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Martín-Gutiérrez A, Leal-Vega L, Coco-Martín MB, Arenillas-Lara JF. A systematic review of the socioeconomic impact of mechanical thrombectomy for acute ischemic stroke. J Stroke Cerebrovasc Dis 2024; 33:107906. [PMID: 39127180 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107906] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Revised: 07/25/2024] [Accepted: 07/29/2024] [Indexed: 08/12/2024] Open
Abstract
BACKGROUND Mechanical Thrombectomy (MT) is an efficacious treatment for severe acute ischemic stroke patients. However, access to MT is limited in many parts of the world, partly due to economic barriers. The purpose of this systematic review is to provide an updated frame about the socioeconomic impact of MT. METHODS To carry out this systematic review we used the PRISMA guidelines. We included scientific articles analyzing the socioeconomic impact of MT for acute ischemic stroke, in which MT was compared to best medical therapy (BMT). The online databases of Pubmed, Scopus and Web of Science were used as main sources of information. To carry out the comparative analysis, the incremental cost-effectiveness ratio (ICER) was used, relating the cost to quality-adjusted life-year (QALY). Risk of bias was assessed with the Consensus Health Economic Criteria (CHEC) and the Consolidated Health Economic Evaluation Reporting Standards (CHEERS). RESULTS Eight hundred thirty-two studies were identified in this systematic review. As a result, studies that used cost-effectiveness analysis show that MT saves costs in the long term and cost-utility analysis show that the cost per QALY is reasonable with a mean ICER value of $14242.36/QALY. CONCLUSIONS MT has a favorable socioeconomic impact, as derived from cost-effectiveness and cost-utility analyses. Therefore, public policies should encourage the implementation of MT for stroke patients around the world.
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Affiliation(s)
- Adrián Martín-Gutiérrez
- Group of Applied Clinical Neurosciences, Department of Medicine, Dermatology and Toxicology, University of Valladolid, Valladolid, Spain
| | - Luis Leal-Vega
- Group of Applied Clinical Neurosciences, Department of Medicine, Dermatology and Toxicology, University of Valladolid, Valladolid, Spain
| | - María Begoña Coco-Martín
- Group of Applied Clinical Neurosciences, Department of Medicine, Dermatology and Toxicology, University of Valladolid, Valladolid, Spain.
| | - Juan F Arenillas-Lara
- Group of Applied Clinical Neurosciences, Department of Medicine, Dermatology and Toxicology, University of Valladolid, Valladolid, Spain; Stroke Unit & Stroke Program, Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
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Lun R, Sreekrishnan A, Liu HY, Albers GW. Ischemic core volumes and collateral status have diurnal fluctuations - A retrospective cohort study of 18,137 patients. J Stroke Cerebrovasc Dis 2024; 33:107965. [PMID: 39187216 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107965] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 08/12/2024] [Accepted: 08/22/2024] [Indexed: 08/28/2024] Open
Abstract
INTRODUCTION Recent observations suggest that circadian rhythms are implicated in the timing of stroke onset and the speed of infarct progression. We aimed to replicate these observations in a large, multi-center, automated imaging database. METHODS The RAPID Insights database was queried from 02/01/2016 to 01/31/2022 for patients with perfusion imaging and automated detection of an ischemic stroke due to a presumed large vessel occlusion. Exclusion criteria included: patient age ≤25, mismatch volume of <0 cc, and failure to register a positive value on either relative cerebral blood flow (rCBF) reduction of 38% less than normal or total mismatch volume. Imaging time was subdivided into three epochs: Night: 23:00h-06:59h and Day: 07:00h-14:59h, and Evening: 15:00h-22:59h. Perfusion parameters were defined using standard conventions for core volume, penumbra, and collateral circulation (measured via the Hypoperfusion Intensity Ratio, HIR). Statistical significance was tested using a sinusoidal regression analysis. RESULTS A total of 18,137 cases were analyzed. The peak incidence of stroke imaging of patients with LVOs occurred around noon. A sinusoidal pattern was present, with larger ischemic core volumes and higher HIR during the night compared to the day: peak ischemic core volume of 23.4 cc occurred with imaging performed at 3:56 AM (p<0.001) and peak HIR of 0.35 at 3:40 AM (p<0.001). CONCLUSION We found that ischemic core volumes were larger and collateral status worse at nighttime compared to daytime in this large national database. These findings support prior data suggesting that poor collateral recruitment with subsequent larger ischemic stroke volumes may occur at night.
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Affiliation(s)
- Ronda Lun
- Department of Neurology, Stanford Hospital, Palo Alto, CA, United States.
| | - Anirudh Sreekrishnan
- Department of Neurology, Stanford Hospital, Palo Alto, CA, United States; Department of Neurology, University of California, San Francisco, United States.
| | - Hung-Yu Liu
- Department of Neurology, Neurological Institute, Taipei Veterans General Hospital, Taipei, Taiwan; School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Gregory W Albers
- Department of Neurology, Stanford Hospital, Palo Alto, CA, United States.
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Ray B, Mathews EP, Hernandez RS, Glaser KR, Washington HH, Salter A, Olson DM, Aiyagari V. Clinical outcome and cost effectiveness of acute ischemic stroke transfers for endovascular reperfusion therapy from geographically distant counties: Stroke transfer outcomes. J Stroke Cerebrovasc Dis 2024; 33:107981. [PMID: 39218419 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2024] [Revised: 07/16/2024] [Accepted: 08/27/2024] [Indexed: 09/04/2024] Open
Abstract
OBJECTIVES Endovascular reperfusion therapy (EVT) for acute ischemic stroke (AIS) with large vessel occlusion (LVO) has resulted in increased patient transfers to comprehensive stroke centers (CSCs). Clinical outcomes including the financial impact of these transfers from geographically dispersed population are lacking. Hence, we studied outcomes and cost-effectiveness of stroke transfers from remote areas. MATERIALS AND METHODS We used a 3-year cohort of AIS patients transferred from geographically dispersed counties (<100 mi., 101-200 mi., and >200 mi.). A 3-month modified Rankin scale (mRS) score of 0-2 defined a favorable clinical outcome. Cost-effectiveness is studied by calculating the incremental cost effectiveness ratio, using hospital costs reimbursed data and utility-weighted (UW)-mRS. RESULTS Among 172 patients transferred for EVT, patients transferred from nearby counties were more likely to undergo intervention compared to other counties (56.9 % vs. 36.7 % vs. 49.2 % p = .11). Irrespective of proximity (in mi.) to CSC [21.5 (14-56.3)] vs. 185 (137-185) vs. 349 (325-355)], there was a similar delay (in min.) to arrival from all locations [321.5 (244-490), 366 (298-432), and 460 (385-554.5) respectively], but no statistically significant differences in favorable outcomes (18.0 %, 34.1 %, and 22.2 %, respectively, p = .41). Patients undergoing EVT had higher hospital costs reimbursed compared to non-EVT patients [$37,303 (25,745-40,658) vs. $14,008 (8,640-21,273) respectively, p < .001] and no statistically significant difference in UW-mRS [0.32 (0.06-0.56) vs. 0.06 (0-0.56), p = .30]. CONCLUSIONS Our study identifies a need for targeted interventions to improve community awareness and optimize systems of care to improve outcomes and cost-effectiveness of EVT.
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Affiliation(s)
- Bappaditya Ray
- Division of Neurocritical Care, Department of Neurology and Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA; Peter O'Donnell Brain Institute, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Essie P Mathews
- Division of Neurocritical Care, Department of Neurology and Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA; Peter O'Donnell Brain Institute, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Roberto S Hernandez
- Division of Statistical Planning and Analysis, Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Peter O'Donnell Brain Institute, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Kimberly R Glaser
- Division of Neurocritical Care, Department of Neurology and Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA; Peter O'Donnell Brain Institute, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Heather H Washington
- Division of Neurocritical Care, Department of Neurology and Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA; Peter O'Donnell Brain Institute, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Amber Salter
- Division of Statistical Planning and Analysis, Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA; Peter O'Donnell Brain Institute, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - DaiWai M Olson
- Division of Neurocritical Care, Department of Neurology and Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA; Peter O'Donnell Brain Institute, University of Texas Southwestern Medical Center, Dallas, TX, USA.
| | - Venkatesh Aiyagari
- Division of Neurocritical Care, Department of Neurology and Neurological Surgery, University of Texas Southwestern Medical Center, Dallas, TX, USA; Peter O'Donnell Brain Institute, University of Texas Southwestern Medical Center, Dallas, TX, USA.
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Chen P, Sun X, Yang L, Xu B, Ding Y, Zhao Y, Leng X, Yan B, Tan Z. Ischemic core volume is associated with hemorrhagic transformation post endovascular thrombectomy. J Stroke Cerebrovasc Dis 2024; 33:107889. [PMID: 39116962 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107889] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 07/08/2024] [Accepted: 07/24/2024] [Indexed: 08/10/2024] Open
Abstract
INTRODUCTION Symtomatic hemorrhagic transformation(sHT) was defined as any intracerebral hemorrhage that combined with clinical deterioration. While recent studies showed low rates of sHT in large core ischemic strokes treated with endovascular thrombectomy (EVT), the specific impact of core size on overall hemorrhagic transformation (HT) remains unclear. We aim to investigate the relationship between ischemic core size and development of HT post thrombectomy. METHODS This prospective study enrolled acute ischemic stroke (AIS) patients with anterior large vessel occlusion undergoing EVT who had baseline MRI from 2017 to 2019. Pre-EVT Arterial Spin Labeling (ASL) and Diffusion-Weighted Imaging (DWI) scans were performed for volume calculations. Primary outcome was HT assessed within 72 h post EVT. Multivariable logistic regression was used to analyze the associations between baseline DWI and ASL volumes and HT occurrence. Discriminative ability for HT was compared using receiver operating curve analysis (c-statistic). RESULTS We included 101 patients (median age: 64 [IQR 56-74] years, baseline NIHSS 13 [IQR 9-16]). Median DWI and ASL volume were 21.0 ml [IQR 8.3-47.2] and 105 ml [59.5-172.9], respectively. 16.8 % recieved intravenous thrombolysis before EVT. HT occurred in 36.6 % of patients, including 16.8 % with sHT. Baseline DWI volume was independently associated with HT (OR = 1.030, 95 % CI 1.008 to 1.053, P = 0.009), while ASL volume wasn't statistically significant(P = 0.330). The DWI model was superior to ASL model in predicting HT within 72 h (c-statistic, 0.787).Neither DWI (P = 0.149) nor ASL volume (P = 0.834) effectively indicated sHT. CONCLUSIONS DWI-based ischemic core volume correlates significantly with HT within 72 h post successful thrombectomy. This highlights the potential clinical utility of DWI in guiding treatment decisions for this population.
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Affiliation(s)
- Ping Chen
- The School of Clinical Medicine, Fujian Medical University, Fuzhou 350122, China; Department of Neurology, the First Hospital of Putian City, Putian 351100, China
| | - Xin Sun
- Department of Outpatient, the First Affiliated Hospital of Jinan University, Guangzhou 510630, China; Department of Neurology, the First Affiliated Hospital of Jinan University, Guangzhou 510630, China
| | - Liu Yang
- Department of Neurology, the Affiliated Hospital of Xiangnan University, Chenzhou 423000, China
| | - Bingdong Xu
- Department of Neurology, the First Affiliated Hospital of Jinan University, Guangzhou 510630, China
| | - Yan Ding
- Department of Neurology, the First Affiliated Hospital of Jinan University, Guangzhou 510630, China
| | - Ying Zhao
- Department of Neurology, the First Affiliated Hospital of Jinan University, Guangzhou 510630, China
| | - Xinyi Leng
- Department of Medicine and Therapeutics, the Chinese University of Hong Kong, Hong Kong SAR 999077, China
| | - Bernard Yan
- Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Melbourne 3010, Australia
| | - Zefeng Tan
- Department of Neurology, the First People's Hospital of Foshan, Foshan 528000, China; Department of Neurology, Shun De Hospital of Jinan University, Foshan 528306, China.
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Chen L, Cui L, Ji YF, Li X. The role of neutrophil and LDL-C levels in predicting intracranial hemorrhage following endovascular thrombectomy in patients with acute ischemic stroke. J Stroke Cerebrovasc Dis 2024; 33:107925. [PMID: 39134160 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2024] [Revised: 07/12/2024] [Accepted: 08/09/2024] [Indexed: 09/07/2024] Open
Abstract
OBJECTIVES To investigate the association between intracranial hemorrhage (ICH) and preoperative levels of neutrophils and low-density lipoprotein-cholesterol (LDL-C) in acute ischemic stroke (AIS) patients following endovascular thrombectomy (EVT), and to assess the predictive value of preoperative levels of neutrophils and LDL-C. METHODS A retrospective analysis was performed on the clinical records of patients diagnosed with AIS who underwent EVT at Nanchong Central Hospital between 2019 and 2023. Multivariate regression analysis was employed to examine the association of preoperative levels of neutrophils and LDL-C with the occurrence of ICH. Furthermore, a receiver operating characteristic curve was constructed to assess the predictive efficacy of these parameters. RESULTS A total of 300 patients with a mean age of 68.0 years (standard deviation, 11.1 years) and a median baseline National Institutes of Health Stroke scale (NIHSS) score of 15.5 (interquartile range, 12.0-19.75) were identified in this cohort. Of these, 28 (9.3%) patients experienced ICH. Multivariate regression analysis revealed that elevated preoperative neutrophil (odds ratio [OR] 1.23, 95% confidence interval [CI] 1.10-1.38, P < 0.001) and LDL-C (OR 2.64, 95% CI 1.52-4.58, P < 0.001) levels were independently associated with ICH. The combined indicator demonstrated a higher area under the curve (AUC 0.759, 95% CI 0.654-0.865) compared with preoperative neutrophil (AUC 0.647, 95% CI 0.532-0.763) and LDL-C (AUC 0.711, 95% CI 0.607-0.814) levels individually.The specificity and sensitivity of the combined indicator were 67.9% and 83.1%, respectively. CONCLUSIONS Preoperative levels of neutrophils and LDL-C may serve as predictive indicators for ICH in patients with AIS who have undergone EVT; moreover, the combination of preoperative neutrophil and LDL-C levels demonstrates enhanced predictive efficacy.
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Affiliation(s)
- Li Chen
- Department of Neurology, The Second Hospital of Tianjin Medical University, Tianjin, China; Department of Neurology, Nanchong Central Hospital/The Second Clinical Medical College of North Sichuan Medical University, Sichuan, China
| | - Lei Cui
- Department of Neurology, Tianjin Third Central Hospital, Tianjin, China
| | - Yi-Fei Ji
- Department of Neurology, Nanchong Central Hospital/The Second Clinical Medical College of North Sichuan Medical University, Sichuan, China
| | - Xin Li
- Department of Neurology, The Second Hospital of Tianjin Medical University, Tianjin, China.
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Creary S, Chung MG, Villella AD, Lo WD. Stroke Prevention and Treatment for Youth with Sickle Cell Anemia: Current Practice and Challenges and Promises for the Future. Curr Neurol Neurosci Rep 2024; 24:537-546. [PMID: 39304580 PMCID: PMC11455693 DOI: 10.1007/s11910-024-01372-9] [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] [Accepted: 08/14/2024] [Indexed: 09/22/2024]
Abstract
PURPOSE OF REVIEW Sickle cell anemia (SCA) is an autosomal recessive inherited hemoglobinopathy that results in a high risk of stroke. SCA primarily affects an underserved minority population of children who are frequently not receiving effective, multi-disciplinary, preventative care. This article reviews primary and secondary stroke prevention and treatment for children with SCA for the general adult and pediatric neurologist, who may play an important role in providing critical neurologic evaluation and care to these children. RECENT FINDINGS Primary stroke prevention is efficacious at reducing ischemic stroke risk, but it is not consistently implemented into clinical practice in the United States, resulting in these children remaining at high risk. Acute symptomatic stroke management requires neurology involvement and emergent transfusion to limit ischemia. Furthermore, while chronic transfusion therapy is a proven secondary preventative modality for those with prior symptomatic or silent cerebral infarcts, it carries significant burden. Newer therapies (e.g., stem cell therapies and voxelotor) deserve further study as they may hold promise in reducing stroke risk and treatment burden. Effective primary and secondary stroke prevention and treatment remain a challenge. Informing and engaging neurology providers to recognize and provide critical neurologic evaluation and treatment has potential to close care gaps.
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Affiliation(s)
- Susan Creary
- Division of Hematology/Oncology/BMT, Dept of Pediatrics, The Ohio State University and Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Melissa G Chung
- Division of Neurology, Dept of Pediatrics, The Ohio State University and Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
- Division of Critical Care, Dept of Pediatrics, The Ohio State University and Nationwide Children's Hospital, Columbus, OH, 43205, USA
| | - Anthony D Villella
- Division of Hematology/Oncology/BMT, Dept of Pediatrics, The Ohio State University and Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA
| | - Warren D Lo
- Division of Neurology, Dept of Pediatrics, The Ohio State University and Nationwide Children's Hospital, 700 Children's Drive, Columbus, OH, 43205, USA.
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Da Ros V, Cavallo A, Di Donna C, D'Onofrio A, Trulli M, Di Candia S, Mancini L, Funari L, Cecchi G, Carini A, Madonna M, Sabuzi F, Di Giuliano F, Zelenak K, Diomedi M, Maestrini I, Garaci F. Ensemble machine learning to predict futile recanalization after mechanical thrombectomy based on non-contrast CT imaging. J Stroke Cerebrovasc Dis 2024; 33:107890. [PMID: 39116963 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107890] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2024] [Revised: 07/20/2024] [Accepted: 07/24/2024] [Indexed: 08/10/2024] Open
Abstract
OBJECTIVES Despite successful recanalization after Mechanical Thrombectomy (MT), approximately 25 % of patients with Acute Ischemic Stroke (AIS) due to Large Vessel Occlusion (LVO) show unfavorable clinical outcomes, namely Futile Recanalization (FR). We aimed to use a Machine Learning (ML) Non-Contrast brain CT (NCCT) imaging predictive model to identify FR in patients undergoing MT. MATERIALS & METHODS Between July 2022 and December 2022, 70 consecutive patients with LVO undergoing a complete recanalization (eTICI 3) with MT within 8 h from onset at our Centre were analyzed. Two NCCT images per patient of middle cerebral artery vascular territory and patients' clinical characteristics were classified by the presence of ischemic features on 24 h NCCT after MT. Each slice was segmented with "Mazda" software ver.4.6 by placing a Region Of Interest (ROI) on the whole brain by two radiologists in consensus. A total of 381 features were extracted for each slice. The dataset was split into train and test set with a 70:30 ratio. RESULTS Eleven classification models were trained. An Ensemble Machine Learning (EML) model was obtained by averaging the predictions of models with accuracy on a test set >70 %, with and without patients' clinical characteristics. The EML model combined with clinical data showed an accuracy of 0.76, a sensitivity of 0.88, a specificity of 0.69 with a NPV of 0.90, a PPV of 0.64, with AUC of 0.84. CONCLUSION NCCT and ML analysis shows promise in predicting FR after complete recanalization following MT in AIS patients. Larger studies are required to confirm these preliminary results.
