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Thomalla G, Fiehler J, Subtil F, Bonekamp S, Aamodt AH, Fuentes B, Gizewski ER, Hill MD, Krajina A, Pierot L, Simonsen CZ, Zeleňák K, Blauenfeldt RA, Cheng B, Denis A, Deutschmann H, Dorn F, Flottmann F, Gellißen S, Gerber JC, Goyal M, Haring J, Herweh C, Hopf-Jensen S, Hua VT, Jensen M, Kastrup A, Keil CF, Klepanec A, Kurča E, Mikkelsen R, Möhlenbruch M, Müller-Hülsbeck S, Münnich N, Pagano P, Papanagiotou P, Petzold GC, Pham M, Puetz V, Raupach J, Reimann G, Ringleb PA, Schell M, Schlemm E, Schönenberger S, Tennøe B, Ulfert C, Vališ K, Vítková E, Vollherbst DF, Wick W, Bendszus M. Endovascular thrombectomy for acute ischaemic stroke with established large infarct (TENSION): 12-month outcomes of a multicentre, open-label, randomised trial. Lancet Neurol 2024; 23:883-892. [PMID: 39074480 DOI: 10.1016/s1474-4422(24)00278-3] [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: 05/26/2024] [Revised: 06/25/2024] [Accepted: 06/26/2024] [Indexed: 07/31/2024]
Abstract
BACKGROUND Long-term data showing the benefits of endovascular thrombectomy for stroke with large infarct are scarce. The TENSION trial showed the safety and efficacy of endovascular thrombectomy in patients with ischaemic stroke and large infarct at 90 days. We aimed to investigate the safety and efficacy at 12 months of endovascular thrombectomy in patients who were enrolled in the TENSION trial. METHODS TENSION was an open-label, blinded endpoint, randomised trial done at 40 hospitals across Europe and one hospital in Canada. We included patients (aged ≥18 years) with acute ischaemic stroke due to large vessel occlusion in the anterior circulation and who had a large infarct, as indicated by an Alberta Stroke Program Early Computed Tomographic Score (ASPECTS) of 3-5 on standard-of-care stroke imaging. We randomly assigned patients (1:1) to receive either endovascular thrombectomy with medical treatment or medical treatment only up to 12 h from stroke onset. The primary outcome was functional outcome across the entire range of the modified Rankin Scale at 90 days. Here, we report the prespecified 12-month follow-up analyses for functional outcome (using the simplified modified Rankin Scale questionnaire), quality of life (using the Patient-Reported Outcomes Measurement Information System 10-item [PROMIS-10] and EQ-5D questionnaires), post-stroke anxiety and depression (using the Patient Health Questionnaire-4 [PHQ-4]), and overall survival. Outcomes (except survival) were assessed in the intention-to-treat population; the survival analysis was based on treatment received. This trial is registered with ClinicalTrials.gov, NCT03094715, and is completed. FINDINGS We enrolled patients between July 17, 2018, and Feb 21, 2023, when the trial was stopped early for efficacy. 253 patients were randomly assigned, 125 (49%) to endovascular thrombectomy and 128 (51%) to medical treatment only. Median follow-up was 8·36 months (IQR 0·02-12·00). Endovascular thrombectomy was associated with a shift in the distribution of scores on the modified Rankin Scale towards better functional outcome at 12 months (adjusted common odds ratio 2·39 [95% CI 1·47-3·90]). Endovascular thrombectomy was also associated with a better quality of life compared with medical treatment only, as reflected by median scores on the EQ-5D questionnaire index (0·7 [IQR 0·4-0·9] vs 0·4 [0·2-0·7]), median scores for health status on the EQ-5D questionnaire visual analogue scale (50 [IQR 35-70] vs 30 [5-60]), and median global physical health scores on the PROMIS-10 questionnaire (T-score 39·8 [IQR 37·4-50·8] vs 37·4 [32·4-44·9]); although there was not enough evidence to suggest a difference between groups in global mental health scores on PROMIS-10 (41·1 [IQR 36·3-48·3] vs 38·8 [31·3-44·7]) or the numbers of patients reporting anxiety (13 [22%] of 58 vs 15 [42%] of 36) and depression (18 [31%] vs 18 [50%]) on PHQ-4. Overall survival was slightly better in the endovascular thrombectomy group compared with medical treatment only (adjusted hazard ratio 0·70 [95% CI 0·50-0·99]). INTERPRETATION In patients with acute ischaemic stroke from large vessel occlusion with established large infarct, compared with medical treatment only, endovascular thrombectomy was associated at 12 months after stroke with better functional outcome, quality of life, and overall survival. These findings suggest that the benefits of endovascular thrombectomy in patients with an ischaemic stroke and a large infarct are sustained in the long term and support the use of endovascular thrombectomy in these patients. FUNDING European Union Horizon 2020 Research and Innovation Programme.
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Affiliation(s)
- Götz Thomalla
- Klinik und Poliklinik für Neurologie, Kopf, und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany.
| | - Jens Fiehler
- Universitätsklinikum Hamburg-Eppendorf, Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Hamburg, Germany; eppdata, Hamburg, Germany
| | - Fabien Subtil
- Service de Biostatistique, Hospices Civils de Lyon, Lyon, France; Laboratoire de Biométrie et Biologie Évolutive, Université de Lyon, Villeurbanne, France; Université Lyon 1, CNRS, Laboratoire de Biométrie et Biologie Évolutive UMR 5558, Villeurbanne, France
| | - Susanne Bonekamp
- Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Anne Hege Aamodt
- Department of Neurology, Oslo University Hospital, Rikshospitalet Oslo, Norway
| | - Blanca Fuentes
- Department of Neurology and Stroke Center, Hospital La Paz Institute for Health Research-IdiPAZ (La Paz University Hospital-Universidad Autonoma de Madrid), Madrid, Spain
| | - Elke R Gizewski
- Department of Neuroradiology, Medical University Innsbruck, Innsbruck, Austria
| | - Michael D Hill
- University of Calgary & Foothills Medical Centre, Department of Clinical Neurosciences, Hotchkiss Brain Institute, HBA 2939, Health Science Centre, Calgary, AB, Canada
| | - Antonin Krajina
- Department of Radiology, Charles University, Faculty of Medicine, Hradec Kralove, Czech Republic
| | - Laurent Pierot
- Department of Neuroradiology, Hôpital Maison-Blanche, Université Reims-Champagne-Ardenne, Reims, France
| | - Claus Z Simonsen
- Department of Neurology, Aarhus University Hospital, Department of Neurology, Aarhus, Denmark
| | - Kamil Zeleňák
- Clinic of Radiology, Jessenius Faculty of Medicine, Comenius University of Bratislava, Martin, Slovakia
| | - Rolf A Blauenfeldt
- Department of Neurology, Aarhus University Hospital, Department of Neurology, Aarhus, Denmark
| | - Bastian Cheng
- Klinik und Poliklinik für Neurologie, Kopf, und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Angélique Denis
- Service de Biostatistique, Hospices Civils de Lyon, Lyon, France; Laboratoire de Biométrie et Biologie Évolutive, Université de Lyon, Villeurbanne, France; Université Lyon 1, CNRS, Laboratoire de Biométrie et Biologie Évolutive UMR 5558, Villeurbanne, France
| | - Hannes Deutschmann
- Division of Neuroradiology, Vascular and Interventional Radiology, Department of Radiology, Medical University Graz, Graz, Austria
| | - Franziska Dorn
- Klinik für Diagnostische und Interventionelle Neuroradiologie, Universitätsklinikum Bonn, Bonn, Germany
| | - Fabian Flottmann
- Universitätsklinikum Hamburg-Eppendorf, Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Hamburg, Germany
| | - Susanne Gellißen
- Universitätsklinikum Hamburg-Eppendorf, Klinik und Poliklinik für Neuroradiologische Diagnostik und Intervention, Hamburg, Germany
| | - Johannes C Gerber
- Institute of Neuroradiology, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany; Dresden Neurovascular Center, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Mayank Goyal
- University of Calgary & Foothills Medical Centre, Department of Clinical Neurosciences, Hotchkiss Brain Institute, HBA 2939, Health Science Centre, Calgary, AB, Canada
| | - Jozef Haring
- Faculty Hospital Trnava, Department of Neurology, Trnava, Slovakia
| | - Christian Herweh
- Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Silke Hopf-Jensen
- DIAKO Krankenhaus, Institut für Diagnostische und Interventionelle Radiologie und Neuroradiologie, Flensburg, Germany
| | - Vi Tuan Hua
- Department of Neuroradiology, Hôpital Maison-Blanche, Université Reims-Champagne-Ardenne, Reims, France
| | - Märit Jensen
- Klinik und Poliklinik für Neurologie, Kopf, und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Kastrup
- Klinik für Neurologie, Klinikum Bremen Mitte, Bremen, Germany
| | - Christiane Fee Keil
- Universitätsklinikum Frankfurt, Institut für Neuroradiologie, Frankfurt am Main, Germany
| | - Andrej Klepanec
- Faculty Hospital Trnava, Department of Neurology, Trnava, Slovakia
| | - Egon Kurča
- Clinic of Neurology, Jessenius Faculty of Medicine, Comenius University of Bratislava, Martin, Slovakia
| | - Ronni Mikkelsen
- Department of Neuroradiology, Aarhus University Hospital, Department of Neurology, Aarhus, Denmark
| | | | - Stefan Müller-Hülsbeck
- DIAKO Krankenhaus, Institut für Diagnostische und Interventionelle Radiologie und Neuroradiologie, Flensburg, Germany
| | - Nico Münnich
- Klinikum Dortmund, Klinikum der Universität Witten/Herdecke, Dortmund, Germany
| | - Paolo Pagano
- Department of Neuroradiology, Hôpital Maison-Blanche, Université Reims-Champagne-Ardenne, Reims, France
| | - Panagiotis Papanagiotou
- Klinik für Diagnostische und Interventionelle Neuroradiologie, Klinikum Bremen Mitte, Bremen, Germany; Department of Radiology, Aretaieion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Gabor C Petzold
- Department of Vascular Neurology, Universitätsklinikum Bonn, Bonn, Germany
| | - Mirko Pham
- Universitätsklinikum Würzburg, Institut für Diagnostische und Interventionelle Neuroradiologie, Würzburg, Germany
| | - Volker Puetz
- Dresden Neurovascular Center, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany; Department of Neurology, Universitätsklinikum Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Jan Raupach
- Department of Radiology, Charles University, Faculty of Medicine, Hradec Kralove, Czech Republic
| | - Gernot Reimann
- Klinikum Dortmund, Klinikum der Universität Witten/Herdecke, Dortmund, Germany
| | | | - Maximilian Schell
- Klinik und Poliklinik für Neurologie, Kopf, und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Eckhard Schlemm
- Klinik und Poliklinik für Neurologie, Kopf, und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | | | - Bjørn Tennøe
- Department of Neuroradiology, Oslo University Hospital, Rikshospitalet Oslo, Norway
| | - Christian Ulfert
- Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Kateřina Vališ
- Department of Medical Imaging, St Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Eva Vítková
- Department of Neurology, Charles University, Faculty of Medicine, Hradec Kralove, Czech Republic
| | | | - Wolfgang Wick
- Neurologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Martin Bendszus
- Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
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Morimoto T, Sakakibara F. Endovascular thrombectomy for large ischaemic stroke: outcomes beyond 90 days. Lancet Neurol 2024; 23:847-849. [PMID: 39074481 DOI: 10.1016/s1474-4422(24)00290-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2024] [Accepted: 07/02/2024] [Indexed: 07/31/2024]
Affiliation(s)
- Takeshi Morimoto
- Department of Data Science, Hyogo Medical University, Nishinomiya, Hyogo 663-8501, Japan.
| | - Fumihiro Sakakibara
- Department of Data Science, Hyogo Medical University, Nishinomiya, Hyogo 663-8501, Japan; Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Hyogo 663-8501, Japan
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Huijberts I, Pinckaers FME, Olthuis SGH, van Kuijk SMJ, Postma AA, Boogaarts HD, Roos YBWEM, Majoie CBLM, van der Lugt A, Dippel DWJ, van Zwam WH, van Oostenbrugge RJ. Collateral-based selection for endovascular treatment of acute ischaemic stroke in the late window (MR CLEAN-LATE): 2-year follow-up of a phase 3, multicentre, open-label, randomised controlled trial in the Netherlands. Lancet Neurol 2024; 23:893-900. [PMID: 38909624 DOI: 10.1016/s1474-4422(24)00228-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 05/22/2024] [Accepted: 05/23/2024] [Indexed: 06/25/2024]
Abstract
BACKGROUND The MR CLEAN-LATE trial provided evidence for the safety and efficacy of endovascular treatment for acute ischaemic stroke within the late window (after 6-24 h) in patients who were preselected based on the presence of collateral flow on CT angiography. We aimed to evaluate clinical outcomes 2 years after randomisation. METHODS MR CLEAN-LATE was a phase 3, multicentre, open-label, blinded-endpoint, randomised controlled trial conducted at 18 stroke intervention centres in the Netherlands. If endovascular treatment could be initiated within 6-24 h of symptom onset or last seen well, patients (aged 18 years or older) with an acute ischaemic stroke due to a large vessel occlusion in the anterior circulation and at least some collateral flow in the affected middle cerebral artery territory on CT angiography were randomly assigned (1:1) to either endovascular treatment with best medical treatment (endovascular treatment group) or best medical treatment alone (control group). Web-based randomisation, stratified by centre, was performed with the use of permuted blocks (block size eight to 20). The researchers who collected clinical outcomes and analysed the results were masked to treatment allocation; treating physicians, local investigators, and patients were aware of the received treatment. The primary outcome of MR CLEAN-LATE was the modified Rankin Scale (mRS) score at 90 days after randomisation. For this 2-year prespecified analysis, the primary outcome was mRS score at 2 years (minus 3 months to plus 6 months). Primary and safety analyses were performed based on the modified intention-to-treat principle, and included patients who provided (deferred) consent or died before consent could be obtained. Missing data were handled with multiple imputation by chained equations. The trial is completed and is registered at ISRCTN, ISRCTN19922220. FINDINGS Between Feb 2, 2018, and Jan 27, 2022, 535 patients were randomly assigned in the MR CLEAN-LATE trial, of whom 502 (94%) gave deferred consent and comprised the modified intention-to-treat population (255 in the endovascular treatment group and 247 in the control group). 261 (52%) patients were female and 241 (48%) were male. Data for mRS score at 2 years were available for 226 (89%) patients in the endovascular treatment group and for 202 (82%) patients in the control group. The median mRS score at 2 years was 4 (IQR 2-6) in the endovascular treatment group and 6 (2-6) in the control group. The endovascular treatment group demonstrated a shift towards better functional outcomes on the mRS (adjusted common odds ratio 1·41 [95% CI 1·00-1·99]; p=0·049). All-cause mortality at 2 years was 34% (87 of 255) in the endovascular treatment group and 41% (101 of 247) in the control group (adjusted hazard ratio 0·81 [95% CI 0·60-1·08]; p=0·15). Major vascular events (ie, transient ischaemic attack, ischaemic stroke, haemorrhagic stroke, and cardiac events) were reported between 90 days and 2 years in 23 patients in the endovascular treatment group and 13 patients in the control group. INTERPRETATION Our results show that the effectiveness of late-window (after 6-24 h) endovascular treatment in improving clinical outcomes is sustained for up to 2 years in a population preselected based on the presence of collateral flow on CT angiography. This finding might be important for prompting further evaluations of cost-effectiveness, health-care policy development, and clinical decision making. FUNDING The Dutch Organization for Health Research and Health Innovation (ZonMW), Collaboration for New Treatments of Acute Stroke Consortium, Dutch Heart Foundation, Stryker, Medtronic, Cerenovus, Health Holland Top Sector Life Sciences & Health, and the Netherlands Brain Foundation.
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Affiliation(s)
- Ilse Huijberts
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, Netherlands; Faculty of Health, Medicine, and Life Sciences, Maastricht University, Maastricht, Netherlands.
| | - Florentina M E Pinckaers
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, Netherlands; School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands; Care and Public Health Research Institute, Maastricht University, Maastricht, Netherlands
| | - Susanne G H Olthuis
- Department of Neurology, Maastricht University Medical Center+, Maastricht, Netherlands; School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Alida A Postma
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, Netherlands; School for Mental Health and Neuroscience, Maastricht University, Maastricht, Netherlands
| | | | - Yvo B W E M Roos
- Department of Neurology, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam Neurosciences, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, Netherlands; School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, Maastricht University Medical Center+, Maastricht, Netherlands; School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
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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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Geraghty JR, Testai FD. Advances in neurovascular research: Scientific highlights from the 2024 international stroke conference. J Stroke Cerebrovasc Dis 2024; 33:107671. [PMID: 38447784 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107671] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Indexed: 03/08/2024] Open
Affiliation(s)
- Joseph R Geraghty
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, 3400 Spruce Street, Philadelphia, PA 19104, USA.
| | - Fernando D Testai
- Department of Neurology & Rehabilitation, University of Illinois College of Medicine, Chicago, IL, USA
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Selman CJ, Lee KJ, Ferguson KN, Whitehead CL, Manley BJ, Mahar RK. Statistical analyses of ordinal outcomes in randomised controlled trials: a scoping review. Trials 2024; 25:241. [PMID: 38582924 PMCID: PMC10998402 DOI: 10.1186/s13063-024-08072-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 03/22/2024] [Indexed: 04/08/2024] Open
Abstract
BACKGROUND Randomised controlled trials (RCTs) aim to estimate the causal effect of one or more interventions relative to a control. One type of outcome that can be of interest in an RCT is an ordinal outcome, which is useful to answer clinical questions regarding complex and evolving patient states. The target parameter of interest for an ordinal outcome depends on the research question and the assumptions the analyst is willing to make. This review aimed to provide an overview of how ordinal outcomes have been used and analysed in RCTs. METHODS The review included RCTs with an ordinal primary or secondary outcome published between 2017 and 2022 in four highly ranked medical journals (the British Medical Journal, New England Journal of Medicine, The Lancet, and the Journal of the American Medical Association) identified through PubMed. Details regarding the study setting, design, the target parameter, and statistical methods used to analyse the ordinal outcome were extracted. RESULTS The search identified 309 studies, of which 144 were eligible for inclusion. The most used target parameter was an odds ratio, reported in 78 (54%) studies. The ordinal outcome was dichotomised for analysis in 47 ( 33 % ) studies, and the most common statistical model used to analyse the ordinal outcome on the full ordinal scale was the proportional odds model (64 [ 44 % ] studies). Notably, 86 (60%) studies did not explicitly check or describe the robustness of the assumptions for the statistical method(s) used. CONCLUSIONS The results of this review indicate that in RCTs that use an ordinal outcome, there is variation in the target parameter and the analytical approaches used, with many dichotomising the ordinal outcome. Few studies provided assurance regarding the appropriateness of the assumptions and methods used to analyse the ordinal outcome. More guidance is needed to improve the transparent reporting of the analysis of ordinal outcomes in future trials.
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Affiliation(s)
- Chris J Selman
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia.
