: A retrospective and comparative study. Eur Stroke J 2024:23969873241254936. [PMID: 38829011 DOI: 10.1177/23969873241254936] [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: 06/05/2024] Open
Abstract
INTRODUCTION In intracranial medium-vessel occlusions (MeVOs), intravenous thrombolysis (IVT) shows inconsistent effectiveness and endovascular interventions remains unproven. We evaluated a new therapeutic strategy based on a second IVT using tenecteplase for MeVOs without early recanalization post-alteplase. PATIENTS AND METHODS This retrospective, comparative study included consecutively low bleeding risk MeVO patients treated with alteplase 0.9 mg/kg at two stroke centers. One center used a conventional single-IVT approach; the other applied a dual-IVT strategy, incorporating a 1-h post-alteplase MRI and additional tenecteplase, 0.25 mg/kg, if occlusion persisted. Primary outcomes were 24-h successful recanalization for efficacy and symptomatic intracranial hemorrhage (sICH) for safety. Secondary outcomes included 3-month excellent outcomes (modified Rankin Scale score of 0-1). Comparisons were conducted in the overall cohort and a propensity score-matched subgroup. RESULTS Among 146 patients in the dual-IVT group, 103 failed to achieve recanalization at 1 h and of these 96 met all eligible criteria and received additional tenecteplase. Successful recanalization at 24 h was higher in the 146 dual-IVT cohort patients than in the 148 single-IVT cohort patients (84% vs 61%, p < 0.0001), with similar sICH rate (3 vs 2, p = 0.68). Dual-IVT strategy was an independent predictor of 24-h successful recanalization (OR, 2.7 [95% CI, 1.52-4.88]; p < 0.001). Dual-IVT cohort patients achieved higher rates of excellent outcome (69% vs 44%, p < 0.0001). Propensity score matching analyses supported all these associations. CONCLUSION In this retrospective study, a dual-IVT strategy in selected MeVO patients was associated with higher odds of 24-h recanalization, with no safety concerns. However, potential center-level confounding and biases seriously limit these findings' interpretation. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT05809921.
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Affiliation(s)
- Nicolas Chausson
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
- INSERM U1266, Paris, France
| | | | | | - Manvel Aghasaryan
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
| | - Pauline Renou
- Unité Neuro-vasculaire, CHU de Bordeaux, Bordeaux, France
| | - Djibril Soumah
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
| | | | - Tony Altarcha
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
| | - Mathilde Poli
- Unité Neuro-vasculaire, CHU de Bordeaux, Bordeaux, France
| | - Yann L'Hermitte
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
| | | | | | | | - Leila Bentamra
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
| | - Narimane Benmoussa
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
| | - Cosmin Alecu
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
| | - Carole Imbernon
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
| | - Léonard Smadja
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
| | - Gary Ouanounou
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
| | | | - Igor Sibon
- Unité Neuro-vasculaire, CHU de Bordeaux, Bordeaux, France
| | - Didier Smadja
- Unité Neuro-vasculaire, Hôpital Sud-Francilien, Corbeil-Essonnes, France
- INSERM U1266, Paris, France
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Zhang L, Xue H, Bu X, Liao J, Tang G, Chen Y, Zhao L, Yang D, Liu L, Liu S. Patchy profile sign in RAPID software: a specific marker for intracranial atherosclerotic stenosis in acute ischemic stroke. Front Neurol 2024; 15:1414959. [PMID: 38872825 PMCID: PMC11169934 DOI: 10.3389/fneur.2024.1414959] [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: 04/09/2024] [Accepted: 05/17/2024] [Indexed: 06/15/2024] Open
Abstract
Purpose Identifying the etiology of acute ischemic stroke (AIS) before endovascular treatment (EVT) is important but challenging. In CT perfusion imaging processed by perfusion software, we observed a phenomenon called patchy profile sign (PPS), that is, the hypoperfusion morphology in RAPID software is a discontinuous sheet pattern. This phenomenon is predominantly observed in patients diagnosed with intracranial atherosclerotic stenosis (ICAS). The study intends to assess whether the PPS can be used to differentiate ICAS from intracranial embolism. Method Patients with AIS due to M1 segment occlusion of the MCA who underwent mechanical thrombectomy were retrospectively enrolled. The receiver operating characteristic (ROC) curve analysis was performed to assess the value of PPS in predicting ICAS. Sensitivity, specificity, positive predictive value (PPV), negative predictive value (NPV), and accuracy of the PPS for prediction of ICAS were calculated. Results A total of 51 patients were included in the study. The PPS was observed in 10 of 19 (52.6%) patients with ICAS, and in 2 of 32 (6.3%) patients with intracranial embolism (p < 0.001). Interobserver agreement for identifying PPS was excellent (κ = 0.944). The sensitivity, specificity, PPV, NPV, and accuracy of the PPS for predicting ICAS were 52.6, 93.8, 83.3, 76.9, and 78.4%, respectively. Conclusion The PPS on RAPID software is an imaging marker with high specificity for ICAS. Larger sample sizes are imperative to validate the findings.
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Affiliation(s)
- Lingwen Zhang
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Cerebrovascular Disease Research, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Hua Xue
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Cerebrovascular Disease Research, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaoqing Bu
- Department of Epidemiology, School of Public Health, Chongqing Medical University, Chongqing, China
| | - Juan Liao
- Chongqing Key Laboratory of Cerebrovascular Disease Research, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Ge Tang
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Cerebrovascular Disease Research, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Yu Chen
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Cerebrovascular Disease Research, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Libo Zhao
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Cerebrovascular Disease Research, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Deyu Yang
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Cerebrovascular Disease Research, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Li Liu
- Chongqing Key Laboratory of Cerebrovascular Disease Research, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
- Department of Health Management, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Shudong Liu
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
- Chongqing Key Laboratory of Cerebrovascular Disease Research, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
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Delora A, Hadjialiakbari C, Percenti E, Torres J, Alderazi YJ, Ezzeldin R, Hassan AE, Ezzeldin M. Viz LVO versus Rapid LVO in detection of large vessel occlusion on CT angiography for acute stroke. J Neurointerv Surg 2024; 16:599-602. [PMID: 37355255 DOI: 10.1136/jnis-2023-020445] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Accepted: 06/10/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Endovascular thrombectomy improves outcomes and reduces mortality for large vessel occlusion (LVO) and is time-sensitive. Computer automation may aid in the early detection of LVOs, but false values may lead to alarm desensitization. We compared Viz LVO and Rapid LVO for automated LVO detection. METHODS Data were retrospectively extracted from Rapid LVO and Viz LVO running concurrently from January 2022 to January 2023 on CT angiography (CTA) images compared with a radiologist interpretation. We calculated diagnostic accuracy measures and performed a McNemar test to look for a difference between the algorithms' errors. We collected demographic data, comorbidities, ejection fraction (EF), and imaging features and performed a multiple logistic regression to determine if any of these variables predicted the incorrect classification of LVO on CTA. RESULTS 360 participants were included, with 47 large vessel occlusions. Viz LVO and Rapid LVO had a specificity of 0.96 and 0.85, a sensitivity of 0.87 and 0.87, a positive predictive value of 0.75 and 0.46, and a negative predictive value of 0.98 and 0.97, respectively. A McNemar test on correct and incorrect classifications showed a statistically significant difference between the two algorithms' errors (P=0.00000031). A multiple logistic regression showed that low EF (Viz P=0.00125, Rapid P=0.0286) and Modified Woodcock Score >1 (Viz P=0.000198, Rapid P=0.000000975) were significant predictors of incorrect classification. CONCLUSION Rapid LVO produced a significantly larger number of false positive values that may contribute to alarm desensitization, leading to missed alarms or delayed responses. EF and intracranial atherosclerosis were significant predictors of incorrect predictions.
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Affiliation(s)
- Adam Delora
- Emergency Medicine, HCA Houston, Kingwood, Texas, USA
| | | | - Eryn Percenti
- Internal Medicine, HCA Houston, Kingwood, Texas, USA
| | - Jordan Torres
- Internal Medicine, HCA Houston, Kingwood, Texas, USA
| | | | - Rime Ezzeldin
- Medicine, Jordan University of Science and Technology, Irbid, Jordan
| | - Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley, Harlingen, Texas, USA
| | - Mohamad Ezzeldin
- Department of Clinical Sciences, College of Medicine, University of Houston, Houston, Texas, USA
- Neuroendovascular Surgery, HCA Houston, Houston, Texas, USA
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Liao Y, Qi W, Li S, Shi X, Wu X, Chi F, Xia R, Qin L, Cao L, Ren L. Analysis of onset-to-door time and its influencing factors in Chinese patients with acute ischemic stroke during the 2020 COVID-19 epidemic: a preliminary, prospective, multicenter study. BMC Health Serv Res 2024; 24:615. [PMID: 38730381 PMCID: PMC11084012 DOI: 10.1186/s12913-024-11088-8] [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: 11/08/2023] [Accepted: 05/08/2024] [Indexed: 05/12/2024] Open
Abstract
BACKGROUND Pre-hospital delay in China is a serious issue with unclear relevant reasons, seriously impeding the adoption of appropriate measures. Herein, we analyzed the onset-to-door time (ODT) in Chinese patients with acute ischemic stroke (AIS) and its influencing factors. METHODS We prospectively recruited 3,459 patients with AIS from nine representative tertiary general hospitals in China between January and June 2022. Patients were divided into ODT ≤ 3 h and ODT > 3 h groups. Following single-factor analysis, binary logistic regression analysis was performed to evaluate the risk factors leading to pre-hospital delay. RESULTS In total, 763 (21.83%) patients arrived at the hospital within 3 h of onset. After adjusting for confounding factors, the risk factors for ODT were residence in rural areas (odds ratio [OR]: 1.478, 95% credibility interval [CI]: 1.024-2.146) and hospital transfer (OR: 7.479, 95% CI: 2.548-32.337). The protective factors for ODT were location of onset ≤ 20 km from the first-visit hospital (OR: 0.355, 95% CI: 0.236-0.530), transportation by emergency medical services (OR: 0.346, 95% CI: 0.216-0.555), history of atrial fibrillation (OR: 0.375, 95% CI: 0.207-0.679), moderate stroke (OR: 0.644, 95% CI: 0.462-0.901), and severe stroke (OR: 0.506, 95% CI: 0.285-0.908). CONCLUSIONS Most patients with AIS fail to reach a hospital within the critical 3-h window. The following measures are recommended to reduce pre-hospital delays: reasonable distribution of hospitals accessible to nearby residents, minimizing interhospital transfer, paying attention to patients with mild stroke, and encouraging patients to use ambulance services. Pre-hospital delays for patients can be reduced by implementing these measures, ultimately improving the timeliness of treatment and enhancing patient prognosis. This study was carried out amid the COVID-19 pandemic, which presented challenges and constraints.
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Affiliation(s)
- Yuqi Liao
- School of Medicine, Shenzhen University, Shenzhen, China
| | - Wenwei Qi
- National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China
- Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shuting Li
- School of Statistics, Shandong Technology and Business University, Yantai, China
| | - Xin Shi
- School of Statistics, Shandong Technology and Business University, Yantai, China
- School of Health Management, China Medical University, Shenyang, China
| | - Xiaohong Wu
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Futian District, Shenzhen City, 518000, China
- Department of Neurology, Shenzhen Second People's Hospital, Shenzhen, China
| | - Feng Chi
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Futian District, Shenzhen City, 518000, China
- Department of Neurology, Shenzhen Second People's Hospital, Shenzhen, China
| | - Runyu Xia
- School of Medicine, Shenzhen University, Shenzhen, China
| | - Limin Qin
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Futian District, Shenzhen City, 518000, China
- Department of Neurology, Shenzhen Second People's Hospital, Shenzhen, China
| | - Liming Cao
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Futian District, Shenzhen City, 518000, China.
- Hunan Provincial Key Laboratory of the Research and Development of Novel Pharmaceutical Preparations, Changsha Medical University, Changsha, China.
| | - Lijie Ren
- Department of Neurology, The First Affiliated Hospital of Shenzhen University, 3002 Sungang West Road, Futian District, Shenzhen City, 518000, China
- Department of Neurology, Shenzhen Second People's Hospital, Shenzhen, China
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Fiorella D, Jovin TG, Arthur AS, Nogueira R, Siddiqui AH, Hirsch JA, Albuquerque FC. Triage of Emergent Large Vessel Occlusion (ELVO) patients directly to Comprehensive Stroke Centers (CSCs) is good practice and benefits patients in Urban and Suburban population Centers - New insights from the TRIAGE-STROKE and RACECAT studies. J Neurointerv Surg 2023; 16:1-3. [PMID: 38114326 DOI: 10.1136/jnis-2023-021341] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/01/2023] [Indexed: 12/21/2023]
Affiliation(s)
- David Fiorella
- Department of Neurosurgery, Stony Brook University, Stony Brook, New York, USA
- SUNY SB, Stony Brook, New York, USA
| | - Tudor G Jovin
- Neurology, Cooper University Hospital, Camden, New Jersey, USA
| | - Adam S Arthur
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
- Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | | | - Adnan H Siddiqui
- Neurosurgery and Radiology and Canon Stroke and Vascular Research Center, University at Buffalo Jacobs School of Medicine and Biomedical Sciences, Buffalo, New York, USA
- Neurosurgery, Gates Vascular Institute, Buffalo, New York, USA
| | - Joshua A Hirsch
- NeuroEndovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
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10
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Maltby S, Garcia-Esperon C, Jackson K, Butcher K, Evans JW, O'Brien W, Dixon C, Russell S, Wilson N, Kluge MG, Ryan A, Paul CL, Spratt NJ, Levi CR, Walker FR. TACTICS VR Stroke Telehealth Virtual Reality Training for Health Care Professionals Involved in Stroke Management at Telestroke Spoke Hospitals: Module Design and Implementation Study. JMIR Serious Games 2023; 11:e43416. [PMID: 38060297 PMCID: PMC10739245 DOI: 10.2196/43416] [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: 10/30/2022] [Revised: 09/06/2023] [Accepted: 10/09/2023] [Indexed: 12/08/2023] Open
Abstract
BACKGROUND Stroke management in rural areas is more variable and there is less access to reperfusion therapies, when compared with metropolitan areas. Delays in treatment contribute to worse patient outcomes. To improve stroke management in rural areas, health districts are implementing telestroke networks. The New South Wales Telestroke Service provides neurologist-led telehealth to 23 rural spoke hospitals aiming to improve treatment delivery and patient outcomes. The training of clinical staff was identified as a critical aspect for the successful implementation of this service. Virtual reality (VR) training has not previously been used in this context. OBJECTIVE We sought to develop an evidence-based VR training module specifically tailored for stroke telehealth. During implementation, we aimed to assess the feasibility of workplace deployment and collected feedback from spoke hospital staff involved in stroke management on training acceptability and usability as well as perceived training impact. METHODS The TACTICS VR Stroke Telehealth application was developed with subject matter experts. During implementation, both quantitative and qualitative data were documented, including VR use and survey feedback. VR hardware was deployed to 23 rural hospitals, and use data were captured via automated Wi-Fi transfer. At 7 hospitals in a single local health district, staff using TACTICS VR were invited to complete surveys before and after training. RESULTS TACTICS VR Stroke Telehealth was deployed to rural New South Wales hospitals starting on April 14, 2021. Through August 20, 2023, a total of 177 VR sessions were completed. Survey respondents (n=20) indicated a high level of acceptability, usability, and perceived training impact (eg, accuracy and knowledge transfer; mean scores 3.8-4.4; 5=strongly agree). Furthermore, respondents agreed that TACTICS VR increased confidence (13/18, 72%), improved understanding (16/18, 89%), and improved awareness (17/18, 94%) regarding stroke telehealth. A comparison of matched pre- and posttraining responses revealed that training improved the understanding of telehealth workflow practices (after training: mean 4.2, SD 0.6; before training: mean 3.2, SD 0.9; P<.001), knowledge on accessing stroke telehealth (mean 4.1, SD 0.6 vs mean 3.1, SD 1.0; P=.001), the awareness of stroke telehealth (mean 4.1, SD 0.6 vs mean 3.4, SD 0.9; P=.03), ability to optimally communicate with colleagues (mean 4.2, SD 0.6 vs mean 3.7, SD 0.9; P=.02), and ability to make improvements (mean 4.0, SD 0.6 vs mean 3.5, SD 0.9; P=.03). Remote training and deployment were feasible, and limited issues were identified, although uptake varied widely (0-66 sessions/site). CONCLUSIONS TACTICS VR Stroke Telehealth is a new VR application specifically tailored for stroke telehealth workflow training at spoke hospitals. Training was considered acceptable, usable, and useful and had positive perceived training impacts in a real-world clinical implementation context. Additional work is required to optimize training uptake and integrate training into existing education pathways.