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Affiliation(s)
- Valerio Da Ros
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome 00133, Italy.
| | - Armando Cavallo
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome 00133, Italy
| | - Carlo Di Donna
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome 00133, Italy
| | - Adolfo D'Onofrio
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome 00133, Italy
| | | | - Simone Di Candia
- University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome, Italy
| | - Ludovica Mancini
- University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome, Italy
| | - Luca Funari
- University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome, Italy
| | - Gianluca Cecchi
- University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome, Italy
| | - Alessandro Carini
- University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome, Italy
| | - Matteo Madonna
- University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome, Italy
| | - Federico Sabuzi
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome 00133, Italy
| | - Francesca Di Giuliano
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome 00133, Italy
| | - Kamil Zelenak
- Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Kollarova 2, Martin 03659, Slovakia
| | - Marina Diomedi
- Stroke Center, Department of Systems Medicine, University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome, Italy
| | - Ilaria Maestrini
- Stroke Center, Department of Systems Medicine, University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome, Italy
| | - Francesco Garaci
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Viale Oxford 81, Rome 00133, Italy
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Dhillon PS, Marei O, Podlasek A, Butt W, Rice H, de Villiers L, do Nascimento VC, McConachie N, Lenthall R, Nair S, Malik L, Bhogal P, Dineen RA, England TJ. Endovascular thrombectomy vs best medical management for late presentation acute ischaemic stroke with large vessel occlusion without CT perfusion or MR imaging selection: A systematic review and meta-analysis. J Stroke Cerebrovasc Dis 2024; 33:108002. [PMID: 39245396 DOI: 10.1016/j.jstrokecerebrovasdis.2024.108002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Revised: 09/04/2024] [Accepted: 09/06/2024] [Indexed: 09/10/2024] Open
Abstract
BACKGROUND The efficacy and safety of endovascular thrombectomy (EVT) beyond 6 hours from stroke onset for patients with large vessel occlusion (LVO) selected without CT perfusion(CTP) or MR imaging(MRI) is undetermined. We conducted a systematic review and meta-analysis of the current literature comparing outcomes for late presenting patients with LVO treated by best medical management (BMM) with those selected for EVT based only on non-contrast CT(NCCT)/CT angiography(CTA) (without CTP or MRI). METHODS PRISMA guidelines were employed. The primary outcome was functional independence (modified Rankin Scale 0-2) at 3 months. Secondary outcomes were symptomatic intracranial haemorrhage (sICH) and mortality at 3 months. Data were analysed using the random-effects model. RESULTS Six studies of 2083 patients, including three randomised controlled trials, were included; 1271 patients were treated with EVT and 812 patients with BMM. Compared to BMM, patients treated with EVT demonstrated higher odds of achieving functional independence (39.0 % EVT vs 22.0 % BMM; OR = 2.55, 95 %CI 1.61-4.05,p < 0.0001, I2 = 74 %). The rates of sICH (OR = 2.09, 95 %CI 0.86-5.04,p = 0.10) and mortality (OR = 0.62, 95 %CI 0.35-1.10,p = 0.10) were not significantly different between each cohort. CONCLUSION Compared to BMM, late presenting stroke patients selected for EVT eligibility with NCCT/CTA only and treated with EVT achieved significantly higher rates of functional independence at 90 days, without increasing the incidence of sICH or mortality. Whilst these findings indicate that NCCT/CTA only may be used for EVT eligibility selection for patients who present beyond 6 hours from stroke onset, the results should be interpreted with caution due to the substantial heterogeneity between studies.
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Affiliation(s)
- Permesh Singh Dhillon
- Interventional Neuroradiology, Gold Coast University Hospital, Southport, Queensland, Australia; Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom; Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom.
| | - Omar Marei
- Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom.
| | - Anna Podlasek
- Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom; Tayside Innovation Medtech Ecosystem (TIME), University of Dundee, United Kingdom.
| | - Waleed Butt
- Interventional Neuroradiology, Queen Elizabeth Hospital, University Hospitals Birmingham NHS Trust, Birmingham, United Kingdom.
| | - Hal Rice
- Interventional Neuroradiology, Gold Coast University Hospital, Southport, Queensland, Australia.
| | - Laetitia de Villiers
- Interventional Neuroradiology, Gold Coast University Hospital, Southport, Queensland, Australia.
| | | | - Norman McConachie
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom.
| | - Robert Lenthall
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom.
| | - Sujit Nair
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom.
| | - Luqman Malik
- Interventional Neuroradiology, Queens Medical Centre, Nottingham University Hospitals NHS Trust, Nottingham, United Kingdom.
| | - Pervinder Bhogal
- Interventional Neuroradiology, Royal London Hospital, Barts Health NHS Trust, London, United Kingdom.
| | - Robert A Dineen
- Radiological Sciences, Mental Health & Clinical Neuroscience, University of Nottingham, Nottingham, United Kingdom; NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, United Kingdom.
| | - Timothy J England
- Stroke, Mental Health and Clinical Neuroscience, School of Medicine, University of Nottingham, Derby, United Kingdom; Stroke, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, United Kingdom.
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Legere B, Mohamed A, Elsherif S, Saqqur R, Schoenfeld D, Slebonick AM, McCartin M, Price J, Zachrison KS, Edlow JA, Saqqur M, Shuaib A, Thomas SH. Success with incrementally faster times to endovascular therapy (SWIFT-EVT): A systematic review and meta-analysis. J Stroke Cerebrovasc Dis 2024; 33:107964. [PMID: 39182706 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2024] [Revised: 08/18/2024] [Accepted: 08/21/2024] [Indexed: 08/27/2024] Open
Abstract
BACKGROUND A major systematic review and meta-analysis assessing trial data through 2014 (the Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials, HERMES) demonstrated that particularly over the initial six hours of acute ischemic stroke (AIS), rapid performance of endovascular therapy (EVT) markedly improves outcomes. The current analysis, Success with Incrementally Faster Times to EVT (SWIFT-EVT), aimed to provide an updated metric summarizing latest estimates for modified Rankin Scale (mRS) improvements accrued by streamlining time to EVT. METHODS A systematic review and meta-analysis was conducted using electronic databases. Eligible studies reported a time-benefit slope with times from AIS onset (or time last known normal) to EVT commencement; the predictor was onset-to-groin (OTG) time. Primary and secondary outcomes were 90-day functional independence (mRS 0-2) and 90-day excellent function (mRS 0-1), respectively. RESULTS Five studies were included. Results showed increased change of good outcome with each hour of pre-EVT time savings for mRS 0-2 for 0-270' (OR 1.25, 95 % CI 1.16-1.35, I2 40 %) and 271-360' time frame (1.22, 95 % CI 1.12-1.33, I2 58 %). For the studies assessing mRS 0-1, estimates were found appropriate for both the 0-270' time frame (OR 1.34, 95 % CI 1.19-1.51, I2 27 %) and the 271-360' time frame (OR 1.20, 95 % CI 1.03-1.38, I2 60 %). CONCLUSIONS Each hour saved from AIS onset to EVT start is associated with a 22-25 % increased odds of achieving functional independence, a useful metric to inform patient-specific and systems planning decisions.
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Affiliation(s)
- Brittney Legere
- Department of Applied Human Sciences, University of Guelph, Guelph, Ontario, Canada.
| | - Ahmed Mohamed
- Department of Physiology, Temerty Faculty of Medicine, University of Toronto, Ontario, Canada.
| | - Salah Elsherif
- Department of Health Sciences, Queens University, Kingston, Ontario, Canada.
| | - Razan Saqqur
- Department of Health, University of Waterloo, Waterloo, Ontario, Canada.
| | - David Schoenfeld
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, MA, USA.
| | | | - Michael McCartin
- Section of Emergency Medicine, University of Chicago, Chicago, IL, USA.
| | - James Price
- Department of Emergency Medicine, Cambridge University NHS Trust, Cambridge, UK.
| | - Kori S Zachrison
- Department of Emergency Medicine, Massachusetts General Hospital & Harvard Medical School, Boston, MA, USA.
| | - Jonathan A Edlow
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, MA, USA.
| | - Maher Saqqur
- Department of Neurology, University of Toronto, Mississauga, ON, Canada.
| | - Ashfaq Shuaib
- Department of Neurology, University of Alberta, Edmonton, AB, Canada.
| | - Stephen H Thomas
- Department of Emergency Medicine, Beth Israel Deaconess Medical Center & Harvard Medical School, Boston, MA, USA; Blizard Institute for Neuroscience, Surgery, & Trauma, Barts & The London School of Medicine, London, UK.
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Hayward KS, Dalton EJ, Campbell BCV, Khatri P, Dukelow SP, Johns H, Walter S, Yogendrakumar V, Pandian JD, Sacco S, Bernhardt J, Parsons MW, Saver JL, Churilov L. Adaptive Trials in Stroke: Current Use and Future Directions. Neurology 2024; 103:e209876. [PMID: 39325999 PMCID: PMC11436319 DOI: 10.1212/wnl.0000000000209876] [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: 04/09/2024] [Accepted: 07/22/2024] [Indexed: 09/28/2024] Open
Abstract
Inclusion of adaptive design features in a clinical trial provides preplanned flexibility to dynamically modify a trial during its conduct while preserving validity and integrity. Adaptive trials are needed to accelerate the conduct of more efficient, informative, and ethical clinical research in the field of neurology. Stroke is a natural candidate for adoption of these innovative approaches to trial design. This Research Methods in Neurology article is informed by a scoping review that identified 45 completed or ongoing adaptive clinical trials in stroke that were appraised: 15 trials had published results with or without a published protocol and 30 ongoing trials (14 trials had a published protocol, and 16 trials were registered only). Interventions spanned acute (n = 28), rehabilitation (n = 8), prevention (n = 8), and rehabilitation and prevention (n = 1). A subsample of these trials was selected to illustrate the utility of adaptive design features and discuss why each adaptive feature was incorporated in the design to best achieve the aim; whether each individual feature was used and whether it resulted in expected efficiencies; and any learnings during preparation, conduct, or reporting. We then discuss the operational, ethical, and regulatory considerations that warrant careful consideration during adaptive trial planning and reflect on the workforce readiness to deliver adaptive trials in practice. We conclude that adaptive trials can be designed, funded, conducted, and published for a wide range of research questions and offer future directions to support adoption of adaptive trial designs in stroke and neurologic research more broadly.
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Affiliation(s)
- Kathryn S Hayward
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Emily J Dalton
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Bruce C V Campbell
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Pooja Khatri
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Sean P Dukelow
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Hannah Johns
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Silke Walter
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Vignan Yogendrakumar
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Jeyaraj D Pandian
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Simona Sacco
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Julie Bernhardt
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Mark W Parsons
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Jeffrey L Saver
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
| | - Leonid Churilov
- From the Melbourne School of Health Sciences (K.S.H., E.J.D.), and Melbourne Medical School (K.S.H., H.J., L.C.), University of Melbourne, Parkville; Stroke Theme (K.S.H., B.C.V.C., J.B., L.C.), The Florey Institute, University of Melbourne, Heidelberg; National Health and Medical Research Council Centre of Research Excellence to Accelerate Stroke Trial Innovation and Translation (K.S.H., B.C.V.C., L.C., J.B., H.J.), University of Melbourne, Parkville; Department of Medicine and Neurology (B.C.V.C., V.Y.), Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia; Department of Neurology and Rehabilitation Medicine (P.K.), University of Cincinnati, OH; Department of Clinical Neuroscience (S.P.D.), and Hotchkiss Brain Institute (S.P.D.), University of Calgary, Alberta, Canada; Department of Neurology (S.W.), Saarland University, Saarbrücken; Department of Neurology (S.W.), Martin-Luther-University, Halle, Germany; Department of Neurology (V.Y.), University of Ottawa, Ontario, Canada; Department of Neurology (J.D.P.), Christian Medical College, Ludhiana, Punjab, India; Department of Biotechnological and Applied Clinical Sciences (S.S.), University of L'Aquila, Italy; Department of Neurology (M.W.P.), Liverpool Hospital, UNSW South Western Sydney Clinical School, Warwick Farm, Australia; Comprehensive Stroke Center and Department of Neurology (J.L.S.), University of California Los Angeles; and Australian Stroke Alliance (L.C.), University of Melbourne, Parkville, Victoria, Australia
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Hall E, Ullberg T, Andsberg G, Wasselius J. Incidence of intracranial hemorrhagic complications after anterior circulation endovascular thrombectomy in relation to occlusion site: a nationwide observational register study. J Neurointerv Surg 2024; 16:1088-1093. [PMID: 37798105 DOI: 10.1136/jnis-2023-020768] [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: 07/03/2023] [Accepted: 08/30/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND Intracranial hemorrhage (ICH) is a potentially severe complication of endovascular thrombectomy (EVT). However, the relationship between the incidence and severity of ICH and vascular occlusion location is not well described. OBJECTIVE To present a comprehensive analysis of subtypes of ICHs and their relationship to the occlusion site following EVT in the anterior circulation. METHODS All patients with anterior circulation vessel occlusion stroke (internal carotid (ICA) and middle cerebral artery's first (M1) and later segments (M2 and beyond)) registered in the two Swedish national quality registers for stroke care and endovascular therapy during 2015-2020 were included. Hemorrhagic complications identified on imaging within 36 hours post-EVT were classified according to Heidelberg Bleeding Classification and further divided into symptomatic (sICH) or non-symptomatic (non-sICH). RESULTS Of the 3077 patients, ICH frequency was 24.2%, which included 4.5% sICH. Subarachnoid hemorrhage (SAH) was the most frequent subtype of hemorrhage (10.9%). The hemorrhagic subtypes differed significantly by occlusion site, but the frequency of any bleed did not. EVT performed in and beyond the M2 more often resulted in SAH, frequently classified as non-sICH. EVT performed in the ICA was associated with more severe hemorrhages, such as intraventricular and large parenchymal hematomas, that were more often classified as sICH. CONCLUSION In this nationwide unselected EVT cohort we found that ICH severity significantly differed between different vessel occlusion sites.
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Affiliation(s)
- Emma Hall
- Department of Clinical Science, Lund University Faculty of Medicine, Lund, Sweden
- Department of Medical Imaging and Physiology, Skåne University Hospital Lund, Lund, Sweden
| | - Teresa Ullberg
- Department of Clinical Science, Lund University Faculty of Medicine, Lund, Sweden
- Department of Neurology, Skåne University Hospital Lund, Lund, Sweden
| | - Gunnar Andsberg
- Department of Clinical Science, Lund University Faculty of Medicine, Lund, Sweden
- Department of Neurology, Skåne University Hospital Lund, Lund, Sweden
| | - Johan Wasselius
- Department of Clinical Science, Lund University Faculty of Medicine, Lund, Sweden
- Department of Medical Imaging and Physiology, Skåne University Hospital Lund, Lund, Sweden
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Cimflova P, Ospel JM, Singh N, Marko M, Kashani N, Mayank A, Demchuk A, Menon B, Poppe AY, Nogueira R, McTaggart R, Rempel JL, Tymianski M, Hill MD, Almekhlafi MA, Goyal M. Effects of reperfusion grade and reperfusion strategy on the clinical outcome: Insights from ESCAPE-NA1 trial. Interv Neuroradiol 2024:15910199241288874. [PMID: 39397754 DOI: 10.1177/15910199241288874] [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: 10/15/2024] Open
Abstract
BACKGROUND We evaluated the association of reperfusion quality and different patterns of achieved reperfusion with clinical and radiological outcomes in the ESCAPE NA1 trial. METHODS Data are from the ESCAPE-NA1 trial. Good clinical outcome [90-day modified Rankin Scale (mRS) 0-2], excellent outcome (90-day mRS0-1), isolated subarachnoid hemorrhage, symptomatic hemorrhage (sICH) on follow-up imaging, and death were compared across different levels of reperfusion defined by expanded Treatment in Cerebral Infarction (eTICI) Scale. Comparisons were also made between patients with (a) first-pass eTICI 2c3 reperfusion vs multiple-pass eTICI 2c3; (b) final eTICI 2b reperfusion vs eTICI 2b converted-to-eTICI 2c3; (c) sudden reperfusion vs gradual reperfusion if >1 pass was required. Multivariable logistic regression was used to test associations of reperfusion grade and clinical outcomes. RESULTS Of 1037 included patients, final eTICI 0-1 was achieved in 46 (4.4%), eTICI 2a in 76 (7.3%), eTICI 2b in 424 (40.9%), eTICI 2c in 284 (27.4%), and eTICI 3 in 207 (20%) patients. The odds for good and excellent clinical outcome gradually increased with improved reperfusion grades (adjOR ranging from 5.7-29.3 and 4.3-17.6) and decreased for sICH and death. No differences in outcomes between first-pass versus multiple-pass eTICI 2c3, eTICI 2b converted-to-eTICI 2c3 versus unchanged eTICI 2b and between sudden versus gradual eTICI 2c3 reperfusion were observed. CONCLUSION Better reperfusion degrees significantly improved clinical outcomes and reduced mortality, independent of the number of passes and whether eTICI 2c3 was achieved suddenly or gradually.
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Affiliation(s)
- Petra Cimflova
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
- Department of Medical Imaging, St. Anne's University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern, Bern, Switzerland
| | - Johanna M Ospel
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, University of Calgary, Calgary, Alberta, Canada
| | - Nishita Singh
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Department of Internal Medicine-Neurology Division, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Martha Marko
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Department of Neurology, Medical University of Vienna, Vienna, Austria
| | - Nima Kashani
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Department of Radiology, Rady Faculty of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Arnuv Mayank
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Andrew Demchuk
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Bijoy Menon
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Alexandre Y Poppe
- Centre Hospitalier de l'Université de Montréal, Montreal, Quebec, Canada
| | - Raul Nogueira
- UPMC Stroke Institute, Department of Neurology and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Ryan McTaggart
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | | | | | - Michael D Hill
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mohammed A Almekhlafi
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Alberta, Canada
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Ash M, Dimisko L, Chalhoub RM, Howard BM, Cawley CM, Matouk C, Pabaney A, Spiotta AM, Jabbour P, Maier I, Wolfe SQ, Rai AT, Kim JT, Psychogios MN, Mascitelli JR, Starke RM, Shaban A, Yoshimura S, De Leacy R, Kan P, Fragata I, Polifka AJ, Arthur AS, Park MS, Crosa RJ, Williamson R, Dumont TM, Levitt MR, Al Kasab S, Tjoumakaris SI, Liman J, Saad H, Samaniego EA, Fargen KM, Grossberg JA, Alawieh A. Comprehensive analysis of the impact of procedure time and the 'golden hour' in subpopulations of stroke thrombectomy patients. J Neurointerv Surg 2024; 16:1069-1075. [PMID: 37875342 DOI: 10.1136/jnis-2023-020792] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2023] [Accepted: 09/19/2023] [Indexed: 10/26/2023]
Abstract
OBJECTIVE To evaluate the effect of procedure time on thrombectomy outcomes in different subpopulations of patients undergoing endovascular thrombectomy (EVT), given the recently expanded indications for EVT. METHODS This multicenter study included patients undergoing EVT for acute ischemic stroke at 35 centers globally. Procedure time was defined as time from groin puncture to successful recanalization (Thrombolysis in Cerebral Infarction score ≥2b) or abortion of procedure. Patients were stratified based on stroke location, use of IV tissue plasminogen activator (tPA), Alberta Stroke Program Early CT score, age group, and onset-to-groin time. Primary outcome was the 90-day modified Rankin Scale (mRS) score, with scores 0-2 designating good outcome. Secondary outcome was postprocedural symptomatic intracranial hemorrhage (sICH). Multivariate analyses were performed using generalized linear models to study the impact of procedure time on outcomes in each subpopulation. RESULTS Among 8961 patients included in the study, a longer procedure time was associated with higher odds of poor outcome (mRS score 3-6), with 10% increase in odds for each 10 min increment. When procedure time exceeded the 'golden hour', poor outcome was twice as likely. The golden hour effect was consistent in patients with anterior and posterior circulation strokes, proximal or distal occlusions, in patients with large core infarcts, with or without IV tPA treatment, and across age groups. Procedures exceeding 1 hour were associated with a 40% higher sICH rate. Posterior circulation strokes, delayed presentation, and old age were the variables most sensitive to procedure time. CONCLUSIONS In this work we demonstrate the universality of the golden hour effect, in which procedures lasting more than 1 hour are associated with worse clinical outcomes and higher rates of sICH across different subpopulations of patients undergoing EVT.
