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Huang X, Sun D, Nguyen TN, Pan Y, Wang M, Abdalkader M, Zaidat OO, Ma N, Gao F, Mo D, Miao Z, Huo X, Zhou Z. Impact of first pass effect in endovascular treatment of large core stroke: a post-hoc analysis of the ANGEL-ASPECT trial. J Neurointerv Surg 2024:jnis-2024-021728. [PMID: 38914460 DOI: 10.1136/jnis-2024-021728] [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: 03/15/2024] [Accepted: 05/15/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND The first-pass effect (FPE) is linked to better safety and efficacy prognosis in patients with small- to- moderate sized ischemic infarctions. We evaluated the incidence, prognosis, and predictors of FPE in patients with large core infarctions (LCIs). METHODS We conducted a post-hoc analysis of data from the Trial of Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients with a Large Infarct Core (ANGEL-ASPECT). The FPE was defined as a successful recanalization (expanded Thrombolysis in Cerebral Infarction (eTICI) 2 c/3, and eTICI 2b-3 as modified FPE (mFPE)) after one pass. The primary outcome was clinical functional independence, and the secondary outcomes were independent ambulation, assessed by the modified Rankin Scale (mRS) at 90 days. Safety outcomes included symptomatic intracranial hemorrhage (sICH) defined by the Heidelberg bleeding classification, any intracranial hemorrhage (ICH), and death within 90 days of stroke onset. RESULTS Of the 226 patients in the study, FPE and mFPE were achieved in 33 (14.6%) and 82 (36.3%) patients, respectively. Patients with FPE exhibited shorter onset-to-puncture times (adjusted odds ratio [OR] 0.915; 95% confidence interval [CI]: 0.84 to 0.996), and patients with mFPE were older (OR 1.039; 95% CI: 1.005 to 1.075). mFPE was significantly associated with favorable outcomes (modified Rankin score [mRS] 0-2: OR 2.64; 95% CI: 1.37 to 5.07; mRS 0-3: OR 3.31; 95% CI: 1.73 to 6.33). FPE tended to improve outcomes (mRS 0-3: OR 2.24; 95% CI: 0.92 to 4.97; p=0.08). ICH rates (OR 0.60; 95% CI: 0.34 to 1.05; p=0.07) and 90-day deaths (OR 0.57; 95% CI: 0.30 to 1.09; p=0.09) tended to decrease in patients who achieved mFPE but not in patients who achieved FPE. CONCLUSIONS In the ANGEL-ASPECT trial, patients who achieved mFPE had a higher rate of independent ambulation and functional independence, and the rates of any ICH and 90-day death tended to decrease.
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Affiliation(s)
- Xianjun Huang
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Dapeng Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Thanh N Nguyen
- Department of Neurology, Radiology, Boston Medical Center, Boston, Massachusetts, USA
| | - Yuesong Pan
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mengxing Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mohamad Abdalkader
- Department of Neurology, Radiology, Boston Medical Center, Boston, Massachusetts, USA
| | - Osama O Zaidat
- Department of Neuroscience, Mercy Saint Vincent Medical Center, Toledo, Ohio, USA
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaochuan Huo
- Cerebrovascular Disease Department, Neurological Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhiming Zhou
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
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2
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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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3
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Mujanovic A, Strbian D, Demeestere J, Marto JP, Puetz V, Nogueira RG, Abdalkader M, Nagel S, Raymond J, Ribo M, Michel P, Yoshimura S, Zaidat OO, Winzer S, Ortega-Gutierrez S, Sheth SA, Siegler JE, Dusart A, Haussen DC, Henon H, Serrallach BL, Mohammaden MH, Möhlenbruch MA, Olive-Gadea M, Puri AS, Sakai N, Klein P, Tomppo L, Caparros F, Ramos JN, Jumaa M, Zaidi S, Dobrocky T, Martinez-Majander N, Nannoni S, Bellante F, Rodriguez-Calienes A, Salazar-Marioni S, Virtanen P, Kaiser DP, Ventura R, Jesser J, Castonguay AC, Qureshi MM, Masoud HE, Galecio-Castillo M, Requena M, Lauha R, Hu W, Lin E, Miao Z, Roy D, Yamagami H, Seiffge DJ, Strambo D, Ringleb PA, Lemmens R, Fischer U, Nguyen TN, Kaesmacher J. Safety and clinical outcomes of endovascular therapy versus medical management in late presentation of large ischemic stroke. Eur Stroke J 2024:23969873241249406. [PMID: 38757713 DOI: 10.1177/23969873241249406] [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: 05/18/2024] Open
Abstract
