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Singh N, Kashani N, Zea Vera AG, Tkach A, Ganesh A. Worldwide Survey on Approach to Thrombolysis in Acute Ischemic Stroke With Large Vessel Occlusion. Neurol Clin Pract 2024; 14:e200317. [PMID: 38863660 PMCID: PMC11164043 DOI: 10.1212/cpj.0000000000200317] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Accepted: 04/02/2024] [Indexed: 06/13/2024]
Abstract
Background and Objectives With recent trials suggesting that endovascular thrombectomy (EVT) alone may be noninferior to combined intravenous thrombolysis (IVT) with alteplase and EVT and that tenecteplase is non-inferior to alteplase in treating acute ischemic stroke, we sought to understand current practices around the world for treating acute ischemic stroke with large vessel occlusion (LVO) depending on the center of practice (IVT-capable vs IVT and EVT-capable stroke center). Methods The electronic survey launched by the Practice Current section of Neurology: Clinical Practice included 6 clinical and 8 demographic questions. A single-case scenario was presented of a 65-year-old man presenting with right hemiplegia with aphasia with a duration of 1 hour. Imaging showed left M1-MCA occlusion with no early ischemic changes. The respondents were asked about their treatment approach in 2 settings: the patient presented to (1) the IVT-only capable center and (2) the IVT and EVT-capable center. They were also asked about the thrombolytic agent of choice in current and ideal circumstances for these settings. Results A total of 203 physicians (42.9% vascular neurologists) from 44 countries completed the survey. Most participants (55.2%) spent ≥50% of their time delivering stroke care. The survey results showed that in current practice, more than 90% of respondents would offer IVT + EVT to patients with LVO stroke presenting to either an EVT-capable (91.1%) or IVT-only-capable center (93.6%). Although nearly 80% currently use alteplase for thrombolysis, around 60% would ideally like to switch to tenecteplase independent of the practice setting. These results were similar between stroke and non-stroke neurologists. Discussion Most physicians prefer IVT before EVT in patients with acute ischemic stroke attributable to large vessel occlusion independent of the practice setting.
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Affiliation(s)
- Nishita Singh
- Department of Internal Medicine (NS), Neurology Division, University of Manitoba, Winnipeg, Canada; Department of Clinical Neurosciences (NS, NK, AG), University of Calgary, Alberta, Canada; Department of Diagnostic and Interventional Neuroradiology (NK), Royal University Hospital, University of Saskatchewan, Saskatoon, Canada; Division of Neurology (AGZV), Children's National Hospital, Washington, DC; and Kelowna General Hospital (AT), University of British Columbia, Canada
| | - Nima Kashani
- Department of Internal Medicine (NS), Neurology Division, University of Manitoba, Winnipeg, Canada; Department of Clinical Neurosciences (NS, NK, AG), University of Calgary, Alberta, Canada; Department of Diagnostic and Interventional Neuroradiology (NK), Royal University Hospital, University of Saskatchewan, Saskatoon, Canada; Division of Neurology (AGZV), Children's National Hospital, Washington, DC; and Kelowna General Hospital (AT), University of British Columbia, Canada
| | - Alonso G Zea Vera
- Department of Internal Medicine (NS), Neurology Division, University of Manitoba, Winnipeg, Canada; Department of Clinical Neurosciences (NS, NK, AG), University of Calgary, Alberta, Canada; Department of Diagnostic and Interventional Neuroradiology (NK), Royal University Hospital, University of Saskatchewan, Saskatoon, Canada; Division of Neurology (AGZV), Children's National Hospital, Washington, DC; and Kelowna General Hospital (AT), University of British Columbia, Canada
| | - Aleksander Tkach
- Department of Internal Medicine (NS), Neurology Division, University of Manitoba, Winnipeg, Canada; Department of Clinical Neurosciences (NS, NK, AG), University of Calgary, Alberta, Canada; Department of Diagnostic and Interventional Neuroradiology (NK), Royal University Hospital, University of Saskatchewan, Saskatoon, Canada; Division of Neurology (AGZV), Children's National Hospital, Washington, DC; and Kelowna General Hospital (AT), University of British Columbia, Canada
| | - Aravind Ganesh
- Department of Internal Medicine (NS), Neurology Division, University of Manitoba, Winnipeg, Canada; Department of Clinical Neurosciences (NS, NK, AG), University of Calgary, Alberta, Canada; Department of Diagnostic and Interventional Neuroradiology (NK), Royal University Hospital, University of Saskatchewan, Saskatoon, Canada; Division of Neurology (AGZV), Children's National Hospital, Washington, DC; and Kelowna General Hospital (AT), University of British Columbia, Canada
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Gerschenfeld G, Turc G, Obadia M, Chausson N, Consoli A, Olindo S, Caroff J, Marnat G, Blanc R, Ben Hassen W, Seners P, Guillon B, Wiener E, Bourcier R, Yger M, Cho TH, Checkouri T, Gory B, Smadja D, Sibon I, Richard S, Piotin M, Eker OF, Pico F, Lapergue B, Alamowitch S. Functional Outcome and Hemorrhage Rates After Bridging Therapy With Tenecteplase or Alteplase in Patients With Large Ischemic Core. Neurology 2024; 103:e209398. [PMID: 38862134 DOI: 10.1212/wnl.0000000000209398] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND AND OBJECTIVES IV tenecteplase is an alternative to alteplase before mechanical thrombectomy (MT) in patients with large-vessel occlusion (LVO) ischemic stroke. Little data are available on its use in patients with large ischemic core. We aimed to compare the efficacy and safety of both thrombolytics in this population. METHODS We conducted a retrospective analysis of patients with anterior circulation LVO strokes and diffusion-weighed imaging Alberta Stroke Program Early CT Score (DWI-ASPECTS) ≤5 treated with tenecteplase or alteplase before MT from the TETRIS (tenecteplase) and ETIS (alteplase) French multicenter registries. Primary outcome was reduced disability at 3 months (ordinal analysis of the modified Rankin scale [mRS]). Safety outcomes were 3-month mortality, parenchymal hematoma (PH), and symptomatic intracranial hemorrhage (sICH). We used propensity score overlap weighting to reduce baseline differences between treatment groups. RESULTS We analyzed 647 patients (tenecteplase: n = 194; alteplase: n = 453; inclusion period 2015-2022). Median (interquartile range) age was 71 (57-81) years, with NIH Stroke Scale score 19 (16-22), DWI-ASPECTS 4 (3-5), and last seen well-to-IV thrombolysis and puncture times 165 minutes (130-226) and 260 minutes (203-349), respectively. After MT, the successful reperfusion rate was 83.1%. After propensity score overlap weighting, all baseline variables were well balanced between both treatment groups. Compared with patients treated with alteplase, patients treated with tenecteplase had better 3-month mRS (common odds ratio [OR] for reduced disability: 1.37, 1.01-1.87, p = 0.046) and lower 3-month mortality (OR 0.52, 0.33-0.81, p < 0.01). There were no significant differences between thrombolytics for PH (OR 0.84, 0.55-1.30, p = 0.44) and sICH incidence (OR 0.70, 0.42-1.18, p = 0.18). DISCUSSION Our data are encouraging regarding the efficacy and reassuring regarding the safety of tenecteplase compared with that of alteplase in bridging therapy for patients with LVO strokes and a large ischemic core in routine clinical care. These results support its consideration as an alternative to alteplase in bridging therapy for patients with large ischemic cores. TRIALS REGISTRATION INFORMATION NCT03776877 (ETIS registry) and NCT05534360 (TETRIS registry). CLASSIFICATION OF EVIDENCE This study provides Class III evidence that patients with anterior circulation LVO stroke and DWI-ASPECTS ≤5 treated with tenecteplase vs alteplase before MT experienced better functional outcomes and lower mortality at 3 months.
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Affiliation(s)
- Gaspard Gerschenfeld
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Guillaume Turc
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Michael Obadia
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Nicolas Chausson
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Arturo Consoli
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Stephane Olindo
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Jildaz Caroff
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Gaultier Marnat
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Raphael Blanc
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Wagih Ben Hassen
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Pierre Seners
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Benoit Guillon
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Emmanuel Wiener
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Romain Bourcier
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Marion Yger
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Tae-Hee Cho
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Thomas Checkouri
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Benjamin Gory
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Didier Smadja
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Igor Sibon
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Sebastien Richard
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Michel Piotin
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Omer F Eker
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Fernando Pico
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Bertrand Lapergue
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
| | - Sonia Alamowitch
- From the AP-HP (G.G., M.Y., T.C., S.A.), Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Sorbonne Université; STARE Team (G.G., M.Y., T.C., S.A.), iCRIN, Institut du Cerveau et de la Moelle épinière, ICM; Institut de Psychiatrie et Neurosciences de Paris (G.G., G.T., N.C., P.S., M.Y., D.S., S.A.), U1266, INSERM, Paris; Neurologie (G.T.), GHU Paris Psychiatrie et Neurosciences; Université Paris Cité (G.T.), FHU Neurovasc; Neurologie (O.M., P.S.), Fondation Rothschild, Paris; Neurologie (N.C., D.S.), Hôpital Sud-Francilien, Corbeil-Essonnes; Neuroradiologie (A.C.), Hôpital Foch, Université Versailles Saint-Quentin en Yvelines, Suresnes; Neurologie (S.O., I.S.), CHU de Bordeaux; AP-HP (J.C.), Neuroradiologie Interventionnelle, Hôpital Bicêtre, Université Paris-Saclay, Kremlin-Bicêtre; Neuroradiologie (G.M.), CHU de Bordeaux; Neuroradiologie (R. Blanc, M.P.), Fondation Rothschild; Neuroradiologie (W.B.H.), GHU Paris Psychiatrie et Neurosciences; Neurologie (B. Guillon), CHU de Nantes; Neurologie (E.W., F.P.), Centre Hospitalier de Versailles, Le Chesnay; Neuroradiologie (R. Bourcier), CHU de Nantes; Neurologie (T.-H.C.), Hospices Civils de Lyon; Neuroradiologie (B. Gory), and Neurologie (S.R.), CHRU de Nancy; Neuroradiologie (O.F.E.), Hospices Civils de Lyon; and Neurologie (B.L.), Hôpital Foch, Suresnes, France
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3
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Hilkens NA, Casolla B, Leung TW, de Leeuw FE. Stroke. Lancet 2024; 403:2820-2836. [PMID: 38759664 DOI: 10.1016/s0140-6736(24)00642-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/08/2024] [Revised: 03/19/2024] [Accepted: 03/26/2024] [Indexed: 05/19/2024]
Abstract
Stroke affects up to one in five people during their lifetime in some high-income countries, and up to almost one in two in low-income countries. Globally, it is the second leading cause of death. Clinically, the disease is characterised by sudden neurological deficits. Vascular aetiologies contribute to the most common causes of ischaemic stroke, including large artery disease, cardioembolism, and small vessel disease. Small vessel disease is also the most frequent cause of intracerebral haemorrhage, followed by macrovascular causes. For acute ischaemic stroke, multimodal CT or MRI reveal infarct core, ischaemic penumbra, and site of vascular occlusion. For intracerebral haemorrhage, neuroimaging identifies early radiological markers of haematoma expansion and probable underlying cause. For intravenous thrombolysis in ischaemic stroke, tenecteplase is now a safe and effective alternative to alteplase. In patients with strokes caused by large vessel occlusion, the indications for endovascular thrombectomy have been extended to include larger core infarcts and basilar artery occlusion, and the treatment time window has increased to up to 24 h from stroke onset. Regarding intracerebral haemorrhage, prompt delivery of bundled care consisting of immediate anticoagulation reversal, simultaneous blood pressure lowering, and prespecified stroke unit protocols can improve clinical outcomes. Guided by underlying stroke mechanisms, secondary prevention encompasses pharmacological, vascular, or endovascular interventions and lifestyle modifications.
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Affiliation(s)
- Nina A Hilkens
- Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands; Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands
| | - Barbara Casolla
- Université Nice Cote d'Azur UR2CA-URRIS, Stroke Unit, CHU Pasteur 2, Nice, France
| | - Thomas W Leung
- Division of Neurology, Department of Medicine and Therapeutics, The Prince of Wales Hospital, The Chinese University of Hong Kong, Shatin, Hong Kong Special Administrative Region, China
| | - Frank-Erik de Leeuw
- Department of Neurology, Radboud University Nijmegen Medical Center, Nijmegen, Netherlands; Donders Institute for Brain, Cognition and Behaviour, Radboud University, Nijmegen, Netherlands.
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4
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Scheldeman L, Sinnaeve P, Albers GW, Lemmens R, Van de Werf F. Acute myocardial infarction and ischaemic stroke: differences and similarities in reperfusion therapies-a review. Eur Heart J 2024:ehae371. [PMID: 38941344 DOI: 10.1093/eurheartj/ehae371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 04/16/2024] [Accepted: 05/28/2024] [Indexed: 06/30/2024] Open
Abstract
Acute ST-elevation myocardial infarction (STEMI) and acute ischaemic stroke (AIS) share a number of similarities. However, important differences in pathophysiology demand a disease-tailored approach. In both conditions, fast treatment plays a crucial role as ischaemia and eventually infarction develop rapidly. Furthermore, in both fields, the introduction of fibrinolytic treatments historically preceded the implementation of endovascular techniques. However, in contrast to STEMI, only a minority of AIS patients will eventually be considered eligible for reperfusion treatment. Non-invasive cerebral imaging always precedes cerebral angiography and thrombectomy, whereas coronary angiography is not routinely preceded by non-invasive cardiac imaging in patients with STEMI. In the late or unknown time window, the presence of specific patterns on brain imaging may help identify AIS patients who benefit most from reperfusion treatment. For STEMI, a uniform time window for reperfusion up to 12 h after symptom onset, based on old placebo-controlled trials, is still recommended in guidelines and generally applied. Bridging fibrinolysis preceding endovascular treatment still remains the mainstay of reperfusion treatment in AIS, while primary percutaneous coronary intervention is the strategy of choice in STEMI. Shortening ischaemic times by fine-tuning collaboration networks between ambulances, community hospitals, and tertiary care hospitals, optimizing bridging fibrinolysis, and reducing ischaemia-reperfusion injury are important topics for further research. The aim of this review is to provide insights into the common as well as diverging pathophysiology behind current reperfusion strategies and to explore new ways to enhance their clinical benefit.
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Affiliation(s)
- Lauranne Scheldeman
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
- Department of Neurosciences, Experimental Neurology KU Leuven - University of Leuven, Leuven, Belgium
| | - Peter Sinnaeve
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven, University of Leuven, Herestraat 49, B-3000 Leuven, Belgium
| | - Gregory W Albers
- Department of Neurology, Stanford University Medical Center, Palo Alto, USA
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
- Department of Neurosciences, Experimental Neurology KU Leuven - University of Leuven, Leuven, Belgium
| | - Frans Van de Werf
- Department of Cardiovascular Sciences, KU Leuven, University of Leuven, Herestraat 49, B-3000 Leuven, Belgium
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5
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Han B, Raynald, Wu Y, Feng G, Liu X, Zhang P, Lu P, Liu Y, Hu W, Sun Y. Thrombectomy versus combined thrombolysis for acute basilar artery occlusion: a secondary analysis of the ATTENTION trial. J Neurointerv Surg 2024:jnis-2024-021678. [PMID: 38937086 DOI: 10.1136/jnis-2024-021678] [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: 03/04/2024] [Accepted: 05/28/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Few studies have compared the outcomes of bridging intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) with those of direct MT in patients with acute basilar artery occlusion (BAO). This study aimed to assess the efficacy and safety of direct endovascular treatment (EVT) and bridging IVT followed by EVT in Chinese patients with acute basilar artery occlusion BAO. METHODS This subanalysis derived from the prospective multicenter randomized controlled trial of the ATTENTION study, included 221 patients with acute BAO categorized into two groups based on whether they received bridging IVT before MT: MT alone or combined IVT+MT. The primary endpoint was the modified Rankin Scale (mRS) score distribution at 90 days. Secondary outcomes included mRS scores within different ranges (0-1, 0-2, and 0-3) at the 90-day point and National Institutes of Health Stroke Scale (NIHSS) scores at 24 hours and 3 days post-intervention. Safety outcomes encompassed intracranial hemorrhage incidence based on the Heidelberg classification criteria (any intracerebral hemorrhage) and mortality assessment at 90 days. RESULTS Direct and bridging IVT before EVT yielded similar primary outcomes. No significant difference in 90-day mRS scores (median, 4.5 vs 4; adjusted odds ratio (aOR), 0.95 [95% confidence interval (CI), 0.79 to 1.15]; p=0.624) was observed between the two groups. Regarding safety outcomes, no significant differences were observed between the groups in terms of death within 90 days or any intracranial hemorrhage within 24 hours. CONCLUSIONS In patients with acute BAO, those treated with bridging IVT before EVT did not demonstrate any advantages in enhanced safety and efficacy outcomes compared with those treated with direct EVT.
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Affiliation(s)
- Bin Han
- Shanxi Key Laboratory of Brain Disease Control, Department of Neurology, Shanxi Provincial People's Hospital, Taiyuan, China
| | - Raynald
- Beijing Tiantan Hospital Department of Interventional Neuroradiology, Beijing, China
| | - Yaxin Wu
- Department of Neurology, Shanxi Provincial People's Hospital, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Ganghua Feng
- Department of Neurology, Shanxi Provincial People's Hospital, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Xuehan Liu
- The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, Hefei, China
| | - Peng Zhang
- Department of Neurology, Shanxi Provincial People's Hospital, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Pengyu Lu
- Department of Neurology, Shanxi Provincial People's Hospital, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Yi Liu
- Department of Neurology, Shanxi Provincial People's Hospital, Shanxi Medical University, Taiyuan, Shanxi, China
| | - Wei Hu
- Department of Neurology, University of Science and Technology of China, Hefei, China
| | - Yaxuan Sun
- Department of Neurology, Shanxi Provincial People's Hospital, Shanxi Medical University, Taiyuan, Shanxi, China
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6
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Mannismäki L, Martinez-Majander N, Suomalainen O, Sibolt G, Girfanova M, Nybondas M, Nissinen H, Curtze S. Comparison of functional and safety outcomes between the extended versus early time window after intravenous thrombolysis and endovascular thrombectomy. J Neurol Sci 2024; 462:123107. [PMID: 38925068 DOI: 10.1016/j.jns.2024.123107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2024] [Revised: 06/02/2024] [Accepted: 06/20/2024] [Indexed: 06/28/2024]
Abstract
INTRODUCTION Based on recent trials regarding the early time window, omitting intravenous thrombolysis (IVT) before endovascular thrombectomy (EVT) in eligible patients seems unjustified. Whether this also concerns the extended time window, 4.5 to 9 h from last seen well, is yet unclear. PATIENTS AND METHODS All consecutive patients treated with IVT, EVT, or IVT plus EVT in the extended time window at Helsinki University Hospital (HUS) between 1/2021 and 12/2022 were compared with matched controls treated in the early time window between 1/2016 and 12/2020. Regression analysis was applied on functional outcome at 90 days, evaluated on modified Rankin Scale (mRS), and on the occurrence of symptomatic intracerebral hemorrhage (sICH), adjusted for potential confounders. RESULTS Altogether 134 patients and 134 matching controls were included. Functional outcomes did not significantly differ between the extended versus early time window. Among patients with IVT plus EVT, the adjusted odds ratio (aOR) for a favorable outcome shift on mRS was 1.15, 95% confidence interval (CI) 0.54-2.43. Although sICH occurred more frequently (2.2% versus 3.0%) in the extended time window, regression analysis did not show a significant difference, aOR 0.96, 95% CI 0.14-6.87. DISCUSSION AND CONCLUSION We found no significant differences in the functional or safety outcomes between the extended versus early time window among patients with either IVT, EVT, or IVT plus EVT. There were no signals indicating, that IVT or EVT should be avoided in eligible patients in the extended time window which aligns with the current clinical treatment guidelines of HUS.