- Department of Paediatrics, University of Melbourne, Parkville, VIC, 3052, Australia.
| | - Katherine J Lee
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Kristin N Ferguson
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Clare L Whitehead
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
- Department of Maternal Fetal Medicine, The Royal Women's Hospital, Parkville, VIC, 3052, Australia
| | - Brett J Manley
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
- Newborn Research, The Royal Women's Hospital, Parkville, VIC, 3052, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
| | - Robert K Mahar
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, VIC, 3052, Australia
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Pinckaers FME, Grutters JPC, Huijberts I, Gabrio A, Boogaarts HD, Postma AA, van Oostenbrugge RJ, van Zwam WH, Evers SMAA. Cost and Utility Estimates per Modified Rankin Scale Score up to 2 Years Post Stroke: Data to Inform Economic Evaluations From a Societal Perspective. VALUE IN HEALTH : THE JOURNAL OF THE INTERNATIONAL SOCIETY FOR PHARMACOECONOMICS AND OUTCOMES RESEARCH 2024; 27:441-448. [PMID: 38244981 DOI: 10.1016/j.jval.2024.01.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Revised: 11/22/2023] [Accepted: 01/02/2024] [Indexed: 01/22/2024]
Abstract
OBJECTIVES Model-based health economic evaluations of ischemic stroke are in need of cost- and utility estimates related to relevant outcome measures. This study aims to describe societal cost- and utility estimates per modified Rankin Scale (mRS)-score at different time points within 2 years post stroke. METHODS Included patients had a stroke between 3 months and 2.5 years ago. mRS and EQ-5D-5L were scored during a telephone interview. Based on the interview date, records were categorized into a time point: 3 months (3M; 3-6 months), 1 year (Y1; 6-18 months), or 2 years (Y2; 18-30 months). Patients completed a questionnaire on healthcare utilization and productivity losses in the previous 3 months. Initial stroke hospitalization costs were assessed. Mean costs and utilities per mRS and time point were derived with multiple imputation nested in bootstrapping. Cost at 3 months post stroke were estimated separately for endovascular treatment (EVT)-/non-EVT-patients. RESULTS 1106 patients were included from 18 Dutch centers. At each time point, higher mRS-scores were associated with increasing average costs and decreasing average utility. Mean societal costs at 3M ranged from €11 943 (mRS 1, no EVT) to €55 957 (mRS 5, no EVT). For Y1, mean costs in the previous 3 months ranged from €885 (mRS 0) to €23 215 (mRS 5), and from €1655 (mRS 0) to €22 904 (mRS 5) for Y2. Mean utilities ranged from 0.07 to 0.96, depending on mRS and time point. CONCLUSIONS The mRS-score is a major determinant of costs and utilities at different post-stroke time points. Our estimates may be used to inform future model-based health economic evaluations.
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Affiliation(s)
- Florentina M E Pinckaers
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands; School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands; Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands.
| | | | - Ilse Huijberts
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands; School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Andrea Gabrio
- Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands; Department of Methodology and Statistics, Maastricht University, Maastricht, The Netherlands
| | | | - Alida A Postma
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands; School for Mental Health and Neuroscience (MHENS), Maastricht University, Maastricht, The Netherlands
| | - Robert J van Oostenbrugge
- School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands; Department of Neurology, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands; School for Cardiovascular Diseases (CARIM), Maastricht University, Maastricht, The Netherlands
| | - Silvia M A A Evers
- Care and Public Health Research Institute (CAPHRI), Maastricht University, Maastricht, The Netherlands; Department of Health Services Research, Maastricht University, Maastricht, The Netherlands; Centre of Economic Evaluation and Machine Learning, Trimbos Institute, Utrecht, The Netherlands
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8
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Heitkamp C, Winkelmeier L, Heit JJ, Albers GW, Lansberg MG, Kniep H, Broocks G, Stracke CP, Schell M, Guenego A, Paech D, Wintermark M, Fiehler J, Faizy TD. Early neurological deterioration in patients with acute ischemic stroke is linked to unfavorable cerebral venous outflow. Eur Stroke J 2024; 9:162-171. [PMID: 38069665 PMCID: PMC10916832 DOI: 10.1177/23969873231208277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 09/29/2023] [Indexed: 03/06/2024] Open
Abstract
INTRODUCTION Early neurological deterioration (END) is associated with poor outcomes in patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO). Causes of END after mechanical thrombectomy (MT) include unsuccessful recanalization and reperfusion hemorrhages. However, little is known about END excluding the aforementioned causes. We aimed to investigate factors associated with unexplained END (ENDunexplained) with regard to the cerebral collateral status. PATIENTS AND METHODS Multicenter retrospective study of AIS-LVO patients with successful MT (mTICI 2b-3). On admission CT angiography (CTA), pial arterial collaterals and venous outflow (VO) were assessed using the modified Tan-Scale and the Cortical Vein Opacification Score (COVES), respectively. ENDunexplained was defined as an increase in NIHSS score of ⩾ 4 within the first 24 hours after MT without parenchymal hemorrhage on follow-up imaging. Multivariable regression analyses were performed to examine factors of ENDunexplained and unfavorable functional outcome (modified Rankin Scale score 3-6). RESULTS A total of 620 patients met the inclusion criteria. ENDunexplained occurred in 10% of patients. While there was no significant difference in pial arterial collaterals, patients with ENDunexplained exhibited more often unfavorable VO (81% vs. 53%; P < 0.001). Unfavorable VO (aOR [95% CI]; 2.56 [1.02-6.40]; P = 0.045) was an independent predictor of ENDunexplained. ENDunexplained was independently associated with unfavorable functional outcomes at 90 days (aOR [95% CI]; 6.25 [2.06-18.94]; P = 0.001). DISCUSSION AND CONCLUSION Unfavorable VO on admission CTA was associated with ENDunexplained. ENDunexplained was independently linked to unfavorable functional outcomes at 90 days. Identifying AIS-LVO patients at risk of ENDunexplained may help to select patients for intensified monitoring and guide to optimal treatment regimes.
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Affiliation(s)
- Christian Heitkamp
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Laurens Winkelmeier
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Gregory W Albers
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Maarten G Lansberg
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Helge Kniep
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Gabriel Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Christian Paul Stracke
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
- Department of Neuroradiology, University Hospital Muenster, Muenster, Germany
| | - Maximilian Schell
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Germany
| | - Adrien Guenego
- Department of Neuroradiology, Erasme Medical Center, Brussels, Belgium
| | - Daniel Paech
- Clinic for Neuroradiology, University Hospital Bonn, Germany
| | - Max Wintermark
- Department of Neuroradiology, MD Anderson, Houston, TX, USA
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
| | - Tobias D Faizy
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany
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9
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Zhang M, Che R, Xu J, Guo W, Chen X, Zhao W, Ren C, Jia M, Ji X. Long term for patients with futile endovascular reperfusion after stroke. CNS Neurosci Ther 2024; 30:e14588. [PMID: 38475869 PMCID: PMC10933383 DOI: 10.1111/cns.14588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Revised: 12/06/2023] [Accepted: 12/20/2023] [Indexed: 03/14/2024] Open
Abstract
AIMS With the progress of thrombectomy technology, the vascular recanalization rate of patients with stroke has been continuously improved, but the proportion of futile recanalization (FR) is still quite a few. The long-term prognosis and survival of patients with FR and its influencing factors remain unclear. METHODS Consecutive patients who received endovascular treatment (EVT) for ischemic stroke were enrolled between 2013 and 2021 from a single-center prospectively registry study. We evaluated the long-term outcome of these patients by Kaplan-Meier survival analysis, and the multivariable logistic regression curve was performed to analyze influencing factors. RESULTS Among 458 patients with FR, 56.4% of patients survived at 1 year, and 50.4% at 2 years. In the multivariate regression analysis, age, premorbid modified Rankin Scale (mRS), National Institutes of Health Stroke Scale (NIHSS), posterior circulation infarct, general anesthesia, symptomatic intracerebral hemorrhage (sICH), and decompressive craniectomy were found to be related to unfavorable outcomes in long-term. Age, premorbid mRS, NIHSS, general anesthesia, and sICH were predictors of long-term mortality. CONCLUSIONS Futile recanalization accounts for a large proportion of stroke patients after thrombectomy. This study on the long-term prognosis of such patients is beneficial to the formulation of treatment plans and the prediction of therapeutic effects.
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Affiliation(s)
- Mengke Zhang
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Ruiwen Che
- Department of Neurology, Beijing ShiJiTan HospitalCapital Medical UniversityBeijingChina
| | - Jiali Xu
- Department of Rehabilitation Medicine, Beijing ShiJiTan HospitalCapital Medical UniversityBeijingChina
| | - Wenting Guo
- Department of NeurologyZhejiang Provincial People's HospitalZhejiangChina
| | - Xi Chen
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Wenbo Zhao
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Changhong Ren
- Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Milan Jia
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Xunming Ji
- Beijing Key Laboratory of Hypoxia Conditioning Translational Medicine, Xuanwu HospitalCapital Medical UniversityBeijingChina
- Department of Neurosurgery, Xuanwu HospitalCapital Medical UniversityBeijingChina
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10
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Sarraj A, Abraham MG, Hassan AE, Blackburn S, Kasner SE, Ortega-Gutierrez S, Hussain MS, Chen M, Johns H, Churilov L, Pujara DK, Shaker F, Maali L, Cardona Portela P, Herial NA, Gibson D, Kozak O, Arenillas JF, Yan B, Pérez de la Ossa N, Sundararajan S, Hu YC, Cordato DJ, Manning NW, Hanel RA, Aghaebrahim AN, Budzik RF, Hicks WJ, Blasco J, Wu TY, Tsai JP, Schaafsma JD, Gandhi CD, Al-Mufti F, Sangha N, Warach S, Kleinig TJ, Yogendrakumar V, Ng F, Samaniego EA, Abdulrazzak MA, Parsons MW, Rahbar MH, Nguyen TN, Fifi JT, Mendes Pereira V, Lansberg MG, Albers GW, Furlan AJ, Jabbour P, Sitton CW, Sila C, Bambakidis N, Davis SM, Wechsler L, Hill MD, Grotta JC, Ribo M, Campbell BCV. Endovascular thrombectomy plus medical care versus medical care alone for large ischaemic stroke: 1-year outcomes of the SELECT2 trial. Lancet 2024; 403:731-740. [PMID: 38346442 DOI: 10.1016/s0140-6736(24)00050-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Revised: 12/29/2023] [Accepted: 01/09/2024] [Indexed: 02/26/2024]
Abstract
BACKGROUND Multiple randomised trials have shown efficacy and safety of endovascular thrombectomy in patients with large ischaemic stroke. The aim of this study was to evaluate long-term (ie, at 1 year) evidence of benefit of thrombectomy for these patients. METHODS SELECT2 was a phase 3, open-label, international, randomised controlled trial with blinded endpoint assessment, conducted at 31 hospitals in the USA, Canada, Spain, Switzerland, Australia, and New Zealand. Patients aged 18-85 years with ischaemic stroke due to proximal occlusion of the internal carotid artery or of the first segment of the middle cerebral artery, showing large ischaemic core on non-contrast CT (Alberta Stroke Program Early Computed Tomographic Score of 3-5 [range 0-10, with lower values indicating larger infarctions]) or measuring 50 mL or more on CT perfusion and MRI, were randomly assigned, within 24 h of ischaemic stroke onset, to thrombectomy plus medical care or to medical care alone. The primary outcome for this analysis was the ordinal modified Rankin Scale (range 0-6, with higher scores indicating greater disability) at 1-year follow-up in an intention-to-treat population. The trial is registered at ClinicalTrials.gov (NCT03876457) and is completed. FINDINGS The trial was terminated early for efficacy at the 90-day follow-up after 352 patients had been randomly assigned (178 to thrombectomy and 174 to medical care only) between Oct 11, 2019, and Sept 9, 2022. Thrombectomy significantly improved the 1-year modified Rankin Scale score distribution versus medical care alone (Wilcoxon-Mann-Whitney probability of superiority 0·59 [95% CI 0·53-0·64]; p=0·0019; generalised odds ratio 1·43 [95% CI 1·14-1·78]). At the 1-year follow-up, 77 (45%) of 170 patients receiving thrombectomy had died, compared with 83 (52%) of 159 patients receiving medical care only (1-year mortality relative risk 0·89 [95% CI 0·71-1·11]). INTERPRETATION In patients with ischaemic stroke due to a proximal occlusion and large core, thrombectomy plus medical care provided a significant functional outcome benefit compared with medical care alone at 1-year follow-up. FUNDING Stryker Neurovascular.
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Affiliation(s)
- Amrou Sarraj
- Department of Neurology, University Hospital Cleveland Medical Center, Cleveland, OH, USA; Department of Neurology, Case Western Reserve University, Cleveland, OH, USA.
| | - Michael G Abraham
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Ameer E Hassan
- Department of Neuroscience, Valley Baptist Medical Center, Harlingen, TX, USA
| | - Spiros Blackburn
- Department of Neurosurgery, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Scott E Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Santiago Ortega-Gutierrez
- Department of Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | - Michael Chen
- Department of Neurosurgery, Rush University Medical Center, Chicago, IL, USA
| | - Hannah Johns
- Department of Medicine and Neurology, University of Melbourne, Parkville, VC, Australia
| | - Leonid Churilov
- Department of Medicine and Neurology, University of Melbourne, Parkville, VC, Australia
| | - Deep K Pujara
- Department of Neurology, University Hospital Cleveland Medical Center, Cleveland, OH, USA; Department of Neurology, Case Western Reserve University, Cleveland, OH, USA
| | - Faris Shaker
- Department of Neurosurgery, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Laith Maali
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | | | - Nabeel A Herial
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Daniel Gibson
- Department of Neurosurgery, Ascension Wisconsin, Indianapolis, IN, USA
| | - Osman Kozak
- Department of Neurosurgery, Abington Jefferson Health, Abington, PA, USA
| | - Juan F Arenillas
- Department of Internal Medicine, Hospital Clínico Universitario Valladolid-University of Valladolid, Valladolid, Spain
| | - Bernard Yan
- Department of Medicine and Neurology, University of Melbourne, Parkville, VC, Australia; Department of Internal Medicine and Neurology, Melbourne Brain Center-The Royal Melbourne Hospital, Parkville, VC, Australia
| | | | - Sophia Sundararajan
- Department of Neurology, University Hospital Cleveland Medical Center, Cleveland, OH, USA; Department of Neurology, Case Western Reserve University, Cleveland, OH, USA
| | - Yin C Hu
- Department of Neurosurgery, University Hospital Cleveland Medical Center, Cleveland, OH, USA; Department of Neurosurgery, Case Western Reserve University, Cleveland, OH, USA
| | - Dennis J Cordato
- Department of Neurology, Liverpool Hospital, Liverpool, NSW, Australia
| | - Nathan W Manning
- Department of Neurosurgery, Ingham Institute, Liverpool, NSW, Australia
| | - Ricardo A Hanel
- Department of Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, FL, USA
| | - Amin N Aghaebrahim
- Department of Neurosurgery, Baptist Medical Center Jacksonville, Jacksonville, FL, USA
| | - Ronald F Budzik
- Department of Neuro-Interventional Radiology, OhioHealth-Riverside Methodist Hospital, Columbus, OH, USA
| | - William J Hicks
- Department of Neurology, OhioHealth-Riverside Methodist Hospital, Columbus, OH, USA
| | - Jordi Blasco
- Department of Interventional Radiology, Hospital Clínic de Barcelona, Barcelona, Spain
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Jenny P Tsai
- Cerebrovascular Center, Cleveland Clinic, Cleveland, OH, USA
| | - Joanna D Schaafsma
- Department of Internal Medicine, Toronto Western Hospital, Toronto, ON, Canada
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center-NY Medical College, Valhalla, NY, USA
| | - Fawaz Al-Mufti
- Department of Neurosurgery, Westchester Medical Center-NY Medical College, Valhalla, NY, USA
| | - Navdeep Sangha
- Department of Neurology, Kaiser Permanente Southern California, Los Angeles, CA, USA
| | - Steven Warach
- Department of Neurology, Dell Medical School at The University of Texas at Austin-Ascension Texas, Austin, TX, USA
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Vignan Yogendrakumar
- Department of Internal Medicine and Neurology, Melbourne Brain Center-The Royal Melbourne Hospital, Parkville, VC, Australia
| | - Felix Ng
- Department of Internal Medicine and Neurology, Melbourne Brain Center-The Royal Melbourne Hospital, Parkville, VC, Australia
| | - Edgar A Samaniego
- Department of Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | - Mark W Parsons
- Department of Neurology, Liverpool Hospital, Liverpool, NSW, Australia
| | - Mohammad H Rahbar
- Department of Internal Medicine, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, Boston, MA, USA
| | - Johanna T Fifi
- Department of Neurology, Icahn School of Medicine at Mount Sinai, New York City, NY, USA
| | | | | | - Greg W Albers
- Department of Neurology, Stanford University, Stanford, CA, USA
| | - Anthony J Furlan
- Department of Neurology, University Hospital Cleveland Medical Center, Cleveland, OH, USA; Department of Neurology, Case Western Reserve University, Cleveland, OH, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Clark W Sitton
- Department of Interventional and Diagnostic Imaging, McGovern Medical School at UTHealth, Houston, TX, USA
| | - Cathy Sila
- Department of Neurology, University Hospital Cleveland Medical Center, Cleveland, OH, USA; Department of Neurology, Case Western Reserve University, Cleveland, OH, USA
| | - Nicholas Bambakidis
- Department of Neurosurgery, University Hospital Cleveland Medical Center, Cleveland, OH, USA; Department of Neurosurgery, Case Western Reserve University, Cleveland, OH, USA
| | - Stephen M Davis
- Department of Internal Medicine and Neurology, Melbourne Brain Center-The Royal Melbourne Hospital, Parkville, VC, Australia
| | - Lawrence Wechsler
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Michael D Hill
- Department of Clinical Neuroscience, University of Calgary, Calgary, AB, Canada
| | - James C Grotta
- Mobile Stroke Unit, Memorial Hermann Hospital, Houston, TX, USA
| | - Marc Ribo
- Department of Neurology, Hospital Vall d'Hebrón, Barcelona, Spain
| | - Bruce C V Campbell
- Department of Medicine and Neurology, University of Melbourne, Parkville, VC, Australia; Department of Internal Medicine and Neurology, Melbourne Brain Center-The Royal Melbourne Hospital, Parkville, VC, Australia; Department of Medicine and Neurology, The Florey Institute for Neuroscience and Mental Health, Parkville, VC, Australia
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11
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Consoli A, Gory B. Long-term results of mechanical thrombectomy for large ischaemic stroke. Lancet 2024; 403:700-701. [PMID: 38346443 DOI: 10.1016/s0140-6736(24)00158-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Accepted: 01/25/2024] [Indexed: 02/26/2024]
Affiliation(s)
- Arturo Consoli
- Diagnostic and Interventional Neuroradiology, Foch Hospital, University of Versailles Saint-Quentin-des-Yvelines, Suresnes 92150, France.