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Affiliation(s)
- Makenna Ash
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Laurie Dimisko
- Nell Hodgson Woodruff School of Nursing, Emory Healthcare, Atlanta, Georgia, USA
| | - Reda M Chalhoub
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Brian M Howard
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
- Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - C Michael Cawley
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Charles Matouk
- Department of Neurosurgery, Yale University, New Haven, Connecticut, USA
| | - Aqueel Pabaney
- Department of Neurosurgery, Grady Memorial Hospital, Atlanta, Georgia, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Ilko Maier
- Department of Neurology, University Medicine Goettingen, Goettingen, NS, Germany
| | - Stacey Q Wolfe
- Department of Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Ansaar T Rai
- Department of Interventional Neuroradiology, West Virginia University Rockefeller Neuroscience Institute, Morgantown, West Virginia, USA
| | - Joon-Tae Kim
- Department of Neurosurgery and Radiology, Chonnam National University, Gwangju, Jeollanam-do, Korea
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Justin R Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami, Florida, USA
- University of Miami School of Medicine, Miami, Florida, USA
| | - Amir Shaban
- Department of Neurology, University of Iowa Roy J and Lucille A Carver College of Medicine, Iowa City, Iowa, USA
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Reade De Leacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Peter Kan
- Department of Neurosurgery, University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Isabel Fragata
- Department of Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Adam J Polifka
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | - Adam S Arthur
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
- Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Min S Park
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Roberto Javier Crosa
- Department of Endovascular Neurosurgery, Médica Uruguaya, Montevideo, Montevideo, Uruguay
| | - Richard Williamson
- Stroke and Cerebrovascular Center, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - Travis M Dumont
- Department of Surgery, Division of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
| | - Michael R Levitt
- Department of Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Sami Al Kasab
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Jan Liman
- Department of Neurology, University Medicine Goettingen, Goettingen, NS, Germany
| | - Hassan Saad
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Edgar A Samaniego
- Department of Neurology, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Kyle M Fargen
- Department of Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Jonathan A Grossberg
- Department of Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Ali Alawieh
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA
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Saito M, Kawano H, Adachi T, Gomyo M, Yokoyama K, Shiokawa Y, Hirano T. The presence of a ghost infarct core is associated with fast core growth in acute ischemic stroke. Eur Stroke J 2024:23969873241289320. [PMID: 39397346 DOI: 10.1177/23969873241289320] [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: 10/15/2024] Open
Abstract
INTRODUCTION The overestimation of ischemic core volume by CT perfusion (CTP) is a critical concern in the selection of candidates for reperfusion therapy. This phenomenon is termed a ghost infarct core (GIC). Core growth rate (CGR) is an indicator of ischemic severity. We aimed to elucidate the association between GIC and CGR. PATIENTS AND METHODS Consecutive patients with acute ischemic stroke who underwent mechanical thrombectomy in our institute from March 2017 to July 2022 were enrolled. The initial ischemic core volume (IICV) was measured by pretreatment CTP, and the final infarct volume (FIV) was measured by diffusion-weighted imaging. A GIC was defined by IICV minus FIV > 10 ml. The CGR was calculated by dividing the IICV by the time from onset to CTP. Univariable analysis and a multivariable logistic regression model were used to evaluate the association between GIC-positive and CGR. RESULTS Of all 91 patients, 21 (23.1%) were GIC-positive. The GIC-positive group had higher CGR (14.2 [2.6-46.7] vs 4.8 [1.6-17.1] ml/h, p = 0.02) and complete recanalization (n = 15 (71.4%) vs 29 (41.4%), p = 0.02) compared to the GIC-negative group. On receiver-operating characteristic curve analysis, the optimal cutoff point of CGR to predict GIC-positive was 22 ml/h (sensitivity, 0.48; specificity, 0.85; AUC, 0.67). Multivariable logistic regression analysis showed that CGR ⩾ 22 ml/h (OR 6.44, 95% CI [1.59-26.10], p = 0.01) and complete recanalization (OR 3.72, 95% CI [1.14-12.08], p = 0.02) were independent predictors of GIC-positive. CONCLUSIONS A GIC was associated with fast CGR in acute ischemic stroke. Overestimation of the initial ischemic core may be determined by core growth speed.
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Affiliation(s)
- Mikito Saito
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Mitaka, Tokyo, Japan
| | - Hiroyuki Kawano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Mitaka, Tokyo, Japan
| | - Takuya Adachi
- Department of Radiology, Kyorin University Hospital, Mitaka, Tokyo, Japan
| | - Miho Gomyo
- Department of Radiology, Kyorin University, Mitaka, Tokyo, Japan
| | - Kenichi Yokoyama
- Department of Radiology, Kyorin University, Mitaka, Tokyo, Japan
| | - Yoshiaki Shiokawa
- Department of Neurosurgery, Fuji Brain Institute and Hospital, Fujinomiya, Shizuoka, Japan
| | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Mitaka, Tokyo, Japan
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15
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Makkawi S, Bukhari JI, Salamatullah HK, Alkulli OA, Alghamdi AE, Bogari A, Aloufi NM, Albadri M, Alnafisi FN, Alghamdi S. Endovascular thrombectomy after anterior circulation large vessel ischemic stroke: an updated meta-analysis. Syst Rev 2024; 13:255. [PMID: 39396031 PMCID: PMC11475204 DOI: 10.1186/s13643-024-02670-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Accepted: 09/26/2024] [Indexed: 10/14/2024] Open
Abstract
BACKGROUND Endovascular thrombectomy (EVT) has emerged as the established standard of care for the treatment of anterior circulation large-vessel occlusion (LVO). However, its benefits remain unclear in specific patient populations. Herein, we present an updated systematic review and meta-analysis aimed at thoroughly assessing the effectiveness and safety of combining EVT with medical treatment (MT) compared with MT alone. METHODS This systematic review was performed in accordance with the PRISMA guideline. The MEDLINE, Embase, and Cochrane databases were systematically searched to identify relevant articles published until December 30, 2023. The inclusion criteria restricted articles to randomized clinical trials (RCTs). We pooled odds ratios (OR) and their respective 95% confidence intervals (CIs). RESULTS Fifteen RCTs involving 3897 patients were included in the study. EVT plus MT was associated with a significant reduction in disability at 90 days (OR = 1.91, [1.61-2.26]), improved functional independence (modified Rankin Scale [mRS] 0-2) (OR = 2.19 [1.81-2.64]), excellent functional outcomes (mRS 0-1) (OR = 2.37, [1.45-3.87]), improved independent ambulation (mRS 0-3) (OR = 2.17, [1.75-2.69]), and higher rates of partial/complete recanalization (OR = 2.18, [1.66-2.87] compared with EVT. Efficacy outcomes for both large and small infarct cores were statistically favorable following EVT. Safety outcomes showed comparable rates, except for intracerebral and subarachnoid hemorrhage, which favored MT alone. CONCLUSION This meta-analysis supports the use of EVT plus MT as the standard of care for acute ischemic stroke patients with LVO of any infarct core size, as it offers substantial improvements in functional outcomes and recanalization. Safety considerations, particularly the risk of hemorrhage, warrant careful patient selection. These findings provide valuable insights for optimizing stroke management protocols and enhancing patient outcomes.
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Affiliation(s)
- Seraj Makkawi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia.
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia.
- Department of Neurosciences, Ministry of the National Guard-Health Affairs, Jeddah, Saudi Arabia.
| | - Jawad I Bukhari
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Hassan K Salamatullah
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Osama A Alkulli
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Abdulrahman E Alghamdi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Asim Bogari
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Naif M Aloufi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Mohammed Albadri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Fay N Alnafisi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Saeed Alghamdi
- Neuroscience Department, King Faisal Specialist Hospital and Research Center, Jeddah, Saudi Arabia
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16
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Ohara N, Imamura H, Satow T, Yamagami H, Yoshimura S, Horie N, Ishii A, Fujinaka T, Matsumoto Y, Tsumoto T, Kohyama S, Matsumaru Y, Iihara K, Kuwayama N, Hirano T, Ito Y, Yamamoto H, Nagai Y, Sakai C, Sakai N. Multicenter clinical trial evaluating the safety and efficacy of mechanical thrombectomy using the Versi Retriever. J Neurointerv Surg 2024:jnis-2024-022207. [PMID: 39389765 DOI: 10.1136/jnis-2024-022207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2024] [Accepted: 09/24/2024] [Indexed: 10/12/2024]
Abstract
BACKGROUND This study aimed to elucidate the safety and efficacy of mechanical thrombectomy using the Versi Retriever in patients with acute ischemic stroke (AIS). METHODS This was a prospective, multicenter, single-arm study conducted at 10 institutes in Japan from December 2018 to March 2021 on mechanical thrombectomy using the Versi Retriever in patients with AIS. The primary efficacy outcome was the modified Rankin scale (mRS) 0-2 at 90 days after the procedure. The primary safety outcome was mortality within 90 days after the procedure. RESULTS Fifty-eight patients with a mean age of 72.7 years were enrolled in the study. The primary efficacy outcome of mRS 0-2 at 90 days was 62.0% (95% CI 47.2-75.3%) in patients within 8 hours of stroke onset. The rate of immediate reperfusion of Thrombolysis in Cerebral Infarction (TICI) grade 2b-3 using the Versi Retriever in three passes was 78.0% (64.0-88.5%). The rate of final reperfusion of TICI 2b-3 was 100% (92.9-100%). The primary safety outcome of mortality within 90 days was 8.0% (2.2-19.2%) in patients within 8 hours of AIS onset. The incidence of intracranial hemorrhage within 24 hours was 12.0% (4.5-24.3%) for symptomatic cases and 32.0% (19.5-46.7%) for asymptomatic cases. CONCLUSION The Versi Retriever proved to be a safe and effective option for mechanical thrombectomy in patients with AIS.
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Affiliation(s)
- Nobuyuki Ohara
- Neurology, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | - Hirotoshi Imamura
- Neurosurgery, National Cerebral and Cardiovascular Center Hospital, Suita, Japan
| | - Tetsu Satow
- Neurosurgery, Kindai University Hospital, Osakasayama, Japan
| | - Hiroshi Yamagami
- Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
- Division of Stroke Prevention and Treatment, University of Tsukuba, Tsukuba, Japan
| | | | - Nobutaka Horie
- Neurosurgery, Hiroshima University, Higashihiroshima, Japan
- Neurosurgery, Nagasaki University, Nagasaki, Japan
| | - Akira Ishii
- Neurosurgery, Juntendo University, Bunkyo-ku, Japan
| | - Toshiyuki Fujinaka
- Neurosurgery, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Yasushi Matsumoto
- Division of Development and Discovery of Interventional Therapy, Tohoku University Hospital, Sendai, Japan
| | - Tomoyuki Tsumoto
- Neurosurgery, Showa University Fujigaoka Hospital, Yokohama, Japan
| | - Shinya Kohyama
- Endovascular Neurosurgery, Saitama Medical University International Medical Center, Hidaka, Japan
| | | | - Koji Iihara
- Neurosurgery, National Cerebral and Cardiovascular Center Hospital, Suita, Japan
| | - Naoya Kuwayama
- Neurosurgery, Graduate School of Medicine and Pharmaceutical Science for Education, Faculty of Medicine, University of Toyama, Toyama, Japan
| | - Teruyuki Hirano
- Stroke and Cerebrovascular Medicine, Kyorin University, Mitaka, Japan
| | - Yasushi Ito
- Neurosurgery, Shinrakuen Hospital, Niigata, Japan
| | - Haruko Yamamoto
- Data Science, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yoji Nagai
- Clinical Research Facilitation, Institute for Advancement of Clinical and Translational Science, Kyoto University Hospital, Kyoto, Japan
| | | | - Nobuyuki Sakai
- Neurovascular Research, Kobe City Medical Center General Hospital, Kobe, Japan
- Seijinkai Shimizu Hospital, Kyoto, Japan
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17
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Mausbach S, Abdallah LA, Ben-David E, Teitcher M, Bornstein NM, Eichel R. CT Perfusion imaging as prognostic factor for outcome of lacunar stroke. Neuroradiology 2024:10.1007/s00234-024-03480-2. [PMID: 39387917 DOI: 10.1007/s00234-024-03480-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Accepted: 09/30/2024] [Indexed: 10/12/2024]
Abstract
BACKGROUND Early neurological deterioration (END) affects 20-30% of patients with lacunar stroke within 48 h despite optimal treatment. Previously established markers included infection and infarct location on imaging. We studied the utility of measuring global cerebral blood flow (gCBF) measured by CT-Perfusion (CTP) as an early predictor of END in patients with lacunar strokes. METHODS 162 patients with lacunar stroke were measured for gCBF including both cerebral hemispheres and cerebellum. We stratified patients by normal gCBF (> 40 ml/100 mg/min) vs. low gCBF (< 40 ml/100 mg/min). Stroke location, vascular risk factors, age and gender were assessed. The primary outcome was the change in the NIHSS score after 48 h from index stroke. RESULTS Mean gCBF of the overall cohort was 37.72 ml/100 mg/min. Both groups had a baseline NIHSS score of 4.2 with similar standard deviations. The NIHSS score decreased by 1.3 points in normal gCBF group and increased by 1.1 points in the low gCBF group. All stroke sites deteriorated in the low gCBF group, particularly the capsula interna, corona radiata, and lateral pontine area. END occurred in 37.8% in low gCBF compared to 3.1% in the normal gCBF patients. In contrast, clinical improvement after 48 h occurred in 64.2% of patients with normal gCBF but only 6.1% with low gCBF. CONCLUSION Our study supports measurement of gCBF by CTP as a potential imaging biomarker for END. Additionally, it adds evidence to the body of supporting the vulnerability of capsula interna and pontine infarctions to END.
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Affiliation(s)
- Stefan Mausbach
- Department of Neurology, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Shmuel Bait 12, Jerusalem, 9103102, Israel.
- 2Department of Neurocritical Care Medicine, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel.
| | - Lamya Ahmad Abdallah
- Department of Neurology, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Shmuel Bait 12, Jerusalem, 9103102, Israel
| | - Eliel Ben-David
- Department of Radiology, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Jerusalem, Israel
| | - Michael Teitcher
- Department of Neurology, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Shmuel Bait 12, Jerusalem, 9103102, Israel
| | - Natan M Bornstein
- Department of Neurology, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Shmuel Bait 12, Jerusalem, 9103102, Israel
| | - Roni Eichel
- Department of Neurology, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Shmuel Bait 12, Jerusalem, 9103102, Israel
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18
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Mortimer A, Flood R, Minks D, Crossley R, Wareham J, Cox A, Goswami A, Dodd J, Grier S, Marsh A, Bosnell R. The move to 24/7 mechanical thrombectomy provision for ischaemic stroke: an observational study of the impact on referrals, activity, procedural efficacy, and safety at a supra-regional centre. Postgrad Med J 2024:qgae136. [PMID: 39387374 DOI: 10.1093/postmj/qgae136] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Revised: 08/12/2024] [Accepted: 09/17/2024] [Indexed: 10/15/2024]
Abstract
BACKGROUND Health systems are striving to improve delivery of mechanical thrombectomy (MT) for ischaemic stroke. With the move to 24/7 provision, we aimed to assess (1) the change in referral and procedural frequency and timing, (2) reasons referrals did not proceed to MT, and (3) nocturnal procedural efficacy and safety. METHODS This was an observational study comparing 12-month data for an extended daytime service (2021/2022, hours, 0800-2000) to that for a 12-month period delivering 24/7 cover (2023-2024). Nocturnal and daytime outcomes (rate of recanalisation using modified TICI scoring), extent of postprocedural infarction (using ASPECTS grading), rate of early neurological improvement (using 24-h NIHSS change), 90-day mortality, and complicating symptomatic intracranial haemorrhage (SICH) in the latter period were compared. RESULTS Both referrals (432 to 851) and procedural caseload (191 to 403) approximately doubled with the move to 24/7 cover; 36% of procedures occurred overnight (n = 145). The dominant reasons for referrals not proceeding to MT were a large core infarct (n = 144) or absence of a large vessel occlusion on baseline imaging (n = 140). There were no significant differences in successful recanalisation (TICI 2B/3: 85.5% vs 87.1%, P = .233), rates of postprocedural ASPECTS≥7 (74.9% vs 75.8%, P = .987), early neurological improvement (NIHSS reduction ≥30%: 43.4% vs 42.4%, P = .917), 90-day mortality (19.6% vs 18.6%, P = .896), or SICH (1.9% vs 4.1%, P = .214) obtained for daytime vs nighttime hours. CONCLUSION 24/7 MT provision has resulted in a rapid rise in the number of patients who may benefit from MT. This service can be provided with an acceptable safety profile during nighttime hours in a high-volume comprehensive UK centre.
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Affiliation(s)
- Alex Mortimer
- Department of Interventional Neuroradiology, North Bristol NHS Trust, Bristol, BS10 5NB, United Kingdom
| | - Richard Flood
- Department of Interventional Neuroradiology, North Bristol NHS Trust, Bristol, BS10 5NB, United Kingdom
| | - David Minks
- Department of Interventional Neuroradiology, North Bristol NHS Trust, Bristol, BS10 5NB, United Kingdom
| | - Robert Crossley
- Department of Interventional Neuroradiology, North Bristol NHS Trust, Bristol, BS10 5NB, United Kingdom
| | - James Wareham
- Department of Interventional Neuroradiology, North Bristol NHS Trust, Bristol, BS10 5NB, United Kingdom
| | - Anthony Cox
- Department of Interventional Neuroradiology, North Bristol NHS Trust, Bristol, BS10 5NB, United Kingdom
| | - Amit Goswami
- Department of Anaesthesia, North Bristol NHS Trust, Bristol, BS10 5NB, United Kingdom
| | - James Dodd
- Department of Stroke Medicine and Vascular Neurology, North Bristol NHS Trust, Bristol, BS10 5NB, United Kingdom
| | - Scott Grier
- Department of Intensive Care Medicine, North Bristol NHS Trust, Bristol, BS10 5NB, United Kingdom
| | - Aidan Marsh
- Department of Intensive Care Medicine, North Bristol NHS Trust, Bristol, BS10 5NB, United Kingdom
| | - Rose Bosnell
- Department of Stroke Medicine and Vascular Neurology, North Bristol NHS Trust, Bristol, BS10 5NB, United Kingdom
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19
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Kamel P, Khalid M, Steger R, Kanhere A, Kulkarni P, Parekh V, Yi PH, Gandhi D, Bodanapally U. Dual Energy CT for Deep Learning-Based Segmentation and Volumetric Estimation of Early Ischemic Infarcts. JOURNAL OF IMAGING INFORMATICS IN MEDICINE 2024:10.1007/s10278-024-01294-5. [PMID: 39384719 DOI: 10.1007/s10278-024-01294-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/15/2024] [Revised: 09/13/2024] [Accepted: 10/03/2024] [Indexed: 10/11/2024]
Abstract
Ischemic changes are not visible on non-contrast head CT until several hours after infarction, though deep convolutional neural networks have shown promise in the detection of subtle imaging findings. This study aims to assess if dual-energy CT (DECT) acquisition can improve early infarct visibility for machine learning. The retrospective dataset consisted of 330 DECTs acquired up to 48 h prior to confirmation of a DWI positive infarct on MRI between 2016 and 2022. Infarct segmentation maps were generated from the MRI and co-registered to the CT to serve as ground truth for segmentation. A self-configuring 3D nnU-Net was trained for segmentation on (1) standard 120 kV mixed-images (2) 190 keV virtual monochromatic images and (3) 120 kV + 190 keV images as dual channel inputs. Algorithm performance was assessed with Dice scores with paired t-tests on a test set. Global aggregate Dice scores were 0.616, 0.645, and 0.665 for standard 120 kV images, 190 keV, and combined channel inputs respectively. Differences in overall Dice scores were statistically significant with highest performance for combined channel inputs (p < 0.01). Small but statistically significant differences were observed for infarcts between 6 and 12 h from last-known-well with higher performance for larger infarcts. Volumetric accuracy trended higher with combined inputs but differences were not statistically significant (p = 0.07). Supplementation of standard head CT images with dual-energy data provides earlier and more accurate segmentation of infarcts for machine learning particularly between 6 and 12 h after last-known-well.
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Affiliation(s)
- Peter Kamel
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 22 S. Greene Street, Baltimore, MD, 21201, USA.