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Affiliation(s)
- Laura Mannismäki
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland.
| | - Nicolas Martinez-Majander
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Olli Suomalainen
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Gerli Sibolt
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Maria Girfanova
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Miranda Nybondas
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Hanna Nissinen
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Sami Curtze
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
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7
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Wang Z, Ji K, Fang Q. Endovascular thrombectomy with or without intravenous alteplase in large-core ischemic stroke: a systematic review and meta-analysis. Neurol Sci 2024:10.1007/s10072-024-07653-y. [PMID: 38896187 DOI: 10.1007/s10072-024-07653-y] [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: 02/29/2024] [Accepted: 06/11/2024] [Indexed: 06/21/2024]
Abstract
The role of bridging intravenous thrombolysis (IVT) with alteplase before endovascular thrombectomy (EVT) in treating large core ischemic stroke remains uncertain. We aimed to compare clinical outcomes and safety of EVT with or without bridging IVT in patients with anterior circulation large vessel occlusion (ACLVO) and baseline Alberta Stroke Program Early CT Score (ASPECTS) ≤ 5. We systematically searched PubMed, Web of Science, Cochrane Library, and Embase from inception until November 2023. The primary outcome was 90-day functional independence (modified Rankin Scale [mRS] 0-2). Secondary outcomes included 90-day independent ambulation (mRS 0-3), successful recanalization, any intracranial hemorrhage (ICH), symptomatic ICH (sICH) and 90-day mortality. A random-effects model was used for data pooling. Five high-quality studies, incorporating 2124 patients (41% treated with bridging IVT), were included. Across both unadjusted and adjusted analyses, no significant differences were found between the bridging IVT and EVT-alone groups in terms of functional independence (odds ratios [OR] = 1.36, 95% confidence interval [CI]: 0.90-2.07, P = 0.14; adjusted OR [aOR] = 1.19, 95% CI: 0.68-2.09, P = 0.53) or independent ambulation (OR = 1.14, 95% CI: 0.80-1.62, P = 0.47; aOR = 1.18, 95% CI: 1.00-1.39, P = 0.05) at 90 days. Furthermore, no differences were observed in successful recanalization, any ICH, sICH, and 90-day mortality between the two treatment groups. Bridging IVT exhibits similar functional and safety outcomes compared to EVT alone in ACLVO patients with baseline ASPECTS ≤ 5. Further research is warranted to confirm these findings.
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Affiliation(s)
- Zekun Wang
- Department of Neurology, The First Affiliated Hospital of Soochow University, No.899 Pinghai Road, Gusu District, Suzhou, 215031, Jiangsu Province, China.
| | - Kangxiang Ji
- Department of Neurology, The First Affiliated Hospital of Soochow University, No.899 Pinghai Road, Gusu District, Suzhou, 215031, Jiangsu Province, China
| | - Qi Fang
- Department of Neurology, The First Affiliated Hospital of Soochow University, No.899 Pinghai Road, Gusu District, Suzhou, 215031, Jiangsu Province, China.
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8
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Rodriguez-Calienes A, Galecio-Castillo M, Vivanco-Suarez J, Mohamed GA, Toth G, Sarraj A, Pujara D, Chowdhury AA, Farooqui M, Ghannam M, Samaniego EA, Jovin TG, Ortega-Gutierrez S. Endovascular thrombectomy beyond 24 hours from last known well: a systematic review with meta-analysis. J Neurointerv Surg 2024; 16:670-676. [PMID: 37355251 DOI: 10.1136/jnis-2023-020443] [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: 04/13/2023] [Accepted: 06/04/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Different studies have demonstrated the benefit of endovascular treatment (EVT) up to 24 hours after acute ischemic stroke (AIS) onset. Recent cohort observational studies suggest that patients with large vessel occlusion AIS may benefit from EVT beyond 24 hours from the last known well (LKW) when adequately selected. We aimed to examine the safety and efficacy of EVT beyond 24 hours from LKW using a meta-analysis of all the literature available. METHODS A systematic search from inception to April 2023 was conducted for studies including AIS patients with EVT beyond 24 hours from LKW in Medline, Embase, Scopus, and Web of Science. Outcomes of interest included favorable functional outcome (90-day modified Rankin scale (mRS) 0-2), successful reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 2b-3), symptomatic intracerebral hemorrhage (sICH), and 90-day mortality. Data were pooled using a random-effects model. RESULTS Twelve studies with 894 patients were included. The rate of favorable functional outcome was 40% (95% CI 31% to 49%; I2=76%). The rate of successful reperfusion was 83% (95% CI 80% to 85%; I2=0%). The sICH rate was 7% (95% CI 5% to 9%; I2=0%) and the 90-day mortality rate was 28% (95% CI 24% to 33%; I2=0%). There was no significant difference in favorable outcomes (OR=0.69; 95% CI 0.41 to 1.14) and 90-day mortality (OR=1.35; 95% CI 0.90 to 2.00) among patients who underwent EVT <24 hours versus >24 hours. CONCLUSIONS EVT beyond 24 hours from LKW may achieve favorable clinical outcomes and high reperfusion rates, with acceptable intracranial hemorrhage rates in selected patients. Considering the current certainty of the evidence and heterogenous individual study results, larger prospective trials are warranted.
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Affiliation(s)
- Aaron Rodriguez-Calienes
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
- Neuroscience, Clinical Effectiveness and Public Health Research Group, Universidad Científica del Sur, Lima, Peru
| | | | - Juan Vivanco-Suarez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Ghada A Mohamed
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Gabor Toth
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Amrou Sarraj
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Deep Pujara
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Aj A Chowdhury
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Mudassir Farooqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Malik Ghannam
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Edgar A Samaniego
- Department of Neurology, Neurosurgery & Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Tudor G Jovin
- Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey, USA
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Neurosurgery & Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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9
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Li H, Zhang H, Hua W, Liu H, Zhang B, Dong H, Liu J, Zhou Y, Yang P, Jing M. Causal relationship between gut microbiota and functional outcomes after ischemic stroke: A comprehensive Mendelian randomization study. J Stroke Cerebrovasc Dis 2024; 33:107814. [PMID: 38880364 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107814] [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: 02/22/2024] [Revised: 05/22/2024] [Accepted: 06/10/2024] [Indexed: 06/18/2024] Open
Abstract
AIMS To investigate the association of the genetic predisposition of specific gut microbiotas with the clinical outcome of ischemic stroke. METHODS We leveraged publicly available genome-wide association study (GWAS) data to perform Mendelian randomization (MR) analysis. The gut microbiota-related GWAS data from 18,340 individuals from the international consortium MiBioGen was used. The summary data for functional outcomes after ischemic stroke was obtained from the Genetics of Ischemic Stroke Functional Outcome (GISCOME) network meta-analysis. The primary outcomes were judged by the modified Rankin Scale (mRS). The principal analyses were conducted using the inverse-variance weighted (IVW) MR method. The Cochran's Q test, weighted median, MR-Egger regression, leave-one-SNP-out analysis, MR-Pleiotropy Residual Sum, and Outlier methods were adopted as sensitivity analyses. Furthermore, we performed bi-directional MR analysis and the MR Steiger directionality test to examine the direction of the causal relations. RESULTS The results demonstrated that the genetic predisposition of genus Lactococcus, genus Ruminococcaceae NK4A214 group, family Peptostreptococcaceae, and genus Odoribacter was positively associated with favorable functional outcome after ischemic stroke. Genus Collinsella, genus Ruminococcaceae UCG005, genus Akkermansia, genus Eubacterium oxidoreducens group, and family Verrucomicrobiaceae were identified to be associated with worse functional outcomes after ischemic stroke. Our results showed no evidence of heterogeneity, directional pleiotropic effects, or collider bias, and the sensitivity of our analysis was acceptable. CONCLUSION The genetic predisposition of different gut microbiotas was associated with the clinical outcome of ischemic stroke. Microbiota adjustment was a promising method to improve the clinical outcome of ischemic stroke.
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Affiliation(s)
- He Li
- Emergency Department, PLA Naval Medical Center, Shanghai, China; Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China
| | - Haojun Zhang
- Emergency Department, PLA Naval Medical Center, Shanghai, China
| | - Weilong Hua
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China
| | - Hanchen Liu
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China
| | - Boyu Zhang
- Emergency Department, PLA Naval Medical Center, Shanghai, China
| | - Hui Dong
- Emergency Department, PLA Naval Medical Center, Shanghai, China
| | - Jianmin Liu
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China
| | - Yu Zhou
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China.
| | - Pengfei Yang
- Emergency Department, PLA Naval Medical Center, Shanghai, China.
| | - Mei Jing
- Neurovascular Center, Naval Medical University Changhai hospital, Shanghai, China.
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10
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Puggaard R, Laugesen NG, Hansen K, Brandt AH, Stavngaard T, Truelsen TC. Outcome and safety of mechanical thrombectomy in patients with acute ischemic stroke due to internal carotid artery dissection. Interv Neuroradiol 2024:15910199241261753. [PMID: 38870399 DOI: 10.1177/15910199241261753] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2024] Open
Abstract
BACKGROUND Mechanical thrombectomy (MT) in patients with symptoms of acute ischemic stroke (AIS) due to internal carotid artery dissection (ICAD) remains controversial. In this study, we present clinical outcome and safety of MT in acute ICAD compared to other acute carotid artery pathology. METHODS Patients with symptoms of AIS due to internal carotid artery pathology, treated with MT from 2017-2021, were categorized as ICAD or non-ICAD. Baseline and procedural characteristics, complications, and functional outcome at 90 days were compared between the two groups. Factors associated with a favorable outcome (modified Rankin Scale 0-2) were analyzed using multivariate logistic regression. Safety analyses included in-stent thrombosis, perforation, intracranial hemorrhage, and mortality. RESULTS Sixty-seven ICAD patients (14.8%) and 387 non-ICAD patients (85.2%) were enrolled. ICAD patients were younger, median age 53 years (interquartile range (IQR) 47-61) vs. non-ICAD 72 years (IQR 64-79), p < 0.001. Favorable outcome was more common in ICAD patients, 49 ICAD patients (76.6%) vs. 158 non-ICAD patients (42.4%), p < 0.001. Post-procedural symptomatic intracranial hemorrhage occurred in 41 patients, 5 (7.5%) ICAD patients vs. 36 (9.3%) non-ICAD patients, p = 0.6. Mortality differed significantly, 6 (9%) ICAD patients vs. 94 (24.3%) non-ICAD patients, p = 0.01. ICAD was not associated with functional outcome in multivariate analysis, OR = 1.25 [95%confidence interval:0.55-2.86]. CONCLUSION ICAD patients achieved a better 90-day functional outcome compared with non-ICAD patients. ICAD patients did not perform worse in safety measures than non-ICAD patients. Our data provide indirect evidence that MT is of clinical benefit in ICAD patients with symptoms of AIS.
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Affiliation(s)
- Rikke Puggaard
- Cerebrovascular Research Unit Rigshospitalet, Department of Neurology, Rigshospitalet, Copenhagen, Denmark
| | - Nicolaj Grønbæk Laugesen
- Cerebrovascular Research Unit Rigshospitalet, Department of Neurology, Rigshospitalet, Copenhagen, Denmark
| | - Klaus Hansen
- Cerebrovascular Research Unit Rigshospitalet, Department of Neurology, Rigshospitalet, Copenhagen, Denmark
- Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andreas H Brandt
- Neurovascular Section, Department of Radiology, Rigshospitalet, Copenhagen, Denmark
| | - Trine Stavngaard
- Neurovascular Section, Department of Radiology, Rigshospitalet, Copenhagen, Denmark
| | - Thomas C Truelsen
- Cerebrovascular Research Unit Rigshospitalet, Department of Neurology, Rigshospitalet, Copenhagen, Denmark
- Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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11
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Han L, Lan K, Kou D, Meng Z, Feng J, Maitland E, Nicholas S, Wang J. Cost-effectiveness of endovascular treatment for acute ischemic stroke in China: evidence from Shandong Peninsula. HEALTH ECONOMICS REVIEW 2024; 14:37. [PMID: 38836982 PMCID: PMC11154974 DOI: 10.1186/s13561-024-00513-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/26/2024] [Accepted: 05/28/2024] [Indexed: 06/06/2024]
Abstract
BACKGROUND Recently, the endovascular treatment (EVT) of acute ischemic stroke has made significant progress in many aspects. Intravenous thrombolysis (IVT) is usually recommended before endovascular treatment in clinical practice, but the value of the practice is controversial. The latest meta-analysis evaluation was that the effect of EVT versus EVT plus IVT did not differ significantly. The cost-effectiveness analysis of EVT plus IVT needs further analysis. This study assesses the health benefits and economic impact of EVT plus IVT in Shandong Peninsula of China. METHOD We followed a cross-section design using the Chinese-Shandong Peninsula public hospital database between 2013 and 2023. The real-world costs and health outcomes were collected through the Hospital Information System (HIS) and published references. We calculated incremental cost-effectiveness ratios (ICERs) from the perspective of Chinese healthcare using the complex decision model to compare the costs and effectiveness between EVT versus EVT + IVT. One-way and Monte Carlo probabilistic sensitivity analyses were performed to assess the robustness of the economic evaluation model. RESULTS EVT alone had a lower cost compared with EVT + IVT whether short-term or long-term. Until 99% dead of AIS patients, the ICER per additional QALY was RMB696399.30 over the willingness-to-pay (WTP) threshold of 3× gross domestic product (GDP) per capita in Shandong. The probabilistic sensitivity analysis of 3 months, 1 year and long-term horizons had a 97.90%, 97.43% and 96.89% probability of cost-effective treatment under the WTP threshold (1×GDP). The results of the one-way sensitivity analysis showed that direct treatment costs for EVT alone and EVT + IVT were all sensitive to ICER. CONCLUSIONS EVT alone was more cost-effective treatment compared to EVT + IVT in the Northeast Coastal Area of China. The data of this study could be used as a reference in China, and the use of the evaluation in other regions should be carefully considered.
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Affiliation(s)
- Lu Han
- Dong Fureng Institute of Economic and Social Development, Wuhan University, Wuhan, China
| | - Kuixu Lan
- The Affiliated Hospital of Qingdao University, Qingdao, China
| | - Dejian Kou
- Dong Fureng Institute of Economic and Social Development, Wuhan University, Wuhan, China
| | - Zehua Meng
- Dong Fureng Institute of Economic and Social Development, Wuhan University, Wuhan, China
| | - Jin Feng
- Dong Fureng Institute of Economic and Social Development, Wuhan University, Wuhan, China
| | - Elizabeth Maitland
- School of Management, University of Liverpool, Liverpool, England, United Kingdom
| | - Stephen Nicholas
- Health Services Research and Workforce Innovation Centre, Newcastle Business School, University of Newcastle, Newcastle, NSW, Australia
- Australian National Institute of Management and Commerce, Australian Technology Park, Sydney, NSW, Australia
| | - Jian Wang
- Center for Health Economics and Management, School of Economics and Management, Wuhan University, Wuhan, China.
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Cai L, Wang L, Campbell BCV, Wu Y, Abdalkader M, Alemseged F, Kaesmacher J, Puetz V, Nagel S, Strbian D, Knapen RRMM, Li C, Ye S, Tian P, Chen J, Li R, Hu W, Qiu Z, Nguyen TN, Schonewille WJ, Guo Q, Dai Z. Endovascular thrombectomy with versus without intravenous thrombolysis in patients with acute basilar artery occlusion: a systematic review and meta-analysis. J Neurol 2024; 271:3039-3049. [PMID: 38597945 DOI: 10.1007/s00415-024-12353-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: 01/19/2024] [Revised: 03/24/2024] [Accepted: 03/25/2024] [Indexed: 04/11/2024]
Abstract
BACKGROUND AND PURPOSE The benefit and safety of intravenous thrombolysis before endovascular thrombectomy in patients with acute ischemic stroke caused by basilar artery occlusion (BAO) remains unclear. This article aims to investigate the clinical outcomes and safety of endovascular thrombectomy with versus without intravenous thrombolysis in acute BAO stroke patients. METHODS We conducted a comprehensive search of PubMed, Embase, Cochrane, and Web of Science databases to identify relevant literature pertaining to patients with acute BAO who underwent endovascular thrombectomy alone or intravenous thrombolysis bridging with endovascular thrombectomy (bridging therapy), until January 10, 2024. The primary outcome was functional independence, defined as a score of 0-2 on the modified Rankin Scale at 90 days. The safety outcome was mortality at 90 days and symptomatic intracranial hemorrhage within 48 h. Effect sizes were computed as risk ratio (RR) with random-effect models. This study was registered in PROSPERO (CRD42023462293). RESULTS A total of 528 articles were obtained through the search and articles that did not meet the inclusion criteria were excluded. Finally, 2 RCTs and 10 cohort studies met the inclusion criteria. The findings revealed that the endovascular thrombectomy alone group had a lower rate of functional independence compared to the bridging therapy group (29% vs 38%; RR 0.78, 95% CI 0.68-0.88, p < 0.001), lower independent ambulation (39% vs 45%; RR 0.89, 95% CI 0.82-0.98, p = 0.01), and higher mortality (36% vs 28%, RR 1.22, 95% CI 1.08-1.37, p = 0.001). However, no differences were detected in symptomatic intracranial hemorrhage between the two groups (6% vs 4%; RR 1.12, 95% CI 0.74-1.71, p = 0.58). CONCLUSION Intravenous thrombolysis plus endovascular thrombectomy seemed to led to better functional independence, independent ambulation, and lower risk of mortality without increasing the incidence of intracranial hemorrhage compared to endovascular thrombectomy alone. However, given the non-randomized nature of this study, further studies are needed to confirm these findings.
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Affiliation(s)
- Lingyu Cai
- Neurology, The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China
| | - Liaoyuan Wang
- The Third District of Air Force Special Service Sanatorium, Hangzhou, 310002, Zhejiang, China
| | - Bruce C V Campbell
- Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VC, Australia
| | - Yuelu Wu
- Neurology, The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China
| | - Mohamad Abdalkader
- Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, USA
| | - Fana Alemseged
- Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, VC, Australia
| | - Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Volker Puetz
- Dresden Neurovascular Center, University Clinics Carl Gustav Carus an der Technischen Universität Dresden, Dresden, Germany
| | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital, and University of Helsinki, Helsinki, Finland
| | - Robrecht R M M Knapen
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Chuanhui Li
- Department of Neurology, The Stroke Center, Xuanwu Hospital of Capital Medical University, Beijing, China
| | - Shitai Ye
- Neurology, The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China
| | - Pengli Tian
- Neurology, The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China
| | - Jingjing Chen
- Neurology, The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China
| | - Ruitian Li
- Community Health Service Center of Sandun Town, Hangzhou, China
| | - Wei Hu
- Department of Neurology, Division of Life Sciences and Medicine, The First Affiliated Hospital of USTC, University of Science and Technology of China, Hefei, China
| | - Zhongming Qiu
- Neurology, The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China
| | - Thanh N Nguyen
- Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, USA
| | | | - Qifeng Guo
- Neurology, The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China.
| | - Zhao Dai
- Neurology, The 903rd Hospital of The Chinese People's Liberation Army, Hangzhou, China.
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Tiwari P, Yadav K, Shukla RP, Bakshi AK, Panwar D, Das S, Mishra PR. Extracellular vesicles-powered immunotherapy: Unleashing the potential for safer and more effective cancer treatment. Arch Biochem Biophys 2024; 756:110022. [PMID: 38697343 DOI: 10.1016/j.abb.2024.110022] [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: 04/29/2024] [Accepted: 04/29/2024] [Indexed: 05/04/2024]
Abstract
Cancer treatment has seen significant advancements with the introduction of Onco-immunotherapies (OIMTs). Although some of these therapies have received approval for use, others are either undergoing testing or are still in the early stages of development. Challenges persist in making immunotherapy widely applicable to cancer treatment. To maximize the benefits of immunotherapy and minimize potential side effects, it's essential to improve response rates across different immunotherapy methods. A promising development in this area is the use of extracellular vesicles (EVs) as novel delivery systems. These small vesicles can effectively deliver immunotherapies, enhancing their effectiveness and reducing harmful side effects. This article discusses the importance of integrating nanomedicines into OIMTs, highlighting the challenges with current anti-OIMT methods. It also explores key considerations for designing nanomedicines tailored for OIMTs, aiming to improve upon existing immunotherapy techniques. Additionally, the article looks into innovative approaches like biomimicry and the use of natural biomaterial-based nanocarriers (NCs). These advancements have the potential to transform the delivery of immunotherapy. Lastly, the article addresses the challenges of moving OIMTs from theory to clinical practice, providing insights into the future of using advanced nanotechnology in cancer treatment.
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Affiliation(s)
- Pratiksha Tiwari
- Division of Pharmaceutics and Pharmacokinetics, CSIR-Central Drug Research Institute Lucknow, India; Jawaharlal Nehru University, New Delhi, India
| | - Krishna Yadav
- Division of Pharmaceutics and Pharmacokinetics, CSIR-Central Drug Research Institute Lucknow, India
| | - Ravi Prakash Shukla
- Division of Pharmaceutics and Pharmacokinetics, CSIR-Central Drug Research Institute Lucknow, India
| | - Avijit Kumar Bakshi
- Division of Pharmaceutics and Pharmacokinetics, CSIR-Central Drug Research Institute Lucknow, India
| | - Dilip Panwar
- Division of Pharmaceutics and Pharmacokinetics, CSIR-Central Drug Research Institute Lucknow, India
| | - Sweety Das
- Division of Pharmaceutics and Pharmacokinetics, CSIR-Central Drug Research Institute Lucknow, India
| | - Prabhat Ranjan Mishra
- Division of Pharmaceutics and Pharmacokinetics, CSIR-Central Drug Research Institute Lucknow, India; Academy of Scientific and Innovation Research (AcSIR), Ghaziabad, 201002, U.P., India.
