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Wang H, Han S, Xie J, Zhao R, Li S, Li J. IL-17A exacerbates caspase-12-dependent neuronal apoptosis following ischemia through the Src-PLCγ-calpain pathway. Exp Neurol 2024; 379:114863. [PMID: 38871070 DOI: 10.1016/j.expneurol.2024.114863] [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: 01/19/2024] [Revised: 06/03/2024] [Accepted: 06/09/2024] [Indexed: 06/15/2024]
Abstract
Interleukin-17 A (IL-17 A) contributes to inflammation and causes secondary injury in post-stroke patients. However, little is known regarding the mechanisms that IL-17 A is implicated in the processes of neuronal death during ischemia. In this study, the mouse models of middle cerebral artery occlusion/reperfusion (MCAO/R)-induced ischemic stroke and oxygen-glucose deprivation/reoxygenation (OGD/R)-simulated in vitro ischemia in neurons were employed to explore the role of IL-17 A in promoting neuronal apoptosis. Mechanistically, endoplasmic reticulum stress (ERS)-induced neuronal apoptosis was accelerated by IL-17 A activation through the caspase-12-dependent pathway. Blocking calpain or phospholipase Cγ (PLCγ) inhibited IL-17 A-mediated neuronal apoptosis under ERS by inhibiting caspase-12 cleavage. Src and IL-17 A are linked, and PLCγ directly binds to activated Src. This binding causes intracellular Ca2+ flux and activates the calpain-caspase-12 cascade in neurons. The neurological scores showed that intracerebroventricular (ICV) injection of an IL-17 A neutralizing mAb decreased the severity of I/R-induced brain injury and suppressed apoptosis in MCAO mice. Our findings reveal that IL-17 A increases caspase-12-mediated neuronal apoptosis, and IL-17 A suppression may have therapeutic potential for ischemic stroke.
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Affiliation(s)
- Hongyu Wang
- Department of Neurobiology, School of Basic Medical Science, Capital Medical University, Beijing 100069, PR China
| | - Song Han
- Department of Neurobiology, School of Basic Medical Science, Capital Medical University, Beijing 100069, PR China
| | - Jinjin Xie
- Department of Neurobiology, School of Basic Medical Science, Capital Medical University, Beijing 100069, PR China
| | - Ruixue Zhao
- Department of Neurobiology, School of Basic Medical Science, Capital Medical University, Beijing 100069, PR China
| | - Shujuan Li
- The Neurological Department, Fu Wai Hospital, National Center for Cardiovascular Diseases, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing 100037, PR China.
| | - Junfa Li
- Department of Neurobiology, School of Basic Medical Science, Capital Medical University, Beijing 100069, PR China.
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2
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Ming J, Liao Y, Song W, Wang Z, Cui J, He L, Chen G, Xu K. Role of intracranial bone marrow mesenchymal stem cells in stroke recovery: A focus on post-stroke inflammation and mitochondrial transfer. Brain Res 2024; 1837:148964. [PMID: 38677450 DOI: 10.1016/j.brainres.2024.148964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2024] [Revised: 04/13/2024] [Accepted: 04/24/2024] [Indexed: 04/29/2024]
Abstract
Stem cell therapy has become a hot research topic in the medical field in recent years, with enormous potential for treating a variety of diseases. In particular, bone marrow mesenchymal stem cells (BMSCs) have wide-ranging applications in the treatment of ischemic stroke, autoimmune diseases, tissue repair, and difficult-to-treat diseases. BMSCs can differentiate into multiple cell types and exhibit strong immunomodulatory properties. Although BMSCs can regulate the inflammatory response activated after stroke, the mechanism by which BMSCs regulate inflammation remains unclear and requires further study. Recently, stem cell therapy has emerged as a potentially effective approach for enhancing the recovery process following an ischemic stroke. For example, by regulating post-stroke inflammation and by transferring mitochondria to exert therapeutic effects. Therefore, this article reviews the therapeutic effects of intracranial BMSCs in regulating post-stroke inflammation and mitochondrial transfer in the treatment of stroke, providing a basis for further research.
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Affiliation(s)
- Jiang Ming
- Department of Neurosurgery, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, Guizhou, China
| | - Yidong Liao
- Department of Cardio-Thoracic Surgery, The First Hospital of Guiyang, Guiyang 550002, Guizhou, China
| | - Wenxue Song
- Department of Neurosurgery, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, Guizhou, China
| | - Zili Wang
- Department of Neurosurgery, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, Guizhou, China
| | - Junshuan Cui
- Department of Neurosurgery, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, Guizhou, China
| | - Longcai He
- Department of Neurosurgery, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, Guizhou, China
| | - Guangtang Chen
- Department of Neurosurgery, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, Guizhou, China.
| | - Kaya Xu
- Department of Neurosurgery, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, Guizhou, China; Department of Hyperbaric Oxygen, The Affiliated Hospital of Guizhou Medical University, Guiyang 550004, Guizhou, China.
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3
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Fan S, Guo C, Huang J, Peng Z, Yue C, Yang J, Li L, Xie D, Yu N, Yang S, Shi X, Yang D, Li F, Yang Q. True first-pass effect in patients undergoing thrombectomy for acute large core strokes. Ann Clin Transl Neurol 2024. [PMID: 39095680 DOI: 10.1002/acn3.52155] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2024] [Revised: 06/10/2024] [Accepted: 07/08/2024] [Indexed: 08/04/2024] Open
Abstract
OBJECTIVE The impact of true first-pass effect (T-FPE, achieving substantial recanalization with extended thrombolysis in cerebral infarction; eTICI 3 after 1 thrombectomy) and outcomes on acute ischemic stroke (AIS) with large ischemic core remains uncertain. We aimed to study the association between T-FPE and outcomes in AIS patients with large core infarct through a real-world multicenter study. METHODS From a prospective multicentric registry, we collected the data of all consecutive acute stroke patients with a large ischemic core who underwent thrombectomy and compared the outcomes of patients who achieved T-FPE and those who did not. In addition, we compared the outcomes of patients with different numbers of thrombectomy pass to identify the effectiveness of T-FPE. Multivariate analysis was performed to determine the predictors of T-FPE. The primary outcome was good functional outcome (modified Rankin Scale score; mRS 0-3) at 90 days. Safety outcomes included a 90-day mortality and symptomatic intracerebral hemorrhage within 48 hours after thrombectomy. RESULTS Between November 2021 and February 2023, 447 eligible patients at 38 stroke centers were enrolled. Out of 447 thrombectomy patients, T-FPE was achieved in 102 individuals (22.8%). T-FPE was significantly associated with a higher proportion of good functional outcome (mRS 0-3 at 3 months, OR 2.221, 95% CI 1.418-3.479, p < 0.001) and lower mortality than non-T-FPE patients (31.4% vs. 45.5%, p = 0.012). The occlusion sites and lower DBP were strong predictors of T-FPE. INTERPRETATION T-FPE was associated with favorable outcomes at 90 days in AIS patients with a large ischemic core who underwent EVT.
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Affiliation(s)
- Shitao Fan
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University, Chongqing, 400037, China
| | - Changwei Guo
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University, Chongqing, 400037, China
| | - Jiacheng Huang
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University, Chongqing, 400037, China
| | - Zhouzhou Peng
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University, Chongqing, 400037, China
| | - Chengsong Yue
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University, Chongqing, 400037, China
| | - Jie Yang
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University, Chongqing, 400037, China
| | - Linyu Li
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University, Chongqing, 400037, China
| | - Dongjing Xie
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University, Chongqing, 400037, China
| | - Nizhen Yu
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University, Chongqing, 400037, China
| | - Shihai Yang
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University, Chongqing, 400037, China
| | - Xiaolei Shi
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University, Chongqing, 400037, China
| | - Dahong Yang
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University, Chongqing, 400037, China
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University, Chongqing, 400037, China
| | - Qingwu Yang
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital of Army Medical University, Chongqing, 400037, China
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Duan Q, Li W, Zhang Y, Zhuang W, Long J, Wu B, He J, Cheng H. Nomogram established on account of Lasso-logistic regression for predicting hemorrhagic transformation in patients with acute ischemic stroke after endovascular thrombectomy. Clin Neurol Neurosurg 2024; 243:108389. [PMID: 38870670 DOI: 10.1016/j.clineuro.2024.108389] [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: 01/01/2024] [Revised: 05/26/2024] [Accepted: 06/09/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Hemorrhagic transformation (HT) is a common and serious complication in patients with acute ischemic stroke (AIS) after endovascular thrombectomy (EVT). This study was performed to determine the predictive factors associated with HT in stroke patients with EVT and to establish and validate a nomogram that combines with independent predictors to predict the probability of HT after EVT in patients with AIS. METHODS All patients were randomly divided into development and validation cohorts at a ratio of 7:3. The least absolute shrinkage and selection operator (LASSO) regression was used to select the optimal factors, and multivariate logistic regression analysis was used to build a clinical prediction model. Calibration plots, decision curve analysis (DCA) and receiver operating characteristic curve (ROC) were generated to assess predictive performance. RESULTS LASSO regression analysis showed that Alberta Stroke Program Early CT Scores (ASPECTS), international normalized ratio (INR), uric acid (UA), neutrophils (NEU) were the influencing factors for AIS with HT after EVT. A novel prognostic nomogram model was established to predict the possibility of HT with AIS after EVT. The calibration curve showed that the model had good consistency. The results of ROC analysis showed that the AUC of the prediction model established in this study for predicting HT was 0.797 in the development cohort and 0.786 in the validation cohort. CONCLUSION This study proposes a novel and practical nomogram based on ASPECTS, INR, UA, NEU, which can well predict the probability of HT after EVT in patients with AIS.
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Affiliation(s)
- Qi Duan
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Wenlong Li
- Radiotherapy Center, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Ye Zhang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Weihao Zhuang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Jingfang Long
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Beilan Wu
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Jincai He
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China.
| | - Haoran Cheng
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China.
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Ferraù L, Giammello F, Tessitore A, Casella C, Iatì D, Ciacciarelli A, Tudisco V, Gardin A, Vinci SL, Musolino RF, La Spina P, Toscano A. Predictors of Good Functional Outcome in Patients with Tandem Occlusion After Revascularization Treatment: Single-Center Experience with 12-Month Follow-Up. World Neurosurg 2024; 188:e382-e389. [PMID: 38823443 DOI: 10.1016/j.wneu.2024.05.120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2024] [Revised: 05/18/2024] [Accepted: 05/20/2024] [Indexed: 06/03/2024]
Abstract
OBJECTIVE The optimal management and procedural strategy for tandem occlusion (TO) in acute ischemic stroke are still unclear, as is the long-term outcome of these patients. The aim of this study was to evaluate predictors of good functional outcome in patients with TO through the analysis of demographics, clinical, and radiological data with a 1-year follow-up. METHODS We collected data on 100 patients with TO who underwent revascularization treatments in our comprehensive stroke center. We divided patients into 2 groups: those with good functional outcome, defined as a modified Rankin Scale 0-2, and those with poor functional outcome, defined as a modified Rankin Scale 3-6 at 3, 6, and 12-month follow-up. Moreover, we investigated which variables were able to influence mortality. RESULTS At multivariate analysis, endovascular treatment with mechanical thrombectomy combined with emergent cervical carotid artery stenting was an independent predictor of good functional outcome at 6 and 12 months (adjusted odds ratio [aOR] 4.3, confidence interval [CI] 1.49-12.31, P = 0.007) (aOR 3.5, CI 1.25-9.61, P = 0.017) and was associated with a lower rate of mortality at 3 and 6 months follow-up (aOR 0.14, CI 0.04-0.57, P = 0.006 and aOR 0.296, CI 0.97-0.902, P = 0.032, respectively). Furthermore, smoking habit was associated with a better outcome at 3-month follow-up (aOR 10.7, CI 2.2-51.6, P = 0.003) but not at 6- and 12-month. CONCLUSIONS Our research, conducted in a small sample size of patients with acute ischemic stroke due to TO of anterior circulation, found that acute stent placement seems to be safe, improving clinical outcome, and it is associated with low rate of mortality at long-term follow-up.
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Affiliation(s)
- Ludovica Ferraù
- Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Fabrizio Giammello
- Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy; Neurology and Stroke Unit, Neuchâtel Hospital Network (RHNe), Neuchâtel, Switzerland.
| | - Agostino Tessitore
- Neuroradiology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Carmela Casella
- Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Domenico Iatì
- Neuroradiology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Antonio Ciacciarelli
- Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy; Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Valentina Tudisco
- Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Anna Gardin
- Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Sergio Lucio Vinci
- Neuroradiology Unit, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Messina, Italy
| | - Rosa Fortunata Musolino
- Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Paolino La Spina
- Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Antonio Toscano
- Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
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Wu J, Peng Z, Zhang H. Impact of stroke imaging selection modality on endovascular thrombectomy outcomes in the early and extended time windows: A meta-analysis. Brain Behav 2024; 14:e3530. [PMID: 39088741 PMCID: PMC11293622 DOI: 10.1002/brb3.3530] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/12/2023] [Revised: 04/12/2024] [Accepted: 04/19/2024] [Indexed: 08/03/2024] Open
Abstract
BACKGROUND The effect of imaging selection modality on endovascular thrombectomy (EVT) clinical outcomes in patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO) remains unclear. This study aims to compare post-EVT outcomes in patients with AIS-LVO who underwent basic imaging (computed tomography with or without computed tomography angiography) and advanced imaging (computed tomography perfusion or magnetic resonance imaging) in early and late time windows. METHOD A systematic literature search was conducted on PubMed, Cochrane Library, and Embase databases from inception until June 10, 2023. Studies investigating the relationship between the imaging selection modality and post-EVT outcomes in patients with AIS-LVO were retrieved. A random-effects model was used to pool the effect estimates of successful reperfusion, symptomatic intracranial hemorrhage (sICH), functional independence, and mortality. The meta-analysis was performed using Review Manager software v.4.3, and the outcomes were assessed using odds ratios (ORs) and 95% confidence intervals (CIs). RESULT A total of 13 non-randomized observational studies, comprising 19,694 patients, were included in this meta-analysis. In the early time windows, AIS-LVO patients receiving advanced imaging demonstrated a higher likelihood of functional independence (OR, 1.25, 95% CI, 1.08-1.46) and a lower risk of mortality (OR,.73 95% CI,.61-.86) compared to those receiving basic imaging. In the extended time windows, AIS-LVO patients undergoing advanced imaging had a lower mortality rate (OR,.79, 95% CI,.68-.92). Regardless of the time of onset, there were no significant differences between the two groups in terms of sICH or successful reperfusion. CONCLUSION Advanced imaging combined with EVT may achieve better clinical outcomes in patients with AIS-LVO. Further high-quality studies are needed to validate these findings.
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Affiliation(s)
- Jiwei Wu
- Department of NeurosurgeryNorthern Jiangsu People's Hospital Affiliated to Yangzhou UniversityYangzhouJiangsuChina
| | - Zhi Peng
- Department of NeurosurgeryNorthern Jiangsu People's Hospital Affiliated to Yangzhou UniversityYangzhouJiangsuChina
| | - Hengzhu Zhang
- Department of NeurosurgeryNorthern Jiangsu People's Hospital Affiliated to Yangzhou UniversityYangzhouJiangsuChina
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Tanaka K, Brown S, Goyal M, Menon BK, Campbell BCV, Mitchell PJ, Jovin TG, Saver JL, Muir KW, White PM, Bracard S, Guillemin F, Roos YBWEM, van Zwam WH, Najm M, Dowlatshahi D, Hill MD, Demchuk AM. HERMES-24 Score Derivation and Validation for Simple and Robust Outcome Prediction After Large Vessel Occlusion Treatment. Stroke 2024; 55:1982-1990. [PMID: 39038101 DOI: 10.1161/strokeaha.123.045871] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 06/04/2024] [Indexed: 07/24/2024]
Abstract
BACKGROUND Clinicians need simple and highly predictive prognostic scores to assist practical decision-making. We aimed to develop a simple outcome prediction score applied 24 hours after anterior circulation acute ischemic stroke treatment with endovascular thrombectomy and validate it in patients treated both with and without endovascular thrombectomy. METHODS Using the HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) collaboration data set (n=1764), patients in the endovascular thrombectomy arm were divided randomly into a derivation cohort (n=430) and a validation cohort (n=441). From a set of candidate predictors, logistic regression modeling using forward variable selection was used to select a model that was both parsimonious and highly predictive for modified Rankin Scale (mRS) ≤2 at 90 days. The score was validated in validation cohort, control arm (n=893), and external validation cohorts from the ESCAPE-NA1 (Efficacy and Safety of Nerinetide for the Treatment of Acute Ischaemic Stroke; n=1066) and INTERRSeCT (Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV Alteplase and Other Treatments Using Serial CT Angiography; n=614). RESULTS In the derivation cohort, we selected 2 significant predictors of mRS ≤2 (National Institutes of Health Stroke Scale score at 24 hours and age [β-coefficient, 0.34 and 0.06]) and derived the HERMES-24 score: age (years)/10+National Institutes of Health Stroke Scale score at 24 hours. The HERMES-24 score was highly predictive for mRS ≤2 (c-statistic 0.907 [95% CI, 0.879-0.935]) in the derivation cohort. In the validation cohort and the control arm, the HERMES-24 score predicts mRS ≤2 (c-statistic, 0.914 [95% CI, 0.886-0.944] and 0.909 [95% CI, 0.887-0.930]). Observed provability of mRS ≤2 ranged between 3.1% and 3.4% when HERMES-24 score ≥25, while it ranged between 90.6% and 93.0% when HERMES-24 score <10 in the derivation cohort, validation cohort, and control arm. The HERMES-24 score also showed c-statistics of 0.894 and 0.889 for mRS ≤2 in the ESCAPE-NA1 and INTERRSeCT populations. CONCLUSIONS The post-treatment HERMES-24 score is a simple validated score that predicts a 3-month outcome after anterior circulation large vessel occlusion stroke regardless of intervention, which helps prognostic discussion with families on day 2.
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Affiliation(s)
- Koji Tanaka
- Department of Clinical Neurosciences (K.T., M.G., B.K.M., M.N., M.D.H., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Scott Brown
- Altair Biostatistics, St. Louis Park, MN (S. Brown)
| | - Mayank Goyal
- Department of Clinical Neurosciences (K.T., M.G., B.K.M., M.N., M.D.H., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Radiology and Hotchkiss Brain Institute (M.G., B.K.M., M.D.H., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Bijoy K Menon
- Department of Clinical Neurosciences (K.T., M.G., B.K.M., M.N., M.D.H., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Radiology and Hotchkiss Brain Institute (M.G., B.K.M., M.D.H., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Community Health Sciences (B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre (B.C.V.C.), Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
| | - Peter J Mitchell
- Department of Radiology (P.J.M.), Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
| | - Tudor G Jovin
- Department of Neurology, Cooper University Health Care, Camden, NJ (T.G.J.)
| | - Jeffrey L Saver
- Department of Radiology and Neuroradiology, Universitätsklinikum Kiel, Schleswig-Holstein, Germany (J.L.S.)
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Scotland, United Kingdom (K.W.M.)
| | - Phil M White
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, England, United Kingdom (P.M.W.)