- University of Maryland Medical Intelligent Imaging (UM2ii) Center, University of Maryland School of Medicine, 22 S. Greene Street, Baltimore, MD, 21201, USA.
| | - Mazhar Khalid
- Department of Neurology, University of Maryland School of Medicine, Baltimore, MD, USA
| | - Rachel Steger
- University of Maryland School of Medicine, Baltimore, MD, USA
| | - Adway Kanhere
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 22 S. Greene Street, Baltimore, MD, 21201, USA
- University of Maryland Medical Intelligent Imaging (UM2ii) Center, University of Maryland School of Medicine, 22 S. Greene Street, Baltimore, MD, 21201, USA
| | - Pranav Kulkarni
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 22 S. Greene Street, Baltimore, MD, 21201, USA
- University of Maryland Medical Intelligent Imaging (UM2ii) Center, University of Maryland School of Medicine, 22 S. Greene Street, Baltimore, MD, 21201, USA
| | - Vishwa Parekh
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 22 S. Greene Street, Baltimore, MD, 21201, USA
- University of Maryland Medical Intelligent Imaging (UM2ii) Center, University of Maryland School of Medicine, 22 S. Greene Street, Baltimore, MD, 21201, USA
| | - Paul H Yi
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 22 S. Greene Street, Baltimore, MD, 21201, USA
- University of Maryland Medical Intelligent Imaging (UM2ii) Center, University of Maryland School of Medicine, 22 S. Greene Street, Baltimore, MD, 21201, USA
| | - Dheeraj Gandhi
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 22 S. Greene Street, Baltimore, MD, 21201, USA
| | - Uttam Bodanapally
- Department of Diagnostic Radiology and Nuclear Medicine, University of Maryland School of Medicine, 22 S. Greene Street, Baltimore, MD, 21201, USA
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20
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Jhou HJ, Yang LY, Chen PH, Lee CH. Thrombectomy for patients with a large infarct core: a study-level meta-analysis with trial sequential analysis. Ther Adv Neurol Disord 2024; 17:17562864241285552. [PMID: 39385996 PMCID: PMC11462614 DOI: 10.1177/17562864241285552] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 09/02/2024] [Indexed: 10/12/2024] Open
Abstract
Background The effectiveness and safety of endovascular treatment compared with medical management alone regarding outcomes for patients with a large infarct core remain uncertain. Objectives To juxtapose the clinical outcomes of thrombectomy versus the best medical care in patients with a large infarct core. Design Systematic review and meta-analysis. Data sources and methods We conducted searches in PubMed, Cochrane, and Embase for articles published up until November 8, 2023. Randomized trials were selected for inclusion if they encompassed patients with large vessel occlusion and sizable strokes receiving thrombectomy. The primary outcome was functional outcomes at 3 months after pooling data using random-effects modeling. Safety outcomes included mortality at 3 months, symptomatic intracranial hemorrhage (SICH), and decompressive craniectomy. We performed a trial sequential analysis to balance type I and II errors. Results From 904 citations, we identified six randomized trials, involving a cohort of 1897 patients with a large ischemic region. Of these, 953 individuals underwent endovascular thrombectomy. At 3 months, thrombectomy was significantly correlated with better neurological prognosis, as evidenced by the increased odds of good functional outcomes (odds ratio (OR), 2.90; 95% confidence interval (CI), 2.08-4.05) and favorable functional outcomes (OR, 2.40; 95% CI, 1.86-3.09). Mortality rates did not demonstrably diminish as a consequence of the endovascular management (OR, 0.78; 95% CI, 0.58-1.06). However, the incidence of SICH was greater in the thrombectomy group compared to those with only medical treatment (5.5% vs 3.2%; OR, 1.77; 95% CI, 1.11-2.83). The application of trial sequential analysis yielded definitive evidence regarding favorable function outcomes and a shift in the distribution of modified Rankin scale scores at 3 months; however, others remained inconclusive. Conclusion The results from most of the included trials display consistency. Meta-analysis of these six randomized trials offers high-quality evidence that thrombectomy significantly mitigates disability in patients with a large infarction, while also increasing the risk of SICH. Trial registration PROSPERO, CRD42023480359.
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Affiliation(s)
- Hong-Jie Jhou
- Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan
- School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Li-Yu Yang
- School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Neurology, Chang Bing Show Chwan Memorial Hospital, Changhua, Taiwan
| | - Po-Huang Chen
- Division of Hematology and Oncology Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, No. 325, Section 2, Cheng-gong Road, Neihu 114, Taipei, Taiwan
| | - Cho-Hao Lee
- Division of Hematology and Oncology Medicine, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Center, No. 325, Section 2, Cheng-gong Road, Neihu 114, Taipei, Taiwan
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21
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Ashayeri Ahmadabad R, Tran KH, Zhang Y, Kate MP, Mishra S, Buck BH, Khan KA, Rempel J, Albers GW, Shuaib A. Utility of automated CT perfusion software in acute ischemic stroke with large and medium vessel occlusion. Ann Clin Transl Neurol 2024. [PMID: 39375881 DOI: 10.1002/acn3.52207] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2024] [Revised: 09/05/2024] [Accepted: 08/29/2024] [Indexed: 10/09/2024] Open
Abstract
BACKGROUND Early diagnosis of large vessel occlusion (LVO) in acute stroke often requires CT angiography (CTA). Automated CT perfusion (CTP) software, which identifies blood flow abnormalities, enhances LVO diagnosis and patient selection for endovascular thrombectomy (EVT). This study evaluates the sensitivity of automated CTP images in detecting perfusion abnormalities in patients with acute ischemic stroke (AIS) and LVO or medium vessel occlusion (MeVO), compared to CTA. METHODS We screened acute ischemic stroke patients presenting within 24 h who underwent CT, CTA, and CTP as per institutional protocol. RAPID AI software processed CTP images, while neuroradiologists reviewed CTA for intracranial arterial occlusions. Sensitivity, specificity, and accuracy of automated CTP maps in detecting occlusions were assessed. RESULTS Of 790 screened patients, 31 were excluded due to lack of RAPID CTP data or poor-quality scans, leaving 759 for analysis. The median age was 71 years (IQR: 61-81), with 47% female. Among them, 678 had AIS, and 81 had AIS ruled out. CTA identified arterial occlusion in 562 patients (74%), with corresponding CTP abnormalities in 537 patients (Tmax > 6 sec). In the 197 without occlusion, CTP was negative in 161. Automated CTP maps had a sensitivity of 95.55% (CI 95: 93.50-97.10%), specificity of 81.73% (CI 95: 75.61-86.86%), negative predictive value of 98.22% (CI 95: 97.39-98.79%), positive predictive value of 63.54% (CI 95: 56.46-70.09%), and overall accuracy of 85.18% (CI 95: 82.45-87.64%). CONCLUSIONS Automated CTP maps demonstrated high sensitivity and negative predictive value for LVOs and MeVOs, suggesting their usefulness as a rapid diagnostic tool, especially in settings without expert neuroradiologists.
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Affiliation(s)
| | - Kim H Tran
- Division of Neurology, University of Alberta, Edmonton, Canada
| | - Yiran Zhang
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, Canada
| | - Mahesh P Kate
- Division of Neurology, University of Alberta, Edmonton, Canada
| | - Sachin Mishra
- Division of Neurology, University of Alberta, Edmonton, Canada
| | - Brian H Buck
- Division of Neurology, University of Alberta, Edmonton, Canada
| | - Khurshid A Khan
- Division of Neurology, University of Alberta, Edmonton, Canada
| | - Jeremy Rempel
- Division of Radiology and Diagnostic Imaging, University of Alberta, Edmonton, Canada
| | | | - Ashfaq Shuaib
- Division of Neurology, University of Alberta, Edmonton, Canada
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22
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Nag DS, Swain A, Sahu S, Sen B, Vatsala, Parween S. Stroke: Evolution of newer treatment modalities for acute ischemic stroke. World J Clin Cases 2024; 12:6137-6147. [PMID: 39371560 PMCID: PMC11362888 DOI: 10.12998/wjcc.v12.i28.6137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/08/2024] [Revised: 06/08/2024] [Accepted: 07/03/2024] [Indexed: 08/13/2024] Open
Abstract
Acute ischemic stroke is one of the leading causes of morbidity and mortality worldwide. Restoration of cerebral blood flow to affected ischemic areas has been the cornerstone of therapy for patients for eligible patients as early diagnosis and treatment have shown improved outcomes. However, there has been a paradigm shift in the management approach over the last decade, and with the emphasis currently directed toward including newer modalities such as neuroprotection, stem cell treatment, magnetic stimulation, anti-apoptotic drugs, delayed recanalization, and utilization of artificial intelligence for early diagnosis and suggesting algorithm-based management protocols.
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Affiliation(s)
- Deb Sanjay Nag
- Department of Anaesthesiology, Tata Main Hospital, Jamshedpur 831001, India
| | - Amlan Swain
- Department of Anaesthesiology, Tata Main Hospital, Jamshedpur 831001, India
- Department of Anaesthesiology, Manipal Tata Medical College, Jamshedpur 831017, India
| | - Seelora Sahu
- Department of Anaesthesiology, Tata Main Hospital, Jamshedpur 831001, India
- Department of Anaesthesiology, Manipal Tata Medical College, Jamshedpur 831017, India
| | - Biswajit Sen
- Department of Anaesthesiology, Tata Main Hospital, Jamshedpur 831001, India
| | - Vatsala
- Department of Anaesthesiology, Tata Main Hospital, Jamshedpur 831001, India
| | - Sadiya Parween
- Department of Anaesthesiology, Tata Main Hospital, Jamshedpur 831001, India
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23
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Xu J, Chen W, Niu G, Meng Y, Qiu K, Li T, Wang L, Zhang L, Lv Y, Ding Z. Evaluating post-thrombectomy effective connectivity changes in anterior circulation stroke. Ann Clin Transl Neurol 2024. [PMID: 39367625 DOI: 10.1002/acn3.52221] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2024] [Revised: 08/29/2024] [Accepted: 09/15/2024] [Indexed: 10/06/2024] Open
Abstract
OBJECTIVE Granger causal analysis (GCA) and amplitude of low-frequency fluctuation (ALFF) are commonly used to evaluate functional alterations in brain disorders. By combining the GCA and ALFF, this study aimed to investigate the effective connectivity (EC) changes in patients with acute ischemic stroke (AIS) and anterior circulation occlusion after mechanical thrombectomy (MT). METHODS Resting-state functional magnetic resonance imaging (rs-fMRI) data were collected from 43 AIS patients with anterior circulation occlusion within 1 week post-MT and 37 healthy controls. ALFF and GCA were calculated for each participant. Patients were further divided into groups based on prognosis and perfusion levels. The differences in ALFF and EC were compared between AIS patients and healthy controls and between subgroups of patients. Pearson correlations between EC, ALFF values, and clinical characteristics of patients were calculated. RESULTS Compared to healthy controls, post-MT, AIS patients exhibited significant ALFF increases in the left precuneus and decreases in the left fusiform gyrus and right caudate. Increased EC from the contralesional lingual gyrus, contralesional putamen, ipsilesional thalamus, and contralesional thalamus to the contralesional caudate was obsrved, while decrease in EC were found for contralesional caudate to the ipsilesional thalamus and medial superior frontal gyrus. EC differences were particularly notable between perfusion groups, with significantly lower EC in the poorly perfused group. EC values were also positively correlated with National Institutes of Health Stroke Scale (NIHSS) scores pre-MT. INTERPRETATION In AIS patients, the caudate nucleus was central to the observed EC changes post-MT, characterized by decreased outputs and increased inputs. These changes indicate functional remodeling within the cortico-basal ganglia-thalamic-cortical pathway.
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Affiliation(s)
- Jiaona Xu
- Department of Rehabilitation, Affiliated Hangzhou First People's Hospital, Westlake University School of Medicine, Hangzhou, China
| | - Weiwei Chen
- Center for Cognition and Brain Disorders, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
| | - Guozhong Niu
- Department of Neurology, Affiliated Hangzhou First People's Hospital, Westlake University School of Medicine, Hangzhou, China
| | - Yuting Meng
- Department of General Practice, Affiliated Hangzhou First People's Hospital, Westlake University School of Medicine, Hangzhou, China
| | - Kefan Qiu
- The Fourth School of Clinical Medicine, Zhejiang Chinese Medical University, Hangzhou, China
| | - Tongyue Li
- Center for Cognition and Brain Disorders, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
| | - Luoyu Wang
- Center for Cognition and Brain Disorders, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
| | - Liqing Zhang
- Department of Radiology, Affiliated Hangzhou First People's Hospital, Westlake University School of Medicine, Hangzhou, China
| | - Yating Lv
- Center for Cognition and Brain Disorders, The Affiliated Hospital of Hangzhou Normal University, Hangzhou, China
| | - Zhongxiang Ding
- Department of Radiology, Affiliated Hangzhou First People's Hospital, Westlake University School of Medicine, Hangzhou, China
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24
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Mossa-Basha M, Zhu C, Pandhi T, Mendoza S, Azadbakht J, Safwat A, Homen D, Zamora C, Gnanasekaran DK, Peng R, Cen S, Duddalwar V, Alger JR, Wang DJJ. Deep Learning Denoising Improves CT Perfusion Image Quality in the Setting of Lower Contrast Dosing: A Feasibility Study. AJNR Am J Neuroradiol 2024; 45:1468-1474. [PMID: 38844370 PMCID: PMC11448976 DOI: 10.3174/ajnr.a8367] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 05/24/2024] [Indexed: 08/11/2024]
Abstract
BACKGROUND AND PURPOSE Considering recent iodinated contrast shortages and a focus on reducing waste, developing protocols with lower contrast dosing while maintaining image quality through artificial intelligence is needed. This study compared reduced iodinated contrast media and standard dose CTP acquisitions, and the impact of deep learning denoising on CTP image quality in preclinical and clinical studies. The effect of reduced X-ray mAs dose was also investigated in preclinical studies. MATERIALS AND METHODS Twelve swine underwent 9 CTP examinations each, performed at combinations of 3 different x-ray (37, 67, and 127 mAs) and iodinated contrast media doses (10, 15, and 20 mL). Clinical CTP acquisitions performed before and during the iodinated contrast media shortage and protocol change (from 40 to 30 mL) were retrospectively included. Eleven patients with reduced iodinated contrast media dosages and 11 propensity-score-matched controls with the standard iodinated contrast media dosages were included. A residual encoder-decoder convolutional neural network (RED-CNN) was trained for CTP denoising using k-space-weighted image average filtered CTP images as the target. The standard, RED-CNN-denoised, and k-space-weighted image average noise-filtered images for animal and human studies were compared for quantitative SNR and qualitative image evaluation. RESULTS The SNR of animal CTP images decreased with reductions in iodinated contrast media and milliampere-second doses. Contrast dose reduction had a greater effect on SNR than milliampere-second reduction. Noise-filtering by k-space-weighted image average and RED-CNN denoising progressively improved the SNR of CTP maps, with RED-CNN resulting in the highest SNR. The SNR of clinical CTP images was generally lower with a reduced iodinated contrast media dose, which was improved by the k-space-weighted image average and RED-CNN denoising (P < .05). Qualitative readings consistently rated RED-CNN denoised CTP as the best quality, followed by k-space-weighted image average and then standard CTP images. CONCLUSIONS Deep learning-denoising can improve image quality for low iodinated contrast media CTP protocols, and could approximate standard iodinated contrast media dose CTP, in addition to potentially improving image quality for low milliampere-second acquisitions.
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Affiliation(s)
- Mahmud Mossa-Basha
- From the Department of Radiology (M.M.-B., C.Z., A.S), University of Washington, Seattle, Washington
| | - Chengcheng Zhu
- From the Department of Radiology (M.M.-B., C.Z., A.S), University of Washington, Seattle, Washington
| | - Tanya Pandhi
- Mark and Mary Stevens Neuroimaging and Informatics Institute (T.P., S.M., D.K.G., D.J.J.W.), Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Steve Mendoza
- Mark and Mary Stevens Neuroimaging and Informatics Institute (T.P., S.M., D.K.G., D.J.J.W.), Keck School of Medicine, University of Southern California, Los Angeles, California
| | | | - Ahmed Safwat
- From the Department of Radiology (M.M.-B., C.Z., A.S), University of Washington, Seattle, Washington
| | - Dean Homen
- Department of Radiology (D.H., C.Z.), University of North Carolina, Chapel Hill, North Carolina
| | - Carlos Zamora
- Department of Radiology (D.H., C.Z.), University of North Carolina, Chapel Hill, North Carolina
| | - Dinesh Kumar Gnanasekaran
- Mark and Mary Stevens Neuroimaging and Informatics Institute (T.P., S.M., D.K.G., D.J.J.W.), Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Ruiyue Peng
- Hura Imaging Inc (R.P., J.R.A.), Los Angeles, California
| | - Steven Cen
- Department of Radiology (S.C., V.D., D.J.J.W.), Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Vinay Duddalwar
- Department of Radiology (S.C., V.D., D.J.J.W.), Keck School of Medicine, University of Southern California, Los Angeles, California
| | - Jeffry R Alger
- Hura Imaging Inc (R.P., J.R.A.), Los Angeles, California
| | - Danny J J Wang
- Mark and Mary Stevens Neuroimaging and Informatics Institute (T.P., S.M., D.K.G., D.J.J.W.), Keck School of Medicine, University of Southern California, Los Angeles, California
- Department of Radiology (S.C., V.D., D.J.J.W.), Keck School of Medicine, University of Southern California, Los Angeles, California
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25
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Otgonbaatar C, Song H, Jung KH, Hwang I, Hun Jeon Y, Choi KS, Yoo DH, Sohn CH. Quantification of Infarct Core Volume in Patients with Acute Ischemic Stroke Using Cerebral Metabolic Rate of Oxygen in CT Perfusion. AJNR Am J Neuroradiol 2024; 45:1432-1440. [PMID: 38806237 PMCID: PMC11448980 DOI: 10.3174/ajnr.a8360] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2024] [Accepted: 05/25/2024] [Indexed: 05/30/2024]
Abstract
BACKGROUND AND PURPOSE The cerebral metabolic rate of oxygen (CMRO2) is considered a robust marker of the infarct core in 15O-tracer-based PET. We aimed to delineate the infarct core in patients with acute ischemic stroke by using commonly used relative CBF (rCBF) < 30% and oxygen metabolism parameter of CMRO2 on CT perfusion in comparison with pretreatment DWI-derived infarct core volume. MATERIALS AND METHODS Patients with acute ischemic stroke who met the inclusion criteria were recruited. The CMRO2 and CBF maps in CT perfusion were automatically generated by using postprocessing software. The infarct core volume was quantified with relative cerebral metabolic rate of oxygen (rCMRO2) <20% -30% and rCBF <30%. The optimal threshold was defined as those that demonstrated the smallest mean absolute error, lowest mean infarct core volume difference, narrowest 95% limit of agreement, and largest intraclass correlation coefficient (ICC) against the DWI. RESULTS This study included 76 patients (mean age ± standard deviation, 69.97 ± 12.15 years, 43 men). The optimal thresholds of rCMRO2 <26% resulted in the lowest mean infarct core volume difference, narrowest 95% limit of agreement, and largest ICC among different thresholds. Bland-Altman analysis demonstrated a volumetric bias of 1.96 mL between DWI and rCMRO2 <26%, whereas in cases of DWI and rCBF <30%, the bias was notably larger at 14.10 mL. The highest correlation was observed for rCMRO2 <26% (ICC = 0.936), whereas rCBF <30% showed a slightly lower ICC of 0.934. CONCLUSIONS CT perfusion-derived CMRO2 is a promising parameter for estimating the infarct core volume in patients with acute ischemic stroke.