INTRODUCTION The benefit of endovascular therapy (EVT) among stroke patients with large ischemic core (ASPECTS 0-5) in the extended time window outside of trial settings remains unclear. We analyzed the effect of EVT among these stroke patients in real-world settings. PATIENTS AND METHODS The CT for Late Endovascular Reperfusion (CLEAR) study recruited patients from 66 centers in 10 countries between 01/2014 and 05/2022. The extended time-window was defined as 6-24 h from last-seen-well to treatment. The primary outcome was shift of the 3-month modified Rankin scale (mRS) score. Safety outcomes included symptomatic intracranial hemorrhage (sICH) and mortality. Outcomes were analyzed with ordinal and logistic regressions. RESULTS Among 5098 screened patients, 2451 were included in the analysis (median age 73, 55% women). Of patients with ASPECTS 0-5 (n = 310), receiving EVT (n = 209/310) was associated with lower 3-month mRS when compared to medical management (median 4 IQR 3-6 vs 6 IQR 4-6; aOR 0.4, 95% CI 0.2-0.7). Patients undergoing EVT had higher sICH (11.2% vs 4.0%; aOR 4.1, 95% CI 1.2-18.8) and lower mortality (31.6% vs 58.4%, aOR 0.4; 95% CI 0.2-0.9) compared to medically managed patients. The relative benefit of EVT was comparable between patients with ASPECTS 0 and 5 and 6-10 in the extended time window (interaction aOR 0.9; 95% CI 0.5-1.7). CONCLUSION In the extended time window, patients with ASPECTS 0-5 may have preserved relative treatment benefit of EVT compared to patients with ASPECTS 6-10. These findings are in line with recent trials showing benefit of EVT among real-world patients with large ischemic core in the extended time window. TRIAL REGISTRATION NUMBER clinicaltrials.gov; Unique identifier: NCT04096248.
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Affiliation(s)
- Adnan Mujanovic
- Diagnostic and Interventional Neuroradiology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Daniel Strbian
- Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Jelle Demeestere
- Neurology, UZ Leuven, Leuven, Belgium
- Laboratory for Neurobiology, KU Leuven, Leuven, Belgium
| | - João Pedro Marto
- Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Volker Puetz
- Neurology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Dresden Neurovascular Center, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Raul G Nogueira
- Neurology, University of Pittsburgh Medical Center, Pittsburgh, USA
- Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, USA
| | - Mohamad Abdalkader
- Neurology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, USA
- Radiology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, USA
| | - Simon Nagel
- Neurology, Klinikum Ludwigshafen, Ludwigshafen, Germany
- Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Jean Raymond
- Interventional Neuroradiology, Centre Hospitalier de l'Universite de Montreal, Radiology, Montreal, Canada
| | - Marc Ribo
- Neurology, Hospital Vall d'Hebron, Barcelona, Spain
| | - Patrik Michel
- Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | | | - Osama O Zaidat
- Neuroscience and Stroke Program, Bon Secours Mercy Health St. Vincent Hospital, Toledo, USA
| | - Simon Winzer
- Neurology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Dresden Neurovascular Center, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | | | - Sunil A Sheth
- Neurology, UTHealth McGovern Medical School, Neurology, Houston, USA
| | | | - Anne Dusart
- Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium
| | | | - Hilde Henon
- Neurology, Centre Hospitalier Universitaire de Lille, Lille, France
| | - Bettina L Serrallach
- Diagnostic and Interventional Neuroradiology, University Hospital Bern, University of Bern, Bern, Switzerland
| | | | | | | | - Ajit S Puri
- Division of Interventional Neuroradiology, University of Massachusetts Memorial Medical Center, Worcester, USA
| | | | - Piers Klein
- Neurology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, USA
- Radiology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, USA
| | - Liisa Tomppo
- Neurology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | | | - João Nuno Ramos
- Neuroradiology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Occidental, Lisbon, Portugal
| | | | - Syed Zaidi
- Neurology, University of Toledo, Toledo, USA
| | - Tomas Dobrocky
- Diagnostic and Interventional Neuroradiology, University Hospital Bern, University of Bern, Bern, Switzerland
| | | | | | | | | | | | - Pekka Virtanen
- Radiology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Daniel Po Kaiser
- Dresden Neurovascular Center, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Institute of Neuroradiology, Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Rita Ventura
- Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Jessica Jesser
- Radiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Muhammad M Qureshi
- Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, USA
- Radiation Oncology, Boston Medical Center, USA
| | | | | | | | - Riikka Lauha
- Radiology, Helsinki University Hospital, University of Helsinki, Helsinki, Finland
| | - Wei Hu
- Neurology, The First Affiliated Hospital of USTC, China
| | - Eugene Lin
- Neuroscience and Stroke Program, Bon Secours Mercy Health St. Vincent Hospital, Toledo, USA
| | - Zhongrong Miao
- Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Daniel Roy
- Interventional Neuroradiology, Centre Hospitalier de l'Universite de Montreal, Radiology, Montreal, Canada
| | - Hiroshi Yamagami
- Division of Stroke Prevention and Treatment, University of Tsukuba, Tsukuba, Japan
| | - David J Seiffge
- Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Davide Strambo
- Neurology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland
| | - Peter A Ringleb
- Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Robin Lemmens
- Neurology, UZ Leuven, Leuven, Belgium
- Laboratory for Neurobiology, KU Leuven, Leuven, Belgium
| | - Urs Fischer
- Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
- Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Thanh N Nguyen
- Radiology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, USA
- Neurology, Boston Medical Center, Boston, USA
| | - Johannes Kaesmacher
- Diagnostic and Interventional Neuroradiology, University Hospital Bern, University of Bern, Bern, Switzerland
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4
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Broocks G, McDonough RV, Bechstein M, Klapproth S, Faizy TD, Schön G, Kniep HC, Bester M, Hanning U, Kemmling A, Zeleñák K, Fiehler J, Meyer L. Thrombectomy in Patients With Ischemic Stroke Without Salvageable Tissue on CT Perfusion. Stroke 2024; 55:1317-1325. [PMID: 38572635 DOI: 10.1161/strokeaha.123.044916] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2023] [Accepted: 02/22/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Computed tomography perfusion (CTP) imaging is regularly used to guide patient selection for mechanical thrombectomy (MT). However, the effect of MT in patients without salvageable tissue on CTP has not been investigated. The purpose of this study was to assess the effect of MT in patients with stroke without perfusion mismatch profiles. METHODS This observational study analyzed patients with ischemic stroke consecutively treated between March 1, 2015, and January 31, 2022, triaged by multimodal-computed tomography undergoing MT. CTP lesion-core mismatch profiles were defined using a mismatch volume/ratio of ≥10 mL/1.2, respectively. The primary end point was the rate of functional independence at 90 days, defined as the modified Rankin Scale score of 0 to 2. Recanalization was evaluated with the modified Thrombolysis in Cerebral Infarction scale. The effect of baseline variables on functional outcome was assessed using multivariable logistic regression analysis. Outcomes of patients with and without CTP-mismatch profiles were compared using 1:1 propensity score matching. RESULTS Of 724 patients who met the inclusion criteria of this retrospective observational study, 110 (15%) patients had no CTP mismatch and were analyzed. The median age was 74 (interquartile range, 62-80) years and 53% were women. Successful recanalization (modified Thrombolysis in Cerebral Infarction score, ≥2b) was achieved in 66% (73) and associated with functional independence at 90 days (adjusted odds ratio, 7.33 [95% CI, 1.22-43.70]; P=0.03). A significant interaction was observed between recanalization and age, as well as the extent of infarction, indicating MT to be most effective in patients <70 years and with a baseline Alberta Stroke Program Early Computed Tomography Score range between 3 and 7. These findings remained stable after propensity score matching, analyzing 152 matched pairs with similar rates of functional independence between patients with and without CTP-mismatch profiles (17% versus 23%; P=0.42). CONCLUSIONS In patients without CTP-mismatch profiles defined according to the EXTEND (Extending the Time for Thrombolysis in Emergency Neurological Deficits) criteria, recanalization was associated with improved functional outcomes. This effect was associated with baseline Alberta Stroke Program Early Computed Tomography Score and age, but not with the time from onset to imaging.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
- Department of Neuroradiology, HELIOS Medical Center, Campus of MSH Medical School Hamburg, Schwerin, Germany (G.B.)
| | | | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Susan Klapproth
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology (G.S.) University Medical Center Hamburg-Eppendorf, Germany
| | - Helge C Kniep
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Maxim Bester
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - André Kemmling
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Marburg, Marburg, Germany (A.K.)
| | - Kamil Zeleñák
- Department of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Martin, Slovakia (K.Z.)
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
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5
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Winkelmeier L, Maros M, Flottmann F, Heitkamp C, Schön G, Thomalla G, Fiehler J, Hanning U. Endovascular Thrombectomy for Large Ischemic Strokes with ASPECTS 0-2: a Meta-analysis of Randomized Controlled Trials. Clin Neuroradiol 2024:10.1007/s00062-024-01414-2. [PMID: 38687364 DOI: 10.1007/s00062-024-01414-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2024] [Accepted: 04/14/2024] [Indexed: 05/02/2024]
Abstract
PURPOSE Randomized controlled trials (RCTs) demonstrated a treatment effect of endovascular thrombectomy in acute ischemic stroke with large infarct, commonly defined as an Alberta Stroke Program Early CT Score (ASPECTS) of 3-5. However, data on endovascular thrombectomy in patients with very low ASPECTS of 0-2 remain scarce. METHODS We conducted a systematic review and meta-analysis of RCTs comparing endovascular thrombectomy versus medical treatment alone in acute ischemic anterior circulation stroke with very large infarct, defined as ASPECTS of 0-2. The primary outcome was the shift toward better functional outcomes on the 90-day modified Rankin Scale (mRS). Random effects meta-analysis was performed using the generic inverse variance method. RESULTS Literature research identified four RCTs which evaluated the treatment effect of endovascular thrombectomy for large infarcts and provided a subgroup analysis of the mRS shift in patients with ASPECTS of 0-2. The pooled analysis showed a significant shift toward better 90-day mRS scores in favor of endovascular thrombectomy (pooled odds ratio, 1.62, 95% confidence interval, 1.29-2.04, P < 0.001). CONCLUSION This meta-analysis suggests a treatment effect of endovascular thrombectomy in specific patients with very low ASPECTS of 0-2, challenging the use of ASPECTS for treatment selection in acute ischemic stroke due to large vessel occlusion. An individual patient meta-analysis of RCTs would strengthen evidence in the treatment of patients with ASPECTS of 0-2.
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Affiliation(s)
- Laurens Winkelmeier
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Máté Maros
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Biomedical Informatics, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Fabian Flottmann
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Heitkamp
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Institute for Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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6
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Aslan A, Abuzahra S, Adeeb N, Musmar B, Salim HA, Kandregula S, Dmytriw AA, Griessenauer CJ, De Alba L, Arevalo O, Burkhardt JK, Pereira VM, Jabbour P, Guthikonda B, Cuellar HH. The feasibility of mechanical thrombectomy versus medical management for acute stroke with a large ischemic territory. J Neurointerv Surg 2024:jnis-2023-021368. [PMID: 38471764 DOI: 10.1136/jnis-2023-021368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2023] [Accepted: 02/14/2024] [Indexed: 03/14/2024]
Abstract
BACKGROUND Mechanical thrombectomy (MT) for acute ischemic stroke is generally avoided when the expected infarction is large (defined as an Alberta Stroke Program Early CT Score of <6). OBJECTIVE To perform a meta-analysis of recent trials comparing MT with best medical management (BMM) for treatment of acute ischemic stroke with large infarction territory, and then to determine the cost-effectiveness associated with those treatments. METHODS A meta-analysis of the RESCUE-Japan, SELECT2, and ANGEL-ASPECT trials was conducted using R Studio. Statistical analysis employed the weighted average normal method for calculating mean differences from medians in continuous variables and the risk ratio for categorical variables. TreeAge software was used to construct a cost-effectiveness analysis model comparing MT with BMM in the treatment of ischemic stroke with large infarction territory. RESULTS The meta-analysis showed significantly better functional outcomes, with higher rates of patients achieving a modified Rankin Scale score of 0-3 at 90 days with MT as compared with BMM. In the base-case analysis using a lifetime horizon, MT led to a greater gain in quality-adjusted life-years (QALYs) of 3.46 at a lower cost of US$339 202 in comparison with BMM, which led to the gain of 2.41 QALYs at a cost of US$361 896. The incremental cost-effectiveness ratio was US$-21 660, indicating that MT was the dominant treatment at a willingness-to-pay of US$70 000. CONCLUSIONS This study shows that, besides having a better functional outcome at 90-days' follow-up, MT was more cost-effective than BMM, when accounting for healthcare cost associated with treatment outcome.