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Affiliation(s)
- Steven Maltby
- Centre for Advanced Training Systems, The University of Newcastle, Newcastle, Australia
- Hunter Medical Research Institute, New Lambton Heights, Australia
- School of Biomedical Sciences & Pharmacy, College of Health, Medicine & Wellbeing, The University of Newcastle, Callaghan, Australia
| | - Carlos Garcia-Esperon
- Hunter Medical Research Institute, New Lambton Heights, Australia
- John Hunter Hospital, New Lambton Heights, Australia
| | - Kate Jackson
- NSW Agency for Clinical Innovation, St Leonards, Australia
| | - Ken Butcher
- School of Clinical Medicine, University of New South Wales, Sydney, Australia
| | - James W Evans
- Department of Neurosciences, Gosford Hospital, Gosford, Australia
| | - William O'Brien
- Department of Neurosciences, Gosford Hospital, Gosford, Australia
| | - Courtney Dixon
- NSW Agency for Clinical Innovation, St Leonards, Australia
| | - Skye Russell
- NSW Agency for Clinical Innovation, St Leonards, Australia
| | - Natalie Wilson
- NSW Agency for Clinical Innovation, St Leonards, Australia
| | - Murielle G Kluge
- Centre for Advanced Training Systems, The University of Newcastle, Newcastle, Australia
- School of Biomedical Sciences & Pharmacy, College of Health, Medicine & Wellbeing, The University of Newcastle, Callaghan, Australia
| | - Annika Ryan
- Hunter Medical Research Institute, New Lambton Heights, Australia
- School of Medicine and Public Health, College of Health, Medicine & Wellbeing, The University of Newcastle, Callaghan, Australia
| | - Christine L Paul
- Hunter Medical Research Institute, New Lambton Heights, Australia
- School of Medicine and Public Health, College of Health, Medicine & Wellbeing, The University of Newcastle, Callaghan, Australia
| | - Neil J Spratt
- Hunter Medical Research Institute, New Lambton Heights, Australia
- School of Biomedical Sciences & Pharmacy, College of Health, Medicine & Wellbeing, The University of Newcastle, Callaghan, Australia
- John Hunter Hospital, New Lambton Heights, Australia
| | - Christopher R Levi
- School of Medicine and Public Health, College of Health, Medicine & Wellbeing, The University of Newcastle, Callaghan, Australia
- John Hunter Health & Innovation Precinct, New Lambton Heights, Australia
| | - Frederick Rohan Walker
- Centre for Advanced Training Systems, The University of Newcastle, Newcastle, Australia
- Hunter Medical Research Institute, New Lambton Heights, Australia
- School of Biomedical Sciences & Pharmacy, College of Health, Medicine & Wellbeing, The University of Newcastle, Callaghan, Australia
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11
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Ohta T, Takeuchi M, Yamagami H, Tsuto K, Yamamoto S, Asai K, Ishii A, Imamura H, Yoshimura S, Fukumitsu R, Sakai C, Sakai N, Tateshima S. First-in-human trial of a self-expandable, temporary dilation system for intracranial atherosclerotic disease in patients presenting with acute ischemic stroke. J Neurointerv Surg 2023:jnis-2023-020983. [PMID: 38041666 DOI: 10.1136/jnis-2023-020983] [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: 09/01/2023] [Accepted: 10/29/2023] [Indexed: 12/03/2023]
Abstract
BACKGROUND Intracranial atherosclerotic disease (ICAD) significantly contributes to ischemic stroke, especially among Asian populations. Large vessel occlusion (LVO) due to underlying ICAD accounts for 15-35% of acute ischemic stroke cases requiring endovascular therapy. However, the successful recanalization rate of ICAD-related LVO remains lower. The TG dilator is a self-expandable device, temporarily dilating ICAD-related blocked blood vessels. OBJECTIVE To demonstrate TG dilator safety and efficacy for ICAD-related acute ischemic stroke. METHODS This was a single-arm, open-label, non-randomized, prospective, multicenter, and investigator-initiated trial that involved patients undergoing TG dilator application for acute ischemic stroke caused by ICAD-related LVO or severe stenosis. RESULTS We enrolled 10 patients in this trial between November 2022 and April 2023. The median (IQR) age was 68 (59.3-75.3) years. Before using the dilator, seven patients received stent retriever treatment. All 10 patients were prescribed a loading dose of aspirin with prasugrel. The median application time was 10 (10-12) min. At the end of the procedure, we achieved significant recanalization immediately in all patients. The stenosis/occlusion decreased from 100% (100-100) to 68% (56.3-75.3). No patient experienced recurrent ischemic stroke or reocclusion within 90 days. We achieved a modified Rankin scale score of 0-2 in 8 patients by day 90. We detected no cases of intracranial hemorrhage, equipment failure, distal embolism, vasospasm, dissection, or perforation requiring intervention. CONCLUSIONS Acute revascularization using the TG dilator on patients with ICAD-related LVO or severe stenosis did not cause any significant adverse event, and consistently improved blood flow at 90 days.
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Affiliation(s)
- Tsuyoshi Ohta
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
- Center for Clinical Research and Innovation, Kobe City Medical Center General Hospital, Kobe, Japan
| | | | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Kazuma Tsuto
- Department of Neurosurgery, Seisho Hospital, Odawara, Japan
| | - Shiro Yamamoto
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Katsunori Asai
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Akira Ishii
- Department of Neurosurgery, Kyoto University, Kyoto, Japan
| | - Hirotoshi Imamura
- Center for Clinical Research and Innovation, Kobe City Medical Center General Hospital, Kobe, Japan
- Department of Neurosurgery, National Cerebral and Cardiovascular Center Hospital, Suita, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Ryu Fukumitsu
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Chiaki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
- Center for Clinical Research and Innovation, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Nobuyuki Sakai
- Center for Clinical Research and Innovation, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Satoshi Tateshima
- Division of Interventional Neuroradiology, Ronald Reagan UCLA Medical Center, Los Angeles, California, USA
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12
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Yoshie T, Ueda T, Hasegawa Y, Takeuchi M, Morimoto M, Tsuboi Y, Yamamoto R, Kaku S, Ayabe J, Akiyama T, Yamamoto D, Mori K, Kagami H, Ito H, Onodera H, Kaga Y, Ohtsubo H, Tatsuno K, Usuki N, Takaishi S, Yamano Y. Ischemic stroke patients with low DWI ASPECTS scores require puncture to recanalization within 30 min for large vessel occlusion. J Neurol Sci 2023; 454:120852. [PMID: 37924594 DOI: 10.1016/j.jns.2023.120852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/24/2023] [Accepted: 10/22/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND The clinical benefits of faster recanalization in acute large vessel occlusion are well recognized, but the optimal procedure time remains uncertain. The aim of this study was to identify patient characteristics that necessitate puncture-to-recanalization (P-R) time within 30 min to achieve favorable outcome. METHODS We evaluated the patients from a prospective, multicenter, observational registry of acute ischemic stroke patients. The study included patients who underwent endovascular therapy for ICA or MCA M1 occlusion and achieved successful recanalization. Patients were categorized into subgroups based on pre-treatment characteristics and the frequency of favorable outcomes was compared between P-R time < 30 min and ≥ 30 min. Interaction terms were incorporated into the models to assess the correlation between each patient characteristic and P-R time. RESULTS A total of 1053 patients were included in the study. Univariate analysis within each subgroup revealed a significant association between P-R < 30 min and favorable outcomes in patients with DWI ASPECTS ≤6, age > 85 and NIHSS ≥16. In the multivariable analysis, NIHSS, age, time from symptom recognition to puncture, and DWI ASPECTS were significant independent predictors of favorable outcomes. Notably, only DWI ASPECTS exhibited interaction terms with P-R < 30 min. The multivariable analysis indicated that P-R < 30 min was an independent predictor for favorable outcome in DWI ASPECTS ≤6 group, whereas not in DWI ≥7. CONCLUSIONS P-R time < 30 min is predictive of favorable outcomes; however, the effect depends on DWI ASPECTS. Target P-R time < 30 min is appropriate for patients with DWI ASPECTS ≤6.
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Affiliation(s)
- Tomohide Yoshie
- Department of Strokology and Neuroendovascular Therapy, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan.
| | - Toshihiro Ueda
- Department of Strokology and Neuroendovascular Therapy, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan
| | - Yasuhiro Hasegawa
- Department of Neurology, St. Marianna University School of Medicine, Kawasaki, Japan
| | | | - Masafumi Morimoto
- Department of Neurosurgery, Yokohama Shintoshi Neurosurgical Hospital, Yokohama, Japan
| | - Yoshifumi Tsuboi
- Department of Neurosurgery, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Ryoo Yamamoto
- Department of Neurology, Yokohama Brain and Spine Center, Yokohama, Japan
| | - Shogo Kaku
- Department of Neurosurgery, Neurosurgical East Yokohama Hospital, Yokohama, Japan
| | - Junichi Ayabe
- Department of Neurosurgery, Yokosuka Kyosai Hospital, Yokohama, Japan
| | - Takekazu Akiyama
- Department of Neurosurgery, Akiyama Neurosurgical Hospital, Yokohama, Japan
| | - Daisuke Yamamoto
- Department of Neurosurgery, Kitasato University Hospital, Sagamihara, Japan
| | - Kentaro Mori
- Department of Neurosurgery, Yokohama Sakae Kyosai Hospital, Yokohama, Japan
| | - Hiroshi Kagami
- Department of Neurosurgery, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Hidemichi Ito
- Department of Neurosurgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hidetaka Onodera
- Department of Neurosurgery, St. Marianna University Yokohama Seibu Hospital, Yokohama, Japan
| | - Yasuyuki Kaga
- Department of Neurology, St. Marianna University School of Medicine, Kawasaki, Japan; ESP corporation, Tokyo, Japan
| | - Haruki Ohtsubo
- Department of Strokology and Neuroendovascular Therapy, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan
| | - Kentaro Tatsuno
- Department of Strokology and Neuroendovascular Therapy, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan
| | - Noriko Usuki
- Department of Strokology and Neuroendovascular Therapy, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan
| | - Satoshi Takaishi
- Department of Strokology and Neuroendovascular Therapy, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan
| | - Yoshihisa Yamano
- Department of Neurology, St. Marianna University School of Medicine, Kawasaki, Japan
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13
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Tarantini L, Merzou F, Luley M, Rollmann A, Schwindling MP, Lesmeister M, Gläss M, Wollenburg J, Schwindling L, Fassbender K. Perceived performance of activities of daily living by stroke patients: key in decision to call EMS and outcomes. Front Neurol 2023; 14:1241391. [PMID: 37808509 PMCID: PMC10556741 DOI: 10.3389/fneur.2023.1241391] [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: 06/16/2023] [Accepted: 09/04/2023] [Indexed: 10/10/2023] Open
Abstract
Background Until recently, public education campaigns aimed at improving help-seeking behavior by acute stroke patients have achieved only limited or even no effects. Better understanding of psychological factors determining help-seeking behavior may be relevant in the design of more effective future campaigns. Methods In this prospective, cross-sectional study, we interviewed 669 acute stroke patients within 72 h after hospital admission. The primary endpoint was the effect of psychological factors on the decision to call emergency medical services (EMS). Secondary endpoints were the effects of such factors on treatment rates and clinical improvement (difference between modified Rankin scale (MRS) scores at admission and at discharge). Results Only 48.7% of the study population called the EMS. Multivariate logistic and linear regression analyses revealed that perception of unimpaired performance of activities of daily living (ADL) was the only psychological factor that predicted EMS use and outcomes. Thus, patients who perceived only minor impairment in performing ADL were less likely to use EMS (odds ratio, 0.54 [95% confidence interval, 0.38-0.76]; p = 0.001), had lower treatment rates, and had less improvement in MRS scores (b = 0.40, p = 0.004). Additional serial mediation analyses involving ischemic stroke patients showed that perception of low impairment in ADL decreased the likelihood of EMS notification, thereby increasing prehospital delays, leading to reduced thrombolysis rates and, finally, to reduced clinical improvement. Conclusion Perception of unimpaired performance of ADL is a crucial barrier to appropriate help-seeking behavior after acute stroke, leading to undertreatment and less improvement in clinical symptoms. Thus, beyond improving the public's knowledge of stroke symptoms, future public education campaigns should focus on the need for calling the EMS in case of stroke symptoms even if daily activities do not seem to be severely impaired.
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Affiliation(s)
- Luca Tarantini
- Experimental Neuropsychology Unit, Department of Psychology, Saarland University, Saarbrücken, Germany
- Department of Psychiatry and Psychotherapy, Saarland University Medical Center, Homburg, Germany
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Fatma Merzou
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Maxine Luley
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Aline Rollmann
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | | | - Martin Lesmeister
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Marietheres Gläss
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Jennifer Wollenburg
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Lenka Schwindling
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
| | - Klaus Fassbender
- Department of Neurology, Saarland University Medical Center, Homburg, Germany
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Rosso C, Belkacem S, Amor-Sahli M, Clarençon F, Leger A, Baronnet F, Dormont D, Alamowitch S, Lehericy S, Samson Y. Persistent perfusion abnormalities at day 1 correspond to different clinical trajectories after stroke. J Neurointerv Surg 2023; 15:e26-e32. [PMID: 35701108 DOI: 10.1136/neurintsurg-2022-018953] [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: 03/24/2022] [Accepted: 06/01/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Perfusion abnormalities after thrombolysis are frequent within and surrounding ischemic lesions, but their relative frequency is not well known. OBJECTIVE To describe the different patterns of perfusion abnormalities observed at 24 hours and compare the characteristics of the patients according to their perfusion pattern. METHODS From our thrombolysis registry, we included 226 consecutive patients with an available arterial spin labeling (ASL) perfusion sequence at day 1. We performed a blinded assessment of the perfusion status (hypoperfusion-h, hyperperfusion-H, or normal-N) in the ischemic lesion and in the surrounding tissue. We compared the time course of clinical recovery, the rate of arterial recanalization, and hemorrhagic transformations in the different perfusion profiles. RESULTS We identified seven different perfusion profiles at day 1. Four of these (h/h, h/H, H/H, and H/N) represented the majority of the population (84.1%). The H/H profile was the most frequent (34.5%) and associated with 3-month good outcome (modified Rankin Scale (mRS): 63.5%). Patients with persistent hypoperfusion within and outside the lesion (h/h, 12.4%) exhibited worse outcomes after treatment (mRS score 0-2: 23.8%) than other patients, were less frequently recanalized (40.7%), and had more parenchymal hematoma (17.8%). The h/H profile had an intermediate clinical trajectory between the h/h profile and the hyperperfused profiles. CONCLUSION ASL hypoperfusion within the infarct and the surrounding tissue was associated with poor outcome. A more comprehensive view of the mechanisms in the hypoperfused surrounding tissue could help to design new therapeutic approaches during and after reperfusion therapies.
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Affiliation(s)
- Charlotte Rosso
- APHP-Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Paris, France
- STARE team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
- Inserm U 1127, CNRS UMR 7225, Sorbonne Université, UPMC Univ Paris 06 UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
| | - Samia Belkacem
- APHP-Neuroradiology Department, Hôpital Pitié-Salpêtrière, Paris, France
| | - Mélika Amor-Sahli
- APHP-Neuroradiology Department, Hôpital Pitié-Salpêtrière, Paris, France
| | - Frédéric Clarençon
- STARE team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
- APHP-Interventional Neuroradiology Department, Hôpital Pitié-Salpêtrière, Paris, France
| | - Anne Leger
- APHP-Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Paris, France
- STARE team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
| | - Flore Baronnet
- APHP-Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Paris, France
- STARE team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
| | - Didier Dormont
- Inserm U 1127, CNRS UMR 7225, Sorbonne Université, UPMC Univ Paris 06 UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
- APHP-Neuroradiology Department, Hôpital Pitié-Salpêtrière, Paris, France
| | - Sonia Alamowitch
- APHP-Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Paris, France
- STARE team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
| | - Stéphane Lehericy
- Inserm U 1127, CNRS UMR 7225, Sorbonne Université, UPMC Univ Paris 06 UMR S 1127, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
- APHP-Neuroradiology Department, Hôpital Pitié-Salpêtrière, Paris, France
| | - Yves Samson
- APHP-Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Paris, France
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Kawauchi S, Chida K, Hamada Y, Tsuruta W. Image Quality and Radiation Dose of Conventional and Wide-Field High-Resolution Cone-Beam Computed Tomography for Cerebral Angiography: A Phantom Study. Tomography 2023; 9:1683-1693. [PMID: 37736987 PMCID: PMC10514806 DOI: 10.3390/tomography9050134] [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: 06/20/2023] [Revised: 08/24/2023] [Accepted: 08/29/2023] [Indexed: 09/23/2023] Open
Abstract
There has been an increase in the use of interventional neuroradiology procedures because of their non-invasiveness compared to surgeries and the improved image quality of fluoroscopy, digital subtraction angiography, and rotational angiography. Although cone-beam computed tomography (CBCT) images are inferior to multi-detector CT images in terms of low-contrast detectability and lower radiation doses, CBCT scans are frequently performed because of their accessibility. This study aimed to evaluate the image quality and radiation dose of two different high-resolution CBCTs (HR CBCT): conventional (C-HR CBCT) and wide-field HR CBCT (W-HR CBCT). The modulation transfer function (MTF), noise power spectrum (NPS), and contrast-to-noise ratio (CNR) were used to evaluate the image quality. On comparing the MTF of C-HR CBCT with a 256 × 256 matrix and that of W-HR CBCT with a 384 × 384 matrix, the MTF of W-HR CBCT with the 384 × 384 matrix was larger. A comparison of the NPS and CNR of C-HR CBCT with a 256 × 256 matrix and W-HR CBCT with a 384 × 384 matrix showed that both values were comparable. The reference air kerma values were equal for C-HR CBCT and W-HR CBCT; however, the value of the kerma area product was 1.44 times higher for W-HR CBCT compared to C-HR CBCT. The W-HR CBCT allowed for improved spatial resolution while maintaining the image noise and low-contrast detectability by changing the number of image matrices from 256 × 256 to 384 × 384. Our study revealed the image characteristics and radiation dose of W-HR CBCT. Given its advantages of low-contrast detectability and wide-area imaging with high spatial resolution, W-HR CBCT may be useful in interventional neuroradiology for acute ischemic stroke.
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Affiliation(s)
- Satoru Kawauchi
- Department of Radiology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo 105-8470, Japan; (S.K.); (Y.H.)