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, INSERM U1254, CHRU-Nancy, Université de Lorraine, Nancy, France
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12
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Zhang Q, Yang S, Cheng XD, Sun H, Li BH, Yu NW. Cerebral blood volume index can predict the long-term prognosis after endovascular thrombectomy in patients with acute ischemic stroke due to large vessel occlusion. J Clin Neurosci 2023; 117:120-124. [PMID: 37801876 DOI: 10.1016/j.jocn.2023.09.030] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 09/13/2023] [Accepted: 09/29/2023] [Indexed: 10/08/2023]
Abstract
Long-term prognosis and factors influencing endovascular therapy (EVT) remain unclear. This study aimed to investigate the association between computed tomography perfusion (CTP) parameters and long-term prognosis of patients with acute ischemic stroke (AIS) treated with EVT. Patients with AIS due to large vessel occlusion treated with EVT were prospectively included for a 1-year follow-up. All patients and their data were grouped based on the hypoperfusion intensity ratio (HIR, <0.3 vs. ≥ 0.3) and cerebral blood volume (CBV) index (>0.7 vs. ≤ 0.7). The primary outcome was favorable prognosis, defined as a modified Rankin Scale (mRS) score of 0-2. Multivariate logistic regression was used to analyze factors influencing long-term favorable prognosis. Of 69 patients included, 35 (50.7 %) achieved mRS 0-2 at one year. A favorable prognosis was observed predominantly in patients with higher CBV index (75.0 % vs. 34.1 %, p= 0.001) and lower HIR (72.0 % vs. 38.6 %, p=0.008). In the multivariate logistic regression, CBV index (odds ratio (OR) = 4.362; 95 % confidence interval (CI): 1.052, 18.082; p = 0.042), baseline National Institutes of Health Stroke Scale (NIHSS) score (OR = 0.913; 95 % CI: 0.836, 0.997; p = 0.044), and symptomatic intracranial hemorrhage (sICH) (OR = 0.089; 95 % CI: 0.009, 0.925; p = 0.043) were independently associated with a long-term favorable prognosis. The CBV index may serve as a predictor of the long-term prognosis of patients treated with EVT. The novel finding is that the baseline NIHSS score and sICH were associated with long-term prognosis.
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Affiliation(s)
- Qi Zhang
- School of Clinical Medicine, University of Electronic Science and Technology of China, Chengdu 610054, China; Department of Neurology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, The Afliated Hospital of University of Electronic Science and Technology of China, Chengdu 610072, China
| | - Shu Yang
- Department of Neurology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, The Afliated Hospital of University of Electronic Science and Technology of China, Chengdu 610072, China
| | - Xu-Dong Cheng
- Department of Neurology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, The Afliated Hospital of University of Electronic Science and Technology of China, Chengdu 610072, China
| | - Hui Sun
- Department of Emergency, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, The Afliated Hospital of University of Electronic Science and Technology of China, Chengdu 610072, China
| | - Bing-Hu Li
- Department of Neurology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, The Afliated Hospital of University of Electronic Science and Technology of China, Chengdu 610072, China.
| | - Neng-Wei Yu
- School of Clinical Medicine, University of Electronic Science and Technology of China, Chengdu 610054, China; Department of Neurology, Sichuan Academy of Medical Sciences and Sichuan Provincial People's Hospital, The Afliated Hospital of University of Electronic Science and Technology of China, Chengdu 610072, China.
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13
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Nguyen CP, Lahr MMH, van der Zee DJ, van Voorst H, Ribo M, Roos YBWM, van den Wijngaard I, Buskens E, Uyttenboogaart M. Cost-effectiveness of Direct Transfer to Angiography Suite of Patients With Suspected Large Vessel Occlusion. Neurology 2023; 101:e1036-e1045. [PMID: 37438129 PMCID: PMC10491438 DOI: 10.1212/wnl.0000000000207583] [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: 02/07/2023] [Accepted: 05/10/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Patients with acute ischemic stroke due to large vessel occlusion (LVO) deemed eligible for endovascular thrombectomy (EVT) are transferred from the emergency room to the angiography suite to undergo the procedure. Recently, the strategy of direct transfer of patients with suspected LVO to the angiography suite (DTAS) has been shown to improve functional outcomes. This study aims to evaluate the cost-effectiveness of the DTAS strategy vs initial transfer of patients with suspected LVO (Rapid Arterial Occlusion Evaluation score >4 and NIH Stroke Scale >10) to the emergency room (ITER). METHODS A decision-analytic Markov model was developed to estimate the cost-effectiveness of the DTAS strategy vs the ITER strategy from a Dutch health care perspective with a 10-year time horizon. The primary outcome was the incremental cost-effectiveness ratio (ICER) using Dutch thresholds of $59,135 (€50,000) and $94,616 (€80,000) per quality-adjusted life year (QALY). Uncertainty of input parameters was assessed using 1-way sensitivity analysis, scenario analysis, and probabilistic sensitivity analysis. RESULTS The DTAS strategy yielded 0.65 additional QALYs at an additional $16,089, resulting in an ICER of $24,925/QALY compared with the ITER strategy. The ICER varied from $27,169 to $38,325/QALY across different scenarios. The probabilistic sensitivity analysis showed that the DTAS strategy had a 91.8% and 97.0% likelihood of being cost-effective at a decision threshold of $59,135/QALY and $94,616/QALY, respectively. DISCUSSION The cost-effectiveness of the DTAS strategy over ITER is robust for patients with suspected LVO. Together with recently published clinical results, this means that implementation of the DTAS strategy may be considered to improve the workflow and outcome of EVT.
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Affiliation(s)
- Chi P Nguyen
- From the Department of Operations (C.P.N., D.-J.v.d.Z., E.B.), Faculty of Economics and Business, University of Groningen; Health Technology Assessment (C.P.N., M.M.H.L., D.-J.v.d.Z., E.B.), Department of Epidemiology, and Departments of Neurology (M.U.), and Radiology, Medical Imaging Center (M.U.), University of Groningen, University Medical Center Groningen, the Netherlands; Department of Pharmaceutical Administration and Economics (C.P.N.), Hanoi University of Pharmacy, Vietnam; Departments of Radiology and Nuclear Medicine (H.v.V.), Biomedical Engineering and Physics (H.v.V.), and Neurology (Y.B.W.M.R.), Amsterdam University Medical Center, the Netherlands; Unitat d'Ictus (M.R.), Servei de Neurologia, Hospital Universitari Vall d'Hebron, Spain; Department of Neurology (I.v.d.W.), Haaglanden Medical Center; and Department of Neurology (I.v.d.W.), Leiden University Medical Center.
| | - Maarten M H Lahr
- From the Department of Operations (C.P.N., D.-J.v.d.Z., E.B.), Faculty of Economics and Business, University of Groningen; Health Technology Assessment (C.P.N., M.M.H.L., D.-J.v.d.Z., E.B.), Department of Epidemiology, and Departments of Neurology (M.U.), and Radiology, Medical Imaging Center (M.U.), University of Groningen, University Medical Center Groningen, the Netherlands; Department of Pharmaceutical Administration and Economics (C.P.N.), Hanoi University of Pharmacy, Vietnam; Departments of Radiology and Nuclear Medicine (H.v.V.), Biomedical Engineering and Physics (H.v.V.), and Neurology (Y.B.W.M.R.), Amsterdam University Medical Center, the Netherlands; Unitat d'Ictus (M.R.), Servei de Neurologia, Hospital Universitari Vall d'Hebron, Spain; Department of Neurology (I.v.d.W.), Haaglanden Medical Center; and Department of Neurology (I.v.d.W.), Leiden University Medical Center
| | - Durk-Jouke van der Zee
- From the Department of Operations (C.P.N., D.-J.v.d.Z., E.B.), Faculty of Economics and Business, University of Groningen; Health Technology Assessment (C.P.N., M.M.H.L., D.-J.v.d.Z., E.B.), Department of Epidemiology, and Departments of Neurology (M.U.), and Radiology, Medical Imaging Center (M.U.), University of Groningen, University Medical Center Groningen, the Netherlands; Department of Pharmaceutical Administration and Economics (C.P.N.), Hanoi University of Pharmacy, Vietnam; Departments of Radiology and Nuclear Medicine (H.v.V.), Biomedical Engineering and Physics (H.v.V.), and Neurology (Y.B.W.M.R.), Amsterdam University Medical Center, the Netherlands; Unitat d'Ictus (M.R.), Servei de Neurologia, Hospital Universitari Vall d'Hebron, Spain; Department of Neurology (I.v.d.W.), Haaglanden Medical Center; and Department of Neurology (I.v.d.W.), Leiden University Medical Center
| | - Henk van Voorst
- From the Department of Operations (C.P.N., D.-J.v.d.Z., E.B.), Faculty of Economics and Business, University of Groningen; Health Technology Assessment (C.P.N., M.M.H.L., D.-J.v.d.Z., E.B.), Department of Epidemiology, and Departments of Neurology (M.U.), and Radiology, Medical Imaging Center (M.U.), University of Groningen, University Medical Center Groningen, the Netherlands; Department of Pharmaceutical Administration and Economics (C.P.N.), Hanoi University of Pharmacy, Vietnam; Departments of Radiology and Nuclear Medicine (H.v.V.), Biomedical Engineering and Physics (H.v.V.), and Neurology (Y.B.W.M.R.), Amsterdam University Medical Center, the Netherlands; Unitat d'Ictus (M.R.), Servei de Neurologia, Hospital Universitari Vall d'Hebron, Spain; Department of Neurology (I.v.d.W.), Haaglanden Medical Center; and Department of Neurology (I.v.d.W.), Leiden University Medical Center
| | - Marc Ribo
- From the Department of Operations (C.P.N., D.-J.v.d.Z., E.B.), Faculty of Economics and Business, University of Groningen; Health Technology Assessment (C.P.N., M.M.H.L., D.-J.v.d.Z., E.B.), Department of Epidemiology, and Departments of Neurology (M.U.), and Radiology, Medical Imaging Center (M.U.), University of Groningen, University Medical Center Groningen, the Netherlands; Department of Pharmaceutical Administration and Economics (C.P.N.), Hanoi University of Pharmacy, Vietnam; Departments of Radiology and Nuclear Medicine (H.v.V.), Biomedical Engineering and Physics (H.v.V.), and Neurology (Y.B.W.M.R.), Amsterdam University Medical Center, the Netherlands; Unitat d'Ictus (M.R.), Servei de Neurologia, Hospital Universitari Vall d'Hebron, Spain; Department of Neurology (I.v.d.W.), Haaglanden Medical Center; and Department of Neurology (I.v.d.W.), Leiden University Medical Center
| | - Yvo B W M Roos
- From the Department of Operations (C.P.N., D.-J.v.d.Z., E.B.), Faculty of Economics and Business, University of Groningen; Health Technology Assessment (C.P.N., M.M.H.L., D.-J.v.d.Z., E.B.), Department of Epidemiology, and Departments of Neurology (M.U.), and Radiology, Medical Imaging Center (M.U.), University of Groningen, University Medical Center Groningen, the Netherlands; Department of Pharmaceutical Administration and Economics (C.P.N.), Hanoi University of Pharmacy, Vietnam; Departments of Radiology and Nuclear Medicine (H.v.V.), Biomedical Engineering and Physics (H.v.V.), and Neurology (Y.B.W.M.R.), Amsterdam University Medical Center, the Netherlands; Unitat d'Ictus (M.R.), Servei de Neurologia, Hospital Universitari Vall d'Hebron, Spain; Department of Neurology (I.v.d.W.), Haaglanden Medical Center; and Department of Neurology (I.v.d.W.), Leiden University Medical Center
| | - Ido van den Wijngaard
- From the Department of Operations (C.P.N., D.-J.v.d.Z., E.B.), Faculty of Economics and Business, University of Groningen; Health Technology Assessment (C.P.N., M.M.H.L., D.-J.v.d.Z., E.B.), Department of Epidemiology, and Departments of Neurology (M.U.), and Radiology, Medical Imaging Center (M.U.), University of Groningen, University Medical Center Groningen, the Netherlands; Department of Pharmaceutical Administration and Economics (C.P.N.), Hanoi University of Pharmacy, Vietnam; Departments of Radiology and Nuclear Medicine (H.v.V.), Biomedical Engineering and Physics (H.v.V.), and Neurology (Y.B.W.M.R.), Amsterdam University Medical Center, the Netherlands; Unitat d'Ictus (M.R.), Servei de Neurologia, Hospital Universitari Vall d'Hebron, Spain; Department of Neurology (I.v.d.W.), Haaglanden Medical Center; and Department of Neurology (I.v.d.W.), Leiden University Medical Center
| | - Erik Buskens
- From the Department of Operations (C.P.N., D.-J.v.d.Z., E.B.), Faculty of Economics and Business, University of Groningen; Health Technology Assessment (C.P.N., M.M.H.L., D.-J.v.d.Z., E.B.), Department of Epidemiology, and Departments of Neurology (M.U.), and Radiology, Medical Imaging Center (M.U.), University of Groningen, University Medical Center Groningen, the Netherlands; Department of Pharmaceutical Administration and Economics (C.P.N.), Hanoi University of Pharmacy, Vietnam; Departments of Radiology and Nuclear Medicine (H.v.V.), Biomedical Engineering and Physics (H.v.V.), and Neurology (Y.B.W.M.R.), Amsterdam University Medical Center, the Netherlands; Unitat d'Ictus (M.R.), Servei de Neurologia, Hospital Universitari Vall d'Hebron, Spain; Department of Neurology (I.v.d.W.), Haaglanden Medical Center; and Department of Neurology (I.v.d.W.), Leiden University Medical Center
| | - Maarten Uyttenboogaart
- From the Department of Operations (C.P.N., D.-J.v.d.Z., E.B.), Faculty of Economics and Business, University of Groningen; Health Technology Assessment (C.P.N., M.M.H.L., D.-J.v.d.Z., E.B.), Department of Epidemiology, and Departments of Neurology (M.U.), and Radiology, Medical Imaging Center (M.U.), University of Groningen, University Medical Center Groningen, the Netherlands; Department of Pharmaceutical Administration and Economics (C.P.N.), Hanoi University of Pharmacy, Vietnam; Departments of Radiology and Nuclear Medicine (H.v.V.), Biomedical Engineering and Physics (H.v.V.), and Neurology (Y.B.W.M.R.), Amsterdam University Medical Center, the Netherlands; Unitat d'Ictus (M.R.), Servei de Neurologia, Hospital Universitari Vall d'Hebron, Spain; Department of Neurology (I.v.d.W.), Haaglanden Medical Center; and Department of Neurology (I.v.d.W.), Leiden University Medical Center
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14
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Hunter RM. The Cost-effectiveness of Improving the Timeliness of Endovascular Thrombectomy by Direct Access to Angiography: Making Time Equal Money. Neurology 2023; 101:422-423. [PMID: 37438125 DOI: 10.1212/wnl.0000000000207729] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 06/15/2023] [Indexed: 07/14/2023] Open
Affiliation(s)
- Rachael Maree Hunter
- From the Department of Applied Health Research, Institute of Epidemiology and Health Care, University College London, United Kingdom.
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15
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Zhou J, Wei Q, Hu H, Liu W, Guan X, Ma A, Wang L. A systematic review and meta-analysis of health utility values among patients with ischemic stroke. Front Neurol 2023; 14:1219679. [PMID: 37731850 PMCID: PMC10507900 DOI: 10.3389/fneur.2023.1219679] [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: 05/09/2023] [Accepted: 08/16/2023] [Indexed: 09/22/2023] Open
Abstract
Purpose Ischemic stroke (IS) has a considerable impact on the health-related quality of life (HRQoL) of patients. A systematic review was conducted to summarize and synthesize the HRQoL reported from IS patients. Methods An electronic search was performed in PubMed, Web of Science, ScienceDirect, Embase, and Cochrane Library databases from inception to February 2022 for studies measuring utility values in IS patients. Basic information about the studies, patient characteristics, measurement of the utility values, and utility values were extracted and summarized. Utility values were pooled according to the time of evaluation, and disease severity was classified with modified Rankin Scale (mRS) scores. The quality of the studies was assessed according to key criteria recommended by the National Institute for Health and Care Excellence. Results A total of 39 studies comprising 30,853 participants were included in the study. Measured with EQ-5D-3L, the pooled utility values were 0.42 [95% confidential interval (CI): 0.13 to 0.71], 0.55 (95% CI: 0.43 to 0.68), 0.65 (95% CI: 0.52 to 0.78), 0.60 (95% CI: 0.43 to 0.78), and 0.67 (95% CI: 0.60 to 0.74) for patients diagnosed with IS within 1, 3, 6, 12, and 24 months or above among poststroke patients. Four studies reported utility values classified by mRS scores where synthesized estimates stratified by mRS scores ranged from 0.91 (95% CI: 0.85 to 0.97) for patients with an mRS score of 1 to-0.04 (95% CI:-0.18 to 0.11) for those with an mRS score of 5. As for the health dimension profiles, usual activity was the most impacted dimension, while self-care was the least impacted one. Conclusion This study indicated that the utility values in IS patients kept increasing from stroke onset and became relatively stabilized at 6 months poststroke. Health utility values decreased significantly as mRS scores increased. These results facilitate economic evaluations in utility retrieval and selection. Further exploration was required regarding the factors that affect the HRQoL of IS patients.
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Affiliation(s)
| | | | | | | | | | - Aixia Ma
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
| | - Luying Wang
- School of International Pharmaceutical Business, China Pharmaceutical University, Nanjing, China
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16
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Nguyen CP, Lahr MMH, van der Zee DJ, van Voorst H, Roos YBWEM, Uyttenboogaart M, Buskens E. Cost-effectiveness of tenecteplase versus alteplase for acute ischemic stroke. Eur Stroke J 2023; 8:638-646. [PMID: 37641549 PMCID: PMC10472948 DOI: 10.1177/23969873231174943] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 04/24/2023] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION Alteplase is widely used as an intravenous thrombolytic drug in acute ischemic stroke (AIS). Recently however, tenecteplase, a modified form of tissue plasminogen activator, has been shown to increase early recanalization rate and has proven to be non-inferior with a similar safety profile compared to alteplase. This study aims to evaluate the cost-effectiveness of 0.25 mg/kg tenecteplase versus 0.9 mg/kg alteplase for intravenous thrombolysis in AIS patients from the Dutch healthcare payer perspective. METHODS A Markov decision-analytic model was constructed to assess total costs, total quality-adjusted life year (QALY), an incremental cost-effectiveness ratio, and incremental net monetary benefit (INMB) of two treatments at willingness-to-pay (WTP) thresholds of €50,000/QALY and €80,000/QALY over a 10-year time horizon. One-way sensitivity analysis, probabilistic sensitivity analysis, and scenario analysis were conducted to test the robustness of results. Clinical data were obtained from large randomized controlled trials and real-world data. RESULTS Treatment with tenecteplase saved €21 per patient while gaining 0.05 QALYs, resulting in INMB of €2381, clearly rendering tenecteplase cost-effective compared to alteplase. Importantly, tenecteplase remained the cost-effective alternative in all scenarios, including AIS patients due to large vessel occlusion (LVO). Probabilistic sensitivity analysis proved tenecteplase to be cost-effective with a 71.0% probability at a WTP threshold of €50,000/QALY. CONCLUSIONS Tenecteplase treatment was cost-effective for all AIS patients (including AIS patients with LVO) compared to alteplase. The finding supports the broader use of tenecteplase in acute stroke care, as health outcomes improve at acceptable costs while having practical advantages, and a similar safety profile.