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Affiliation(s)
- Assala Aslan
- Department of Radiology, Louisiana State University Shreveport, Shreveport, Louisiana, USA
| | - Saad Abuzahra
- Department of Radiology, Louisiana State University Shreveport, Shreveport, Louisiana, USA
| | - Nimer Adeeb
- Department of Neurosurgery, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
| | - Basel Musmar
- Department of Neurosurgery, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
| | - Hamza A Salim
- Department of Neurosurgery, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
| | - Sandeep Kandregula
- Department of Neurosurgery, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital & Brigham and Women's Hospital, Boston, Massachusetts, USA
- Divisions of Therapeutic Neuroradiology & Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Christoph J Griessenauer
- Department of Neurosurgery, Christian Doppler University Hospital & Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Luis De Alba
- Department of Radiology, Louisiana State University Shreveport, Shreveport, Louisiana, USA
| | - Octavio Arevalo
- Department of Radiology, Louisiana State University Shreveport, Shreveport, Louisiana, USA
| | - Jan Karl Burkhardt
- Department of Neurosurgery, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Vitor M Pereira
- Divisions of Therapeutic Neuroradiology & Neurosurgery, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Bharat Guthikonda
- Department of Neurosurgery, Louisiana State University Health Sciences Center Shreveport, Shreveport, Louisiana, USA
| | - Hugo H Cuellar
- Department of Radiology, Louisiana State University Shreveport, Shreveport, Louisiana, USA
- Department of Neurosurgery, Hospital of University of Pennsylvania, Philadelphia, Pennsylvania, USA
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7
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Yang LN, Sun Y, Wang YZ, Wang J, Qi YS, Mu SS, Liu YP, Zhang ZQ, Chen ZM, Wang XJ, Xie WX, Wei CW, Wang Y, Wu AS. Effect of Postoperative Prolonged sedation with Dexmedetomidine after successful reperfusion with Endovascular Thrombectomy on long-term prognosis in patients with acute ischemic stroke (PPDET): study protocol for a randomized controlled trial. Trials 2024; 25:166. [PMID: 38439027 PMCID: PMC10913237 DOI: 10.1186/s13063-024-08015-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] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Accepted: 02/23/2024] [Indexed: 03/06/2024] Open
Abstract
BACKGROUND Endovascular thrombectomy (EVT) is a standard treatment for acute ischemic stroke (AIS) with large vessel occlusion. Hypertension and increased blood pressure variability within the first 24 h after successful reperfusion are related to a higher risk of symptomatic intracerebral hemorrhage and higher mortality. AIS patients might suffer from ischemia-reperfusion injury following reperfusion, especially within 24 h. Dexmedetomidine (DEX), a sedative commonly used in EVT, can stabilize hemodynamics by inhibiting the sympathetic nervous system and alleviate ischemia-reperfusion injury through anti-inflammatory and antioxidative properties. Postoperative prolonged sedation for 24 h with DEX might be a potential pharmacological approach to improve long-term prognosis after EVT. METHODS This single-center, open-label, prospective, randomized controlled trial will include 368 patients. The ethics committee has approved the protocol. After successful reperfusion (modified thrombolysis in cerebral infarction scores 2b-3, indicating reperfusion of at least 50% of the affected vascular territory), participants are randomly assigned to the intervention or control group. In the intervention group, participants will receive 0.1~1.0 μg/kg/h DEX for 24 h. In the control group, participants will receive an equal dose of saline for 24 h. The primary outcome is the functional outcome at 90 days, measured with the categorical scale of the modified Rankin Scale, ranging from 0 (no symptoms) to 6 (death). The secondary outcome includes (1) the changes in stroke severity between admission and 24 h and 7 days after EVT, measured by the National Institute of Health Stroke Scale (ranging from 0 to 42, with higher scores indicating greater severity); (2) the changes in ischemic penumbra volume/infarct volume between admission and 7 days after EVT, measured by neuroimaging scan; (3) the length of ICU/hospital stay; and (4) adverse events and the all-cause mortality rate at 90 days. DISCUSSION This randomized clinical trial is expected to verify the hypothesis that postoperative prolonged sedation with DEX after successful reperfusion may promote the long-term prognosis of patients with AIS and may reduce the related socio-economic burden. TRIAL REGISTRATION ClinicalTrials.gov NCT04916197. Prospectively registered on 7 June 2021.