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, Imagerie Adaptative Diagnostique et Interventionnelle (S. Bracard), Centre Hospitalier Régional Universitaire de Nancy, Institut national de la santé et de la recherche médicale, Université de Lorraine, France
| | - Francis Guillemin
- Clinical Epidemiology Center (F.G.), Centre Hospitalier Régional Universitaire de Nancy, Institut national de la santé et de la recherche médicale, Université de Lorraine, France
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam University Medical Center, North Holland, the Netherlands (Y.B.W.E.M.R.)
| | - Wim H van Zwam
- Department of Radiology, Maastricht University Medical Center, Rotterdam, South Holland, the Netherlands (W.H.v.Z.)
| | - Mohamed Najm
- Department of Clinical Neurosciences (K.T., M.G., B.K.M., M.N., M.D.H., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Dar Dowlatshahi
- Department of Medicine and Ottawa Hospital Research Institute, University of Ottawa, ON, Canada (D.D.)
| | - Michael D Hill
- Department of Clinical Neurosciences (K.T., M.G., B.K.M., M.N., M.D.H., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Radiology and Hotchkiss Brain Institute (M.G., B.K.M., M.D.H., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Community Health Sciences (B.K.M., M.D.H.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Medicine (M.D.H.), Cumming School of Medicine, University of Calgary, AB, Canada
| | - Andrew M Demchuk
- Department of Clinical Neurosciences (K.T., M.G., B.K.M., M.N., M.D.H., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
- Department of Radiology and Hotchkiss Brain Institute (M.G., B.K.M., M.D.H., A.M.D.), Cumming School of Medicine, University of Calgary, AB, Canada
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Pei Y, Chen Y, Zhong W, He Y, Luo Z, Lou M, Chen Z. Effect of computed tomography vs. computed tomography perfusion on mechanical thrombectomy outcomes within 6 hours. Eur Radiol 2024; 34:5331-5338. [PMID: 38175220 DOI: 10.1007/s00330-023-10545-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 11/12/2023] [Accepted: 11/25/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVES It is unclear which selection strategy, plain CT vs. CT perfusion (CTP), is more powerful in predicting outcome after mechanical thrombectomy (MT). We aimed to compare the effect of plain CT and CTP in predicting outcome after MT within 6 h. METHODS We conducted a prospective analysis of a retrospective cohort from our single-center study, which had occlusion of the internal carotid artery and middle cerebral artery up to the proximal M2 segment and received MT within 6 h. According to the Alberta Stroke Program Early CT Score (ASPECTS), patients were divided into a high-ASPECTS group (≥ 6) and a low ASPECTS group (< 6). Similarly, patients were divided into mismatch and no-mismatch groups according to the DEFUSE3 criteria for CTP. A good outcome was defined as a 90-day modified Rankin Scale (mRS) score of ≤ 3. Univariate and binary logistic regression analyses were used to investigate the association between different imaging modality and 90-day mRS score, and mortalities, respectively. RESULTS The high ASPECTS group included 307 patients (89.2%). The mismatch group included 189 (54.9%) patients meeting the DEFUSE3 criterion. Compared to the low ASPECTS group, the high ASPECTS group had a good outcome (odds ratio (OR), 2.285; [95% confidence interval (CI) (1.106, 4.723)], p = 0.026) and lower mortality (OR, 0.350; [95% CI (0.163, 0.752)], p = 0.007). However, there were no significant differences in good outcomes and mortality between the mismatch and no-mismatch groups. CONCLUSIONS Compared with plain CT, CTP does not provide additional benefits in the selection of patients suitable for MT within 6 h. CLINICAL RELEVANCE STATEMENT CT perfusion is not superior to plain CT for the prediction of clinical outcomes when selecting patients for mechanical thrombectomy in the first 6 h. In that clinical setting, plain CT may be safe in the absence of perfusion data. KEY POINTS • The advantage of CT perfusion (CTP) over CT in pre-mechanical thrombectomy (MT) screening has not been proven for patients with a large infarct core. • CTP is not better than plain CT in predicting good outcome following MT within 6 h. • Plain CT is sufficient for selecting patients suitable for MT within 6 h of large artery occlusion.
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Affiliation(s)
- Yingjian Pei
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, 310009, China
| | - Yuping Chen
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, 310009, China
| | - Wansi Zhong
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, 310009, China
| | - Yaode He
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, 310009, China
| | - Zhongyu Luo
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, 310009, China
| | - Min Lou
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, 310009, China.
| | - Zhicai Chen
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, 310009, China.
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9
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Shen Y, You H, Yang Y, Tang R, Ji Z, Liu H, Du M, Zhou M. Predicting brain edema and outcomes after thrombectomy in stroke: Frontal delta/alpha ratio as an optimal quantitative EEG index. Clin Neurophysiol 2024; 164:149-160. [PMID: 38896932 DOI: 10.1016/j.clinph.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 04/26/2024] [Accepted: 05/17/2024] [Indexed: 06/21/2024]
Abstract
OBJECTIVE We aimed to determine whether quantitative electroencephalography (QEEG) measures have predictive value for cerebral edema (CED) and clinical outcomes in acute ischemic stroke (AIS) patients with anterior circulation large vessel occlusion who underwent mechanical thrombectomy (MT). METHODS A total of 105 patients with AIS in the anterior circulation were enrolled in this prospective study. The occurrence and severity of CED were assessed through computed tomography conducted 24 h after MT. Clinical outcomes were evaluated based on early neurological deterioration (END) and 3-month functional status, as measured by the modified Rankin scale (mRS). Electroencephalography (EEG) recordings were performed 24 h after MT, and QEEG indices were calculated from the standard 16 electrodes and 2 frontal channels (F3-C3, F4-C4). The delta/alpha ratio (DAR), the (delta + theta) / (alpha + beta) ratio (DTABR), and relative delta power were averaged over all electrodes (global) and the F3-C3 and F4-C4 channels (frontal). The predictive effect and value of QEEG indices for CED and clinical outcomes were assessed using ordinal and logistic regression models, as well as receiver operating characteristic (ROC) curves. RESULTS Significantly, both global and frontal DAR were found to be associated with the severity of CED, END, and poor functional outcomes at 90 days, while global and frontal DTABR and relative delta power were not associated with outcomes. In ROC analysis, the best predictive effect was observed in frontal DAR, with an area under the curve of approximately 0.80. It exhibited approximately 75% sensitivity and 71% specificity for radiological and clinical outcomes when a threshold of 3.3 was used. CONCLUSIONS QEEG techniques may be considered an efficient bedside monitoring method for assessing treatment efficacy, identifying patients at higher risk of severe CED and END, and predicting long-term functional outcomes. SIGNIFICANCE QEEG can help identify patients at risk of severe neurological complications that can impact long-term functional recovery in AIS patients who underwent MT.
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Affiliation(s)
- Yeru Shen
- Department of Critical Care Medicine, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Heyang You
- Department of Critical Care Medicine, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Yanyan Yang
- Department of Critical Care Medicine, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Rui Tang
- Department of Critical Care Medicine, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Zongshu Ji
- Department of Critical Care Medicine, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Haiyan Liu
- Department of Critical Care Medicine, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Min Du
- Department of Critical Care Medicine, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Min Zhou
- Department of Critical Care Medicine, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China.
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10
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Alexandre AM, Monforte M, Brunetti V, Scarcia L, Cirillo L, Zini A, Scala I, Nardelli V, Arbia F, Arbia G, Frisullo G, Kalsoum E, Camilli A, De Leoni D, Colò F, Abruzzese S, Piano M, Rollo C, Macera A, Ruggiero M, Lafe E, Gabrieli JD, Cester G, Limbucci N, Arba F, Ferretti S, Da Ros V, Bellini L, Salsano G, Mavilio N, Russo R, Bergui M, Caragliano AA, Vinci SL, Romano DG, Frauenfelder G, Semeraro V, Ganimede MP, Lozupone E, Romi A, Cavallini A, Milonia L, Muto M, Candelaresi P, Calabresi P, Pedicelli A, Broccolini A. Baseline clinical and neuroradiological predictors of outcome in patients with large ischemic core undergoing mechanical thrombectomy: A retrospective multicenter study. Int J Stroke 2024; 19:779-788. [PMID: 38546177 DOI: 10.1177/17474930241245828] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/17/2024]
Abstract
BACKGROUND Recent randomized trials have shown the benefit of mechanical thrombectomy (MT) also in patients with an established large ischemic core. AIMS The purpose of this study was to define baseline predictors of clinical outcome in patients with large vessel occlusion (LVO) in the anterior circulation and an Alberta Stroke Program Early CT score (ASPECTS) ⩽ 5, undergoing MT. MATERIAL AND METHODS The databases of 16 comprehensive stroke centers were retrospectively screened for patients with LVO and ASPECTS ⩽5 that received MT. Baseline clinical and neuroradiological features, including the differential contribution of all ASPECTS regions to the composite score, were collected. Primary clinical outcome measure was a 90-day modified Rankin Scale (mRS) score of 0-2. Statistical analysis used a logistic regression model and random forest algorithm. RESULTS A total of 408 patients were available for analysis. In multivariate model, among baseline features, lower age (odd ratio (OR) = 0.962, 95% confidence interval (CI) = 0.943-0.982) and lower National Institute of Health Stroke Scale (NIHSS) score (OR = 0.911, 95% CI = 0.862-0.963) were associated with the mRS score 0-2. Involvement of the M2 (OR = 0.398, 95% CI = 0.206-0.770) or M4 (OR = 0.496, 95% CI = 0.260-0.945) ASPECTS regions was associated with an unfavorable outcome. Random forest analysis confirmed that age and baseline NIHSS score are the most important variables influencing clinical outcome, whereas involvement of cortical regions M5, M4, M2, and M1 can have a negative impact. CONCLUSION Our retrospective analysis shows that, along with age and baseline clinical impairment, presence of early ischemic changes involving cortical areas has a role in clinical outcome in patients with large ischemic core undergoing MT. DATA ACCESS STATEMENT The data that support the findings of this study are available upon reasonable request.
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Affiliation(s)
- Andrea M Alexandre
- Interventional Neuroradiology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Mauro Monforte
- Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Valerio Brunetti
- Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Luca Scarcia
- Neuroradiology Unit, Henri Mondor Hospital, Creteil, France
| | - Luigi Cirillo
- Department of Neurology and Stroke Center, IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital, Bologna, Italy
| | - Andrea Zini
- Department of Neurology and Stroke Center, IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital, Bologna, Italy
| | - Irene Scala
- Catholic University School of Medicine, Rome, Italy
| | - Vincenzo Nardelli
- Department of Statistical Sciences, Catholic University, Rome, Italy
| | - Francesco Arbia
- Department of Neuroradiology, S. Andrea Hospital, Rome, Italy
| | - Giuseppe Arbia
- Department of Statistical Sciences, Catholic University, Rome, Italy
| | - Giovanni Frisullo
- Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Erwah Kalsoum
- Neuroradiology Unit, Henri Mondor Hospital, Creteil, France
| | | | | | | | | | - Mariangela Piano
- Neuroradiology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Claudia Rollo
- Neuroradiology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Antonio Macera
- Neuroradiology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Maria Ruggiero
- Neuroradiology Unit, M. Bufalini Hospital, Cesena, Italy
| | - Elvis Lafe
- Neuroradiology Unit, M. Bufalini Hospital, Cesena, Italy
| | | | - Giacomo Cester
- Neuroradiology Unit, Padua University Hospital, Padua, Italy
| | - Nicola Limbucci
- Interventional Neurovascular Unit, A.O.U. Careggi, Florence, Italy
| | | | - Simone Ferretti
- NEUROFARBA Department, University of Florence, Florence, Italy
| | - Valerio Da Ros
- Department of Biomedicine and Prevention, "Tor Vergata" University Hospital, Rome, Italy
| | - Luigi Bellini
- Department of Biomedicine and Prevention, "Tor Vergata" University Hospital, Rome, Italy
| | | | - Nicola Mavilio
- Neuroradiology Unit, "San Martino" Hospital, Genoa, Italy
| | - Riccardo Russo
- Neuroradiology Unit, A.O. "Città della Salute e della Scienza," Turin, Italy
| | - Mauro Bergui
- Neuroradiology Unit, A.O. "Città della Salute e della Scienza," Turin, Italy
| | | | - Sergio L Vinci
- Neuroradiology Unit, "G. Martino" Hospital, Messina, Italy
| | - Daniele G Romano
- Neuroradiology Unit, AOU "S Giovanni di Dio e Ruggi di Aragona," Salerno, Italy
| | - Giulia Frauenfelder
- Neuroradiology Unit, AOU "S Giovanni di Dio e Ruggi di Aragona," Salerno, Italy
| | - Vittorio Semeraro
- Interventional Radiology Unit, "SS Annunziata" Hospital, Taranto, Italy
| | | | | | - Andrea Romi
- Neuroradiology Unit, IRCCS "San Matteo" Hospital, Pavia, Italy
| | - Anna Cavallini
- Cerebrovascular Diseases Unit, IRCCS Fondazione Mondino, Pavia, Italy
| | - Luca Milonia
- Interventional Neuroradiology Unit, "Umberto I" University Hospital, Rome, Italy
| | - Massimo Muto
- Neuroradiology Unit, A.O.R.N. "Antonio Cardarelli," Naples, Italy
| | | | - Paolo Calabresi
- Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Catholic University School of Medicine, Rome, Italy
| | - Alessandro Pedicelli
- Interventional Neuroradiology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
| | - Aldobrando Broccolini
- Neurology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Rome, Italy
- Catholic University School of Medicine, Rome, Italy
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11
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Alet MJ, Balcarce P, Ameriso SF. Early dual antiplatelet therapy in patients with minor ischemic stroke after intravenous thrombolysis. J Stroke Cerebrovasc Dis 2024:107903. [PMID: 39084339 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2024] [Revised: 07/22/2024] [Accepted: 07/28/2024] [Indexed: 08/02/2024] Open
Abstract
OBJECTIVES Minor stroke is defined by a score of 5 or less on the National Institutes of Health Stroke Scale (NIHSS). Prior trials have shown efficacy of short term dual antiplatelet therapy (DAPT) in secondary prevention of stroke among patients with transient ischemic attack (TIA) or minor ischemic stroke, but no randomized clinical trials have studied this benefit after intravenous thrombolysis (IVT). Our aim was to investigate the safety of DAPT within 90 days after IVT in patients with acute minor ischemic stroke. PATIENTS and methods We reviewed medical records of patients older than 18 years that received IVT between January 2015 and December 2022. Patients had a diagnosis of acute minor stroke or averted stroke (complete recovery and negative image on follow-up). Single or dual antiplatelet treatment was started 24 hours after thrombolysis according to the physician's judgment. Patients were divided in two groups: single and dual antiplatelet therapy. We assessed clinical outcome using the modified Rankin scale (mRS), symptomatic intracranial hemorrhage (SICH) and mortality at 90 days. RESULTS Fifty-three patients met the inclusion criteria, 68% men aged 64±16,5 years. Seventy five percent had an ischemic stroke and 25% had an averted stroke. Median door-to-needle time was 50 minutes. Fifty one percent were in the single antiplatelet group and 49% in the dual antiplatelet therapy group. There were no differences in demographic and clinical characteristics between groups. The 90-day mRS did not show significant difference between groups. No patients had SICH nor died during follow-up. One patient in the single antiplatelet group had stroke recurrence. CONCLUSIONS Dual antiplatelet therapy after IVT with rt-PA for acute minor ischemic stroke appears not to increase the risk of bleeding and mortality compared to single antiplatelet therapy in the first three months after the event. This is the first study to assess this subject in a Latin American population.
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Affiliation(s)
- Matías J Alet
- Centro Integral de Neurología Vascular, Departamento de Neurología, Fleni, Buenos Aires, Argentina..
| | - Pilar Balcarce
- Departamento de Neurología, Fleni, Buenos Aires, Argentina..
| | - Sebastián F Ameriso
- Centro Integral de Neurología Vascular, Departamento de Neurología, Fleni, Buenos Aires, Argentina..
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12
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Ali A, Rao R, Sharkey B, Gega A, Oliver M, Chen T, Burgess R, Jumaa M, Zaidi S. Medium vessel occlusion thrombectomy: Single center experience using the 3 MAX catheter. Interv Neuroradiol 2024:15910199241264328. [PMID: 39051591 DOI: 10.1177/15910199241264328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024] Open
Abstract
INTRODUCTION Thrombectomy for medium vessel occlusion is a topic of great interest. We describe a single-center experience with the Penumbra 3-MAX aspiration catheter in stroke thrombectomy of medium vessel occlusion(MeVO). We investigated the use of 3-MAX as a de-novo first pass catheter and as a rescue aspiration device following attempted thrombectomy with other devices. This is the first description of the first pass effect and successful recanalization rate of the 3-MAX catheter in de-novo vs. rescue use of this catheter. METHODS From January 2017 to January 2023, 84 patients underwent mechanical thrombectomy with use of a Penumbra 3MAX aspiration catheter at our comprehensive stroke center. Patient charts were retrospectively reviewed. Primary efficacy outcome was successful recanalization following mechanical thrombectomy. Primary safety outcome was intracerebral hemorrhage. RESULTS A total of 84 patients underwent MT with the 3MAX device. It was used as a de novo catheter in 27(32.1%) and as a rescue catheter in 57(67.9%) patients. 35(41.6%) patients achieved angiographic TICI grade ≥ 2c. De novo 3MAX use led to 68.18% successful recanalization and rescue use led to 72.22% recanalization (p = 0.67) as measured by TICI score of 2c or better. Parenchymal intracerebral hemorrhages (PH) were present in 8 patients (9.5%). CONCLUSION The Penumbra 3MAX catheter is safe and effective when used as a first pass or a rescue device in mechanical thrombectomy. We found similar rates of successful recanalization and minimal hemorrhagic risk when comparing the 3MAX as a rescue or de novo aspiration catheter.