- Department of Radiological Technology, Tohoku University Graduate School of Medicine, 2-1 Seiryo, Aoba-ku, Sendai 980-8575, Miyagi, Japan
- Okinaka Memorial Institute for Medical Research, 2-2-2 Toranomon, Minato-ku, Tokyo 105-8470, Japan
| | - Koichi Chida
- Department of Radiological Technology, Tohoku University Graduate School of Medicine, 2-1 Seiryo, Aoba-ku, Sendai 980-8575, Miyagi, Japan
- Department of Radiation Disaster Medicine, International Research Institute of Disaster Science, Tohoku University, 468-1 Aramaki Aza-Aoba, Aoba-ku, Sendai 980-0845, Miyagi, Japan
| | - Yusuke Hamada
- Department of Radiology, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo 105-8470, Japan; (S.K.); (Y.H.)
| | - Wataro Tsuruta
- Department of Endovascular Neurosurgery, Toranomon Hospital, 2-2-2 Toranomon, Minato-ku, Tokyo 105-8470, Japan;
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Fakih R, Ma X, Lodhi A, Bains N, French BR, Siddiq F, Gomez CR, Qureshi AI. Effect of race/ethnicity on arterial recanalization following intravenous thrombolysis in acute ischemic stroke patients. J Stroke Cerebrovasc Dis 2023; 32:107218. [PMID: 37453215 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107218] [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: 01/17/2023] [Revised: 06/08/2023] [Accepted: 06/10/2023] [Indexed: 07/18/2023] Open
Abstract
INTRODUCTION Several reports have identified that clinical outcomes such as death or disability in acute ischemic stroke (AIS) patients following intravenous (IV) tissue plasminogen activator (tPA) treatment can vary according to race and ethnicities. We determined the effect of race/ethnicity on rates of arterial recanalization in AIS patients with large vessel occlusion (LVO) after IV tPA. METHODS We analyzed 234 patients with LVO detected on computed tomographic angiography (CTA) who received IV tPA and subsequently underwent angiography for potential thrombectomy. The primary occlusion sites on CTA and digital subtracted angiography (DSA) were compared and a score was given to the level of recanalization with values ranging from 1 (complete recanalization), 2 (partial recanalization), or 3 (no recanalization).The effect of race/ethnicity were assessed for predicting vessel recanalization using the covariates of age, gender, time since stroke onset, tPA dose received, NIHSS (National Institute of Health Stroke Scale) score at baseline, and location of the occlusion, using logistic regression analysis. RESULTS Five patients (2.1%) were Hispanic or Latino, 8 (3.4%) Asian, 24 (10.3%) African American, and 197 (84.2%) White. A total of 50% had a distal ICA/proximal M1 occlusion, 20% distal M1 occlusion, and 16% single M2 occlusion. At the primary occlusion site, 44 (18.8%) had complete recanalization on post IV tPA angiogram, 17 (7.3%) had partial recanalization, and 165 (70.5%) had no recanalization. We did not find any association between race/ethnicity and vessel recanalization post IV tPA (Nonwhite combined [OR=1.49, p=0.351]; Asian [OR=1.460, p=0.650]; African American [OR=1.508, p=0.415]; White [OR=0.672, p=0.351]; ethnicity (Hispanic or Latino) [OR= 1.008, p=0.374]); Occlusion location (OR=0.189, p<0.001). Final TICI scores and mRS at 90 days were similar among the different groups. CONCLUSION Approximately 19% of patients had complete recanalization after IV tPA, but race and ethnicity did not seem to have an effect on arterial recanalization. Arterial recanalization was only affected by location of occlusion.
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Affiliation(s)
- Rami Fakih
- Department of Neurology, University of Missouri, Columbia, Missouri, United States.
| | - Xiaoyu Ma
- Department of Neurology, University of Missouri, Columbia, Missouri, United States.
| | - Abdullah Lodhi
- Department of Neurology, University of Missouri, Columbia, Missouri, United States; Zeenat Qureshi Stroke Institute, St Cloud, Minnesota, United States.
| | - Navpreet Bains
- Department of Neurology, University of Missouri, Columbia, Missouri, United States.
| | - Brandi R French
- Department of Neurology, University of Missouri, Columbia, Missouri, United States.
| | - Farhan Siddiq
- Department of Neurosurgery, University of Missouri, Columbia, Missouri, United States.
| | - Camilo R Gomez
- Department of Neurology, University of Missouri, Columbia, Missouri, United States.
| | - Adnan I Qureshi
- Department of Neurology, University of Missouri, Columbia, Missouri, United States; Zeenat Qureshi Stroke Institute, St Cloud, Minnesota, United States.
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17
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Fukuda H, Hyohdoh Y, Ninomiya H, Ueba Y, Ohta T, Kawanishi Y, Kadota T, Hamada F, Fukui N, Nonaka M, Kawada K, Fukuda M, Nishimoto Y, Matsushita N, Nojima Y, Kida N, Hayashi S, Izumidani T, Nishimura H, Moriki A, Ueba T. Impact of areal socioeconomic status on prehospital delay of acute ischaemic stroke: retrospective cohort study from a prefecture-wide survey in Japan. BMJ Open 2023; 13:e075612. [PMID: 37620264 PMCID: PMC10450073 DOI: 10.1136/bmjopen-2023-075612] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 08/09/2023] [Indexed: 08/26/2023] Open
Abstract
OBJECTIVES To examine whether the Areal Deprivation Index (ADI), an indicator of the socioeconomic status of the community the patient resides in, is associated with delayed arrival at the hospital and poor outcomes in patients with acute ischaemic stroke from a prefecture-wide stroke database in Japan. DESIGN Retrospective study. SETTING Twenty-nine acute stroke hospitals in Kochi prefecture, Japan. PARTICIPANTS Nine thousand and six hundred fifty-one patients with acute ischaemic stroke who were urgently hospitalised, identified using the Kochi Acute Stroke Survey of Onset registry. Capital and non-capital areas were analysed separately. PRIMARY AND SECONDARY OUTCOME MEASURES Prehospital delay defined as hospital arrival ≥4-hour after stroke onset, poor hospital outcomes (in-hospital mortality and discharge to a nursing facility) and the opportunities of intravenous recombinant tissue plasminogen activator (rt-PA) and endovascular reperfusion therapy. RESULTS In the overall cohort, prehospital delay was observed in 6373 (66%) patients. Among individuals residing in non-capital areas, those living in municipalities with higher ADI (more deprived) carried a significantly higher risk of prehospital delay (per one-point increase, OR (95% CI) 1.45 (1.26 to 1.66)) by multivariable logistic regression analysis. In-hospital mortality (1.45 (1.02 to 2.06)), discharge to a nursing facility (1.31 (1.03 to 1.66)), and delayed candidate arrival ≥2-hour of intravenous rt-PA (2.04 (1.30 to 3.26)) and endovascular reperfusion therapy (2.27 (1.06 to 5.00)), were more likely to be observed in the deprived areas with higher ADI. In the capital areas, postal-code-ADI was not associated with prehospital delay (0.97 (0.66 to 1.41)). CONCLUSIONS Living in socioeconomically disadvantaged municipalities was associated with prehospital delays of acute ischaemic stroke in non-capital areas in Kochi prefecture, Japan. Poorer outcomes of those patients may be caused by delayed treatment of intravenous rt-PA and endovascular reperfusion therapy. Further studies are necessary to determine social risk factors in the capital areas. TRIAL REGISTRATION NUMBER This article is linked to a clinical trial to UMIN000050189, No.: R000057166 and relates to its Result stage.
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Affiliation(s)
- Hitoshi Fukuda
- Department of Neurosurgery, Kochi Medical School Hospital, Nankoku, Japan
| | - Yuki Hyohdoh
- Centre of Medical Information Science, Kochi University, Kochi, Japan
| | - Hitoshi Ninomiya
- Department of Integrated Centre for Advanced Medical Technologies, Kochi Medical School Hospital, Nankoku, Japan
| | - Yusuke Ueba
- Department of Neurosurgery, Kochi Medical School Hospital, Nankoku, Japan
| | - Tsuyoshi Ohta
- Department of Neurosurgery, Kochi Health Sciences Centre, Kochi, Japan
| | - Yu Kawanishi
- Department of Neurosurgery, Kochi Medical School Hospital, Nankoku, Japan
| | - Tomohito Kadota
- Department of Neurosurgery, Kochi Medical School Hospital, Nankoku, Japan
| | - Fumihiro Hamada
- Department of Neurosurgery, Kochi Medical School Hospital, Nankoku, Japan
| | - Naoki Fukui
- Department of Neurosurgery, Kochi Medical School Hospital, Nankoku, Japan
| | - Motonobu Nonaka
- Department of Neurosurgery, Kochi Medical School Hospital, Nankoku, Japan
| | - Kei Kawada
- Department of Pharmacy, Kochi Medical School Hospital, Nankoku, Japan
| | - Maki Fukuda
- Department of Neurosurgery, Kochi Health Sciences Centre, Kochi, Japan
| | - Yo Nishimoto
- Department of Neurosurgery, Chikamori Hospital, Kochi, Japan
| | | | - Yuji Nojima
- Department of Neurosurgery, Hata Kenmin Hospital, Sukumo, Japan
| | - Namito Kida
- Department of Neurosurgery, Aki General Hospital, Kochi, Japan
| | - Satoru Hayashi
- Department of Neurosurgery, Chikamori Hospital, Kochi, Japan
| | | | | | - Akihito Moriki
- Department of Neurosurgery, Mominoki Hospital, Kochi, Japan
| | - Tetsuya Ueba
- Department of Neurosurgery, Kochi Medical School Hospital, Nankoku, Japan
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18
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Yoshimoto T, Inoue M, Tanaka K, Koge J, Shiozawa M, Kamogawa N, Ishiyama H, Abe S, Imamura H, Kataoka H, Koga M, Ihara M, Toyoda K. Tmax Mismatch Ratio to Identify Intracranial Atherosclerotic Stenosis-Related Large-Vessel Occlusion Before Endovascular Therapy. J Am Heart Assoc 2023:e029899. [PMID: 37421278 PMCID: PMC10382114 DOI: 10.1161/jaha.123.029899] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/24/2023] [Accepted: 05/12/2023] [Indexed: 07/10/2023]
Abstract
Background We aimed to clarify which time-to-maximum of the tissue residue function (Tmax) mismatch ratio is useful in predicting anterior intracranial atherosclerotic stenosis (ICAS)-related large-vessel occlusion (LVO) before endovascular therapy. Methods and Results Patients with ischemic stroke who underwent perfusion-weighted imaging before endovascular therapy for anterior intracranial LVO were divided into those with ICAS-related LVO and those with embolic LVO. Tmax ratios of >10 s/>8 s, >10 s/>6 s, >10 s/>4 s, >8 s/>6 s, >8 s/>4 s, and >6 s/>4 s were considered Tmax mismatch ratios. Binominal logistic regression was used to identify ICAS-related LVO, and the adjusted odds ratio (aOR) and 95% CI for each Tmax mismatch ratio increase of 0.1 were calculated. A similar analysis was performed for ICAS-related LVO with and without embolic sources, using embolic LVO as the reference. Of 213 patients (90 women [42.0%]; median age, 79 years), 39 (18.3%) had ICAS-related LVO. The aOR (95% CI) per 0.1 increase in Tmax mismatch ratio in ICAS-related LVO with embolic LVO as reference was lowest with Tmax mismatch ratio >10 s/>6 s (0.56 [0.43-0.73]). Multinomial logistic regression analysis also showed the lowest aOR (95% CI) per 0.1 increase in Tmax mismatch ratio with Tmax >10 s/>6 s (ICAS-related LVO without embolic source: 0.60 [0.42-0.85]; ICAS-related LVO with embolic source: 0.55 [0.38-0.79]). Conclusions A Tmax mismatch ratio of >10 s/>6 s was the optimal predictor of ICAS-related LVO compared with other Tmax profiles, with or without an embolic source before endovascular therapy. Registration clinicaltrials.gov. Identifier NCT02251665.
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Affiliation(s)
- Takeshi Yoshimoto
- Department of Neurology National Cerebral and Cardiovascular Center Suita Japan
| | - Manabu Inoue
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Kanta Tanaka
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Junpei Koge
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Masayuki Shiozawa
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Naruhiko Kamogawa
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Hiroyuki Ishiyama
- Department of Neurology National Cerebral and Cardiovascular Center Suita Japan
| | - Soichiro Abe
- Department of Neurology National Cerebral and Cardiovascular Center Suita Japan
| | - Hirotoshi Imamura
- Department of Neurosurgery National Cerebral and Cardiovascular Center Suita Japan
| | - Hiroharu Kataoka
- Department of Neurosurgery National Cerebral and Cardiovascular Center Suita Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
| | - Masafumi Ihara
- Department of Neurology National Cerebral and Cardiovascular Center Suita Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine National Cerebral and Cardiovascular Center Suita Japan
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19
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Yoshimoto T. Imaging diagnosis of intracranial atherosclerosis stenosis-related large vessel occlusion before and during endovascular therapy. Front Neurol 2023; 14:1168004. [PMID: 37416315 PMCID: PMC10320000 DOI: 10.3389/fneur.2023.1168004] [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: 02/17/2023] [Accepted: 05/26/2023] [Indexed: 07/08/2023] Open
Abstract
It is becoming increasingly important to identify the type of stroke, especially the mechanism of occlusion, before and during its treatment. In the case of intracranial atherosclerotic stenosis-related large vessel occlusion, it is necessary to develop a treatment strategy that includes not only mechanical thrombectomy but also adjunctive therapies such as primary or rescue therapy (percutaneous angioplasty, intracranial/carotid stenting, local fibrinolysis) and perioperative antithrombotic therapy. However, in clinical practice we often encounter cases where it is difficult to identify the occlusive mechanism before endovascular treatment because of insufficient information in the minimal circumstances of the hyperacute phase of stroke. Here we focus on the imaging diagnosis before and during treatment of intracranial atherosclerotic stenosis-related large vessel occlusion with in situ thrombotic occlusion as the mechanism of thrombotic occlusion, based on previous reports. We describe the diagnosis of intracranial atherosclerotic stenosis-related large vessel occlusion from the perspectives of "thrombus imaging," "perfusion," and "occlusion margin."
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20
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Hoelter P, Lang S, Beuscher V, Kallmuenzer B, Manhart M, Schwab S, Doerfler A. Extended Multimodal Flat Detector CT Imaging in Acute Ischemic Stroke: A Pilot Study. J Digit Imaging 2023; 36:1198-1207. [PMID: 36650300 PMCID: PMC10287862 DOI: 10.1007/s10278-022-00699-4] [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: 06/17/2021] [Revised: 08/18/2022] [Accepted: 08/25/2022] [Indexed: 01/19/2023] Open
Abstract
By using Flat detector computed tomography (FD-CT), a one-stop-shop approach in the diagnostic workup of acute ischemic stroke (AIS) might be achieved. Although information on upstream vessels is warranted, dedicated FD-CT protocols which include the imaging of the cervical vasculature are still lacking. We aimed to prospectively evaluate the implementation of a new multimodal FD-CT protocol including cervical vessel imaging in AIS patients. In total, 16 patients were included in this study. Eight patients with AIS due to large vessel occlusion (LVO) prospectively received a fully multimodal FD-CT imaging, including non-enhanced flat detector computed tomography (NE-FDCT), dynamic perfusion flat detector computed tomography (FD-CTP) and flat detector computed tomography angiography (FD-CTA) including cervical imaging. For comparison of time metrics and image quality, eight AIS patients, which received multimodal CT imaging, were included retrospectively. Although image quality of NE-FDCT and FD-CTA was rated slightly lower than NE-CT and CTA, all FD-CT datasets were of diagnostic quality. Intracerebral hemorrhage exclusion and LVO detection was reliably possible. Median door-to-image time was comparable for the FD-CT group and the control group (CT:30 min, IQR27-58; FD-CT:44.5 min, IQR31-55, p = 0.491). Door-to-groin-puncture time (CT:79.5 min, IQR65-90; FD-CT:59.5 min, IQR51-67; p = 0.016) and image-to-groin-puncture time (CT:44 min, IQR30-50; FD-CT:14 min, IQR12-18; p < 0.001) were significantly shorter, when patients were directly transferred to the angiosuite, where FD-CT took place. Our study indicates that using a new fully multimodal FD-CT approach including imaging of cervical vessels for first-line imaging in AIS patients is feasible and comparable to multimodal CT imaging with substantial potential to streamline the stroke workflow.