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Mujanovic A, Dobrocky T, Pfeilschifter W, Remonda L, Caroff J, Behme D, Seiffge DJ, Cereda CW, Kägi G, Leyon J, Piechowiak EI, Costalat V, Wagner J, Chabert E, Meinel TR, Jansen O, Alonso A, Loehr C, Liebeskind DS, Gralla J, Fischer U, Kaesmacher J. Value of intravenous alteplase before thrombectomy among patients with tandem lesions and emergent carotid artery stenting: A subgroup analysis of the SWIFT DIRECT trial. Eur J Neurol 2024; 31:e16256. [PMID: 38409874 DOI: 10.1111/ene.16256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/26/2024] [Accepted: 02/07/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND AND PURPOSE The value of intravenous thrombolysis (IVT) in eligible tandem lesion patients undergoing endovascular treatment (EVT) is unknown. We investigated treatment effect heterogeneity of EVT + IVT versus EVT-only in tandem lesion patients. Additional analyses were performed for patients undergoing emergent internal carotid artery (ICA) stenting. METHODS SWIFT DIRECT randomized IVT-eligible patients to either EVT + IVT or EVT-only. Primary outcome was 90-day functional independence (modified Rankin Scale score 0-2) after the index event. Secondary endpoints were reperfusion success, 24 h intracranial hemorrhage rate, and 90-day all-cause mortality. Interaction models were fitted for all predefined outcomes. RESULTS Among 408 included patients, 63 (15.4%) had a tandem lesion and 33 (52.4%) received IVT. In patients with tandem lesions, 20 had undergone emergent ICA stenting (EVT + IVT: 9/33, 27.3%; EVT: 11/30, 36.7%). Tandem lesion did not show treatment effect modification of IVT on rates of functional independence (tandem lesion EVT + IVT vs. EVT: 63.6% vs. 46.7%, non-tandem lesion EVT + IVT vs. EVT: 65.6% vs. 58.2%; p for interaction = 0.77). IVT also did not increase the risk of intracranial hemorrhage among tandem lesion patients (tandem lesion EVT + IVT vs. EVT: 34.4% vs. 46.7%, non-tandem lesion EVT + IVT vs. EVT: 33.5% vs. 26.3%; p for interaction = 0.15). No heterogeneity was noted for other endpoints (p for interaction > 0.05). CONCLUSIONS No treatment effect heterogeneity of EVT + IVT versus EVT-only was observed among tandem lesion patients. Administering IVT in patients with anticipated emergent ICA stenting seems safe, and the latter should not be a factor to consider when deciding to administer IVT before EVT.
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Affiliation(s)
- Adnan Mujanovic
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Tomas Dobrocky
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Waltraud Pfeilschifter
- Department of Neurology, University Hospital Frankfurt, Goethe University, Frankfurt am Main, Germany
| | - Luca Remonda
- Department of Neuroradiology, Cantonal Hospital Aarau, Aarau, Switzerland
| | - Jildaz Caroff
- Department of Interventional Neuroradiology, NEURI Brain Vascular Center, Bicêtre Hospital, Paris-Saclay University, Le Kremlin-Bicêtre, France
| | - Daniel Behme
- Department for Neuroradiology, Otto von Guericke University Hospital Magdeburg, University of Magdeburg, Magdeburg, Germany
| | - David J Seiffge
- Department of Neurology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Carlo W Cereda
- Stroke Center, Neurology, Neurocenter of Southern Switzerland (EOC), Lugano, Switzerland
| | - Georg Kägi
- Department of Neurology, Cantonal Hospital St. Gallen, University of St. Gallen, St. Gallen, Switzerland
| | - Joe Leyon
- Department of Neuroradiology, St. George's University Hospital, London, UK
| | - Eike I Piechowiak
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Vincent Costalat
- Department of Neuroradiology, University Hospital Montpellier, Montpellier, France
| | - Judith Wagner
- Department of Neurology, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
- Department of Neurology, Evangelisches Klinikum Gelsenkirchen, Academic Hospital University Essen-Duisburg, Gelsenkirchen, Germany
| | - Emmanuel Chabert
- Department of Neuroradiology, University Hospital Clermont-Ferrand, Clermont-Ferrand, France
| | - Thomas R Meinel
- Department of Neurology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Olav Jansen
- Department of Radiology and Neuroradiology, University Hospital Schleswig-Holstein, University of Kiel, Kiel, Germany
| | - Angelika Alonso
- Department of Neurology, Medical Faculty Mannheim, University of Heidelberg, Mannheim, Germany
| | - Christian Loehr
- Department of Radiology and Neuroradiology, Klinikum Vest, Recklinghausen, Germany
| | - David S Liebeskind
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, USA
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Johannes Kaesmacher
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern Inselspital, University of Bern, Bern, Switzerland
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Khan MO, Shah SA, Mahmood S, Aijaz A, Jatoi NN, Shakil F, Nusrat K, Siddiqui OM, Hameed I. Is endovascular treatment alone as effective and safe as that with preceding intravenous thrombolysis for acute ischemic stroke? A meta-analysis of randomized controlled trials. J Neurosurg Sci 2024; 68:338-347. [PMID: 37389453 DOI: 10.23736/s0390-5616.23.06058-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
INTRODUCTION This meta-analysis aimed to evaluate the safety and efficacy of direct endovascular therapy (EVT) and bridging therapy (EVT with preceding intravenous thrombolysis i.e. IVT), in acute anterior circulation, large vessel occlusion stroke. EVIDENCE ACQUISITION Following the PRISMA guidelines, a systematic literature review of the English language literature was conducted using PubMed, Cochrane CENTRAL, SCOPUS and ClinicalTrials.gov. Outcomes of interest were measured by the modified Rankin Scale (mRS), and included: no disability (mRS0), no significant disability despite some symptoms (mRS1), slight disability (mRS2), moderate disability (mRS3), moderately severe disability (mRS4), severe disability (mRS5), mortality (mRS6). Additionally, we inspected patients having excellent outcome, functional independence outcome, and poor outcome, along with successful reperfusion and intracranial hemorrhage. We calculated pooled risk ratios (RRs) and their corresponding 95% confidence intervals (CI). EVIDENCE SYNTHESIS A total of seven RCTs involving 2,392 patients were finally included. The chances of achieving successful reperfusion were significantly more with IVT+EVT as compared to EVT alone (RR: 0.97; 95% CI: 0.94, 1.00; P=0.03) (I2=0%). There was no significant difference in the number of patients having outcomes ranging from mRS0 to mRS6, excellent outcome, functional independence, poor outcome or incidence of intracranial hemorrhage, who underwent either EVT alone or IVT+EVT. CONCLUSIONS Additional trials are needed to determine if the absence of significant differences is due to insufficient sample size or if the combination therapy is truly not beneficial.
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Affiliation(s)
- Mohammad O Khan
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Syeda A Shah
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Samar Mahmood
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Ashnah Aijaz
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Nadia N Jatoi
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Firzah Shakil
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Khushboo Nusrat
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Omer M Siddiqui
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan
| | - Ishaque Hameed
- Department of Internal Medicine, Dow University of Health Sciences, Karachi, Pakistan -
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Li Z, Gao T, Wang J, Zhang X, Zhang Y, Zhang L, Yang P, Liu J. Ferroptosis mediated by TNFSF9 interferes in acute ischaemic stroke reperfusion injury with the progression of acute ischaemic stroke. J Neurochem 2024; 168:1030-1044. [PMID: 38344886 DOI: 10.1111/jnc.16058] [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: 08/03/2023] [Revised: 12/22/2023] [Accepted: 01/09/2024] [Indexed: 05/31/2024]
Abstract
In this study, we investigated the potential involvement of TNFSF9 in reperfusion injury associated with ferroptosis in acute ischaemic stroke patients, mouse models and BV2 microglia. We first examined TNFSF9 changes in peripheral blood from stroke patients with successful reperfusion, and constructed oxygen-glucose deprivation-reperfusion (OGD-R) on BV2 microglia, oxygen-glucose deprivation for 6 h followed by reoxygenation and re-glucose for 24 h, and appropriate over-expression or knockdown of TNFSF9 manipulation on BV2 cells and found that in the case of BV2 cells encountering OGD-R over-expression of TNFSF9 resulted in increased BV2 apoptosis. Still, the knockdown of TNFSF9 ameliorated apoptosis and ferroptosis. In an in vivo experiment, we constructed TNFSF9 over-expression or knockout mice by intracerebral injection of TNFSF9-OE or sh-TNFSF9 adenovirus. We performed the middle cerebral artery occlusion (MCAO) model on day four, 24 h after ligation of the proximal artery, for half an hour to recanalize. As luck would have it, over-expression of TNFSF9 resulted in increased brain infarct volumes, neurological function scores and abnormalities in TNFSF9-related TRAF1 and ferroptosis-related pathways, but knockdown of TNFSF9 improved brain infarcts in mice as well as reversing TNFSF9-related signalling pathways. In conclusion, our data provide the first evidence that TNFSF9 triggers microglia activation by activating the ferroptosis signalling pathway following ischaemic stroke, leading to brain injury and neurological deficits.
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Affiliation(s)
- Zifu Li
- Neurovascular center, Changhai Hospital, Shanghai, P. R. China
| | - Tianxiang Gao
- University of Shanghai for Science and Technology, Shanghai, P. R. China
| | - Jing Wang
- Neurovascular center, Changhai Hospital, Shanghai, P. R. China
| | - Xiaoxi Zhang
- Neurovascular center, Changhai Hospital, Shanghai, P. R. China
| | - Yongxin Zhang
- Neurovascular center, Changhai Hospital, Shanghai, P. R. China
| | - Lei Zhang
- Neurovascular center, Changhai Hospital, Shanghai, P. R. China
| | - Pengfei Yang
- Neurovascular center, Changhai Hospital, Shanghai, P. R. China
| | - Jianmin Liu
- Neurovascular center, Changhai Hospital, Shanghai, P. R. China
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Qin B, Wei T, Gao W, Qin HX, Liang YM, Qin C, Chen H, Yang MX. Real-world setting comparison of bridging therapy versus direct mechanical thrombectomy for acute ischemic stroke: A meta-analysis. Clinics (Sao Paulo) 2024; 79:100394. [PMID: 38820696 PMCID: PMC11177057 DOI: 10.1016/j.clinsp.2024.100394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Revised: 04/15/2024] [Accepted: 05/13/2024] [Indexed: 06/02/2024] Open
Abstract
BACKGROUND AND PURPOSE Intravenous Thrombolysis (IVT) prior to Mechanical Thrombectomy (MT) for Acute Ischaemic Stroke (AIS) due to Large-Vessel Occlusion (LVO) remains controversial. Therefore, the authors performed a meta-analysis of the available real-world evidence focusing on the efficacy and safety of Bridging Therapy (BT) compared with direct MT in patients with AIS due to LVO. METHODS Four databases were searched until 01 February 2023. Retrospective and prospective studies from nationwide or health organization registry databases that compared the clinical outcomes of BT and direct MT were included. Odds Ratios (ORs) and 95 % Confidence Intervals (CIs) for efficacy and safety outcomes were pooled using a random-effects model. RESULTS Of the 12 studies, 86,695 patients were included. In patients with AIS due to LVO, BT group was associated with higher odds of achieving excellent functional outcome (modified Rankin Scale score 0-1) at 90 days (OR = 1.48, 95 % CI 1.25-1.75), favorable discharge disposition (to the home with or without services) (OR = 1.33, 95 % CI 1.29-1.38), and decreased mortality at 90 days (OR = 0.62, 95 % CI 0.56-0.70), as compared with the direct MT group. In addition, the risk of symptomatic intracranial hemorrhage did not increase significantly in the BT group. CONCLUSION The present meta-analysis indicates that BT was associated with favorable outcomes in patients with AIS due to LVO. These findings support the current practice in a real-world setting and strengthen their validity. For patients eligible for both IVT and MT, BT remains the standard treatment until more data are available.
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Affiliation(s)
- Bin Qin
- Department of Neurology, Liuzhou People's Hospital, Liuzhou, Guangxi, China; Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China; Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Tao Wei
- Department of Neurology, Liuzhou People's Hospital, Liuzhou, Guangxi, China; Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China
| | - Wen Gao
- Department of Neurology, Liuzhou People's Hospital, Liuzhou, Guangxi, China; Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China
| | - Hui-Xun Qin
- Department of Neurology, Liuzhou People's Hospital, Liuzhou, Guangxi, China; Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China
| | - Yu-Ming Liang
- Department of Neurology, Liuzhou People's Hospital, Liuzhou, Guangxi, China; Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China
| | - Cheng Qin
- Department of Neurology, Liuzhou People's Hospital, Liuzhou, Guangxi, China; Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China
| | - Hong Chen
- Department of Neurology, Liuzhou People's Hospital, Liuzhou, Guangxi, China; Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China
| | - Ming-Xiu Yang
- Department of Neurology, Liuzhou People's Hospital, Liuzhou, Guangxi, China; Liuzhou Key Laboratory of Epilepsy Prevention and Research, Liuzhou, Guangxi, China.
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Wang Y, Liu Z, Li L, Zhang Z, Zhang K, Chu M, Liu Y, Mao X, Wu D, Xu D, Zhao J. Anti-ferroptosis exosomes engineered for targeting M2 microglia to improve neurological function in ischemic stroke. J Nanobiotechnology 2024; 22:291. [PMID: 38802919 PMCID: PMC11129432 DOI: 10.1186/s12951-024-02560-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: 01/20/2024] [Accepted: 05/16/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND Stroke is a devastating disease affecting populations worldwide and is the primary cause of long-term disability. The inflammatory storm plays a crucial role in the progression of stroke. In the acute phase of ischemic stroke, there is a transient increase in anti-inflammatory M2 microglia followed by a rapid decline. Due to the abundant phospholipid in brain tissue, lipid peroxidation is a notable characteristic of ischemia/reperfusion (I/R), constituting a structural foundation for ferroptosis in M2 microglia. Slowing down the decrease in M2 microglia numbers and controlling the inflammatory microenvironment holds significant potential for enhancing stroke recovery. RESULTS We found that the ferroptosis inhibitor can modulate inflammatory response in MCAO mice, characterizing that the level of M2 microglia-related cytokines was increased. We then confirmed that different subtypes of microglia exhibit distinct sensitivities to I/R-induced ferroptosis. Adipose-derived stem cells derived exosome (ADSC-Exo) effectively decreased the susceptibility of M2 microglia to ferroptosis via Fxr2/Atf3/Slc7a11, suppressing the inflammatory microenvironment and promoting neuronal survival. Furthermore, through plasmid engineering, a more efficient M2 microglia-targeted exosome, termed M2pep-ADSC-Exo, was developed. In vivo and in vitro experiments demonstrated that M2pep-ADSC-Exo exhibits significant targeting specificity for M2 microglia, further inhibiting M2 microglia ferroptosis and improving neurological function in ischemic stroke mice. CONCLUSION Collectively, we illustrated a novel potential therapeutic mechanism that Fxr2 in ADSC-Exo could alleviate the M2 microglia ferroptosis via regulating Atf3/Slc7all expression, hence inhibiting the inflammatory microenvironment, improving neurofunction recovery in cerebral I/R injury. We obtained a novel exosome, M2pep-ADSC-Exo, through engineered modification, which exhibits improved targeting capabilities toward M2 microglia. This provides a new avenue for the treatment of stroke.
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Affiliation(s)
- Yong Wang
- Department of Neurology, Minhang Hospital, Fudan University, Shanghai, 201100, China
- Department of Neurology, Zhongshan Hospital, Fudan University, Shanghai, 200030, China
| | - Zhuohang Liu
- Department of Neurology, Minhang Hospital, Fudan University, Shanghai, 201100, China
| | - Luyu Li
- Department of Dermatology, Shanghai Ninth People's Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, 200001, China
| | - Zengyu Zhang
- Department of Neurology, Minhang Hospital, Fudan University, Shanghai, 201100, China
| | - Kai Zhang
- Department of Cardiovascular Medicine, Pujiang Traditional Chinese Medicine Hospital, Zhejiang, 322200, China
| | - Min Chu
- Department of Neurology, Minhang Hospital, Fudan University, Shanghai, 201100, China
| | - Yang Liu
- Department of Neurology, Minhang Hospital, Fudan University, Shanghai, 201100, China
| | - Xueyu Mao
- Department of Neurology, Minhang Hospital, Fudan University, Shanghai, 201100, China
| | - Di Wu
- Department of Neurology, Minhang Hospital, Fudan University, Shanghai, 201100, China
| | - Dongsheng Xu
- College of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, 200120, China
- Engineering Research Center of Traditional Chinese Medicine Intelligent Rehabilitation, Ministry of Education, Shanghai, 200120, China
| | - Jing Zhao
- Department of Neurology, Minhang Hospital, Fudan University, Shanghai, 201100, China.
- Institute of Healthy Yangtze River Delta, Shanghai Jiao Tong University, Shanghai, 200001, China.
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Yu B, Shi G, Yang F, Xu W. Correlation of LP-PLA2 and MMP-9 with the occurrence of early neurological deterioration in patients with acute ischemic stroke. Medicine (Baltimore) 2024; 103:e38310. [PMID: 38788013 PMCID: PMC11124703 DOI: 10.1097/md.0000000000038310] [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] [Indexed: 05/26/2024] Open
Abstract
Early neurological deterioration is a common complication of acute ischemic stroke (AIS), which aggravates symptoms, worsens the condition, and counteracts the benefits of clinical treatment. The aim of this paper was to analyze the correlation between lipoprotein-associated phospholipase A2 (Lp-PLA2), matrix metalloproteinase-9 (MMP-9), and the occurrence of early neurological deterioration (END) in patients with AIS and to explore the clinical prediction of END by the combination of the 2 assays for the clinical prediction of END. A total of 500 AIS patients admitted to our hospital from October 2022 to October 2023 were included as study subjects, and the clinical data of all AIS patients were collected and organized to detect the levels of Lp-PLA2 and MMP-9. Categorized into END and non-END groups according to whether END occurred within 7 days of the onset of AIS, and comparing the clinical baseline data and laboratory index levels of the 2 groups. Logistic regression analysis was performed to determine the independent predictors of END, and the predictive effects of Lp-PLA2 and MMP-9 levels on END were assessed by subject work characteristics (ROC) curves. END occurred in 111 (22.2%) of 500 AIS patients. Multivariate logistic regression analysis showed that diabetes (OR 2.717, 95% CI:1.53-4.81, P < .001), baseline NIHSS score (OR 1.65, 95% CI:1.41-1.94, P < .001), Lp-PLA2 (OR 1.07, 95% CI:1.05-1.09, P < .001) and MMP-9 (OR 1.12, 95% CI:1.09-1.16, P < .001) levels were independent influences on the occurrence of END in patients with AIS after correcting for confounders. ROC curve analysis showed that Lp-PLA2, MMP-9, and a combination of both predicted END with an area under the curve was 0.730, 0.763, and 0.831, respectively, and the area under the curve for the combination of both predicting END was significantly higher than that for any of the inflammatory markers alone (P < .05). Both inflammatory markers, Lp-PLA2 and MMP-9, were independent predictors of the development of END in patients with AIS, and the combination of the two had a higher predictive value.
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Affiliation(s)
- Baiyang Yu
- Department of Neurology, Taixing Clinical College of Bengbu Medical College, Taixing, China
| | - Guomei Shi
- Department of Neurology, Taixing People's Hospital, Taixing, China
| | - Faming Yang
- Department of Gastroenterology, Taixing Clinical College of Bengbu Medical College, Taixing, China
| | - Wu Xu
- Department of Neurology, Taixing Clinical College of Bengbu Medical College, Taixing, China
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Yuan G, Zhang J, Ye Z, Sun J, Huo X, Pan Y, Wang M, Peng X, Zheng C, Lei X, Miao Z, Cai X. Effectiveness and safety of bridging therapy and endovascular therapy in patients with large cerebral infarctions: from ANGEL-ASPECT. Stroke Vasc Neurol 2024:svn-2024-003120. [PMID: 38777348 DOI: 10.1136/svn-2024-003120] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 05/07/2024] [Indexed: 05/25/2024] Open
Abstract
BACKGROUND AND PURPOSE The benefits of thrombolytic therapy before endovascular thrombectomy in cases of acute ischaemic stroke, with a large infarction volume, remain unclear. This analysis aims to evaluate the effectiveness and safety of bridging therapy and endovascular therapy among patients with large cerebral infarctions. METHODS In this post-hoc analysis of the multicentre prospective study of ANGEL-ASPECT (Acute Anterior Circulation Large Vessel Occlusive Patients with a Large Infarct Core), participants were divided into two groups: an endovascular therapy group and a bridging therapy group. The primary outcome was the modified Rankin Scale (mRS) score at 90 days. The primary safety outcome was symptomatic intracranial haemorrhage. Ordinal logistic regression was performed to compare the primary endpoint between the two groups. Subgroup analyses were conducted to further explore potential risk factors associated with the outcomes. RESULTS 122 patients were included, of whom 77 (63%) underwent endovascular therapy and 45 (37%) underwent bridging therapy. The median scores on mRS at 90 days of the bridging therapy group and the endovascular therapy group were 3 (2-5) and 4 (2-6), with no significant differences (common OR 1.36; 95% CI 0.71 to 2.61). Symptomatic intracranial haemorrhage was reported in three patients who were in the endovascular and bridging therapy groups (relative risk (RR) 1.71; 95% CI 0.36 to 8.12). The mortality between two groups did not differ (RR 0.75; 95% CI 0.37 to 1.54). CONCLUSIONS Our study indicated that endovascular therapy alone might be a viable option for patients with large cerebral infarctions, displaying no noticeable disparity in outcomes compared with bridging therapy.