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Affiliation(s)
- Aizaz Ali
- College of Medicine and Life Sciences, University of Toledo, Toledo, OH, USA
- Department of Neurology, Promedica Toledo Hospital, Toledo, OH, USA
| | - Rahul Rao
- College of Medicine and Life Sciences, University of Toledo, Toledo, OH, USA
- Department of Neurology, Promedica Toledo Hospital, Toledo, OH, USA
| | - Brandon Sharkey
- College of Medicine and Life Sciences, University of Toledo, Toledo, OH, USA
| | - Alisa Gega
- College of Medicine and Life Sciences, University of Toledo, Toledo, OH, USA
| | - Marion Oliver
- Department of Neurology, Advocate Aurora Health, Park Ridge, IL, USA
| | - Tahao Chen
- Department of Biostatistics, Bowling Green University, Bowling Green, OH, USA
| | - Richard Burgess
- College of Medicine and Life Sciences, University of Toledo, Toledo, OH, USA
- Department of Neurology, Promedica Toledo Hospital, Toledo, OH, USA
| | - Mouhammad Jumaa
- College of Medicine and Life Sciences, University of Toledo, Toledo, OH, USA
- Department of Neurology, Promedica Toledo Hospital, Toledo, OH, USA
| | - Syed Zaidi
- College of Medicine and Life Sciences, University of Toledo, Toledo, OH, USA
- Department of Neurology, Promedica Toledo Hospital, Toledo, OH, USA
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13
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Sembill JA, Sprügel MI, Haupenthal D, Kremer S, Knott M, Mühlen I, Kallmünzer B, Kuramatsu JB. Endovascular thrombectomy in patients with anterior circulation stroke: an emulated real-world comparison. Neurol Res Pract 2024; 6:37. [PMID: 39049127 PMCID: PMC11270839 DOI: 10.1186/s42466-024-00331-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2024] [Accepted: 06/21/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Endovascular thrombectomy (EVT) has been proven effective in anterior circulation stroke due to large vessel occlusion (LVO). However, translation from randomized clinical trials (RCTs) with highly selected patients to real-world requires confirmation, particularly to identify associations outside of strict selection criteria. AIMS This study aims to compare functional outcomes after EVT in real-world with those reported in RCTs, and to identify associations with functional outcome after EVT outside RCT-criteria. METHODS This study analyzed longitudinal German real-world data from the Stroke Research Consortium in Northern Bavaria (STAMINA) cohort from January, 2015 to June, 2019. We conducted a trial emulation, comparing patients with anterior circulation stroke and LVO meeting selection criteria for RCTs investigating EVT (1) predominantly within 6 hours with those from HERMES meta-analysis, and (2) within 6-24 hours with those from AURORA meta-analysis. We (3) analyzed treatment effects of EVT and association with functional outcome in patients treated outside RCT criteria. RESULTS Of 598 patients, 281 (47.0%) met RCT-criteria for treatment within 6 hours (hereinafter STAMINA-HERMES), 74 (12.4%) met RCT-criteria for treatment within 6-24 hours (STAMINA-AURORA), and 277 (46.3%) patients received EVT outside RCT-criteria. We observed no difference in rates of functional independence or mortality, comparing STAMINA-HERMES with HERMES meta-analysis (mRS 0-1: n=120/281 [43%] vs. 291/633 [46%], p=0.36; mortality: n=34/281 [12%] vs. 97/633 [15%], p=0.20), and STAMINA-AURORA with AURORA meta-analysis (mRS 0-1: n=26/74 [35%] vs. 122/266 [46%], p=0.10, mortality: n=10/74 [14%] vs. 45/266 [17%], p=0.48). Patients treated outside RCT-criteria had worse outcome (mRS 0-1: n=38/277 [14%], mortality: n=90/277 [32%], both p<0.001); possibly driven by pre-existing functional dependence (n=172/277 [62%]). Compared to matched controls, EVT outside of RCT-criteria was associated with lower mortality (absolute treatment effect: -14%, 95% Confidence Interval [CI] -23 to -5, p<0.01), but not with recovery to functional independence or premorbid functional status (treatment effect: 4%, CI -4 to 11, p=0.34), which was associated with lower NIHSS (Odds ratio [OR] 0.86, CI 0.80-0.92, p<0.001) and age (OR 0.95, CI 0.93-0.98, p=0.002). CONCLUSIONS Translation of EVT outcomes reported in RCTs into real-world is possible, however, almost half of patients did not meet trial criteria. Identification of patients who functionally benefit from frequently performed EVT outside RCT-criteria requires further investigation. TRIAL REGISTRATION Clinicaltrials.gov, NCT04357899.
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Affiliation(s)
- Jochen A Sembill
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany.
| | - Maximilian I Sprügel
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - David Haupenthal
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Svenja Kremer
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Michael Knott
- Department of Neuroradiology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Iris Mühlen
- Department of Neuroradiology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Bernd Kallmünzer
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Joji B Kuramatsu
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
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14
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Chung D, Lee JS, Oh MS, Park JM, Chung JW, Bang OY, Kim GM, Seo WK. Temporal trends of sex differences in acute reperfusion therapy and early outcomes of acute ischemic stroke in South Korea: 10-year analysis of the nationwide stroke registry. Int J Stroke 2024:17474930241261877. [PMID: 38836445 DOI: 10.1177/17474930241261877] [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: 06/06/2024]
Abstract
BACKGROUND Sex differences in stroke outcomes are notable, with women experiencing higher incidence rates, greater disability-adjusted life years, and poorer recovery compared to men, even after adjusting for age and comorbidities. Despite the disproportionate burden in women, studies have reported that women are less likely to receive appropriate stroke treatment than men. AIM This study investigated temporal trends of sex differences in acute reperfusion therapy and early outcomes in patients with acute ischemic stroke over 10 years in South Korea. METHODS A retrospective analysis of Korean Stroke Registry included patients with acute ischemic stroke from 2012 to 2021. The study outcomes were the temporal trends of acute reperfusion therapy and early outcomes over 10 years in men and women, respectively. In addition, this study analyzed the temporal trends of sex differences in these parameters during the same period. Early outcomes include the proportions of favorable functional outcomes at discharge, discharge patterns, and in-hospital mortality. RESULTS A total of 93,692 patients (68.4 years, 40.1% women) with acute ischemic stroke were finally enrolled. Women had a higher age at stroke onset, a higher prevalence of atrial fibrillation, and more severe strokes than men. Women had lower proportion of favorable functional outcomes at discharge and higher proportion of in-hospital mortality compared to men each year. The proportion of patients who received intravenous thrombolysis was lower or similar in women compared to men in most years, and the proportion of patients who received endovascular thrombectomy did not significantly differ between sexes annually. Sex differences in acute reperfusion therapy remained unchanged over 10 years. CONCLUSION Women have received acute reperfusion therapy at similar or lower rates than men and experienced poorer outcomes, despite having more stroke risk factors and often more severe strokes.
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Affiliation(s)
- Darda Chung
- Department of Neurology and Stroke center, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea
| | - Ji Sung Lee
- Department of Clinical Research Center, Asan Medical Center, College of Medicine, University of Ulsan, Ulsan, Republic of Korea
| | - Mi-Sun Oh
- Department of Neurology, Hallym University Sacred Heart Hospital, College of Medicine, Hallym University, Chuncheon-si, Republic of Korea
| | - Jong-Moo Park
- Department of Neurology, Uijeongbu Eulji Medical Center, School of Medicine, Eulji University, Daejeon, Republic of Korea
| | - Jong-Won Chung
- Department of Neurology and Stroke center, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea
| | - Oh Young Bang
- Department of Neurology and Stroke center, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea
| | - Gyeong-Moon Kim
- Department of Neurology and Stroke center, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea
| | - Woo-Keun Seo
- Department of Neurology and Stroke center, Samsung Medical Center, School of Medicine, Sungkyunkwan University, Seoul, Republic of Korea
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15
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Salim HA, Yedavalli V, Musmar B, Adeeb N, E L Naamani K, Henninger N, Sundararajan SH, Kühn AL, Khalife J, Ghozy S, Scarcia L, Tan BYQ, Heit JJ, Regenhardt RW, Cancelliere NM, Bernstock JD, Rouchaud A, Fiehler J, Essibayi MA, Sheth SA, Puri AS, Barreau X, Colasurdo M, Renieri L, Dyzmann C, Marotta T, Spears J, Mowla A, Jabbour P, Filipe JP, Biswas A, Harker P, Clarençon F, Radu RA, Siegler JE, Nguyen TN, Varela R, Ota T, Gonzalez N, Moehlenbruch MA, Altschul D, Gory B, Costalat V, Stracke CP, Aziz-Sultan MA, Hecker C, Shaikh H, Liebeskind DS, Baker A, Pedicelli A, Alexandre A, Faizy TD, Tancredi I, Kalsoum E, Lubicz B, Patel AB, Mendes Pereira V, Guenego A, Dmytriw AA. Endovascular therapy versus best medical management in distal medium middle cerebral artery acute ischaemic stroke: a multinational multicentre propensity score-matched study. J Neurol Neurosurg Psychiatry 2024:jnnp-2024-333669. [PMID: 39043567 DOI: 10.1136/jnnp-2024-333669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 06/24/2024] [Indexed: 07/25/2024]
Abstract
BACKGROUND The efficacy of endovascular treatment (EVT) in acute ischaemic stroke due to distal medium vessel occlusion (DMVO) remains uncertain. Our study aimed to evaluate the safety and efficacy of EVT compared with the best medical management (BMM) in DMVO. METHODS In this prospectively collected, retrospectively reviewed, multicentre cohort study, we analysed data from the Multicentre Analysis of primary Distal medium vessel occlusions: effect of Mechanical Thrombectomy registry. Patients with acute ischaemic stroke due to DMVO in the M2, M3 and M4 segments who underwent EVT or received BMM were included. Primary outcome measures comprised 10 co-primary endpoints, including functional independence (mRS 0-2), excellent outcome (mRS 0-1), mortality (mRS 6) and haemorrhagic complications. Propensity score matching was employed to balance the cohorts. RESULTS Among 2125 patients included in the primary analysis, 1713 received EVT and 412 received BMM. After propensity score matching, each group comprised 391 patients. At 90 days, no significant difference was observed in achieving mRS 0-2 between EVT and BMM (adjusted OR 1.00, 95% CI 0.67 to 1.50, p>0.99). However, EVT was associated with higher rates of symptomatic intracerebral haemorrhage (8.4% vs 3.0%, adjusted OR 3.56, 95% CI 1.69 to 7.48, p<0.001) and any intracranial haemorrhage (37% vs 19%, adjusted OR 2.61, 95% CI 1.81 to 3.78, p<0.001). Mortality rates were similar between groups (13% in both, adjusted OR 1.48, 95% CI 0.87 to 2.51, p=0.15). CONCLUSION Our findings suggest that while EVT does not significantly improve functional outcomes compared with BMM in DMVO, it is associated with higher risks of haemorrhagic complications. These results support a cautious approach to the use of EVT in DMVO and highlight the need for further prospective randomised trials to refine treatment strategies.
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Affiliation(s)
- Hamza Adel Salim
- Radiology, Johns Hopkins Medicine, Baltimore, Maryland, USA
- Neuroendovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
- Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
| | | | - Basel Musmar
- Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
| | - Nimer Adeeb
- Neurosurgery, BIDMC, Shreveport, Louisiana, USA
| | | | - Nils Henninger
- Neurology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Sri Hari Sundararajan
- New York-Presbyterian Hospital/Weill Cornell Medical Center, New York, New York, USA
| | | | - Jane Khalife
- Cooper Hospital University Medical Center, Camden, New Jersey, USA
| | - Sherief Ghozy
- Radiology Neuroradiology Department, Mayo Clinic, Rochester, Minnesota, USA
| | - Luca Scarcia
- Policlinico Universitario Agostino Gemelli, Roma, Lazio, Italy
| | | | | | - Robert W Regenhardt
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston MA, Boston, Massachusetts, USA
| | | | | | - Aymeric Rouchaud
- Interventional Neuroradiology, Hopital Bicetre, Paris Kremlin Bicêtre, France
- Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Jens Fiehler
- Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | - Sunil A Sheth
- Neurology, University of Texas - Houston, Houston, Texas, USA
| | - Ajit S Puri
- Radiology and Neurosurgery, Univ Massachusetts, Worcester, Massachusetts, USA
| | | | | | - Leonardo Renieri
- Interventional Neurovascular Unit, Azienda Ospedaliero Universitaria Careggi, Firenze, Italy
| | | | | | - Julian Spears
- Department of Medical Imaging, Division of Diagnostic and Therapeutic Neuroradiology, St. Michael's Hospital, University of Toronto, Department of Medical Imaging, Division of Diagnostic and Therapeutic Neuroradiology, St. Michael's Hospital, University of Toronto, Pessac, France
- Department of Surgery, Division of Neurosurgery, University of Toronto, Department of Surgery, Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
| | - Askan Mowla
- USC Keck School of Medicine, Los Angeles, California, USA
| | - Pascal Jabbour
- Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | | | - Arundhati Biswas
- Neurosurgery, Albert Einstein College of Medicine, Bronx, New York, USA
| | | | - Frédéric Clarençon
- Interventional Neuroradiology, University Hospital Pitié Salpêtrière, Paris, France
| | | | - James E Siegler
- Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Thanh N Nguyen
- Neurology, Neurosurgery, Radiology, Boston University Medical Center, Boston, Massachusetts, USA
| | - Ricardo Varela
- Neurology, University of California, Los Angeles, Los Angeles, California, USA
| | - Takahiro Ota
- Radiological Sciences, Catholic University of Sacred Heart, "A. Gemelli" Hospital, Rome, Italy
| | - Nestor Gonzalez
- Radiology and Neuroradiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Benjamin Gory
- Hôpital Civil Marie Curie à Lodelinsart, Charleroi, Belgium
| | | | | | | | - Constantin Hecker
- Institute of Neurointervention, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Hamza Shaikh
- Interventional Neuroradiology Department, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - David S Liebeskind
- Neurology, University of California, Los Angeles, Los Angeles, California, USA
| | - Amanda Baker
- Montefiore Medical Center, New York, New York, USA
| | - Alessandro Pedicelli
- Radiological Sciences, Catholic University of Sacred Heart, "A. Gemelli" Hospital, Rome, Italy
| | - Andrea Alexandre
- Radiology and Neuroradiology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | | | - Erwah Kalsoum
- Neuroradiology, Henri Mondor Hospital, Créteil, France
| | - Boris Lubicz
- Centre Universitair Bruxelles Hôpital Erasme, Bruxelles, Belgium
| | - Aman B Patel
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Adrien Guenego
- Interventional Neuroradiology Department, Centre Hospitalier Universitaire de Toulouse, Toulouse, France
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
- Neurovascular Centre, Divisions of Therapeutic Neuroradiology and Neurosurgery, St. Michael Hospital, University of Toronto, Toronto, ON, Canada
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Dolia JN, Grossberg JA, Martins PN, Tarek MA, Pabaney A, Al-Bayati AR, Nogueira RG, Haussen DC. Reliability assessment of distal occlusion eTICI scoring. Interv Neuroradiol 2024:15910199241262844. [PMID: 39034141 DOI: 10.1177/15910199241262844] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024] Open
Abstract
BACKGROUND The eThrombolysis in Cerebral Infarction (eTICI) score has been validated in proximal large artery occlusion (pLAOs). Despite the growing number of distal medium vessel occlusions (DMVOs) mechanical thrombectomies (MT) and the widespread utilization of the eTICI scoring system, its reliability and standardization for more distal occlusions have not been validated. We aim to evaluate the interrater reliability of eTICI scores in primary DMVOs. METHODS This was a retrospective analysis of a prospectively maintained database for consecutive patients with pLAO and DMVO MT at a single comprehensive stroke center from 2015 to 2022. Two fellowship-trained neurointerventionalists blindly/independently assessed digital subtraction angiograms for final eTICI, followed by consensus reads for discrepancies. RESULTS 59 DMVO of 2248 thrombectomies [M3:29(50%)/M4:1(2%)/A1:3(5%)/A2:12(22%)/A3: 5(9%)/P1:7(12%)/P2:1(2%)] and 124 pLAOs of 308 thrombectomies [i-ICA:13(11%)/MCA-M1: 111(90%)] were included. The distribution of final eTICI scores was comparable between pLAO vs DMVOs (p = 0.82). The pLAO final eTICI score assessment between two readers demonstrated moderate reliability with a kappa0.77 (95%CI: 0.67-0.88), while the DMVO eTICI score assessment exhibited almost-perfect agreement with kappa 0.94 (95%CI: 0.90-0.99). The agreement between the consensus read and the original report in DMVOs was 0.86 (95% CI: 0.71-1.00) while for pLAO it was 0.83(95% CI: 0.76-0.90). The performance of eTICI was comparable amongst different DMVO territories as well as for distal vs. very distal occlusions. CONCLUSION eTICI score exhibited comparable performance for DMVO as compared to pLAO strokes. Further studies investigating DMVO eTICI grading and clinical outcomes are warranted.
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Affiliation(s)
- Jaydevsinh N Dolia
- Department of Neurology, Emory University School of Medicine-Atlanta, Atlanta, GA, USA
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, Atlanta, GA, USA
| | - Jonathan A Grossberg
- Department of Neurology, Emory University School of Medicine-Atlanta, Atlanta, GA, USA
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, Atlanta, GA, USA
| | - Pedro N Martins
- Department of Neurology, Emory University School of Medicine-Atlanta, Atlanta, GA, USA
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, Atlanta, GA, USA
| | - Mohamed A Tarek
- Department of Neurology, Emory University School of Medicine-Atlanta, Atlanta, GA, USA
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, Atlanta, GA, USA
| | - Aqueel Pabaney
- Department of Neurology, Emory University School of Medicine-Atlanta, Atlanta, GA, USA
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, Atlanta, GA, USA
| | | | - Raul G Nogueira
- Department of Neurology, UPMC, Stroke Institute, Pittsburgh, PA, USA
| | - Diogo C Haussen
- Department of Neurology, Emory University School of Medicine-Atlanta, Atlanta, GA, USA
- Marcus Stroke & Neuroscience Center, Grady Memorial Hospital-Atlanta, Atlanta, GA, USA
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Su S, Bai X, Li Q, Yue C, Yang J, Huang J, Kong W, Guo C, Hu J, Liu S, Yang D, Song J, Peng Z, Li L, Tian Y, Li F, Zi W, Liu X. Safety and efficacy of tirofiban combined with intravenous thrombolysis and endovascular treatment in acute large vessel occlusion stroke. Clin Neurol Neurosurg 2024; 244:108463. [PMID: 39053321 DOI: 10.1016/j.clineuro.2024.108463] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/16/2023] [Revised: 07/14/2024] [Accepted: 07/20/2024] [Indexed: 07/27/2024]
Abstract
OBJECTIVE This study assesses the safety and efficacy of tirofiban for patients with large vessel occlusion stroke after intravenous thrombolysis. METHODS This study data was from SUSTAIN, DEVT, and RESCUE BT trials. According to whether the use of tirofiban who underwent endovascular treatment and preceding intravenous thrombolysis was divided into the tirofiban group and the no-tirofiban group. The safety outcomes were symptomatic intracranial hemorrhage, any intracranial hemorrhage within 48 h, and 3-month mortality. The efficacy outcome was defined as a score of 0-2 on the modified Rankin Scale scores at 3 months. RESULTS A total of 372 patients with intravenous thrombolysis were included in these SUSTAIN, DEVT, and RESCUE BT trials. Adjusted multivariate analysis showed that tirofiban with intravenous thrombolysis was not associated with symptomatic intracranial hemorrhage (aOR, 0.87; 95 % CI, 0.49-1.57; P=0.65), any intracranial hemorrhage within 48 h (aOR, 1.00; 95 % CI, 0.60-1.66; P=1.00), 3-month mortality (aOR, 1.10; 95 % CI, 0.56-2.19; P=0.78) and 3-month modified Rankin Scale scores 0-2 (aOR, 0.72; 95 % CI, 0.42-1.25; P=0.25) in patients with acute large vessel occlusion. In the subgroup analysis, we found that tirofiban was not recommended for females (aOR, 0.34; 95 % CI, 0.12-0.93), baseline Alberta Stroke Program Early CT Score≤9 (aOR, 0.37; 95 % CI, 0.18-0.76), and cardiogenic embolism (aOR, 0.36; 95 % CI, 0.14-0.97). CONCLUSION Tirofiban combined with intravenous thrombolysis in patients with acute large vessel occlusion may be safe. Further studies need to confirm the effectiveness of tirofiban after intravenous thrombolysis in different stroke etiology.
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Affiliation(s)
- Shixing Su
- Neurosurgery Center, Department of Cerebrovascular Surgery, Engineering Technology Research Center of Education Ministry of China on Diagnosis and Treatment of Cerebrovascular Disease, Zhujiang Hospital, Southern Medical University, Guangzhou, Guangdong 510280, China
| | - Xiubin Bai
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Qin Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Chengsong Yue
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jie Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jiacheng Huang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Weilin Kong
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Changwei Guo
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jinrong Hu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Shuai Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Dahong Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jiaxing Song
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Zhouzhou Peng
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Linyu Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Yan Tian
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China.
| | - Xiang Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China.