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Affiliation(s)
- Philip Hoelter
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen- Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany.
| | - Stefan Lang
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen- Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Vanessa Beuscher
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Bernd Kallmuenzer
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Michael Manhart
- Siemens Healthcare GmbH, Advanced Therapies, Siemensstr. 1, 91301, Forchheim, Germany
| | - Stefan Schwab
- Department of Neurology, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen-Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
| | - Arnd Doerfler
- Department of Neuroradiology, University Hospital Erlangen, Friedrich-Alexander-Universität (FAU) Erlangen- Nürnberg, Schwabachanlage 6, 91054, Erlangen, Germany
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21
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Sha A, Yu F, Zhang M, Shan Y, Guo D, Shakya MR, Bai X, Ma Q, Jiao L, Lu J. Multimodal CT imaging characteristics may predict post-reperfusion infarct volume in wake-up stroke patients. Quant Imaging Med Surg 2023; 13:878-888. [PMID: 36819283 PMCID: PMC9929407 DOI: 10.21037/qims-22-614] [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: 06/16/2022] [Accepted: 12/04/2022] [Indexed: 01/05/2023]
Abstract
Background Accurate prediction of subsequent infarct volume in acute ischemic stroke (AIS) patients helps determine appropriate interventions and prognosis. The objectives are to assess whether early multimodal CT imaging characteristics of wake-up stroke (WUS) patients could predict post-reperfusion infarct volume and evaluate the accuracy of baseline infarct and penumbra volumes for predicting follow-up infarct volume. Methods This retrospective study included WUS patients, last seen well (LSW) >6 h, with multimodal CT imaging at baseline. Baseline non-contrast CT (NCCT) and CT perfusion were analyzed using RAPID software, and CT angiography using maximum intensity projection. Post-reperfusion infarct volume was assessed at 24-h following reperfusion on magnetic resonance diffusion-weighted imaging (DWI). Patients were stratified by treatment module for analyses. Results Of 34 eligible patients, 9 (26.5%) received intravenous recombinant tissue plasminogen activator (r-tPA) alone and 25 (73.5%) received both endovascular thrombectomy (EVT) and r-tPA. All patients had a strong correlation between baseline NCCT alberta stroke program early CT score, clot burden score (CBS), Tan score, infarct volume, penumbra volume with 24-h post-reperfusion infarct volume (respectively, r=0.172, P=0.015; r=0.118, P=0.047; r=0.149, P=0.024; r=0.311, P=0.001 and r=0.120; P=0.045). Among reperfusion therapies, WUS patients who received EVT had a significantly lower 24-h post-reperfusion infarct volume and had a significant difference between baseline infarct volume and 24-h post-reperfusion infarct volume (respectively, 82 vs. 14, P=0.032 and 47 vs. 14, P=0.04). Conclusions Primarily obtained multimodal CT imaging characteristics may predict post-reperfusion infarct volume in WUS patients, and those who underwent EVT had a significantly lower post-reperfusion infarct volume.
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Affiliation(s)
- Arman Sha
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China;,Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, China
| | - Fan Yu
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China;,Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, China
| | - Miao Zhang
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China;,Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, China
| | - Yi Shan
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China;,Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, China
| | - Daode Guo
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China;,Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, China
| | - Milind Ratna Shakya
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China;,Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, China
| | - Xuesong Bai
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China;,China International Neuroscience Institute (China-INI), Beijing, China
| | - Qingfeng Ma
- Department of Neurology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China;,China International Neuroscience Institute (China-INI), Beijing, China;,Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jie Lu
- Department of Radiology and Nuclear Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China;,Beijing Key Laboratory of Magnetic Resonance Imaging and Brain Informatics, Beijing, China
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22
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Pan X, Ma S, Sui X, Xie L, Li F, Cheng Z, Cui L, Zhao H. The effects of the coronavirus disease pandemic on intravenous thrombolytic therapy among patients with acute ischemic stroke in Dalian, China. BMC Neurol 2023; 23:10. [PMID: 36624392 PMCID: PMC9827008 DOI: 10.1186/s12883-023-03053-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2022] [Accepted: 01/04/2023] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND We investigated the influence of the coronavirus disease 2019 (COVID-19) pandemic on the number of patients with acute ischemic stroke who received intravenous thrombolytic therapy (ITT) in Dalian, China, in 2020. METHODS This retrospective descriptive study, conducted from February 1, 2020, to August 31, 2020, examined 13 hospitals in Dalian that participated in the "stroke emergency map". To use this "stroke emergency map" of China, patients followed the official "Stroke Map" WeChat account and dialed 120 for emergency medical services. We analyzed the number of patients with acute ischemic stroke who underwent ITT. In particular, we examined the onset-to-door time (ODT), door-to-needle time (DNT), onset-to-needle time (ONT), mode of transportation to the hospital, and National Institutes of Health Stroke Scale (NIHSS) scores before and after ITT. Data were collected for the aforementioned period and compared with the 2021 baseline data from the same time of year. The Mann‒Whitney U test was performed for data analysis. RESULTS Compared with the data from 2020, the number of patients with acute ischemic stroke who underwent ITT increased (from 735 to 1719 cases) in 2021, but the DNT decreased (from 59 to 45 min; P = 0.002). Moreover, 83.9% of patients in 2020 presented to the hospital without ambulance transport, compared to 81.1% of patients in the 2021 non-COVID-19 pandemic period. Patients with NIHSS scores of 6-14 were more likely to call an ambulance for transport to the hospital than to transport themselves to the emergency department. CONCLUSIONS During the 2020 COVID-19 pandemic, the DNT was prolonged as a result of strengthened fever surveillance. In 2021, the number of patients with acute ischemic stroke who underwent ITT increased compared to the previous year. Notably, the growth in the number of patients with acute ischemic stroke who underwent ITT benefited from both the "stroke emergency map" of China and the "green channel," a novel treatment approach that focuses on the rational design of the rescue process. TRIAL REGISTRATION Our study was a retrospective descriptive study, not a clinical trial, thus we did not have to register for clinical trials.
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Affiliation(s)
- Xin Pan
- grid.452337.40000 0004 0644 5246Department of Neurology, Dalian Municipal Central Hospital Affiliated With Dalian Medical University, No. 826, Southwest Road, Shahekou District, Dalian, 116033 Liaoning Province China
| | - Shubei Ma
- grid.452337.40000 0004 0644 5246Department of Neurology, Dalian Municipal Central Hospital Affiliated With Dalian Medical University, No. 826, Southwest Road, Shahekou District, Dalian, 116033 Liaoning Province China
| | - Xiaowen Sui
- grid.452337.40000 0004 0644 5246Department of Neurology, Dalian Municipal Central Hospital Affiliated With Dalian Medical University, No. 826, Southwest Road, Shahekou District, Dalian, 116033 Liaoning Province China
| | - Lili Xie
- grid.452337.40000 0004 0644 5246Department of Neurology, Dalian Municipal Central Hospital Affiliated With Dalian Medical University, No. 826, Southwest Road, Shahekou District, Dalian, 116033 Liaoning Province China
| | - Furong Li
- grid.452337.40000 0004 0644 5246Department of Neurology, Dalian Municipal Central Hospital Affiliated With Dalian Medical University, No. 826, Southwest Road, Shahekou District, Dalian, 116033 Liaoning Province China
| | - Zhengping Cheng
- grid.452337.40000 0004 0644 5246Department of Neurology, Dalian Municipal Central Hospital Affiliated With Dalian Medical University, No. 826, Southwest Road, Shahekou District, Dalian, 116033 Liaoning Province China
| | - Li Cui
- grid.452337.40000 0004 0644 5246Department of Neurology, Dalian Municipal Central Hospital Affiliated With Dalian Medical University, No. 826, Southwest Road, Shahekou District, Dalian, 116033 Liaoning Province China
| | - Hongling Zhao
- grid.452337.40000 0004 0644 5246Department of Neurology, Dalian Municipal Central Hospital Affiliated With Dalian Medical University, No. 826, Southwest Road, Shahekou District, Dalian, 116033 Liaoning Province China ,grid.452337.40000 0004 0644 5246Stroke Center, Dalian Municipal Central Hospital Affiliated With Dalian Medical University, Dalian, 116033 Liaoning Province China
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23
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Bui TA, Jickling GC, Winship IR. Neutrophil dynamics and inflammaging in acute ischemic stroke: A transcriptomic review. Front Aging Neurosci 2022; 14:1041333. [PMID: 36620775 PMCID: PMC9813499 DOI: 10.3389/fnagi.2022.1041333] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2022] [Accepted: 11/28/2022] [Indexed: 12/24/2022] Open
Abstract
Stroke is among the leading causes of death and disability worldwide. Restoring blood flow through recanalization is currently the only acute treatment for cerebral ischemia. Unfortunately, many patients that achieve a complete recanalization fail to regain functional independence. Recent studies indicate that activation of peripheral immune cells, particularly neutrophils, may contribute to microcirculatory failure and futile recanalization. Stroke primarily affects the elderly population, and mortality after endovascular therapies is associated with advanced age. Previous analyses of differential gene expression across injury status and age identify ischemic stroke as a complex age-related disease. It also suggests robust interactions between stroke injury, aging, and inflammation on a cellular and molecular level. Understanding such interactions is crucial in developing effective protective treatments. The global stroke burden will continue to increase with a rapidly aging human population. Unfortunately, the mechanisms of age-dependent vulnerability are poorly defined. In this review, we will discuss how neutrophil-specific gene expression patterns may contribute to poor treatment responses in stroke patients. We will also discuss age-related transcriptional changes that may contribute to poor clinical outcomes and greater susceptibility to cerebrovascular diseases.
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Affiliation(s)
- Truong An Bui
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
| | - Glen C. Jickling
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
- Department of Medicine, Division of Neurology, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Ian R. Winship
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
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Lin CW, Huang HY, Guo JH, Chen WL, Shih HM, Chu HT, Wang CC, Hsu TY. Does Weekends Effect Exist in Asia? Analysis of Endovascular Thrombectomy for Acute Ischemic Stroke in A Medical Center. Curr Neurovasc Res 2022; 19:225-231. [PMID: 35894472 PMCID: PMC9900696 DOI: 10.2174/1567202619666220727094020] [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: 04/03/2022] [Revised: 04/14/2022] [Accepted: 04/22/2022] [Indexed: 01/27/2023]
Abstract
BACKGROUND Discussing the quality measurements based on interrupted time series in ischemic stroke, delays are often attributed to weekends effect. This study compared the metrics and outcomes of emergent endovascular thrombectomy (EST) during working hours versus non-working hours in the emergency department of an Asian medical center. METHODS A total of 297 patients who underwent EST between January 2015 and December 2018 were retrospectively included, with 52.5% of patients presenting during working hours and 47.5% presenting during nights, weekends, or holidays. RESULTS Patients with diabetes were more in non-working hours than in working hours (53.9% vs. 41.0%; p=0.026). It took longer during nonworking hours than working hours in door-to -image times (13 min vs. 12 min; p=0.04) and door-to-groin puncture times (median: 112 min vs. 104 min; p=0.042). Significant statistical differences were not observed between the two groups in neurological outcomes, including successful reperfusion and complications such as intracranial hemorrhage and mortality. However, the change in National Institute of Health Stroke Scale (NIHSS) scores in 24 hours was better in the working-hour group than in the nonworking-hour group (4 vs. 2; p=0.058). CONCLUSION This study revealed that nonworking-hour effects truly exist in patients who received EST. Although delays in door-to-groin puncture times were noticed during nonworking hours, significant differences in neurological functions and mortality were not observed between working and non-working hours. Nevertheless, methods to improve the process during non-working hours should be explored in the future.
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Affiliation(s)
- Chia-Wei Lin
- Department of Emergency Medicine, China Medical University Hospital, Taichung, Taiwan;,Doctoral Degree Program in Artificial Intelligence, Asia University, Taichung, Taiwan
| | - Hung-Yu Huang
- Department of Neurology, China Medical University Hospital, Taichung, Taiwan
| | - Jeng-Hung Guo
- Department of Neurosurgery, China Medical University Hospital, Taichung, Taiwan;,Graduate Institute of Biomedical Sciences, China Medical University, Taichung, Taiwan
| | - Wei-Laing Chen
- Department of Neuroradiology, China Medical University Hospital, Taichung, Taiwan
| | - Hong-Mo Shih
- Department of Emergency Medicine, China Medical University Hospital, Taichung, Taiwan;,Department of Public Health, China Medical University, Taipei, Taiwan
| | - Hsueh-Ting Chu
- Doctoral Degree Program in Artificial Intelligence, Asia University, Taichung, Taiwan
| | - Charles C.N. Wang
- Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan;,Center for Precision Health Research, Asia University, Taichung, Taiwan,Address correspondence to these authors at the Department of Bioinformatics and Medical Engineering, Asia University, Taichung, Taiwan and Center for Precision Health Research, Asia University, Taichung, Taiwan; E-mails: ;
| | - Tai-Yi Hsu
- Department of Emergency Medicine, China Medical University Hospital, Taichung, Taiwan
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Han S, Huang R, Yao F, Lu Z, Zhu J, Wang H, Li Y. Pre-treatment spectral CT combined with CT perfusion can predict hemorrhagic transformation after thrombolysis in patients with acute ischemic stroke. Eur J Radiol 2022; 156:110543. [PMID: 36179464 DOI: 10.1016/j.ejrad.2022.110543] [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: 06/28/2022] [Revised: 08/18/2022] [Accepted: 09/19/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE To investigate the value of pre-treatment spectral CT angiography (CTA) in predicting hemorrhagic transformation (HT) after intravenous thrombolysis (IVT) treatment in acute ischemic stroke (AIS) patients. MATERIALS AND METHODS AIS patients who underwent IVT with recombinant tissue plasminogen activator and pre-treatment head and neck spectral CTA and head CT perfusion (CTP) from January 2018 to June 2020 were reviewed retrospectively. Finally, 20 patients were included in the HT group and 22 age-matched patients were included in the non-HT group. Spectral and CTP parameters of the region of interest on pre-treatment CTA axial raw images and CTP images, including the infarct core (IC) and ischemic penumbral (IP) regions, were recorded. The differences in clinical variables, CTP, collateral scores and spectral parameters between the two groups were analyzed. Three multivariate logistic regression models were then developed, where model 1 included clinical and spectral parameters, model 2 included clinical and CTP parameters and a combined model included clinical, CTP, and spectral parameters. Receiver operating characteristic analysis was used to evaluate the performance of the multivariate model. RESULTS Patients with HT had higher Safe Implementation of Treatments in Stroke (SITS) score (p = 0.023), the volume of perfusion lesions (p = 0.005), the volume of IP (p = 0.003), the mean transit time (MIT) in the IC area (p = 0.012), as well as the TTP in IP area (p = 0.015) compared with patients without HT. The HT group showed significantly lower CBF in the IC area (p = 0.019), iodine concentration (p = 0.017) and the effective atomic number (p = 0.024) in the IP area than non-HT group. And the slope of the spectral curve of the HT group in the IP region was larger than that of the non-HT group (p = 0.023). Gender, age, SITS score, the volume of entire perfusion lesion, CBF and MIT in the IC area, TTP in the IP area, as well as iodine concentration in the IP area were included in the final multivariate model for predicting HT. And CBF in the IC area (OR = 0.779, 95 % CI:0.609-0.996, p = 0.046) as well as the iodine concentration of IP area (OR = 0.343, 95 % CI: 0.131-0.901, p = 0.030) were proved to be independent predictors for HT. The combined model including clinical, spectral, and CTP parameters, showed improved accuracy compared to the other two models, while the Delong test did not suggest a statistically significant difference (both p values > 0.05). CONCLUSIONS The iodine concentration of IP area derived from pre-treatment spectral CTA was an independent predictor of HT after IVT treatment for AIS patients. Moreover, multivariate models combined with clinical, spectral, and CTP parameters may be able to predict HT.
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Affiliation(s)
- Shuting Han
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou City, Jiangsu Province 215000, PR China
| | - Renjun Huang
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou City, Jiangsu Province 215000, PR China
| | - Feirong Yao
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou City, Jiangsu Province 215000, PR China
| | - Ziwei Lu
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou City, Jiangsu Province 215000, PR China
| | - Jingfen Zhu
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou City, Jiangsu Province 215000, PR China
| | - Hui Wang
- Department of Neurology, The First Affiliated Hospital of Soochow University, Suzhou City, Jiangsu Province 215000, PR China.
| | - Yonggang Li
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou City, Jiangsu Province 215000, PR China; Institute of Medical Imaging, Soochow University, Suzhou City, Jiangsu Province 215000, PR China; National Clinical Research Center for Hematologic Diseases, the First Affiliated Hospital of Soochow University, Suzhou City, Jiangsu Province 215000, PR China.
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Ohgaki F, Shimizu N, Suenaga J, Tateishi K, Ikegaya N, Suzuki R, Yamamura K, Yamamoto T. Availability of tracheal shift in the chest X-ray image as pre-treatment evaluation of mechanical thrombectomy. Neuroradiol J 2022; 35:627-633. [PMID: 35581955 PMCID: PMC9513920 DOI: 10.1177/19714009221084237] [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: 11/16/2022] Open
Abstract
BACKGROUND The use of mechanical thrombectomy (MT) for treatment of acute large vessel occlusion has recently increased. Prompt and timely guiding catheter (GC) induction is necessary to improve prognosis of MT and reduce the time for recanalization. However, difficulties in GC induction are encountered in some patients. This GC induction depends mainly on the aortic arch structure. Therefore, this study focused on assessing presence of tracheal shift on chest X-ray images as pre-treatment evaluation method for GC induction due to its wide availability as an indicator for status of the mediastinum. METHODS We retrospectively examined 33 patients who underwent MT at our facilities between April 2017 and March 2021. The patients were divided into two groups according to presence or absence of tracheal shift on chest X-ray images. Background characteristics and treatment courses in these two groups were compared. RESULTS Among 33 patients, tracheal shift was observed on the chest X-ray images of 14 patients. Furthermore, tracheal shift was positively correlated with the time of GC induction (32.9 min vs. 11.6 min, [p < 0.05]) and the female sex (p = 0.03). Additionally, tracheal shift exhibited correlations with multiple risk factors of atherosclerosis (p = 0.04). CONCLUSIONS In patients with tracheal shift, GC induction could be expectedly difficult. Therefore, advanced disinfection of the right upper arm and affected side of the neck during MT in preparation for changing an approach route is required.