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Affiliation(s)
- Guangxiong Yuan
- Emergency, Xiangtan Central Hospital, Xiangtan, Hunan, China
| | - Jun Zhang
- School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
| | - Zekang Ye
- Department of Neurology, Lishui Central Hospital and Fifth Affiliated Hospital of Wenzhou Medical College, Lishui, Zhejiang, China
- Lishui Clinical Research Center for Neurological Diseases, Lishui, Zhejiang, China
| | - Jingping Sun
- Department of Neurology, Lishui Central Hospital and Fifth Affiliated Hospital of Wenzhou Medical College, Lishui, Zhejiang, China
- Lishui Clinical Research Center for Neurological Diseases, Lishui, Zhejiang, China
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuesong Pan
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Mengxing Wang
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiao Peng
- Department of Neurology, Lishui Central Hospital and Fifth Affiliated Hospital of Wenzhou Medical College, Lishui, Zhejiang, China
- Lishui Clinical Research Center for Neurological Diseases, Lishui, Zhejiang, China
| | - Chanjuan Zheng
- Lishui Clinical Research Center for Neurological Diseases, Lishui, Zhejiang, China
| | - Xueyao Lei
- Lishui Clinical Research Center for Neurological Diseases, Lishui, Zhejiang, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xueli Cai
- School of Medicine, Zhejiang University, Hangzhou, Zhejiang, China
- Department of Neurology, Lishui Central Hospital and Fifth Affiliated Hospital of Wenzhou Medical College, Lishui, Zhejiang, China
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21
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Wang CY, Lai SZ, Kang BC, Lin YZ, Cao CJ, Huang XB, Wang JQ. Association of pulse pressure with hematoma expansion in patients with spontaneous supratentorial intracerebral hemorrhage. Front Neurol 2024; 15:1374198. [PMID: 38813243 PMCID: PMC11133623 DOI: 10.3389/fneur.2024.1374198] [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: 01/21/2024] [Accepted: 04/26/2024] [Indexed: 05/31/2024] Open
Abstract
Objective Recent reports have demonstrated that a wider pulse pressure upon admission is correlated with heightened in-hospital mortality following spontaneous supratentorial intracerebral hemorrhage (ssICH). However, the underlying mechanism remains ambiguous. We investigated whether a wider pulse pressure was associated with hematoma expansion (HE). Methods Demographic information, clinical features, and functional outcomes of patients diagnosed with ssICH were retrospectively collected and analyzed. Multivariate logistic regression was conducted to identify independent predictors of HE. Weighted logistic regression, restricted cubic spline models, and propensity score matching (PSM) were employed to estimate the association between pulse pressure and HE. Results We included 234 eligible adult ssICH patients aged 60 (51-71) years, and 55.56% were male. The mean pulse pressure was 80.94 ± 23.32 mmHg. Twenty-seven patients (11.54%) developed early HE events, and 116 (49.57%) experienced a poor outcome (modified Rankin scale 3-6). A wider mean pulse pressure as a continuous variable was a predictor of HE [odds ratios (OR) 1.026, 95% confidence interval (CI) 1.007-1.046, p = 0.008] in multivariate analysis. We transformed pulse pressure into a dichotomous variable based on its cutoff value. After adjusting for confounding of HE variables, the occurrence of HE in patients with ssICH with wider pulse pressure levels (≥98 mmHg) had 3.78 times (OR 95% CI 1.47-9.68, p = 0.006) compared to those with narrower pulse pressure levels (<98 mmHg). A linear association was observed between pulse pressure and increased HE risk (P for overall = 0.036, P for nonlinear = 0.759). After 1:1 PSM (pulse pressure ≥98 mmHg vs. pulse pressure <98 mmHg), the rates of HE events and poor outcome still had statistically significant in wider-pulse pressure group [HE, 12/51 (23.53%) vs. 4/51 [7.84%], p = 0.029; poor outcome, 34/51 (66.67%) vs. 19/51 (37.25%), p = 0.003]. Conclusion Widened acute pulse pressure (≥98 mmHg) levels at admission are associated with increased risks of early HE and unfavorable outcomes in patients with ssICH.
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Affiliation(s)
- Chao-Ying Wang
- Department of Neurosurgery, Dehua County Hospital, Quanzhou, China
| | - Su-Zhen Lai
- Department of Imaging, Dehua County Hospital, Quanzhou, China
| | - Bao-Cai Kang
- Department of Internal Medicine, Dehua County Hospital, Quanzhou, China
- Department of Geriatrics, Changji People’s Hospital, Changji, China
| | - Yi-Zhao Lin
- Department of Laboratory Medicine, Dehua County Hospital, Quanzhou, China
| | - Chun-Juan Cao
- Department of Imaging, Dehua County Hospital, Quanzhou, China
| | - Xin-Bing Huang
- Department of Neurology, Dehua County Hospital, Quanzhou, China
| | - Jian-Qun Wang
- Department of Neurosurgery, Dehua County Hospital, Quanzhou, China
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22
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Arnalich-Montiel A, Burgos-Santamaría A, Pazó-Sayós L, Quintana-Villamandos B. Comprehensive Management of Stroke: From Mechanisms to Therapeutic Approaches. Int J Mol Sci 2024; 25:5252. [PMID: 38791292 PMCID: PMC11120719 DOI: 10.3390/ijms25105252] [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: 03/10/2024] [Revised: 04/29/2024] [Accepted: 05/05/2024] [Indexed: 05/26/2024] Open
Abstract
Acute ischemic stroke (AIS) is a challenging disease, which needs urgent comprehensive management. Endovascular thrombectomy (EVT), alone or combined with iv thrombolysis, is currently the most effective therapy for patients with acute ischemic stroke (AIS). However, only a limited number of patients are eligible for this time-sensitive treatment. Even though there is still significant room for improvement in the management of this group of patients, up until now there have been no alternative therapies approved for use in clinical practice. However, there is still hope, as clinical research with novel emerging therapies is now generating promising results. These drugs happen to stop or palliate some of the underlying molecular mechanisms involved in cerebral ischemia and secondary brain damage. The aim of this review is to provide a deep understanding of these mechanisms and the pathogenesis of AIS. Later, we will discuss the potential therapies that have already demonstrated, in preclinical or clinical studies, to improve the outcomes of patients with AIS.
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Affiliation(s)
- Ana Arnalich-Montiel
- Department of Anaesthesia and Intensive Care, Gregorio Marañón’s University Hospital, 28007 Madrid, Spain; (A.B.-S.); (B.Q.-V.)
- Department of Pharmacology, College of Medicine, Complutense University, 28040 Madrid, Spain
| | - Alba Burgos-Santamaría
- Department of Anaesthesia and Intensive Care, Gregorio Marañón’s University Hospital, 28007 Madrid, Spain; (A.B.-S.); (B.Q.-V.)
| | - Laia Pazó-Sayós
- Department of Anaesthesia and Intensive Care, Gregorio Marañón’s University Hospital, 28007 Madrid, Spain; (A.B.-S.); (B.Q.-V.)
| | - Begoña Quintana-Villamandos
- Department of Anaesthesia and Intensive Care, Gregorio Marañón’s University Hospital, 28007 Madrid, Spain; (A.B.-S.); (B.Q.-V.)
- Department of Pharmacology, College of Medicine, Complutense University, 28040 Madrid, Spain
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23
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Tan Z, Zhang L, Huang L, Qiao H, Guan M, Yang B, Yang P, Zhang Y, Shen H, Zhou Y, Hong B, Shi H, Han H, Leng X, Dong Y, Lian C, Chen W, Xu A, Liu J. Thrombus migration in patients with acute ischaemic stroke undergoing endovascular thrombectomy. Stroke Vasc Neurol 2024; 9:126-133. [PMID: 37290931 PMCID: PMC11103155 DOI: 10.1136/svn-2022-002257] [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: 12/20/2022] [Accepted: 04/12/2023] [Indexed: 06/10/2023] Open
Abstract
OBJECTIVE The impact of thrombus migration (TM) prior to endovascular thrombectomy (EVT) on clinical outcomes and revascularisation rates remains unknown. We aimed to examine whether preinterventional TM modifies the treatment effects of direct EVT versus bridging EVT in acute large vessel occlusion patients. METHODS All patients undergoing catheter angiography in the Direct Intra-arterial thrombectomy in order to Revascularise acute ischaemic stroke patients with large vessel occlusion Efficiently in Chinese Tertiary hospitals: A Multicentre randomised clinical Trial were included. TM was determined by radiologists unaware of the study by analysing discrepancies between computed tomographic angiography at baseline and first-run digital subtraction angiography before EVT. The primary outcome was the score on the modified Rankin scale (mRS) assessed at 90 days. RESULTS Of 627 included patients, the TM rate was 11.3% (71/627). In the multivariable logistic regression model, baseline National Institutes of Health Stroke Scale score (adjusted OR 0.956, 95% CI 0.916 to 0.999; p=0.043) and intravenous thrombolysis (adjusted OR 2.614, 95% CI 1.514 to 4.514; p<0.001) were independently associated with TM. The patients with TM were less likely to be completely recanalised than those without TM (21.27% vs 36.23%, p=0.040). The interaction of TM and the EVT treatment effect did not significantly affect mRS shift analysis (p=0.687) or mRS scores of 0 to 1 (p=0.436). CONCLUSION Preinterventional TM does not modify the treatment effects of direct versus bridging EVT on functional outcomes in patients with acute ischaemic stroke with anterior large vessel occlusion. TM leads to a lower complete recanalisation rate. TRIAL REGISTRATION NUMBER
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Affiliation(s)
- ZeFeng Tan
- Neurology, First People's Hospital of Foshan, Foshan, Guangdong, China
- Department of Neurology, Jinan University First Affiliated Hospital, Guangzhou, Guangdong, China
| | - Lei Zhang
- Neurovascular Center, Changhai Hospital,Naval Medical University, Shanghai, China
| | - Li'an Huang
- Department of Neurology, Jinan University First Affiliated Hospital, Guangzhou, Guangdong, China
| | - Hongyu Qiao
- Department of Neurology, Jinan University First Affiliated Hospital, Guangzhou, Guangdong, China
| | - Min Guan
- Department of Neurology, Jinan University First Affiliated Hospital, Guangzhou, Guangdong, China
| | - Bing Yang
- Department of Neurology, Jinan University First Affiliated Hospital, Guangzhou, Guangdong, China
| | - Pengfei Yang
- Neurovascular Center, Changhai Hospital,Naval Medical University, Shanghai, China
| | - Yongwei Zhang
- Neurovascular Center, Changhai Hospital,Naval Medical University, Shanghai, China
| | - Hongjian Shen
- Neurovascular Center, Changhai Hospital,Naval Medical University, Shanghai, China
| | - Yu Zhou
- Neurovascular Center, Changhai Hospital,Naval Medical University, Shanghai, China
| | - Bo Hong
- Neurovascular Center, Changhai Hospital,Naval Medical University, Shanghai, China
| | - Huaizhang Shi
- Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hongxing Han
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong, China
| | - Xinyi Leng
- Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Yi Dong
- Neurology, Huashan Hospital Fudan University, Shanghai, China
| | - Changlin Lian
- Neurology, First People's Hospital of Foshan, Foshan, Guangdong, China
| | - Wenhuo Chen
- Neurology, Zhangzhou Municipal Hospital of Fujian Province and Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, Fujian, China
| | - Anding Xu
- Department of Neurology, Jinan University First Affiliated Hospital, Guangzhou, Guangdong, China
- Stroke Center, Jinan University First Affiliated Hospital, Guangzhou, Guangdong, China
| | - Jianmin Liu
- Neurovascular Center, Changhai Hospital,Naval Medical University, Shanghai, China
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24
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Bao Q, Huang X, Wu X, Huang H, Zhang X, Yang M. Safety and efficacy of intravenous thrombolysis before mechanical thrombectomy in patients with atrial fibrillation. Syst Rev 2024; 13:118. [PMID: 38689365 PMCID: PMC11061942 DOI: 10.1186/s13643-024-02532-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 04/13/2024] [Indexed: 05/02/2024] Open
Abstract
BACKGROUND Intravenous thrombolysis (IVT) before endovascular thrombectomy (EVT) is the standard treatment for patients with acute ischemic stroke caused by large vessel occlusion (AIS-LVO). However, the efficacy and safety of IVT before EVT in AIS-LVO patients with atrial fibrillation (AF) remains controversial. Thus, this study aims to assess the benefit of IVT plus EVT and direct EVT alone in AIS-LVO patients with AF. METHOD Relevant studies that evaluated the outcomes of IVT plus EVT versus direct EVT alone in AIS-LVO patients with AF were systematically searched in PubMed, Embase, and Cochrane Library from inception to August 10, 2023. The outcomes included successful reperfusion (score of 2b to 3 for thrombolysis in cerebral infarction), symptomatic intracerebral hemorrhage (sICH), good clinical outcome (modified Rankin scale score ≤ 2) at 3 months, and 3-month mortality. RESULT Eight eligible observational studies involving 6998 (3827 in the IVT plus EVT group and 3171 in the direct EVT group) patients with AIS-LVO complicated by AF were included. Compared with direct EVT, IVT plus EVT resulted in better 3-month clinical outcomes (odds ratio [OR] 1.27, 95% confidence interval [CI] 1.05-1.54) and lower 3-month mortality (OR 0.78, 95% CI 0.68-0.88). However, the incidence of sICH (OR 1.26, 95% CI 0.91-1.75) and the rate of successful reperfusion (OR 0.98, 95% CI 0.83-1.17) were not significantly different between treatment modalities. CONCLUSION IVT plus EVT leads to better functional outcomes and lower mortality in AIS-LVO patients with AF. Withholding IVT plus EVT from patients with AF alone may not be justified.
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Affiliation(s)
- Qiangji Bao
- Department of Neurosurgery, Guang'an People's Hospital, Guang'an, Sichuan, China
| | - Xiaodong Huang
- Department of Neurosurgery, Taihe Hospital Affiliated Hospital of Hubei University of Medicine, Shiyan, Hubei, China
| | - Xinting Wu
- Department of Anesthesia, Guang'an People's Hospital, Guang'an, Sichuan, 638000, China
| | - Hao Huang
- Department of Neurosurgery, Guang'an People's Hospital, Guang'an, Sichuan, China
| | - Xiaoqiang Zhang
- Department of Neurosurgery, Guang'an People's Hospital, Guang'an, Sichuan, China.
| | - Mingfei Yang
- Department of Neurosurgery, Qinghai Provincial People's Hospital, Xining, Qinghai, 810007, China.
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25
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Fu W, Yu X, Lai M, Li Y, Yang Y, Qin Y, Yu M, Wang F, Wang C. Gamma oscillations induced by 40-Hz visual-auditory stimulation for the treatment of acute-phase limb motor rehabilitation after stroke: study protocol for a prospective randomized controlled trial. Trials 2024; 25:284. [PMID: 38671516 PMCID: PMC11046895 DOI: 10.1186/s13063-024-08121-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
BACKGROUND The incidence of hemiparetic limb dysfunction reaches 85% in stroke patients, emerging as a critical factor influencing their daily lives. However, the effectiveness of current rehabilitation treatments is considerably limited, particularly in patients with upper extremity impairment. This study aims to conduct a prospective clinical trial to validate the safety and effectiveness of gamma oscillations induced by 40-Hz visual-auditory stimulation in treating post-stroke upper limb dysfunction and to explore the relevant mechanisms. METHODS This trial is a prospective, randomized controlled, double-blind study. All enrolled patients were randomly assigned to two groups. The experimental group received intervention through 40-Hz visual-auditory stimulation, while the control group underwent intervention with randomly matched visual-auditory stimulation frequencies. The primary efficacy endpoint is the change in motor function. Secondary efficacy endpoints include motor-evoked potentials, cerebral hemodynamic changes, neural network connectivity, and alterations in synaptic-related genes. Safety evaluation included major adverse events, all-cause mortality, and photosensitive epilepsy. Assessments will be conducted at baseline, after a 14-day treatment period, and during subsequent follow-up visits (at 3 and 6 months) post-treatment. The differences between the two groups will be compared. DISCUSSION This study will evaluate the safety and efficacy of gamma oscillations induced by 40-Hz visual-auditory stimulation in treating patients with upper extremity dysfunction after an acute cerebral stroke. Concurrently, we will explore potential mechanisms, including changes in synaptic-related genes and neural network connectivity. This trial is expected to provide evidence for the effectiveness of this new technique in treating upper extremity dysfunction after a stroke and improving patients' quality of life. TRIAL REGISTRATION The study protocol has been registered with the Chinese Clinical Trial Registry (ChiCTR) under registration number ChiCTR2300076579 on October 12, 2023.
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Affiliation(s)
- Wang Fu
- Department of Neurology, Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Datong Rd. 358, Shanghai, 200137, China
| | - Xiaoming Yu
- Department of Rehabilitation, Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, 200137, China
| | - Minghui Lai
- Department of Rehabilitation, Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, 200137, China
| | - Yuanli Li
- Department of Rehabilitation, Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Shanghai, 200137, China
- Engineering Research Center of Traditional Chinese Medicine Intelligent Rehabilitation, Ministry of Education, Shanghai, 201203, China
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China
| | - Yingting Yang
- Department of Neurology, Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Datong Rd. 358, Shanghai, 200137, China
| | - Yong Qin
- Department of Neurology, Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Datong Rd. 358, Shanghai, 200137, China
| | - Min Yu
- Department of Neurology, Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Datong Rd. 358, Shanghai, 200137, China
| | - Feng Wang
- Department of Neurology, Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Datong Rd. 358, Shanghai, 200137, China
| | - Cong Wang
- Department of Neurology, Seventh People's Hospital of Shanghai University of Traditional Chinese Medicine, Datong Rd. 358, Shanghai, 200137, China.
- Engineering Research Center of Traditional Chinese Medicine Intelligent Rehabilitation, Ministry of Education, Shanghai, 201203, China.
- School of Rehabilitation Science, Shanghai University of Traditional Chinese Medicine, Shanghai, 201203, China.
- Queensland Brain Institute, the University of Queensland, Brisbane, 4072, Australia.
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26
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Tan KS, Pandian JD, Liu L, Toyoda K, Leung TWH, Uchiyama S, Kuroda S, Suwanwela NC, Aaron S, Chang HM, Venketasubramanian N. Stroke in Asia. Cerebrovasc Dis Extra 2024; 14:58-75. [PMID: 38657577 DOI: 10.1159/000538928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 04/08/2024] [Indexed: 04/26/2024] Open
Abstract
BACKGROUND There is a significant burden of stroke in Asia. Asia has the largest population in the world in 2023, estimated at 4.7 billion. Approximately 9.5-10.6 million strokes will be anticipated annually in the backdrop of a diverse group of well-developed and less developed countries with large disparities in stroke care resources. In addition, Asian countries are in varying phases of epidemiological transition. SUMMARY In this review, we examined recent epidemiological features of ischaemic stroke and intracerebral haemorrhage in Asia with recent developments in hyperacute stroke reperfusion therapy and technical improvements in intracerebral haemorrhage. The article also discussed the spectrum of cerebrovascular diseases in Asia, which include intracranial atherosclerosis, intracerebral haemorrhage, infective aetiologies of stroke, moyamoya disease, vascular dissection, radiation vasculopathy, and cerebral venous thrombosis. KEY MESSAGES The review of selected literature and recent updates calls for attention to the different requirements for resources within Asia and highlights the breadth of cerebrovascular diseases still requiring further research and more effective therapies.