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Affiliation(s)
- Chi Phuong Nguyen
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Pharmaceutical Management and Economic, Hanoi University of Pharmacy, Vietnam
| | - Maarten MH Lahr
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Durk-Jouke van der Zee
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Henk van Voorst
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Location University of Amsterdam, Amsterdam, The Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Center, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Yvo BWEM Roos
- Department of Neurology, Amsterdam University Medical Center, Location University of Amsterdam, Amsterdam, The Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
- Department of Radiology, Medical Imaging Center, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Erik Buskens
- Department of Operations, Faculty of Economics and Business, University of Groningen, Groningen, The Netherlands
- Health Technology Assessment, Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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17
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van den Berg LA, Berkhemer OA, Fransen PSS, Beumer D, Majoie CBL, Dippel DWJ, van der Lugt A, van Oostenbrugge RJ, van Zwam WH, Roos YB, Dijkgraaf MGW. Budget impact of endovascular treatment for acute ischaemic stroke patients in the Netherlands for 2015-2021. Neth Heart J 2023; 31:254-259. [PMID: 37171711 DOI: 10.1007/s12471-023-01788-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/24/2023] [Indexed: 05/13/2023] Open
Abstract
INTRODUCTION Endovascular treatment (EVT) has been proven to be both effective and cost-effective for patients with acute ischaemic stroke. We investigated the budget impact of large-scale implementation of EVT for acute ischaemic stroke patients in the Netherlands for 2015-2021. METHODS An analysis was performed from a healthcare perspective as a preplanned substudy of the Multicenter Randomized Clinical trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN). Estimated yearly costs during follow-up after stroke for patients who had or had not been treated with EVT as add-on to usual care were linked to numbers of new patients retrieved from 2 Dutch registries of EVT that started after the last inclusion in MR CLEAN (2014). Aggregated costs and costs per care sector were calculated based on prevalence using a population dynamic tool. RESULTS From 2015, the yearly number of new acute ischaemic stroke patients receiving EVT increased almost threefold, from 812 in 2015 to 2,370 in 2021. The introduction of EVT plus usual care resulted in estimated net annual savings that increased from € 2.9 million in 2015 to € 58 million in 2021. CONCLUSION Offering EVT as add-on to usual care for acute ischaemic stroke patients was increasingly cost saving from a national healthcare perspective but affected distinct healthcare sectors differently.
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Affiliation(s)
- Lucie A van den Berg
- Department of Neurology, Amsterdam University Medical Centres, location Academic Medical Centre, Amsterdam, The Netherlands.
- Department of Epidemiology and Data Science, Amsterdam University Medical Centres, location Academic Medical Centre, Amsterdam, The Netherlands.
- Amsterdam Neuroscience Research Institute, Neurovascular disorders research programme, Amsterdam University Medical Centres, location Academic Medical Centre, Amsterdam, The Netherlands.
- Amsterdam Cardiovascular Sciences Research Institute, Atherosclerosis and Ischemic syndromes, Amsterdam University Medical Centres, location Academic Medical Centre, Amsterdam, The Netherlands.
- Microcirculation research programme, Amsterdam University Medical Centres, location Academic Medical Centre, Amsterdam, The Netherlands.
- Amsterdam Public Health Research Institute, Methodology research programme, Amsterdam University Medical Centres, location Academic Medical Centre, Amsterdam, The Netherlands.
| | - Olvert A Berkhemer
- Amsterdam Neuroscience Research Institute, Neurovascular disorders research programme, Amsterdam University Medical Centres, location Academic Medical Centre, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Atherosclerosis and Ischemic syndromes, Amsterdam University Medical Centres, location Academic Medical Centre, Amsterdam, The Netherlands
- Microcirculation research programme, Amsterdam University Medical Centres, location Academic Medical Centre, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Methodology research programme, Amsterdam University Medical Centres, location Academic Medical Centre, Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centres, location Academic Medical Centre, Amsterdam, The Netherlands
| | - Puck S S Fransen
- Departments of Neurology, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Debbie Beumer
- Departments of Neurology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Charles B L Majoie
- Amsterdam Neuroscience Research Institute, Neurovascular disorders research programme, Amsterdam University Medical Centres, location Academic Medical Centre, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Atherosclerosis and Ischemic syndromes, Amsterdam University Medical Centres, location Academic Medical Centre, Amsterdam, The Netherlands
- Microcirculation research programme, Amsterdam University Medical Centres, location Academic Medical Centre, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Methodology research programme, Amsterdam University Medical Centres, location Academic Medical Centre, Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centres, location Academic Medical Centre, Amsterdam, The Netherlands
| | - Diederik W J Dippel
- Departments of Neurology, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Aad van der Lugt
- Radiology and Nuclear Medicine, Erasmus University Medical Centre Rotterdam, Rotterdam, The Netherlands
| | - Robert J van Oostenbrugge
- Departments of Neurology, Maastricht University Medical Centre, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Wim H van Zwam
- Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht, Maastricht, The Netherlands
| | - Yvo B Roos
- Department of Neurology, Amsterdam University Medical Centres, location Academic Medical Centre, Amsterdam, The Netherlands
- Department of Epidemiology and Data Science, Amsterdam University Medical Centres, location Academic Medical Centre, Amsterdam, The Netherlands
- Amsterdam Neuroscience Research Institute, Neurovascular disorders research programme, Amsterdam University Medical Centres, location Academic Medical Centre, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences Research Institute, Atherosclerosis and Ischemic syndromes, Amsterdam University Medical Centres, location Academic Medical Centre, Amsterdam, The Netherlands
- Microcirculation research programme, Amsterdam University Medical Centres, location Academic Medical Centre, Amsterdam, The Netherlands
- Amsterdam Public Health Research Institute, Methodology research programme, Amsterdam University Medical Centres, location Academic Medical Centre, Amsterdam, The Netherlands
| | - Marcel G W Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam University Medical Centres, location Academic Medical Centre, Amsterdam, The Netherlands
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18
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Meerwaldt AE, Straathof M, Oosterveld W, van Heijningen CL, van Leent MMT, Toner YC, Munitz J, Teunissen AJP, Daemen CC, van der Toorn A, van Vliet G, van Tilborg GAF, De Feyter HM, de Graaf RA, Hol EM, Mulder WJM, Dijkhuizen RM. In vivo imaging of cerebral glucose metabolism informs on subacute to chronic post-stroke tissue status - A pilot study combining PET and deuterium metabolic imaging. J Cereb Blood Flow Metab 2023; 43:778-790. [PMID: 36606595 PMCID: PMC10108187 DOI: 10.1177/0271678x221148970] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 11/04/2022] [Accepted: 11/21/2022] [Indexed: 01/07/2023]
Abstract
Recanalization therapy after acute ischemic stroke enables restoration of cerebral perfusion. However, a significant subset of patients has poor outcome, which may be caused by disruption of cerebral energy metabolism. To assess changes in glucose metabolism subacutely and chronically after recanalization, we applied two complementary imaging techniques, fluorodeoxyglucose (FDG) positron emission tomography (PET) and deuterium (2H) metabolic imaging (DMI), after 60-minute transient middle cerebral artery occlusion (tMCAO) in C57BL/6 mice. Glucose uptake, measured with FDG PET, was reduced at 48 hours after tMCAO and returned to baseline value after 11 days. DMI revealed effective glucose supply as well as elevated lactate production and reduced glutamate/glutamine synthesis in the lesion area at 48 hours post-tMCAO, of which the extent was dependent on stroke severity. A further decrease in oxidative metabolism was evident after 11 days. Immunohistochemistry revealed significant glial activation in and around the lesion, which may play a role in the observed metabolic profiles. Our findings indicate that imaging (altered) active glucose metabolism in and around reperfused stroke lesions can provide substantial information on (secondary) pathophysiological changes in post-ischemic brain tissue.
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Affiliation(s)
- Anu E Meerwaldt
- Biomedical MR Imaging and
Spectroscopy Group, Center for Image Sciences, University Medical Center
Utrecht/Utrecht University, Utrecht, Netherlands
- BioMedical Engineering and Imaging
Institute, Icahn School of Medicine at Mount Sinai, New York, USA
- Diagnostic, Molecular and
Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY,
USA
| | - Milou Straathof
- Biomedical MR Imaging and
Spectroscopy Group, Center for Image Sciences, University Medical Center
Utrecht/Utrecht University, Utrecht, Netherlands
| | - Wija Oosterveld
- Biomedical MR Imaging and
Spectroscopy Group, Center for Image Sciences, University Medical Center
Utrecht/Utrecht University, Utrecht, Netherlands
| | - Caroline L van Heijningen
- Biomedical MR Imaging and
Spectroscopy Group, Center for Image Sciences, University Medical Center
Utrecht/Utrecht University, Utrecht, Netherlands
| | - Mandy MT van Leent
- BioMedical Engineering and Imaging
Institute, Icahn School of Medicine at Mount Sinai, New York, USA
- Diagnostic, Molecular and
Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY,
USA
| | - Yohana C Toner
- BioMedical Engineering and Imaging
Institute, Icahn School of Medicine at Mount Sinai, New York, USA
- Diagnostic, Molecular and
Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY,
USA
- Department of Internal Medicine and
Radboud Center for Infectious Diseases, Radboud University Medical Center,
Nijmegen, Netherlands
| | - Jazz Munitz
- BioMedical Engineering and Imaging
Institute, Icahn School of Medicine at Mount Sinai, New York, USA
- Diagnostic, Molecular and
Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY,
USA
| | - Abraham JP Teunissen
- BioMedical Engineering and Imaging
Institute, Icahn School of Medicine at Mount Sinai, New York, USA
- Diagnostic, Molecular and
Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY,
USA
- Cardiovascular Research Institute,
Icahn School of Medicine at Mount Sinai, New York, USA
- Icahn Genomics Institute, Icahn
School of Medicine at Mount Sinai, New York, USA
| | - Charlotte C Daemen
- Department of Translational
Neuroscience, University Medical Center Utrecht Brain Center, Utrecht
University, Utrecht, The Netherlands
| | - Annette van der Toorn
- Biomedical MR Imaging and
Spectroscopy Group, Center for Image Sciences, University Medical Center
Utrecht/Utrecht University, Utrecht, Netherlands
| | - Gerard van Vliet
- Biomedical MR Imaging and
Spectroscopy Group, Center for Image Sciences, University Medical Center
Utrecht/Utrecht University, Utrecht, Netherlands
| | - Geralda AF van Tilborg
- Biomedical MR Imaging and
Spectroscopy Group, Center for Image Sciences, University Medical Center
Utrecht/Utrecht University, Utrecht, Netherlands
| | - Henk M De Feyter
- Department of Radiology and
Biomedical Imaging, Magnetic Resonance Research Center, Yale University School
of Medicine, New Haven, CT, USA
| | - Robin A de Graaf
- Department of Radiology and
Biomedical Imaging, Magnetic Resonance Research Center, Yale University School
of Medicine, New Haven, CT, USA
- Department of Biomedical
Engineering, Yale University School of Medicine, New Haven, CT, USA
| | - Elly M Hol
- Department of Translational
Neuroscience, University Medical Center Utrecht Brain Center, Utrecht
University, Utrecht, The Netherlands
| | - Willem JM Mulder
- BioMedical Engineering and Imaging
Institute, Icahn School of Medicine at Mount Sinai, New York, USA
- Diagnostic, Molecular and
Interventional Radiology, Icahn School of Medicine at Mount Sinai, New York, NY,
USA
- Department of Internal Medicine and
Radboud Center for Infectious Diseases, Radboud University Medical Center,
Nijmegen, Netherlands
- Department of Chemical Biology,
Eindhoven University of Technology, Eindhoven, Netherlands
| | - Rick M Dijkhuizen
- Biomedical MR Imaging and
Spectroscopy Group, Center for Image Sciences, University Medical Center
Utrecht/Utrecht University, Utrecht, Netherlands
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19
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Karamchandani RR, Satyanarayana S, Yang H, Rhoten JB, Strong D, Patel NM, Clemente JD, Defilipp G, Bernard JD, Stetler WR, Parish JM, Asimos AW. The Charlotte Large Artery Occlusion Endovascular Therapy Outcome Score Predicts Poor Outcomes 1 Year After Endovascular Thrombectomy. World Neurosurg 2023; 173:e415-e421. [PMID: 36805504 DOI: 10.1016/j.wneu.2023.02.066] [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: 11/08/2022] [Revised: 02/12/2023] [Accepted: 02/13/2023] [Indexed: 02/22/2023]
Abstract
OBJECTIVE We evaluated the ability of several outcome prognostic scales to predict poor 1-year outcomes and mortality after endovascular thrombectomy. METHODS In this retrospective analysis from the stroke registry of a large integrated health system, consecutive patients presenting from August 2020 to September 2021 with an anterior circulation large-vessel occlusion stroke treated with endovascular thrombectomy were included. Multivariable logistic regression was performed to determine the ability of each scale to predict the primary outcome (1-year modified Rankin Scale [mRS] score of 4-6) and the secondary outcome (1-year mortality). Area under the curve analyses were performed for each scale. RESULTS In 237 included patients (mean age 68 [±15] years; median National Institutes of Health Stroke Scale score 16 [11-21]), poor 1-year outcomes were present in 116 patients (49%) and 1-year mortality was 34%. The CLEOS (Charlotte Large Artery Occlusion Endovascular Therapy Outcome Score), which incorporates age, baseline National Institutes of Health Stroke Scale score, initial glucose level, and computed tomography perfusion cerebral blood volume index, had a significant association with poor 1-year outcomes (per 25-point increase; odds ratio, 1.0134; P = 0.02). CLEOS and PRE (Pittsburgh Response to Endovascular Therapy) were both significantly associated with 1-year mortality. Area under the curve values were comparable for CLEOS, PRE, Houston Intra-Arterial Therapy 2, and Totaled Health Risks in Vascular Events to predict 1-year mRS score 4-6 and mortality. Only 1 of 18 patients with CLEOS ≥690 had a 1-year mRS score of 0-3. CONCLUSIONS CLEOS can predict poor 1-year outcomes and mortality for patients with anterior circulation large-vessel occlusion using prethrombectomy variables.
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Affiliation(s)
- Rahul R Karamchandani
- Department of Neurology, Neurosciences Institute, Atrium Health, Charlotte, North Carolina, USA.
| | - Sagar Satyanarayana
- Information and Analytics Services, Atrium Health, Charlotte, North Carolina, USA
| | - Hongmei Yang
- Information and Analytics Services, Atrium Health, Charlotte, North Carolina, USA
| | - Jeremy B Rhoten
- Department of Neurology, Neurosciences Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Dale Strong
- Information and Analytics Services, Atrium Health, Charlotte, North Carolina, USA
| | - Nikhil M Patel
- Department of Internal Medicine, Pulmonary and Critical Care, Neurosciences Institute, Charlotte, North Carolina, USA
| | - Jonathan D Clemente
- Charlotte Radiology, Neurosciences Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Gary Defilipp
- Charlotte Radiology, Neurosciences Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Joe D Bernard
- Carolina Neurosurgery and Spine Associates, Neurosciences Institute, Atrium Health, Charlotte, North Carolina, USA
| | - William R Stetler
- Carolina Neurosurgery and Spine Associates, Neurosciences Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Jonathan M Parish
- Carolina Neurosurgery and Spine Associates, Neurosciences Institute, Atrium Health, Charlotte, North Carolina, USA
| | - Andrew W Asimos
- Department of Emergency Medicine, Neurosciences Institute, Atrium Health, Charlotte, North Carolina, USA
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20
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Weller JM, Dorn F, Meissner JN, Stösser S, Beckonert NM, Nordsiek J, Kindler C, Deb-Chatterji M, Petzold GC, Bode FJ. Endovascular thrombectomy in young patients with stroke. Int J Stroke 2023; 18:453-461. [PMID: 35912650 DOI: 10.1177/17474930221119602] [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: 11/15/2022]
Abstract
BACKGROUND Endovascular treatment (ET) is standard of care in patients with acute ischemic stroke due to large vessel occlusion, but data on ET in young patients remain limited. AIM We aim to compare outcomes for young stroke patients undergoing ET in a matched cohort. METHODS We analyzed patients from an observational multicenter cohort with acute ischemic stroke and ET, the German Stroke Registry-Endovascular Treatment trial. Baseline characteristics, procedural parameters, and functional outcome at 90 days were compared between young (<50 years) and older (⩾50 years) patients with and without nearest-neighbor 1:1 propensity score matching. RESULTS Out of 6628 acute ischemic stroke patients treated with ET, 363 (5.5%) were young. Young patients differed with regard to prognostic outcome characteristics. Specifically, National Institutes of Health Stroke Scale (NIHSS) at admission was lower (median 13, interquartile range (IQR) 8-17 vs. 15, IQR 9-19, p < 0.001), and prestroke dependence was less frequent (2.9% vs. 12.2%, p < 0.001) than in older patients. Compared to a matched cohort of older patients, ET was faster (time from groin puncture to flow restoration, 35 vs. 45 min, p < 0.001) and intracranial hemorrhage was less frequent in young patients (10.0% vs. 25.9%, p < 0.001). Good functional outcome (modified Rankin Scale (mRS) 0-2) at 3 months was achieved more frequently in young patients (71.6% vs. 44.1%, p < 0.001), and overall mortality was lower (6.7% vs. 25.4%, p < 0.001). Among previously employed young patients (n = 177), 37.9% returned to work at 3-month follow-up, while 74.1% of the remaining patients were still undergoing rehabilitation. CONCLUSION Young stroke patients undergoing ET have better outcomes compared to older patients, even when matched for prestroke condition, comorbidities, and stroke severity. Hence, more liberal guidelines to perform ET for younger patients may have to be established by future studies.