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Affiliation(s)
- Fukutaro Ohgaki
- Department of Neurosurgery,
Graduate School of Medicine, School of Medicine, Yokohama City
University, Yokohama, Japan
| | - Nobuyuki Shimizu
- Department of Neurosurgery,
Graduate School of Medicine, School of Medicine, Yokohama City
University, Yokohama, Japan
| | - Jun Suenaga
- Department of Neurosurgery,
Graduate School of Medicine, School of Medicine, Yokohama City
University, Yokohama, Japan
| | - Kensuke Tateishi
- Department of Neurosurgery,
Graduate School of Medicine, School of Medicine, Yokohama City
University, Yokohama, Japan
| | - Naoki Ikegaya
- Department of Neurosurgery,
Graduate School of Medicine, School of Medicine, Yokohama City
University, Yokohama, Japan
| | - Ryosuke Suzuki
- Department of Neurosurgery,
Graduate School of Medicine, School of Medicine, Yokohama City
University, Yokohama, Japan
| | - Koji Yamamura
- Department of Neurosurgery, Nishiarai Hospital, Tokyo, Japan
| | - Tetsuya Yamamoto
- Department of Neurosurgery,
Graduate School of Medicine, School of Medicine, Yokohama City
University, Yokohama, Japan
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Kilbride BF, Narsinh KH, Jordan CD, Mueller K, Moore T, Martin AJ, Wilson MW, Hetts SW. MRI-guided endovascular intervention: current methods and future potential. Expert Rev Med Devices 2022; 19:763-778. [PMID: 36373162 PMCID: PMC9869980 DOI: 10.1080/17434440.2022.2141110] [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: 04/06/2022] [Accepted: 10/25/2022] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Image-guided endovascular interventions, performed using the insertion and navigation of catheters through the vasculature, have been increasing in number over the years, as minimally invasive procedures continue to replace invasive surgical procedures. Such endovascular interventions are almost exclusively performed under x-ray fluoroscopy, which has the best spatial and temporal resolution of all clinical imaging modalities. Magnetic resonance imaging (MRI) offers unique advantages and could be an attractive alternative to conventional x-ray guidance, but also brings with it distinctive challenges. AREAS COVERED In this review, the benefits and limitations of MRI-guided endovascular interventions are addressed, systems and devices for guiding such interventions are summarized, and clinical applications are discussed. EXPERT OPINION MRI-guided endovascular interventions are still relatively new to the interventional radiology field, since significant technical hurdles remain to justify significant costs and demonstrate safety, design, and robustness. Clinical applications of MRI-guided interventions are promising but their full potential may not be realized until proper tools designed to function in the MRI environment are available. Translational research and further preclinical studies are needed before MRI-guided interventions will be practical in a clinical interventional setting.
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Affiliation(s)
- Bridget F. Kilbride
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Kazim H. Narsinh
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | | | | | - Teri Moore
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Alastair J. Martin
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Mark W. Wilson
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
| | - Steven W. Hetts
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, San Francisco, CA, USA
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28
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Holtmannspötter M, Crossley RA, Liebig T, Gallagher AG. Metric-Based Simulation Training to Proficiency for Endovascular Thrombectomy in Ischemic Stroke. Front Neurol 2022; 13:742263. [PMID: 36237633 PMCID: PMC9551015 DOI: 10.3389/fneur.2022.742263] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 06/22/2022] [Indexed: 11/17/2022] Open
Abstract
Ischemic stroke is one of the leading causes of death and long-term disability in the West. Mechanical revascularization techniques are considered the standard of care for large vessel occlusive stroke. Traditional apprenticeship models involve doctors training their skills on patients. Simulation platforms have long been recognized as an alternative to this. There has however been very little robust assessment of the training outcomes achieved on some of these platforms. At best, these simulations increase understanding of the procedural process and may help improve some technical skills; at worst they may instill bad habits and poor technique. The prerequisite of any simulation process must be to teach what to do, with which devices, in the correct sequence as well as what not to do. It should provide valid metric-based feedback to the trainee that is objective, transparent, and fair for formative and summative performance feedback. It should deliver a training program that measures the performance progress of trainees against expert benchmarks—benchmarks that represent an evidence-based peer-reviewed standard. In this paper, we present a perspective for PBP training for thrombectomy based on our experience with the process of procedure characterization, metric validation, and early experience of using this approach for proficiency training. Patient outcomes are not only determined by optimal performance in the Angio Suite but also by an efficient patient procedure pathway. There will be value in utilizing the PBP training standard not only for the procedure itself but also for the constituent elements of the stroke pathway to further improve treatment outcomes for ischemic stroke patients.
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Affiliation(s)
- Markus Holtmannspötter
- Department of Neuroradiology, Nuremberg General Hospital, Paracelsus Medical University, Nuremberg, Germany
- *Correspondence: Markus Holtmannspötter
| | - Robert A. Crossley
- North Bristol National Health Service (NHS) Trust, Bristol, United Kingdom
| | - Thomas Liebig
- Department of Neuroradiology, Ludwig-Maximilians-University (LMU) Munich University Hospital, Munich, Germany
| | - Anthony G. Gallagher
- Faculty of Medicine, Katholieke Universiteit (KU) Leuven, Leuven, Belgium
- Orsi Academy, Melle, Belgium
- School of Medicine, Faculty of Life and Health Sciences, University of Ulster, Coleraine, United Kingdom
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Hypoperfusion Intensity Ratio is Associated with Stroke Mechanism in Patients Undergoing Mechanical Thrombectomy. J Stroke Cerebrovasc Dis 2022; 31:106539. [PMID: 35550982 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106539] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2022] [Revised: 04/17/2022] [Accepted: 04/24/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Hypoperfusion Intensity Ratio (HIR), defined as Tmax >10s/Tmax >6s on computed tomography perfusion (CTP), and stroke mechanisms have been independently correlated with angiographic collaterals and patient outcomes. Slowly developing atherosclerotic stenosis may foster collateral development, whereas cardioembolic occlusion may occur before collaterals mature. We hypothesized that favorable HIR is associated with large artery atherosclerosis (LAA) stroke mechanism and good clinical outcome. METHODS Retrospective study of consecutive endovascularly-treated stroke patients with intracranial ICA or MCA M1/M2 occlusions, who underwent CTP before intervention, between January 2018 and August 2021. Patients were dichotomized into LAA+ or LAA- based on presence of LAA on angiography. HIR was dichotomized into favorable (HIR+) or unfavorable (HIR-) groups based on published thresholds. Good early outcome was defined as discharge mRS of 0-2. Bivariate and multivariable logistic regression were performed. RESULTS 143 patients met inclusion. 21/143 were LAA+ (15%) and 65/143 (45%) were HIR+. HIR+ was significantly more frequent in LAA+ patients (67% vs. 42%, p= 0.035). Controlling for demographics, stroke severity, imaging findings, and medical comorbidities, LAA+ remained independently associated with HIR+ (OR 5.37 [95% CI 1.43 - 20.14]; p=0.013) as did smaller infarction core volume (<30 mL of CBF <30%: OR 7.92 [95% CI 2.27 - 27.64]; p = 0.001). HIR+ was not associated with good clinical outcome. CONCLUSIONS Large artery atherosclerosis was independently associated with favorable HIR in patients undergoing mechanical thrombectomy. While favorable HIR was associated with smaller pre-treatment core infarcts, reflecting more robust collaterals, it was not associated with good clinical outcome.
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30
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Pennington Z, Michalopoulos GD, Biedermann AJ, Ziegler JR, Durst SL, Spinner RJ, Meyer FB, Daniels DJ, Bydon M. Positive impact of the pandemic: the effect of post-COVID-19 virtual visit implementation on departmental efficiency and patient satisfaction in a quaternary care center. Neurosurg Focus 2022; 52:E10. [PMID: 35921181 DOI: 10.3171/2022.3.focus2243] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 03/07/2022] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The coronavirus disease 2019 (COVID-19) pandemic has significantly changed clinical practice across US healthcare. Increased adoption of telemedicine has emerged as an alternative to in-person contact for patient-physician interactions. The aim of this study was to analyze the impact of telemedicine on workflow and care delivery from January 2019 to December 2021 in a neurosurgical department at a quaternary care center. METHODS Prospectively captured data on clinic appointment utilization, duration, and outcomes were queried. Visits were divided into in-person visits and telemedicine appointments, categorized as follow-up visits of previously surgically treated patients, internal consultations, new patient visits, and early postoperative returns after surgery. Appointment volume was compared pre- and postpandemic using March 2020 as the pandemic onset. Clinical efficiency was measured by time to appointment, rate of on-time appointments, proportion of appointments resulting in surgical intervention (surgical yield), and patient-reported satisfaction, the latter measured as the proportion of patients indicating "high likelihood to recommend practice." RESULTS A total of 54,562 visits occurred, most commonly for follow-up for previously operated patients (51.8%), internal new patient referrals (24.5%), and external new patient referrals (19.8%). Total visit volume was stable pre- to postpandemic (1521.3 vs 1512, p = 0.917). However, in-person visits significantly decreased (1517/month vs 1220/month, p < 0.001), with a nadir in April 2020, while telemedicine appointment utilization increased significantly (0.3% vs 19.1% of all visits). Telemedicine utilization remained stable throughout the 1st calendar year following the pandemic. Telemedicine appointments were associated with shorter time to appointment than in-person visits both before and after the pandemic onset (0-5 days from appointment request: 60% vs 33% vs 29.8%, p < 0.001). Patients had on-time appointments in 87% of telemedicine encounters. Notably, telemedicine appointments resulted in surgery in 31.8% of internal consultations or new patient visits, a significantly lower rate than that for in-person visits (51.8%). After the widespread integration of telemedicine, patient satisfaction for all visits was higher than before the pandemic onset (85.9% vs 88.5%, p = 0.027). CONCLUSIONS Telemedicine use significantly increased following the pandemic onset, compensating for observed decreases in face-to-face visits. Utilization rates have remained stable, suggesting effective integration, and delays between referrals and appointments were lower than for in-person visits. Importantly, telemedicine integration was not associated with a decrease in overall patient satisfaction, although telemedicine appointments had a lower surgical yield. These data suggest that telemedicine smoothened the impact of the pandemic on clinical workflow and helped to maintain continuity and quality of outpatient care.
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Affiliation(s)
- Zach Pennington
- 1Department of Neurologic Surgery and.,2Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
| | - Giorgos D Michalopoulos
- 1Department of Neurologic Surgery and.,2Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
| | | | | | | | | | | | | | - Mohamad Bydon
- 1Department of Neurologic Surgery and.,2Neuro-Informatics Laboratory, Mayo Clinic, Rochester, Minnesota
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31
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Ortega‐Gutierrez S, Quispe‐Orozco D, Schafer S, Farooqui M, Zevallos CB, Dandapat S, Mendez‐Ruiz A, Aagaard‐Kienitz B, Petersen N, Derdeyn CP. Angiography suite cone-beam CT perfusion for selection of thrombectomy patients: A pilot study. J Neuroimaging 2022; 32:493-501. [PMID: 35315169 PMCID: PMC9314685 DOI: 10.1111/jon.12988] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 02/07/2022] [Accepted: 02/26/2022] [Indexed: 11/30/2022] Open
Abstract
BACKGROUND AND PURPOSE The availability of cone-beam CT perfusion (CBCTP) in angiography suites may improve large-vessel occlusion (LVO) triage and reduce reperfusion times for patients presenting during extended time window. We aim to evaluate the perfusion maps correlation and agreement between multidetector CT perfusion (MDCTP) and CBCTP when obtained sequentially in patients undergoing endovascular therapy. METHODS This is a prospective, pilot, single-arm interventional cohort study of consecutive patients with anterior circulation LVO. All patients underwent MDCTP and CBCTP prior to endovascular therapy, generating cerebral blood flow (CBF), cerebral blood volume (CBV), mean transit time (MTT), and time-to-maximum/time to peak contrast concentration maps. We compared the two imaging modalities using three different methods: (1) six regions of interest (ROIs) placed in the anterior circulation territory; (2) ROIs placed in all 10 Alberta Stroke Program Early CT Score regions; and (3) ROI drawn around the entire ischemic area. ROI ratios (unaffected/affected area) were compared for all sequences in each method. We used the intraclass correlation coefficient to calculate the correlation between the studies. Bland-Altman plots were also created to measure the degree of agreement. Finally, a sensitivity analysis was done comparing both modalities in patients with low infarct growth rate. RESULTS Fourteen patients were included (median age 81 years [74-87], 50% males, median National Institutes of Health Stroke Scale 19 [14-22]). Median time between studies was 42 minutes (interquartile range 29-61). Independently of the method used, we found moderate to excellent correlation in CBF, CBV, and MTT between modalities. CBF correlation further improved in patients with low infarct growth. CONCLUSION These results demonstrate promising accuracy of CBCTP in evaluating ischemic tissue in patients presenting with LVO ischemic stroke.
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Affiliation(s)
- Santiago Ortega‐Gutierrez
- Department of NeurologyUniversity of Iowa Carver College of Medicine, Comprehensive Stroke CenterIowa CityIowaUSA
- Department of NeurosurgeryUniversity of Iowa Carver College of Medicine, Comprehensive Stroke CenterIowa CityIowaUSA
- Department of RadiologyUniversity of Iowa Carver College of Medicine, Comprehensive Stroke CenterIowa CityIowaUSA
| | - Darko Quispe‐Orozco
- Department of NeurologyUniversity of Iowa Carver College of Medicine, Comprehensive Stroke CenterIowa CityIowaUSA
| | | | - Mudassir Farooqui
- Department of NeurologyUniversity of Iowa Carver College of Medicine, Comprehensive Stroke CenterIowa CityIowaUSA
| | - Cynthia B Zevallos
- Department of NeurologyUniversity of Iowa Carver College of Medicine, Comprehensive Stroke CenterIowa CityIowaUSA
| | | | - Alan Mendez‐Ruiz
- Department of NeurologyUniversity of Iowa Carver College of Medicine, Comprehensive Stroke CenterIowa CityIowaUSA
| | - Beverly Aagaard‐Kienitz
- Department of RadiologyUniversity of Wisconsin School of Medicine and Public HealthMadisonWisconsinUSA
| | - Nils Petersen
- Department of NeurologyYale University School of MedicineNew HavenConnecticutUSA
| | - Colin P. Derdeyn
- Department of NeurologyUniversity of Iowa Carver College of Medicine, Comprehensive Stroke CenterIowa CityIowaUSA
- Department of NeurosurgeryUniversity of Iowa Carver College of Medicine, Comprehensive Stroke CenterIowa CityIowaUSA
- Department of RadiologyUniversity of Iowa Carver College of Medicine, Comprehensive Stroke CenterIowa CityIowaUSA
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Hariharan P, Tariq MB, Grotta JC, Czap AL. Mobile Stroke Units: Current Evidence and Impact. Curr Neurol Neurosci Rep 2022; 22:71-81. [PMID: 35129761 DOI: 10.1007/s11910-022-01170-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/15/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE OF REVIEW Several approaches have been developed to optimize prehospital systems for acute stroke given poor access and significant delays to timely treatment. Specially equipped ambulances that directly initiate treatment, known as Mobile Stroke Units (MSUs), have rapidly proliferated across the world. This review provides a comprehensive summary on the efficacy of MSUs in acute stroke, its various applications beyond thrombolysis, as well as the establishment, optimal setting and cost-effectiveness of incorporating an MSU into healthcare systems. RECENT FINDINGS MSUs speed stroke treatment into the first "golden hour" when better outcomes from thrombolysis are achieved. While evidence for the positive impact of MSUs on outcomes was previously unavailable, two recent landmark controlled trials, B_PROUD and BEST-MSU, show that MSUs result in significantly lesser disability compared to conventional ambulance care. Emerging literature prove the significant impact of MSUs. Adaptability however remains limited by significant upfront financial investment, challenges with reimbursements and pending evidence on their cost-effectiveness.
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Affiliation(s)
- Praveen Hariharan
- Department of Neurology, McGovern Medical School at the University of Texas Health Science Center, 6431 Fannin St, MSB 7.044, Houston, TX, 77030, USA
| | - Muhammad Bilal Tariq
- Department of Neurology, McGovern Medical School at the University of Texas Health Science Center, 6431 Fannin St, MSB 7.044, Houston, TX, 77030, USA
| | - James C Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital Texas Medical Center, Houston, TX, USA
| | - Alexandra L Czap
- Department of Neurology, McGovern Medical School at the University of Texas Health Science Center, 6431 Fannin St, MSB 7.044, Houston, TX, 77030, USA.