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Affiliation(s)
- Chuluunbaatar Otgonbaatar
- From the Department of Radiology, College of Medicine (C.O., C.-H.S.), Seoul National University, Seoul, South Korea
| | - Huijin Song
- Biomedical Research Institute (H.S.), Seoul National University Hospital, Seoul, South Korea
| | - Keun-Hwa Jung
- Departments of Neurology (K.-H.J.), Seoul National University Hospital, Seoul, South Korea
| | - Inpyeong Hwang
- Departments of Radiology (I.H., Y.H.J., K.S.C., D.H.Y., C.-H.S.), Seoul National University Hospital, Seoul, South Korea
| | - Young Hun Jeon
- Departments of Radiology (I.H., Y.H.J., K.S.C., D.H.Y., C.-H.S.), Seoul National University Hospital, Seoul, South Korea
| | - Kyu Sung Choi
- Departments of Radiology (I.H., Y.H.J., K.S.C., D.H.Y., C.-H.S.), Seoul National University Hospital, Seoul, South Korea
| | - Dong Hyun Yoo
- Departments of Radiology (I.H., Y.H.J., K.S.C., D.H.Y., C.-H.S.), Seoul National University Hospital, Seoul, South Korea
| | - Chul-Ho Sohn
- From the Department of Radiology, College of Medicine (C.O., C.-H.S.), Seoul National University, Seoul, South Korea
- Departments of Radiology (I.H., Y.H.J., K.S.C., D.H.Y., C.-H.S.), Seoul National University Hospital, Seoul, South Korea
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26
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Yedavalli V, Salim HA, Mei J, Lakhani DA, Balar A, Musmar B, Adeeb N, Hoseinyazdi M, Luna L, Deng F, Hyson NZ, Dmytriw AA, Guenego A, Faizy TD, Heit JJ, Albers GW, Lu H, Urrutia VC, Nael K, Marsh EB, Hillis AE, Llinas R. Decreased Quantitative Cerebral Blood Volume Is Associated With Poor Outcomes in Large Core Patients. Stroke 2024; 55:2409-2419. [PMID: 39185560 DOI: 10.1161/strokeaha.124.047483] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2024] [Revised: 07/02/2024] [Accepted: 07/23/2024] [Indexed: 08/27/2024]
Abstract
BACKGROUND Recent large core trials have highlighted the effectiveness of mechanical thrombectomy (MT) in acute ischemic stroke with large vessel occlusion. Variable perfusion-imaging thresholds and poor Alberta Stroke Program Early Computed Tomography Score reliability underline the need for more standardized, quantitative ischemia measures for MT patient selection. We aimed to identify the computed tomography perfusion parameter most strongly associated with poor outcomes in patients with acute ischemic stroke-large vessel occlusion with significant ischemic cores. METHODS In this study from 2 comprehensive stroke centers from 2 comprehensive stroke centers within the Johns Hopkins Medical Enterprise (Johns Hopkins Hospita-East Baltimore and Bayview Medical Campus) from July 29, 2019 to January 29, 2023 in a continuously maintained database, we included patients with acute ischemic stroke-large vessel occlusion with ischemic core volumes defined as relative cerebral blood flow <30% and ≥50 mL on computed tomography perfusion or Alberta Stroke Program Early Computed Tomography Score <6. We used receiver operating characteristics to find the optimal cutoff for parameters like cerebral blood volume (CBV) <34%, 38%, 42%, and relative cerebral blood flow >20%, 30%, 34%, 38%, and time-to-maximum >4, 6, 8, and 10 seconds. The primary outcome was unfavorable outcomes (90-day modified Rankin Scale score 4-6). Multivariable models were adjusted for age, sex, diabetes, baseline National Institutes of Health Stroke Scale, intravenous thrombolysis, and MT. RESULTS We identified 59 patients with large ischemic cores. A receiver operating characteristic curve analysis showed that CBV<42% ≥68 mL is associated with unfavorable outcomes (90-day modified Rankin Scale score 4-6) with an area under the curve of 0.90 (95% CI, 0.82-0.99) in the total and MT-only cohorts. Dichotomizing at this CBV threshold, patients in the ≥68 mL group exhibited significantly higher relative cerebral blood flow, time-to-maximum >8 and 10 seconds volumes, higher CBV volumes, higher HIR, and lower CBV index. The multivariable model incorporating CBV<42% ≥68 mL predicted poor outcomes robustly in both cohorts (area under the curve for MT-only subgroup was 0.87 [95% CI, 0.75-1.00]). CONCLUSIONS CBV<42% ≥68 mL most effectively forecasts poor outcomes in patients with large-core stroke, confirming its value alongside other parameters like time-to-maximum in managing acute ischemic stroke-large vessel occlusion.
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Affiliation(s)
- Vivek Yedavalli
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD (V.Y., H.A.S., J.M., D.A.L., A.B., M.H., L.L., F.D., N.Z.H., H.L., V.C.U., E.B.M., A.E.H., R.L.)
| | - Hamza Adel Salim
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD (V.Y., H.A.S., J.M., D.A.L., A.B., M.H., L.L., F.D., N.Z.H., H.L., V.C.U., E.B.M., A.E.H., R.L.)
| | - Janet Mei
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD (V.Y., H.A.S., J.M., D.A.L., A.B., M.H., L.L., F.D., N.Z.H., H.L., V.C.U., E.B.M., A.E.H., R.L.)
| | - Dhairya A Lakhani
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD (V.Y., H.A.S., J.M., D.A.L., A.B., M.H., L.L., F.D., N.Z.H., H.L., V.C.U., E.B.M., A.E.H., R.L.)
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston (D.A.L., A.A.D.)
| | - Aneri Balar
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD (V.Y., H.A.S., J.M., D.A.L., A.B., M.H., L.L., F.D., N.Z.H., H.L., V.C.U., E.B.M., A.E.H., R.L.)
| | - Basel Musmar
- Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University (B.M., N.A.)
| | - Nimer Adeeb
- Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University (B.M., N.A.)
| | - Meisam Hoseinyazdi
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD (V.Y., H.A.S., J.M., D.A.L., A.B., M.H., L.L., F.D., N.Z.H., H.L., V.C.U., E.B.M., A.E.H., R.L.)
| | - Licia Luna
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD (V.Y., H.A.S., J.M., D.A.L., A.B., M.H., L.L., F.D., N.Z.H., H.L., V.C.U., E.B.M., A.E.H., R.L.)
| | - Francis Deng
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD (V.Y., H.A.S., J.M., D.A.L., A.B., M.H., L.L., F.D., N.Z.H., H.L., V.C.U., E.B.M., A.E.H., R.L.)
| | - Nathan Z Hyson
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD (V.Y., H.A.S., J.M., D.A.L., A.B., M.H., L.L., F.D., N.Z.H., H.L., V.C.U., E.B.M., A.E.H., R.L.)
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston (D.A.L., A.A.D.)
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St. Michael's Hospital, Toronto, ON, Canada (A.A.D.)
| | - Adrien Guenego
- Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium (A.G.)
| | - Tobias D Faizy
- Department of Radiology, Neuroendovascular Program, University Medical Center Münster, Germany (T.D.F.)
| | - Jeremy J Heit
- Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, CA (J.J.H., G.W.A.)
| | - Gregory W Albers
- Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, CA (J.J.H., G.W.A.)
| | - Hanzhang Lu
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD (V.Y., H.A.S., J.M., D.A.L., A.B., M.H., L.L., F.D., N.Z.H., H.L., V.C.U., E.B.M., A.E.H., R.L.)
| | - Victor C Urrutia
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD (V.Y., H.A.S., J.M., D.A.L., A.B., M.H., L.L., F.D., N.Z.H., H.L., V.C.U., E.B.M., A.E.H., R.L.)
| | - Kambiz Nael
- David Geffen School of Medicine at UCLA, Los Angeles, CA (K.N.)
| | - Elisabeth B Marsh
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD (V.Y., H.A.S., J.M., D.A.L., A.B., M.H., L.L., F.D., N.Z.H., H.L., V.C.U., E.B.M., A.E.H., R.L.)
| | - Argye E Hillis
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD (V.Y., H.A.S., J.M., D.A.L., A.B., M.H., L.L., F.D., N.Z.H., H.L., V.C.U., E.B.M., A.E.H., R.L.)
| | - Raf Llinas
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medical Center, Baltimore, MD (V.Y., H.A.S., J.M., D.A.L., A.B., M.H., L.L., F.D., N.Z.H., H.L., V.C.U., E.B.M., A.E.H., R.L.)
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Psychogios K, Theodorou A, Kargiotis O, Safouris A, Velonakis G, Palaiodimou L, Spiliopoulos S, Giannopoulos S, Magoufis G, Tsivgoulis G. Hypoperfusion index ratio and pretreatment with intravenous thrombolysis are independent predictors of good functional outcome in acute ischemic stroke patients with large vessel occlusion treated with acute reperfusion therapies. Neurol Sci 2024; 45:4881-4893. [PMID: 38761259 DOI: 10.1007/s10072-024-07558-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Accepted: 04/22/2024] [Indexed: 05/20/2024]
Abstract
INTRODUCTION We aimed to investigate the performance of several neuroimaging markers provided by perfusion imaging of Acute Ischemic Stroke (AIS) patients with large vessel occlusion (LVO) in order to predict clinical outcomes following reperfusion treatments. METHODS We prospectively evaluated consecutive AIS patients with LVO who were treated with reperfusion therapies, during a six-year period. In order to compare patients with good (mRS scores 0-2) and poor (mRS scores 3-6) functional outcomes, data regarding clinical characteristics, the Alberta Stroke Programme Early Computed Tomography Score (ASPECTS) based on unenhanced computed tomography (CT), CT angiography collateral status and perfusion parameters including ischemic core, hypoperfusion volume, mismatch volume between core and penumbra, Tmax > 10 s volume, CBV index and the Hypoperfusion Index Ratio (HIR) were assessed. RESULTS A total of 84 acute stroke patients with LVO who met all the inclusion criteria were enrolled. In multivariable logistic regression models increasing age (odds ratio [OR]: 0.93; 95%CI: 0.88-0.96, p = 0.001), lower admission National Institute of Health Stroke Scale (NIHSS)-score (OR: 0.88; 95%CI: 0.80-0.95, p = 0.004), pretreatment with intravenous thrombolysis (OR: 3.83; 95%CI: 1.29-12.49, p = 0.019) and HIR (OR:0.36; 95%CI: 0.10-0.95, p = 0.042) were independent predictors of good functional outcome at 3 months. The initial univariable associations between HIR and higher likelihood for symptomatic intracranial hemorrhage (sICH) and parenchymal hematoma type 2 (PH2) were attenuated in multivariable analyses failing to reach statistical significance. DISCUSSION Our pilot observational study of unselected AIS patients with LVO treated with reperfusion therapies demonstrated that pre-treatment low HIR in perfusion imaging and IVT were associated with better functional outcomes.
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Affiliation(s)
- Klearchos Psychogios
- Stroke Unit, Metropolitan Hospital, 18547, Piraeus, Greece
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Rimini 1, 12462, Chaidari, Athens, Greece
| | - Aikaterini Theodorou
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Rimini 1, 12462, Chaidari, Athens, Greece
| | | | - Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, 18547, Piraeus, Greece
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Rimini 1, 12462, Chaidari, Athens, Greece
| | - Georgios Velonakis
- Second Department of Radiology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462, Athens, Greece
| | - Lina Palaiodimou
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Rimini 1, 12462, Chaidari, Athens, Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional Radiology Unit, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462, Athens, Greece
| | - Sotirios Giannopoulos
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Rimini 1, 12462, Chaidari, Athens, Greece
| | - Georgios Magoufis
- Second Department of Radiology, Interventional Radiology Unit, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, 12462, Athens, Greece
- Neuroradiology Department, Metropolitan Hospital, 18547, Piraeus, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, "Attikon" University Hospital, School of Medicine, National and Kapodistrian University of Athens, Rimini 1, 12462, Chaidari, Athens, Greece.
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, 38163, USA.
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Almallouhi E, Spiotta A. Thrombectomy for Very Large Core Strokes…The Next Frontier in Endovascular Therapy?? World Neurosurg 2024; 190:522. [PMID: 39198115 DOI: 10.1016/j.wneu.2024.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2024]
Affiliation(s)
- Eyad Almallouhi
- Department of Neuroscience, Sarasota Memorial Hospital, Sarasota, Florida, USA
| | - Alejandro Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
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Vincis E, Prandin G, Furlanis G, Scali I, Buoite Stella A, Cillotto T, Lugnan C, Caruso P, Naccarato M, Manganotti P. Sex differences in Wake-Up Stroke patients characteristics and outcomes. Neurol Sci 2024; 45:4871-4879. [PMID: 38772977 DOI: 10.1007/s10072-024-07597-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2024] [Accepted: 05/14/2024] [Indexed: 05/23/2024]
Abstract
OBJECTIVES Wake-up Stroke (WUS) accounts for about 25% of all ischemic strokes. Differences according to sex in the WUS subgroup has been poorly investigated so far, so we aimed to assess these differences by differentiating the enrolled population based on treatment administered. MATERIALS & METHODS We retrospectively analysed clinical and imaging data of WUS patients admitted to our hospital between November 2013 and December 2018 dividing them in two groups: rTPA-treated and non-rTPA treated group. To point out outcome differences we evaluated: NIHSS at 7 days or at discharge, mRS at discharge and ΔNIHSS. RESULTS We enrolled 149 WUS patients, 74 rTPA treated and 75 non-rTPA treated. Among rTPA treated patients, time from last known well (LKW) to Emergency Department (ED) admission was longer in females than males (610 vs 454 min), while females had a higher ΔNIHSS than males (5 vs 3). Finally, among non-rTPA treated patients, females were older than males (85 vs 79 years), had a higher pre-admission mRS (although very low in both cases), had a longer length of stay (17 vs 13 days) and shown a higher NIHSS at discharge (4 vs 2) compared to males. CONCLUSIONS Females not receiving thrombolytic treatment had worse functional outcome than males, showing a higher NIHSS at discharge but, in contrast, when treated with rTPA they showed better neurological recovery as measured by a greater ΔNIHSS. We emphasize the importance of a prompt recognition of WUS in females since they seem to benefit more from rTPA treatment.
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Affiliation(s)
- Emanuele Vincis
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada Di Fiume, 447 - 34149, Trieste, Italy.
| | - Gabriele Prandin
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada Di Fiume, 447 - 34149, Trieste, Italy
| | - Giovanni Furlanis
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada Di Fiume, 447 - 34149, Trieste, Italy
| | - Ilario Scali
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada Di Fiume, 447 - 34149, Trieste, Italy
| | - Alex Buoite Stella
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada Di Fiume, 447 - 34149, Trieste, Italy
| | - Tommaso Cillotto
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada Di Fiume, 447 - 34149, Trieste, Italy
| | - Carlo Lugnan
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada Di Fiume, 447 - 34149, Trieste, Italy
| | - Paola Caruso
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada Di Fiume, 447 - 34149, Trieste, Italy
| | - Marcello Naccarato
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada Di Fiume, 447 - 34149, Trieste, Italy
| | - Paolo Manganotti
- Clinical Unit of Neurology, Department of Medicine, Surgery and Health Sciences, Cattinara University Hospital ASUGI, University of Trieste, Strada Di Fiume, 447 - 34149, Trieste, Italy
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Mamer LE, Kocher KE, Cranford JA, Scott PA. Longitudinal changes in the US emergency department use of advanced neuroimaging in the mechanical thrombectomy era. Emerg Radiol 2024; 31:695-703. [PMID: 39002104 DOI: 10.1007/s10140-024-02260-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2024] [Accepted: 06/24/2024] [Indexed: 07/15/2024]
Abstract
PURPOSE To describe ED neuroimaging trends across the time-period spanning the early adoption of endovascular therapy for acute stroke (2013-2018). MATERIALS AND METHODS We performed a retrospective, cross-sectional study of ED visits using the 2013-2018 National Emergency Department Sample, a 20% sample of ED encounters in the United States. Neuroimaging use was determined by Common Procedural Terminology (CPT) code for non-contrast head CT (NCCT), CT angiography head (CTA), CT perfusion (CTP), and MRI brain (MRI) in non-admitted ED patients. Data was analyzed according to sampling weights and imaging rates were calculated per 100,000 ED visits. Multivariate logistic regression analysis was performed to identify hospital-level factors associated with imaging utilization. RESULTS Study population comprised 571,935,906 weighted adult ED encounters. Image utilization increased between 2013 and 2018 for all modalities studied, although more pronounced in CTA (80.24/100,000 ED visits to 448.26/100,000 ED visits (p < 0.001)) and CTP (1.75/100,000 ED visits to 28.04/100,000 ED visits p < 0.001)). Regression analysis revealed that teaching hospitals were associated with higher odds of high CTA utilization (OR 1.88 for 2018, p < 0.05), while low-volume EDs and public hospitals showed the reverse (OR 0.39 in 2018, p < 0.05). CONCLUSIONS We identified substantial increases in overall neuroimaging use in a national sample of non-admitted emergency department encounters between 2013 and 2018 with variability in utilization according to both patient and hospital properties. Further investigation into the appropriateness of this imaging is required to ensure that access to acute stroke treatment is balanced against the timing and cost of over-imaging.
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Affiliation(s)
- Lauren E Mamer
- Department of Emergency Medicine, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109-5301, USA.
| | - Keith E Kocher
- Department of Emergency Medicine, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109-5301, USA
- Department of Learning Health Sciences, University of Michigan Medical School, Ann Arbor, USA
| | - James A Cranford
- Department of Emergency Medicine, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109-5301, USA
| | - Phillip A Scott
- Department of Emergency Medicine, University of Michigan, 1500 E. Medical Center Dr, Ann Arbor, MI, 48109-5301, USA
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Lu X, Lin X, Shen Y, Hu M, Zhu D, Xu D. Effect of coastal and island geographic environments on patients with acute ischemic stroke in southeastern China. J Int Med Res 2024; 52:3000605241285141. [PMID: 39391979 PMCID: PMC11472418 DOI: 10.1177/03000605241285141] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2024] [Accepted: 09/02/2024] [Indexed: 10/12/2024] Open
Abstract
OBJECTIVE To analyze the geographic variation in characteristics and treatment processes of patients with acute ischemic stroke (AIS) in coastal, island, and inland regions. METHODS We conducted a retrospective, cross-sectional analysis of data from patients with AIS in southeastern China. We collected demographic and clinical information, including the time from stroke onset to treatment for those receiving reperfusion therapy, using a time-tracking table. RESULTS Among 8069 patients with AIS, 26.6% received reperfusion therapy, with a higher proportion undergoing endovascular therapy in maritime hospitals than in inland hospitals (14.2% vs. 6.7%). Maritime hospitals had a higher prevalence of atrial fibrillation (15.1% vs. 11.9%) and cardioembolism (17.2% vs. 13.6%) than inland hospitals. Patients in maritime hospitals had shorter in-hospital processing times than those in inland hospitals (39 vs. 46 minutes). Island hospitals showed different patterns, with a shorter time from stroke onset to emergency room arrival (80 vs. 120 minutes) but a longer in-hospital process time (51 vs. 36 minutes), than coastline hospitals. CONCLUSIONS Our study suggests geographic variation in AIS characteristics and treatment processes across southeastern China, emphasizing the need for region-specific strategies. These findings are essential for tailoring public health policies and guidelines to improve stroke outcomes in various regions.
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Affiliation(s)
- Xudong Lu
- Department of Neurology, the Second Affiliated Hospital of Jiaxing University, Jiaxing, China
| | - Xiaoci Lin
- Department of Neurology, the First People’s Hospital of Daishan, Zhoushan, China
| | - Yilei Shen
- Department of Neurology, Dongyang Affiliated Hospital of Wenzhou Medical University, Jinhua, China
| | - Mengmeng Hu
- Department of Neurology, Dongyang Affiliated Hospital of Wenzhou Medical University, Jinhua, China
| | - Daijun Zhu
- Department of Neurology, the First People’s Hospital of Daishan, Zhoushan, China
| | - Dongjuan Xu
- Department of Neurology, Dongyang Affiliated Hospital of Wenzhou Medical University, Jinhua, China
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Elawady SS, Cunningham C, Matsukawa H, Uchida K, Lin S, Maier I, Jabbour P, Kim JT, Wolfe SQ, Rai A, Starke RM, Psychogios MN, Samaniego EA, Arthur A, Yoshimura S, Cuellar H, Grossberg JA, Alawieh A, Romano DG, Tanweer O, Mascitelli J, Fragata I, Polifka A, Osbun J, Crosa R, Matouk C, Park MS, Levitt MR, Brinjikji W, Moss M, Dumont T, Williamson R, Navia P, Kan P, De Leacy R, Chowdhry S, Ezzeldin M, Spiotta AM, Al Kasab S. Outcomes of Mechanical Thrombectomy for Patients With Stroke Presenting With Low Alberta Stroke Program Early Computed Tomography Score in Early and Late Time Windows. Neurosurgery 2024; 95:877-885. [PMID: 39293795 DOI: 10.1227/neu.0000000000002992] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2023] [Accepted: 02/14/2024] [Indexed: 05/19/2024] Open
Abstract
BACKGROUND AND OBJECTIVES This study aimed to compare outcomes of low Alberta Stroke Program Early Computed Tomography Score (ASPECTS) patients with stroke who underwent mechanical thrombectomy (MT) within 6 hours or 6 to 24 hours after stroke onset. METHODS A retrospective cohort study was conducted using data from a large multicenter international registry from 2013 to 2023. Patients with low ASPECTS (2-5) who underwent MT for anterior circulation intracranial large vessel occlusion were included. A propensity matching analysis was conducted for patients presented in the early (<6 hours) vs late (6-24 hours) time window after symptom onset or last known normal. RESULTS Among the 10 229 patients who underwent MT, 274 met the inclusion criteria. 122 (44.5%) patients were treated in the late window. Early window patients were older (median age, 74 years [IQR, 63-80] vs 66.5 years [IQR, 54-77]; P < .001), had lower proportion of female patients (40.1% vs 54.1%; P = .029), higher median admission National Institutes of Health Stroke Scale score (20 [IQR, 16-24] vs 19 [IQR, 14-22]; P = .004), and a higher prevalence of atrial fibrillation (46.1% vs 27.3; P = .002). Propensity matching yielded a well-matched cohort of 84 patients in each group. Comparing the matched cohorts showed there was no significant difference in acceptable outcomes at 90 days between the 2 groups (odds ratio = 0.90 [95% CI = 0.47-1.71]; P = .70). However, the rate of symptomatic ICH was significantly higher in the early window group compared with the late window group (odds ratio = 2.44 [95% CI = 1.06-6.02]; P = .04). CONCLUSION Among patients with anterior circulation large vessel occlusion and low ASPECTS, MT seems to provide a similar benefit to functional outcome for patients presenting <6 hours or 6 to 24 hours after onset.