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Affiliation(s)
- Johannes M Weller
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Franziska Dorn
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Julius N Meissner
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Sebastian Stösser
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Niklas M Beckonert
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Julia Nordsiek
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Christine Kindler
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Gabor C Petzold
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Felix J Bode
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
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Sallustio F, Mascolo AP, Marrama F, D'Agostino F, Proietti M, Greco L, Di Giuliano F, Alemseged F, Gandini R, Martorana A, Diomedi M, Koch G. Temporal lobe atrophy as a potential predictor of functional outcome in older adults with acute ischemic stroke. Acta Neurol Belg 2023:10.1007/s13760-022-02167-w. [PMID: 36637792 DOI: 10.1007/s13760-022-02167-w] [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: 08/19/2022] [Accepted: 12/15/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND To explore whether temporal lobe atrophy predicts 3-month functional outcome in a population of patients with anterior circulation acute ischemic stroke (AIS) treated with mechanical thrombectomy (MT). METHODS We retrospectively selected patients > 65 years from our prospective endovascular stroke registry between June 2013 and August 2018. According to 3-month modified Rankin Scale (mRS), patients were divided in two groups, named good (mRS ≤ 2) and poor (mRS > 2) outcome. Measures of temporal lobe atrophy (i.e., interuncal distance [IUD], medial temporal lobe thickness [mTLT] and radial width of temporal horn [rWTH]) were assessed on pre-treatment CT scan. Cutoff values for good outcome were obtained for IUD, mTLT and rWTH by means of non-parametric ROC curve analysis. Multivariate analysis was performed to identify predictors of outcome. Ordinal shift analysis based on cutoff values was built to evaluate differences in 3-month mRS. RESULTS Among 340 patients, 130 (38.2%) had good and 210 (61.8%) had poor outcome. We found the following cutoff values for good outcome: < 25 mm for IUD, > 15 mm for mTLT and < 4 mm for rWTH. Lower IUD (OR 0.71; 95% CI 0.63-0.80; p < 0.0001) and rWTH (OR 0.73; 95% CI 0.61-0.87; p < 0.0001) and higher mTLT (OR 1.30; 95% CI 1.14-1.49; p < 0.0001) were independently associated with good outcome. Ordinal shift analysis based on cutoff values revealed significant differences in the rate of good outcome for rWTH (49 vs 27%; p < 0.0001), mTLT (52 vs 21%; p < 0.0001) and IUD (57 vs 17%; p < 0.0001). CONCLUSIONS Assessment of temporal lobe atrophy may predict functional outcome in patients with AIS treated with MT.
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Affiliation(s)
- Fabrizio Sallustio
- Comprehensive Stroke Center, Department of Systems Medicine, University of Tor Vergata, Viale Oxford 81, 00133, Rome, Italy. .,Department of Clinical and Behavioural Neurology, Santa Lucia Foundation IRCCS, 0039, Rome, Italy.
| | - Alfredo Paolo Mascolo
- Comprehensive Stroke Center, Department of Systems Medicine, University of Tor Vergata, Viale Oxford 81, 00133, Rome, Italy
| | - Federico Marrama
- Comprehensive Stroke Center, Department of Systems Medicine, University of Tor Vergata, Viale Oxford 81, 00133, Rome, Italy
| | - Federica D'Agostino
- Comprehensive Stroke Center, Department of Systems Medicine, University of Tor Vergata, Viale Oxford 81, 00133, Rome, Italy
| | - Marco Proietti
- Department of Clinical Sciences and Community Health, University of Milan, Milan, Italy.,Geriatric Unit, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Laura Greco
- Diagnostic Neuroradiology Unit, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Francesca Di Giuliano
- Diagnostic Neuroradiology Unit, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Fana Alemseged
- Comprehensive Stroke Center, Department of Systems Medicine, University of Tor Vergata, Viale Oxford 81, 00133, Rome, Italy.,Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Roberto Gandini
- Diagnostic Neuroradiology Unit, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Alessandro Martorana
- Comprehensive Stroke Center, Department of Systems Medicine, University of Tor Vergata, Viale Oxford 81, 00133, Rome, Italy
| | - Marina Diomedi
- Comprehensive Stroke Center, Department of Systems Medicine, University of Tor Vergata, Viale Oxford 81, 00133, Rome, Italy
| | - Giacomo Koch
- Department of Clinical and Behavioural Neurology, Santa Lucia Foundation IRCCS, 0039, Rome, Italy.,Department of Psychology, eCampus University, Novedrate, Italy
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22
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Junttola U, Lahtinen S, Isokangas JM, Hietanen S, Vakkala M, Kaakinen T, Liisanantti J. Long-term mortality after endovascular thrombectomy for stroke. J Stroke Cerebrovasc Dis 2022; 31:106832. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 09/28/2022] [Accepted: 10/10/2022] [Indexed: 11/06/2022] Open
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Safety and Efficacy of Tirofiban in Severe Ischemic Stroke Patients Undergoing Mechanical Thrombectomy. J Cardiovasc Dev Dis 2022; 9:jcdd9110408. [PMID: 36421943 PMCID: PMC9699197 DOI: 10.3390/jcdd9110408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/02/2022] [Revised: 11/12/2022] [Accepted: 11/15/2022] [Indexed: 11/23/2022] Open
Abstract
Tirofiban has recently shown encouraging efficacy and safety among acute ischemic stroke (AIS) patients with mechanical thrombectomy (MT). However, the benefits of tirofiban varied among studies depending on the patient’s condition, which was often not well analyzed. This study aimed to identify the characteristics of patients who may obtain the largest benefits from tirofiban. The efficacy endpoint was a favorable outcome defined as a modified Rankin Scale (mRS) score of 0~2 at 90 days. The safety endpoints were intracranial hemorrhage (ICH), symptomatic intracranial hemorrhage (sICH) and mortality at 90 days. Adjusted logistic regression analysis and subgroup analyses were utilized to investigate the factors associated with tirofiban and the outcome. All of 285 patients fit the inclusion criteria. Tirofiban was associated with a higher rate of favorable outcome (aOR 2.033, 95% CI, 1.002~4.123, p = 0.043) but not with an increased risk of ICH, sICH or mortality (p > 0.05). Moreover, subgroup analyses revealed that tirofiban was associated with favorable outcomes in patients with NIHSS > 14 (aOR 2.778, 95% CI 1.056~7.356, p = 0.038) but not in patients with NIHSS ≤ 14 (aOR 1.719, 95% CI 0.646~4.578, p = 0.278). No significant heterogeneity was found in the effect of tirofiban across the subgroups of age, sex, ASPECTS, time from onset to puncture, use of t-PA or stroke etiology (p for interaction > 0.05). The administration of tirofiban was associated with favorable outcomes in severe ischemic stroke patients, and further studies are needed to confirm this finding.
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24
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Aihara M, Shimizu T, Yamaguchi R, Aishima K, Shimauchi H, Wada H, Shintoku R, Yoshimoto Y. Evaluation of Occluded Distal Vessels with Variable Flip-Angle 3-Dimensional Turbo Spin-Echo Magnetic Resonance Imaging Before Acute Mechanical Thrombectomy. World Neurosurg 2022; 167:9-16. [PMID: 36030009 DOI: 10.1016/j.wneu.2022.08.085] [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: 07/26/2022] [Accepted: 08/17/2022] [Indexed: 11/29/2022]
Abstract
OBJECTIVE The aim of this study was to evaluate the course of occluded distal vessels before mechanical thrombectomy (MT) for acute large vessel occlusion (LVO) with non-contrast magnetic resonance imaging (MRI). The variable flip-angle three-dimensional turbo spin-echo (VRFA-3D-TSE) method was used to evaluate the course of occluded distal vessels quickly and clearly in acute LVO cases before MT. METHODS Patients with acute LVO who were indicated for MT between April 2021 and March 2022 were examined by the VRFA-3D-TSE method to evaluate the distal course of occluded vessels. We included internal carotid artery (ICA) occlusion, M1 occlusion of the middle cerebral artery, and basilar artery (BA) occlusion. Preoperative images were compared to the angiographic findings after recanalization or with follow-up magnetic resonance angiography, and the results were assessed by 2 endovascular treatment specialists as excellent, good, or poor imaging. RESULTS MT was performed in a total of 27 patients. There were 17 patients with intracranial occlusion of the ICA, M1, and BA. Occlusion was found in the intracranial ICA in 6 patients, the M1 in 7, and the BA in 4. VRFA-3D-TSE MRI was performed in all patients, and the imaging was rated (by the 2assessors) as excellent in 12 of 17 and 14 of 17 cases, good in 5 of 17 and 3 of 17 cases, and poor in 0 of 17 cases. CONCLUSIONS In patients with acute LVO, VRFA-3D-TSE MRI enabled rapid and good depiction of the course of occluded distal vessels before MT without the use of contrast medium.
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Affiliation(s)
- Masanori Aihara
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan.
| | - Tatsuya Shimizu
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Rei Yamaguchi
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Kaoru Aishima
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Hiroya Shimauchi
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Hajime Wada
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Ryosuke Shintoku
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
| | - Yuhei Yoshimoto
- Department of Neurosurgery, Gunma University Graduate School of Medicine, Maebashi, Gunma, Japan
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Blanco S, Martínez-Lara E, Siles E, Peinado MÁ. New Strategies for Stroke Therapy: Nanoencapsulated Neuroglobin. Pharmaceutics 2022; 14:pharmaceutics14081737. [PMID: 36015363 PMCID: PMC9412405 DOI: 10.3390/pharmaceutics14081737] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2022] [Revised: 08/15/2022] [Accepted: 08/17/2022] [Indexed: 01/12/2023] Open
Abstract
Stroke is a global health and socio-economic problem. However, no efficient preventive and/or palliative treatments have yet been found. Neuroglobin (Ngb) is an endogen neuroprotective protein, but it only exerts its beneficial action against stroke after increasing its basal levels. Therefore, its systemic administration appears to be an efficient therapy applicable to stroke and other neurodegenerative pathologies. Unfortunately, Ngb cannot cross the blood-brain barrier (BBB), making its direct pharmacological use unfeasible. Thus, the association of Ngb with a drug delivery system (DDS), such as nanoparticles (NPs), appears to be a good strategy for overcoming this handicap. NPs are a type of DDS which efficiently transport Ngb and increase its bioavailability in the infarcted area. Hence, we previously built hyaluronate NPS linked to Ngb (Ngb-NPs) as a therapeutic tool against stroke. This nanoformulation induced an improvement of the cerebral infarct prognosis. However, this innovative therapy is still in development, and a more in-depth study focusing on its long-lasting neuroprotectant and neuroregenerative capabilities is needed. In short, this review aims to update the state-of-the-art of stroke therapies based on Ngb, paying special attention to the use of nanotechnological drug-delivering tools.
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26
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Gong C, Huang J, Kong W, Li F, Liu C, Yang J, Liu S, Qiu Z, Lin M, Guo Z, Yan Z, Huang X, Zhang S, Ling W, Zhou P, Wang Z, Liu Y, Xue D, Zhong Y, Yang S, Wan Y, Fang J, Huang W, Liu H, Luo J, Li R, Wen C, Fu X, Tu M, Wang L, Tian X, Peng H, Wu Z, Zeng G, Zi W, Yang Q. Five-Year Outcomes After Endovascular Treatment for Large Vessel Occlusion Stroke. Front Neurosci 2022; 16:920731. [PMID: 35911988 PMCID: PMC9326078 DOI: 10.3389/fnins.2022.920731] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Accepted: 06/20/2022] [Indexed: 11/13/2022] Open
Abstract
Background The long-term outcomes of acute large vessel occlusion (LVO) in anterior circulation treated by endovascular treatment (EVT) remains to be determined. The aim of this study was to assess the 5-year outcomes of patients with LVO who underwent EVT. Methods This study was an observational, nationwide registry of consecutive patients with acute LVO who received EVT in 28 comprehensive stroke centers in China. The primary outcome was the proportion of favorable outcome [modified Rankin Scale score (mRS) 0–2] at 5 years. Secondary outcomes included proportions of patients with excellent outcome (mRS 0–1), all-cause mortality and risk of stroke recurrence at 5 years. Results A total of 807 patients were included into the study and had 90-day follow-up data, 657 patients had 5-year follow-up data. At 90 days, 218 patients (27.0%) had an excellent outcome, 349 patients (43.2%) had a favorable functional outcome. 199 patients (24.7%) died. At 5 years, 190 patients (28.9%) had an excellent outcome, 261 patients (39.7%) had a favorable functional outcome, 317 patients (48.2%) died and 129 (28.2%) had stroke recurrence. Because of missing 5-year follow-up data, among available 269 patients who achieved functional independence at 90 days, 208 (77.3%) maintained favorable outcome, 19 (7.1%) had disability (mRS 3–5) and 42 (15.6%) died at 5 years. Furthermore, among available 189 patients with mRS 3–5 at 90 days, 53 (28.0%) patients achieved favorable functional outcome, 60 (31.7%) patients maintained unfavorable functional outcome and 76 (40.2%) patients died within 5 years. Multivariate analyses identified that younger age [odds ratio (OR): 0.96; 95% CI, 0.93–0.99; P = 0.009], lower mRS at 90 days (OR: 0.15; 95% CI, 0.10–0.23; P < 0.001) and absence of stroke recurrence (OR: 0.001; 95% CI, 0.000–0.006; P < 0.001) were significantly associated with favorable outcome at 5 years. Advanced age (OR: 1.06, 95% CI, 1.04–1.08; P < 0.001), higher mRS at 90 days (OR: 0.84; 95% CI, 0.73–0.98; P = 0.021) and atrial fibrillation (OR: 1.63; 95% CI, 1.02–2.60; P = 0.04) were independent factors for stroke recurrence. Conclusion Our results indicated that the beneficial effect of EVT in patients with acute LVO can be sustained during the course of at least 5 years. Reducing the risk of stroke recurrence by anticoagulation for atrial fibrillation may be a crucial strategy to improve long-term outcome.
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Affiliation(s)
- Changxiong Gong
- 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
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Chang Liu
- 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
| | - Shuai Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Zhongming Qiu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Min Lin
- Department of Neurology, The Second Affiliated Hospital and Fujian University of Traditional Chinese Medicine, Fuzhou, China
- Department of Neurology, The 900th Hospital of The People’s Liberation Army, Fuzhou, China
| | - Zhangbao Guo
- Department of Neurology, Wuhan No. 1 Hospital, Wuhan, China
| | - Zhizhong Yan
- Department of Neurosurgery, The 904th Hospital of The People’s Liberation Army, Wuxi, China
| | - Xianjun Huang
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Shuai Zhang
- Department of Neurology, The Affiliated Hospital of Yangzhou University, Yangzhou, China
| | - Wentong Ling
- Department of Neurology, Zhongshan People’s Hospital, Zhongshan, China
| | - Peiyang Zhou
- Department of Neurology, The First People’s Hospital of Xiangyang and Hubei Medical University, Xiangyang, China
| | - Zhen Wang
- Department of Neurology, Changsha Central Hospital, Changsha, China
| | - Yong Liu
- Department of Neurology, Lu’an Affiliated Hospital of Anhui Medical University, Lu’an, China
| | - Dongzhang Xue
- Department of Neurology, The 902th Hospital of The People’s Liberation Army, Bengbu, China
| | - Yaoyi Zhong
- Department of Neurology, The 175th Hospital of The People’s Liberation Army, Zhangzhou, China
| | - Shu Yang
- Department of Neurology, Sichuan Provincial People’s Hospital, Chengdu, China
| | - Yue Wan
- Department of Neurology, Hubei Zhongshan Hospital, Wuhan, China
| | - Jiayang Fang
- Department of Neurology, The 476th Hospital of The People’s Liberation Army, Fuzhou, China
| | - Wenguo Huang
- Department of Neurology, Chinese Medical Hospital of Maoming, Maoming, China
| | - Huihui Liu
- Department of Neurology and Suzhou Clinical Research Center of Neurological Disease, Second Affiliated Hospital of Soochow, Suzhou, China
| | - Jun Luo
- Department of Neurology, Sichuan Mianyang 404 Hospital, Mianyang, China
| | - Rongzhong Li
- Department of Neurology, The 924th Hospital of The People’s Liberation Army, Guilin, China
| | - Changming Wen
- Department of Neurology, Nanyang Central Hospital, Nanyang, China
| | - Xinmin Fu
- Department of Neurology, Xuzhou Central Hospital, Xuzhou, China
| | - Mingyi Tu
- Department of Neurology, Hubei Wuchang Hospital, Wuhan, China
| | - Li Wang
- Department of Neurology, The Third People’s Hospital of Zigong, Zigong, China
| | - Xiguang Tian
- Department of Neurology, The Chinese Armed Police Force Guangdong Armed Police Corps Hospital, Guangzhou, China
| | - Huiyuan Peng
- Department of Neurology, Chinese Medical Hospital of Zhongshan, Zhongshan, China
| | - Zhilin Wu
- Department of Neurology, Yunfu People’s Hospital, Yunfu, China
| | - Guoyong Zeng
- Department of Neurology, Ganzhou People’s Hospital, Ganzhou, China
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
- *Correspondence: Wenjie Zi,
| | - Qingwu Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
- Qingwu Yang,
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Volovici V, Vogels VI, Dammers R, Meling TR. Neurosurgical Evidence and Randomized Trials: The Fragility Index. World Neurosurg 2022; 161:224-229.e14. [DOI: 10.1016/j.wneu.2021.12.096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Accepted: 12/26/2021] [Indexed: 10/18/2022]
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Beyeler M, Weber L, Kurmann CC, Piechowiak EII, Mosimann PJ, Zibold F, Meinel TR, Branca M, Goeldlin M, Pilgram-Pastor SM, Grunder L, Arnold M, Seiffge D, Meier R, Heldner MR, Dobrocky T, Mordasini P, Gralla J, Fischer U, Kaesmacher J. Association of reperfusion success and emboli in new territories with long term mortality after mechanical thrombectomy. J Neurointerv Surg 2022; 14:326-332. [PMID: 33911015 DOI: 10.1136/neurintsurg-2021-017422] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Revised: 04/13/2021] [Accepted: 04/14/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND The degree of reperfusion is the most important modifiable predictor of 3 month functional outcome and mortality in ischemic stroke patients treated with mechanical thrombectomy. Whether the beneficial effect of reperfusion also leads to a reduction in long term mortality is unknown. METHODS Patients undergoing mechanical thrombectomy between January 2010 and December 2018 were included. The post-thrombectomy degree of reperfusion and emboli in new territories were core laboratory adjudicated. Reperfusion was evaluated according to the expanded Thrombolysis in Cerebral Infarction (eTICI) scale. Vital status was obtained from the Swiss population register. Adjusted hazard ratios (aHRs) using time split Cox regression models were calculated. Subgroup analyses were performed in patients with borderline indications. RESULTS Our study included 1264 patients (median follow-up per patient 2.5 years). Patients with successful reperfusion had longer survival times, attributable to a lower hazard of death within 0-90 days and for >90 days to 2 years (aHR 0.34, 95% CI 0.26 to 0.46; aHR 0.37, 95% CI 0.22 to 0.62). This association was homogeneous across all predefined subgroups (p for interaction >0.05). Among patients with successful reperfusion, a significant difference in the hazard of death was observed between eTICI2b50 and eTICI3 (aHR 0.51, 95% CI 0.33 to 0.79). Emboli in new territories were present in 5% of patients, and were associated with increased mortality (aHR 2.3, 95% CI 1.11 to 4.86). CONCLUSION Successful, and ideally complete, reperfusion without emboli in new territories is associated with a reduction in long term mortality in patients treated with mechanical thrombectomy, and this was evident across several subgroups.