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Affiliation(s)
- Kay Sin Tan
- Division of Neurology, Department of Medicine, University of Malaya, Kuala Lumpur, Malaysia
| | | | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | | | - Thomas Wai Hon Leung
- Department of Medicine and Therapeutics, Faculty of Medicine, The Prince of Wales Hospital, Chinese University of Hong Kong, Hong Kong, China
| | - Shinichiro Uchiyama
- Centre for Brain and Cerebral Vessels, Sanno Medical Centre, International University of Health and Welfare, Tokyo, Japan
| | - Sathoshi Kuroda
- Department of Neurosurgery, Toyama University, Toyama, Japan
| | - Nijasri C Suwanwela
- Chulalongkorn Stroke Centre, King Chulalongkorn Memorial Hospital, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Sanjith Aaron
- Department of Medicine, Christian Medical College, Vellore, India
| | - Hui Meng Chang
- Department of Neurology, National Neuroscience Institute, Singapore General Hospital, Singapore, Singapore
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Wen HF, Li Q, Wang PF, Li JL, Du JC. Endovascular thrombectomy in wake-up stroke guided by arterial spin-labeling and fluid-attenuated inversion recovery versus diffusion-weighted imaging mismatch on MRI. J Thromb Thrombolysis 2024:10.1007/s11239-024-02973-4. [PMID: 38662115 DOI: 10.1007/s11239-024-02973-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/24/2024] [Indexed: 04/26/2024]
Abstract
OBJECTIVE This purpose of this study is to investigate the effectiveness and safety of utilizing the arterial spin-labeling (ASL) combined with diffusion-weighted imaging (DWI) and fluid-attenuated inversion recovery (FLAIR) combined with DWI double mismatch in the endovascular treatment of patients diagnosed with wake-up stroke (WUS). METHODS In this single-center trial, patients diagnosed with WUS underwent thrombectomy if acute ischemic lesions were observed on DWI indicating large precerebral circulation occlusion. Patients with no significant parenchymal hypersignal on FLAIR and ASL imaging showing a hypoperfusion tissue to infarct core volume ratio of at least 1.2 were included. The participants were divided into groups receiving endovascular thrombectomy plus medical therapy or medical therapy alone, based on their subjective preference. Functional outcomes were assessed using the ordinal score on the modified Rankin scale (mRs) at 90 days, along with the rate of functional independence. RESULTS In this study, a total of 77 patients were included, comprising 38 patients in the endovascular therapy group and 39 patients in the medical therapy group. The endovascular therapy group exhibited more favorable changes in the distribution of functional prognosis measured by mRs at 90 days, compared to the medical therapy group (adjusted common odds ratio, 3.25; 95% CI, 1.03 to 10.26; P < 0.01). Additionally, the endovascular therapy group had a higher proportion of patients achieving functional independence (odds ratio, 4.0; 95% CI, 1.36 to 11.81; P < 0.01). Importantly, there were no significant differences observed in the incidence of intracranial hemorrhage or mortality rates between the two groups. CONCLUSION Guided by the ASL-DWI and FLAIR-DWI double mismatch, endovascular thrombectomy combined with standard medical treatment appears to yield superior functional outcomes in patients with WUS and large vessel occlusion compared to standard medical treatment alone.
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Affiliation(s)
- Hong-Feng Wen
- Department of Neurology, Aerospace Center Hospital, No. 15 Yuquan Road, Haidian District, Beijing, 100049, China
| | - Qin Li
- Department of Neurology, Aerospace Center Hospital, No. 15 Yuquan Road, Haidian District, Beijing, 100049, China
| | - Pei-Fu Wang
- Department of Neurology, Aerospace Center Hospital, No. 15 Yuquan Road, Haidian District, Beijing, 100049, China.
| | - Ji-Lai Li
- Department of Neurology, Aerospace Center Hospital, No. 15 Yuquan Road, Haidian District, Beijing, 100049, China
| | - Ji-Chen Du
- Department of Neurology, Aerospace Center Hospital, No. 15 Yuquan Road, Haidian District, Beijing, 100049, China.
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Selman CJ, Lee KJ, Ferguson KN, Whitehead CL, Manley BJ, Mahar RK. Statistical analyses of ordinal outcomes in randomised controlled trials: a scoping review. Trials 2024; 25:241. [PMID: 38582924 PMCID: PMC10998402 DOI: 10.1186/s13063-024-08072-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2023] [Accepted: 03/22/2024] [Indexed: 04/08/2024] Open
Abstract
BACKGROUND Randomised controlled trials (RCTs) aim to estimate the causal effect of one or more interventions relative to a control. One type of outcome that can be of interest in an RCT is an ordinal outcome, which is useful to answer clinical questions regarding complex and evolving patient states. The target parameter of interest for an ordinal outcome depends on the research question and the assumptions the analyst is willing to make. This review aimed to provide an overview of how ordinal outcomes have been used and analysed in RCTs. METHODS The review included RCTs with an ordinal primary or secondary outcome published between 2017 and 2022 in four highly ranked medical journals (the British Medical Journal, New England Journal of Medicine, The Lancet, and the Journal of the American Medical Association) identified through PubMed. Details regarding the study setting, design, the target parameter, and statistical methods used to analyse the ordinal outcome were extracted. RESULTS The search identified 309 studies, of which 144 were eligible for inclusion. The most used target parameter was an odds ratio, reported in 78 (54%) studies. The ordinal outcome was dichotomised for analysis in 47 ( 33 % ) studies, and the most common statistical model used to analyse the ordinal outcome on the full ordinal scale was the proportional odds model (64 [ 44 % ] studies). Notably, 86 (60%) studies did not explicitly check or describe the robustness of the assumptions for the statistical method(s) used. CONCLUSIONS The results of this review indicate that in RCTs that use an ordinal outcome, there is variation in the target parameter and the analytical approaches used, with many dichotomising the ordinal outcome. Few studies provided assurance regarding the appropriateness of the assumptions and methods used to analyse the ordinal outcome. More guidance is needed to improve the transparent reporting of the analysis of ordinal outcomes in future trials.
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Affiliation(s)
- Chris J Selman
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia.
- Department of Paediatrics, University of Melbourne, Parkville, VIC, 3052, Australia.
| | - Katherine J Lee
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
- Department of Paediatrics, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Kristin N Ferguson
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
| | - Clare L Whitehead
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
- Department of Maternal Fetal Medicine, The Royal Women's Hospital, Parkville, VIC, 3052, Australia
| | - Brett J Manley
- Department of Obstetrics and Gynaecology, University of Melbourne, Parkville, VIC, 3052, Australia
- Newborn Research, The Royal Women's Hospital, Parkville, VIC, 3052, Australia
- Clinical Sciences, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
| | - Robert K Mahar
- Clinical Epidemiology and Biostatistics Unit, Murdoch Children's Research Institute, Parkville, VIC, 3052, Australia
- Centre for Epidemiology and Biostatistics, Melbourne School of Population and Global Health, University of Melbourne, Parkville, VIC, 3052, Australia
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Hernández-Bernal F, Estenoz-García D, Gutiérrez-Ronquillo JH, Martín-Bauta Y, Catasús-Álvarez K, Gutiérrez-Castillo M, Guevara-Rodríguez M, Castro-Jeréz A, Fuentes-González Y, Pinto-Cruz Y, Valenzuela-Silva C, Muzio-González VL, Pérez-Saad H, Subirós-Martínez N, Guillén-Nieto GE, Garcia-del-Barco-Herrera D. Combination therapy of Epidermal Growth Factor and Growth Hormone-Releasing Hexapeptide in acute ischemic stroke: a phase I/II non-blinded, randomized clinical trial. Front Neurol 2024; 15:1303402. [PMID: 38638315 PMCID: PMC11024445 DOI: 10.3389/fneur.2024.1303402] [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: 09/27/2023] [Accepted: 03/14/2024] [Indexed: 04/20/2024] Open
Abstract
Objective This study tested the hypothesis that a neuroprotective combined therapy based on epidermal growth factor (EGF) and growth hormone-releasing hexapeptide (GHRP6) could be safe for acute ischemic stroke patients, admitting up to 30% of serious adverse events (SAE) with proven causality. Methods A multi-centric, randomized, open-label, controlled, phase I-II clinical trial with parallel groups was conducted (July 2017 to January 2018). Patients aged 18-80 years with a computed tomography-confirmed ischemic stroke and less than 12 h from the onset of symptoms were randomly assigned to the study groups I (75 μg rEGF + 3.5 mg GHRP6 i.v., n=10), II (75 μg rEGF + 5 mg GHRP6 i.v., n=10), or III (standard care control, n=16). Combined therapy was given BID for 7 days. The primary endpoint was safety over 6 months. Secondary endpoints included neurological (NIHSS) and functional [Barthel index and modified Rankin scale (mRS)] outcomes. Results The study population had a mean age of 66 ± 11 years, with 21 men (58.3%), a baseline median NIHSS score of 9 (95% CI: 8-11), and a mean time to treatment of 7.3 ± 2.8 h. Analyses were conducted on an intention-to-treat basis. SAEs were reported in 9 of 16 (56.2%) patients in the control group, 3 of 10 (30%) patients in Group I (odds ratio (OR): 0.33; 95% CI: 0.06-1.78), and 2 of 10 (20%) patients in Group II (OR: 0.19; 95% CI: 0.03-1.22); only two events in one patient in Group I were attributed to the intervention treatment. Compliance with the study hypothesis was greater than 0.90 in each group. Patients treated with EGF + GHRP6 had a favorable neurological and functional evolution at both 90 and 180 days, as evidenced by the inferential analysis of NIHSS, Barthel, and mRS and by their moderate to strong effect size. At 6 months, proportion analysis evidenced a higher survival rate for patients treated with the combined therapy. Ancillary analysis including merged treated groups and utility-weighted mRS also showed a benefit of this combined therapy. Conclusion EGF + GHRP6 therapy was safe. The functional benefits of treatment in this study supported a Phase III study. Clinical Trial Registration RPCEC00000214 of the Cuban Public Registry of Clinical Trials, Unique identifier: IG/CIGB-845I/IC/1601.
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Affiliation(s)
- Francisco Hernández-Bernal
- Clinical Trial Direction, Center for Genetic Engineering and Biotechnology, Havana, Cuba
- Department of Comprehensive General Medicine, Latin American School of Medicine (ELAM), Havana, Cuba
| | | | | | - Yenima Martín-Bauta
- Clinical Trial Direction, Center for Genetic Engineering and Biotechnology, Havana, Cuba
| | - Karen Catasús-Álvarez
- Clinical Trial Direction, Center for Genetic Engineering and Biotechnology, Havana, Cuba
| | | | | | | | | | | | | | | | - Héctor Pérez-Saad
- Neuroprotection Project, Biomedical Research Direction, Center for Genetic Engineering and Biotechnology, Havana, Cuba
| | - Nelvys Subirós-Martínez
- Neuroprotection Project, Biomedical Research Direction, Center for Genetic Engineering and Biotechnology, Havana, Cuba
| | - Gerardo E. Guillén-Nieto
- Biomedical Research Direction, Center for Genetic Engineering and Biotechnology, Havana, Cuba
- Department of Physiology, Latin American School of Medicine (ELAM), Havana, Cuba
| | - Diana Garcia-del-Barco-Herrera
- Neuroprotection Project, Biomedical Research Direction, Center for Genetic Engineering and Biotechnology, Havana, Cuba
- Department of Physiology, Latin American School of Medicine (ELAM), Havana, Cuba
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Gory B, Finitsis S, Olivot JM, Richard S, Marnat G, Sibon I, Viguier A, Cognard C, Mazighi M, Chamorro A, Lapergue B, Maïer B. Intravenous Thrombolysis before Complete Angiographic Reperfusion: Beyond Angiographic Assessment to Target Microvascular Obstruction? Ann Neurol 2024; 95:762-773. [PMID: 38148607 DOI: 10.1002/ana.26867] [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: 08/02/2023] [Revised: 12/19/2023] [Accepted: 12/20/2023] [Indexed: 12/28/2023]
Abstract
OBJECTIVE Recent data have suggested that ineffective tissue reperfusion despite successful angiographic reperfusion was partly responsible for unfavorable outcomes after endovascular therapy (EVT) and might be modulated by intravenous thrombolysis (IVT) use before EVT. To specifically decipher the effect played by IVT before EVT, we compared the clinical and safety outcomes of patients who experienced a complete reperfusion at the end of EVT according to IVT use before EVT. METHODS The Endovascular Treatment in Ischemic Stroke (ETIS) registry is an ongoing, prospective, observational study at 21 centers that perform EVT in France. Patients were included if they had an anterior large vessel occlusion of the intracranial internal carotid artery or middle cerebral artery (M1/M2 segments) and complete reperfusion (expanded Thrombolysis in Cerebral Infarction score = 3) with EVT within 6 hours, between January 2015 and December 2021. The cohort was divided into two groups according to IVT use before EVT, and propensity score matching (PSM) was used to balance the two groups. Primary outcome was the shift in the degree of disability as measured by the modified Rankin Scale (mRS) at 90 days. Secondary outcomes included favorable outcome (mRS 0-2) at 90 days. Safety outcomes included symptomatic intracranial hemorrhage and 90-day mortality. Outcomes were estimated with multivariate logistic models adjusted for age, National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT Score, and time from symptom onset to puncture. RESULTS Among 5,429 patients included in the ETIS registry, 1,093 were included in the study, including 651 patients with complete recanalization treated with IVT before EVT. After PSM, 488 patients treated with IVT before EVT were compared to 337 patients without IVT. In the matched cohort analysis, the IVT+EVT group had a favorable shift in the overall mRS score distribution (adjusted odds ratio [aOR] = 1.41, 95% confidence interval [CI] = 1.04-1.91, p = 0.023) and higher rates of favorable outcome (61.1% vs 48.7%, aOR = 1.49, 95% CI = 1.02-2.20, p = 0.041) at 90 days compared with the EVT alone group. Rates of symptomatic intracerebral hemorrhage were comparable between both groups (6.0% vs 4.3%, aOR = 1.16, 95% CI = 0.53-2.54, p = 0.709). INTERPRETATION In clinical practice, even after complete angiographic reperfusion by EVT, prior IVT use improves clinical outcomes of patients without increasing bleeding risk. ANN NEUROL 2024;95:762-773.
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Affiliation(s)
- Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, CHRU-Nancy, Nancy, France
- INSERM U1254, IADI, Université de Lorraine, 54511, Vandoeuvre-les-Nancy, France
| | - Stephanos Finitsis
- Aristotle University of Thessaloniki, Ahepa Hospital, Thessaloniki, Greece
| | - Jean-Marc Olivot
- Department of Vascular Neurology, University Hospital of Toulouse, Toulouse, France
| | - Sébastien Richard
- Department of Neurology, Stroke Unit, Université de Lorraine, CHRU-Nancy, Nancy, France
- CIC-P 1433, INSERM U1116, CHRU-Nancy, Nancy, France
| | - Gaultier Marnat
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
| | - Igor Sibon
- Neurology Department, University Hospital of Bordeaux, Bordeaux, France
| | - Alain Viguier
- Department of Vascular Neurology, University Hospital of Toulouse, Toulouse, France
| | | | - Mikael Mazighi
- Department of Interventional Neuroradiology, Hôpital Fondation A. de Rothschild, Paris, France
- Department of Neurology, Hôpital Lariboisière, Paris, France
- Université Paris-Cité, Paris, France
- Université Paris-Cité and Université Sorbonne Paris Nord, Paris, France
| | - Angel Chamorro
- Department of Neuroscience, Comprehensive Stroke Center, Hospital Clinic of Barcelona, Barcelona, Spain
| | - Bertrand Lapergue
- Department of Neurology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - Benjamin Maïer
- Department of Interventional Neuroradiology, Hôpital Fondation A. de Rothschild, Paris, France
- Université Paris-Cité, Paris, France
- Université Paris-Cité and Université Sorbonne Paris Nord, Paris, France
- Department of Neurology, Hôpital Saint-Joseph, Paris, France
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Yepes M. Fibrinolytic and Non-fibrinolytic Roles of Tissue-type Plasminogen Activator in the Ischemic Brain. Neuroscience 2024; 542:69-80. [PMID: 37574107 DOI: 10.1016/j.neuroscience.2023.08.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 08/03/2023] [Accepted: 08/06/2023] [Indexed: 08/15/2023]
Abstract
The neurovascular unit (NVU) is assembled by endothelial cells (ECs) and pericytes, and encased by a basement membrane (BM) surveilled by microglia and surrounded by perivascular astrocytes (PVA), which in turn are in contact with synapses. Cerebral ischemia induces the rapid release of the serine proteinase tissue-type plasminogen activator (tPA) from endothelial cells, perivascular astrocytes, microglia and neurons. Owning to its ability to catalyze the conversion of plasminogen into plasmin, in the intravascular space tPA functions as a fibrinolytic enzyme. In contrast, the release of astrocytic, microglial and neuronal tPA have a plethora of effects that not always require the generation of plasmin. In the ischemic brain tPA increases the permeability of the NVU, induces microglial activation, participates in the recycling of glutamate, and has various effects on neuronal survival. These effects are mediated by different receptors, notably subunits of the N-methyl-D-aspartate receptor (NMDAR) and the low-density lipoprotein receptor-related protein-1 (LRP-1). Here we review data on the role of tPA in the NVU under non-ischemic and ischemic conditions, and analyze how this knowledge may lead to the development of potential strategies for the treatment of acute ischemic stroke patients.
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Affiliation(s)
- Manuel Yepes
- Department of Neurology, Emory University, Atlanta, GA, USA; Division of Neuropharmacology and Neurologic Diseases, Emory Primate Research Center, Atlanta, GA, USA; Department of Neurology, Veterans Affairs Medical Center, Atlanta, GA, USA.
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Sedghi A, Kaiser DPO, Cuberi A, Schreckenbauer S, Wojciechowski C, Friehs I, Reichmann H, Barlinn J, Barlinn K, Puetz V, Siepmann T. Intravenous Thrombolysis Before Thrombectomy Improves Functional Outcome After Stroke Independent of Reperfusion Grade. J Am Heart Assoc 2024; 13:e031854. [PMID: 38456409 PMCID: PMC11009998 DOI: 10.1161/jaha.123.031854] [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: 07/19/2023] [Accepted: 01/17/2024] [Indexed: 03/09/2024]
Abstract
BACKGROUND We studied the association of bridging intravenous thrombolysis (IVT) before thrombectomy for anterior circulation large-vessel occlusion and functional outcome and scrutinized its dependence on grade of reperfusion and distal thrombus migration. METHODS AND RESULTS We included consecutive patients with anterior circulation large-vessel occlusion from our prospective registry of thrombectomy-eligible patients treated from January 1, 2017 to January 1, 2023 at a tertiary stroke center in Germany in this retrospective cohort study. To evaluate the association of bridging IVT and functional outcome quantified via modified Rankin Scale score at 90 days we used multivariable logistic and lasso regression including interaction terms with grade of reperfusion quantified via modified Thrombolysis in Cerebral Infarction (mTICI) scale and distal thrombus migration adjusted for demographic and cardiovascular risk profiles, clinical and imaging stroke characteristics, onset-to-recanalization time and distal thrombus migration. We performed sensitivity analysis using propensity score matching. In our study population of 1000 thrombectomy-eligible patients (513 women; median age, 77 years [interquartile range, 67-84]), IVT emerged as a predictor of favorable functional outcome (modified Rankin Scale score, 0-2) independent of modified mTICI score (adjusted odds ratio, 0.49 [95% CI, 0.32-0.75]; P=0.001). In those who underwent thrombectomy (n=812), the association of IVT and favorable functional outcome was reproduced (adjusted odds ratio, 0.49 [95% CI, 0.31-0.74]; P=0.001) and was further confirmed on propensity score analysis, where IVT led to a 0.35-point decrease in 90-day modified Rankin Scale score (ß=-0.35 [95 CI%, -0.68 to 0.01]; P=0.04). The additive benefit of IVT remained independent of modified mTICI score (ß=-1.79 [95% CI, -3.43 to -0.15]; P=0.03) and distal thrombus migration (ß=-0.41 [95% CI, -0.69 to -0.13]; P=0.004) on interaction analysis. Consequently, IVT showed an additive association with functional outcome in the subpopulation of patients undergoing thrombectomy who achieved successful reperfusion (mTICI ≥2b; ß=-0.46 [95% CI, -0.74 to -0.17]; P=0.002) and remained beneficial in those with unsuccessful reperfusion (mTICI ≤2a; ß=-0.47 [95% CI, -0.96 to 0.01]; P=0.05). CONCLUSIONS In thrombectomy-eligible patients with anterior circulation large-vessel occlusion, IVT improves functional outcome independent of grade of reperfusion and distal thrombus migration.