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Affiliation(s)
- Li-Na Yang
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Yi Sun
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Yu-Zhu Wang
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Jing Wang
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Yi-Sha Qi
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Shan-Shan Mu
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Yun-Peng Liu
- Department of Neurosurgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Zi-Qing Zhang
- Department of Neurosurgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Zi-Mo Chen
- Department of Neurology, Beijing Tian-tan Hospital, Capital Medical University, Beijing, 100050, People's Republic of China
| | - Xiao-Jie Wang
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China
| | - Wu-Xiang Xie
- Peking University Clinical Research Institute, Peking University Health Science Center, Beijing, 101125, People's Republic of China
| | - Chang-Wei Wei
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China.
| | - Yang Wang
- Department of Neurosurgery, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China.
| | - An-Shi Wu
- Department of Anesthesiology, Beijing Chao-Yang Hospital, Capital Medical University, Beijing, 100020, People's Republic of China.
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8
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Steffen P, Winkelmeier L, Kniep H, Geest V, Soltanipanah S, Fiehler J, Broocks G. Quantification of ischemic brain edema after mechanical thrombectomy using dual-energy computed tomography in patients with ischemic stroke. Sci Rep 2024; 14:4148. [PMID: 38378795 PMCID: PMC10879140 DOI: 10.1038/s41598-024-54600-0] [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: 09/27/2023] [Accepted: 02/14/2024] [Indexed: 02/22/2024] Open
Abstract
Net water uptake (NWU) is a quantitative imaging biomarker used to assess cerebral edema resulting from ischemia via Computed Tomography (CT)-densitometry. It serves as a strong predictor of clinical outcome. Nevertheless, NWU measurements on follow-up CT scans after mechanical thrombectomy (MT) can be affected by contrast staining. To improve the accuracy of edema estimation, virtual non-contrast images (VNC-I) from dual-energy CT scans (DECT) were compared to conventional polychromatic CT images (CP-I) in this study. We examined NWU measurements derived from VNC-I and CP-I to assess their agreement and predictive value in clinical outcome. 88 consecutive patients who received DECT as follow-up after MT were included. NWU was quantified on CP-I (cNWU) and VNC-I (vNWU). The clinical endpoint was functional independence at discharge. cNWU and vNWU were highly correlated (r = 0.71, p < 0.0001). The median difference between cNWU and vNWU was 8.7% (IQR: 4.5-14.1%), associated with successful vessel recanalization (mTICI2b-3) (ß: 11.6%, 95% CI 2.9-23.0%, p = 0.04), and age (ß: 4.2%, 95% CI 1.3-7.0%, p = 0.005). The diagnostic accuracy to classify outcome between cNWU and vNWU was similar (AUC:0.78 versus 0.77). Although there was an 8.7% median difference, indicating potential edema underestimation on CP-I, it did not have short-term clinical implications.