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Affiliation(s)
- Sameh Samir Elawady
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston , South Carolina , USA
| | - Conor Cunningham
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston , South Carolina , USA
| | - Hidetoshi Matsukawa
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston , South Carolina , USA
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya , Japan
| | - Kazutaka Uchida
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston , South Carolina , USA
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya , Japan
| | - Steven Lin
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston , South Carolina , USA
| | - Ilko Maier
- Department of Neurology, University Medical Center Göttingen, Göttingen , Germany
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University Hospitals, Philadelphia , Pennsylvania , USA
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Medical School, Chonnam National University Hospital, Gwangju , Korea
| | - Stacey Quintero Wolfe
- Department of Neurosurgery, Wake Forest School of Medicine, Winston-Salem , North Carolina , USA
| | - Ansaar Rai
- Department of Radiology, West Virginia School of Medicine, Morgantown , West Virginia , USA
| | - Robert M Starke
- Department of Neurosurgery, University of Miami Health System, Miami , Florida , USA
| | - Marios-Nikos Psychogios
- Department of Interventional and Diagnostical Neuroradiology, University of Basel, Basel , Switzerland
| | - Edgar A Samaniego
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City , Iowa , USA
| | - Adam Arthur
- Department of Neurosurgery, Semmes-Murphey Neurologic and Spine Clinic, University of Tennessee Health Science Center, Memphis , Tennessee , USA
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya , Japan
| | - Hugo Cuellar
- Department of Neurosurgery and Neurointerventional Radiology, Louisiana State University, Shreveport , Louisiana , USA
| | - Jonathan A Grossberg
- Neurosurgery, Radiology and Imaging Sciences, Emory University, Atlanta , Georgia , USA
| | - Ali Alawieh
- Neurosurgery, Radiology and Imaging Sciences, Emory University, Atlanta , Georgia , USA
| | - Daniele G Romano
- Department of Neuroradiology, University Hospital San Giovanni di Dio e Ruggi d'Aragona, University of Salerno, Salerno , Italy
| | - Omar Tanweer
- Department of Neurosurgery, Baylor College of Medicine, Houston , Texas , USA
| | - Justin Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio , Texas , USA
| | - Isabel Fragata
- Department of Neuroradiology, Hospital São José Centro Hospitalar, Lisboa , Portugal
| | - Adam Polifka
- Department of Neurosurgery, University of Florida, Gainesville , Florida , USA
| | - Joshua Osbun
- Department of Neurological Surgery, Washington University, St Louis , Missouri , USA
| | - Roberto Crosa
- Department of Neurosurgery, Endovascular Neurological Center, Montevideo , Uruguay
| | - Charles Matouk
- Department of Neurosurgery, Yale School of Medicine, New Haven , Connecticut , USA
| | - Min S Park
- Department of Neurosurgery, University of Virginia, Charlottesville , Virginia , USA
| | - Michael R Levitt
- Department of Neurosurgery, University of Washington, Seattle , Washington , USA
| | - Waleed Brinjikji
- Department of Radiology, Mayo Clinic, Rochester , Minnesota , USA
- Department of Neurosurgery, Mayo Clinic, Rochester , Minnesota , USA
| | - Mark Moss
- Department of Neuroradiology, Washington Regional J.B. Hunt Transport Services Neuroscience Institute, Fayetteville , Arizona , USA
| | - Travis Dumont
- Department of Neurosurgery, University of Arizona, Tucson , Arizona , USA
| | - Richard Williamson
- Department of Neurosurgery, Allegheny Health Network, Pittsburgh , Pennsylvania , USA
| | - Pedro Navia
- Department of Neuroradiology, Hospital Universitario La Paz, Madrid , Spain
| | - Peter Kan
- Department of Neurological Surgery, University of Texas Medical Branch, Galveston , Texas , USA
| | - Reade De Leacy
- Department of Neurosurgery, Mount Sinai Health System, New York , New York , USA
| | - Shakeel Chowdhry
- Department of Neurosurgery, NorthShore University Health System, Evanston , Illinois , USA
| | - Mohamad Ezzeldin
- Department of Clinical Neuroscience, University of Houston, HCA Houston Healthcare Kingwood, Houston , Texas , USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston , South Carolina , USA
| | - Sami Al Kasab
- Department of Neurosurgery, Division of Neuroendovascular Surgery, Medical University of South Carolina, Charleston , South Carolina , USA
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Brenna S, Glatzel M, Magnus T, Puig B, Galliciotti G. Neuroserpin and Extracellular Vesicles in Ischemic Stroke: Partners in Neuroprotection? Aging Dis 2024; 15:2191-2204. [PMID: 39191396 PMCID: PMC11346402 DOI: 10.14336/ad.2024.0518] [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: 04/30/2024] [Accepted: 06/05/2024] [Indexed: 08/29/2024] Open
Abstract
Ischemic stroke represents a significant global health challenge, often resulting in death or long-term disability, particularly among the elderly, where advancing age stands as the most unmodifiable risk factor. Arising from the blockage of a brain-feeding artery, the only therapies available to date aim at removing the blood clot to restore cerebral blood flow and rescue neuronal cells from death. The prevailing treatment approach involves thrombolysis by administration of recombinant tissue plasminogen activator (tPA), albeit with a critical time constraint. Timely intervention is imperative, given that delayed thrombolysis increases tPA leakage into the brain parenchyma, causing harmful effects. Strategies to preserve tPA's vascular benefits while shielding brain cells from its toxicity have been explored. Notably, administering neuroserpin (Ns), a brain-specific tPA inhibitor, represents one such approach. Following ischemic stroke, Ns levels rise and correlate with favorable post-stroke outcomes. Studies in rodent models of focal cerebral ischemia have demonstrated the beneficial effects of Ns administration. Ns treatment maintains blood-brain barrier (BBB) integrity, reducing stroke volume. Conversely, Ns-deficient animals exhibit larger stroke injury, increased BBB permeability and enhanced microglia activation. Furthermore, Ns administration extends the therapeutic window for tPA intervention, underscoring its potential in stroke management. Remarkably, our investigation reveals the presence of Ns within extracellular vesicles (EVs), small membrane-surrounded particles released by all cells and critical for intercellular communication. EVs influence disease outcome following stroke through cargo transfer between cells. Clarifying the role of EVs containing NS could open up urgently needed novel therapeutic approaches to improve post-ischemic stroke outcome.
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Affiliation(s)
- Santra Brenna
- Experimental Research in Stroke and Inflammation (ERSI) Group, Department of Neurology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Markus Glatzel
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Tim Magnus
- Experimental Research in Stroke and Inflammation (ERSI) Group, Department of Neurology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Berta Puig
- Experimental Research in Stroke and Inflammation (ERSI) Group, Department of Neurology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Giovanna Galliciotti
- Institute of Neuropathology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
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Asmundo L, Zanardo M, Cressoni M, Ambrogi F, Bet L, Giatsidis F, Di Leo G, Sardanelli F, Vitali P. Ischemic core detection threshold of computed tomography perfusion (CTP) in acute stroke. LA RADIOLOGIA MEDICA 2024; 129:1522-1529. [PMID: 39162940 DOI: 10.1007/s11547-024-01868-x] [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: 03/11/2024] [Accepted: 08/01/2024] [Indexed: 08/21/2024]
Abstract
PURPOSE This study aimed to determine the accuracy of detecting ischemic core volume using computed tomography perfusion (CTP) in patients with suspected acute ischemic stroke compared to diffusion-weighted magnetic resonance imaging (DW-MRI) as the reference standard. METHODS This retrospective monocentric study included patients who underwent CTP and DW-MRI for suspected acute ischemic stroke. The ischemic core size was measured at DW-MRI. The detectability threshold volume was defined as the lowest volume detected by each method. Clinical data on revascularization therapy, along with the clinical decision that influenced the choice, were collected. Volumes of the ischemic cores were compared using the Mann-Whitney U test. RESULTS Of 83 patients who underwent CTP, 52 patients (median age 73 years, IQR 63-80, 36 men) also had DW-MRI and were included, with a total of 70 ischemic cores. Regarding ischemic cores, only 18/70 (26%) were detected by both CTP and DW-MRI, while 52/70 (74%) were detected only by DW-MRI. The median volume of the 52 ischemic cores undetected on CTP (0.6 mL, IQR 0.2-1.3 mL) was significantly lower (p < 0.001) than that of the 18 ischemic cores detected on CTP (14.2 mL, IQR 7.0-18.4 mL). The smallest ischemic core detected on CTP had a volume of 5.0 mL. Among the 20 patients with undetected ischemic core on CTP, only 10% (2/20) received thrombolysis treatment. CONCLUSIONS CTP maps failed in detecting ischemic cores smaller than 5 mL. DW-MRI remains essential for suspected small ischemic brain lesions to guide a correct treatment decision-making.
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Affiliation(s)
- Luigi Asmundo
- Postgraduate School in Radiodiagnostics, Università degli Studi di Milano, Via Festa del Perdono 7, 20122, Milan, Italy
| | - Moreno Zanardo
- Radiology Unit, IRCCS Policlinico San Donato, Via Morandi 30, 20097, San Donato Milanese, Italy.
| | - Massimo Cressoni
- Radiology Unit, IRCCS Policlinico San Donato, Via Morandi 30, 20097, San Donato Milanese, Italy
| | - Federico Ambrogi
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Via Della Commenda 19, 20122, Milan, Italy
- Scientific Directorate, IRCCS Policlinico San Donato, Via Morandi 30, 20097, San Donato Milanese, Italy
| | - Luciano Bet
- Neurology Unit, IRCCS Policlinico San Donato, Via Morandi 30, 20097, San Donato Milanese, Italy
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133, Milan, Italy
| | - Fabio Giatsidis
- Neurology Unit, IRCCS Policlinico San Donato, Via Morandi 30, 20097, San Donato Milanese, Italy
| | - Giovanni Di Leo
- Radiology Unit, IRCCS Policlinico San Donato, Via Morandi 30, 20097, San Donato Milanese, Italy
| | - Francesco Sardanelli
- Radiology Unit, IRCCS Policlinico San Donato, Via Morandi 30, 20097, San Donato Milanese, Italy
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133, Milan, Italy
| | - Paolo Vitali
- Radiology Unit, IRCCS Policlinico San Donato, Via Morandi 30, 20097, San Donato Milanese, Italy
- Department of Biomedical Sciences for Health, Università degli Studi di Milano, Via Mangiagalli 31, 20133, Milan, Italy
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Loggini A, Hornik J, Henson J, Wesler J, Nelson M, Hornik A. Comparison of Telemedicine-Administered Thrombolytic Therapy for Acute Ischemic Stroke by Neurology Subspecialty: A Cross-Sectional Study. Neurohospitalist 2024; 14:413-418. [PMID: 39308460 PMCID: PMC11412448 DOI: 10.1177/19418744241276244] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2024] [Revised: 08/01/2024] [Accepted: 08/04/2024] [Indexed: 09/25/2024] Open
Abstract
Background and Purpose To determine if any difference exists in safety and outcomes of thrombolytic therapy for acute ischemic stroke administered via telemedicine, based on the subspeciality of the treating neurologist. Methods We performed a retrospective cross-sectional study using data from our local stroke registry of thrombolytic therapy administered via telemedicine at our rural stroke network over 5 years. The cohort was divided in 2 groups based on the subspecialty of the treating neurologist: vascular neurology (VN) and neurocritical care (NCC). Demographics, clinical characteristics, stroke metrics, thrombolytic complications, and final diagnosis were reviewed. In-hospital mortality and mRS and 30 days were noted. Results Among 142 patients who received thrombolytic therapy via telemedicine, 44 (31%) were treated by VN specialists; 98 (69%) by NCC specialist. There was no difference in baseline characteristics and stroke metrics between the 2 groups. Compared to NCC, VN had a trend toward higher, but non-significant, sICH (6% vs 1%, P = 0.05). In a logistic regression analysis, correcting for NIHSS, SBP, door-to-needle time, and use of antiplatelet therapy, the type of neurology subspecialty was not independently associated with development of sICH (OR: 0.141, SE: 0.188, P = 0.141). The rate of in-hospital mortality was also similar between VN and NCC (7% vs 5%, P = 0.8). In a model that accounted for stroke severity, no association was established between the type of neurology subspecialty and mRS at 30 days (OR: 1.589, SE: 0.662, P = 0.266). Conclusions Safety and outcome of thrombolytic therapy via telemedicine was not influenced by the subspecialty of treating neurologist. Our study supports the expansion of telemedicine for acute stroke patients in rural and underserved areas.
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Affiliation(s)
- Andrea Loggini
- Brain and Spine Institute, Southern Illinois Healthcare, Carbondale, IL, USA
- School of Medicine, Southern Illinois University, Carbondale, IL, USA
| | - Jonatan Hornik
- Brain and Spine Institute, Southern Illinois Healthcare, Carbondale, IL, USA
- School of Medicine, Southern Illinois University, Carbondale, IL, USA
| | - Jessie Henson
- Brain and Spine Institute, Southern Illinois Healthcare, Carbondale, IL, USA
| | - Julie Wesler
- Brain and Spine Institute, Southern Illinois Healthcare, Carbondale, IL, USA
| | - Madison Nelson
- School of Medicine, Southern Illinois University, Carbondale, IL, USA
| | - Alejandro Hornik
- Brain and Spine Institute, Southern Illinois Healthcare, Carbondale, IL, USA
- School of Medicine, Southern Illinois University, Carbondale, IL, USA
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Cong Y, Xia X, Liao J, Zhang A, Zhang T, Cao X, Liu P, Ma F, Tang X, Chen J, Han Y, Chen Z, Li W, Zhu Y, Yao B, Wu M. Association of Systemic Inflammatory Response Index and Neutrophil-to-Lymphocyte Ratio on Unfavorable Functional Outcomes in Acute Ischemic Stroke Patients After Endovascular Therapy. World Neurosurg 2024; 190:e1071-e1080. [PMID: 39151692 DOI: 10.1016/j.wneu.2024.08.065] [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: 07/25/2024] [Accepted: 08/11/2024] [Indexed: 08/19/2024]
Abstract
BACKGROUND Inflammatory markers for the prognosis of acute ischemic stroke (AIS) with endovascular therapy remain unclear. The purpose of this study was to investigate the association between the systemic inflammatory response index (SIRI) and neutrophil-to-lymphocyte ratio (NLR) with unfavorable functional outcomes at 90-day in individuals of AIS who underwent endovascular therapy. METHODS A total of 128 AIS patients who had endovascular therapy were enrolled from the Nanjing Stroke Registry between September 2019 and November 2022. Peripheral venous blood was collected from patients within 24 h of admission for information on the following parameters: neutrophil count, lymphocyte count, and monocyte count. Then, the SIRI and NLR values were calculated and the association among SIRI, NLR, and modifled Rankin Scale scores 90 days after endovascular therapy was examined via univariate and multivariate logistic analyses. Receiver operating characteristic curves were utilized to determine the best threshold for SIRI and NLR in predicting negative neurological outcomes following endovascular treatment for patients with AIS. RESULTS A total of 128 participants were evaluated, among which 50% had unfavorable outcomes. Linear regression analysis showed that the best threshold for SIRI was >1.407 (odds ratio = 1.265; 95% confidence interval, 1.071-1.493; P = 0.006), and for NLR it was >5.347 (odds ratio = 1.088; 95% confidence interval, 1.007-1.175; P = 0.033). These results revealed NLR and SIRI as significant predictors of unfavorable outcomes at 90 days. The area under the curve for SIRI and NLR in predicting 90-day adverse outcomes was 0.643 and 0.609, respectively. CONCLUSIONS Higher SIRI and NLR levels at admission may lead to unfavorable outcomes at 90 days for AIS patients with endovascular therapy.
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Affiliation(s)
- Yujun Cong
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China; Department of Neurology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China; The First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China; Department of Neurology, Rushan Hospital of Traditional Chinese Medicine, Weihai, China
| | - Xin Xia
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China; Department of Neurology, Rugao Boai hospital, Nantong, China
| | - Junqi Liao
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China; Department of Neurology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Aimei Zhang
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China; Department of Neurology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China
| | - Tianrui Zhang
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China; Department of Neurology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China; The First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Xiaofeng Cao
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China; Department of Neurology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China; The First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Peian Liu
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China; Department of Neurology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China; The First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Fei Ma
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China; Department of Neurology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China; The First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Xiaogang Tang
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China; Department of Neurology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China; The First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Jingyi Chen
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China; Department of Neurology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China; The First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Yang Han
- Department of Neurology, Changshu Hospital Affiliated to Nanjing University of Chinese Medicine, Suzhou, China
| | - Zhaoyao Chen
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China; Department of Neurology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China; The First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Wenlei Li
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China; Department of Neurology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China; The First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Yuan Zhu
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China; Department of Neurology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China; The First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Beibei Yao
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China; Department of Neurology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China; The First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China
| | - Minghua Wu
- Department of Neurology, Affiliated Hospital of Nanjing University of Chinese Medicine, Nanjing, China; Department of Neurology, Jiangsu Province Hospital of Chinese Medicine, Nanjing, China; The First Clinical Medical College, Nanjing University of Chinese Medicine, Nanjing, China.
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Katz JM, Wang JJ, Sanmartin MX, Naidich JJ, Rula E, Sanelli PC. Ten-year trends, disparities, and clinical impact of stroke thrombectomy and thrombolysis: A single center experience 2012-2021. J Stroke Cerebrovasc Dis 2024; 33:107914. [PMID: 39098365 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 07/31/2024] [Accepted: 08/01/2024] [Indexed: 08/06/2024] Open
Abstract
OBJECTIVES As indications for acute ischemic stroke treatment expand, it is unclear whether disparities in treatment utilization and outcome still exist. The main objective of this study was to investigate disparities in acute ischemic stroke treatment and determine impact on outcome. MATERIALS AND METHODS Retrospective observational cohort study of consecutive ischemic stroke admissions to a comprehensive stroke center from 2012-2021 was performed. Primary exposure was intravenous thrombolysis and/or endovascular thrombectomy. Primary end points were discharge modified Rankin Scale, home disposition, and expired/hospice. Multivariable logistic regression analyses were conducted to elucidate disparities in treatment utilization and determine impact on outcome. RESULTS Of 517,615 inpatient visits, there were 7,540 (1.46 %) ischemic stroke admissions, increasing from 1.14 % to 1.79 % from 2012-2021. Intravenous thrombolysis significantly decreased from 14.4 % to 9.8 % while endovascular thrombectomy significantly increased from 0.8 % to 10.5 %. Both intravenous thrombolysis and endovascular thrombectomy increased odds of discharge home and modified Rankin Scale 0-2, and thrombectomy decreased odds of expired/hospice. After adjusting for covariates, decreased odds of thrombectomy was associated with Medicaid insurance (Odds Ratio [95 % Confidence Interval] 0.55 [0.32-0.93]), age 80+ (0.49 [0.35-0.69]), prior stroke (0.49 [0.31-0.77]), and diabetes mellitus (0.55 [0.39-0.79]), while low median household income (<$80,000/year) increased odds of no acute treatment (1.34 [1.16-1.56]). No sex or racial disparities were observed. Medicaid and low-income were not associated with worse clinical outcomes. CONCLUSIONS Less endovascular thrombectomy occurred in Medicaid, older, prior stroke, and diabetic patients, while low-income was associated with no treatment. The observed socioeconomic disparities did not impact discharge outcome.