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33
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Jahan R, Saver JL. Endovascular Treatment of Acute Ischemic Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00067-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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34
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Navarro JC, Kofke WA. Perioperative Management of Acute Central Nervous System Injury. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00024-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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35
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Boltyenkov AT, Martinez G, Pandya A, Katz JM, Wang JJ, Naidich JJ, Rula E, Sanelli PC. Cost-Consequence Analysis of Advanced Imaging in Acute Ischemic Stroke Care. Front Neurol 2021; 12:774657. [PMID: 34899583 PMCID: PMC8662622 DOI: 10.3389/fneur.2021.774657] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2021] [Accepted: 11/02/2021] [Indexed: 12/02/2022] Open
Abstract
Introduction: The purpose of this study was to illustrate the potential costs and health consequences of implementing advanced CT angiography and perfusion (CTAP) as the initial imaging in patients presenting with acute ischemic stroke (AIS) symptoms at a comprehensive stroke center (CSC). Methods: A decision-simulation model based on the American Heart Association's recommendations for AIS care pathways was developed to assess imaging strategies for a 5-year period from the institutional perspective. The following strategies were compared: (1) advanced CTAP imaging: NCCT + CTA + CT perfusion at the time of presentation; (2) standard-of-care: non-contrast CT (NCCT) at the time of presentation, with CT angiography (CTA) ± CT perfusion only in select patients (initial imaging to exclude hemorrhage and extensive ischemia) for mechanical thrombectomy (MT) evaluation. Model parameters were defined with evidence-based data. Cost-consequence and sensitivity analyses were performed. The modified Rankin Scale (mRS) at 90 days was used as the outcome measure. Results: The decision-simulation modeling revealed that adoption of the advanced CTAP imaging increased per-patient imaging costs by 1.19% ($9.28/$779.72), increased per-patient treatment costs by 33.25% ($729.96/$2,195.24), and decreased other per-patient acute care costs by 0.7% (–$114.12/$16,285.85). The large increase in treatment costs was caused by higher proportion of patients being treated. However, improved outcomes lowered the other per-patient acute care costs. Over the five-year period, advanced CTAP imaging led to 1.63% (66/4,040) more patients with good outcomes (90-day mRS 0-2), 2.23% (66/2,960) fewer patients with poor outcomes (90-day mRS 3-5), and no change in mortality (90-day mRS 6). Our CT equipment utilization analysis showed that the demand for CT equipment in terms of scanner time (minutes) was 24% lower in the advanced CTAP imaging strategy compared to the standard-of-care strategy. The number of EVT procedures performed at the CSC may increase by 50%. Conclusions: Our study reveals that adoption of advanced CTAP imaging at presentation increases the demand for treatment of acute ischemic stroke patients as more patients are diagnosed within the treatment time window compared to standard-of-care imaging. Advanced imaging also leads to more patients with good functional outcomes and fewer patients with dependent functional status.
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Affiliation(s)
- Artem T Boltyenkov
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, NY, United States.,Siemens Healthcare, Malvern, PA, United States.,Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Hempstead, NY, United States
| | - Gabriela Martinez
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, NY, United States.,Siemens Healthcare, Malvern, PA, United States.,Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Hempstead, NY, United States
| | - Ankur Pandya
- Department of Health Policy and Management, School of Public Health, Harvard University, Boston, MA, United States
| | - Jeffrey M Katz
- Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Hempstead, NY, United States.,Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Hempstead, NY, United States
| | - Jason J Wang
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, NY, United States
| | - Jason J Naidich
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, NY, United States.,Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Hempstead, NY, United States
| | - Elizabeth Rula
- Harvey L. Neiman Health Policy Institute, Reston, VA, United States
| | - Pina C Sanelli
- Center for Health Innovations and Outcomes Research, Feinstein Institute for Medical Research, Manhasset, NY, United States.,Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra-Northwell, Hempstead, NY, United States
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Hood RJ, Maltby S, Keynes A, Kluge MG, Nalivaiko E, Ryan A, Cox M, Parsons MW, Paul CL, Garcia-Esperon C, Spratt NJ, Levi CR, Walker FR. Development and Pilot Implementation of TACTICS VR: A Virtual Reality-Based Stroke Management Workflow Training Application and Training Framework. Front Neurol 2021; 12:665808. [PMID: 34858305 PMCID: PMC8631764 DOI: 10.3389/fneur.2021.665808] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2021] [Accepted: 10/18/2021] [Indexed: 11/13/2022] Open
Abstract
Delays in acute stroke treatment contribute to severe and negative impacts for patients and significant healthcare costs. Variability in clinical care is a contributor to delayed treatment, particularly in rural, regional and remote (RRR) areas. Targeted approaches to improve stroke workflow processes improve outcomes, but numerous challenges exist particularly in RRR settings. Virtual reality (VR) applications can provide immersive and engaging training and overcome some existing training barriers. We recently initiated the TACTICS trial, which is assessing a "package intervention" to support advanced CT imaging and streamlined stroke workflow training. As part of the educational component of the intervention we developed TACTICS VR, a novel VR-based training application to upskill healthcare professionals in optimal stroke workflow processes. In the current manuscript, we describe development of the TACTICS VR platform which includes the VR-based training application, a user-facing website and an automated back-end data analytics portal. TACTICS VR was developed via an extensive and structured scoping and consultation process, to ensure content was evidence-based, represented best-practice and is tailored for the target audience. Further, we report on pilot implementation in 7 Australian hospitals to assess the feasibility of workplace-based VR training. A total of 104 healthcare professionals completed TACTICS VR training. Users indicated a high level of usability, acceptability and utility of TACTICS VR, including aspects of hardware, software design, educational content, training feedback and implementation strategy. Further, users self-reported increased confidence in their ability to make improvements in stroke management after TACTICS VR training (post-training mean ± SD = 4.1 ± 0.6; pre-training = 3.6 ± 0.9; 1 = strongly disagree, 5 = strongly agree). Very few technical issues were identified, supporting the feasibility of this training approach. Thus, we propose that TACTICS VR is a fit-for-purpose, evidence-based training application for stroke workflow optimisation that can be readily deployed on-site in a clinical setting.
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Affiliation(s)
- Rebecca J Hood
- Centre for Advanced Training Systems, The University of Newcastle, Callaghan, NSW, Australia.,School of Biomedical Sciences and Pharmacy, College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Steven Maltby
- Centre for Advanced Training Systems, The University of Newcastle, Callaghan, NSW, Australia.,School of Biomedical Sciences and Pharmacy, College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
| | - Angela Keynes
- Centre for Advanced Training Systems, The University of Newcastle, Callaghan, NSW, Australia.,School of Biomedical Sciences and Pharmacy, College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, NSW, Australia
| | - Murielle G Kluge
- Centre for Advanced Training Systems, The University of Newcastle, Callaghan, NSW, Australia.,School of Biomedical Sciences and Pharmacy, College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, NSW, Australia
| | - Eugene Nalivaiko
- Centre for Advanced Training Systems, The University of Newcastle, Callaghan, NSW, Australia.,School of Biomedical Sciences and Pharmacy, College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, NSW, Australia
| | - Annika Ryan
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia.,School of Medicine and Public Health, College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, NSW, Australia
| | - Martine Cox
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia.,School of Medicine and Public Health, College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, NSW, Australia
| | - Mark W Parsons
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, Melbourne, VIC, Australia
| | - Christine L Paul
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia.,School of Medicine and Public Health, College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, NSW, Australia
| | - Carlos Garcia-Esperon
- Hunter Medical Research Institute, New Lambton Heights, NSW, Australia.,Department of Neurology, John Hunter Hospital, New Lambton Heights, NSW, Australia
| | - Neil J Spratt
- School of Biomedical Sciences and Pharmacy, College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, Australia.,Department of Neurology, John Hunter Hospital, New Lambton Heights, NSW, Australia
| | - Christopher R Levi
- School of Medicine and Public Health, College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, NSW, Australia.,Department of Neurology, John Hunter Hospital, New Lambton Heights, NSW, Australia.,The Sydney Partnership for Health, Education, Research and Enterprise (SPHERE), Sydney, NSW, Australia
| | - Frederick R Walker
- Centre for Advanced Training Systems, The University of Newcastle, Callaghan, NSW, Australia.,School of Biomedical Sciences and Pharmacy, College of Health Medicine and Wellbeing, The University of Newcastle, Callaghan, NSW, Australia.,Hunter Medical Research Institute, New Lambton Heights, NSW, Australia
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Jones E, Kumar A, Lopez-Rivera V, Sebaugh J, Kamal H, Sheth SA, Sharrief A, Zha A. Racial and Ethnic Disparities in Functional Outcome after Thrombectomy: A Cohort Study of an Integrated Stroke Network. J Stroke Cerebrovasc Dis 2021; 30:106131. [PMID: 34655973 PMCID: PMC8578430 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106131] [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: 03/30/2021] [Revised: 09/11/2021] [Accepted: 09/17/2021] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Previous studies have shown racial disparities in access to treatment and outcomes in ischemic stroke patients. We sought to define racial disparities in functional outcomes among ischemic stroke patients receiving endovascular thrombectomy (EVT). MATERIALS AND METHODS We performed a retrospective review of patients in our institution's prospectively collected stroke patient registry from 08/2015 to 06/2019 at 1 comprehensive and 2 thrombectomy-ready stroke centers. We reviewed patients aged ≥ 18 who received mechanical thrombectomy including only patients with race/ethnicity data belonging to the 3 largest race/ethnic groups: Non-Hispanic White (NHW), Non-Hispanic Black (NHB), and Hispanic (HIS). We compared baseline characteristics and performed multivariable logistic regression to evaluate differences in good functional outcome defined as 90-day modified Rankin score (90 day mRS 0-2) as the primary outcome. Secondary outcomes were discharge disposition, length of stay, and excellent functional outcome (90 day mRS 0-1). Results are given as OR [95% CI]. RESULTS Among 666 patients that met inclusion criteria, 45% were NHW, 30% were NHB, and 19% were HIS. NHB and HIS patients were younger than NHW (average age NHB 62; HIS 64; and NHW 70; p < 0.001). Diabetes was more prevalent in NHB (32%, p = 0.02) and HIS (47%, p < 0.001) compared to NHW (23%). There were no significant racial differences in pre-morbid mRS, arrival NIHSS, tPA treatment rates. There was no difference in primary outcome by race comparing NHW to the other racial groups (OR 1.08 [0.68-1.72]) but compared to HIS patients, NHW had a higher likelihood of the secondary outcome of excellent functional outcome (aOR 2.23 [1.01-4.93]) defined as mRS 0-1. CONCLUSIONS In this study of over 600 patients treated with EVT, we did not find significant racial disparities in functional outcome except for less excellent functional outcome in HIS compared to NHW. Further study on disparities in post-acute stroke care is needed.
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Affiliation(s)
- Erica Jones
- Department of Neurology, University of Texas Southwestern, 5323 Harry Hines Blvd, Dallas, TX 75390, United States.
| | - Aditya Kumar
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX 77030, United States
| | - Victor Lopez-Rivera
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX 77030, United States
| | - Jacob Sebaugh
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX 77030, United States
| | - Haris Kamal
- Department of Neurosurgery, New York Medical College Westchester Medical Center, White Plains, NY 10605, United States
| | - Sunil A Sheth
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX 77030, United States
| | - Anjail Sharrief
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX 77030, United States; Department of Neurology, Institute of Stroke and Cerebrovascular Disease, University of Texas McGovern Medical School, Houston, TX 77030, United States
| | - Alicia Zha
- Department of Neurology, University of Texas McGovern Medical School, Houston, TX 77030, United States; Department of Neurology, Institute of Stroke and Cerebrovascular Disease, University of Texas McGovern Medical School, Houston, TX 77030, United States
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Kim SC, Lee CY, Kim CH, Sohn SI, Hong JH, Park H. The effectiveness of systemic and endovascular intra-arterial thrombectomy protocol for decreasing door-to-recanalization time duration. J Cerebrovasc Endovasc Neurosurg 2021; 24:24-35. [PMID: 34696551 PMCID: PMC8984638 DOI: 10.7461/jcen.2021.e2021.07.009] [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: 07/26/2021] [Accepted: 08/21/2021] [Indexed: 11/29/2022] Open
Abstract
Objective Variable treatment strategies and protocols have been applied to reduce time durations in the process of acute stroke management. The aim of this study is to investigate the effectiveness of our intra-arterial thrombectomy (IAT) protocol for decreasing door-to-recanalization time duration and improve successful recanalization. Methods A systemic and endovascular protocol included door-to-image, image-to-puncture and puncture-to-recanalization. We retrospectively analyzed the patients of pre- (Sep 2012–Apr 2014) and post-IAT protocol (May 2014–Jul 2018). Univariate analysis was used for the statistical significance according to variable factors (age, gender, the location of occluded vessel, successful recanalization TICI 2b-3). Independent t-test was used to compare the time duration. Results Among all 267 patients with acute stroke of anterior circulation, there were 50 and 217 patients with pre- and post-IAT protocol. Age, gender, and the location of occluded vessel have no statistical significance (p>0.05). In pre- and post-IAT group, successful recanalization was 39 of 50 (78.0%) and 185/217 (85.3%), respectively (p<0.05). Post-IAT (48.8%, 106/217) group had a higher tendency of good outcome than pre-IAT group (36.0%, 18/50) (p>0.05). Pre- and post-IAT group showed 61.7±21.4 vs. 25±16.0 (p<0.05), 102.0±29.8 vs. 82.7±30.4 (min) (p<0.05), and 79.1±47.5 vs. 58.4±75.3 (p<0.05) in three steps, respectively. Conclusions We suggest that the application of systemic and endovascular IAT protocols showed a significant time reduction for faster recanalization in patients with LVO. To build-up the well-designed IAT protocol through puncture-to-recanalization can be needed to decrease time duration and improve clinical outcome in recanalization therapy in acute stroke patients.
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Affiliation(s)
- Su Chel Kim
- Department of Neurosurgery, Keimyung University, Dong-San Medical Center, Daegu, Korea
| | - Chang-Young Lee
- Department of Neurosurgery, Keimyung University, Dong-San Medical Center, Daegu, Korea
| | - Chang-Hyun Kim
- Department of Neurosurgery, Keimyung University, Dong-San Medical Center, Daegu, Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University, Dong-San Medical Center, Daegu, Korea
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University, Dong-San Medical Center, Daegu, Korea
| | - Hyungjong Park
- Department of Neurology, Keimyung University, Dong-San Medical Center, Daegu, Korea
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Dowbiggin PL, Infinger AE, Purick GT, Swanson DR, Asimos A, Rhoten JB, VonCannon S, Dometrovich M, Studnek JR. Prehospital Evaluation of the FAST-ED as a Secondary Stroke Screen to Identify Large Vessel Occlusion Strokes. PREHOSP EMERG CARE 2021; 26:333-338. [PMID: 34524065 DOI: 10.1080/10903127.2021.1979701] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Introduction: The Field Assessment Stroke Triage for Emergency Destination (FAST-ED) was developed to identify Large Vessel Occlusion Strokes (LVOS) presenting out of hospital, although there is limited prospective research validating its use in this setting. This study evaluated the test characteristics of the FAST-ED to identify LVOS when used as a secondary stroke screen in the prehospital environment. Secondary analysis compared the performance of the CPSS and the FAST-ED in identifying an LVOS. Methods: This prospective, observational study was conducted from April 2018 to December 2019 in a municipal EMS system with all ALS ambulance response. The FAST-ED was implemented as a secondary screening tool for emergent stroke patients who had at least one positive Cincinnati Prehospital Stroke Screen (CPSS) item. CPSS and FAST-ED scores were extracted from prehospital electronic care reports, while the presence of LVOS was extracted from hospital records. Results: A total 1,359 patients were enrolled; 55.3% female, 47.5% white, with a mean age of 69.4 (SD 15.8). In this cohort, 11.3% of patients experienced an LVOS. The mean FAST-ED for a patient experiencing an LVOS was 5.33 (95%CI 4.97-5.69) compared to 3.06 (95%CI 2.95-3.12) (p < 0.001). A score of greater or equal to 4 yielded the highest combination of sensitivity (77.78%) and specificity (65.34%) with positive likelihood ratio 2.24 (95% CI 2.00-2.52) and negative likelihood ratio 0.34 (95% CI 0.25-0.46). Area under the ROC curve was 0.77 (95%CI 0.73, 0.81). A CPSS with all three items positive demonstrated a sensitivity of 73.20% and 69.57% specificity, with an ROC area of 0.73 (95% CI 0.70-0.77). When comparing a FAST-ED ≥4 to a CPSS of all positive items, there was no significant difference in sensitivity (p > 0.05), and the FAST-ED had a significantly lower specificity than the CPSS (p < 0.005). Conclusion: As stroke care advances, EMS agencies must consider their destination triage needs. This study suggests agencies must consider the use of single versus secondary scales, and to determine the ideal sensitivity and specificity for their system.
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Jang SH, Park H, Yoo J, Hong JH, Lee JS, Lee SJ, Kim YW, Hong JM, Choi JW, Kang DH, Kim YS, Hwang YH, Sohn SI. Intracranial non-occlusive intraluminal thrombus may indicate underlying etiology of large vessel occlusion in patients undergoing endovascular therapy. J Neurointerv Surg 2021; 14:997-1001. [PMID: 34615687 DOI: 10.1136/neurintsurg-2021-017995] [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: 07/08/2021] [Accepted: 09/27/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND The underlying etiology of intracranial non-occlusive intraluminal thrombus (iNOT) remains unknown. This study aimed to investigate whether the presence of iNOT can indicate the underlying etiology of large vessel occlusion (LVO) in patients undergoing endovascular therapy (EVT). METHODS Among patients who underwent EVT at three comprehensive stroke centers, we included those with intracranial LVO in the anterior circulation. The presence of iNOT was determined by pretreatment DSA. We investigated the association between iNOT and intracranial atherosclerotic stenosis (ICAS) related LVO. RESULTS Of 546 patients, 44 (8.1%) had iNOT. Patients with iNOT were younger, had less hypertension, atrial fibrillation, and a history of antiplatelet use. In addition, the involvement of the M1 segment of the middle cerebral artery (MCA) was more frequent. However, they had a lower National Institutes of Health Stroke Scale (NIHSS) score on admission and longer onset to recanalization time compared with patients with no iNOT. In a logistic regression model adjusting for age, sex, atrial fibrillation, smoking, prior antiplatelet and anticoagulant use, intravenous tissue plasminogen activator, NIHSS on admission, number of technical trials, intraprocedural re-occlusion, and the location of LVO (p<0.10 in the univariate analysis), the presence of iNOT was significantly associated with ICAS related LVO (adjusted OR 3.04; 95% CI 1.33 to 6.90; p=0.007). CONCLUSIONS The presence of iNOT may reflect an underlying ICAS related LVO in patients undergoing EVT.