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Affiliation(s)
- Annahita Sedghi
- Dresden Neurovascular Center, Department of Neurology, Medical Faculty and University Hospital Carl Gustav CarusDresden University of TechnologyDresdenGermany
- Division of Health Care SciencesDresden International UniversityDresdenGermany
| | - Daniel P. O. Kaiser
- Dresden Neurovascular Center, Institute of Neuroradiology, Medical Faculty and University Hospital Carl Gustav Carus, Dresden University of TechnologyDresdenGermany
| | - Ani Cuberi
- Institute of Radiology, Medical Faculty and University Hospital Carl Gustav Carus, Dresden University of TechnologyDresdenGermany
| | - Sonja Schreckenbauer
- Dresden Neurovascular Center, Department of Neurology, Medical Faculty and University Hospital Carl Gustav CarusDresden University of TechnologyDresdenGermany
| | - Claudia Wojciechowski
- Dresden Neurovascular Center, Department of Neurology, Medical Faculty and University Hospital Carl Gustav CarusDresden University of TechnologyDresdenGermany
| | - Ingeborg Friehs
- Department of Cardiac SurgeryBoston Children’s Hospital, Harvard Medical SchoolBostonMAUSA
| | - Heinz Reichmann
- Dresden Neurovascular Center, Department of Neurology, Medical Faculty and University Hospital Carl Gustav CarusDresden University of TechnologyDresdenGermany
| | - Jessica Barlinn
- Dresden Neurovascular Center, Department of Neurology, Medical Faculty and University Hospital Carl Gustav CarusDresden University of TechnologyDresdenGermany
| | - Kristian Barlinn
- Dresden Neurovascular Center, Department of Neurology, Medical Faculty and University Hospital Carl Gustav CarusDresden University of TechnologyDresdenGermany
| | - Volker Puetz
- Dresden Neurovascular Center, Department of Neurology, Medical Faculty and University Hospital Carl Gustav CarusDresden University of TechnologyDresdenGermany
| | - Timo Siepmann
- Dresden Neurovascular Center, Department of Neurology, Medical Faculty and University Hospital Carl Gustav CarusDresden University of TechnologyDresdenGermany
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Yan Y, Du L, Shangguan X, Li L, Chi Y, Wang Y, Cheng S, Huang Q, Pan Y, Xin T. Construction and application of a time-saving mode in China for the treatment of acute ischemic stroke. Front Neurol 2024; 15:1367801. [PMID: 38566851 PMCID: PMC10985155 DOI: 10.3389/fneur.2024.1367801] [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: 01/09/2024] [Accepted: 03/11/2024] [Indexed: 04/04/2024] Open
Abstract
Objective To explore the construction and application in the practice of green channel in No. 971 Naval Hospital of PLA (No. 971 Hospital mode) for the treatment of acute ischemic stroke (AIS). Methods This retrospective study involved a cohort of 694 suspected stroke patients from December 2022 to November 2023 undergoing emergency treatment for stroke at our institution. Among them, 483 patients were treated with standard green channel (the control group), and 211 patients adopted the No. 971 Hospital mode for treatment (the study group). The biggest difference between the two groups was that the treatment process started before admission. We compared the effectiveness of the emergency treatment between the two groups and the thrombolysis treatment. Results Compared with control group, the accuracy rate of determining stroke and the rate of thrombolysis were significantly higher (p = 0.002, 0.039) and the door to doctor arrival time (DAT) and the door to CT scan time (DCT) of the study group was significantly shorter (all p < 0.001). There were 49 patients (10.1%) and 33 patients (15.6%) from the control group and study group receiving thrombolysis, respectively. The DAT, DCT, imaging to needle time (INT), and door to needle time (DNT) of patients receiving thrombolysis in the study group were significantly shorter than that in the control group (all p < 0.01). The NIHSS in the study group after the thrombolysis was lower than that in the control group (p = 0.042). Conclusion No. 971 Hospital model can effectively shorten DAT, DCT, INT, and DNT, and improve the effectiveness of thrombolysis and prognoses of AIS patients.
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Affiliation(s)
- Yazhou Yan
- Stroke Center, No. 971 Naval Hospital of PLA, Qingdao, China
| | - Li Du
- Stroke Center, No. 971 Naval Hospital of PLA, Qingdao, China
| | - Xiu Shangguan
- Stroke Center, No. 971 Naval Hospital of PLA, Qingdao, China
| | - Lujun Li
- Stroke Center, No. 971 Naval Hospital of PLA, Qingdao, China
| | - Yuxiang Chi
- Stroke Center, No. 971 Naval Hospital of PLA, Qingdao, China
| | - Yu Wang
- Stroke Center, No. 971 Naval Hospital of PLA, Qingdao, China
| | - Shuai Cheng
- Stroke Center, No. 971 Naval Hospital of PLA, Qingdao, China
| | - Qinghai Huang
- Department of Neurovascular Center, Changhai Hospital Affiliated to the Naval Medical University, Shanghai, China
| | - Yuan Pan
- Stroke Center, No. 971 Naval Hospital of PLA, Qingdao, China
| | - Tao Xin
- Stroke Center, No. 971 Naval Hospital of PLA, Qingdao, China
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Nogueira RG, Kimura K, Matsumaru Y, Suzuki K, Qiu Z, Zi W, Moran TP, Li F, Sang H, Luo W, Liu S, Yuan J, Song J, Huang J, Takeuchi M, Morimoto M, Otsuka T, Yang Q. Systemic THrombolysis Randomization IN Endovascular Stroke Therapy (SHRINE) Collaboration: a patient-level pooled analysis of the SKIP and DEVT Trials. J Neurointerv Surg 2024; 16:359-364. [PMID: 37290918 DOI: 10.1136/jnis-2023-020307] [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: 03/08/2023] [Accepted: 04/29/2023] [Indexed: 06/10/2023]
Abstract
OBJECTIVE To evaluate the non-inferiority of endovascular treatment (EVT) alone versus intravenous thrombolysis (IVT) followed by EVT and to assess its heterogeneity across prespecified subgroups. METHODS We pooled data from two trials (SKIP in Japan; DEVT in China). Individual patient data were pooled to assess outcomes and heterogeneity of treatment effect. The primary outcome was functional independence (modified Rankin Scale score 0-2) at 90 days. Safety outcomes included symptomatic intracranial hemorrhage (sICH) and 90-day mortality. RESULTS We included 438 patients (217 EVT alone; 221 combined IVT+EVT). The meta-analysis failed to demonstrate the non-inferiority of EVT alone over combined IVT+EVT in achieving 90-day functional independence (56.7% vs 51.6%; adjusted common odds ratio (cOR)=1.27, 95% CI 0.84 to 1.92, pnon-inferiority=0.06). Effect sizes favoring EVT alone were present with stroke onset to puncture time longer than 180 min (cOR=2.28, 95% CI 1.18 to 4.38, pinteraction ≤180 vs >180 min=0.02) and intracranial internal carotid artery ICA occlusions (for ICA cOR=3.04, 95% CI 1.10 to 8.43, pinteraction ICA vs MCA=0.08). The rates of sICH (6.5% vs 9.0%; cOR=0.77, 95% CI 0.37 to 1.61) and 90-day mortality (12.9% vs 13.6%; cOR=1.05, 95% CI 0.58 to 1.89) were comparable. CONCLUSIONS The cumulative data of these two recent Asian trials failed to unequivocally demonstrate the non-inferiority of EVT alone over combined IVT+EVT. However, our study suggests a potential role for more individualized decision-making. Specifically, Asian patients with stroke onset to EVT longer than 180 min, as well as those with intracranial ICA occlusions and those with atrial fibrillation might have better outcomes with EVT alone than with combined IVT+EVT.
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Affiliation(s)
- Raul G Nogueira
- Department of Neurology and Neurosurgery, University of Pittsburgh Medical Center Health System, Pittsburgh, Pennsylvania, USA
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Yuji Matsumaru
- Division of Stroke Prevention and Treatment, Faculty of Medicine, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Zhongming Qiu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
- Department of Neurology, 903th Hospital of PLA, Hangzhou, Zhejiang, China
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Timothy P Moran
- Department of Emergency Medicine, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Hongfei Sang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Weidong Luo
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Shuai Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Junjie Yuan
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jiaxing Song
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jiacheng Huang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | | | - Masafumi Morimoto
- Department of Neurosurgery, Yokohama Shintoshi Neurosurgery Hospital, Kanagawa, Yokohama, Japan
| | - Toshiaki Otsuka
- Department of Hygiene and Public Health, Nippon Medical School, Bunkyo-ku, Japan
| | - Qingwu Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
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Li Z, Zhou Y, Zhang X, Zhang L, Zhang Y, Xing P, Zhang Y, Huang Q, Li Q, Zuo Q, Ye X, Liu J, Yang P. Effect of Clot Burden Score on Safety and Efficacy of Intravenous Alteplase Prior to Mechanical Thrombectomy in Acute Ischemic Stroke: A Subgroup Analysis of a Randomized Phase 3 Trial. AJNR Am J Neuroradiol 2024; 45:296-301. [PMID: 38388688 DOI: 10.3174/ajnr.a8134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 12/04/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND AND PURPOSE Whether thrombus burden in acute ischemic stroke modify the effect of intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) remains uncertain. We aim to investigate the treatment effect of stratified clot burden score (CBS) on the efficacy and safety of direct versus bridging MT. MATERIALS AND METHODS This is an exploratory subgroup analysis of a randomized trial evaluating the effect of CBS on clinical outcome in the DIRECT-MT trial. CBS was divided into 3 groups (0-3, 4-6, and 7-10) based on preoperative CTA, where higher scores indicated a lower clot burden. We report the adjusted common odds ratio for a shift toward better outcomes on the mRS after thrombectomy alone compared with combination treatment by stratified CBS groups. RESULTS No modification effect of mRS distribution was observed by CBS subgroups (CBS 0-3: adjusted common ratio odds 1.519 [95% CI, 0.928-2.486]; 4-6: 0.924 [0.635-1.345]; 7-10: 1.040 [0.481-2.247]). Patients with CBS 4-6 had a higher rate of early reperfusion (adjusted OR (aOR), 0.3 [95% CI, 0.1-0.9]), final reperfusion (aOR 0.5 [95% CI, 0.3-0.9]), and fewer thrombectomy attempts (aOR 0.4 [95% CI, 0.1-0.7]). Patients with CBS 7-10 had a higher rate of asymptomatic intracranial hemorrhage (14.9% versus 36.8%, P = .0197) for bridging MT. No significant difference was observed in other safety outcomes by trichotomized CBS. CONCLUSIONS The subgroup analysis of DIRECT-MT suggested that thrombus burden did not alter the treatment effect of IVT before MT on functional outcomes in CBS subgroups.
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Affiliation(s)
- Zifu Li
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yu Zhou
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xiaoxi Zhang
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Lei Zhang
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yongwei Zhang
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Pengfei Xing
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yongxin Zhang
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qinghai Huang
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qiang Li
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qiao Zuo
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xiaofei Ye
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jianmin Liu
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Pengfei Yang
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
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Kaesmacher J, Cavalcante F, Kappelhof M, Treurniet KM, Rinkel L, Liu J, Yan B, Zi W, Kimura K, Eker OF, Zhang Y, Piechowiak EI, van Zwam W, Liu S, Strbian D, Uyttenboogaart M, Dobrocky T, Miao Z, Suzuki K, Zhang L, van Oostenbrugge R, Meinel TR, Guo C, Seiffge D, Yin C, Bütikofer L, Lingsma H, Nieboer D, Yang P, Mitchell P, Majoie C, Fischer U, Roos Y, Gralla J. Time to Treatment With Intravenous Thrombolysis Before Thrombectomy and Functional Outcomes in Acute Ischemic Stroke: A Meta-Analysis. JAMA 2024; 331:764-777. [PMID: 38324409 PMCID: PMC10851137 DOI: 10.1001/jama.2024.0589] [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: 10/04/2023] [Accepted: 01/16/2024] [Indexed: 02/09/2024]
Abstract
Importance The benefit of intravenous thrombolysis (IVT) for acute ischemic stroke declines with longer time from symptom onset, but it is not known whether a similar time dependency exists for IVT followed by thrombectomy. Objective To determine whether the benefit associated with IVT plus thrombectomy vs thrombectomy alone decreases with treatment time from symptom onset. Design, Setting, and Participants Individual participant data meta-analysis from 6 randomized clinical trials comparing IVT plus thrombectomy vs thrombectomy alone. Enrollment was between January 2017 and July 2021 at 190 sites in 15 countries. All participants were eligible for IVT and thrombectomy and presented directly at thrombectomy-capable stroke centers (n = 2334). For this meta-analysis, only patients with an anterior circulation large-vessel occlusion were included (n = 2313). Exposure Interval from stroke symptom onset to expected administration of IVT and treatment with IVT plus thrombectomy vs thrombectomy alone. Main Outcomes and Measures The primary outcome analysis tested whether the association between the allocated treatment (IVT plus thrombectomy vs thrombectomy alone) and disability at 90 days (7-level modified Rankin Scale [mRS] score range, 0 [no symptoms] to 6 [death]; minimal clinically important difference for the rates of mRS scores of 0-2: 1.3%) varied with times from symptom onset to expected administration of IVT. Results In 2313 participants (1160 in IVT plus thrombectomy group vs 1153 in thrombectomy alone group; median age, 71 [IQR, 62 to 78] years; 44.3% were female), the median time from symptom onset to expected administration of IVT was 2 hours 28 minutes (IQR, 1 hour 46 minutes to 3 hours 17 minutes). There was a statistically significant interaction between the time from symptom onset to expected administration of IVT and the association of allocated treatment with functional outcomes (ratio of adjusted common odds ratio [OR] per 1-hour delay, 0.84 [95% CI, 0.72 to 0.97], P = .02 for interaction). The benefit of IVT plus thrombectomy decreased with longer times from symptom onset to expected administration of IVT (adjusted common OR for a 1-step mRS score shift toward improvement, 1.49 [95% CI, 1.13 to 1.96] at 1 hour, 1.25 [95% CI, 1.04 to 1.49] at 2 hours, and 1.04 [95% CI, 0.88 to 1.23] at 3 hours). For a mRS score of 0, 1, or 2, the predicted absolute risk difference was 9% (95% CI, 3% to 16%) at 1 hour, 5% (95% CI, 1% to 9%) at 2 hours, and 1% (95% CI, -3% to 5%) at 3 hours. After 2 hours 20 minutes, the benefit associated with IVT plus thrombectomy was not statistically significant and the point estimate crossed the null association at 3 hours 14 minutes. Conclusions and Relevance In patients presenting at thrombectomy-capable stroke centers, the benefit associated with IVT plus thrombectomy vs thrombectomy alone was time dependent and statistically significant only if the time from symptom onset to expected administration of IVT was short.
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Affiliation(s)
- Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Fabiano Cavalcante
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Kilian M. Treurniet
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
- Department of Radiology, Haaglanden Medical Center, the Hague, the Netherlands
| | - Leon Rinkel
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Jianmin Liu
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
- Oriental Pan-Vascular Devices Innovations College, University of Shanghai for Science and Technology, Shanghai, China
| | - Bernard Yan
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Kazumi Kimura
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Omer F. Eker
- Department of Neuroradiology, Hospices Civils de Lyon, Lyon, France
| | - Yongwei Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Eike I. Piechowiak
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Wim van Zwam
- Department of Radiology, Maastricht University Medical Centre, Maastricht, the Netherlands
| | - Sheng Liu
- Department of Radiology, Jiangsu Provincial People’s Hospital of Nanjing Medical University, Nanjing, China
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Maarten Uyttenboogaart
- Department of Neurology, University Medical Center Groningen, Groningen, the Netherlands
| | - Tomas Dobrocky
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Kentaro Suzuki
- Department of Neurology, Nippon Medical School, Tokyo, Japan
| | - Lei Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Robert van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, the Netherlands
| | - Thomas R. Meinel
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Changwei Guo
- Department of Neurology, Xinqiao Hospital and the Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - David Seiffge
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Congguo Yin
- Department of Neurology, Hangzhou First People’s Hospital of Zhejiang University, Hangzhou, China
| | | | - Hester Lingsma
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherland
| | - Daan Nieboer
- Department of Public Health, Erasmus Medical Center, Rotterdam, the Netherland
| | - Pengfei Yang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
- Oriental Pan-Vascular Devices Innovations College, University of Shanghai for Science and Technology, Shanghai, China
| | - Peter Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Charles Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Urs Fischer
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
- Department of Neurology, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Yvo Roos
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam Neuroscience, Amsterdam, the Netherlands
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
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Wang J, Yang C, Zhang R, Hu W, Yang P, Jiang Y, Hong W, Shan R, Jiang Y. Development and validation of a predictive model for stroke associated pneumonia in patients after thrombectomy for acute ischemic stroke. Front Med (Lausanne) 2024; 11:1370986. [PMID: 38504915 PMCID: PMC10948544 DOI: 10.3389/fmed.2024.1370986] [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: 01/15/2024] [Accepted: 02/22/2024] [Indexed: 03/21/2024] Open
Abstract
Objective This study aims to identify the risk factors associated with stroke-associated pneumonia (SAP) in patients who have undergone thrombectomy for acute ischemic stroke and to develop a nomogram chart model for predicting the occurrence of pneumonia. Methods Consecutive patients who underwent thrombectomy for acute ischemic stroke were enrolled from three hospitals at Taizhou Enze Medical Center. They were randomly divided into a training group and a validation group in a 7:3 ratio. The training group data was used to screen for effective predictive factors using LASSO regression. Multiple logistic regression was then conducted to determine the predictive factors and construct a nomogram chart. The model was evaluated using the validation group, analyzing its discrimination, calibration, and clinical decision curve. Finally, the newly constructed model was compared with the AIS-APS, A2DS2, ISAN, and PANTHERIS scores for acute ischemic stroke-associated pneumonia. Results Out of 913 patients who underwent thrombectomy, 762 were included for analysis, consisting of 473 males and 289 females. The incidence rate of SAP was 45.8%. The new predictive model was constructed based on three main influencing factors: NIHSS ≥16, postoperative LMR, and difficulty swallowing. The model demonstrated good discrimination and calibration. When applying the nomogram chart to threshold probabilities between 7 and 90%, net returns were increased. Furthermore, the AUC was higher compared to other scoring systems. Conclusion The constructed nomogram chart in this study outperformed the AIS-APS, A2DS2 score, ISAN score, and PANTHERIS score in predicting the risk of stroke-associated pneumonia in patients with acute ischemic stroke after thrombectomy. It can be utilized for clinical risk prediction of stroke-associated pneumonia in patients after thrombectomy for acute ischemic stroke.
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Affiliation(s)
- Jingying Wang
- Department of Emergency Medicine, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Chao Yang
- Department of Emergency Medicine, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Ruihai Zhang
- Department of Neurosurgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Wei Hu
- Department of Neurosurgery, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Peng Yang
- Department of Emergency Medicine, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Yiqing Jiang
- Department of Neurology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Weijun Hong
- Department of Neurology, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Renfei Shan
- Department of Emergency Medicine, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
- Department of Critical Care Medicine, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
| | - Yongpo Jiang
- Department of Emergency Medicine, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
- Department of Critical Care Medicine, Taizhou Hospital of Zhejiang Province Affiliated to Wenzhou Medical University, Taizhou, China
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Marnat G, Lapergue B, Gory B, Kyheng M, Labreuche J, Turc G, Olindo S, Sibon I, Caroff J, Smadja D, Chausson N, Clarençon F, Seners P, Bourcier R, Pop R, Olivot JM, Mazighi M, Moulin S, Janot K, Cognard C, Alamowitch S, Gerschenfeld G. Intravenous thrombolysis with tenecteplase versus alteplase combined with endovascular treatment of anterior circulation tandem occlusions: A pooled analysis of ETIS and TETRIS. Eur Stroke J 2024; 9:124-134. [PMID: 37837202 PMCID: PMC10916828 DOI: 10.1177/23969873231206894] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 09/21/2023] [Indexed: 10/15/2023] Open
Abstract
BACKGROUND Tandem occlusions are a singular large vessel occlusion entity involving specific endovascular and perioperative antithrombotic management. In this context, data on safety and efficacy of prior intravenous thrombolysis (IVT) with tenecteplase is scarce. We aimed to compare IVT with tenecteplase or alteplase in patients with acute tandem occlusions intended for endovascular treatment. PATIENTS AND METHODS A retrospective pooled analysis of two large observational registries (ETIS (Endovascular Treatment of Ischemic Stroke) and TETRIS (Tenecteplase Treatment in Ischemic Stroke)) was performed on consecutive patients presenting with anterior circulation tandem occlusion treated with IVT using either alteplase (ETIS) or tenecteplase (TETRIS) followed by endovascular treatment between January 2015 and June 2022. Sensitivity analyses on atherosclerosis related tandem occlusions and on patient treated with emergent carotid stenting were conducted. Propensity score overlap weighting analyses were performed. RESULTS We analyzed 753 patients: 124 in the tenecteplase and 629 in the alteplase group. The overall odds of favorable outcome (3-month modified Rankin score 0-2) were comparable between both groups (49.4% vs 47.1%; OR = 1.10, 95%CI 0.85-1.41). Early recanalization, final successful recanalization and mortality favored the use of tenecteplase. The occurrence of any intracranial hemorrhage (ICH) was more frequent after tenecteplase use (OR = 2.24; 95%CI 1.75-2.86). However, risks of symptomatic ICH and parenchymal hematoma remained similar. In atherosclerotic tandems, favorable outcome, mortality, parenchymal hematoma, early recanalization, and final successful recanalization favored the tenecteplase group. In the carotid stenting subgroup, PH were less frequent in the tenecteplase group (OR = 0.18; 95%CI 0.05-0.69). CONCLUSION In patients with tandem occlusions, IVT with tenecteplase seemed reasonably safe in particular with increased early recanalization rates. These findings remain preliminary and should be further confirmed in randomized trials.