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Affiliation(s)
- Morin Beyeler
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Loris Weber
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Christoph C Kurmann
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Eike Immo I Piechowiak
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Pascal J Mosimann
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
- Department of Diagnostic and Interventional Neuroradiology, Alfried-Krupp Krankenhaus, Essen, Nordrhein-Westfalen, Germany
| | - Felix Zibold
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Thomas Raphael Meinel
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Mattia Branca
- Institute of Social and Preventive Medicine, CTU Bern, University of Bern, Switzerland, Bern, Switzerland
| | - Martina Goeldlin
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Sara M Pilgram-Pastor
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Lorenz Grunder
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - David Seiffge
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Raphael Meier
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
- Support Center for Advanced Neuroimaging, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Mirjam R Heldner
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Tomas Dobrocky
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
| | - Johannes Kaesmacher
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
- Department of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
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Finley Caulfield A, Mlynash M, Eyngorn I, Lansberg MG, Afjei A, Venkatasubramanian C, Buckwalter MS, Hirsch KG. Prognostication of ICU Patients by Providers with and without Neurocritical Care Training. Neurocrit Care 2022; 37:190-199. [PMID: 35314970 DOI: 10.1007/s12028-022-01467-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2021] [Accepted: 02/04/2022] [Indexed: 12/21/2022]
Abstract
BACKGROUND Predictions of functional outcome in neurocritical care (NCC) patients impact care decisions. This study compared the predictive values (PVs) of good and poor functional outcome among health care providers with and without NCC training. METHODS Consecutive patients who were intubated for ≥ 72 h with primary neurological illness or neurological complications were prospectively enrolled and followed for 6-month functional outcome. Medical intensive care unit (MICU) attendings, NCC attendings, residents (RES), and nurses (RN) predicted 6-month functional outcome on the modified Rankin scale (mRS). The primary objective was to compare these four groups' PVs of a good (mRS score 0-3) and a poor (mRS score 4-6) outcome prediction. RESULTS Two hundred eighty-nine patients were enrolled. One hundred seventy-six had mRS scores predicted by a provider from each group and were included in the primary outcome analysis. At 6 months, 54 (31%) patients had good outcome and 122 (69%) had poor outcome. Compared with other providers, NCC attendings expected better outcomes (p < 0.001). Consequently, the PV of a poor outcome prediction by NCC attendings was higher (96% [95% confidence interval [CI] 89-99%]) than that by MICU attendings (88% [95% CI 80-93%]), RES (82% [95% CI 74-88%]), and RN (85% [95% CI 77-91%]) (p = 0.047, 0.002, and 0.012, respectively). When patients who had withdrawal of life-sustaining therapy (n = 67) were excluded, NCC attendings remained better at predicting poor outcome (NCC 90% [95% CI 75-97%] vs. MICU 73% [95% CI 59-84%], p = 0.064). The PV of a good outcome prediction was similar among groups (MICU 65% [95% CI 52-76%], NCC 63% [95% CI 51-73%], RES 71% [95% CI 55-84%], and RN 64% [95% CI 50-76%]). CONCLUSIONS Neurointensivists expected better outcomes than other providers and were better at predicting poor functional outcomes. The PV of a good outcome prediction was modest among all providers.
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Affiliation(s)
- Anna Finley Caulfield
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA.
| | - Michael Mlynash
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
| | - Irina Eyngorn
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
| | - Maarten G Lansberg
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
| | - Anousheh Afjei
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
| | - Chitra Venkatasubramanian
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
| | - Marion S Buckwalter
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
| | - Karen G Hirsch
- Department of Neurology and Neurological Sciences, Stanford Stroke Center, Stanford University, 453 Quarry Rd, MC 5235, Palo Alto, CA, USA
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Nivelle E, Dewilde S, Peeters A, Vanhooren G, Thijs V. Thrombectomy is a cost-saving procedure up to 24 h after onset. Acta Neurol Belg 2022; 122:163-171. [PMID: 34586595 DOI: 10.1007/s13760-021-01810-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2021] [Accepted: 09/16/2021] [Indexed: 11/26/2022]
Abstract
INTRODUCTION AND AIM The treatment of ischemic stroke due to large-vessel occlusion has been revolutionized by mechanical thrombectomy (MT), as multiple trials have consistently shown improved functional outcomes compared to standard medical management both in the early and late time windows after symptom onset. However, MT is an interventional procedure that is more costly than best supportive care (BSC). METHODS We set out to study the cost-utility and budget impact of MT + BSC versus BSC alone for large-vessel occlusion using a combined decision tree and Markov model. The analysis was conducted from a Belgian payer perspective over a lifetime horizon, and health states were defined by the modified Rankin Scale (mRS). The treatment effect of MT + BSC combined clinical outcomes from all published early and late treatment window studies showing improved mRS after 90 days. Resource use and utilities were informed by an observational Belgian study of 569 stroke patients. Long-term mRS transitions were sourced from the Oxford Vascular study. RESULTS MT + BSC generated 1.31 additional quality-adjusted life years and resulted in cost savings of €10,216 per patient over lifetime. Deterministic sensitivity analyses demonstrated dominance of MT over a wide range of parameter inputs. In a Belgian setting, adding MT to BSC within an early time window for 1575 eligible stroke patients every year produced cost savings between €6.3 million (year 1) and €14.6 million (year 5), or a total cost saving of €56.2 million over 5 years. CONCLUSION Mechanical thrombectomy is a highly cost-effective treatment for ischemic stroke patients, providing quality-adjusted survival at lower health care cost, both when given in an early time window, as well as in a late time window.
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Affiliation(s)
| | - Sarah Dewilde
- Services in Health Economics (SHE), Brussels, Belgium
- Department of Public Health, University of Ghent, Ghent, Belgium
| | - André Peeters
- Service de Neurologie, UCL St Luc, Unité Neuro-Vasculaire, Avenue Hippocrate 10, Brussels, Belgium
| | - Geert Vanhooren
- Department of Neurology, AZ Sint-Jan Brugge-Oostende, Ruddershove 10, Bruges, Belgium
| | - Vincent Thijs
- Stroke Theme, Florey Institute of Neuroscience and Mental Health, University of Melbourne, 245 Burgundy Street, Heidelberg, VIC, Australia.
- Department of Neurology, Austin Health, 145 Studley Road, Heidelberg, VIC, Australia.
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31
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Mechanisms of Thrombosis and Thrombolysis. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00002-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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32
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van Voorst H, Kunz WG, van den Berg LA, Kappelhof M, Pinckaers FME, Goyal M, Hunink MGM, Emmer BJ, Mulder MJHL, Dippel DWJ, Coutinho JM, Marquering HA, Boogaarts HD, van der Lugt A, van Zwam WH, Roos YBWEM, Buskens E, Dijkgraaf MGW, Majoie CBLM. Quantified health and cost effects of faster endovascular treatment for large vessel ischemic stroke patients in the Netherlands. J Neurointerv Surg 2021; 13:1099-1105. [PMID: 33479037 PMCID: PMC8606465 DOI: 10.1136/neurintsurg-2020-017017] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2020] [Revised: 12/16/2020] [Accepted: 12/18/2020] [Indexed: 12/04/2022]
Abstract
BACKGROUND The effectiveness of endovascular treatment (EVT) for large vessel occlusion (LVO) stroke severely depends on time to treatment. However, it remains unclear what the value of faster treatment is in the years after index stroke. The aim of this study was to quantify the value of faster EVT in terms of health and healthcare costs for the Dutch LVO stroke population. METHODS A Markov model was used to simulate 5-year follow-up functional outcome, measured with the modified Rankin Scale (mRS), of 69-year-old LVO patients. Post-treatment mRS was extracted from the MR CLEAN Registry (n=2892): costs per unit of time and Quality-Adjusted Life Years (QALYs) per mRS sub-score were retrieved from follow-up data of the MR CLEAN trial (n=500). Net Monetary Benefit (NMB) at a willingness to pay of €80 000 per QALY was reported as primary outcome, and secondary outcome measures were days of disability-free life gained and costs. RESULTS EVT administered 1 min faster resulted in a median NMB of €309 (IQR: 226;389), 1.3 days of additional disability-free life (IQR: 1.0;1.6), while cumulative costs remained largely unchanged (median: -€15, IQR: -65;33) over a 5-year follow-up period. As costs over the follow-up period remained stable while QALYs decreased with longer time to treatment, which this results in a near-linear decrease of NMB. Since patients with faster EVT lived longer, they incurred more healthcare costs. CONCLUSION One-minute faster EVT increases QALYs while cumulative costs remain largely unaffected. Therefore, faster EVT provides better value of care at no extra healthcare costs.
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Affiliation(s)
- Henk van Voorst
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Wolfgang G Kunz
- Department of Radiology, University Hospital, LMU Munich, Münich, Germany
| | - Lucie A van den Berg
- Department of Neurology, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam, The Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Floor M E Pinckaers
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Mayank Goyal
- Department of Radiology and Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Myriam G M Hunink
- Department of Clinical Epidemiology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Departments of Radiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Bart J Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Maxim J H L Mulder
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Henk A Marquering
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Hieronymus D Boogaarts
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Aad van der Lugt
- Departments of Radiology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Erik Buskens
- Department of Epidemiology, University Medical Centre Groningen, Groningen, The Netherlands
| | - Marcel G W Dijkgraaf
- Department of Epidemiology and Data Science, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam, The Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location AMC, University of Amsterdam, Amsterdam, The Netherlands
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Liu J, Yang Y, Liu H. Efficacy outcomes and safety measures of intravenous tirofiban or eptifibatide for patients with acute ischemic stroke: a systematic review and meta-analysis of prospective studies. J Thromb Thrombolysis 2021; 53:898-910. [PMID: 34780001 DOI: 10.1007/s11239-021-02584-3] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/03/2021] [Indexed: 12/12/2022]
Abstract
To review the literature for randomized control trials (RCTs) and prospective cohort studies investigating the safety and efficacy of tirofiban and eptifibatide in patients with acute ischemic stroke (AIS). PubMed, Embase, and the Cochrane library were searched for available papers published up to September 2021. The efficacy was evaluated based on the 3-month favorable outcome [modified Rankin scale (mRS) = 0-1], functional outcome (mRS = 0-2), and the last available National Institutes of Health Stroke Scale (NIHSS) score measured in each study. Twelve studies (two RCTs and 10 prospective cohorts) and 2926 patients were included. Treatment with tirofiban or eptifibatide had no effects on the favorable outcome (RR = 1.09, 95% CI 0.89-1.35, P = 0.411), functional outcome (RR = 1.12, 95% CI 0.98-1.28, P = 0.010), and last available NIHSS (WMD = - 2.32, 95% CI - 5.14 to 0.50, P = 0.106), but might increase mortality (RR = 0.84, 95% CI 0.71-0.99, P = 0.121). The sensitivity analyses showed that the meta-analyses were robust. There was no significant publication bias. Tirofiban did not increase the risk of ICH (P = 0. 423) and sICH (P = 0. 990) but increased the risk of fatal ICH (RR = 3.59, 95% CI 1.62-7.96, P = 0.002). Thrombolysis/thrombectomy did not influence any of the outcomes. Adding tirofiban or eptifibatide to thrombolysis/thrombectomy was not significantly associated with a favorable outcome (mRS = 0-1) nor functional outcome (mRS = 0-2) in patients with AIS at 3 months, but might be associated with mortality, possibly due to fatal ICH. The NIHSS was also not significantly different between the intervention and control groups after treatments.
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Affiliation(s)
- Jingting Liu
- Xiangya School of Medicine, Central South University, Changsha, 410013, China
| | - Yihong Yang
- Department of Emergency, Fuyang People's Hospital, Fuyang, 236000, China
| | - Hongbo Liu
- Department of Emergency, Fuyang People's Hospital, Fuyang, 236000, China.
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van den Berg LA, Berkhemer OA, Fransen PSS, Beumer D, Lingsma H, Majoie CBM, Dippel DWJ, van der Lugt A, van Oostenbrugge RJ, van Zwam WH, Roos YB, Dijkgraaf MGW. Economic Evaluation of Endovascular Treatment for Acute Ischemic Stroke. Stroke 2021; 53:968-975. [PMID: 34645287 DOI: 10.1161/strokeaha.121.034599] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND AND PURPOSE Endovascular treatment for acute ischemic stroke has been proven clinically effective, but evidence of the cost-effectiveness based on real-world data is scarce. The aim of this study was to assess whether endovascular therapy plus usual care is cost-effective in comparison to usual care alone in acute ischemic stroke patients. METHODS An economic evaluation was performed from a societal perspective with a 2-year time horizon. Empirical data on health outcomes and the use of resources following endovascular treatment were gathered parallel to the MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) and its 2-year follow-up study. Incremental cost-effectiveness ratios were calculated as the extra costs per additional patient with functional independence (modified Rankin Scale score 0-2) and the extra cost per quality-adjusted life year gained. RESULTS The mean costs per patient in the intervention group were $126 494 versus $143 331 in the control group (mean difference, -$16 839 [95% CI, -$38 113 to $5456]). Compared with patients in the control group, more patients in the intervention group achieved functional independence, 37.2% versus 23.9% (absolute difference, 13.3% [95% CI, 4.0%-22.0%]) and they generated more quality-adjusted life years, 0.99 versus 0.83 (mean difference of 0.16 [95% CI, 0.04-0.29]). Endovascular treatment dominated standard treatment with $18 233 saved per extra patient with a good outcome and $105 869 saved per additional quality-adjusted life year. CONCLUSIONS Endovascular treatment added to usual care is clinically effective, and cost saving in comparison to usual care alone in patients with acute ischemic stroke. REGISTRATION URL: https://www.trialregister.nl/trial/695; Unique identifier: NL695. https://www.isrctn.com/ISRCTN10888758; Unique identifier: ISRCTN10888758.
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Affiliation(s)
- Lucie A van den Berg
- Departments of Neurology, Amsterdam University Medical Center, the Netherlands. (L.A.v.d.B., Y.B.R.)
| | - Olvert A Berkhemer
- Radiology and Nuclear Medicine, Amsterdam University Medical Center, the Netherlands. (C.B.M.M., O.A.B.).,Department of Neurology, Erasmus MC University Medical Center Rotterdam, the Netherlands. (O.A.B., P.S.S.F., D.W.J.D.).,Department of Radiology, Erasmus MC University Medical Center Rotterdam, the Netherlands. (O.A.B., A.v.d.L.).,Department of Radiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, the Netherlands. (O.A.B., W.H.v.Z.)
| | - Puck S S Fransen
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, the Netherlands. (O.A.B., P.S.S.F., D.W.J.D.)
| | - Debbie Beumer
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, the Netherlands. (D.B., R.J.v.O.)
| | - Hester Lingsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, the Netherlands. (H.L.)
| | - Charles B M Majoie
- Radiology and Nuclear Medicine, Amsterdam University Medical Center, the Netherlands. (C.B.M.M., O.A.B.)
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center Rotterdam, the Netherlands. (O.A.B., P.S.S.F., D.W.J.D.)
| | - Aad van der Lugt
- Department of Radiology, Erasmus MC University Medical Center Rotterdam, the Netherlands. (O.A.B., A.v.d.L.)
| | - Robert J van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, the Netherlands. (D.B., R.J.v.O.)
| | - Wim H van Zwam
- Department of Radiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, the Netherlands. (O.A.B., W.H.v.Z.)
| | - Yvo B Roos
- Departments of Neurology, Amsterdam University Medical Center, the Netherlands. (L.A.v.d.B., Y.B.R.)
| | - Marcel G W Dijkgraaf
- Clinical Epidemiology, Biostatistics, and Bioinformatics, Amsterdam University Medical Center, the Netherlands. (M.G.W.D.)
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de Havenon A, Tirschwell DL, Heitsch L, Cramer SC, Braun R, Cole J, Reddy V, Majersik JJ, Lindgren A, Worrall BB. Variability of the Modified Rankin Scale Score Between Day 90 and 1 Year After Ischemic Stroke. Neurol Clin Pract 2021; 11:e239-e244. [PMID: 34484897 DOI: 10.1212/cpj.0000000000000954] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2020] [Accepted: 08/07/2020] [Indexed: 11/15/2022]
Abstract
Objective Studies indicate that the functional outcome evolves in the year after ischemic stroke onset. However, the traditional outcome measure in stroke trials is the modified Rankin Scale (mRS) at 90 days from onset. To determine mRS fluctuations in the first year after stroke, we examined data from 3 major stroke trials. Methods In a secondary analysis, we evaluated intrapatient mRS between 90 days and 1 year from stroke onset, the mRS shift (∆mRS = 1 year-day 90), and the trials' primary outcome at day 90 and 1 year. Results We included 624 patients from the National Institute of Neurological Disorders and Stroke rt-PA Stroke Study, 587 from Albumin Treatment for Acute Ischaemic Stroke, and 611 from Interventional Management of Stroke III, for which the proportion of patients with a ∆mRS change between day 90 and 1 year was 36.5%, 41.7%, and 36.0%. However, the trials' primary outcomes did not differ at 1 year vs 90 days. Similar findings were seen in a second cohort where we pooled the trials and excluded patients with recurrent stroke or death during the follow-up. In those 1,314 patients, 544 (41.4%) had a ∆mRS change, of which 379 (28.9%) had improvement and 165 (12.5%) had worsening, apart from death. Conclusion We describe the patient-level spectrum of mRS change from day 90 to 1 year after ischemic stroke in 3 high-quality randomized trials. The patient-level shifts consisted of a sufficiently counterbalanced number of mRS improvements and declines, which masked clinical evolution occurring in over one-third of patients. These results may have important implications, both for clinical trial design and outcome adjudication in stroke research and duration of rehabilitative therapy.