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Affiliation(s)
- Seong Hwa Jang
- Department of Neurology, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Hyungjong Park
- Department of Neurology, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Joonsang Yoo
- Department of Neurology, Keimyung University School of Medicine, Daegu, Republic of Korea.,Department of Neurology, Yonsei University College of Medicine, Yonging Severance Hospital, Yongin, Republic of Korea
| | - Jeong-Ho Hong
- Department of Neurology, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Jin Soo Lee
- Department of Neurology, School of Medicine Ajou University, Suwon, Republic of Korea
| | - Seong-Joon Lee
- Department of Neurology, School of Medicine Ajou University, Suwon, Republic of Korea
| | - Yong-Won Kim
- Department of Neurology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Ji Man Hong
- Department of Neurology, School of Medicine Ajou University, Suwon, Republic of Korea
| | - Jin Wook Choi
- Department of Radiology, School of Medicine, Ajou University, Suwon, Republic of Korea
| | - Dong-Hun Kang
- Department of Neurosurgery, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Yong-Sun Kim
- Department of Radiology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Yang-Ha Hwang
- Department of Neurology, School of Medicine, Kyungpook National University, Daegu, Republic of Korea
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University School of Medicine, Daegu, Republic of Korea
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Katz JM, Wang JJ, Boltyenkov AT, Martinez G, O'Hara J, Feizullayeva C, Gribko M, Pandya A, Sanelli PC. Rescan Time Delays in Ischemic Stroke Imaging: A Retrospective Observation and Analysis of Causes and Clinical Impact. AJNR Am J Neuroradiol 2021; 42:1798-1806. [PMID: 34385142 DOI: 10.3174/ajnr.a7227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Accepted: 05/03/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND AND PURPOSE Delays to reperfusion negatively impact outcomes of patients with ischemic stroke, yet current guidelines recommend selective sequential imaging for thrombectomy candidates. We aimed to quantify and analyze time delays associated with rescanning in sequential acute stroke imaging. MATERIALS AND METHODS This was a retrospective cohort study of consecutive patients with acute ischemic stroke who underwent imaging for treatment decision-making from January 1, 2017, to June 30, 2020. Rescan time delay was defined as ≥10-minute difference between initial NCCT and CTA ± CTP. Mean rescan time delays in comprehensive and primary stroke centers were compared. Bivariate and multivariable regression analyses assessed clinical and imaging factors associated with rescanning time delays and early outcomes. RESULTS A total of 588 patients with acute ischemic were included in statistical analyses. Rescanning occurred in 27.9% (164/588 patients), with a mean time delay of 53.7 (SD, 43.4) minutes. For patients presenting at primary compared with comprehensive stroke centers, rescan time delays were more common (59.6% versus 11.8%, P < .001), with longer delays (65.4 [SD, 45.4] minutes versus 23.6 [SD, 14.0] minutes, P < .001). Independent predictors of rescan time delays included primary stroke center presentation, intravenous thrombolysis administration, black race, admission NIHSS ≥10, baseline independent ambulation, and onset-to-comprehensive stroke center arrival in ≥6 hours. Protocols for early simultaneous comprehensive CT (NCCT + CTA + CTP) were associated with lower odds of time delays (OR = 0.34; 95% CI, 0.21-0.55). Rescanning was associated with lower odds of home discharge (OR = 0.53; 95% CI, 0.30-0.95). CONCLUSIONS A sequential approach to CT-based imaging may be significantly associated with prolonged acute stroke evaluations. Adoption of early simultaneous comprehensive CT could minimize treatment delays and improve outcomes.
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Affiliation(s)
- J M Katz
- From the Department of Neurology (J.M.K., M.G.), Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Department of Radiology (J.M.K., A.T.B., G.M., P.C.S.), Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - J J Wang
- Feinstein Institutes for Medical Research (J.J.W., A.T.B., G.M. J.O., C.F., P.C.S.), Manhasset, New York
| | - A T Boltyenkov
- Department of Radiology (J.M.K., A.T.B., G.M., P.C.S.), Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Feinstein Institutes for Medical Research (J.J.W., A.T.B., G.M. J.O., C.F., P.C.S.), Manhasset, New York
- Siemens Medical Solutions (A.T.B., G.M.), Malvern, Pennsylvania
| | - G Martinez
- Department of Radiology (J.M.K., A.T.B., G.M., P.C.S.), Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Feinstein Institutes for Medical Research (J.J.W., A.T.B., G.M. J.O., C.F., P.C.S.), Manhasset, New York
- Siemens Medical Solutions (A.T.B., G.M.), Malvern, Pennsylvania
| | - J O'Hara
- Feinstein Institutes for Medical Research (J.J.W., A.T.B., G.M. J.O., C.F., P.C.S.), Manhasset, New York
| | - C Feizullayeva
- Feinstein Institutes for Medical Research (J.J.W., A.T.B., G.M. J.O., C.F., P.C.S.), Manhasset, New York
| | - M Gribko
- From the Department of Neurology (J.M.K., M.G.), Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - A Pandya
- Department of Health Policy and Management (A.P.), Harvard T.H. Chan School of Public Health, Boston, Massachusetts
| | - P C Sanelli
- Department of Radiology (J.M.K., A.T.B., G.M., P.C.S.), Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
- Feinstein Institutes for Medical Research (J.J.W., A.T.B., G.M. J.O., C.F., P.C.S.), Manhasset, New York
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Haight T, Tabaac B, Patrice KA, Phipps MS, Butler J, Johnson B, Aycock A, Toral L, Yarbrough KL, Schrier C, Lawrence E, Goldszmidt A, Marsh EB, Urrutia VC. The Maryland Acute Stroke Emergency Medical Services Routing Pilot: Expediting Access to Thrombectomy for Stroke. Front Neurol 2021; 12:663472. [PMID: 34539541 PMCID: PMC8445030 DOI: 10.3389/fneur.2021.663472] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2021] [Accepted: 08/06/2021] [Indexed: 12/24/2022] Open
Abstract
Background: Mechanical thrombectomy (MT) is the standard of care for acute ischemic stroke caused by large vessel occlusion, but is not available at all stroke centers. Transfers between hospitals lead to treatment delays. Transport directly to a facility capable of MT based on a prehospital stroke severity scale score has been recommended, if transportation time is less than 30 min. Aims: We hypothesized that an Emergency Medical Services (EMS) routing algorithm for stroke, using the Los Angeles Motor Scale (LAMS) in the field, would improve time from last known well to MT, without causing patients to miss the IV Thrombolysis (IVT) window. Methods: An EMS algorithm in the Baltimore metro area using the LAMS was implemented. Patients suspected of having an acute stroke were assessed by EMS using the LAMS. Patients scoring 4 or higher and within 20 h from last known well, were transported directly to a Thrombectomy Center, if transport could be completed within 30 min. The algorithm was evaluated retrospectively with prospectively collected data at the Thrombectomy Centers. The primary outcome variables were proportion of patients with suspected stroke rerouted by EMS, proportion of rerouted ischemic stroke patients receiving MT, time to treatment, and whether the IVT window was missed. Results: A total of 303 patients were rerouted out of 2459 suspected stroke patients over a period of 6 months. Of diverted patients, 47% had acute ischemic stroke. Of these, 48% received an acute stroke treatment: 16.8% IVT, 17.5% MT, and 14% MT+IVT. Thrombectomy occurred 119 min earlier in diverted patients compared to patients transferred from other hospitals (P = 0.006). 55.3% of diverted patients undergoing MT and 38.2% of patients transferred from hospital to hospital were independent at 90 days (modified Rankin score 0–2) (P = 0.148). No patient missed the time window for IVT due to the extra travel time. Conclusions: In this retrospective analysis of prospectively acquired data, implementation of a pre-hospital clinical screening score to detect patients with suspected acute ischemic stroke due to large vessel occlusion was feasible. Rerouting patients directly to a Thrombectomy Center, based on the EMS algorithm, led to a shorter time to thrombectomy.
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Affiliation(s)
- Taylor Haight
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Burton Tabaac
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Kelly-Ann Patrice
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Michael S Phipps
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, United States
| | - Jaime Butler
- The Johns Hopkins Hospital, Baltimore, MD, United States
| | - Brenda Johnson
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States.,The Johns Hopkins Hospital, Baltimore, MD, United States
| | - Anna Aycock
- Maryland Institute for Emergency Medical Services System (MIEMSS), Baltimore, MD, United States
| | - Linda Toral
- Sinai Hospital, Baltimore, MD, United States
| | | | - Chad Schrier
- University of Maryland Medical Center, Baltimore, MD, United States
| | - Erin Lawrence
- Johns Hopkins Bayview Medical Center, Baltimore, MD, United States
| | | | - Elisabeth B Marsh
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
| | - Victor C Urrutia
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, MD, United States
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43
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de la Rosa E, Sima DM, Menze B, Kirschke JS, Robben D. AIFNet: Automatic vascular function estimation for perfusion analysis using deep learning. Med Image Anal 2021; 74:102211. [PMID: 34425318 DOI: 10.1016/j.media.2021.102211] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 06/25/2021] [Accepted: 08/04/2021] [Indexed: 12/30/2022]
Abstract
Perfusion imaging is crucial in acute ischemic stroke for quantifying the salvageable penumbra and irreversibly damaged core lesions. As such, it helps clinicians to decide on the optimal reperfusion treatment. In perfusion CT imaging, deconvolution methods are used to obtain clinically interpretable perfusion parameters that allow identifying brain tissue abnormalities. Deconvolution methods require the selection of two reference vascular functions as inputs to the model: the arterial input function (AIF) and the venous output function, with the AIF as the most critical model input. When manually performed, the vascular function selection is time demanding, suffers from poor reproducibility and is subject to the professionals' experience. This leads to potentially unreliable quantification of the penumbra and core lesions and, hence, might harm the treatment decision process. In this work we automatize the perfusion analysis with AIFNet, a fully automatic and end-to-end trainable deep learning approach for estimating the vascular functions. Unlike previous methods using clustering or segmentation techniques to select vascular voxels, AIFNet is directly optimized at the vascular function estimation, which allows to better recognise the time-curve profiles. Validation on the public ISLES18 stroke database shows that AIFNet almost reaches inter-rater performance for the vascular function estimation and, subsequently, for the parameter maps and core lesion quantification obtained through deconvolution. We conclude that AIFNet has potential for clinical transfer and could be incorporated in perfusion deconvolution software.
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Affiliation(s)
- Ezequiel de la Rosa
- icometrix, Leuven, Belgium; Department of Computer Science, Technical University of Munich, Munich, Germany.
| | | | - Bjoern Menze
- Department of Computer Science, Technical University of Munich, Munich, Germany
| | - Jan S Kirschke
- Neuroradiology, School of Medicine, Technical University of Munich, Munich, Germany
| | - David Robben
- icometrix, Leuven, Belgium; Medical Imaging Research Center (MIRC), KU Leuven, Leuven, Belgium; Medical Image Computing (MIC), ESAT-PSI, Department of Electrical Engineering, KU Leuven, Leuven, Belgium
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44
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Lim DZ, Yeo M, Dahan A, Tahayori B, Kok HK, Abbasi-Rad M, Maingard J, Kutaiba N, Russell J, Thijs V, Jhamb A, Chandra RV, Brooks M, Barras C, Asadi H. Development of a machine learning-based real-time location system to streamline acute endovascular intervention in acute stroke: a proof-of-concept study. J Neurointerv Surg 2021; 14:799-803. [PMID: 34426539 DOI: 10.1136/neurintsurg-2021-017858] [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: 06/05/2021] [Accepted: 08/05/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Delivery of acute stroke endovascular intervention can be challenging because it requires complex coordination of patient and staff across many different locations. In this proof-of-concept paper we (a) examine whether WiFi fingerprinting is a feasible machine learning (ML)-based real-time location system (RTLS) technology that can provide accurate real-time location information within a hospital setting, and (b) hypothesize its potential application in streamlining acute stroke endovascular intervention. METHODS We conducted our study in a comprehensive stroke care unit in Melbourne, Australia that offers a 24-hour mechanical thrombectomy service. ML algorithms including K-nearest neighbors, decision tree, random forest, support vector machine and ensemble models were trained and tested on a public WiFi dataset and the study hospital WiFi dataset. The hospital dataset was collected using the WiFi explorer software (version 3.0.2) on a MacBook Pro (AirPort Extreme, Broadcom BCM43x×1.0). Data analysis was implemented in the Python programming environment using the scikit-learn package. The primary statistical measure for algorithm performance was the accuracy of location prediction. RESULTS ML-based WiFi fingerprinting can accurately predict the different hospital zones relevant in the acute endovascular intervention workflow such as emergency department, CT room and angiography suite. The most accurate algorithms were random forest and support vector machine, both of which were 98% accurate. The algorithms remain robust when new data points, which were distinct from the training dataset, were tested. CONCLUSIONS ML-based RTLS technology using WiFi fingerprinting has the potential to streamline delivery of acute stroke endovascular intervention by efficiently tracking patient and staff movement during stroke calls.
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Affiliation(s)
- Dee Zhen Lim
- Department of Radiology, Austin Health, Heidelberg, Victoria, Australia
| | - Melissa Yeo
- Melbourne Medical School, The University of Melbourne Faculty of Medicine Dentistry and Health Sciences, Melbourne, Victoria, Australia
| | - Ariel Dahan
- Department of Radiology, Austin Health, Heidelberg, Victoria, Australia
| | - Bahman Tahayori
- Department of Biomedical Engineering, The University of Melbourne, Melbourne, Victoria, Australia
| | - Hong Kuan Kok
- Department of Radiology, Northern Health, Epping, Victoria, Australia.,School of Medicine, Faculty of Health, Deakin University, Burwood, Victoria, Australia
| | | | - Julian Maingard
- Department of Radiology, Monash Health, Clayton, Victoria, Australia.,Faculty of Medicine Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Numan Kutaiba
- Department of Radiology, Austin Health, Heidelberg, Victoria, Australia
| | - Jeremy Russell
- Department of Neurosurgery, Austin Health, Heidelberg, Victoria, Australia
| | - Vincent Thijs
- Department of Neurology, Austin Health, Heidelberg, Victoria, Australia.,Stroke Theme, Florey Neuroscience Institutes, Parkville, Victoria, Australia
| | - Ashu Jhamb
- Department of Radiology, St Vincent Health, Fitzroy, Victoria, Australia
| | - Ronil V Chandra
- Department of Radiology, Monash Health, Clayton, Victoria, Australia.,Faculty of Medicine Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Mark Brooks
- Department of Radiology, Austin Health, Heidelberg, Victoria, Australia.,School of Medicine, Faculty of Health, Deakin University, Burwood, Victoria, Australia
| | - Christen Barras
- School of Medicine, University of Adelaide, Adelaide, South Australia, Australia.,South Australian Health and Medical Research Institute, Adelaide, South Australia, Australia
| | - Hamed Asadi
- Department of Radiology, Austin Health, Heidelberg, Victoria, Australia.,School of Medicine, Faculty of Health, Deakin University, Burwood, Victoria, Australia
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45
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Yao Z, Xu H, Cheng Y, Xu Y. Relationship between estimated glomerular filtration rate and outcome of ischemic stroke patients after mechanical thrombectomy. CNS Neurosci Ther 2021; 27:1281-1288. [PMID: 34254732 PMCID: PMC8504529 DOI: 10.1111/cns.13700] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Revised: 06/13/2021] [Accepted: 06/15/2021] [Indexed: 12/24/2022] Open
Abstract
Aims We aimed to determine whether preprocedural renal function affects the outcome of acute ischemic stroke (AIS) patients with mechanical thrombectomy (MT) and whether this effect is modified by the onset‐to‐reperfusion time (OTR) and mediated by collateral status. Methods Eligible patients with anterior circulation large vessel occlusion (LVO) who underwent MT between August 2018 and August 2020 were reviewed. The main outcome was good functional outcome [defined as modified Rankin Scale (mRS) of 0–2] at 3 months. Multivariable logistic regression analyses were conducted to explore the relationship between renal function and good functional outcome. A moderation analysis and the Johnson‐Neyman technique were performed to assess the interaction between renal function and OTR to predict the outcome of AIS patients with MT. Results Among 100 enrolled patients, 36 (36%) exhibited good functional outcome. A decreased preprocedural estimated glomerular filtration rate (pre‐eGFR) was significantly associated with worse functional outcome [adjusted OR, 1.059 (1.012–1.108); p, 0.014], and this effect was partly mediated by collateral circulation. An interaction between OTR and pre‐eGFR on functional outcome was observed (P for interaction, 0.22), and pre‐eGFR only had a significant effect on functional outcome when OTR exceeded 455.8 min. Moreover, the adverse effect of OTR on functional outcome became no longer significant when the pre‐eGFR was higher than 89.0 mL/min/1.73 mL/min/1.73 m². Conclusions Renal function was related to functional outcome at 3 months, and this relationship could be modified by OTR. The results suggested that reducing OTR and improving collateral circulation may mitigate the adverse effect of reduced kidney function on functional outcome.