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Affiliation(s)
- Gaultier Marnat
- Neuroradiology, Bordeaux University Hospital, Bordeaux, France
| | | | - Benjamin Gory
- Neuroradiology, Nancy University Hospital, Université de Lorraine, IADI, INSERM U1254, Nancy, France
| | - Maeva Kyheng
- Biostatistics, Lille University Hospital, Lille, France
| | | | - Guillaume Turc
- Neurology, GHU Paris Psychiatrie et Neurosciences, INSERM U1266, Université Paris Cité, FHU NeuroVasc, Paris, France
| | | | - Igor Sibon
- Neurology, Bordeaux University Hospital, Bordeaux, France
| | - Jildaz Caroff
- Interventional Neuroradiology − NEURI Brain Vascular Center, Bicêtre Hospital, APHP, Le Kremlin Bicêtre, France
| | - Didier Smadja
- Unité Neuro-vasculaire, Hôpital Sud Francilien, Corbeil-Essonnes, France
| | - Nicolas Chausson
- Unité Neuro-vasculaire, Hôpital Sud Francilien, Corbeil-Essonnes, France
| | | | - Pierre Seners
- Neurology, Fondation Rothschild, Paris, Île-de-France, France
| | | | - Raoul Pop
- Neuroradiology, Strasbourg University Hospital, Strasbourg, France
| | | | - Mikael Mazighi
- Neurology, Lariboisiere Hospital, and Interventional Neuroradiology, Fondation Rothschild Hospital, University of Paris Cité, INSERM 1144, FHU Neurovasc, Paris, France
| | - Solène Moulin
- Neurology, Stroke Unit; Reims University Hospital, Reims, France
| | - Kevin Janot
- Neuroradiology, Tours University Hospital, Tours, France
| | | | - Sonia Alamowitch
- Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, AP-HP, Hôpital Saint-Antoine, Sorbonne Université, Paris, France; STARE Team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
| | - Gaspard Gerschenfeld
- Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, AP-HP, Hôpital Saint-Antoine, Sorbonne Université, Paris, France; STARE Team, iCRIN, Institut du Cerveau et de la Moelle épinière, ICM, Paris, France
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Pop R, Räty S, Riva R, Marnat G, Dobrocky T, Alexandre PL, Lefebvre M, Albucher JF, Boulanger M, Di Maria F, Richard S, Soize S, Piechowiak EI, Liman J, Reich A, Ribo M, Meinel T, Mpotsaris A, Liebeskind DS, Gralla J, Fischer U, Kaesmacher J. Effect of Bridging Thrombolysis on the Efficacy of Stent Retriever Thrombectomy Techniques : Insights from the SWIFT-DIRECT trial. Clin Neuroradiol 2024; 34:93-103. [PMID: 37640839 DOI: 10.1007/s00062-023-01340-9] [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] [Received: 02/18/2023] [Accepted: 07/11/2023] [Indexed: 08/31/2023]
Abstract
BACKGROUND There are little available data regarding the influence of intravenous thrombolysis (IVT) on the efficacy of different first line endovascular treatment (EVT) techniques. METHODS We used the dataset of the SWIFT-DIRECT trial which randomized 408 patients to IVT + EVT or EVT alone at 48 international sites. The protocol required the use of a stent retriever (SR), but concomitant use of a balloon guide catheter (BGC) and/or distal aspiration (DA) catheter was left to the discretion of the operators. Four first line techniques were applied in the study population: SR, SR + BGC, SR + DA, SR + DA + BGC. To assess whether the effect of allocation to IVT + EVT versus EVT alone was modified by the first line technique, interaction models were fitted for predefined outcomes. The primary outcome was first pass mTICI 2c‑3 reperfusion (FPR). RESULTS This study included 385 patients of whom 172 were treated with SR + DA, 121 with SR + DA + BGC, 57 with SR + BGC and 35 with SR. There was no evidence that the effect of IVT + EVT versus EVT alone would be modified by the choice of first line technique; however, allocation to IVT + EVT increased the odds of FPR by a factor of 1.68 (95% confidence interval, CI 1.11-2.54). CONCLUSION This post hoc analysis does not suggest treatment effect heterogeneity of IVT + EVT vs EVT alone in different stent retriever techniques but provides evidence for increased FPR if bridging IVT is administered before stent retriever thrombectomy.
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Affiliation(s)
- Raoul Pop
- Interventional Neuroradiology Department, Strasbourg University Hospitals, Strasbourg, France.
- INSERM U1255, University of Strasbourg, Strasbourg, France.
- Institut de Chirurgie Minime Invasive Guidée par l'Image, Strasbourg, France.
| | - Silja Räty
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Roberto Riva
- Department of Neuroradiology, Hospices Civils de Lyon, Lyon, France
| | - Gaultier Marnat
- Department of Interventional and Diagnostic Neuroradiology, CHU Bordeaux, University of Bordeaux, Bordeaux, France
| | - Tomas Dobrocky
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Pierre Louis Alexandre
- Department of Diagnostic and Interventional Neuroradiology, Centre Hospitalier Universitaire de Nantes, Nantes Université, Nantes, France
| | | | | | - Marion Boulanger
- Service de Neurologie, Université Caen Normandie, CHU Caen Normandie, Caen, France
| | - Federico Di Maria
- Department of Stroke and Diagnostic and Interventional Neuroradiology, Foch Hospital, Suresnes, France
| | - Sébastien Richard
- Department of Neurology, Stroke Unit, CHRU-Nancy, INSERM U1116, Université de Lorraine, Nancy, France
| | | | - Eike Immo Piechowiak
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Jan Liman
- Department of Neurology, University Medical Center Goettingen, Goettingen, Germany
- Department of Neurology, University Medical Center Nuremberg, Paracelsus Private University, Nuremberg, Germany
| | - Arno Reich
- Department of Neurology, University Hospital RWTH Aachen, Aachen, Germany
| | - Marc Ribo
- Stroke Unit. Department of Neurology, Vall d'Hebron Hospital, Barcelona, Spain
| | - Thomas Meinel
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | | | - David S Liebeskind
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles, USA
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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Liu T, Liu M, Sha Z, Wu C, Zhao Z, Yuan J, Feng D, Nie M, Jiang R. Chinese Neurosurgical Randomized Controlled Trials: Dynamics in Trial Implementation and Completion. Neurosurgery 2024; 94:497-507. [PMID: 37796000 DOI: 10.1227/neu.0000000000002702] [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: 05/11/2023] [Accepted: 08/03/2023] [Indexed: 10/06/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The focus on evidence-based neurosurgery has led to a considerable amount of neurosurgical evidence based on randomized controlled trials (RCTs) being published. Nevertheless, there has been no systematic appraisal of China's contribution to RCTs. Information about the changes in characteristics of Chinese neurosurgical RCTs before and during the COVID-19 pandemic is limited. This study aims to perform a detailed examination and comprehensive analysis of the characteristics of Chinese neurosurgical RCTs and to examine the differences before and during the COVID-19 pandemic. METHODS We conducted a comprehensive database search including PubMed, Web of Science, Embase, and Cochrane Library up to March 2023, with a criterion of inclusion based on an impact factor above 0. We subsequently examined the design and quality parameters of the included RCTs and assessed the differences before and during the COVID-19 pandemic (based on follow-up ending before or after January 2020). Moreover, we investigated potential factors that may affect the quality and developmental trends of neurosurgical RCTs in China. RESULTS The main focus of the 91 neurosurgical RCTs was vascular disease (47.3%) and trauma (18.7%). Over half of the trials used Consolidated Standards of Reporting Trial diagrams (69.2%), and the majority compared nonsurgical treatments (63.7%). Larger trials tended to have better quality scores, but those with significant efficacy were less likely to have power calculations. Over time, there was an increase in the use of Consolidated Standards of Reporting Trial diagrams and well-specified outcomes. The COVID-19 pandemic may have hindered the completion of neurosurgical RCTs in China, but it has had little impact on the design and quality so far. CONCLUSION Chinese neurosurgeons have made significant progress in advancing neurosurgical RCTs despite challenges. However, shortcomings in sample size and power calculation need attention. Improving the rigor, rationality, and completeness of neurosurgical RCT design is crucial.
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Affiliation(s)
- Tao Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin , China
- Key Laboratory of Post Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Ministry of Education, Tianjin , China
| | - Mingqi Liu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin , China
- Key Laboratory of Post Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Ministry of Education, Tianjin , China
| | - Zhuang Sha
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin , China
- Key Laboratory of Post Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Ministry of Education, Tianjin , China
| | - Chenrui Wu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin , China
- Key Laboratory of Post Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Ministry of Education, Tianjin , China
| | - Zhihao Zhao
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin , China
- Key Laboratory of Post Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Ministry of Education, Tianjin , China
| | - Jiangyuan Yuan
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin , China
- Key Laboratory of Post Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Ministry of Education, Tianjin , China
| | - Dongyi Feng
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin , China
- Key Laboratory of Post Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Ministry of Education, Tianjin , China
| | - Meng Nie
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin , China
- Key Laboratory of Post Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Ministry of Education, Tianjin , China
| | - Rongcai Jiang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin , China
- Key Laboratory of Post Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Tianjin Neurological Institute, Tianjin Medical University General Hospital, Ministry of Education, Tianjin , China
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Niu J, Chen K, Wu J, Ma L, Zhao G, Ding Y. Thrombectomy versus combined thrombolysis and thrombectomy in patients with large vessel occlusion and chronic kidney disease. Heliyon 2024; 10:e26110. [PMID: 38404773 PMCID: PMC10884842 DOI: 10.1016/j.heliyon.2024.e26110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2023] [Revised: 01/12/2024] [Accepted: 02/07/2024] [Indexed: 02/27/2024] Open
Abstract
Background Whether intravenous thrombolysis (IVT) should be bridged before mechanical thrombectomy (MT) remains uncertain in patients with large vessel occlusion (LVO) and chronic kidney disease (CKD). Methods This research systematically enrolled every patient with both acute ischemic stroke (AIS) and CKD who received MT and fulfilled the criteria for IVT from January 2015 to December 2022. According to whether they underwent IVT, the patients were categorized into two cohorts: MT and combined IVT + MT. A binary logistic regression model was used to adjust for potential confounders, and propensity score matching analysis was used to assess the efficacy and safety of IVT in AIS patients with CKD who underwent MT. Results A total number of 406 patients were ultimately included in this study, with 236 patients in the MT group and 170 in the combined group. After PSM, there were 170 patients in the MT group and 170 in the combined group, and the clinical characteristics between the two groups were well balanced. The MT + IVT group had better long-term functional outcomes than the MT group (35.9% versus 21.2%, P = 0.003) and more modified thrombolysis in cerebral infarction (mTICI) (2b-3) (94.1% versus 87.6%, P = 0.038), while no significant difference was found regarding symptomatic intracranial hemorrhage (sICH). In line with the results observed in the in the postmatched population, the logistic regression revealed that patients in the IVT + MT group demonstrated superior clinical outcomes (adjusted OR 0.440 [95% CI (0.267-0.726)], P = 0.001) in the prematched population. Conclusion For LVO patients with CKD and indications for IVT, IVT bridging MT improves their prognosis compared with direct MT.
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Affiliation(s)
- Jiali Niu
- Department of Clinical Pharmacy, Jingjiang People's Hospital, the Seventh Affiliated Hospital of Yangzhou University, Jiangsu, China
| | - Kaixia Chen
- Department of Pharmacy, JingJiang People's Hospital, the Seventh Affiliated Hospital of Yangzhou University, Jiangsu, China
| | - Jian Wu
- Hospital office, JingJiang People's Hospital, the Seventh Affiliated Hospital of Yangzhou University, Jiangsu, China
| | - Li Ma
- Department of Neurology, Shaoxing Second Hospital, the Second Affiliated Hospital of Shaoxing University, Zhejiang, China
| | - Guangyu Zhao
- Department of Clinical Pharmacy, Jingjiang People's Hospital, the Seventh Affiliated Hospital of Yangzhou University, Jiangsu, China
| | - Yunlong Ding
- Department of Neurology, Jingjiang People's Hospital, the Seventh Affiliated Hospital of Yangzhou University, Jiangsu, China
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Silva GS, Alves MM, Barros FCD, Frudit ME, Pontes-Neto OM, Mont'Alverne FJ, Rebello LC, Carbonera LA, Abud DG, Lima F, de Souza AC, Liebeskind D, Mosmann G, Bezerra D, Saver J, Cardoso F, Nogueira RG, Martins SO. The role of intravenous thrombolysis before mechanical Thrombectomy: A subgroup analysis of the RESILIENT trial. J Neurol Sci 2024; 457:122853. [PMID: 38182456 DOI: 10.1016/j.jns.2023.122853] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Revised: 11/20/2023] [Accepted: 12/17/2023] [Indexed: 01/07/2024]
Abstract
BACKGROUND Randomized trials have recently evaluated the non-inferiority of direct thrombectomy versus intravenous thrombolysis (IVT) followed by endovascular therapy in anterior circulation large vessel occlusion (LVO) stroke in patients eligible for IVT within 4.5 h from stroke onset with controversial results. We aimed to assess the effect of IVT on the clinical outcome of mechanical thrombectomy (MT) in the RESILIENT trial. METHODS RESILIENT was a randomized, prospective, multicenter, controlled trial assessing the safety and efficacy of thrombectomy versus medical treatment alone. A total of 221 patients were enrolled. The trial showed a substantial benefit of MT when added to medical management. All eligible patients received intravenous tPA within the 4.5-h-window. Ordinal logistic and binary regression analyses using intravenous tPA as an interaction term were performed with adjustments for potential confounders, including age, baseline NIHSS score, occlusion site, and ASPECTS. A p-value <0.05 was considered statistically significant. RESULTS Among 221 randomized patients (median NIHSS, 18 IQR [14-21]), 155 (70%) were treated with IVT. There was no difference in the mRS ordinal shift and frequency of functional independence between patients who received or not IV tPA; the odds ratio for the ordinal mRS shift was 2.63 [1.48-4.69] for the IVT group and 1.54 [0.63-3.74] for the no IVT group, with a p-value of 0.42. IVT also did not affect the frequency of good recanalization (TICI 2b or higher) and hemorrhagic transformation. CONCLUSIONS The large effect size of MT on LVO outcomes was not significantly affected by IVT. TRIAL REGISTRATION RESILIENT ClinicalTrials.gov number, NCT02216643.
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Affiliation(s)
- Gisele Sampaio Silva
- Universidade Federal de São Paulo, São Paulo, Brazil; Hospital Israelita Albert Einstein, São Paulo, SP, Brazil.
| | | | | | | | | | | | | | | | - Daniel Giansante Abud
- Faculdade de Medicina de Ribeirão Preto, Universidade de São Paulo, Ribeirão Preto, Brazil
| | | | | | | | | | | | - Jeffrey Saver
- Ronald Reagan UCLA Medical Center, Los Angeles, CA, USA
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Colasurdo M, Chen H, Schrier C, Khalid M, Khunte M, Miller TR, Cherian J, Malhotra A, Gandhi D. Predictors for large vessel recanalization before stroke thrombectomy: the HALT score. J Neurointerv Surg 2024; 16:237-242. [PMID: 37100595 DOI: 10.1136/jnis-2023-020220] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Accepted: 04/16/2023] [Indexed: 04/28/2023]
Abstract
BACKGROUND Large vessel recanalization (LVR) before endovascular therapy (EVT) for acute large vessel ischemic strokes is a poorly understood phenomenon. Better understanding of predictors for LVR is important for optimizing stroke triage and patient selection for bridging thrombolysis. METHODS In this retrospective cohort study, consecutive patients presenting to a comprehensive stroke center for EVT treatment were identified from 2018 to 2022. Demographic information, clinical characteristics, intravenous thrombolysis (IVT) use, and LVR before EVT were recorded. Factors independently associated with different rates of LVR were identified, and a prediction model for LVR was constructed. RESULTS 640 patients were identified. 57 (8.9%) patients had LVR before EVT. A minority (36.4%) of LVR patients had significant improvements in National Institutes of Health Stroke Scale. Independent predictors for LVR were identified and used to construct the 8-point HALT score: hyperlipidemia (1 point), atrial fibrillation (1 point), location of vascular occlusion (internal carotid: 0 points, M1: 1 point, M2: 2 points, vertebral/basilar: 3 points), and thrombolysis at least 1.5 hours before angiography (3 points). The HALT score had an area under the receiver-operating curve (AUC) of 0.85 (95% CI 0.81 to 0.90, P<0.001) for predicting LVR. LVR before EVT occurred in only 1 of 302 patients (0.3%) with low (0-2) HALT scores. CONCLUSIONS IVT at least 1.5 hours before angiography, site of vascular occlusion, atrial fibrillation, and hyperlipidemia are independent predictors for LVR. The 8-point HALT score proposed in this study may be a valuable tool for predicting LVR before EVT.
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Affiliation(s)
- Marco Colasurdo
- Division of Interventional Neuroradiology, Department of Diagnostic Radiology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Huanwen Chen
- Division of Interventional Neuroradiology, Department of Diagnostic Radiology, University of Maryland Medical Center, Baltimore, Maryland, USA
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Chad Schrier
- Department of Neurology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Mazhar Khalid
- Department of Neurology, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Mihir Khunte
- Warren Alpert Medical School of Brown University, Providence, Rhode Island, USA
| | - Timothy R Miller
- Division of Interventional Neuroradiology, Department of Diagnostic Radiology, University of Maryland Medical Center, Baltimore, Maryland, USA
| | - Jacob Cherian
- Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Dheeraj Gandhi
- Division of Interventional Neuroradiology, Department of Diagnostic Radiology, University of Maryland Medical Center, Baltimore, Maryland, USA
- Department of Neurology, University of Maryland Medical Center, Baltimore, Maryland, USA
- Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
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Liu J, Gu Y, Zhang DZ. Cerebral circulation time on DSA after thrombectomy associated with hemorrhagic transformation in acute ischemic stroke. Acta Neurochir (Wien) 2024; 166:64. [PMID: 38315216 DOI: 10.1007/s00701-024-05959-6] [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: 10/11/2023] [Accepted: 01/04/2024] [Indexed: 02/07/2024]
Abstract
BACKGROUND To investigate the association between cerebral circulation time (CCT) on digital subtraction angiography immediately after thrombectomy and hemorrhagic transformation (HT) in acute ischemic stroke (AIS). METHODS Retrospectively enrolled consecutive AIS patients presented with large vessel occlusion who received thrombectomy and achieved successful recanalization between January 2019 and June 2021. The time interval from the beginning of the siphon segment of internal carotid artery visualization until the end of the arterial phase during cerebral angiography was calculated as CCT. The independent association of CCT with HT was evaluated using logistic regression analyses. The receiver operating characteristic curve was analyzed to evaluate the association between CCT and HT. RESULTS Two hundred and twenty-four patients were included, of whom 86 (38.4%) suffered HT. Compared with patients without HT, patients with HT were of advanced age, less commonly male, had more diabetes mellitus, had higher baseline National Institutes of Health Stroke Scale score, lower Alberta Stroke Program Early Computed Tomographic Score, and shorter CCT (P < 0.05). Multivariable logistic regression suggested that CCT was independently associated with HT (adjusted odds ratio, 0.170; 95% confidence interval, 0.004-0.450; P < 0.001). According to the receiver operating characteristic curve, the optimal cut-off value for the strong correlation between CCT and HT was 1.72 s, which had 76.6% sensitivity, 81.6% specificity, and the area under the curve was 0.846. CONCLUSION Shorter post-thrombectomy CCT was independently associated with HT.
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Affiliation(s)
- Jianyu Liu
- Department of Interventional Radiology, Jiangsu Taizhou People's Hospital, Hailing District, Taizhou, Jiangsu, China
| | - Yuanyuan Gu
- Department of Emergency Medicine, The Affiliated Taizhou People's Hospital of Nanjing Medical University, Taizhou, China
| | - Da-Zhong Zhang
- Department of Interventional Radiology, Jiangsu Taizhou People's Hospital, Hailing District, Taizhou, Jiangsu, China.