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Affiliation(s)
- Adam de Havenon
- Departments of Neurology, University of Utah (AdH, JJM, VR); University of Washington (DLT); University of Virginia (BBW); University of Maryland (RB, JC); University of California Los Angeles (SCC); Lund University (AL); and the Department of Emergency Medicine, Washington University (LH)
| | - David L Tirschwell
- Departments of Neurology, University of Utah (AdH, JJM, VR); University of Washington (DLT); University of Virginia (BBW); University of Maryland (RB, JC); University of California Los Angeles (SCC); Lund University (AL); and the Department of Emergency Medicine, Washington University (LH)
| | - Laura Heitsch
- Departments of Neurology, University of Utah (AdH, JJM, VR); University of Washington (DLT); University of Virginia (BBW); University of Maryland (RB, JC); University of California Los Angeles (SCC); Lund University (AL); and the Department of Emergency Medicine, Washington University (LH)
| | - Steven C Cramer
- Departments of Neurology, University of Utah (AdH, JJM, VR); University of Washington (DLT); University of Virginia (BBW); University of Maryland (RB, JC); University of California Los Angeles (SCC); Lund University (AL); and the Department of Emergency Medicine, Washington University (LH)
| | - Robynne Braun
- Departments of Neurology, University of Utah (AdH, JJM, VR); University of Washington (DLT); University of Virginia (BBW); University of Maryland (RB, JC); University of California Los Angeles (SCC); Lund University (AL); and the Department of Emergency Medicine, Washington University (LH)
| | - John Cole
- Departments of Neurology, University of Utah (AdH, JJM, VR); University of Washington (DLT); University of Virginia (BBW); University of Maryland (RB, JC); University of California Los Angeles (SCC); Lund University (AL); and the Department of Emergency Medicine, Washington University (LH)
| | - Vivek Reddy
- Departments of Neurology, University of Utah (AdH, JJM, VR); University of Washington (DLT); University of Virginia (BBW); University of Maryland (RB, JC); University of California Los Angeles (SCC); Lund University (AL); and the Department of Emergency Medicine, Washington University (LH)
| | - Jennifer J Majersik
- Departments of Neurology, University of Utah (AdH, JJM, VR); University of Washington (DLT); University of Virginia (BBW); University of Maryland (RB, JC); University of California Los Angeles (SCC); Lund University (AL); and the Department of Emergency Medicine, Washington University (LH)
| | - Arne Lindgren
- Departments of Neurology, University of Utah (AdH, JJM, VR); University of Washington (DLT); University of Virginia (BBW); University of Maryland (RB, JC); University of California Los Angeles (SCC); Lund University (AL); and the Department of Emergency Medicine, Washington University (LH)
| | - Bradford B Worrall
- Departments of Neurology, University of Utah (AdH, JJM, VR); University of Washington (DLT); University of Virginia (BBW); University of Maryland (RB, JC); University of California Los Angeles (SCC); Lund University (AL); and the Department of Emergency Medicine, Washington University (LH)
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Parameshwaran B, Cordato D, Parsons M, Cheung A, Manning N, Wenderoth J, Cappelen-Smith C. The Benefit of Endovascular Thrombectomy for Stroke on Functional Outcome Is Sustained at 12 Months. Cerebrovasc Dis Extra 2021; 11:81-86. [PMID: 34469885 PMCID: PMC8460944 DOI: 10.1159/000517929] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 06/09/2021] [Indexed: 11/19/2022] Open
Abstract
Background and Purpose The short-term benefits of endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) have been widely documented, yet there is limited evidence to show that this is sustained in the long term. We aimed to determine whether the benefit of EVT on functional outcome at 3 months is maintained at 12 months and the factors correlating with functional independence and quality of life. Methods Data for analysis came from a prospective registry of consecutive patients undergoing EVT at a single Comprehensive Stroke Center (Oct 2018–Sep 2019). A phone interview was conducted for 12-month patient outcomes. Functional outcome was assessed by the modified Rankin Scale (mRS). Quality of life was determined by return to usual place of residence, work, or driving and calculation of a health utility index using the European Quality of Life-5 Dimensions questionnaire (EQ-5D-3L). Results Of the 151 patients who underwent EVT during the study period, 12-month follow-up was available for 145 (96%). At 12 months, 44% (n = 64) of patients were functionally independent (mRS 0–2) compared to 48% at 3 months. Mortality at 12 months was 26% compared to 17% at 3 months. Significant predictors of functional independence at 12 months were younger age and lower baseline National Institutes of Health Stroke Scale. Better quality of life significantly correlated with return to usual place of residence and driving. Conclusion Three-month functional independence was sustained at 12 months, indicating that EVT remains beneficial for patients with AIS in the longer term.
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Affiliation(s)
- Balaki Parameshwaran
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, New South Wales, Australia, .,South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia,
| | - Dennis Cordato
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Mark Parsons
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
| | - Andrew Cheung
- Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia.,Department of Interventional Neuroradiology, Liverpool Hospital, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Nathan Manning
- Department of Interventional Neuroradiology, Liverpool Hospital, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,The Florey Institute of Neuroscience, Melbourne, Victoria, Australia
| | - Jason Wenderoth
- Department of Interventional Neuroradiology, Liverpool Hospital, Sydney, New South Wales, Australia.,Prince of Wales Clinical School, University of New South Wales, Sydney, New South Wales, Australia
| | - Cecilia Cappelen-Smith
- Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, New South Wales, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, New South Wales, Australia.,Ingham Institute for Applied Medical Research, Sydney, New South Wales, Australia
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Endovascular Thrombectomy Treatment: Beyond Early Time Windows and Small Core. Top Magn Reson Imaging 2021; 30:173-180. [PMID: 34397966 DOI: 10.1097/rmr.0000000000000291] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
ABSTRACT Tremendous advancements in the treatment of acute ischemic stroke in the last 25 years have been based on the principle of reperfusion in early time windows and identification of small core infarct for intravenous thrombolysis and mechanical thrombectomy. Advances in neuroimaging have made possible the safe treatment of patients with acute ischemic stroke in longer time windows and with more specific selection of patients with salvageable brain tissue. In this review, we discuss the history of endovascular stroke thrombectomy trials and highlight the neuroimaging-based trials that validated mechanical thrombectomy techniques in the extended time window with assessment of penumbral tissue. We conclude with a survey of currently open trials that seek to safely expand eligibility for this highly efficacious treatment.
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38
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Ganesh A, Ospel JM, Marko M, van Zwam WH, Roos YBWEM, Majoie CBLM, Goyal M. From Three-Months to Five-Years: Sustaining Long-Term Benefits of Endovascular Therapy for Ischemic Stroke. Front Neurol 2021; 12:713738. [PMID: 34381418 PMCID: PMC8350336 DOI: 10.3389/fneur.2021.713738] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Accepted: 06/28/2021] [Indexed: 11/28/2022] Open
Abstract
Background and Purpose: During the months and years post-stroke, treatment benefits from endovascular therapy (EVT) may be magnified by disability-related differences in morbidity/mortality or may be eroded by recurrent strokes and non-stroke-related disability/mortality. Understanding the extent to which EVT benefits may be sustained at 5 years, and the factors influencing this outcome, may help us better promote the sustenance of EVT benefits until 5 years post-stroke and beyond. Methods: In this review, undertaken 5 years after EVT became the standard of care, we searched PubMed and EMBASE to examine the current state of the literature on 5-year post-stroke outcomes, with particular attention to modifiable factors that influence outcomes between 3 months and 5 years post-EVT. Results: Prospective cohorts and follow-up data from EVT trials indicate that 3-month EVT benefits will likely translate into lower 5-year disability, mortality, institutionalization, and care costs and higher quality of life. However, these group-level data by no means guarantee maintenance of 3-month benefits for individual patients. We identify factors and associated “action items” for stroke teams/systems at three specific levels (medical care, individual psychosocioeconomic, and larger societal/environmental levels) that influence the long-term EVT outcome of a patient. Medical action items include optimizing stroke rehabilitation, clinical follow-up, secondary stroke prevention, infection prevention/control, and post-stroke depression care. Psychosocioeconomic aspects include addressing access to primary care, specialist clinics, and rehabilitation; affordability of healthy lifestyle choices and preventative therapies; and optimization of family/social support and return-to-work options. High-level societal efforts include improving accessibility of public/private spaces and transportation, empowering/engaging persons with disability in society, and investing in treatments/technologies to mitigate consequences of post-stroke disability. Conclusions: In the longtime horizon from 3 months to 5 years, several factors in the medical and societal spheres could negate EVT benefits. However, many factors can be leveraged to preserve or magnify treatment benefits, with opportunities to share responsibility with widening circles of care around the patient.
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Affiliation(s)
- Aravind Ganesh
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | | | - Martha Marko
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Wim H van Zwam
- Department of Radiology, Maastricht University Medical Centre, Maastricht, Netherlands
| | | | | | - Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada.,Department of Radiology, University of Calgary, Calgary, AB, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
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39
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Mitochondrial Quality Control in Cerebral Ischemia-Reperfusion Injury. Mol Neurobiol 2021; 58:5253-5271. [PMID: 34275087 DOI: 10.1007/s12035-021-02494-8] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 07/12/2021] [Indexed: 12/27/2022]
Abstract
Ischemic stroke is one of the leading causes of death and also a major cause of adult disability worldwide. Revascularization via reperfusion therapy is currently a standard clinical procedure for patients with ischemic stroke. Although the restoration of blood flow (reperfusion) is critical for the salvage of ischemic tissue, reperfusion can also, paradoxically, exacerbate neuronal damage through a series of cellular alterations. Among the various theories postulated for ischemia/reperfusion (I/R) injury, including the burst generation of reactive oxygen species (ROS), activation of autophagy, and release of apoptotic factors, mitochondrial dysfunction has been proposed to play an essential role in mediating these pathophysiological processes. Therefore, strict regulation of the quality and quantity of mitochondria via mitochondrial quality control is of great importance to avoid the pathological effects of impaired mitochondria on neurons. Furthermore, timely elimination of dysfunctional mitochondria via mitophagy is also crucial to maintain a healthy mitochondrial network, whereas intensive or excessive mitophagy could exacerbate cerebral I/R injury. This review will provide a comprehensive overview of the effect of mitochondrial quality control on cerebral I/R injury and introduce recent advances in the understanding of the possible signaling pathways of mitophagy and potential factors responsible for the double-edged roles of mitophagy in the pathological processes of cerebral I/R injury.
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40
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Indications for Surgical Intervention in the Treatment of Ischemic Stroke. Stroke 2021. [DOI: 10.36255/exonpublications.stroke.surgicalintervention.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
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41
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Yamashita S, Sato M, Yamazaki T, Yasuda S, Kato N. Identifying Cerebral Large Vessel Occlusion in Acute Ischemic Stroke by MRI Positioning Scanning. Neurol Med Chir (Tokyo) 2021; 61:521-527. [PMID: 34121049 PMCID: PMC8443971 DOI: 10.2176/nmc.oa.2021-0028] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
Various approaches have been tried for acute ischemic stroke (AIS) treatment to shorten the time from onset to recanalization. MRI positioning scanning (PS), which must be taken before any MRI sequences, was examined whether it can detect cerebral large vessel occlusion. A total of 68 consecutive patients with AIS who underwent MRI and were treated with intravenous recombinant tissue plasminogen activator or mechanical thrombectomy at our hospital were retrospectively included in this study. Occluded vessels were identified on the axial or coronal views of PS images, and these images were compared with 3D time-of-flight MRA and digital subtraction angiogram. The sensitivities, positive predictive values (PPVs), and negative predictive values (NPVs) for internal carotid artery (ICA), the proximal M1, distal M1, and M2 segment of the middle cerebral artery occlusion were assessed, and the number of PS slices was assessed. The sensitivities of the axial slices for ICA, proximal M1, distal M1, and M2 occlusion were 62%, 21%, 35%, and 86%, respectively. The PPVs of the axial slices for ICA, proximal M1, distal M1, and M2 occlusion were 81%, 88%, 100%, and 97%, respectively, and the NPVs of the axial slices for ICA, proximal M1, distal M1, and M2 occlusion were 94%, 90%, 86%, and 100%, respectively. The detection rate for the ICA was significantly higher with three axial slices (91%) than with two slices (47%) (p <0.01). MRI PS is warranted to be referred to detect large cerebral vessel occlusion.
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Affiliation(s)
- Shota Yamashita
- Department of Neurosurgery, Mito Medical Center, Organization of National Hospital
| | - Masayuki Sato
- Department of Neurosurgery, Mito Medical Center, Organization of National Hospital
| | - Tomosato Yamazaki
- Department of Neurosurgery, Mito Medical Center, Organization of National Hospital
| | - Susumu Yasuda
- Department of Neurosurgery, Mito Medical Center, Organization of National Hospital
| | - Noriyuki Kato
- Department of Neurosurgery, Mito Medical Center, Organization of National Hospital
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42
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Kitano T, Hori Y, Okazaki S, Shimada Y, Iwamoto T, Kanki H, Sugiyama S, Sasaki T, Nakamura H, Oyama N, Hoshi T, Beck G, Takai H, Matsubara S, Mizuno H, Nishimura H, Tamaki R, Iida J, Iba J, Uno M, Kishima H, Fushimi H, Hattori S, Murayama S, Morii E, Sakaguchi M, Yagita Y, Shimazu T, Mochizuki H, Todo K. An Older Thrombus Delays Reperfusion after Mechanical Thrombectomy for Ischemic Stroke. Thromb Haemost 2021; 122:415-426. [PMID: 34077976 PMCID: PMC8899314 DOI: 10.1055/a-1522-4507] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Background
Thrombosis is a dynamic process, and a thrombus undergoes physical and biochemical changes that may alter its response to reperfusion therapy. This study assessed whether thrombus age influenced reperfusion quality and outcomes after mechanical thrombectomy for cerebral embolism.
Methods
We retrospectively evaluated 185 stroke patients and thrombi that were collected during mechanical thrombectomy at three stroke centers. Thrombi were pathologically classified as fresh or older based on their granulocytes' nuclear morphology and organization. Thrombus components were quantified, and the extent of NETosis (the process of neutrophil extracellular trap formation) was assessed using the density of citrullinated histone H3-positive cells. Baseline patient characteristics, thrombus features, endovascular procedures, and functional outcomes were compared according to thrombus age.
Results
Fresh thrombi were acquired from 43 patients, and older thrombi were acquired from 142 patients. Older thrombi had a lower erythrocyte content (
p
< 0.001) and higher extent of NETosis (
p
= 0.006). Restricted mean survival time analysis revealed that older thrombi were associated with longer puncture-to-reperfusion times (difference: 15.6 minutes longer for older thrombi,
p
= 0.002). This association remained significant even after adjustment for erythrocyte content and the extent of NETosis (adjusted difference: 10.8 minutes, 95% confidence interval [CI]: 0.6–21.1 minutes,
p
= 0.039). Compared with fresh thrombi, older thrombi required more device passes before reperfusion (
p
< 0.001) and were associated with poorer functional outcomes (adjusted common odds ratio: 0.49; 95% CI: 0.24–0.99).
Conclusion
An older thrombus delays reperfusion after mechanical thrombectomy for ischemic stroke. Adding therapies targeting thrombus maturation may improve the efficacy of mechanical thrombectomy.
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Affiliation(s)
- Takaya Kitano
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan.,Department of Stroke Medicine, Kawasaki Medical School, Okayama, Japan
| | - Yumiko Hori
- Department of Pathology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shuhei Okazaki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Yuki Shimada
- Department of Neurology, Osaka General Medical Center, Osaka, Japan
| | - Takanori Iwamoto
- Department of Stroke Medicine, Kawasaki Medical School, Okayama, Japan
| | - Hideaki Kanki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Shintaro Sugiyama
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Tsutomu Sasaki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hajime Nakamura
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Naoki Oyama
- Department of Stroke Medicine, Kawasaki Medical School, Okayama, Japan
| | - Taku Hoshi
- Department of Neurology, Osaka General Medical Center, Osaka, Japan
| | - Goichi Beck
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hiroki Takai
- Department of Neurosurgery, Kawasaki Medical School, Okayama, Japan
| | - Shunji Matsubara
- Department of Neurosurgery, Kawasaki Medical School, Okayama, Japan
| | - Hiroya Mizuno
- Department of Cardiovascular Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | | | - Ryo Tamaki
- Department of Neurosurgery, Osaka General Medical Center, Osaka, Japan
| | - Junichi Iida
- Department of Neurosurgery, Osaka General Medical Center, Osaka, Japan
| | - Jiro Iba
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Masaaki Uno
- Department of Neurosurgery, Kawasaki Medical School, Okayama, Japan
| | - Haruhiko Kishima
- Department of Neurosurgery, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hiroaki Fushimi
- Department of Pathology, Osaka General Medical Center, Osaka, Japan
| | - Satoshi Hattori
- Department of Integrated Medicine, Biomedical Statistics, Osaka University Graduate School of Medicine, Osaka, Japan.,Institute for Open and Transdisciplinary Research Initiatives, Osaka University, Osaka, Japan
| | - Shigeo Murayama
- Brain Bank for Neurodevelopmental, Neurological and Psychiatric Disorders, United Graduate School of Child Development, Osaka University, Osaka, Japan.,Department of Neurology and Neuropathology (the Brain Bank for Aging Research), Tokyo Metropolitan Geriatric Hospital and Institute of Gerontology, Tokyo, Japan
| | - Eiichi Morii
- Department of Pathology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Manabu Sakaguchi
- Department of Neurology, Osaka General Medical Center, Osaka, Japan
| | - Yoshiki Yagita
- Department of Stroke Medicine, Kawasaki Medical School, Okayama, Japan
| | - Takeshi Shimazu
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Hideki Mochizuki
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
| | - Kenichi Todo
- Department of Neurology, Osaka University Graduate School of Medicine, Osaka, Japan
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Joundi RA, Rebchuk AD, Field TS, Smith EE, Goyal M, Demchuk AM, Dowlatshahi D, Poppe AY, Williams DJ, Mandzia JL, Buck BH, Jadhav AP, Pikula A, Menon BK, Hill MD. Health-Related Quality of Life Among Patients With Acute Ischemic Stroke and Large Vessel Occlusion in the ESCAPE Trial. Stroke 2021; 52:1636-1642. [PMID: 33691504 DOI: 10.1161/strokeaha.120.033872] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Raed A Joundi
- Department of Clinical Neurosciences, University of Calgary, Canada (R.A.J.)
| | - Alexander D Rebchuk
- Division of Neurosurgery (A.D.R.), University of British Columbia, Vancouver, Canada
| | - Thalia S Field
- Vancouver Stroke Program (T.S.F.), University of British Columbia, Vancouver, Canada
| | - Eric E Smith
- Department of Clinical Neurosciences (E.E.S.), Hotchkiss Brain Institute, University of Calgary, Canada
| | - Mayank Goyal
- Department of Clinical Neurosciences, Department of Radiology (M.G., A.M.D.), Hotchkiss Brain Institute, University of Calgary, Canada
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, Department of Radiology (M.G., A.M.D.), Hotchkiss Brain Institute, University of Calgary, Canada
| | - Dar Dowlatshahi
- Department of Medicine (Neurology), University of Ottawa Brain and Mind Institute and Ottawa Hospital Research Institute, Canada (D.D.)
| | - Alexandre Y Poppe
- Neurovascular Health Program, Department of Medicine (Neurology), Centre Hospitalier de l'Université de Montréal, Canada (A.Y.P.)
| | - David J Williams
- Department of Geriatric and Stroke Medicine, RCSI University of Medicine and Health Sciences, Dublin, Ireland (D.J.W.)
| | - Jennifer L Mandzia
- Department of Clinical Neurological Sciences, Western University, London, Canada (J.L.M.)
| | - Brian H Buck
- Department of Medicine, Division of Neurology, University of Alberta, Edmonton, Canada (B.H.B.)
| | | | - Aleksandra Pikula
- Department of Medicine (Neurology), University of Toronto, Krembil Brain Institute, University Health Network, Canada (A.P.)
| | - Bijoy K Menon
- Department of Clinical Neurosciences, Department of Radiology, Department of Community Health Sciences (B.K.M., M.D.H), Hotchkiss Brain Institute, University of Calgary, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, Department of Radiology, Department of Community Health Sciences (B.K.M., M.D.H), Hotchkiss Brain Institute, University of Calgary, Canada
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44
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Polding LC, Tate WJ, Mlynash M, Marks MP, Heit JJ, Christensen S, Kemp S, Albers GW, Lansberg MG. Quality of Life in Physical, Social, and Cognitive Domains Improves With Endovascular Therapy in the DEFUSE 3 Trial. Stroke 2021; 52:1185-1191. [PMID: 33596675 DOI: 10.1161/strokeaha.120.031490] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The DEFUSE 3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3) randomized clinical trial demonstrated the efficacy of endovascular therapy in treating ischemic stroke 6 to 16 hours after onset, resulting in better functional outcomes than standard medical therapy alone. The objective of this secondary analysis is to analyze the effect of late-window endovascular treatment of ischemic stroke on quality of life (QoL) outcomes. METHODS Patients (n=182) who presented between 6 and 16 hours after they were last known to be well with acute anterior circulation ischemic stroke were randomized to endovascular thrombectomy plus standard medical therapy or standard medical therapy alone and followed-up through 90 days poststroke. QoL at day 90 was assessed with the QoL in Neurological Disorders measurement tool. RESULTS Of the 146 subjects alive at day 90, 136 (95%) filled out QoL in Neurological Disorders short forms. Patients treated with endovascular therapy had better QoL scores in each domain: mobility, social participation, cognitive function, and depression (P<0.01 for all). Variables other than endovascular therapy that were independently associated with better QoL included lower baseline National Institutes of Health Stroke Scale, younger age, and male sex. The degree to which the modified Rankin Scale captures differences in QoL between patients varied by domain; the modified Rankin Scale score accounted for a high proportion of the variability in mobility (Rs2=0.82), a moderate proportion in social participation (Rs2=0.62), and a low proportion in cognition (Rs2=0.31) and depression (Rs2=0.19). CONCLUSIONS Patients treated with endovascular therapy 6 to 16 hours after stroke have better QoL than patients treated with medical therapy alone, including better mobility, more social participation, superior cognition, and less depression. The modified Rankin Scale fails to capture patients' outcomes in cognition and depression, which should therefore be assessed with dedicated QoL tools. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02586415.