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18
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Lu ZJ, Lai JX, Huang JR, Xie SH, Lai ZH. Predictive value of intracranial high-density areas in neurological function. World J Psychiatry 2024; 14:1080-1086. [PMID: 39050205 PMCID: PMC11262925 DOI: 10.5498/wjp.v14.i7.1080] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2024] [Revised: 05/21/2024] [Accepted: 06/05/2024] [Indexed: 07/12/2024] Open
Abstract
BACKGROUND Intracranial high-density areas (HDAs) have attracted considerable attention for predicting clinical outcomes; however, whether HDAs predict worse neurological function and mental health remains controversial and unclear, which requires further investigation. AIM To investigate the predictive value of intracranial HDAs for neurological function and mental health after endovascular treatment. METHODS In this prospective study, 96 patients with acute ischemic stroke (AIS) who accepted endovascular mechanical thrombectomy (EMT) were included. The enrolled patients underwent cranial computed tomography (CT) examination within 24 hours after EMT. Clinical data in terms of National Institutes of Health Stroke Scale (NIHSS), the 3-month modified Rankin Scale (mRS), self-rating depression scale (SDS), and self-rating anxiety scale (SAS) scores were collected and compared between patients with HDAs and non-HDAs and between patients with good and poor clinical prognosis. RESULTS Compared to patients without HDAs, patients with HDAs presented severe neurological deficits (admission NIHSS score: 18 ± 3 vs 19 ± 4), were more likely to have post-stroke disabilities (mRS < 3: 35% vs 62%), and suffered more severe depression (SDS score: 58 ± 16 vs 64 ± 13) and anxiety disorder (SAS score: 52 ± 8 vs 59 ± 10). Compared to patients with a good prognosis, patients with a poor prognosis presented severe neurological deficits (admission NIHSS score: 17 ± 4 vs 20 ± 3), were more likely to have HDAs on CT images (64% vs 33%), and suffered more severe depression (SDS score: 55 ± 19 vs 65 ± 11) and anxiety (SAS score: 50 ± 8 vs 58 ± 12). Multivariate analysis revealed that HDAs were independent negative prognostic factors. CONCLUSION In conclusion, HDAs on CT images predicted poor prognosis and severe depressive and anxiety symptoms in patients with AIS who underwent EMT.
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Affiliation(s)
- Zhi-Juan Lu
- Department of Neurology, Ganzhou People’s Hospital, Ganzhou 341000, Jiangxi Province, China
| | - Jin-Xing Lai
- Department of Neurology, Ganzhou People’s Hospital, Ganzhou 341000, Jiangxi Province, China
| | - Jing-Ru Huang
- Department of Neurology, Ganzhou People’s Hospital, Ganzhou 341000, Jiangxi Province, China
| | - Shu-Hua Xie
- Department of Neurology, Ganzhou People’s Hospital, Ganzhou 341000, Jiangxi Province, China
| | - Zhao-Hui Lai
- Department of Neurology, Ganzhou People’s Hospital, Ganzhou 341000, Jiangxi Province, China
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Petrović I, Broggi S, Killer-Oberpfalzer M, Pfaff JAR, Griessenauer CJ, Milosavljević I, Balenović A, Mutzenbach JS, Pikija S. Predictors of In-Hospital Mortality after Thrombectomy in Anterior Circulation Large Vessel Occlusion: A Retrospective, Machine Learning Study. Diagnostics (Basel) 2024; 14:1531. [PMID: 39061668 PMCID: PMC11275350 DOI: 10.3390/diagnostics14141531] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Revised: 07/08/2024] [Accepted: 07/14/2024] [Indexed: 07/28/2024] Open
Abstract
BACKGROUND Despite the increased use of mechanical thrombectomy (MT) in recent years, there remains a lack of research on in-hospital mortality rates following the procedure, the primary factors influencing these rates, and the potential for predicting them. This study aimed to utilize interpretable machine learning (ML) to help clarify these uncertainties. METHODS This retrospective study involved patients with anterior circulation large vessel occlusion (LVO)-related ischemic stroke who underwent MT. The patient division was made into two groups: (I) the in-hospital death group, referred to as miserable outcome, and (II) the in-hospital survival group, or favorable outcome. Python 3.10.9 was utilized to develop the machine learning models, which consisted of two types based on input features: (I) the Pre-MT model, incorporating baseline features, and (II) the Post-MT model, which included both baseline and MT-related features. After a feature selection process, the models were trained, internally evaluated, and tested, after which interpretation frameworks were employed to clarify the decision-making processes. RESULTS This study included 602 patients with a median age of 76 years (interquartile range (IQR) 65-83), out of which 54% (n = 328) were female, and 22% (n = 133) had miserable outcomes. Selected baseline features were age, baseline National Institutes of Health Stroke Scale (NIHSS) value, neutrophil-to-lymphocyte ratio (NLR), international normalized ratio (INR), the type of the affected vessel ('Vessel type'), peripheral arterial disease (PAD), baseline glycemia, and premorbid modified Rankin scale (pre-mRS). The highest odds ratio of 4.504 was observed with the presence of peripheral arterial disease (95% confidence interval (CI), 2.120-9.569). The Pre-MT model achieved an area under the curve (AUC) value of around 79% utilizing these features, and the interpretable framework discovered the baseline NIHSS value as the most influential factor. In the second data set, selected features were the same, excluding pre-mRS and including puncture-to-procedure-end time (PET) and onset-to-puncture time (OPT). The AUC value of the Post-MT model was around 84% with age being the highest-ranked feature. CONCLUSIONS This study demonstrates the moderate to strong effectiveness of interpretable machine learning models in predicting in-hospital mortality following mechanical thrombectomy for ischemic stroke, with AUCs of 0.792 for the Pre-MT model and 0.837 for the Post-MT model. Key predictors included patient age, baseline NIHSS, NLR, INR, occluded vessel type, PAD, baseline glycemia, pre-mRS, PET, and OPT. These findings provide valuable insights into risk factors and could improve post-procedural patient management.
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Affiliation(s)
- Ivan Petrović
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia; (I.M.); (A.B.)
| | - Serena Broggi
- Neurology and Stroke Unit, ASST dei Sette Laghi, 21100 Varese, Italy;
| | - Monika Killer-Oberpfalzer
- Department of Neurology, University Hospital Salzburg, Christian Doppler Klinik, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; (M.K.-O.); (J.S.M.)
- Institute of Neurointervention, Christian Doppler Klinik, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria
| | - Johannes A. R. Pfaff
- Department of Neuroradiology, University Hospital Salzburg, Christian Doppler Klinik, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria;
| | - Christoph J. Griessenauer
- Department of Neurosurgery, University Hospital Salzburg, Christian Doppler Klinik, Paracelsus Medical University, 5020 Salzburg, Austria;
| | | | - Ana Balenović
- Faculty of Medicine, University of Novi Sad, 21000 Novi Sad, Serbia; (I.M.); (A.B.)
| | - Johannes S. Mutzenbach
- Department of Neurology, University Hospital Salzburg, Christian Doppler Klinik, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; (M.K.-O.); (J.S.M.)
| | - Slaven Pikija
- Department of Neurology, University Hospital Salzburg, Christian Doppler Klinik, Paracelsus Medical University Salzburg, 5020 Salzburg, Austria; (M.K.-O.); (J.S.M.)
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20
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Dabhi N, Kumar J, Kellogg RT, Park MS. Mechanical thrombectomy for treatment of acute ischemic stroke in frail patients: a systematic review of the literature. J Neurointerv Surg 2024; 16:788-793. [PMID: 37487691 DOI: 10.1136/jnis-2023-020476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/07/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND The overall safety and efficacy of mechanical thrombectomy (MT) for acute ischemic stroke (AIS) in frail patients is not well delineated. This systematic review aims to summarize and compare outcomes in frail and non-frail patients who underwent MT for AIS. METHODS A systematic review of the literature was performed using PubMed, Ovid Medline, and Web of Science to identify studies with outcomes-related data for frail patients with MT-treated AIS. The recanalization rate, procedural complications, and clinical outcome at 90-day follow-up were collected. RESULTS In the four included studies there were 642 frail patients and 499 non-frail patients. Frail patients had reduced rates of good functional outcomes (29% vs 42%; χ2=22, p<0.01) and increased 90-day mortality (51% vs 25%; χ2=38, p<0.01) compared with non-frail patients. CONCLUSION MT for treatment of AIS in frail patients may be associated with worse rates of morbidity and mortality along with reduced efficacy. Given that no studies to date directly compare conservative measures with endovascular management for AIS in frail patients, more studies are required to further evaluate and identify characteristics that may improve outcomes in these patients.
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Affiliation(s)
- Nisha Dabhi
- Department of Neurosurgery, Univerisity of Virginia, Charlottesville, Virginia, USA
| | - Jeyan Kumar
- Department of Neurosurgery, Univerisity of Virginia, Charlottesville, Virginia, USA
| | - Ryan T Kellogg
- Department of Neurosurgery, Univerisity of Virginia, Charlottesville, Virginia, USA
| | - Min S Park
- Department of Neurosurgery, Univerisity of Virginia, Charlottesville, Virginia, USA
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Mannismäki L, Martinez-Majander N, Suomalainen O, Sibolt G, Girfanova M, Nybondas M, Nissinen H, Curtze S. Comparison of functional and safety outcomes between the extended versus early time window after intravenous thrombolysis and endovascular thrombectomy. J Neurol Sci 2024; 462:123107. [PMID: 38925068 DOI: 10.1016/j.jns.2024.123107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 06/02/2024] [Accepted: 06/20/2024] [Indexed: 06/28/2024]
Abstract
INTRODUCTION Based on recent trials regarding the early time window, omitting intravenous thrombolysis (IVT) before endovascular thrombectomy (EVT) in eligible patients seems unjustified. Whether this also concerns the extended time window, 4.5 to 9 h from last seen well, is yet unclear. PATIENTS AND METHODS All consecutive patients treated with IVT, EVT, or IVT plus EVT in the extended time window at Helsinki University Hospital (HUS) between 1/2021 and 12/2022 were compared with matched controls treated in the early time window between 1/2016 and 12/2020. Regression analysis was applied on functional outcome at 90 days, evaluated on modified Rankin Scale (mRS), and on the occurrence of symptomatic intracerebral hemorrhage (sICH), adjusted for potential confounders. RESULTS Altogether 134 patients and 134 matching controls were included. Functional outcomes did not significantly differ between the extended versus early time window. Among patients with IVT plus EVT, the adjusted odds ratio (aOR) for a favorable outcome shift on mRS was 1.15, 95% confidence interval (CI) 0.54-2.43. Although sICH occurred more frequently (2.2% versus 3.0%) in the extended time window, regression analysis did not show a significant difference, aOR 0.96, 95% CI 0.14-6.87. DISCUSSION AND CONCLUSION We found no significant differences in the functional or safety outcomes between the extended versus early time window among patients with either IVT, EVT, or IVT plus EVT. There were no signals indicating, that IVT or EVT should be avoided in eligible patients in the extended time window which aligns with the current clinical treatment guidelines of HUS.
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Affiliation(s)
- Laura Mannismäki
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland.
| | - Nicolas Martinez-Majander
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Olli Suomalainen
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Gerli Sibolt
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Maria Girfanova
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Miranda Nybondas
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Hanna Nissinen
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Sami Curtze
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
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22
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Mamer LE, Kocher KE, Cranford JA, Scott PA. Longitudinal changes in the US emergency department use of advanced neuroimaging in the mechanical thrombectomy era. Emerg Radiol 2024:10.1007/s10140-024-02260-y. [PMID: 39002104 DOI: 10.1007/s10140-024-02260-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Accepted: 06/24/2024] [Indexed: 07/15/2024]
Abstract
PURPOSE To describe ED neuroimaging trends across the time-period spanning the early adoption of endovascular therapy for acute stroke (2013-2018). MATERIALS AND METHODS We performed a retrospective, cross-sectional study of ED visits using the 2013-2018 National Emergency Department Sample, a 20% sample of ED encounters in the United States. Neuroimaging use was determined by Common Procedural Terminology (CPT) code for non-contrast head CT (NCCT), CT angiography head (CTA), CT perfusion (CTP), and MRI brain (MRI) in non-admitted ED patients. Data was analyzed according to sampling weights and imaging rates were calculated per 100,000 ED visits. Multivariate logistic regression analysis was performed to identify hospital-level factors associated with imaging utilization. RESULTS Study population comprised 571,935,906 weighted adult ED encounters. Image utilization increased between 2013 and 2018 for all modalities studied, although more pronounced in CTA (80.24/100,000 ED visits to 448.26/100,000 ED visits (p < 0.001)) and CTP (1.75/100,000 ED visits to 28.04/100,000 ED visits p < 0.001)). Regression analysis revealed that teaching hospitals were associated with higher odds of high CTA utilization (OR 1.88 for 2018, p < 0.05), while low-volume EDs and public hospitals showed the reverse (OR 0.39 in 2018, p < 0.05). CONCLUSIONS We identified substantial increases in overall neuroimaging use in a national sample of non-admitted emergency department encounters between 2013 and 2018 with variability in utilization according to both patient and hospital properties. Further investigation into the appropriateness of this imaging is required to ensure that access to acute stroke treatment is balanced against the timing and cost of over-imaging.
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Affiliation(s)
- Lauren E Mamer
- Department of Emergency Medicine, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109-5301, USA.
| | - Keith E Kocher
- Department of Emergency Medicine, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109-5301, USA
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, USA
| | - James A Cranford
- Department of Emergency Medicine, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109-5301, USA
| | - Phillip A Scott
- Department of Emergency Medicine, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109-5301, USA
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23
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Ma Y, Dai Y, Zhao Y, Song Z, Hu C, Zhang Y. Radiomics model based on dual-energy CT can determine the source of thrombus in strokes with middle cerebral artery occlusion. Neuroradiology 2024:10.1007/s00234-024-03422-y. [PMID: 38985319 DOI: 10.1007/s00234-024-03422-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 06/29/2024] [Indexed: 07/11/2024]
Abstract
PURPOSE To develop thrombus radiomics models based on dual-energy CT (DECT) for predicting etiologic cause of stroke. METHODS We retrospectively enrolled patients with occlusion of the middle cerebral artery who underwent computed tomography (NCCT) and DECT angiography (DECTA). 70 keV virtual monoenergetic images (simulate conventional 120kVp CTA images) and iodine overlay maps (IOM) were reconstructed for analysis. Five logistic regression radiomics models for predicting cardioembolism (CE) were built based on the features extracted from NCCT, CTA and IOM images. From these, the best one was selected to integrate with clinical information for further construction of the combined model. The performance of the different models was evaluated and compared using ROC curve analysis, clinical decision curves (DCA), calibration curves and Delong test. RESULTS Among all the radiomic models, model NCCT+IOM performed the best, with AUC = 0.95 significantly higher than model NCCT, model CTA, model IOM and model NCCT+CTA in the training set (AUC = 0.88, 0.78, 0.90,0.87, respectively, P < 0.05), and AUC = 0.92 in the testing set, significantly higher than model CTA (AUC = 0.71, P < 0.05). Smoking and NIHSS score were independent predictors of CE (P < 0.05). The combined model performed similarly to the model NCCT+IOM, with no statistically significant difference in AUC either in the training or test sets. (0.96 vs. 0.95; 0.94 vs. 0.92, both P > 0.05). CONCLUSION Radiomics models constructed based on NCCT and IOM images can effectively determine the source of thrombus in stroke without relying on clinical information.
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Affiliation(s)
- Yuzhu Ma
- Department of Radiology, The Fourth Affiliated Hospital of Soochow University, Suzhou, 215124, China
| | - Yao Dai
- Department of Radiology, The Fourth Affiliated Hospital of Soochow University, Suzhou, 215124, China
| | - Ying Zhao
- Department of Radiology, The Fourth Affiliated Hospital of Soochow University, Suzhou, 215124, China
| | - Ziyang Song
- Department of Radiology, The Fourth Affiliated Hospital of Soochow University, Suzhou, 215124, China
| | - Chunhong Hu
- Department of Radiology, The First Affiliated Hospital of Soochow University, Suzhou, 215006, China
| | - Yu Zhang
- Department of Radiology, The Fourth Affiliated Hospital of Soochow University, Suzhou, 215124, China.
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24
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Favilla CG, Patel H, Abassi MH, Thon J, Mullen MT, Kasner SE, Song JW, Cummings S, Messé SR. Infarct density defined by ADC threshold is associated with long-term functional outcome after endovascular thrombectomy. J Stroke Cerebrovasc Dis 2024:107857. [PMID: 38997048 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107857] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2023] [Revised: 07/03/2024] [Accepted: 07/10/2024] [Indexed: 07/14/2024] Open
Abstract
OBJECTIVES Endovascular thrombectomy (EVT) dramatically improves clinical outcomes, but the reduction in final infarct volume only accounts for 10-15% of the treatment benefit. We aimed to develop a novel MRI-ADC-based metric that quantify the degree of tissue injury to test the hypothesis that it outperforms infarct volume in predicting long-term outcome. MATERIALS AND METHODS A single-center cohort consisted of consecutive acute stroke patients with anterior circulation large vessel occlusion, successful recanalization via EVT (mTICI ≥2b), and MRI of the brain between 12 hours and 7 days post-EVT. Imaging was processed via RAPID software. Final infarct volume was based on the traditional ADC <620 threshold. Logistic regression quantified the association of lesion volumes and good outcome (90-day modified Rankin Scale ≤2) at a range of lower ADC thresholds (<570, <520, and <470). Infarct density was calculated as the percentage of the final infarct volume below the ADC threshold with the greatest effect size. Univariate and multivariate logistic regression quantified the association between imaging/clinical metrics and functional outcome. RESULTS 120 patients underwent MRI after successful EVT. Lesion volume based on the ADC threshold <470 had the strongest association with good outcome (OR: 0.81 per 10mL; 95% CI: 0.66-0.99). In a multivariate model, infarct density (<470/<620 * 100) was independently associated with good outcome (aOR 0.68 per 10%; 95% CI: 0.49-0.95), but final infarct volume was not (aOR 0.98 per 10mL; 95% CI: 0.85-1.14). CONCLUSIONS Infarct density after EVT is more strongly associated with long-term clinical outcome than infarct volume.
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Affiliation(s)
| | - Heta Patel
- University of Pennsylvania, Department of Neurology, Philadelphia, PA, USA.
| | | | - Jesse Thon
- Cooper University, Department of Neurology, Camden, NJ, USA.
| | - Michael T Mullen
- Temple University, Department of Neurology, Philadelphia, PA, USA.
| | - Scott E Kasner
- University of Pennsylvania, Department of Neurology, Philadelphia, PA, USA.
| | - Jae W Song
- University of Pennsylvania, Department of Radiology, Philadelphia, PA, USA.
| | - Stephanie Cummings
- University of Pennsylvania, Department of Neurology, Philadelphia, PA, USA.
| | - Steven R Messé
- University of Pennsylvania, Department of Neurology, Philadelphia, PA, USA.