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Affiliation(s)
- Jeffrey M Katz
- Northwell Health, New Hyde Park, NY, USA; Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset NY, USA; Department of Neurology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset NY, USA.
| | - Jason J Wang
- Northwell Health, New Hyde Park, NY, USA; Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset NY, USA; Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, The Feinstein Institutes for Medical Research, Manhasset, NY, USA.
| | - Maria X Sanmartin
- Northwell Health, New Hyde Park, NY, USA; Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset NY, USA; Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, The Feinstein Institutes for Medical Research, Manhasset, NY, USA.
| | - Jason J Naidich
- Northwell Health, New Hyde Park, NY, USA; Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset NY, USA.
| | - Elizabeth Rula
- Harvey L. Neiman Health Policy Institute, Reston, VA, USA.
| | - Pina C Sanelli
- Northwell Health, New Hyde Park, NY, USA; Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Manhasset NY, USA; Imaging Clinical Effectiveness and Outcomes Research, Center for Health Innovations and Outcomes Research, The Feinstein Institutes for Medical Research, Manhasset, NY, USA.
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Zhu CM, Li Q, Zeng W, Liu AF, Zhou J, Zhang M, Jiang YF, Li X, Jiang WJ. Safety and efficacy of endovascular recanalization in patients with mild anterior stroke due to large-vessel occlusion exceeding 24 hours. Int J Neurosci 2024; 134:1104-1113. [PMID: 37458211 DOI: 10.1080/00207454.2023.2236781] [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: 06/06/2023] [Revised: 07/04/2023] [Accepted: 07/10/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND Endovascular recanalization (ER) has demonstrated efficacy as a treatment modality for patients presenting with acute ischemic stroke (AIS) caused by large-vessel occlusion (LVO) within a 24-hour timeframe. Nevertheless, the safety and effectiveness of ER in patients with a time of onset exceeding 24 h remain uncertain. OBJECTIVE To evaluate the safety and efficacy of ER treatment for mild ischemic stroke beyond 24-h from symptom onset. METHODS A retrospectively maintained database of mild AIS due to LVO from March2018 to September 2022 at a comprehensive stroke center was screened.Patients received ER or standard medical therapies (SMT) for anterior circulation AIS due to LVO > 24-h were selected. RESULTS We included 47 LVO patients with mild AIS beyond 24-h who suffered neurological deterioration (ND). 34 of these patients underwent ER, the other 13 received SMT. The technical success rate of recanalization was 82.4% (28/34). Patients received ER had significantly lower NIHSS score at discharge and 90-day mRS score (p = 0.028, p = 0.037, respectively) compared to SMT. In addition, they had significantly lower 90-day recurrence of ischemic stroke and lower incidence of moderate-severe stroke (with a NIHSS score at least 5) (p = 0.037, p = 0.033). There were 4 patients (11.7%) had perioperative complications, and no symptomatic intracranial hemorrhage occurred. CONCLUSION ER treatment for mild AIS due to LVO encountered ND was generally safe and effective, even beyond 24-h, and resulted in a good prognosis and lower 90-day recurrence compared to SMT.
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Affiliation(s)
- Can-Min Zhu
- Department of Medicine, Soochow University School of Medicine, Suzhou, Jiang-su, China
- Department of Neurology, The First people's Hospital of Jiangxia District, Wuhan, Hu-bei, China
- Department of Vascular Neurosurgery, The PLA Rocket Force Characteristic Medical Center, Soochow University School of Medicine, Beijing, China
| | - Qiang Li
- Department of Neurology, Wuhan Fifth Hospital, Jianghan University School of Medicine, Wuhan, Hu-bei, China
| | - Wei Zeng
- Department of Neurology, Wuhan Fifth Hospital, Jianghan University School of Medicine, Wuhan, Hu-bei, China
| | - Ao-Fei Liu
- Department of Vascular Neurosurgery, The PLA Rocket Force Characteristic Medical Center, Soochow University School of Medicine, Beijing, China
| | - Ji Zhou
- Department of Vascular Neurosurgery, The PLA Rocket Force Characteristic Medical Center, Soochow University School of Medicine, Beijing, China
| | - Mei Zhang
- Department of Neurology, Wuhan Fifth Hospital, Jianghan University School of Medicine, Wuhan, Hu-bei, China
| | - Yuan-Feng Jiang
- Department of Vascular Neurosurgery, The PLA Rocket Force Characteristic Medical Center, Soochow University School of Medicine, Beijing, China
| | - Xia Li
- Department of Vascular Neurosurgery, The PLA Rocket Force Characteristic Medical Center, Soochow University School of Medicine, Beijing, China
| | - Wei-Jian Jiang
- Department of Medicine, Soochow University School of Medicine, Suzhou, Jiang-su, China
- Department of Vascular Neurosurgery, The PLA Rocket Force Characteristic Medical Center, Soochow University School of Medicine, Beijing, China
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Lu X, Che H, Guan H. Big data analysis of endovascular treatment for acute ischemic stroke: a study based on bibliometric analysis. ARQUIVOS DE NEURO-PSIQUIATRIA 2024; 82:1-13. [PMID: 39216487 DOI: 10.1055/s-0044-1789228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/04/2024]
Abstract
BACKGROUND While bibliometric analyses are prevalent in the medical field, few have focused on ther endovascular treatment for acute ischemic stroke (AIS). OBJECTIVE To employ big data analysis to examine the research status, trends, and hotspots in endovascular treatment for AIS. METHODS We conducted a comprehensive search using the Web of Science (WOS) database to identify relevant articles on the endovascular treatment for AIS from 1980 to the present. We used various tools for data analysis, including an online platform (https://bibliometric.com/app), the Citespace software, the Vosviewer software, and the ArcMap software, version 10.8. A number of bibliometric indicators were collected and analyzed, such as publication date, country where the studies were conducted, institutions to which the authors were affiliated, authors, high-frequency keywords, cooperative relationship etc. RESULTS: A total of 5,576 articles were retrieved. A substantial increase in the number of articles occurred after 2010. High-frequency keywords included terms such as large vessel occlusion, reperfusion, outcome, and basilar artery occlusion. Among the top 10 most productive authors, Raul G. Nogueira ranked first, with 136 published articles. Among the journals, The New England Journal of Medicine ranked first, with 5,631 citations. The United States has the closest collaborative ties with other nations. CONCLUSION In the present study, we found that the reports of endovascular treatment for AIS gradually increased after 2010. Among them, Raul G. Nogueira was the most productive author in this field. The New England Journal of Medicine was the most cited, and it had the greatest impact. The Multicenter Randomized Clinical Trial of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands (MR CLEAN) trial study was the most cited, and it was a landmark study. There are many interesting studies on endovascular treatment for AIS, such as ischemic penumbra, collateral circulation, bridging therapy etc.
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Affiliation(s)
- Xin Lu
- Yanbian University Hospital, Department of Neurology, Yanji, Jilin Province, China
| | - Huiying Che
- Yanbian University Hospital, Department of General Practice, Yanji, Jilin Province, China
| | - Hongjian Guan
- Yanbian University Hospital, Department of Neurology, Yanji, Jilin Province, China
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Favilla CG, Patel H, Abassi MH, Thon J, Mullen MT, Kasner SE, Song JW, Cummings S, Messé SR. Infarct density defined by ADC threshold is associated with long-term functional outcome after endovascular thrombectomy. J Stroke Cerebrovasc Dis 2024; 33:107857. [PMID: 38997048 PMCID: PMC11380574 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107857] [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: 08/24/2023] [Revised: 07/03/2024] [Accepted: 07/10/2024] [Indexed: 07/14/2024] Open
Abstract
OBJECTIVES Endovascular thrombectomy (EVT) dramatically improves clinical outcomes, but the reduction in final infarct volume only accounts for 10-15 % of the treatment benefit. We aimed to develop a novel MRI-ADC-based metric that quantify the degree of tissue injury to test the hypothesis that it outperforms infarct volume in predicting long-term outcome. MATERIALS AND METHODS A single-center cohort consisted of consecutive acute stroke patients with anterior circulation large vessel occlusion, successful recanalization via EVT (mTICI ≥2b), and MRI of the brain between 12 h and 7 days post-EVT. Imaging was processed via RAPID software. Final infarct volume was based on the traditional ADC <620 threshold. Logistic regression quantified the association of lesion volumes and good outcome (90-day modified Rankin Scale ≤2) at a range of lower ADC thresholds (<570, <520, and <470). Infarct density was calculated as the percentage of the final infarct volume below the ADC threshold with the greatest effect size. Univariate and multivariate logistic regression quantified the association between imaging/clinical metrics and functional outcome. RESULTS 120 patients underwent MRI after successful EVT. Lesion volume based on the ADC threshold <470 had the strongest association with good outcome (OR: 0.81 per 10 mL; 95 % CI: 0.66-0.99). In a multivariate model, infarct density (<470/<620 * 100) was independently associated with good outcome (aOR 0.68 per 10 %; 95 % CI: 0.49-0.95), but final infarct volume was not (aOR 0.98 per 10 mL; 95 % CI: 0.85-1.14). CONCLUSIONS Infarct density after EVT is more strongly associated with long-term clinical outcome than infarct volume.
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Affiliation(s)
| | - Heta Patel
- University of Pennsylvania, Department of Neurology, Philadelphia, PA, USA
| | | | - Jesse Thon
- Cooper University, Department of Neurology, Camden, NJ, USA
| | - Michael T Mullen
- Temple University, Department of Neurology, Philadelphia, PA, USA
| | - Scott E Kasner
- University of Pennsylvania, Department of Neurology, Philadelphia, PA, USA
| | - Jae W Song
- University of Pennsylvania, Department of Radiology, Philadelphia, PA, USA
| | - Stephanie Cummings
- University of Pennsylvania, Department of Neurology, Philadelphia, PA, USA
| | - Steven R Messé
- University of Pennsylvania, Department of Neurology, Philadelphia, PA, USA
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Benz AP, Meinel TR, Salerno A, Beyeler M, Strambo D, Kaesmacher J, Polymeris AA, Kahles T, Katan M, Engelter ST, Carrera E, Dirren E, Peters N, Cereda CW, Kägi G, Renaud S, Wegener S, Bolognese M, Bonati LH, Fischer U, Arnold M, Michel P, Shoamanesh A, Connolly SJ, Seiffge DJ. Prevalence and Distribution of Intracranial Vessel Occlusion on Angiography and Its Association with Functional Outcome in Patients with Atrial Fibrillation Presenting with Ischemic Stroke. Ann Neurol 2024. [PMID: 39344685 DOI: 10.1002/ana.27084] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2023] [Revised: 09/06/2024] [Accepted: 09/10/2024] [Indexed: 10/01/2024]
Abstract
OBJECTIVES To determine the prevalence and distribution of intracranial vessel occlusion identified on computed tomography (CT) or magnet resonance (MR) angiography and to explore its association with functional outcome in patients with atrial fibrillation (AF) and ischemic stroke. METHODS Multicenter cohort study enrolling consecutive patients with AF with imaging-confirmed ischemic stroke who underwent CT- or MR-angiography on admission (2014-2022). Multivariable regression was used to explore the association between intracranial vessel occlusion and poor functional outcome (modified Rankin Scale score 3-6) at 90 days. RESULTS The analysis included 10,164 patients (median age 81.5 years, 47.8% female, median National Institutes of Health Stroke Scale score on admission 6; 14.7% on a vitamin K antagonist [VKA], 27.5% on a direct oral anticoagulant [DOAC], 57.8% not receiving oral anticoagulation). Angiography showed intracranial vessel occlusion in 5,190 patients (51.1%), affecting the anterior cerebral circulation in 87.4%. Overall, 29.2% and 29.4% of patients received thrombolysis and mechanical thrombectomy, respectively. The proportion of patients with poor functional outcome at 90 days was 60.6% and 42.7% in those with and without vessel occlusion, respectively. In multivariable analyses, vessel occlusion was associated with poor functional outcome (adjusted odds ratio [aOR]: 1.95, 95% confidence interval [CI]: 1.71-2.22) with consistent results in subgroups according to oral anticoagulation use (VKA, aOR: 1.98, 95% CI: 1.40-2.80; DOAC, aOR: 2.35, 95% CI: 1.83-3.03; none, aOR: 1.76, 95% CI: 1.49-2.09). INTERPRETATION Intracranial vessel occlusion is common in patients with AF with ischemic stroke, mainly affects the anterior circulation and is associated with poor functional outcome. ANN NEUROL 2024.
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Affiliation(s)
- Alexander P Benz
- Population Health Research Institute, McMaster University, Hamilton, Canada
- Department of Cardiology, University Medical Center Mainz, Johannes Gutenberg-University, Mainz, Germany
| | - Thomas R Meinel
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
| | - Alexander Salerno
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Morin Beyeler
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
| | - Davide Strambo
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Johannes Kaesmacher
- Diagnostic and Interventional Neuroradiology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
| | - Alexandros A Polymeris
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Timo Kahles
- Department of Neurology, Kantonsspital Aarau, Aarau, Switzerland
| | - Mira Katan
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | - Stefan T Engelter
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Neurology and Neurorehabilitation, Center for Medicine of Aging and Rehabilitation, University of Basel and University, Felix Platter Hospital, Basel, Switzerland
| | - Emmanuel Carrera
- Department of Neurology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Elisabeth Dirren
- Department of Neurology, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Nils Peters
- Stroke Center, Klinik Hirslanden, Zürich, Switzerland
| | - Carlo W Cereda
- Stroke Center, Neurocenter of Southern Switzerland, Lugano, Switzerland
| | - Georg Kägi
- Department of Neurology, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Susanne Renaud
- Department of Neurology, Neuchâtel Hospital Network, Neuchâtel, Switzerland
| | - Susanne Wegener
- Department of Neurology, University Hospital Zurich, Zurich, Switzerland
| | | | - Leo H Bonati
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
- Reha Rheinfelden, Rheinfelden, Switzerland
| | - Urs Fischer
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
- Department of Neurology and Stroke Center, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Marcel Arnold
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
| | - Patrik Michel
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Ashkan Shoamanesh
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Stuart J Connolly
- Population Health Research Institute, McMaster University, Hamilton, Canada
| | - David J Seiffge
- Department of Neurology, Stroke Research Center Bern, Inselspital University Hospital Bern and University of Bern, Bern, Switzerland
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Chung HI, Lee Y, Yoon BA, Kim DH, Cha JK, Lee S. Delayed door to puncture time during off-duty hours is associated with unfavorable outcomes after mechanical thrombectomy in the early window of acute ischemic stroke. BMC Neurol 2024; 24:357. [PMID: 39342130 PMCID: PMC11438392 DOI: 10.1186/s12883-024-03874-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Accepted: 09/20/2024] [Indexed: 10/01/2024] Open
Abstract
BACKGROUNDS The impact of off-duty hours mechanical thrombectomy on outcomes remains a subject of controversy. The impacts of off-duty hours on procedures are influenced by various factors, but the most critical one is the time delay in initiating the procedure after the patient's arrival at the emergency room. Recently, a report suggested that the impact of time delay on post-procedural outcomes is evident in patients who arrive at the emergency room within 6 h of symptom onset, referred to as the "early window." We hypothesized that the impact of procedure delays on outcomes during off duty-hours would be most significant within this early window. This study aimed to investigate the impact of door-to-puncture time (DTPT) delays in patients who underwent mechanical thrombectomy for acute ischemic stroke (AIS) during off-duty hours in both the early and late time windows. METHODS We investigated patients who presented to the emergency center between 2014 and 2022. Among a total of 6,496 AIS patients, we selected those who underwent mechanical thrombectomy within 24 h of the onset of acute anterior circulation occlusion. The eligible patients were divided into two groups: those who arrived within 6 h of symptom onset and received the procedure within 8 h (early window), and those who received the procedure between 8 h and 24 h after symptom onset (late window). The study assessed the association between the onset to puncture time in each group and poor outcomes, measured by the modified Rankin scores(mRs) at 90 days. Furthermore, the study analyzed the impact of receiving the procedure during off-hours in both the early and late windows on outcomes. Specifically, the analysis focused on the impact of delayed DTPT in patients during off-duty hours on outcomes measured by the 90-days mRS. RESULTS Among the eligible patients, a total of 501 AIS patients underwent mechanical thrombectomy for acute anterior circulation occlusion within 24 h. Of these, 395 patients (78.8%) fell into the early window category, and 320 patients (63.9%) underwent the procedure during off-duty hours. In the early window, for every 60-minute increase in OTPT, the probability of occurrence a poor outcome at 90 days significantly increased in the fully adjusted model (OR = 1.21; 95% CI, 1.02 to 1.43; p = 0.03). In the early window, delayed procedures during off-duty hours (exceeding 103 min of DTPT) were identified as an independent predictor of poor outcomes (OR = 1.85; 95% CI, 1.05 to 3.24; p = 0.03). However, in the late window, there was no association between DTPT and outcomes at 90 days, and the impact of DTPT delays during off-hours was not observed. CONCLUSIONS Through this study, it became evident that the impacts of off-duty hours in mechanical thrombectomy were most pronounced in the early window, where the impact of time delay was clear. Therefore, it is believed that improvements in the treatment system are necessary to address this issue.
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Affiliation(s)
- Hye-In Chung
- Stroke Center, Department of Neurology, College of Medicine, Dong-A University, Daesingongwon-ro 26, Seo-gu, Busan, 49201, Republic of Korea
| | - Yoonkyung Lee
- Stroke Center, Department of Neurology, College of Medicine, Dong-A University, Daesingongwon-ro 26, Seo-gu, Busan, 49201, Republic of Korea
| | - Byeol-A Yoon
- Stroke Center, Department of Neurology, College of Medicine, Dong-A University, Daesingongwon-ro 26, Seo-gu, Busan, 49201, Republic of Korea
| | - Dae-Hyun Kim
- Stroke Center, Department of Neurology, College of Medicine, Dong-A University, Daesingongwon-ro 26, Seo-gu, Busan, 49201, Republic of Korea
| | - Jae-Kwan Cha
- Stroke Center, Department of Neurology, College of Medicine, Dong-A University, Daesingongwon-ro 26, Seo-gu, Busan, 49201, Republic of Korea.
| | - Seungho Lee
- Department of Preventive Medicine, College of Medicine, Dong-A University, Busan, Republic of Korea
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43
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Nguyen TN, Abdalkader M, Fischer U, Qiu Z, Nagel S, Chen HS, Miao Z, Khatri P. Endovascular management of acute stroke. Lancet 2024; 404:1265-1278. [PMID: 39341645 DOI: 10.1016/s0140-6736(24)01410-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 03/30/2024] [Accepted: 07/04/2024] [Indexed: 10/01/2024]
Abstract
Stroke related to large vessel occlusion is a leading cause of disability and death worldwide. Advances in endovascular therapy to reopen occluded arteries have been shown to reduce patient disability and mortality. Expanded indications to treat patients with large vessel occlusion in the late window (>6 h from symptom onset), with basilar artery occlusion, and with large ischaemic core at presentation have enabled treatment of more patients with simplified imaging methods. Ongoing knowledge gaps include an understanding of which patients with large ischaemic infarct are more likely to benefit from endovascular therapy, the role of endovascular therapy in patients who present with low National Institutes of Health Stroke Scale scores or medium or distal vessel occlusion, and optimal management of patients with underlying intracranial atherosclerotic disease. As reperfusion can now be facilitated by intravenous thrombolysis, mechanical thrombectomy, or both, the development of cytoprotective or adjunctive drugs to slow infarct growth, enhance reperfusion, or decrease haemorrhagic risk has gained renewed interest with the hope to improve patient outcomes.