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Affiliation(s)
| | - William J Tate
- Stanford University School of Medicine, CA (L.C.P., W.J.T.)
| | - Michael Mlynash
- Stanford Stroke Center, Palo Alto, CA (M.M., S.C., S.K., G.W.A., M.G.L.)
| | - Michael P Marks
- Department of Radiology, Stanford University School of Medicine, Palo Alto, CA (M.P.M., J.J.H.)
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Palo Alto, CA (M.P.M., J.J.H.)
| | - Soren Christensen
- Stanford Stroke Center, Palo Alto, CA (M.M., S.C., S.K., G.W.A., M.G.L.)
| | | | - Gregory W Albers
- Stanford Stroke Center, Palo Alto, CA (M.M., S.C., S.K., G.W.A., M.G.L.)
| | - Maarten G Lansberg
- Stanford Stroke Center, Palo Alto, CA (M.M., S.C., S.K., G.W.A., M.G.L.)
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45
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MR CLEAN-NO IV: intravenous treatment followed by endovascular treatment versus direct endovascular treatment for acute ischemic stroke caused by a proximal intracranial occlusion-study protocol for a randomized clinical trial. Trials 2021; 22:141. [PMID: 33588908 PMCID: PMC7885482 DOI: 10.1186/s13063-021-05063-5] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2020] [Accepted: 01/20/2021] [Indexed: 12/15/2022] Open
Abstract
Background Endovascular treatment (EVT) has greatly improved the prognosis of acute ischemic stroke (AIS) patients with a proximal intracranial large vessel occlusion (LVO) of the anterior circulation. Currently, there is clinical equipoise concerning the added benefit of intravenous alteplase administration (IVT) prior to EVT. The aim of this study is to assess the efficacy and safety of omitting IVT before EVT in patients with AIS caused by an anterior circulation LVO. Methods MR CLEAN-NO IV is a multicenter randomized open-label clinical trial with blinded outcome assessment (PROBE design). Patients ≥ 18 years of age with a pre-stroke mRS < 3 with an LVO confirmed on CT angiography/MR angiography eligible for both IVT and EVT are randomized to receive either IVT (0.9 mg/kg) followed by EVT, or direct EVT in a 1:1 ratio. The primary objective is to assess superiority of direct EVT. Secondarily, non-inferiority of direct EVT compared to IVT before EVT will be explored. The primary outcome is the score on the modified Rankin Scale at 90 days. Ordinal regression with adjustment for prognostic variables will be used to estimate treatment effect. Secondary outcomes include reperfusion graded with the eTICI scale after EVT and stroke severity (National Institutes of Health Stroke Scale) at 24 h. Safety outcomes include intracranial hemorrhages scored according to the Heidelberg criteria. A total of 540 patients will be included. Discussion IVT prior to EVT might facilitate early reperfusion before EVT or improved reperfusion rates during EVT. Conversely, among other potential adverse effects, the increased risk of bleeding could nullify the beneficial effects of IVT. MR CLEAN-NO IV will provide insight into whether IVT is still of added value in patients eligible for EVT. Trial registration www.isrctn.com: ISRCTN80619088. Registered on 31 October 2017. Supplementary Information The online version contains supplementary material available at 10.1186/s13063-021-05063-5.
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Yamagami H, Hayakawa M, Inoue M, Iihara K, Ogasawara K, Toyoda K, Hasegawa Y, Ohata K, Shiokawa Y, Nozaki K, Ezura M, Iwama T. Guidelines for Mechanical Thrombectomy in Japan, the Fourth Edition, March 2020: A Guideline from the Japan Stroke Society, the Japan Neurosurgical Society, and the Japanese Society for Neuroendovascular Therapy. Neurol Med Chir (Tokyo) 2021; 61:163-192. [PMID: 33583863 DOI: 10.2176/nmc.nmc.st.2020-0357] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Affiliation(s)
- Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Osaka, Japan
| | - Mikito Hayakawa
- Division of Stroke Prevention and Treatment, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Manabu Inoue
- Division of Stroke Care Unit/Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Koji Iihara
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kuniaki Ogasawara
- Department of Neurosurgery, Iwate Medical University, Morioka, Iwate, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yasuhiro Hasegawa
- Department of Neurology, St. Marianna University School of Medicine, Kawasaki, Kanagawa, Japan.,Stroke Center and Department of Neurology, Shin-yurigaoka General Hospital, Kawasaki, Kanagawa, Japan
| | - Kenji Ohata
- Department of Neurosurgery, Osaka City University Graduate School of Medicine, Osaka, Osaka, Japan
| | | | - Kazuhiko Nozaki
- Department of Neurosurgery, Shiga University of Medical Science, Otsu, Shiga, Japan
| | - Masayuki Ezura
- Department of Neurosurgery, National Hospital Organization Sendai Medical Center, Sendai, Miyagi, Japan
| | - Toru Iwama
- Department of Neurosurgery, Gifu University Graduate School of Medicine, Gifu, Gifu, Japan
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47
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Nozaki T, Noda M, Ishibashi T, Otani K, Kogiku M, Abe K, Kishi H, Morita A. Distal Vessel Imaging via Intra-arterial Flat Panel Detector CTA during Mechanical Thrombectomy. AJNR Am J Neuroradiol 2021; 42:306-312. [PMID: 33361373 DOI: 10.3174/ajnr.a6906] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2020] [Accepted: 09/05/2020] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Obtaining information on invisible vasculature distal to the occlusion site helps to deploy a stent retriever safely during mechanical thrombectomy for large-vessel occlusion. It is essential to reduce the amount of contrast used for detecting the vessels distal to the occlusion site because acute ischemic stroke patients tend to have chronic kidney disease and patients with severe chronic kidney disease are at an increased risk of contrast-associated acute kidney injury. We assessed whether vessels distal to the occlusion site during acute ischemic stroke with large-vessel occlusion could be visualized on angiographic images using flat panel detector CT acquired following intra-arterial diluted contrast injection, compared with MRA findings. MATERIALS AND METHODS Between May 2019 and January 2020, we enrolled 28 consecutive patients with large-vessel occlusions of the anterior circulation eligible for mechanical thrombectomy following MR imaging. The patients underwent CBV imaging using flat panel detector CT with an intra-arterial diluted contrast injection instead of intravenous injection. Flat panel detector CT angiographic images reconstructed from the same dataset were evaluated for image quality, collateral status of the MCA territory, and visualization of the vessels distal to the occlusion site. These findings were compared with MRA findings. RESULTS Twenty-two patients were retrospectively examined. Flat panel detector CT angiographic image quality in 20 patients (91%) was excellent or good. The distal portion of the occluded vessel segment was visualized in 14 patients (70%), while the proximal portion of the segment adjacent to the occluded vessel in 3 (15%) was visualized. No visualization was observed in only 1 patient (5%) with no collateral supply. Flat panel detector CT angiographic images were shown to evaluate vessels distal to the occlusion site more accurately than MRA. CONCLUSIONS In acute ischemic stroke with large-vessel occlusion, flat panel detector CT angiographic images could successfully visualize vessels distal to the occlusion site with a small amount of contrast material.
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Affiliation(s)
- T Nozaki
- From the Department of Neurosurgery (T.N., M.N., M.K., K.A., H.K.), Yokohama Shin-Midori General Hospital, Kanagawa, Japan
- Department of Neurological Surgery (T.N., A.M.), Nippon Medical School Hospital, Tokyo, Japan
| | - M Noda
- From the Department of Neurosurgery (T.N., M.N., M.K., K.A., H.K.), Yokohama Shin-Midori General Hospital, Kanagawa, Japan
| | - T Ishibashi
- Department of Neurosurgery (T.I.), Jikei University School of Medicine, Tokyo, Japan
| | - K Otani
- Siemens Healthcare K.K. (K.O.), Tokyo, Japan
| | - M Kogiku
- From the Department of Neurosurgery (T.N., M.N., M.K., K.A., H.K.), Yokohama Shin-Midori General Hospital, Kanagawa, Japan
| | - K Abe
- From the Department of Neurosurgery (T.N., M.N., M.K., K.A., H.K.), Yokohama Shin-Midori General Hospital, Kanagawa, Japan
| | - H Kishi
- From the Department of Neurosurgery (T.N., M.N., M.K., K.A., H.K.), Yokohama Shin-Midori General Hospital, Kanagawa, Japan
| | - A Morita
- Department of Neurological Surgery (T.N., A.M.), Nippon Medical School Hospital, Tokyo, Japan
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48
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Liu Z, Sanossian N, Starkman S, Avila-Rinek G, Eckstein M, Sharma LK, Liebeskind D, Conwit R, Hamilton S, Saver JL. Adiposity and Outcome After Ischemic Stroke: Obesity Paradox for Mortality and Obesity Parabola for Favorable Functional Outcomes. Stroke 2020; 52:144-151. [PMID: 33272129 DOI: 10.1161/strokeaha.119.027900] [Citation(s) in RCA: 26] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND AND PURPOSE A survival advantage among individuals with higher body mass index (BMI) has been observed for diverse acute illnesses, including stroke, and termed the obesity paradox. However, prior ischemic stroke studies have generally tested only for linear rather than nonlinear relations between body mass and outcome, and few studies have investigated poststroke functional outcomes in addition to mortality. METHODS We analyzed consecutive patients with acute ischemic stroke enrolled in a 60-center acute treatment trial, the NIH FAST-MAG acute stroke trial. Outcomes at 3 months analyzed were (1) death; (2) disability or death (modified Rankin Scale score, 2-6); and (3) low stroke-related quality of life (Stroke Impact Scale<median). Relations with BMI were analyzed univariately and in multivariate models adjusting for 14 additional prognostic variables. RESULTS Among 1033 patients with acute ischemic stroke, average age was 71 years (±13), 45.1% female, National Institutes of Health Stroke Scale 10.6 (±8.3), and BMI 27.5 (±5.6). In both unadjusted and adjusted analysis, increasing BMI was linearly associated with improved 3-month survival (P=0.01) odds ratios in adjusted analysis for mortality declined across the BMI categories of underweight (odds ratio, 1.7 [CI, 0.6-4.9]), normal (odds ratio, 1), overweight (0.9 [CI, 0.5-1.4]), obese (0.5, [CI, 0.3-1.0]), and severely obese (0.4 [CI, 0.2-0.9]). In unadjusted analysis, increasing BMI showed a U-shaped relation to poststroke disability or death (modified Rankin Scale score, 2-6), with odds ratios of modified Rankin Scale score, 2 to 6 for underweight, overweight, and obese declined initially when compared with normal weight patients, but then increased again in severely obese patients, suggesting a U-shaped or J-shaped relation. After adjustment, including for baseline National Institutes of Health Stroke Scale, modified Rankin Scale score 2 to 6 was no longer related to adiposity. CONCLUSIONS Mortality and functional outcomes after acute ischemic stroke have disparate relations with patients' adiposity. Higher BMI is linearly associated with increased survival; and BMI has a U-shaped or J-shaped relation to disability and stroke-related quality of life. Potential mechanisms including nutritional reserve aiding survival during recovery and greater frequency of atherosclerotic than thromboembolic infarcts in individuals with higher BMI.
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Affiliation(s)
- Zuolu Liu
- Sutter Health, CPMC Comprehensive Stroke Care Center (Z.L.)
| | | | - Sidney Starkman
- University of California, Los Angeles (S.S., G.A.-R., L.K.S., D.L., J.L.S.)
| | - Gilda Avila-Rinek
- University of California, Los Angeles (S.S., G.A.-R., L.K.S., D.L., J.L.S.)
| | | | - Latisha K Sharma
- University of California, Los Angeles (S.S., G.A.-R., L.K.S., D.L., J.L.S.)
| | - David Liebeskind
- University of California, Los Angeles (S.S., G.A.-R., L.K.S., D.L., J.L.S.)
| | - Robin Conwit
- National Institute of Neurological Disorders and Stroke (R.C.)
| | | | - Jeffrey L Saver
- University of California, Los Angeles (S.S., G.A.-R., L.K.S., D.L., J.L.S.)
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49
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Ritvonen J, Sairanen T, Silvennoinen H, Virtanen P, Salonen O, Lindsberg PJ, Strbian D. Outcomes and long-term mortality after basilar artery occlusion-A cohort with up to 20 years' follow-up. Eur J Neurol 2020; 28:816-822. [PMID: 33141492 DOI: 10.1111/ene.14628] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2020] [Accepted: 10/28/2020] [Indexed: 11/27/2022]
Abstract
BACKGROUND The data on long-term outcome after basilar artery occlusion (BAO) are scarce. Little is known about BAO survivors´ outcome over decades. AIM We set out to investigate long-term survival and causes of death in BAO patients with up to two decades of follow-up. We also evaluated differences in outcome trends. METHODS Two hundred and seven BAO patients treated with intravenous thrombolysis (IVT) at the Department of Neurology, Helsinki University Hospital, between 1995 and 2016, were analyzed. Short-term outcome was assessed by modified Rankin Scale (mRS) at 3 months. Long-term cumulative survival rate was analyzed using Kaplan-Meier analysis. Factors associated with mortality were analyzed with Cox regression. RESULTS Moderate outcome (mRS 0-3) was achieved in 41.1% and good outcome (mRS 0-2) in 30.4% of patients at 3 months. Three-month mortality was 39.6%, of which 89% died within the first month. The median follow-up time in 3-month survivors was 8.9 years (maximum 21.8 years). Total mortality during follow-up was 52.2%. Cumulative mortality rate was 25.7%. Older age, coronary artery disease and more extensive ischemic changes on admission brain imaging were independently associated with long-term mortality. After the acute phase, the rate of other vascular causes of death increased in relation to stroke. CONCLUSIONS The described evolution of a large, single-center BAO cohort shows a trend towards a higher rate of good and/or moderate outcome during later years in IVT-treated patients. Survivors showed relative longevity, and the rate of cardiac and other vascular causes of death increased in relation to stroke sequelae over the long term.
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Affiliation(s)
- Juhani Ritvonen
- Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Tiina Sairanen
- Clinical Neurosciences, University of Helsinki, Helsinki, Finland.,Neurological Research Unit, Department of Neurology, Neurocenter, Helsinki University Hospital, Helsinki, Finland
| | - Heli Silvennoinen
- Helsinki Medical Imaging Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Pekka Virtanen
- Helsinki Medical Imaging Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Oili Salonen
- Helsinki Medical Imaging Center, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Perttu J Lindsberg
- Clinical Neurosciences, University of Helsinki, Helsinki, Finland.,Neurological Research Unit, Department of Neurology, Neurocenter, Helsinki University Hospital, Helsinki, Finland
| | - Daniel Strbian
- Clinical Neurosciences, University of Helsinki, Helsinki, Finland.,Neurological Research Unit, Department of Neurology, Neurocenter, Helsinki University Hospital, Helsinki, Finland
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50
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Fasen BACM, Heijboer RJJ, Hulsmans FJH, Kwee RM. Diagnostic performance of single-phase CT angiography in detecting large vessel occlusion in ischemic stroke: A systematic review. Eur J Radiol 2020; 134:109458. [PMID: 33302028 DOI: 10.1016/j.ejrad.2020.109458] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2020] [Revised: 09/24/2020] [Accepted: 11/30/2020] [Indexed: 11/17/2022]
Abstract
PURPOSE To systematically review the diagnostic performance of single-phase CT angiography (CTA) in detecting intracranial large vessel occlusion (LVO). METHOD MEDLINE and Embase were searched for studies investigating the diagnostic performance of single-phase CTA in detecting LVO. Study quality was assessed. Sensitivity and specificity were calculated and meta-analyzed with a bivariate random-effects model. Heterogeneity was assessed with a chi-squared test. RESULTS Eleven studies were included. High risk of bias with regard to "patient selection", "reference standard", and "flow and timing" was present in 4, 1, and 2 studies, respectively. In 7 studies, it was unclear whether reference tests were interpreted blinded to CTA readings. There was variability in types of vessel segments analyzed, resulting in heterogeneous sensitivity and specificity (P < 0.05). Two studies provided data for the proximal anterior circulation (distal intracranial carotid artery, A1-, A2-, M1- and M2-segments), with pooled sensitivity of 88.4 % (95 % CI: 62.2-97.2 %) and pooled specificity of 98.5 % (95 % CI: 33.2-100 %). One study suggested that multiphase CTA improved agreement between nonexperts and an expert in detecting A1-, A2-, M1-, M2-, and M3-segment occlusions compared to single-phase CTA (ĸ = 0.72-0.76 vs. ĸ = 0.32-0.45). No other included study reported added value of advanced CTA (CT perfusion, 4D-CTA, or multiphase CTA) compared to single-phase CTA in detecting proximal anterior circulation LVO. CONCLUSION There is lack of high-quality studies on the diagnostic performance of single-phase CTA for LVO detection in the proximal anterior circulation. The added value of advanced CTA techniques in detecting proximal anterior circulation LVO is not completely clear yet.
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Affiliation(s)
- Bram A C M Fasen
- Department of Radiology, Zuyderland Medical Center, Heerlen/Sittard/Geleen, the Netherlands
| | - Roeland J J Heijboer
- Department of Radiology, Zuyderland Medical Center, Heerlen/Sittard/Geleen, the Netherlands
| | - Frans-Jan H Hulsmans
- Department of Radiology, Zuyderland Medical Center, Heerlen/Sittard/Geleen, the Netherlands
| | - Robert M Kwee
- Department of Radiology, Zuyderland Medical Center, Heerlen/Sittard/Geleen, the Netherlands.
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