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25
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Kühn AL, Puri AS, Salim HA, Musmar B, Ghozy S, Siegler J, Shaikh H, Khalife J, Abdalkader M, Klein P, Nguyen TN, Heit JJ, Regenhardt RW, Diestro JDB, Cancelliere NM, Sweid A, Naamani KE, Hasan Z, Gopinathan A, Amllay A, Meyer L, Dusart A, Bellante F, Forestier G, Rouchaud A, Saleme S, Mounayer C, Fiehler J, Dyzmann C, Kan PT, Singh J, Colasurdo M, Marnat G, Berge J, Barreau X, Sibon I, Nedelcu S, Henninger N, Marotta TR, Stapleton CJ, Rabinov JD, Ota T, Dofuku S, Yeo LL, Tan BYQ, Martinez-Gutierrez JC, Salazar-Marioni S, Sheth S, Renieri L, Capirossi C, Mowla A, Tjoumakaris SI, Jabbour P, Khandelwal P, Biswas A, Clarençon F, Elhorany M, Premat K, Valente I, Pedicelli A, Filipe JP, Varela R, Quintero-Consuegra M, Gonzalez NR, Möhlenbruch MA, Jesser J, Costalat V, Ter Schiphorst A, Yedavalli V, Harker P, Chervak L, Aziz Y, Gory B, Stracke CP, Hecker C, Killer-Oberpfalzer M, Griessenauer CJ, Thomas A, Hsieh CY, Liebeskind DS, Radu RA, Alexandre AM, Fahed R, Tancredi I, Faizy TD, Weyland C, Lubicz B, Patel AB, Pereira VM, Guenego A, Dmytriw AA. Multicenter evaluation of mechanical thrombectomy for distal medium vessel occlusions with National Institute of Health Stroke Scale Scores ≥ 6 and ≤ 6. J Neurol 2024:10.1007/s00415-024-12537-4. [PMID: 38967650 DOI: 10.1007/s00415-024-12537-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 06/21/2024] [Accepted: 06/24/2024] [Indexed: 07/06/2024]
Abstract
BACKGROUND While mechanical thrombectomy is considered standard of care for large vessel occlusions, scientific evidence to support treatment for distal and medium vessel occlusions remains scarce. PURPOSE To evaluate feasibility, safety, and outcomes in patients with low National Institute of Health Stroke Scale scores undergoing mechanical thrombectomy for treatment of distal medium vessel occlusions. MATERIALS AND METHODS Retrospective data review and analysis of prospectively maintained databases at 41 academic centers in North America, Asia, and Europe between January 2017 and January 2022. Characteristics and outcomes were compared between groups with low stroke scale score (≤ 6) versus and higher stroke scale scores (> 6). Propensity score matching using the optimal pair matching method and 1:1 ratio was performed. RESULTS Data were collected on a total of 1068 patients. After propensity score matching, there were a total of 676 patients included in the final analysis, with 338 patients in each group. High successful reperfusion rates were seen in both groups, 90.2% in ≤ 6 and 88.7% in the > 6 stroke scale groups. The frequency of excellent and good functional outcome was seen more common in low versus higher stroke scale score patients (64.5% and 81.1% versus 39.3% and 58.6%, respectively). The 90-day mortality rate observed in the ≤ 6 stroke scale group was 5.3% versus 13.3% in the > 6 stroke scale group. CONCLUSION Mechanical thrombectomy in distal and medium vessel occlusions, specifically in patients with low stroke scale scores is feasible, though it may not necessarily improve outcomes over IVT.
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Affiliation(s)
- Anna Luisa Kühn
- Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Ajit S Puri
- Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical Center, Worcester, MA, USA
| | - Hamza Adel Salim
- Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Los Angeles, USA.
- Brigham and Women's Hospital, Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA.
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD, USA.
| | - Basel Musmar
- Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Los Angeles, USA
| | - Sherief Ghozy
- Departments of Neurological Surgery & Radiology, Mayo Clinic, Rochester, MN, USA
| | - James Siegler
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA
| | - Hamza Shaikh
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA
| | - Jane Khalife
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA
| | - Mohamad Abdalkader
- Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA
| | - Piers Klein
- Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA
| | - Thanh N Nguyen
- Departments of Radiology & Neurology, Boston Medical Center, Boston, MA, USA
| | - Jeremy J Heit
- Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, CA, USA
| | - Robert W Regenhardt
- Brigham and Women's Hospital, Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Jose Danilo Bengzon Diestro
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Nicole M Cancelliere
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Ahmad Sweid
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Kareem El Naamani
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Zuha Hasan
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Anil Gopinathan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Abdelaziz Amllay
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anne Dusart
- Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium
| | - Flavio Bellante
- Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium
| | - Géraud Forestier
- Neuroradiology Department, University Hospital of Limoges, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252, Limoges, France
| | - Aymeric Rouchaud
- Neuroradiology Department, University Hospital of Limoges, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252, Limoges, France
| | - Suzana Saleme
- Neuroradiology Department, University Hospital of Limoges, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252, Limoges, France
| | - Charbel Mounayer
- Neuroradiology Department, University Hospital of Limoges, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252, Limoges, France
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Dyzmann
- Neuroradiology Department, Sana Kliniken, Lübeck GmbH, Lübeck, Germany
| | - Peter T Kan
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Jasmeet Singh
- Brigham and Women's Hospital, Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Marco Colasurdo
- Department of Neurosurgery, University of Texas Medical Branch, Galveston, TX, USA
| | - Gaultier Marnat
- Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France
| | - Jérôme Berge
- Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France
| | - Xavier Barreau
- Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France
| | - Igor Sibon
- Neurology Department, Bordeaux University Hospital, Bordeaux, France
| | - Simona Nedelcu
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Nils Henninger
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Thomas R Marotta
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Christopher J Stapleton
- Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Los Angeles, USA
| | - James D Rabinov
- Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Los Angeles, USA
| | - Takahiro Ota
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Shogo Dofuku
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Leonard Ll Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | - Benjamin Y Q Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
| | | | | | - Sunil Sheth
- Interventistica Neurovascolare, Ospedale Careggi Di Firenze, Florence, Italy
| | - Leonardo Renieri
- Interventistica Neurovascolare, Ospedale Careggi Di Firenze, Florence, Italy
| | - Carolina Capirossi
- Interventistica Neurovascolare, Ospedale Careggi Di Firenze, Florence, Italy
| | - Ashkan Mowla
- Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), 1200 North State St, Suite 3300, Los Angeles, CA, USA
| | | | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, PA, USA
| | - Priyank Khandelwal
- Department of Endovascular Neurosurgery and Neuroradiology NJMS, Newark, NJ, USA
| | - Arundhati Biswas
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, NY, USA
| | - Frédéric Clarençon
- Department of Neuroradiology, GRC BioFast, Sorbonne University. Paris VI, Pitié-Salpêtrière Hospital, Paris, France
| | - Mahmoud Elhorany
- Department of Neuroradiology, GRC BioFast, Sorbonne University. Paris VI, Pitié-Salpêtrière Hospital, Paris, France
| | - Kevin Premat
- Department of Neuroradiology, GRC BioFast, Sorbonne University. Paris VI, Pitié-Salpêtrière Hospital, Paris, France
| | - Iacopo Valente
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy
| | - Alessandro Pedicelli
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy
| | - João Pedro Filipe
- Department of Diagnostic and Interventional Neuroradiology, Centro Hospitalar Universitário Do Porto, Porto, Portugal
| | - Ricardo Varela
- Department of Neurology, Centro Hospitalar Universitário Do Porto, Porto, Portugal
| | | | - Nestor R Gonzalez
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA, USA
| | - Markus A Möhlenbruch
- Sektion Vaskuläre Und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Jessica Jesser
- Sektion Vaskuläre Und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Vincent Costalat
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Adrien Ter Schiphorst
- Department of Neurology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Vivek Yedavalli
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD, USA
| | - Pablo Harker
- Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Lina Chervak
- Department of Neurology and Radiology, University of Cincinnati, Cincinnati, OH, USA
| | - Yasmin Aziz
- Department of Neurology, University of Cincinnati Medical Center, Cincinnati, OH, USA
| | - Benjamin Gory
- Department of Interventional Neuroradiology, Nancy University Hospital, Nancy, France
| | - Christian Paul Stracke
- Department of Radiology, Interventional Neuroradiology Section, University Medical Center, Münster, Germany
| | - Constantin Hecker
- Departments of Neurology and Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Monika Killer-Oberpfalzer
- Departments of Neurology and Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Christoph J Griessenauer
- Departments of Neurology and Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Ajith Thomas
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, NJ, USA
| | | | - David S Liebeskind
- UCLA Stroke Center and Department of Neurology Department, UCLA, Los Angeles, CA, USA
| | - Răzvan Alexandru Radu
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Andrea M Alexandre
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS Roma, Rome, Italy
| | - Robert Fahed
- Department of Medicine, Division of Neurology, The Ottawa Hospital, Ottawa Hospital Research Institute and University of Ottawa, Ottawa, ON, Canada
| | - Illario Tancredi
- Department of Medicine, Division of Neurology, The Ottawa Hospital, Ottawa Hospital Research Institute and University of Ottawa, Ottawa, ON, Canada
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Charlotte Weyland
- Sektion Vaskuläre Und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Boris Lubicz
- Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Aman B Patel
- Brigham and Women's Hospital, Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA
| | - Vitor Mendes Pereira
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada
| | - Adrien Guenego
- Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Adam A Dmytriw
- Brigham and Women's Hospital, Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, MA, USA.
- Division of Diagnostic and Therapeutic Neuroradiology, Department of Radiology, St. Michael's Hospital, University of Toronto, Toronto, ON, Canada.
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26
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Lampmann T, Dorn F, Schievelkamp AH, Banat M, Vatter H, Hamed M. Delayed Internal Carotid Artery Dissection Mimicking Cerebral Vasospasms after Subarachnoid Hemorrhage: A Case Report. J Neurol Surg A Cent Eur Neurosurg 2024. [PMID: 37595627 DOI: 10.1055/a-2156-5181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Abstract
BACKGROUND Delayed cerebral ischemia (DCI) is usually caused by cerebral vasospasm (CVS). To detect DCI and CVS, a cranial computed tomography (CT) scan will be performed, but cervical vessels are not necessarily displayed. METHODS A 63-year-old female patient who suffered from aneurysmal subarachnoid hemorrhage (SAH) was treated at the authors' institution. After an initially unremarkable clinical course, she developed aphasia on day 11. CT angiography (CTA) and perfusion imaging revealed significant hypoperfusion of the left hemisphere. In addition, the CTA showed a subtotal stenosis of the internal carotid artery (ICA) at the level of the petrous segment, suspicious for a dissection. This was not detectable angiographically in the final control of the intervention and was also not clinically evident until day 11. RESULTS Cerebral perfusion as well as the clinical symptoms normalized rapidly after stent reconstruction of the ICA. CONCLUSION Even though CVS is the most common cause of hypoperfusion in patients after an SAH, a peri-interventional dissection can also lead to relevant stenosis and thus to a disturbed cerebral perfusion and corresponding neurologic deficits. The time delay between the intervention and the clinical and CTA manifestation in our case is remarkable.
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Affiliation(s)
- Tim Lampmann
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Franziska Dorn
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | | | - Mohammed Banat
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
| | - Motaz Hamed
- Department of Neurosurgery, University Hospital Bonn, Bonn, Germany
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27
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Ippen FM, Schregel K, Ungerer M, Feisst M, Ringleb PA, Gumbinger CK. Outcomes in elderly patients undergoing endovascular thrombectomy in association with premorbid Rankin Scale scores. Front Neurol 2024; 15:1418415. [PMID: 39022738 PMCID: PMC11252042 DOI: 10.3389/fneur.2024.1418415] [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: 04/16/2024] [Accepted: 06/10/2024] [Indexed: 07/20/2024] Open
Abstract
Background Endovascular thrombectomy (EVT) reduces disability in patients with acute ischemic stroke (AIS); however, its efficacy in patients aged >80 years remains unclear. Objectives This study aimed to assess the impact of premorbid modified Rankin Scale (pmRS) scores and age on patients with AIS undergoing EVT and the effect of EVT on functional outcome and mortality. Methods We conducted a retrospective cohort study and screened the Heidelberg Recanalization Registry (HeiReKa) database for patients with AIS between 1999 and 2021. Outcomes were stratified by age (<80, 80-89, and ≥90 years) and pmRS score (0-2 vs. 3-5). Adjusted odds ratios for outcomes and mortality at 3 months after treatment were examined. Results Finally, 2,591 patients were included [including those aged ≥90 years (n = 158)]. Poor functional outcomes were associated with advanced age, vascular risk factors, stroke severity, and vessel status. Conversely, lower prestroke disability and younger age were associated with better outcomes and reduced mortality. A pmRS of 3-5 was associated with an increased risk of mortality and worse functional outcomes regardless of age. Notably, patients aged ≥90 years with a pmRS of 0-2 had significantly better outcomes than those aged <80 years with a pmRS of 3-5. Conclusion Both age and pmRS are important in assessing the benefits of EVT. However, prestroke functional status might be more crucial than biological age in determining outcomes following EVT.
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Affiliation(s)
- Franziska M. Ippen
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Katharina Schregel
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Matthias Ungerer
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Manuel Feisst
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Peter A. Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
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Kawamoto K, Nagao Y, Naganuma M, Inatomi Y, Hashimoto Y, Yonehara T, Nakajima M. Stent-retriever characteristics and strategies associated with recanalization in thrombectomy for acute ischemic stroke. Clin Neurol Neurosurg 2024; 242:108332. [PMID: 38781805 DOI: 10.1016/j.clineuro.2024.108332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 04/29/2024] [Accepted: 05/11/2024] [Indexed: 05/25/2024]
Abstract
INTRODUCTION Predictive factors for successful reperfusion in mechanical thrombectomy for acute ischemic stroke, and especially technical factors, remain controversial. We investigated various techniques for better angiographic outcomes. METHODS In this retrospective study, acute ischemic stroke patients with large vessel occlusion treated with mechanical thrombectomy with combined technique were included. Scoring of the reperfusion grade for each attempt was conducted, and each attempt was divided into two groups based on successful reperfusion, which was defined using the presence or absence of modified thrombolysis in cerebral infarction 2b-3. The following characteristics were evaluated: the choice of stent-retriever, its length, occlusion site, thrombus position relative to deployed stent-retriever, methods of thrombectomy, and successful advancement of the distal access catheter to the proximal end of the thrombus. RESULTS Among 251 patients who underwent mechanical thrombectomy, 154 patients (255 attempts: mTICI 0-2a group, n = 119; mTICI 2b-3 group, n = 136) were included in the analysis. The thrombus position relative to the deployed stent-retriever was likely associated with successful reperfusion, although it was not statistically significant (proximal two-thirds 56.8 %; distal one-third 44.3 %, p = 0.09). Successful advancement of the distal access catheter was related to successful reperfusion both in univariate analysis (success 57.9 %; fail 35.8 %, p < 0.01) and in multivariate regression analysis (odds ratio 2.45; 95 % confidence interval: 1.30-4.61, p < 0.01). CONCLUSIONS Successful advancement of the distal access catheter to the proximal end of thrombus might be a key component for successful reperfusion in mechanical thrombectomy.
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Affiliation(s)
- Keisuke Kawamoto
- Department of Neurology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Yoichiro Nagao
- Department of Neurology, Saiseikai Kumamoto Hospital, Kumamoto, Japan.
| | - Masaki Naganuma
- Department of Neurology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Yuichiro Inatomi
- Department of Neurology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | | | - Toshiro Yonehara
- Department of Neurology, Saiseikai Kumamoto Hospital, Kumamoto, Japan
| | - Makoto Nakajima
- Department of Neurology, Kumamoto University Hospital, Kumamoto, Japan
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Bae JW, Hyun DK. Endovascular Thrombectomy for Acute Ischemic Stroke : Current Concept in Management. J Korean Neurosurg Soc 2024; 67:397-410. [PMID: 38549263 PMCID: PMC11220414 DOI: 10.3340/jkns.2023.0181] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2023] [Revised: 10/30/2023] [Accepted: 11/23/2023] [Indexed: 07/04/2024] Open
Abstract
Endovascular thrombectomy (EVT) has been established as the standard of care in the treatment of acute ischemic stroke (AIS) based on landmark randomized controlled trials. Nevertheless, while the strict eligibility of EVT for AIS patients restrict the wide application of EVT, a considerable population still undergoes off-label EVT. Besides, it is important to acknowledge that recanalization is not achieved in approximately 20% of procedures, and more than 50% of patients who undergo EVT still do not experience a favorable outcome. This article reviews the brief history of EVT trials and recent progressions in the treatment of AIS, with focusing on the expanding eligibility criteria, new target for EVT, and the evolution of EVT techniques.
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Affiliation(s)
- Jin Woo Bae
- Department of Neurosurgery, Inha University Hospital, Incheon, Korea
- Incheon Regional Cardio-cerebrovascular Disease Center, Incheon, Korea
| | - Dong Keun Hyun
- Department of Neurosurgery, Inha University Hospital, Incheon, Korea
- Incheon Regional Cardio-cerebrovascular Disease Center, Incheon, Korea
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Lim J, Aguirre AO, Rattani A, Baig AA, Monteiro A, Kuo CC, Siddiqi M, Im J, Housley SB, McPheeters MJ, Ciecierska SSK, Jaikumar V, Vakharia K, Davies JM, Snyder KV, Levy EI, Siddiqui AH. Thrombectomy outcomes for acute ischemic stroke in lower-middle income countries: A systematic review and analysis. World Neurosurg X 2024; 23:100317. [PMID: 38511159 PMCID: PMC10950731 DOI: 10.1016/j.wnsx.2024.100317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2023] [Accepted: 02/21/2024] [Indexed: 03/22/2024] Open
Affiliation(s)
- Jaims Lim
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Alexander O. Aguirre
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Abbas Rattani
- Department of Radiation Oncology, Tufts University Medical Center, Boston, MA, USA
| | - Ammad A. Baig
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Andre Monteiro
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Cathleen C. Kuo
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Manhal Siddiqi
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Justin Im
- Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Steven B. Housley
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Matthew J. McPheeters
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | | | - Vinay Jaikumar
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
| | - Kunal Vakharia
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Jason M. Davies
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
- Department of Bioinformatics, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA
- Jacobs Institute, Buffalo, NY, USA
| | - Kenneth V. Snyder
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA
- Jacobs Institute, Buffalo, NY, USA
| | - Elad I. Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA
- Jacobs Institute, Buffalo, NY, USA
- Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
| | - Adnan H. Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, NY, USA
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, NY, USA
- Jacobs Institute, Buffalo, NY, USA
- Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, NY, USA
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Joundi RA, Smith EE, Ganesh A, Nogueira RG, McTaggart RA, Demchuk AM, Poppe AY, Rempel JL, Field TS, Dowlatshahi D, Sahlas J, Swartz R, Shah R, Sauvageau E, Puetz V, Silver FL, Campbell B, Chapot R, Tymianski M, Goyal M, Hill MD. Time From Hospital Arrival Until Endovascular Thrombectomy and Patient-Reported Outcomes in Acute Ischemic Stroke. JAMA Neurol 2024; 81:752-761. [PMID: 38829660 PMCID: PMC11148789 DOI: 10.1001/jamaneurol.2024.1562] [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: 01/08/2024] [Accepted: 03/29/2024] [Indexed: 06/05/2024]
Abstract
Importance The time-benefit association of endovascular thrombectomy (EVT) in ischemic stroke with patient-reported outcomes is unknown. Objective To assess the time-dependent association of EVT with self-reported quality of life in patients with acute ischemic stroke. Design, Setting, and Participants Data were used from the Safety and Efficacy of Nerinetide in Subjects Undergoing Endovascular Thrombectomy for Stroke (ESCAPE-NA1) trial, which tested the effect of nerinetide on functional outcomes in patients with large vessel occlusion undergoing EVT and enrolled patients from March 1, 2017, to August 12, 2019. The ESCAPE-NA1 trial was an international randomized clinical trial that recruited patients from 7 countries. Patients with EuroQol 5-dimension 5-level (EQ-5D-5L) index values at 90 days and survivors with complete domain scores were included in the current study. Data were analyzed from July to September 2023. Exposure Hospital arrival to arterial puncture time and other time metrics. Main Outcomes and Measures EQ-5D-5L index scores were calculated at 90 days using country-specific value sets. The association between time from hospital arrival to EVT arterial-access (door-to-puncture) and EQ-5D-5L index score, quality-adjusted life years, and visual analog scale (EQ-VAS) were evaluated using quantile regression, adjusting for age, sex, stroke severity, stroke imaging, wake-up stroke, alteplase, and nerinetide treatment and accounting for clustering by site. Using logistic regression, the association between door-to-puncture time and reporting no or slight symptoms (compared with moderate, severe, or extreme problems) was determined in each domain (mobility, self-care, usual activities, pain or discomfort, and anxiety or depression) or across all domains. Time from stroke onset was also evaluated, and missing data were imputed in sensitivity analyses. Results Among 1105 patients in the ESCAPE-NA1 trial, there were 1043 patients with EQ-5D-5L index values at 90 days, among whom 147 had died and were given a score of 0, and 1039 patients (mean [SD] age, 69.0 [13.7] years; 527 male [50.7%]) in the final analysis as 4 did not receive EVT. There were 896 survivors with complete domain scores at 90 days. There was a strong association between door-to-puncture time and EQ-5D-5L index score (increase of 0.03; 95% CI, 0.02-0.04 per 15 minutes of earlier treatment), quality-adjusted life years (increase of 0.29; 95% CI, 0.08-0.49 per 15 minutes of earlier treatment), and EQ-VAS (increase of 1.65; 95% CI, 0.56-2.72 per 15 minutes of earlier treatment). Each 15 minutes of faster door-to-puncture time was associated with higher probability of no or slight problems in each of 5 domains and all domains concurrently (range from 1.86%; 95% CI, 1.14-2.58 for pain or discomfort to 3.55%; 95% CI, 2.06-5.04 for all domains concurrently). Door-to-puncture time less than 60 minutes was associated higher odds of no or slight problems in each domain, ranging from odds ratios of 1.49 (95% CI, 1.13-1.95) for pain or discomfort to 2.59 (95% CI, 1.83-3.68) for mobility, with numbers needed to treat ranging from 7 to 17. Results were similar after multiple imputation of missing data and attenuated when evaluating time from stroke onset. Conclusions and Relevance Results suggest that faster door-to-puncture EVT time was strongly associated with better health-related quality of life across all domains. These results support the beneficial impact of door-to-treatment speed on patient-reported outcomes and should encourage efforts to improve patient-centered care in acute stroke by optimizing in-hospital processes and workflows.