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Zhan Y, Dai Y, Ding Z, Lu M, He Z, Chen Z, Liu Y, Li Z, Cheng G, Peng S, Liu Y. Application of stimuli-responsive nanomedicines for the treatment of ischemic stroke. Front Bioeng Biotechnol 2024; 11:1329959. [PMID: 38370870 PMCID: PMC10869484 DOI: 10.3389/fbioe.2023.1329959] [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: 10/30/2023] [Accepted: 11/27/2023] [Indexed: 02/20/2024] Open
Abstract
Ischemic stroke (IS) refers to local brain tissue necrosis which is caused by impaired blood supply to the carotid artery or vertebrobasilar artery system. As the second leading cause of death in the world, IS has a high incidence and brings a heavy economic burden to all countries and regions because of its high disability rate. In order to effectively treat IS, a large number of drugs have been designed and developed. However, most drugs with good therapeutic effects confirmed in preclinical experiments have not been successfully applied to clinical treatment due to the low accumulation efficiency of drugs in IS areas after systematic administration. As an emerging strategy for the treatment of IS, stimuli-responsive nanomedicines have made great progress by precisely delivering drugs to the local site of IS. By response to the specific signals, stimuli-responsive nanomedicines change their particle size, shape, surface charge or structural integrity, which enables the enhanced drug delivery and controlled drug release within the IS tissue. This breakthrough approach not only enhances therapeutic efficiency but also mitigates the side effects commonly associated with thrombolytic and neuroprotective drugs. This review aims to comprehensively summarize the recent progress of stimuli-responsive nanomedicines for the treatment of IS. Furthermore, prospect is provided to look forward for the better development of this field.
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Affiliation(s)
- Yongyi Zhan
- Zhuhai Interventional Medical Center, Cerebrovascular Diseases Department, Zhuhai Clinical Medical College of Jinan University (Zhuhai People’s Hospital), Zhuhai, China
| | - Yue Dai
- Zhuhai Interventional Medical Center, Cerebrovascular Diseases Department, Zhuhai Clinical Medical College of Jinan University (Zhuhai People’s Hospital), Zhuhai, China
| | - Zhejing Ding
- Zhuhai Interventional Medical Center, Cerebrovascular Diseases Department, Zhuhai Clinical Medical College of Jinan University (Zhuhai People’s Hospital), Zhuhai, China
| | - Mingtian Lu
- Zhuhai Interventional Medical Center, Cerebrovascular Diseases Department, Zhuhai Clinical Medical College of Jinan University (Zhuhai People’s Hospital), Zhuhai, China
| | - Zehua He
- Zhuhai Interventional Medical Center, Cerebrovascular Diseases Department, Zhuhai Clinical Medical College of Jinan University (Zhuhai People’s Hospital), Zhuhai, China
| | - Zhengwei Chen
- Zhuhai Interventional Medical Center, Cerebrovascular Diseases Department, Zhuhai Clinical Medical College of Jinan University (Zhuhai People’s Hospital), Zhuhai, China
| | - Yongkang Liu
- Zhuhai Interventional Medical Center, Cerebrovascular Diseases Department, Zhuhai Clinical Medical College of Jinan University (Zhuhai People’s Hospital), Zhuhai, China
| | - Zhongliang Li
- Zhuhai Interventional Medical Center, Cerebrovascular Diseases Department, Zhuhai Clinical Medical College of Jinan University (Zhuhai People’s Hospital), Zhuhai, China
| | - Guangsen Cheng
- Zhuhai Interventional Medical Center, Cerebrovascular Diseases Department, Zhuhai Clinical Medical College of Jinan University (Zhuhai People’s Hospital), Zhuhai, China
| | - Shaojun Peng
- Zhuhai Institute of Translational Medicine, Zhuhai Clinical Medical College of Jinan University (Zhuhai People’s Hospital), Zhuhai, China
| | - Yu Liu
- Zhuhai Interventional Medical Center, Cerebrovascular Diseases Department, Zhuhai Clinical Medical College of Jinan University (Zhuhai People’s Hospital), Zhuhai, China
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Chen W, Wang X, Liu J, Wang M, Yang S, Yang L, Gong Z, Hu W. Association Between Hypoperfusion Intensity Ratio and Postthrombectomy Malignant Brain Edema for Acute Ischemic Stroke. Neurocrit Care 2024; 40:196-204. [PMID: 38148437 DOI: 10.1007/s12028-023-01900-4] [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: 06/28/2023] [Accepted: 11/22/2023] [Indexed: 12/28/2023]
Abstract
BACKGROUND Malignant brain edema (MBE) is a life-threatening complication that can occur after mechanical thrombectomy (MT) for acute ischemic stroke. The hypoperfusion intensity ratio (HIR) reflects the tissue-level perfusion status within the ischemic territory. This study investigated the association between HIR and MBE occurrence after MT in patients with anterior circulation large artery occlusion. METHODS We conducted a retrospective cohort study of patients who received MT at a comprehensive stroke center from February 2020 to June 2022. Using computed tomography perfusion, the HIR was derived from the ratio of tissue volume with a time to maximum (Tmax) > 10 s to that with a Tmax > 6 s. We dichotomized patients based on the occurrence of MBE following MT. The primary outcome, assessed using a multivariable logistic regression model, was the MBE occurrence post MT. The secondary outcome focused on favorable outcomes, defined as achieving a modified Rankin Scale score of 0-2 at 90 days. RESULTS Of the 603 included patients, 90 (14.9%) developed MBE after MT. The median HIR exhibited a significantly higher value in the MBE group compared with the non-MBE group (0.5 vs. 0.3; P < 0.001). Multivariable logistic regression analysis indicated that a higher HIR (adjusted odds ratio [aOR] 8.98; 95% confidence interval [CI] 2.85-28.25; P < 0.001), baseline large infarction (Alberta Stroke Program Early Computed Tomography Score < 6; aOR 1.77; 95% CI 1.04-3.01; P = 0.035), internal carotid artery occlusion (aOR 1.80; 95% CI 1.07-3.01; P = 0.028), and unsuccessful recanalization (aOR 8.45; 95% CI 4.75-15.03; P < 0.001) were independently associated with MBE post MT. Among those with successful recanalization, a higher HIR (P = 0.017) and baseline large infarction (P = 0.032) remained as predictors of MBE occurrence. Furthermore, a higher HIR (P = 0.001) and the occurrence of MBE (P < 0.001) both correlated with reduced odds of achieving favorable outcomes. CONCLUSIONS The presence of a higher HIR on pretreatment perfusion imaging serves as a robust predictor for MBE occurrence after MT, irrespective of successful recanalization.
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Affiliation(s)
- Wang Chen
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang, Beijing, 100020, China
| | - Xianjun Wang
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong, China
| | - Ji Liu
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong, China
| | - Mengen Wang
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong, China
| | - Shuna Yang
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang, Beijing, 100020, China
| | - Lei Yang
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang, Beijing, 100020, China
| | - Zixiang Gong
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong, China
| | - Wenli Hu
- Department of Neurology, Beijing Chaoyang Hospital, Capital Medical University, No. 8 Gongti South Road, Chaoyang, Beijing, 100020, China.
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Yang W, Zhang H, Zhang L, Li Z, Xing P, Shen H, Zhang Y, Zhang X, Ye X, Huang Q, Xu Y, Zhang Y, Liu J, Li C, Yang P. Thrombectomy alone vs thrombectomy with over 2/3-dose intravenous thrombolysis pretreatment in the DIRECT-MT trial. J Neuroradiol 2024; 51:52-58. [PMID: 37120144 DOI: 10.1016/j.neurad.2023.04.004] [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: 01/25/2023] [Revised: 04/19/2023] [Accepted: 04/24/2023] [Indexed: 05/01/2023]
Abstract
BACKGROUND The DIRECT-MT trial showed that endovascular thrombectomy (EVT) alone was noninferior to EVT preceded by intravenous alteplase. However, the infusion of intravenous alteplase was uncompleted before the initiation of EVT in most cases of this trial. Therefore, the additional benefit and risk of over 2/3-dose intravenous alteplase pretreatment remain to be assessed. METHODS We assessed patients with acute anterior circulation ischemic stroke who received EVT alone or with over 2/3-dose intravenous alteplase pretreatment from the DIRECT-MT trial. Patients were assigned to the thrombectomy-alone group and the alteplase pretreatment group. The primary outcome was the distribution of modified Rankin Scale (mRS) at 90 days. The interaction of treatment allocation and collateral capacity was assessed. RESULTS A total of 393 patients (thrombectomy alone: 315; alteplase pretreatment: 78) were identified. The thrombectomy alone was comparable with alteplase pretreatment prior to the thrombectomy on the distribution of mRS at 90 days without significant effect modification by collateral capacity (adjusted common odds ratio (acOR), 1.12; 95% CI, 0.72-1.74; adjusted P for interaction = 0.83). Successful reperfusion before thrombectomy and the number of passes in the thrombectomy alone group differed significantly from the alteplase pretreatment group (2.6% vs. 11.5%; corrected P = 0.02 and 2 vs. 1; corrected P = 0.003). There was no interaction between treatment allocation and collateral capacity on all outcomes. CONCLUSIONS EVT alone and EVT preceded by over 2/3-dose intravenous alteplase might have equal efficacy and safety for patients with acute anterior circulation large vessel occlusion, except for successful perfusion before thrombectomy and the number of passes.
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Affiliation(s)
- Wenjin Yang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Hongjian Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Lei Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Zifu Li
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Pengfei Xing
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Hongjian Shen
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Yongxin Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Xiaoxi Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Xiaofei Ye
- Health Statistics Department, Naval Medical University, Shanghai, China
| | - Qinghai Huang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Yi Xu
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Yongwei Zhang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Jianmin Liu
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Conghui Li
- Department of Neurosurgery, First Hospital of Hebei Medical University, Shijiazhuang, China
| | - Pengfei Yang
- Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China.
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Havlíček R, Šaňák D, Černík D, Neradová J, Leško N, Gdovinová Z, Köcher M, Cihlář F, Malik J, Fedorko J, Pedowski P, Zapletalová J. Predictors of Good Clinical Outcome After Endovascular Treatment for Acute Ischemic Stroke due to Tandem Lesion in Anterior Circulation: Results from the ASCENT Study. Cardiovasc Intervent Radiol 2024; 47:218-224. [PMID: 38216741 PMCID: PMC10844141 DOI: 10.1007/s00270-023-03649-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2023] [Accepted: 12/11/2023] [Indexed: 01/14/2024]
Abstract
PURPOSE Endovascular treatment (EVT) of tandem lesion (TL) in anterior circulation (AC) acute ischemic stroke (AIS) represents still a clinical challenge. We aimed to evaluate selected factors related to EVT and assess other possible predictors of good clinical outcome besides the generally known ones. METHODS AIS patients with TL in AC treated with EVT were enrolled in the multicenter retrospective ASCENT study. A good three-month clinical outcome was scored as 0-2 points in modified Rankin Scale (mRS) and achieved recanalization using the TICI scale. Symptomatic intracerebral hemorrhage (SICH) was assessed using the SITS-MOST criteria. Logistic regression analysis was used for the assessment of possible predictors of mRS 0-2 with adjustment for potential confounders. RESULTS In total, 300 (68.7% males, mean age 67.3 ± 10.2 years) patients with median of admission NIHSS 17 were analyzed. Recanalization (TICI 2b-3) was achieved in 290 (96.7%) patients and 176 (58.7%) had mRS 0-2. Besides the age, admission NIHSS and SICH, admission glycemia (p = 0.005, OR: 0.884) the stent patency within the first 30 days after EVT (p = 0.0003, OR: 0.219), dual antiplatelet therapy (DAPT) started within 12 h after EVT (p < 0.0001, OR: 5.006) and statin therapy started within 24 h after stenting (p < 0.0001, OR: 5.558) were found as other predictors. CONCLUSION Admission glycemia, start of DAPT within 12 h and statin therapy within 24 h after EVT, and stent patency within the first 30 days after EVT were found as other predictors of good three-month clinical outcome in AIS patients treated with EVT for TL.
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Affiliation(s)
- Roman Havlíček
- Comprehensive Stroke Center, Department of Neurology, Palacký University Medical School and University Hospital Olomouc, Olomouc, Czech Republic
- Comprehensive Stroke Center, Department of Neurology, Central Military Hospital Prague, Prague, Czech Republic
| | - Daniel Šaňák
- Comprehensive Stroke Center, Department of Neurology, Palacký University Medical School and University Hospital Olomouc, Olomouc, Czech Republic.
| | - David Černík
- Comprehensive Stroke Center, Department of Neurology, Masaryk Hospital, KZ a.S., Ústí Nad Labem, Czech Republic
| | - Jarmila Neradová
- Comprehensive Stroke Center, Department of Neurology, Masaryk Hospital, KZ a.S., Ústí Nad Labem, Czech Republic
| | - Norbert Leško
- Department of Neurology, P.J. Šafarik University, Faculty of Medicine and University Hospital L. Pasteur Košice, Košice, Slovakia
| | - Zuzana Gdovinová
- Department of Neurology, P.J. Šafarik University, Faculty of Medicine and University Hospital L. Pasteur Košice, Košice, Slovakia
| | - Martin Köcher
- Department of Radiology, Palacký University Medical School and University Hospital Olomouc, Olomouc, Czech Republic
| | - Filip Cihlář
- Department of Radiology, J. E. Purkinje University, Masaryk Hospital, KZ a.S., Ústí Nad Labem, Czech Republic
| | - Jozef Malik
- Department of Radiology, Central Military Hospital Prague, Prague, Czech Republic
| | - Jakub Fedorko
- Department of Radiodiagnostics and Imagine Techniques, P.J. Šafarik University, Faculty of Medicine and University Hospital L. Pasteur Košice, Košice, Slovakia
| | - Piotr Pedowski
- Department of Radiodiagnostics and Imagine Techniques, P.J. Šafarik University, Faculty of Medicine and University Hospital L. Pasteur Košice, Košice, Slovakia
| | - Jana Zapletalová
- Department of Biophysics and Statistics, Palacký University Medical School Olomouc, Olomouc, Czech Republic
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49
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Zhang Y, Zhang P, Tao A, Wang X, Ying J, Wang Z, Yang P, Zhang Y, Zhang L, Li Z, Zhang M, Xu C, Liu J. The Efficacy and Safety of Tirofiban Use in Endovascular Thrombectomy for Intravenous Thrombolysis Applicable Patients with Large Vessel Occlusion Stroke-a Post Hoc Analysis from the Direct-MT Trial. Cardiovasc Intervent Radiol 2024; 47:208-215. [PMID: 37798430 PMCID: PMC10844137 DOI: 10.1007/s00270-023-03540-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 08/13/2023] [Indexed: 10/07/2023]
Abstract
PURPOSE The purpose of the study was to evaluate the efficacy and safety of tirofiban use in endovascular thrombectomy for intravenous thrombolysis applicable patients of large vessel occlusion stroke with data from Direct-MT trial. MATERIALS AND METHODS Direct-MT was the first randomized controlled trial to prove the non-inferiority of thrombectomy alone to bridging therapy (intravenous thrombolysis before thrombectomy) for large vessel occlusion stroke. Patients who underwent endovascular procedure were included and divided into thrombectomy-alone group and bridging therapy group. The effect of tirofiban use on 90 days MRS distribution, MRS 0-2 and mortality, successful reperfusion, the ASPECTS and outcome lesion volume of index stroke, re-occlusion of the treated vessel, futile recanalization and safety outcomes were further evaluated in both groups after adjustment for relevant confounding factors. The interaction between tirofiban and rt-PA was also assessed. RESULTS Of 639 patients included in this analysis, 180 patients underwent thrombectomy with tirofiban use (28.2%). Patients with tirofiban use had lower percentage of bridging therapy (41.1% vs 54.3%, P = 0.003), higher proportion of large artery atherosclerosis (P < 0.001) and more emergent stenting (30.56% vs 6.97%, P < 0.001). After adjustment for confounding factors, the 90-day modified Rankin Scale distribution, successful final recanalization rate, outcome lesion volume of index stroke on CT and intracranial hemorrhage risk showed no difference after tirofiban use in thrombectomy-alone group and in bridging therapy group. No interaction effect between tirofiban and rt-PA was detected. CONCLUSION Based on data from Direct-MT trial, tirofiban is a safe medication for intravenous thrombolysis applicable patients with large vessel occlusion stroke undergoing thrombectomy. LEVEL OF EVIDENCE Level 3, cohort study of randomized trial.
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Affiliation(s)
- Yingying Zhang
- Department of Neurology, Fudan University Zhongshan Hospital, Shanghai, China
| | - Ping Zhang
- Department of Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
- Department of Neurology, Naval Medical University Naval Medical Center of PLA, Shanghai, China
| | - Anyang Tao
- Department of Neurology, Taizhou First People's Hospital, 218 Hengjie Road, Taizhou, 318020, Zhejiang, China
| | - Xinliang Wang
- Department of Neurology, Taizhou First People's Hospital, 218 Hengjie Road, Taizhou, 318020, Zhejiang, China
| | - Jiangxian Ying
- Department of Neurology, Taizhou First People's Hospital, 218 Hengjie Road, Taizhou, 318020, Zhejiang, China
| | - Zhimin Wang
- Department of Neurology, Taizhou First People's Hospital, 218 Hengjie Road, Taizhou, 318020, Zhejiang, China
| | - Pengfei Yang
- Department of Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Yongwei Zhang
- Department of Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Lei Zhang
- Department of Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Zifu Li
- Department of Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
| | - Meng Zhang
- Department of Neurosurgery, Liaocheng People's Hospital of Shandong First Medical University, 67 West Dongchang Road, Liaocheng, 252200, Shandong, China.
| | - Chenghua Xu
- Department of Neurology, Taizhou First People's Hospital, 218 Hengjie Road, Taizhou, 318020, Zhejiang, China.
| | - Jianmin Liu
- Department of Neurovascular Center, Naval Medical University Changhai Hospital, Shanghai, China
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50
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Pikija S, Killer-Oberpfalzer M, Pfaff JAR, Griessenauer CJ, Sonnberger M, Vosko M, Mutzenbach JS, Schwarzenhofer D, Constantin H. Thrombus migration in emergent M1 middle cerebral artery occlusion. Clin Neurol Neurosurg 2024; 237:108132. [PMID: 38310761 DOI: 10.1016/j.clineuro.2024.108132] [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: 08/27/2023] [Revised: 12/17/2023] [Accepted: 01/22/2024] [Indexed: 02/06/2024]
Abstract
BACKGROUND AND PURPOSE Thrombus migration (TM) is a well-established phenomenon in patients with intracranial vessel occlusion, particularly in those who receive alteplase. However, the relationship between TM, reperfusion success, and clinic-radiological outcomes is still being determined. This study aimed to describe the various outcomes in the event of TM in patients with M1 middle cerebral artery (M1 MCA) occlusion. MATERIALS AND METHODS The study involved a retrospective analysis of patients undergoing endovascular thrombectomy (EVT) due to M1 MCA occlusion from two tertiary centers between January 2015 and December 2020. The proximal positions of thrombi were measured using a curve tool on CT or MR angiography before EVT. Subsequently, measurements were taken on angiographic imaging. Patients were grouped based on the amount of difference between the two measurements: growth (≤ - 10 mm), stability (> -10 mm and ≤ 10 mm), migration (> 10 mm), and resolution. RESULTS A total of 463 patients (266 [57%] females, median 76 [interquartile range IQR: 65-83] years) were analyzed. Of them, 106 (22.8%) expressed any degree of TM. In multivariate ordinal regression analysis, the alteplase was significantly associated with TM (t = 2.192, p = 0.028), as was the greater interval from first imaging to angiography (t = 2.574, p = 0.010). In multivariate logistical regression analysis, the good clinical outcome measured by the modified Rankin scale (0-2) was not associated with TM status. CONCLUSIONS Thrombus migration within the M1 MCA segment occurs in almost a quarter of patients, is associated with alteplase administration, and is mainly irrelevant to radiological and clinical outcome.
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Affiliation(s)
- Slaven Pikija
- Department of Neurology, University Hospital Salzburg, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria.
| | - Monika Killer-Oberpfalzer
- Department of Neurology, University Hospital Salzburg, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria; Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Johannes A R Pfaff
- Department of Neuroradiology, University Hospital Salzburg, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Christoph J Griessenauer
- Department of Neurosurgery, University Hospital Salzburg, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Michael Sonnberger
- Department of Neuroradiology, Neuromed Campus, Johannes Kepler University, Linz, Austria
| | - Milan Vosko
- Department of Neurology, Neuromed Campus, Johannes Kepler University, Linz, Austria
| | - Johannes S Mutzenbach
- Department of Neurology, University Hospital Salzburg, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | | | - Hecker Constantin
- Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria; Department of Neurosurgery, University Hospital Salzburg, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
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