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Affiliation(s)
- Thanh N Nguyen
- Department of Neurology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA; Department of Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA.
| | - Mohamad Abdalkader
- Department of Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Urs Fischer
- Department of Neurology, University Hospital Bern, Bern, Switzerland
| | - Zhongming Qiu
- Department of Neurology, The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China
| | - Simon Nagel
- Department of Neurology, Klinikum Ludwigshafen, Ludwigshafen, Germany; Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Hui-Sheng Chen
- Department of Neurology, General Hospital of Northern Theatre Command, Shenyang, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Pooja Khatri
- Department of Neurology and Rehabilitation, University of Cincinnati, Cincinnati, OH, USA
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44
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Cernigliaro M, Stanca C, Spinetta M, Tettoni SM, Sassone M, Siani A, Coda C, Laganà D, Minici R, Airoldi C, Campone G, Fiore RD, Galbiati A, Guzzardi G, Carriero A. StentRetriever- aspiration (SRa) vs direct aspiration (DA) in the treatment of acute M2 segment occlusion of middle cerebral artery: A single center randomized prospective study. J Stroke Cerebrovasc Dis 2024; 33:108037. [PMID: 39349266 DOI: 10.1016/j.jstrokecerebrovasdis.2024.108037] [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: 02/14/2024] [Revised: 09/23/2024] [Accepted: 09/24/2024] [Indexed: 10/02/2024] Open
Abstract
Decision making and patient selection for isolated occlusion of the M2 segment of the middle cerebral artery is challenging, with the efficacy of treatment for such distal occlusions still controversial in recent studies, as occlusion in such small and thin vessels tends to manifest with less severe symptoms initially and hold higher surgical risks. It is even less clear which endovascular technique is more effective for this type of occlusion, with the choice usually left to the radiologist's preference. We conducted a controlled prospective study of consecutive patients presenting to Novara Hospital with an acute M2 occlusion diagnosed at the AngioCt and, following a predetermined randomization, we divided them into two treatment arms with either stent retriever aspiration (SRa) or direct aspiration (DA). All patients were examined on admission, at discharge and after 3 months, and clinical data as well as mRS and NIHSS scale scores were recorded. Our primary aim was to evaluate the difference in recanalization rate in the two groups by comparing the angiographic eTICI obtained with the two techniques. We then investigated whether there were differences in clinical outcomes and complications. Our data confirm a good recanalization rate with an eTICI ≥ 2b in 76.19% of patients in the cohort. An overall good outcome was achieved in 57% of patients as ∆NIHSS and in 50.79% of patients considering mRS. We found no statistically significant difference in recanalization rate nor higher complication rate in either the SRa or DA group. Both techniques are safe, effective and can be considered equally.
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Affiliation(s)
- M Cernigliaro
- Azienda Ospedaliero Universitaria Maggiore della Carità: Novara, Piemonte, Italy.
| | - C Stanca
- Azienda Ospedaliero Universitaria Maggiore della Carità: Novara, Piemonte, Italy
| | - M Spinetta
- Azienda Ospedaliero Universitaria Maggiore della Carità: Novara, Piemonte, Italy
| | - S M Tettoni
- Azienda Ospedaliero Universitaria Maggiore della Carità: Novara, Piemonte, Italy
| | - M Sassone
- Azienda Ospedaliero Universitaria Maggiore della Carità: Novara, Piemonte, Italy
| | - A Siani
- Azienda Ospedaliero Universitaria Maggiore della Carità: Novara, Piemonte, Italy
| | - C Coda
- Azienda Ospedaliero Universitaria Maggiore della Carità: Novara, Piemonte, Italy
| | - D Laganà
- Radiology Unit, Dulbecco University Hospital, Catanzaro, Italy
| | - R Minici
- Fondazione IRCCS San Gerardo dei Tintori, Monza, Lombardia, Italy
| | - C Airoldi
- Azienda Ospedaliero Universitaria Maggiore della Carità: Novara, Piemonte, Italy
| | - G Campone
- Azienda Ospedaliero Universitaria Maggiore della Carità: Novara, Piemonte, Italy
| | - R Di Fiore
- Azienda Ospedaliero Universitaria Maggiore della Carità: Novara, Piemonte, Italy
| | - A Galbiati
- Azienda Ospedaliero Universitaria Maggiore della Carità: Novara, Piemonte, Italy
| | - G Guzzardi
- Azienda Ospedaliero Universitaria Maggiore della Carità: Novara, Piemonte, Italy
| | - A Carriero
- Azienda Ospedaliero Universitaria Maggiore della Carità: Novara, Piemonte, Italy
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45
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Chaudhari A, Majali MA, Lin EI, Zaidat OO. Trans-Clot MAP gradient: A novel innovative technique during thrombectomy for acute ischemic stroke with potential applications for assessing collateral circulation, determining clot etiology, informing device selection, and predicting first-pass success. Interv Neuroradiol 2024:15910199241286547. [PMID: 39328169 DOI: 10.1177/15910199241286547] [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: 09/28/2024] Open
Abstract
Endovascular mechanical thrombectomy has significantly improved recovery in acute ischemic stroke (AIS). While traditional patient selection has relied on factors such as last known well and penumbra volume, emerging research highlights the importance of collateral circulation in influencing thrombectomy success. However, current methods to assess collateral circulation are often unreliable and lack standardization, limiting their integration into clinical decision-making and prompting the need for innovative approaches. This study introduces trans-clot manometry as a promising approach for quantitatively assessing collateral blood flow before thrombectomy. Two patients were included in this study: a 64-year-old female with a left M1 near-complete occlusion and an 81-year-old male with a left P1 occlusion. After receiving intravenous tenecteplase, each patient underwent emergent thrombectomy where intraoperative trans-clot manometry revealed significant trans-clot mean arterial pressure (MAP) gradients (66.7% for Patient 1 and 96.9% for Patient 2). Both patients had successful first-pass thrombectomy (Patient 1: TICI 3; Patient 2: TICI 3), with substantial clinical improvement (Patient 1: NIHSS 11 to 1; Patient 2: NIHSS 19 to 8). Intraoperative trans-clot manometry offers a simple yet powerful, objective, and generalizable measure of collateral circulation, applicable to a wide range of AIS cases regardless of clot location or vessel size. In addition, real-time correlations with heart-rate variability and radial artery pressures provide an intrinsic quality control, ensuring proper execution of the technique and accuracy of the resulting MAP gradient. Future research will focus on validating this approach, determining its generalizability, and establishing MAP gradient thresholds to enhance device selection and predict first-pass success.
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Affiliation(s)
| | | | - Eugene I Lin
- Mercy Health St Vincent Medical Center, Toledo, OH, USA
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Zhang L, Chen F, Nguyen TN, Pan Y, Liu Y, Wang M, Li S, Sun D, Huo X, Jia B, Miao Z. Spontaneous recanalization in acute large core ischemic stroke due to large vessel occlusion: a post-hoc analysis of the ANGEL-ASPECT trial. J Neurointerv Surg 2024:jnis-2024-022357. [PMID: 39332900 DOI: 10.1136/jnis-2024-022357] [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: 08/13/2024] [Accepted: 09/15/2024] [Indexed: 09/29/2024]
Abstract
BACKGROUND Previous studies have indicated that a subset of patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO) experience spontaneous recanalization (SR), but the prognosis and factors associated with SR in these individuals are not well characterized. METHODS We conducted a post hoc secondary analysis of the Study of Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients with a Large Infarct Core (ANGEL-ASPECT) trial. SR in the medical management group was defined as a modified arterial occlusive lesion (AOL) grade of 2 or 3 on computed tomography angiography (CTA) or magnetic resonance angiography (MRA) at 36 hours (±12 hours). RESULTS SR was detected in 67 out of 184 patients (36.4%) in the medical management (MM) group. The median age of patients was 67 years (interquartile range (IQR) 58-72), and 48 (71.6%) were male. The adjusted odds ratio (aOR) for 90-day modified Rankin Scale (mRS) score shift toward better outcomes of the MM with SR group vs the MM without SR group was 1.83, with marginally significant difference (95% confidence interval (CI) 0.992 to 3.36; P=0.053). No significant difference was found between the MM with SR group and EVT recanalization group (aOR 1.45; 95% CI 0.86 to 2.43; P=0.16) with similar findings in the inverse probability treatment weighting analysis (OR 0.85; 95% CI 0.49 to 1.48; P=0.57). Multivariable regression analysis showed that hypertension, atherothrombotic stroke and higher clot burden score were factors associated with SR. CONCLUSIONS SR in medically managed patients with acute large ischemic stroke caused by LVO was associated with good functional outcome. An improved understanding of SR patients may be helpful to develop therapeutic strategy in patients with large infarct due to LVO in anterior circulation. TRIAL REGISTRATION NUMBER NCT04551664.
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Affiliation(s)
- Longhui Zhang
- Department of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Capital Medical University, Beijing, China
| | - Fangguang Chen
- Department of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Capital Medical University, Beijing, China
| | - Thanh N Nguyen
- Neurology, Boston University School of Medicine, Boston, Massachusetts, USA
| | - Yuesong Pan
- Department of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Yufan Liu
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Mengxing Wang
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Shuo Li
- Cerebrovascular Disease Department, Neurological Disease Center, Beijing Anzhen Hospital Affiliated to Capital Medical University, Beijing, China
| | - Dapeng Sun
- Department of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Xiaochuan Huo
- Cerebrovascular Disease Department, Neurological Disease Center, Beijing Anzhen Hospital Affiliated to Capital Medical University, Beijing, China
| | - BaiXue Jia
- Department of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Capital Medical University, Beijing, China
- China National Clinical Research Centre for Neurological Diseases, Beijing, China
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Caffarelli M, Wood AJ, Crowe RP, Amorim E, Kamel H, Kim AS, Guterman EL. Prevalence and Determinants of Prehospital Impression of Stroke in Ischemic Stroke Patients. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.09.25.24314407. [PMID: 39398987 PMCID: PMC11469348 DOI: 10.1101/2024.09.25.24314407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 10/15/2024]
Abstract
BACKGROUND Emergency Medical Services (EMS) clinicians are front-line in evaluating patients with stroke in the community. Their ability to correctly identify stroke influences downstream management decisions. We sought to use a large national database of prehospital clinical data to determine risk factors associated with missed EMS stroke identification. METHODS Retrospective study examining EMS evaluation of adults with Emergency Department (ED) stroke diagnosis. We leveraged the ESO Data Collaborative research dataset containing EHR data from 2019-2022 that has a subset of encounters with linked hospital diagnostic codes. Our primary outcome was the presence of an EMS diagnosis of stroke. We evaluated the association between demographic and clinical variables with EMS stroke identification using Pearson χ2 test for demographic variables and multivariable GLM for clinical variables with adjustment for demographic variables. RESULTS We identified 34,504 EMS encounters for patients with ED stroke diagnosis. Of these, 11,077 (32.1%) strokes had missed EMS stroke identification and instead had an EMS impression of "Generalized Weakness" (25.9%), "Altered Level of Consciousness" (24.9%), and "Dizziness" (7.2%). Patients more likely to have missed prehospital stroke identification were of Black race (p=0.0001) and Hispanic ethnicity (p=0.0001). Clinical variables associated with higher risk of missed EMS stroke identification were suspected alcohol or drug use (RR 1.48, 95% CI 1.37-1.59), low GCS (RR 1.17, 95% CI 1.10-1.24), tachycardia (RR 1.05, 95% CI 1.01-1.09), and hypotension (RR 1.47, 95% CI 1.34-1.61). CONCLUSIONS Approximately 1-in-3 patients transported by EMS did not have their stroke identified in the prehospital setting. Factors associated with lower odds of missed EMS stroke identification provide a starting point for future performance improvement initiatives.
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48
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Valente M, Bivard A, Yan B, Davis SM, Campbell BCV, Mitchell PJ, Ma H, Parsons MW. Determinants of infarct progression and perfusion core growth in transferred LVO patients from remote regions. Front Neurol 2024; 15:1476796. [PMID: 39372700 PMCID: PMC11449691 DOI: 10.3389/fneur.2024.1476796] [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: 08/06/2024] [Accepted: 09/04/2024] [Indexed: 10/08/2024] Open
Abstract
Introduction Repeat imaging when regional and remote stroke patients arrive at a comprehensive stroke center (CSC) can delay endovascular thrombectomy (EVT). We examined which clinical and imaging parameters predict infarct progression and perfusion core growth during transport. Methods We included patients recruited from 2017 to 2023 in a prospective database who were transferred from remote sites with large vessel occlusion, had CT perfusion imaging at the primary stroke center (PSC), and had repeat CT on arrival at the CSC demonstrating persistent occlusion. The key imaging characteristics were perfusion core change (rCBF < 30%) and ASPECTS change. Multiple and ordinal logistic regression analyses were used to assess the relationship between background clinical and imaging variables and the CT-perfusion core and ASPECTS on arrival. DEFUSE 3 criteria (ASPECTS ≥ 6, perfusion core < 70 mL) were used to define "favorable imaging." Results In 90 patients with CT perfusion at both PSC and CSC and persistent occlusion, the median time from onset to PSC presentation was 279 min (IQR 143-702). The median time from PSC presentation to CSC arrival was 243.5 min (IQR 186-335), and the median distance traveled was 186.5 km (IQR 101-258). Lower baseline ASPECTS (per point) was associated with a 7 mL increase (95%CI 2-11 mL) in perfusion core between scans (p = 0.004). The time from onset, the time between PSC and CSC, and the distance traveled were not significantly associated with either ASPECTS or perfusion core growth during transport. In total, 11 out of 78 patients (14%) had deterioration of initially favorable imaging profiles during transport. Conclusion Perfusion core growth during transport was uncommon and most strongly associated with lower ASPECTS at the PSC. Initially, favorable PSC imaging May predict whether repeat imaging is necessary at the CSC.
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Affiliation(s)
- Michael Valente
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
- Department of Neurology, Monash Health, Clayton, VIC, Australia
| | - Andrew Bivard
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Stephen M. Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Bruce C. V. Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Peter J. Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Henry Ma
- Department of Neurology, Monash Health, Clayton, VIC, Australia
| | - Mark W. Parsons
- Department of Neurology, South Western Sydney Clinical School, Ingham Institute of Applied Medical Research, Liverpool Hospital, University of New South Wales, Liverpool, NSW, Australia
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Kim JG, Ha SY, Kang YR, Hong H, Kim D, Lee M, Sunwoo L, Ryu WS, Kim JT. Automated detection of large vessel occlusion using deep learning: a pivotal multicenter study and reader performance study. J Neurointerv Surg 2024:jnis-2024-022254. [PMID: 39304193 DOI: 10.1136/jnis-2024-022254] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2024] [Accepted: 09/06/2024] [Indexed: 09/22/2024]
Abstract
BACKGROUND To evaluate the stand-alone efficacy and improvements in diagnostic accuracy of early-career physicians of the artificial intelligence (AI) software to detect large vessel occlusion (LVO) in CT angiography (CTA). METHODS This multicenter study included 595 ischemic stroke patients from January 2021 to September 2023. Standard references and LVO locations were determined by consensus among three experts. The efficacy of the AI software was benchmarked against standard references, and its impact on the diagnostic accuracy of four residents involved in stroke care was assessed. The area under the receiver operating characteristic curve (AUROC), sensitivity, and specificity of the software and readers with versus without AI assistance were calculated. RESULTS Among the 595 patients (mean age 68.5±13.4 years, 56% male), 275 (46.2%) had LVO. The median time interval from the last known well time to the CTA was 46.0 hours (IQR 11.8-64.4). For LVO detection, the software demonstrated a sensitivity of 0.858 (95% CI 0.811 to 0.897) and a specificity of 0.969 (95% CI 0.943 to 0.985). In subjects whose symptom onset to imaging was within 24 hours (n=195), the software exhibited an AUROC of 0.973 (95% CI 0.939 to 0.991), a sensitivity of 0.890 (95% CI 0.817 to 0.936), and a specificity of 0.965 (95% CI 0.902 to 0.991). Reading with AI assistance improved sensitivity by 4.0% (2.17 to 5.84%) and AUROC by 0.024 (0.015 to 0.033) (all P<0.001) compared with readings without AI assistance. CONCLUSIONS The AI software demonstrated a high detection rate for LVO. In addition, the software improved diagnostic accuracy of early-career physicians in detecting LVO, streamlining stroke workflow in the emergency room.
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Affiliation(s)
- Jae Guk Kim
- Department of Neurology, Daejeon Eulji University Hospital, Daejeon, Daejeon, Korea
| | - Sue Young Ha
- Artificial Intelligence Research Center, JLK Inc, Seoul, Korea
| | - You-Ri Kang
- Department of Neurology, Chonnam National University Medical School, Gwangju, Korea
| | - Hotak Hong
- Artificial Intelligence Research Center, JLK Inc, Seoul, Korea
| | - Dongmin Kim
- Artificial Intelligence Research Center, JLK Inc, Seoul, Korea
| | - Myungjae Lee
- Artificial Intelligence Research Center, JLK Inc, Seoul, Korea
| | - Leonard Sunwoo
- Department of Radiology, Seoul National University Bundang Hospital, Seongnam, Gyeonggi-do, Korea
| | - Wi-Sun Ryu
- Artificial Intelligence Research Center, JLK Inc, Seoul, Korea
| | - Joon-Tae Kim
- Department of Neurology, Chonnam National University Medical School, Gwangju, Korea
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50
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Takamiya S, Oura D, Ihara R, Niiya Y, Furukawa K, Gekka M, Nakazaki A, Fujimura M. The time threshold to reperfusion for DWI reversal in acute ischemic stroke depends on pre-interventional ADC value. Neuroradiology 2024:10.1007/s00234-024-03463-3. [PMID: 39297954 DOI: 10.1007/s00234-024-03463-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2024] [Accepted: 09/02/2024] [Indexed: 09/21/2024]
Abstract
PURPOSE The aims of this study are to explore the apparent diffusion coefficient (ADC)-dependent thresholds for time to reperfusion in reversible lesions following mechanical thrombectomy for acute ischemic stroke, and to investigate the associated risks of hemorrhagic transformation. METHODS We conducted a retrospective case-control study, enrolling patients with large-vessel occlusion who underwent mechanical thrombectomy in Otaru General Hospital from 2016 to 2021. Reversible lesions were identified using volumetric ADC data, and the mean time from image to reperfusion (TIR) in each ADC range was compared between groups with and without reversible lesions, as well as those with and without parenchymal hematoma. The Wilcoxon rank sum test and chi-square test were used for comparison between two groups, and receiver operating characteristic curves were created to determine optimal thresholds. RESULTS Seventy-five patients were included and 581 volumetric data were obtained. The mean TIR in the group with reversible lesions was shorter than in that without, and time thresholds were 131, 123 and 112 min for ADC values > 540 × 10-6, 500-540 × 10-6 and 440-500 × 10-6 mm2/s, respectively. Furthermore, in patients with parenchymal hematoma, the mean TIR was significantly longer, and the average ADC value was significantly lower than those without hematoma. CONCLUSION The time thresholds for the irreversible ischemic core may vary depending on the ADC value, and they may be shorter when the ADC value is lower. Moreover, both the low ADC value and the late reperfusion might be associated with an increased risk of parenchymal hematoma.
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Affiliation(s)
- Soichiro Takamiya
- Department of Neurosurgery, Otaru General Hospital, Otaru, Japan.
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan.
| | - Daisuke Oura
- Department of Radiology, Otaru General Hospital, Otaru, Japan
| | - Riku Ihara
- Department of Radiology, Otaru General Hospital, Otaru, Japan
| | - Yoshimasa Niiya
- Department of Neurosurgery, Otaru General Hospital, Otaru, Japan
| | - Koji Furukawa
- Department of Neurosurgery, Otaru General Hospital, Otaru, Japan
| | - Masayuki Gekka
- Department of Neurosurgery, Otaru General Hospital, Otaru, Japan
| | - Asuka Nakazaki
- Department of Neurosurgery, Otaru General Hospital, Otaru, Japan
| | - Miki Fujimura
- Department of Neurosurgery, Hokkaido University Graduate School of Medicine, Sapporo, Japan
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