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Affiliation(s)
- Raed A. Joundi
- Division of Neurology, Department of Medicine, Hamilton Health Sciences, McMaster University, Hamilton, Ontario, Canada
- Population Health Research Institute, McMaster University and Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Eric E. Smith
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Aravind Ganesh
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Raul G. Nogueira
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
| | - Ryan A. McTaggart
- Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, Rhode Island
| | - Andrew M. Demchuk
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, Alberta, Canada
| | - Alexandre Y. Poppe
- Centre Hospitalier de l’Université de Montréal, Montréal, Québec, Canada
| | - Jeremy L. Rempel
- Department of Radiology, University of Alberta Hospital, Edmonton, Canada
| | - Thalia S. Field
- Department of Neurology, University of British Columbia, Vancouver, British Columbia, Canada
| | - Dar Dowlatshahi
- Department of Neurology, Ottawa Hospital, University of Ottawa, Ottawa, Ontario, Canada
| | - Jim Sahlas
- Division of Neurology, Department of Medicine, McMaster University, Hamilton, Ontario, Canada
| | - Richard Swartz
- Department of Neurology, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Ruchir Shah
- Department of Neurology, Erlanger Hospital, Chattanooga, Tennessee
| | - Eric Sauvageau
- Lyerly Neurosurgery, Baptist Hospital, Jacksonville, Florida
| | - Volker Puetz
- Department of Neurology, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
- Dresden Neurovascular Center, University Hospital Carl Gustav Carus Dresden, Dresden, Germany
| | - Frank L. Silver
- University Health Network, Department of Medicine, Division of Neurology, University of Toronto, Toronto, Ontario, Canada
| | - Bruce Campbell
- Department of Medicine and Neurology, The Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - René Chapot
- Department of Neuroradiology, Alfred Krupp Krankenhaus Essen, Essen, Germany
| | | | - Mayank Goyal
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, Alberta, Canada
| | - Michael D. Hill
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, Alberta, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, Alberta, Canada
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Zarrintan A, Musmar B, Ghozy S, Mansour M, Kadirvel R, Kallmes DF. Outcomes of mechanical thrombectomy in octogenarians and nonagenarians patients with Acute Ischemic Stroke: A Systematic Review and Network Meta-Analysis. Eur J Radiol 2024; 176:111506. [PMID: 38759542 DOI: 10.1016/j.ejrad.2024.111506] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 04/30/2024] [Accepted: 05/12/2024] [Indexed: 05/19/2024]
Abstract
PURPOSE Acute ischemic stroke (AIS) imposes a major healthcare burden, with the elderly population often underrepresented in clinical trials. This systematic review and network meta-analysis aims to evaluate the safety and efficacy of mechanical thrombectomy (MT) among octogenarians and nonagenarians with AIS due to large vessel occlusion (LVO). METHODS A systematic search was conducted using PubMed, Web of Science, and Scopus databases. Outcomes of interest were modified Rankin Scale (mRS) score of 0-2, thrombolysis in cerebral infarction (TICI) score of 2b-3, 90-day mortality, and symptomatic intracerebral hemorrhage (sICH). The study followed Preferred Reporting Items for Systematic reviews and Meta-Analyses guidelines. RESULTS The analysis included 47 studies. Significantly lower rates of mRS score 0-2 were observed in nonagenarians (17.4 %) and octogenarians (21.3 %) compared to younger (40.2 %) patients (Odds Ratio (OR) = 3.30, 95 % Confidence Interval (CI):2.35-4.65 and OR = 2.47, 95 % CI: 2.07-2.94). 90-day mortality was significantly higher in nonagenarians (38.9 %) compared to octogenarians (25.4 %) and younger (14.0 %) patients (OR = 0.58, 95 % CI: 0.41-0.83 and OR = 0.31, 95 % CI: 0.21-0.44), and in octogenarians compared to younger patients (OR = 0.52, 95 % CI: 0.41-0.66). No significant differences were observed in TICI 2b-3 and sICH rates across groups. CONCLUSIONS Our findings indicate that MT is a viable treatment option for AIS due to LVO among octogenarians and nonagenarians, albeit with nuanced differences. Specifically, octogenarians had lower 90-day mortality rates compared to nonagenarians. These insights support the need for individualized treatment plans for elderly patients with AIS due to LVO and highlight the importance of including this demographic in future clinical trials.
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Affiliation(s)
- Armin Zarrintan
- Department of Radiology, Mayo Clinic, Rochester, MN, USA; Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA.
| | - Basel Musmar
- Department of Neurosurgery, Duke University Hospital, Durham, NC, USA.
| | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN, USA; Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA.
| | - Mohamed Mansour
- Department of Neurology, George Washington University, Washington, DC, USA.
| | - Ramanathan Kadirvel
- Department of Radiology, Mayo Clinic, Rochester, MN, USA; Department of Neurosurgery, Mayo Clinic, Rochester, MN, USA.
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Al-Amoodi A, Debicki D, Sefein O, Bainbridge D. Ischemic Stroke in the Cardiac Surgery Intensive Care Unit: A Quality Improvement Study. J Cardiothorac Vasc Anesth 2024; 38:1524-1530. [PMID: 38614942 DOI: 10.1053/j.jvca.2024.03.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 02/09/2024] [Accepted: 03/08/2024] [Indexed: 04/15/2024]
Abstract
OBJECTIVE To investigate the frequency of stroke and code stroke activation and the factors influencing code stroke management in postoperative cardiac surgical patients. DESIGN A retrospective quality improvement study was conducted between January 1, 2016, and December 31, 2021. SETTING The Cardiac Surgery Recovery Unit (CSRU) at London Health Sciences Centre in London, Ontario, Canada. PARTICIPANTS Postcardiac surgery patients aged 18 years or older who developed ischemic stroke during their admission to the CSRU. INTERVENTIONS No specific interventions were administered as part of this study. Code stroke activation mobilizes a specialized team. The objectives include assessment by a physician within 10 minutes, obtaining neuroimaging and interpretation within 45 minutes, and beginning treatment within 60 minutes. MEASUREMENTS AND MAIN RESULTS The incidence rate of stroke in the CSRU was 1.3%, and 34% of these patients had code stroke activated. The time since the last known well status was 11 ± 8 hours. The most common reasons for not activating code stroke were not meeting both timing and clinical criteria. The average time for computed tomography (CT) scan was 36 ± 22 minutes. Among patients who had code stroke activated, 24% had large- vessel occlusion (LVO), and 67% of those with LVO had an established stroke on their initial CT. CONCLUSION Code stroke was activated in only one-third of patients who experienced a stroke following cardiac surgery. Additionally, out of those who had code stroke activated, only one-fourth were diagnosed with LVO. Among those with LVO, two-thirds were found to have a well-established stroke on noncontrast CT scans and were deemed ineligible for intervention.
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Affiliation(s)
- Abobakr Al-Amoodi
- Division of Critical Care, Department of Medicine, Western University, London, ON, Canada
| | - Derek Debicki
- Department of Neurosciences, Department of Neurology, Western University, London, ON, Canada
| | - Osama Sefein
- Department of Anesthesiology, Department of Medicine, Division of Critical Care, Western University, London, ON, Canada
| | - Daniel Bainbridge
- Department of Anesthesiology, Department of Medicine, Division of Critical Care, Western University, London, ON, Canada
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Xu Y, Liu X, Li H. A comparison of endovascular therapy and medical management in patients with large vessel occlusion mild stroke treated between 2015 and 2023: a systematic review and meta-analysis. J Stroke Cerebrovasc Dis 2024; 33:107721. [PMID: 38616013 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107721] [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: 07/27/2023] [Revised: 04/10/2024] [Accepted: 04/11/2024] [Indexed: 04/16/2024] Open
Abstract
OBJECTIVE Endovascular therapy (EVT) is recommended for patients with acute large-vessel occlusion (LVO) However, its efficacy and safety compared to medical management (MM) in patients with a National Institutes of Health Stroke Scale (NIHSS) score of ≤6 remains unclear. This meta-analysis compared EVT with medical MM in patients with large vessel occlusion mild stroke treated between 2015 and 2023, following the publication of the first randomized controlled trial. MATERIALS AND METHODS Biomedical database searches (inception to March 21, 2023) retrieved articles reporting favorable functional outcome(modified Rankin Scale [mRS] 0-1) and functional independence (mRS 0-2), 90-day mortality and symptomatic intracranial hemorrhage (sICH). We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA) to maintain methodological rigor and transparency in our meta-analysis. RESULTS We conducted a meta-analysis of 22 studies (4,985 patients) to reveal no significant differences in favorable functional outcomes and independence across all groups. However, in patients treated between 2015 and 2023, EVT exhibited a higher risk of 90-day mortality (Odds Ratio [OR] = 1.84, 95% Confidence Interval [CI] [1.10, 3.07], p = 0.02) and sICH (OR = 3.36, 95% CI [1.96, 6.66], p < 0.01). EVT correlated with elevated sICH in the anterior circulation (OR=2.94, 95%CI [1.82, 4.74], p<0.01) regardless of the proximal (OR=2.20, 95%CI [1.04, 4.69], p=0.04) or distal (OR=3.44, 95%CI [1.43, 8.32], p<0.01) location of the occlusion. EVT correlated with elevated sICH rates in patients treated within 6 hours of symptom onset or those with NHISS≤5. CONCLUSION In patients treated between 2015 and 2023, EVT and MM did not differ in efficacy in acute LVO mild stroke; MM associated with better safety outcomes. Rigorous randomized controlled trials are warranted.
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Affiliation(s)
- Yiqiao Xu
- Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, PR China; Capital Medical University, Beijing, PR China
| | - Xin Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Hao Li
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, PR China; China National Clinical Research Center for Neurological Diseases, Beijing, PR China.
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Hilkens NA, Casolla B, Leung TW, de Leeuw FE. Stroke. Lancet 2024; 403:2820-2836. [PMID: 38759664 DOI: 10.1016/s0140-6736(24)00642-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/19/2024] [Accepted: 03/26/2024] [Indexed: 05/19/2024]
Abstract
Stroke affects up to one in five people during their lifetime in some high-income countries, and up to almost one in two in low-income countries. Globally, it is the second leading cause of death. Clinically, the disease is characterised by sudden neurological deficits. Vascular aetiologies contribute to the most common causes of ischaemic stroke, including large artery disease, cardioembolism, and small vessel disease. Small vessel disease is also the most frequent cause of intracerebral haemorrhage, followed by macrovascular causes. For acute ischaemic stroke, multimodal CT or MRI reveal infarct core, ischaemic penumbra, and site of vascular occlusion. For intracerebral haemorrhage, neuroimaging identifies early radiological markers of haematoma expansion and probable underlying cause. For intravenous thrombolysis in ischaemic stroke, tenecteplase is now a safe and effective alternative to alteplase. In patients with strokes caused by large vessel occlusion, the indications for endovascular thrombectomy have been extended to include larger core infarcts and basilar artery occlusion, and the treatment time window has increased to up to 24 h from stroke onset. Regarding intracerebral haemorrhage, prompt delivery of bundled care consisting of immediate anticoagulation reversal, simultaneous blood pressure lowering, and prespecified stroke unit protocols can improve clinical outcomes. Guided by underlying stroke mechanisms, secondary prevention encompasses pharmacological, vascular, or endovascular interventions and lifestyle modifications.
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Affiliation(s)
- Nina A Hilkens
- Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands; Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands
| | - Barbara Casolla
- Université Nice Cote d'Azur UR2CA-URRIS, Stroke Unit, CHU Pasteur 2, Nice, France
| | - Thomas W Leung
- Division of Neurology, Department of Medicine and Therapeutics, The Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Frank-Erik de Leeuw
- Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands; Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands.
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HUA Q, FAN L, WANG ZW, LI J. 2023 Guideline for the management of hypertension in the elderly population in China. J Geriatr Cardiol 2024; 21:589-630. [PMID: 38973827 PMCID: PMC11224653 DOI: 10.26599/1671-5411.2024.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/09/2024] Open
Affiliation(s)
| | - Qi HUA
- Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Li FAN
- Chinese PLA General Hospital, Beijing, China
| | - Zeng-Wu WANG
- Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jing LI
- Xuanwu Hospital, Capital Medical University, Beijing, China
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Mendes GN, Jacquin G, Katsanos AH, Singh N, Stotts G, Ferguson DB, Yip S, Poppe AY. Safety of acute internal carotid artery stenting during endovascular thrombectomy in patients with acute ischemic stroke: a retrospective analysis of the OPTIMISE registry. J Neurointerv Surg 2024:jnis-2024-021915. [PMID: 38937083 DOI: 10.1136/jnis-2024-021915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 06/14/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND The optimal management of tandem carotid lesions during endovascular thrombectomy (EVT) remains uncertain. The safety and efficacy of acute carotid artery stenting (aCAS) are debated, including safety concerns such as procedural complications and symptomatic intracerebral hemorrhage (sICH). We aimed to assess aCAS safety among EVT-treated patients using a large Canadian registry. METHODS We retrospectively analyzed the OPTIMISE registry and compared adult patients undergoing EVT and aCAS versus EVT only. The primary outcome was a composite of in-hospital death, long-term care facility destination at discharge, sICH, or any EVT-related procedural complications. Secondary outcomes included individual components of the primary outcome, EVT workflow times, final modified Thrombolysis in Cerebral Ischemia score and 90-day modified Rankin Scale score. Statistical significance was evaluated by a multivariate logistic regression model. RESULTS 4205 patients were included (330 with EVT-aCAS and 3875 with EVT-only). Both groups were similar with regard to baseline National Institutes of Health Stroke Scale score, Alberta Stroke Program Early CT Score and use of IV thrombolysis, but differed in age (EVT-aCAS group 67.2±12.1 years vs EVT-only group 71.3±14.1 years, P<0.001), proportion of women (28.2% vs 53.3%, P<0.001), and occlusion location (internal carotid artery terminus 44% vs 16%, P<0.001). The EVT-aCAS group showed a non-significant increase in odds of composite safety outcomes (adjusted OR 1.35 (95% CI 0.97 to 1.84), P=0.06) with a significantly higher proportion of procedural complications (10.0% vs 6.2%, P=0.002). CONCLUSION In a large national registry, EVT-aCAS was associated with a higher proportion of unfavorable safety outcomes, driven by more frequent procedural complications. Further research is needed to clarify the role of aCAS in tandem occlusion stroke.
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Affiliation(s)
- George Nilton Mendes
- Neurosciences Axis, Centre de Recherche du CHUM, Montreal, Quebec, Canada
- Neurosciences, Centre Hospitalier de L'Universite de Montreal, Montreal, Quebec, Canada
| | - Grégory Jacquin
- Neurosciences Axis, Centre de Recherche du CHUM, Montreal, Quebec, Canada
- Neurosciences, Centre Hospitalier de L'Universite de Montreal, Montreal, Quebec, Canada
| | - Aristeidis H Katsanos
- Medicine (Neurology), McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Nishita Singh
- Internal Medicine (Neurology), University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Grant Stotts
- Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Darren B Ferguson
- Diagnostic Radiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Samuel Yip
- Medicine (Neurology), The University of British Columbia, Vancouver, British Columbia, Canada
| | - Alexandre Y Poppe
- Neurosciences Axis, Centre de Recherche du CHUM, Montreal, Quebec, Canada
- Neurosciences, Centre Hospitalier de L'Universite de Montreal, Montreal, Quebec, Canada
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Wang Z, Yasheng A, Ling Y, Zhao H, Mao Y, Yang S, Cao W. CT perfusion for predicting intracranial atherosclerotic middle cerebral artery occlusion. Front Neurol 2024; 15:1406224. [PMID: 38974684 PMCID: PMC11224468 DOI: 10.3389/fneur.2024.1406224] [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: 03/24/2024] [Accepted: 06/11/2024] [Indexed: 07/09/2024] Open
Abstract
Backgrounds and purpose Identifying the underlying cause of acute middle cerebral artery occlusion (MCAO) as intracranial atherosclerotic stenosis (ICAS) or embolism is essential for determining the optimal treatment strategy before endovascular thrombectomy. We aimed to evaluate whether baseline computed tomography perfusion (CTP) characteristics could differentiate ICAS-related MCAO from embolic MCAO. Methods We conducted a retrospective analysis of the clinical and baseline CTP data from patients who underwent endovascular thrombectomy for acute MCAO between January 2018 and December 2022. Core volume growth rate was defined as core volume on CTP divided by onset to CTP time. Multivariate logistic analysis was utilized to identify independent predictors for ICAS-related acute MCAO, and the diagnostic performance of these predictors was evaluated using receiver operating characteristic curve analysis. Results Among the 97 patients included (median age, 71 years; 60% male), 31 (32%) were diagnosed with ICAS-related MCAO, and 66 (68%) had embolism-related MCAO. The ICAS group was younger (p = 0.002), had a higher proportion of males (p = 0.04) and smokers (p = 0.001), a lower prevalence of atrial fibrillation (AF) (p < 0.001), lower NIHSS score at admission (p = 0.04), smaller core volume (p < 0.001), slower core volume growth rate (p < 0.001), and more frequent core located deep in the brain (p < 0.001) compared to the embolism group. Multivariate logistic analysis identified core volume growth rate (aOR 0.46, 95% CI 0.26-0.83, p = 0.01) as an independent predictor of ICAS-related MCAO. A cutoff value of 2.5 mL/h for core volume growth rate in predicting ICAS-related MCAO was determined from the receiver operating characteristic curve analysis, with a sensitivity of 81%, specificity of 80%, positive predictive value of 66%, and negative predictive value of 90%. Conclusion Slow core volume growth rate identified on baseline CTP can predict ICAS-related MCAO. Further prospective studies are warranted to confirm and validate these findings.