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Affiliation(s)
- Zhelv Yao
- Department of Neurology, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, China.,Jiangsu Key Laboratory for Molecular Medicine, Nanjing University Medical School, Nanjing, China.,Nanjing Medicine Center for Neurological and Psychiatric Diseases, Nanjing, China
| | - Hengheng Xu
- Department of Neurology, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, China.,Jiangsu Key Laboratory for Molecular Medicine, Nanjing University Medical School, Nanjing, China.,Nanjing Medicine Center for Neurological and Psychiatric Diseases, Nanjing, China
| | - Yue Cheng
- Department of Neurology, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, China.,Jiangsu Key Laboratory for Molecular Medicine, Nanjing University Medical School, Nanjing, China.,Nanjing Medicine Center for Neurological and Psychiatric Diseases, Nanjing, China
| | - Yun Xu
- Department of Neurology, Affiliated Drum Tower Hospital, Nanjing University Medical School, Nanjing, China.,Jiangsu Key Laboratory for Molecular Medicine, Nanjing University Medical School, Nanjing, China.,Nanjing Medicine Center for Neurological and Psychiatric Diseases, Nanjing, China
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46
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Baek JH, Jung C, Kim BM, Heo JH, Kim DJ, Nam HS, Kim YD, Lim EH, Kim JH, Kim JY, Kim JH. Combination of Rescue Stenting and Antiplatelet Infusion Improved Outcomes for Acute Intracranial Atherosclerosis-Related Large-Vessel Occlusion. Front Neurol 2021; 12:608270. [PMID: 34290659 PMCID: PMC8287123 DOI: 10.3389/fneur.2021.608270] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2020] [Accepted: 05/11/2021] [Indexed: 11/20/2022] Open
Abstract
Background and Purpose: Intracranial atherosclerosis-related large-vessel occlusion caused by in situ thrombo-occlusion (ICAS-LVO) has been regarded an important reason for refractoriness to mechanical thrombectomy (MT). To achieve better outcomes for ICAS-LVO, different endovascular strategies should be explored. We aimed to investigate an optimal endovascular strategy for ICAS-LVO. Methods: We retrospectively reviewed three prospective registries of acute stroke underwent endovascular treatment. Among them, patients with ICAS-LVO were assigned to four groups based on their endovascular strategy: (1) MT alone, (2) rescue intracranial stenting after MT failure (MT-RS), (3) glycoprotein IIb/IIIa inhibitor infusion after MT failure (MT-GPI), and (4) a combination of MT-RS and MT-GPI (MT-RS+GPI). Baseline characteristics and outcomes were compared among the groups. To evaluate whether the endovascular strategy resulted in favorable outcome, multivariable analysis was also performed. Results: A total of 184 patients with ICAS-LVO were included. Twenty-four patients (13.0%) were treated with MT alone, 25 (13.6%) with MT-RS, 84 (45.7%) with MT-GPI, and 51 (27.7%) with MT-RS+GPI. The MT-RS+GPI group showed the highest recanalization efficiency (98.0%). Frequency of patent arteries on follow-up (98.0%, p < 0.001) and favorable outcome (84.3%, p < 0.001) were higher in the MT-RS+GPI group than other groups. The MT-RS+GPI strategy remained an independent factor for favorable outcome (odds ratio, 20.4; 95% confidence interval, 1.97–211.4; p = 0.012). Conclusion: Endovascular strategy was significantly associated with procedural and clinical outcomes in acute stroke by ICAS-LVO. A combination of RS and GPI infusion might be an optimal rescue modality when frontline MT fails.
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Affiliation(s)
- Jang-Hyun Baek
- Department of Neurology, Kangbuk Samsung Hospital, Sungkyunkwan University School of Medicine, Seoul, South Korea.,Department of Neurology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Cheolkyu Jung
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Byung Moon Kim
- Interventional Neuroradiology, Department of Radiology, Severance Hospital, Severance Stroke Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Ji Hoe Heo
- Department of Neurology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Dong Joon Kim
- Interventional Neuroradiology, Department of Radiology, Severance Hospital, Severance Stroke Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Hyo Suk Nam
- Department of Neurology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Young Dae Kim
- Department of Neurology, Severance Stroke Center, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Eun Hyun Lim
- Department of Neurosurgery, Andong Hospital, Andong, South Korea
| | - Jun-Hwee Kim
- Interventional Neuroradiology, Department of Radiology, Severance Hospital, Severance Stroke Center, Yonsei University College of Medicine, Seoul, South Korea
| | - Jun Yup Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam, South Korea
| | - Jae Hyoung Kim
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, South Korea
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47
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Rocha M, Desai S, Son J, Tonetti DA, Jovin T, Jadhav AP. Clinical characteristics of fast and slow progressors of infarct growth in anterior circulation large vessel occlusion stroke. J Cereb Blood Flow Metab 2021; 41:271678X211015068. [PMID: 34139885 PMCID: PMC8221763 DOI: 10.1177/0271678x211015068] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2020] [Revised: 04/12/2021] [Accepted: 04/13/2021] [Indexed: 11/16/2022]
Abstract
Fast and slow progressor phenotypes of infarct growth due to anterior circulation large vessel occlusion (ACLVO) remain poorly understood. We aimed to define clinical predictors of fast and slow progressors in a retrospective study of patients with ACLVO who underwent baseline advanced imaging within 24 hours of stroke onset. Fast progressors (ischemic core > 70 ml, < 6 hours after onset) and slow progressors (ischemic core ≤ 30 ml, 6 to 24 hours after onset) were identified amongst 185 patients. Clinical and laboratory variables were tested for association with fast or slow progressor status. In the early epoch, no significant differences were found between fast progressors and controls. In the delayed epoch, slow progressors had a median NIHSS of 14 versus 20 (p < 0.01) and MCA occlusion in 80% versus 63% (p < 0.05) relative to controls. In multivariate analyses, NIHSS (OR 0.83, 95% CI 0.73-0.95), hyperlipidemia (OR 4.24, 95% CI 1.01 - 19.3) and hemoglobin concentration (OR 0.75, 95% CI 0.57 - 0.99) were independently associated with slow progressor status. This study indicates that lower initial stroke symptom severity, a history of hyperlipidemia and mild anemia are associated with individual tolerance to ACLVO stroke.
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Affiliation(s)
- Marcelo Rocha
- Department of Neurology , University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Shashvat Desai
- Department of Neurology , University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Jiyeon Son
- Department of Neurology , University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Daniel A Tonetti
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Tudor Jovin
- Cooper University Hospital Neurological Institute, Camden, NJ, USA
| | - Ashutosh P Jadhav
- Department of Neurology , University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
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48
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Kitano T, Hori Y, Okazaki S, Shimada Y, Iwamoto T, Kanki H, Sugiyama S, Sasaki T, Nakamura H, Oyama N, Hoshi T, Beck G, Takai H, Matsubara S, Mizuno H, Nishimura H, Tamaki R, Iida J, Iba J, Uno M, Kishima H, Fushimi H, Hattori S, Murayama S, Morii E, Sakaguchi M, Yagita Y, Shimazu T, Mochizuki H, Todo K. An Older Thrombus Delays Reperfusion after Mechanical Thrombectomy for Ischemic Stroke. Thromb Haemost 2021; 122:415-426. [PMID: 34077976 PMCID: PMC8899314 DOI: 10.1055/a-1522-4507] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Background
Thrombosis is a dynamic process, and a thrombus undergoes physical and biochemical changes that may alter its response to reperfusion therapy. This study assessed whether thrombus age influenced reperfusion quality and outcomes after mechanical thrombectomy for cerebral embolism.
Methods
We retrospectively evaluated 185 stroke patients and thrombi that were collected during mechanical thrombectomy at three stroke centers. Thrombi were pathologically classified as fresh or older based on their granulocytes' nuclear morphology and organization. Thrombus components were quantified, and the extent of NETosis (the process of neutrophil extracellular trap formation) was assessed using the density of citrullinated histone H3-positive cells. Baseline patient characteristics, thrombus features, endovascular procedures, and functional outcomes were compared according to thrombus age.
Results
Fresh thrombi were acquired from 43 patients, and older thrombi were acquired from 142 patients. Older thrombi had a lower erythrocyte content (
p
< 0.001) and higher extent of NETosis (
p
= 0.006). Restricted mean survival time analysis revealed that older thrombi were associated with longer puncture-to-reperfusion times (difference: 15.6 minutes longer for older thrombi,
p
= 0.002). This association remained significant even after adjustment for erythrocyte content and the extent of NETosis (adjusted difference: 10.8 minutes, 95% confidence interval [CI]: 0.6–21.1 minutes,
p
= 0.039). Compared with fresh thrombi, older thrombi required more device passes before reperfusion (
p
< 0.001) and were associated with poorer functional outcomes (adjusted common odds ratio: 0.49; 95% CI: 0.24–0.99).
Conclusion
An older thrombus delays reperfusion after mechanical thrombectomy for ischemic stroke. Adding therapies targeting thrombus maturation may improve the efficacy of mechanical thrombectomy.
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Affiliation(s)
- Takaya Kitano
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan.,Department of Stroke Medicine, Kawasaki Medical School, Okayama, Japan
| | - Yumiko Hori
- Department of Pathology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shuhei Okazaki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yuki Shimada
- Department of Neurology, Osaka General Medical Center, Osaka, Japan
| | - Takanori Iwamoto
- Department of Stroke Medicine, Kawasaki Medical School, Okayama, Japan
| | - Hideaki Kanki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shintaro Sugiyama
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tsutomu Sasaki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hajime Nakamura
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Naoki Oyama
- Department of Stroke Medicine, Kawasaki Medical School, Okayama, Japan
| | - Taku Hoshi
- Department of Neurology, Osaka General Medical Center, Osaka, Japan
| | - Goichi Beck
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hiroki Takai
- Department of Neurosurgery, Kawasaki Medical School, Okayama, Japan
| | - Shunji Matsubara
- Department of Neurosurgery, Kawasaki Medical School, Okayama, Japan
| | - Hiroya Mizuno
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | | | - Ryo Tamaki
- Department of Neurosurgery, Osaka General Medical Center, Osaka, Japan
| | - Junichi Iida
- Department of Neurosurgery, Osaka General Medical Center, Osaka, Japan
| | - Jiro Iba
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Masaaki Uno
- Department of Neurosurgery, Kawasaki Medical School, Okayama, Japan
| | - Haruhiko Kishima
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hiroaki Fushimi
- Department of Pathology, Osaka General Medical Center, Osaka, Japan
| | - Satoshi Hattori
- Department of Integrated Medicine, Biomedical Statistics, Osaka University Graduate School of Medicine, Osaka, Japan.,Institute for Open and Transdisciplinary Research Initiatives, Osaka University, Osaka, Japan
| | - Shigeo Murayama
- Brain Bank for Neurodevelopmental, Neurological and Psychiatric Disorders, United Graduate School of Child Development, Osaka University, Osaka, Japan.,Department of Neurology and Neuropathology (the Brain Bank for Aging Research), Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Tokyo, Japan
| | - Eiichi Morii
- Department of Pathology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Manabu Sakaguchi
- Department of Neurology, Osaka General Medical Center, Osaka, Japan
| | - Yoshiki Yagita
- Department of Stroke Medicine, Kawasaki Medical School, Okayama, Japan
| | - Takeshi Shimazu
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hideki Mochizuki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kenichi Todo
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
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49
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Bageac DV, Gershon BS, Vargas J, Mokin M, Ren Z, Chada D, Turk AS, Chaudry MI, Turner RD, Fifi JT, Shigematsu T, De Leacy R. Comparative study of intracranial access in thrombectomy using next generation 0.088 inch guide catheter technology. J Neurointerv Surg 2021; 14:390-396. [PMID: 34039682 DOI: 10.1136/neurintsurg-2021-017341] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2021] [Revised: 05/05/2021] [Accepted: 05/09/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND Most conventional 0.088 inch guide catheters cannot safely navigate intracranial vasculature. The objective of this study is to evaluate the safety of stroke thrombectomy using a novel 0.088 inch guide catheter designed for intracranial navigation. METHODS This is a multicenter retrospective study, which included patients over 18 years old who underwent thrombectomy for anterior circulation large vessel occlusions. Technical outcomes for patients treated using the TracStar Large Distal Platform (TracStar LDP) or earlier generation TRX LDP were compared with a matched cohort of patients treated with other commonly used guide catheters. The primary outcome measure was device-related complications. Secondary outcome measures included guide catheter failure and time between groin puncture and clot engagement. RESULTS Each study arm included 45 patients. The TracStar group was non-inferior to the control group with regard to device-related complications (6.8% vs 8.9%), and the average time to clot engagement was 8.89 min shorter (14.29 vs 23.18 min; p=0.0017). There were no statistically significant differences with regard to other technical outcomes, including time to recanalization (modified Thrombolysis In Cerebral Infarction (mTICI) ≥2B). The TracStar was successfully advanced into the intracranial internal carotid artery in 33 cases (73.33%); in three cases (6.67%), it was swapped for an alternate catheter. Successful reperfusion (mTICI 2B-3) was achieved in 95.56% of cases. Ninety-day follow-up data were available for 86.67% of patients, among whom 46.15% had an modified Rankin Score of 0-2%, and 10.26% were deceased. CONCLUSIONS Tracstar LDP is safe for use during stroke thrombectomy and was associated with decreased time to clot engagement. Intracranial access was regularly achieved.
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Affiliation(s)
- Devin V Bageac
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
| | - Blake S Gershon
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
| | - Jan Vargas
- Department of Neurosurgery, Prisma Health, Greenville, South Carolina, USA
| | - Maxim Mokin
- Neurosurgery and Brain Repair, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Zeguang Ren
- Neurosurgery and Brain Repair, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Deeksha Chada
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
| | - Aquilla S Turk
- Department of Neurosurgery, Prisma Health, Greenville, South Carolina, USA
| | - M Imran Chaudry
- Department of Neurosurgery, Prisma Health, Greenville, South Carolina, USA
| | - Raymond D Turner
- Department of Neurosurgery, Prisma Health, Greenville, South Carolina, USA
| | - Johanna T Fifi
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
| | | | - Reade De Leacy
- Department of Neurosurgery, Mount Sinai Health System, New York, New York, USA
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Cao J, Lin H, Lin M, Ke K, Zhang Y, Zhang Y, Zheng W, Chen X, Wang W, Zhang M, Xuan J, Peng Y. RECO Flow Restoration Device Versus Solitaire FR With the Intention for Thrombectomy Study (REDIRECT): a prospective randomized controlled trial. J Neurosurg 2021; 134:1569-1577. [PMID: 32502991 DOI: 10.3171/2020.3.jns193356] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2019] [Accepted: 03/17/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The RECO flow restoration (FR) device is a new stent retriever designed for rapid flow restoration in acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). Here, the authors compared the efficacy and safety of the RECO device with the predicate Solitaire FR stent retriever. METHODS The RECO Flow Restoration Device Versus Solitaire FR With the Intention for Thrombectomy Study (REDIRECT) was a multicenter, prospective, open randomized controlled trial. Patients with acute LVO at 7 Chinese stroke centers participated in the study. The primary efficacy endpoint was defined as a modified thrombolysis in cerebral infarction (mTICI) reperfusion grade ≥ 2 within three passes. The primary safety endpoint comprised any serious adverse device effect, symptomatic intracerebral hemorrhage (sICH), and any serious adverse event (SAE; defined as cerebral palsy or death) within 24 hours after the procedure. The secondary efficacy endpoints consisted of functional independence (modified Rankin Scale score 0-2), procedure duration, and 90-day all-cause mortality. RESULTS Between January 2014 and August 2016, 67 patients were randomly allocated to the RECO group and 69 patients to the Solitaire FR group. The primary efficacy endpoint (mTICI grade ≥ 2 within three passes) was similar in the two treatment groups (91% vs 87%, respectively, p = 0.5861), and the rate of reperfusion with an mTICI grade 2b/3 was 87% versus 75% (p = 0.1272). There were no serious adverse device effects in any patient. The rates of sICH (1.5% vs 7.2%, p = 0.1027) and SAEs (6.0% vs 1.4%, p = 0.2050) within 24 hours after the procedure were similar in the two treatment groups. There was no significant difference in the rate of functional independence (63% vs 46%, p = 0.0609) or 90-day all-cause mortality (13% vs 23%, p = 0.1848) or in procedure duration (85.39 ± 47.01 vs 89.94 ± 53.34 minutes, p = 0.5986) between the two groups. CONCLUSIONS The RECO stent retriever is effective and safe as a mechanical thrombectomy device for AIS due to LVO. Clinical trial registration no.: NCT01983644 (clinicaltrials.gov).
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Affiliation(s)
- Jie Cao
- 1Department of Neurosurgery, The First People's Hospital of Changzhou/The Third Affiliated Hospital of Soochow University, Changzhou
| | - Hang Lin
- 2Department of Neurology, Fuzhou General Hospital of Nanjing Military Command, Fuzhou
| | - Min Lin
- 2Department of Neurology, Fuzhou General Hospital of Nanjing Military Command, Fuzhou
| | - Kaifu Ke
- 3Department of Neurology, The Affiliated Hospital of Nantong University, Nantong
| | - Yunfeng Zhang
- 3Department of Neurology, The Affiliated Hospital of Nantong University, Nantong
| | - Yong Zhang
- 4Department of Neurology, The Affiliated Hospital of Qingdao University, Qingdao
| | - Weihong Zheng
- 5Department of Neurology, Zhongshan Hospital of Xiamen University, Xiamen
| | - Xingyu Chen
- 5Department of Neurology, Zhongshan Hospital of Xiamen University, Xiamen
| | - Wei Wang
- 6Department of Imaging, Yangzhou No. 1 People's Hospital, Yangzhou; and
| | - Meng Zhang
- 7Department of CCU, Daping Hospital, Chongqing, People's Republic of China
| | - Jinggang Xuan
- 1Department of Neurosurgery, The First People's Hospital of Changzhou/The Third Affiliated Hospital of Soochow University, Changzhou
| | - Ya Peng
- 1Department of Neurosurgery, The First People's Hospital of Changzhou/The Third Affiliated Hospital of Soochow University, Changzhou
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