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Affiliation(s)
- Zigao Wang
- Department of Neurology and Institute of Neurology, Huashan Hospital, Fudan University, Shanghai, China
- Department of Neurology, Kashi Prefecture Second People’s Hospital, Kashi, China
| | | | - Yifeng Ling
- Department of Neurology and Institute of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Hongchen Zhao
- Department of Neurology and Institute of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Yiting Mao
- Department of Neurology and Institute of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Shilin Yang
- Department of Neurology and Institute of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Wenjie Cao
- Department of Neurology and Institute of Neurology, Huashan Hospital, Fudan University, Shanghai, China
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Vandelanotte S, Staessens S, François O, De Wilde M, Desender L, De Sloovere AS, Dewaele T, Tersteeg C, Vanhoorelbeke K, Vanacker P, Andersson T, De Meyer SF. Association between thrombus composition and first-pass recanalization after thrombectomy in acute ischemic stroke. J Thromb Haemost 2024:S1538-7836(24)00357-X. [PMID: 38897388 DOI: 10.1016/j.jtha.2024.05.034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Revised: 05/27/2024] [Accepted: 05/30/2024] [Indexed: 06/21/2024]
Abstract
BACKGROUND Achieving first-pass recanalization (FPR) has become the primary procedural objective during thrombectomy in acute ischemic stroke patients as it correlates with the best clinical outcome. Understanding factors contributing to FPR failures is essential to enhance FPR success rates. As the central target of thrombectomy, the thrombus itself may be a significant factor influencing FPR. OBJECTIVES This study aimed to investigate the association between thrombus composition and FPR success rates. METHODS In total, thrombi from 267 ischemic stroke patients were collected in the AZ Groeninge Hospital (Kortrijk, Belgium). Thrombus composition was determined via detailed histologic analysis of red blood cells (RBCs), fibrin, von Willebrand factor, platelets, leukocytes, citrullinated histone 3 (marker for neutrophil extracellular traps), and intracellular and extracellular DNA. FPR was defined as obtaining a modified thrombolysis in cerebral infarction (mTICI) score of 2c/3 after the first pass. RESULTS An mTICI score of 2c/3 was obtained in 180 patients, which was achieved via a successful FPR procedure in 126 cases or after multiple passes in 54 cases. Interestingly, thrombi from FPR cases had a different composition from thrombi that needed multiple passes to obtain an mTICI score of 2c/3. FPR thrombi contained significantly more RBCs (P = .0264), less fibrin (P = .0196), and less extracellular DNA (P = .0457). CONCLUSION Our results indicate that thrombi characterized by lower RBC content, higher fibrin levels, and increased extracellular DNA are less likely to result in an FPR. These results are important to guide future research aiming at improving procedures or technologies to obtain FPR rates in RBC-poor thrombi.
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Affiliation(s)
| | - Senna Staessens
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium
| | | | - Maaike De Wilde
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium
| | - Linda Desender
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium
| | | | - Tom Dewaele
- Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
| | - Claudia Tersteeg
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium
| | | | - Peter Vanacker
- Department of Neurology, AZ Groeninge, Kortrijk, Belgium; Department of Neurology, University Hospitals Antwerp, Antwerp, Belgium; Department of Translational Neuroscience, University of Antwerp, Antwerp, Belgium
| | - Tommy Andersson
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden; Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Simon F De Meyer
- Laboratory for Thrombosis Research, KU Leuven Kulak, Kortrijk, Belgium.
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40
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Riegler C, von Rennenberg R, Bollweg K, Nguyen TN, Kleine JF, Tiedt S, Audebert HJ, Siebert E, Nolte CH. Endovascular therapy in patients with internal carotid artery occlusion and patent circle of Willis. J Neurointerv Surg 2024; 16:644-651. [PMID: 37491381 PMCID: PMC11228208 DOI: 10.1136/jnis-2023-020556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/24/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Occlusion of the internal carotid artery (ICA) may extend into the middle or anterior cerebral artery (ICA-T) or be confined to the intracranial (ICA-I) or extracranial segment (ICA-E). While there is excellent evidence for endovascular therapy (EVT) in ICA-T occlusions, studies on EVT in non-tandem ICA-I or ICA-E occlusions are scarce. OBJECTIVE To characterize EVT-treated patients with ICA-I- and ICA-E occlusion by comparing them with ICA-T occlusions. METHODS The German Stroke Registry (GSR), a national, multicenter, prospective registry was searched for EVT-treated patients with isolated ICA occlusion between June 2015 and December 2021. We stratified patients by ICA occlusion site: (a) ICA-T, (b) ICA-I, (c) ICA-E. Baseline factors, procedural variables, technical (modified Thrombolysis in Cerebral Infarction (mTICI)), and functional outcomes (modified Rankin scale score at 3 months) were analyzed. RESULTS Of 13 082 GSR patients, 2588 (19.8%) presented with an isolated ICA occlusion, thereof 1946 (75.2%) ICA-T, 366 (14.1%) ICA-I, and 276 (10.7%) ICA-E patients. The groups differed in age (77 vs 76 vs 74 years, Ptrend=0.02), sex (53.4 vs 48.9 vs 43.1% female, Ptrend<0.01), and stroke severity (median National Institutes of Health Stroke Scale score at admission 17 vs 14 vs 13 points, Ptrend<0.001). In comparison with ICA-T occlusions, both ICA-I and ICA-E occlusions had lower rates of successful recanalization (mTICI 2b/3: 85.4% vs 80.4% vs 76.3%; aOR (95% CI for ICA-I vs ICA-T 0.71 (0.53 to 0.95); aOR (95% CI) for ICA-E vs ICA-T 0.57 (0.42 to 0.78)). In adjusted analyses, ICA-E occlusion was associated with worse outcome when compared with ICA-T occlusion (mRS ordinal shift, cOR (95% CI) 0.70 (0.52 to 0.93)). CONCLUSION Patient characteristics and outcomes differ substantially between ICA-T, ICA-I, and ICA-E occlusions. These results warrant further studies on EVT in ICA-I and ICA-E patients.
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Affiliation(s)
- Christoph Riegler
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitatsmedizin Berlin, Berlin, Germany
| | - Regina von Rennenberg
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitatsmedizin Berlin, Berlin, Germany
| | - Kerstin Bollweg
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitatsmedizin Berlin, Berlin, Germany
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, Boston, Massachusetts, USA
- Department of Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Justus F Kleine
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research, University Hospital, Ludwig Maximilians University Munich, Munich, Germany
| | - Heinrich J Audebert
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitatsmedizin Berlin, Berlin, Germany
| | - Eberhard Siebert
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitatsmedizin Berlin, Berlin, Germany
- Berlin Insititute of Health at Charité, Universitätsmedizin Berlin, Berlin, Germany
- Deutsches Zentrum für Herz-Kreislaufforschung (DZHK), Berlin, Germany
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41
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Loggini A. Commentary: The SON2A2 score: a novel grading scale for predicting hemorrhage and outcomes after thrombolysis. Front Neurol 2024; 15:1414432. [PMID: 38952467 PMCID: PMC11215011 DOI: 10.3389/fneur.2024.1414432] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2024] [Accepted: 05/27/2024] [Indexed: 07/03/2024] Open
Affiliation(s)
- Andrea Loggini
- Brain and Spine Institute, Southern Illinois Healthcare, Carbondale, IL, United States
- Southern Illinois University School of Medicine, Carbondale, IL, United States
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42
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Guo D, Hu L, Xie P, Sun P, Yu W. Seipin is involved in oxygen-glucose deprivation/reoxygenation induced neuroinflammation by regulating the TLR3/TRAF3/NF-κB pathway. Int Immunopharmacol 2024; 134:112182. [PMID: 38703568 DOI: 10.1016/j.intimp.2024.112182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2024] [Revised: 04/25/2024] [Accepted: 04/27/2024] [Indexed: 05/06/2024]
Abstract
Seipin plays a crucial role in lipid metabolism and is involved in neurological disorders. However, the function and mechanism of action of seipin in acute ischemic stroke have not yet been elucidated. Here, we aimed to investigate the effect of seipin on neuroinflammation induced by oxygen-glucose deprivation/reoxygenation (OGD/R) and further explore the molecular mechanism by functional experiments. Our results revealed a significant decrease in seipin mRNA levels, accompanied by enhanced expression of TNF-α in patients with AIS, and a significant negative correlation between seipin and TNF-α was observed. Additionally, there was a negative correlation between seipin levels and the National Institutes of Health Stroke Scale (NIHSS) score. Furthermore, seipin levels were also decreased in middle cerebral artery occlusion/reperfusion (MCAO/R) mice and OGD/R-treated BV2 cells. RNA sequencing analysis showed that seipin knockdown altered the Toll-like receptor 3 (TLR3) signaling pathway. It was further confirmed in vitro that seipin knockdown caused significantly increased secretion of inflammatory factors including TNF-α, interleukin (IL)-1β, and interferon (IFN)-β. Meanwhile, seipin knockdown activated the Tlr3 signal pathway while this effect could be reversed by Tlr3 inhibitor in OGD/R treated BV2 cells. Furthermore, neuroinflammation induced by OGD/R was significantly reduced by seipin overexpression. Overall, our study demonstrate that seipin deficiency aggravates neuroinflammation by activating the TLR3/TRAF3/NF-κB signaling pathway after OGD/R stimuli, and suggest that seipin may be a potential therapeutic target for AIS.
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Affiliation(s)
- Dongfen Guo
- Key Laboratory of Endemic and Ethnic Diseases, Ministry of Education, School of Basic Medical Science, Guizhou Medical University, 09 Beijing Road, Guiyang 550004, Guizhou, China
| | - Lele Hu
- Department of Neurology, The Second People's Hospital of Guiyang, Guiyang 550023, Guizhou, China
| | - Peng Xie
- Key Laboratory of Endemic and Ethnic Diseases, Ministry of Education, School of Basic Medical Science, Guizhou Medical University, 09 Beijing Road, Guiyang 550004, Guizhou, China
| | - Ping Sun
- Department of Neurology, The Second People's Hospital of Guiyang, Guiyang 550023, Guizhou, China.
| | - Wenfeng Yu
- Key Laboratory of Endemic and Ethnic Diseases, Ministry of Education, School of Basic Medical Science, Guizhou Medical University, 09 Beijing Road, Guiyang 550004, Guizhou, China; Key Laboratory of Human Brain Bank for Functions and Diseases of Department of Education of Guizhou Province, Guizhou Medical University, Guiyang 550025, Guizhou, China.
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43
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D'Anna L, Abu-Rumeileh S, Merlino G, Ornello R, Foschi M, Diana F, Barba L, Mastrangelo V, Romoli M, Lobotesis K, Bax F, Kuris F, Valente M, Otto M, Korompoki E, Sacco S, Gigli GL, Nguyen TN, Banerjee S. Safety and Outcomes of Mechanical Thrombectomy in Acute Ischemic Stroke Attributable to Cardiological Diseases: A Scoping Review. J Am Heart Assoc 2024:e034783. [PMID: 38874062 DOI: 10.1161/jaha.124.034783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/15/2024]
Abstract
There is limited evidence on the outcomes and safety of mechanical thrombectomy (MT) among patients with acute ischemic stroke (AIS) in the context of cardiac diseases. Our study reviews MT in AIS within the context of cardiac diseases, aiming to identify existing and emerging needs and gaps. PubMed and Scopus were searched until December 31, 2023, using a combination of cardiological diseases and "mechanical thrombectomy" or "endovascular treatment" as keywords. Study design included case reports/series, observational studies, randomized clinical trials, and meta-analyses/systematic reviews. We identified 943 articles, of which 130 were included in the review. Results were categorized according to the cardiac conditions. MT shows significant benefits in patients with atrial fibrillation (n=139) but lacks data for stroke occurring after percutaneous coronary intervention (n=2) or transcatheter aortic valve implantation (n=5). MT is beneficial in AIS attributable to infective endocarditis (n=34), although functional benefit may be limited. Controversy surrounds the functional outcomes and mortality of patients with AIS with heart failure undergoing MT (n=11). Despite technical challenges, MT appears feasible in aortic dissection cases (n=4), and in patients with left ventricular assist device or total artificial heart (n=10). Data on AIS attributable to congenital heart disease (n=4) primarily focus on pediatric cases requiring technical modifications. Treatment outcomes of MT in patients with cardiac tumors (n=8) vary because of clot consistency differences. After cardiac surgery stroke, MT may improve outcomes with early intervention (n=13). Available data outline the feasibility of MT in patients with AIS attributable to large-vessel occlusion in the context of cardiac diseases.
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Affiliation(s)
- Lucio D'Anna
- Department of Stroke and Neuroscience Charing Cross Hospital, Imperial College London NHS Healthcare Trust London United Kingdom
- Department of Brain Sciences Imperial College London London United Kingdom
| | - Samir Abu-Rumeileh
- Department of Neurology Martin-Luther-University Halle-Wittenberg Halle (Saale) Germany
| | - Giovanni Merlino
- Stroke Unit and Clinical Neurology Udine University Hospital Udine Italy
| | - Raffaele Ornello
- Department of Biotechnological and Applied Clinical Sciences University of L'Aquila L'Aquila Italy
| | - Matteo Foschi
- Department of Biotechnological and Applied Clinical Sciences University of L'Aquila L'Aquila Italy
| | - Francesco Diana
- Interventional Neuroradiology Vall d'Hebron University Hospital Barcelona Catalunya Spain
| | - Lorenzo Barba
- Department of Neurology Martin-Luther-University Halle-Wittenberg Halle (Saale) Germany
| | | | - Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience Bufalini Hospital, Azienda Unità Sanitaria Locale Romagna Cesena Italy
| | - Kyriakos Lobotesis
- Neuroradiology, Department of Imaging, Charing Cross Hospital, Imperial College London NHS Healthcare Trust London United Kingdom
| | - Francesco Bax
- Philip Kistler Research Center, Department of Neurology Massachusetts General Hospital and Harvard Medical School Boston MA USA
| | - Fedra Kuris
- Stroke Unit and Clinical Neurology Udine University Hospital Udine Italy
| | - Mariarosaria Valente
- Clinical Neurology Udine University Hospital and Dipartmento di Area Medica, University of Udine Udine Italy
| | - Markus Otto
- Department of Neurology Martin-Luther-University Halle-Wittenberg Halle (Saale) Germany
| | - Eleni Korompoki
- Department of Brain Sciences Imperial College London London United Kingdom
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences University of L'Aquila L'Aquila Italy
| | - Gian Luigi Gigli
- Stroke Unit and Clinical Neurology Udine University Hospital Udine Italy
| | - Thanh N Nguyen
- Department of Neurology, Radiology Boston Medical Center Boston MA USA
| | - Soma Banerjee
- Department of Stroke and Neuroscience Charing Cross Hospital, Imperial College London NHS Healthcare Trust London United Kingdom
- Department of Brain Sciences Imperial College London London United Kingdom
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44
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Babenko VA, Yakupova EI, Pevzner IB, Bocharnikov AD, Zorova LD, Fedulova KS, Grebenchikov OA, Kuzovlev AN, Grechko AV, Silachev DN, Rahimi-Moghaddam P, Plotnikov EY. Effects of Lithium Ions on tPA-Induced Hemorrhagic Transformation under Stroke. Biomedicines 2024; 12:1325. [PMID: 38927532 PMCID: PMC11201972 DOI: 10.3390/biomedicines12061325] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2024] [Revised: 06/07/2024] [Accepted: 06/12/2024] [Indexed: 06/28/2024] Open
Abstract
Thrombolytic therapy with the tissue plasminogen activator (tPA) is a therapeutic option for acute ischemic stroke. However, this approach is subject to several limitations, particularly the increased risk of hemorrhagic transformation (HT). Lithium salts show neuroprotective effects in stroke, but their effects on HT mechanisms are still unknown. In our study, we use the models of photothrombosis (PT)-induced brain ischemia and oxygen-glucose deprivation (OGD) to investigate the effect of Li+ on tPA-induced changes in brain and endothelial cell cultures. We found that tPA did not affect lesion volume or exacerbate neurological deficits but disrupted the blood-brain barrier. We demonstrate that poststroke treatment with Li+ improves neurological status and increases blood-brain barrier integrity after thrombolytic therapy. Under conditions of OGD, tPA treatment increased MMP-2/9 levels in endothelial cells, and preincubation with LiCl abolished this MMP activation. Moreover, we observed the effect of Li+ on glycolysis in tPA-treated endothelial cells, which we hypothesized to have an effect on MMP expression.
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Affiliation(s)
- Valentina A. Babenko
- A.N. Belozersky Research Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119991 Moscow, Russia; (V.A.B.); (E.I.Y.); (I.B.P.); (A.D.B.); (L.D.Z.); (K.S.F.); (D.N.S.)
- V.I. Kulakov National Medical Research Center of Obstetrics, Gynecology and Perinatology, 117997 Moscow, Russia
| | - Elmira I. Yakupova
- A.N. Belozersky Research Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119991 Moscow, Russia; (V.A.B.); (E.I.Y.); (I.B.P.); (A.D.B.); (L.D.Z.); (K.S.F.); (D.N.S.)
| | - Irina B. Pevzner
- A.N. Belozersky Research Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119991 Moscow, Russia; (V.A.B.); (E.I.Y.); (I.B.P.); (A.D.B.); (L.D.Z.); (K.S.F.); (D.N.S.)
- V.I. Kulakov National Medical Research Center of Obstetrics, Gynecology and Perinatology, 117997 Moscow, Russia
| | - Alexey D. Bocharnikov
- A.N. Belozersky Research Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119991 Moscow, Russia; (V.A.B.); (E.I.Y.); (I.B.P.); (A.D.B.); (L.D.Z.); (K.S.F.); (D.N.S.)
- Advanced Engineering School “Intelligent Theranostics Systems”, Sechenov First Moscow State Medical University, 119992 Moscow, Russia
| | - Ljubava D. Zorova
- A.N. Belozersky Research Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119991 Moscow, Russia; (V.A.B.); (E.I.Y.); (I.B.P.); (A.D.B.); (L.D.Z.); (K.S.F.); (D.N.S.)
- V.I. Kulakov National Medical Research Center of Obstetrics, Gynecology and Perinatology, 117997 Moscow, Russia
| | - Kseniya S. Fedulova
- A.N. Belozersky Research Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119991 Moscow, Russia; (V.A.B.); (E.I.Y.); (I.B.P.); (A.D.B.); (L.D.Z.); (K.S.F.); (D.N.S.)
| | - Oleg A. Grebenchikov
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia; (O.A.G.); (A.N.K.); (A.V.G.)
| | - Artem N. Kuzovlev
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia; (O.A.G.); (A.N.K.); (A.V.G.)
| | - Andrey V. Grechko
- Federal Research and Clinical Center of Intensive Care Medicine and Rehabilitology, 107031 Moscow, Russia; (O.A.G.); (A.N.K.); (A.V.G.)
| | - Denis N. Silachev
- A.N. Belozersky Research Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119991 Moscow, Russia; (V.A.B.); (E.I.Y.); (I.B.P.); (A.D.B.); (L.D.Z.); (K.S.F.); (D.N.S.)
- V.I. Kulakov National Medical Research Center of Obstetrics, Gynecology and Perinatology, 117997 Moscow, Russia
| | - Parvaneh Rahimi-Moghaddam
- Department of Pharmacology, School of Medicine, Iran University of Medical Sciences, Tehran 14496-14535, Iran;
| | - Egor Y. Plotnikov
- A.N. Belozersky Research Institute of Physico-Chemical Biology, Lomonosov Moscow State University, 119991 Moscow, Russia; (V.A.B.); (E.I.Y.); (I.B.P.); (A.D.B.); (L.D.Z.); (K.S.F.); (D.N.S.)
- V.I. Kulakov National Medical Research Center of Obstetrics, Gynecology and Perinatology, 117997 Moscow, Russia
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45
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Victor P, Bian E, Mamdouh H, Mohamed GA, Nour HA, Miller K, Singh K, Patel S, Segovis C, Nahab F. Upfront vascular imaging in acute stroke: Impact on thrombectomy transfer time at a primary stroke center. J Stroke Cerebrovasc Dis 2024; 33:107815. [PMID: 38878844 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2023] [Revised: 05/17/2024] [Accepted: 06/10/2024] [Indexed: 06/24/2024] Open
Abstract
OBJECTIVES Early cerebral arterial imaging is currently only recommended in the subgroup of acute ischemic stroke (AIS) patients suspected of having large vessel occlusion (LVO). There is limited data on the impact of early cerebrovascular imaging in all suspected AIS patients presenting within 24 h of symptom onset and the impact on door in-door out (DIDO) time. MATERIALS AND METHODS In January 2020, our Primary Stroke Center implemented a protocol to perform upfront head and neck CT angiography (CTA) with initial non-contrast CT head for all suspected ischemic stroke patients screening positive for BE-FAST stroke symptoms within 24 h from last known normal time. We retrospectively reviewed IV alteplase and thrombectomy-eligible patients before (January 1-December 31, 2019) and after protocol implementation (January 1, 2020-June 30, 2022). RESULTS Of 86 patients meeting study criteria, up-front CTA was associated with significant reductions in door-to-CTA start (median 37 vs 15 min, p = 0.003), door-to-CTA result (median 83 vs 52 min, p = 0.023) and DIDO times (median 150 vs 106 min, p = 0.023). There was no significant difference in door-to-needle time before and after protocol implementation (median 48 vs 43 min, p = 0.450). CONCLUSION Up-front cerebrovascular imaging with CTA in suspected AIS patients presenting within 24 h resulted in shorter DIDO times without delaying door-to-needle times. Primary Stroke Centers should consider this approach to detect LVO early and expedite patient transport to thrombectomy capable centers.
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Affiliation(s)
- Patricia Victor
- Emory Healthcare, 1365 Clifton Road NE, Clinic B, Suite 2200, Atlanta, GA 30322, Georgia
| | | | | | - Ghada A Mohamed
- Medical University of South Carolina, Charleston, South Carolina
| | - Hassan Aboul Nour
- Departments of Neurology and Neurosurgery, University of Kentucky College of Medicine, Lexington, KY
| | | | | | | | | | - Fadi Nahab
- Emory Healthcare, 1365 Clifton Road NE, Clinic B, Suite 2200, Atlanta, GA 30322, Georgia; Emory University, Atlanta, Georgia.
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46
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Puggaard R, Laugesen NG, Hansen K, Brandt AH, Stavngaard T, Truelsen TC. Outcome and safety of mechanical thrombectomy in patients with acute ischemic stroke due to internal carotid artery dissection. Interv Neuroradiol 2024:15910199241261753. [PMID: 38870399 DOI: 10.1177/15910199241261753] [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: 06/15/2024] Open
Abstract
BACKGROUND Mechanical thrombectomy (MT) in patients with symptoms of acute ischemic stroke (AIS) due to internal carotid artery dissection (ICAD) remains controversial. In this study, we present clinical outcome and safety of MT in acute ICAD compared to other acute carotid artery pathology. METHODS Patients with symptoms of AIS due to internal carotid artery pathology, treated with MT from 2017-2021, were categorized as ICAD or non-ICAD. Baseline and procedural characteristics, complications, and functional outcome at 90 days were compared between the two groups. Factors associated with a favorable outcome (modified Rankin Scale 0-2) were analyzed using multivariate logistic regression. Safety analyses included in-stent thrombosis, perforation, intracranial hemorrhage, and mortality. RESULTS Sixty-seven ICAD patients (14.8%) and 387 non-ICAD patients (85.2%) were enrolled. ICAD patients were younger, median age 53 years (interquartile range (IQR) 47-61) vs. non-ICAD 72 years (IQR 64-79), p < 0.001. Favorable outcome was more common in ICAD patients, 49 ICAD patients (76.6%) vs. 158 non-ICAD patients (42.4%), p < 0.001. Post-procedural symptomatic intracranial hemorrhage occurred in 41 patients, 5 (7.5%) ICAD patients vs. 36 (9.3%) non-ICAD patients, p = 0.6. Mortality differed significantly, 6 (9%) ICAD patients vs. 94 (24.3%) non-ICAD patients, p = 0.01. ICAD was not associated with functional outcome in multivariate analysis, OR = 1.25 [95%confidence interval:0.55-2.86]. CONCLUSION ICAD patients achieved a better 90-day functional outcome compared with non-ICAD patients. ICAD patients did not perform worse in safety measures than non-ICAD patients. Our data provide indirect evidence that MT is of clinical benefit in ICAD patients with symptoms of AIS.
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Affiliation(s)
- Rikke Puggaard
- Cerebrovascular Research Unit Rigshospitalet, Department of Neurology, Rigshospitalet, Copenhagen, Denmark
| | - Nicolaj Grønbæk Laugesen
- Cerebrovascular Research Unit Rigshospitalet, Department of Neurology, Rigshospitalet, Copenhagen, Denmark
| | - Klaus Hansen
- Cerebrovascular Research Unit Rigshospitalet, Department of Neurology, Rigshospitalet, Copenhagen, Denmark
- Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andreas H Brandt
- Neurovascular Section, Department of Radiology, Rigshospitalet, Copenhagen, Denmark
| | - Trine Stavngaard
- Neurovascular Section, Department of Radiology, Rigshospitalet, Copenhagen, Denmark
| | - Thomas C Truelsen
- Cerebrovascular Research Unit Rigshospitalet, Department of Neurology, Rigshospitalet, Copenhagen, Denmark
- Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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47
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Venketasubramanian N, Yeo TT, Chen CLH. Translational Medicine in Acute Ischemic Stroke and Traumatic Brain Injury-NeuroAiD Trials, from Traditional Beliefs to Evidence-Based Therapy. Biomolecules 2024; 14:680. [PMID: 38927083 PMCID: PMC11202287 DOI: 10.3390/biom14060680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Revised: 06/08/2024] [Accepted: 06/09/2024] [Indexed: 06/28/2024] Open
Abstract
Acute ischemic stroke (AIS) and traumatic brain injury (TBI) are two severe neurological events, both being major causes of death and prolonged impairment. Their incidence continues to rise due to the global increase in the number of people at risk, representing a significant burden on those remaining impaired, their families, and society. These molecular and cellular mechanisms of both stroke and TBI present similarities that can be targeted by treatments with a multimodal mode of action, such as traditional Chinese medicine. Therefore, we performed a detailed review of the preclinical and clinical development of MLC901 (NeuroAiDTMII), a natural multi-herbal formulation targeting several biological pathways at the origin of the clinical deficits. The endogenous neurobiological processes of self-repair initiated by the brain in response to the onset of brain injury are often insufficient to achieve complete recovery of impaired functions. This review of MLC901 and its parent formulation MLC601 confirms that it amplifies the natural self-repair process of brain tissue after AIS or TBI. Following AIS and TBI where "time is brain", many patients enter the post-acute phase with their functions still impaired, a period when "the brain needs time to repair itself". The treatment goal must be to accelerate recovery as much as possible. MLC901/601 demonstrated a significant reduction by 18 months of recovery time compared to a placebo, indicating strong potential for facilitating the improvement of health outcomes and the more efficient use of healthcare resources.
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Affiliation(s)
| | - Tseng Tsai Yeo
- Division of Neurosurgery, Department of Surgery, National University Hospital, 5 Lower Kent Ridge Road, Singapore 119074, Singapore;
| | - Christopher Li Hsian Chen
- Memory Aging and Cognition Centre, Department of Pharmacology, Yong Loo Lin School of Medicine, National University of Singapore, Blk MD3, 16 Medical Drive, #04-01, Singapore 117600, Singapore;
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48
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Lee S, Yuan F, Garcia M, MacLellan A, Mlynash M, Meseguer E, Arnold M, Häusler KG, Sporns PB, Perera KS. Thrombectomy in young adults with embolic stroke of undetermined source: Analysis of the Young ESUS study. J Stroke Cerebrovasc Dis 2024; 33:107811. [PMID: 38866118 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2024] [Revised: 06/05/2024] [Accepted: 06/08/2024] [Indexed: 06/14/2024] Open
Abstract
OBJECTIVES Embolic Stroke of Undetermined Source (ESUS) is a distinct stroke entity that disproportionately affects young adults. We sought to describe characteristics, workup and outcomes of young adult ESUS patients who underwent thrombectomy, and compare outcomes to those reported in different age groups. MATERIALS AND METHODS Young-ESUS is a multicenter longitudinal cohort study that enrolled consecutive patients aged 21-50 years at 41 stroke centers in 13 countries between 2017- 2019. Between-group comparisons were performed using Wilcoxon rank sum test for continuous variables or Fisher's exact test for binary variables. Distribution of functional outcomes after thrombectomy for our young adult cohort versus pediatric and older adult cohorts reported in the literature were described using the Kruskal-Wallis test. RESULTS Of 535 patients enrolled in Young-ESUS, 65 (12.1%) were treated with endovascular thrombectomy. Patients who underwent thrombectomy were more likely to undergo in-depth cardiac testing than those who did not, but cardiac abnormalities were not detected more often in this group. Among thrombectomy patients, 35/63 (55.6%) had minimal to no functional disability at follow up. When adjusted for age, stroke severity and IV alteplase, the odds of achieving favorable outcome did not differ between treated versus untreated patients. CONCLUSIONS Thrombectomy is not rare in young adults with ESUS. Despite extensive workup, cardiac abnormalities were not more prevalent in the thrombectomy group. More research to determine optimal workup, etiologic factors and favorable outcome of stroke across the lifespan is needed.
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Affiliation(s)
- Sarah Lee
- Stanford Stroke Center, Department of Neurology, Stanford School of Medicine, Stanford, CA, USA; Division of Child Neurology, Department of Neurology, Stanford School of Medicine, Stanford, CA, USA.
| | - Fei Yuan
- Department of Statistics, Population Health Research Institute, Hamilton, ON, Canada
| | - Madelleine Garcia
- Stanford Stroke Center, Department of Neurology, Stanford School of Medicine, Stanford, CA, USA
| | - Adam MacLellan
- Division of Neurology, University of British Columbia, Vancouver, Canada
| | - Michael Mlynash
- Stanford Stroke Center, Department of Neurology, Stanford School of Medicine, Stanford, CA, USA
| | | | - Marcel Arnold
- Department of Neurology, University Hospital Bern, Bern, Switzerland
| | - Karl Georg Häusler
- Department of Neurology, Universitätsklinikum Würzburg, Würzburg, Germany
| | - Peter B Sporns
- Department of Diagnostic and Interventional Radiology, University Hospital Basel, Basel, Switzerland
| | - Kanjana S Perera
- Department of Medicine (Neurology), McMaster University/ Population Health Research Institute/ Hamilton Health Sciences, Hamilton, ON, Canada
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49
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Han N, Zhang X, Zhang Y, Liu Y, Ma H, Ge H, Wang Y, Li S, Yan X, Li T, Wu Y, Ma J, Shi W, Zhang G, Tian Y, Chang M. Endovascular thrombectomy versus medical management on outcomes with infarct volumes more than 70 mL. Ann Clin Transl Neurol 2024. [PMID: 38858521 DOI: 10.1002/acn3.52124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2024] [Revised: 05/06/2024] [Accepted: 05/27/2024] [Indexed: 06/12/2024] Open
Abstract
OBJECTIVE Endovascular thrombectomy (EVT) in patients with large infarct volume remains controversial. The aim of this study is to compare clinical outcomes between EVT and medical management in acute large vessel occlusion with infarct volumes larger than 70 mL on diffusion-weighted magnetic resonance imaging (DWI). METHODS A prospective observational cohort study was conducted, including patients with anterior cerebral circulation occlusion due to ischemic stroke with infarct volumes larger than 70 mL within 24 h of onset between July 2018 and June 2023. Eligible patients were divided into two groups: the EVT group and the medical management (non-EVT) group. The main outcomes were functional independence and mortality at 90 days. To assess clinical endpoints, we selected variables including age, NIHSS score, infarct volume, and occlusion location for 1:1 propensity score (PS) matching and PS adjustment using inverse probability of treatment weighting (IPTW). RESULTS Among the 131 identified patients (mean [SD] age, 69.9 [13.7] years; 58 female), the median infarct volume was 123.6 mL. Of these patients, 75 (57.3%) underwent EVT. After PS adjustment, EVT was not associated with functional independence (10.9% vs. 10.9%; p = 1.000) or mortality (43.5% vs. 47.8%; p = 0.675). Additionally, after PS adjustment using IPTW, EVT was also not associated with a functional independence (15.8% vs. 13.7%; p = 0.767) or mortality (46.8% vs. 44.0%; p = 0.762). CONCLUSION This study provides real-world evidence regarding infarct volumes larger than 70 mL, indicating that EVT does not provide benefits compared to medical management alone when considering age, NIHSS score, infarct volume, and occlusion location.
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Affiliation(s)
- Nannan Han
- Department of Neurology, The Affiliated Hospital of Northwest University, Xi'an, China
| | - Xiaobo Zhang
- The College of Life Sciences, Northwest University, Xi'an, China
| | - Yu Zhang
- The College of Life Sciences, Northwest University, Xi'an, China
| | - Yu Liu
- School of Information Science and Technology, Northwest University, Xi'an, China
| | - Haojun Ma
- Department of Neurology, The Affiliated Hospital of Northwest University, Xi'an, China
| | - Hanming Ge
- Department of Neurology, The Affiliated Hospital of Northwest University, Xi'an, China
| | - Yanfei Wang
- Department of Neurology, The Affiliated Hospital of Northwest University, Xi'an, China
| | - Shilin Li
- Department of Neurology, The Affiliated Hospital of Northwest University, Xi'an, China
| | - Xudong Yan
- Department of Neurology, The Affiliated Hospital of Northwest University, Xi'an, China
| | - Tengfei Li
- Department of Neurology, The Affiliated Hospital of Northwest University, Xi'an, China
| | - Yulun Wu
- Department of Neurology, The Affiliated Hospital of Northwest University, Xi'an, China
| | - Juan Ma
- Department of Neurology, The Affiliated Hospital of Northwest University, Xi'an, China
| | - Wenzhen Shi
- Xi'an Key Laboratory of Cardiovascular and Cerebrovascular Diseases, The Affiliated Hospital of Northwest University, Xi'an, China
- Clinical Medical Research Center, The Affiliated Hospital of Northwest University, Xi'an, China
| | - Gejuan Zhang
- Department of Neurology, The Affiliated Hospital of Northwest University, Xi'an, China
| | - Ye Tian
- Department of Neurology, The Affiliated Hospital of Northwest University, Xi'an, China
- Xi'an Key Laboratory of Cardiovascular and Cerebrovascular Diseases, The Affiliated Hospital of Northwest University, Xi'an, China
- Clinical Medical Research Center, The Affiliated Hospital of Northwest University, Xi'an, China
| | - Mingze Chang
- Department of Neurology, The Affiliated Hospital of Northwest University, Xi'an, China
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50
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Taboada M, Estany-Gestal A, Fernández J, Barreiro L, Williams K, Rodríguez-Yáñez M, Otero P, Naveira A, Caruezo V, Veiras S, San Luis E, Dos Santos L, Diaz-Vieito M, Arias-Rivas S, Santamaría-Cadavid M, Rodríguez-Castro E, Vázquez F, Blanco M, Mosquera A, Castiñeiras JA, Muniategui I, Ferreiroa E, Cariñena A, Tubio A, Campaña O, Selas S, Aneiros F, Martínez A, Eiras M, Costa J, Prieto JM, Álvarez J. Effect of early vs. delayed extubation on functional outcome among patients with acute ischemic stroke treated with endovascular thrombectomy under general anesthesia: the prospective, randomized controlled EDESTROKE trial study protocol. Trials 2024; 25:357. [PMID: 38835061 PMCID: PMC11151624 DOI: 10.1186/s13063-024-08181-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2024] [Accepted: 05/17/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND Recent meta-analyses and randomized studies have shown that among patients with acute ischemic stroke undergoing endovascular thrombectomy, general anesthesia with mechanical ventilation is associated with better functional status compared to local anesthesia and sedation, and they recommend its use. But once the procedure is completed, when is the optimal moment for extubation? Currently, there are no guidelines recommending the optimal moment for extubation. Prolonged mechanical ventilation time could potentially be linked to increased complications such as pneumonia or disturbances in cerebral blood flow due to the vasodilatation produced by most anesthetic drugs. However, premature extubation in a patient who has suffered a stroke could led to complications such as agitation, disorientation, abolished reflexes, sudden fluctuations in blood pressure, alterations in cerebral blood flow, respiratory distress, bronchial aspiration, and the need for reintubation. We therefore designed a randomized study hypothesizing that early compared with delayed extubation is associated with a better functional outcome 3 months after endovascular thrombectomy treatment under general anesthesia for acute ischemic stroke. METHODS This investigator-initiated, single-center, prospective, parallel, evaluated blinded, superiority, randomized controlled trial will include 178 patients with a proximal occlusion of the anterior circulation treated with successful endovascular thrombectomy (TICI 2b-3) under general anesthesia. Patients will be randomly allocated to receive early (< 6 h) or delayed (6-12 h) extubation after the procedure. The primary outcome measure is functional independence (mRS of 0-2) at 90 days, measured with the modified Rankin Score (mRS), ranging from 0 (no symptoms) to 6 (death). DISCUSSION This will be the first trial to compare the effect of mechanical ventilation duration (early vs delayed extubation) after satisfactory endovascular thrombectomy for acute ischemic stroke under general anesthesia. TRIAL REGISTRATION The study protocol was approved April 11, 2023, by the by the Santiago-Lugo Research Ethics Committee (CEI-SL), number 2023/127, and was registered into the clinicaltrials.gov clinical trials registry with No. NCT05847309. Informed consent is required. Participant recruitment begins on April 18, 2023. The results will be submitted for publication in a peer-reviewed journal and presented at one or more scientific conferences.
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Affiliation(s)
- Manuel Taboada
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain.
| | - Ana Estany-Gestal
- Research Methodology Unit, Fundación Instituto de Investigaciones Sanitarias (FIDIS), Santiago, Spain
| | - Jorge Fernández
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Laura Barreiro
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Kora Williams
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | | | - Pablo Otero
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Alberto Naveira
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Valentín Caruezo
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Sonia Veiras
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Eva San Luis
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Laura Dos Santos
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - María Diaz-Vieito
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Susana Arias-Rivas
- Department of Neurology, University Clinical Hospital of Santiago, Santiago, Spain
| | | | | | - Fernando Vázquez
- Department of Neuroradiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Miguel Blanco
- Department of Neuroradiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Antonio Mosquera
- Department of Neuroradiology, University Clinical Hospital of Santiago, Santiago, Spain
| | | | - Ignacio Muniategui
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Esteban Ferreiroa
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Agustín Cariñena
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Ana Tubio
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Olga Campaña
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Salomé Selas
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Francisco Aneiros
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Adrián Martínez
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - María Eiras
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Jose Costa
- Department of Neuroradiology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Jose María Prieto
- Department of Neurology, University Clinical Hospital of Santiago, Santiago, Spain
| | - Julián Álvarez
- Department of Anesthesiology, University Clinical Hospital of Santiago, Santiago, Spain
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