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Affiliation(s)
- Paul Steffen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany.
| | - Laurens Winkelmeier
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
| | - Vincent Geest
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
| | - Setareh Soltanipanah
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20251, Hamburg, Germany
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9
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Pham J, Ng FC. Novel advanced imaging techniques for cerebral oedema. Front Neurol 2024; 15:1321424. [PMID: 38356883 PMCID: PMC10865379 DOI: 10.3389/fneur.2024.1321424] [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: 10/14/2023] [Accepted: 01/09/2024] [Indexed: 02/16/2024] Open
Abstract
Cerebral oedema following acute ischemic infarction has been correlated with poor functional outcomes and is the driving mechanism of malignant infarction. Measurements of midline shift and qualitative assessment for herniation are currently the main CT indicators for cerebral oedema but have limited sensitivity for small cortical infarcts and are typically a delayed sign. In contrast, diffusion-weighted (DWI) or T2-weighted magnetic resonance imaging (MRI) are highly sensitive but are significantly less accessible. Due to the need for early quantification of cerebral oedema, several novel imaging biomarkers have been proposed. Based on neuroanatomical shift secondary to space-occupying oedema, measures such as relative hemispheric volume and cerebrospinal fluid displacement are correlated with poor outcomes. In contrast, other imaging biometrics, such as net water uptake, T2 relaxometry and blood brain barrier permeability, reflect intrinsic tissue changes from the influx of fluid into the ischemic region. This review aims to discuss quantification of cerebral oedema using current and developing advanced imaging techniques, and their role in predicting clinical outcomes.
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Affiliation(s)
- Jenny Pham
- Department of Radiology, Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Felix C. Ng
- Department of Neurology, Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Neurology, Austin Health, Heidelberg, VIC, Australia
- Department of Medicine at Royal Melbourne Hospital, Melbourne Brain Centre, University of Melbourne, Parkville, VIC, Australia
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10
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Broocks G, Meyer L, Bechstein M, Elsayed S, Schön G, Kniep H, Kemmling A, Hanning U, Fiehler J, McDonough RV. Penumbra salvage in extensive stroke: exploring limits for reperfusion therapy. J Neurointerv Surg 2023; 15:e419-e425. [PMID: 36878689 DOI: 10.1136/jnis-2022-020025] [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: 12/22/2022] [Accepted: 02/17/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND The effect of thrombectomy in patients presenting with extensive ischemic stroke at baseline is currently being investigated; it remains uncertain to what extent brain tissue may be saved by reperfusion in such patients. Penumbra salvage volume (PSV) has been described as a tool to measure the volume of rescued penumbra. OBJECTIVE To assess whether the effect of recanalization on PSV is dependent on the extent of early ischemic changes. METHODS Observational study of patients with anterior circulation ischemic stroke triaged by multimodal-CT undergoing thrombectomy. PSV was defined as the difference between baseline penumbra volume and net infarct growth to follow-up. The effect of vessel recanalization on PSV depending on the extent of early ischemic changes (defined using Alberta Stroke Program Early CT Score (ASPECTS) and core volumes based on relative cerebral blood flow) was determined using multivariable linear regression analysis, and the association with functional outcome at day 90 was tested using multivariable logistic regression. RESULTS 384 patients were included, of whom 292 (76%) achieved successful recanalization (modified Thrombolysis in Cerebral Infarction ≥2b). Successful recanalization was independently associated with 59 mL PSV (95% CI 29.8 to 88.8 mL) and was linked to increased penumbra salvage up to an ASPECTS of 3 and core volume up to 110 mL. Recanalization was associated with a higher probability of a modified Rankin Scale score of ≤2 up to a core volume of 100 mL. CONCLUSIONS Recanalization was associated with significant penumbra salvage up to a lower ASPECTS margin of 3 and upper core volume margin of 110 mL. The clinical benefit of recanalization for patients with very large ischemic regions of >100 mL or ASPECTS <3 remains uncertain and requires prospective investigation.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sarah Elsayed
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rosalie V McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
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11
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Panigrahi B, Thakur Hameer S, Bhatia R, Haldar P, Sharma A, Srivastava MVP. Effect of endovascular therapy in large anterior circulation ischaemic strokes: A systematic review and meta-analysis of randomised controlled trials. Eur Stroke J 2023; 8:932-941. [PMID: 37641885 PMCID: PMC10683735 DOI: 10.1177/23969873231196381] [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: 06/10/2023] [Accepted: 07/25/2023] [Indexed: 08/31/2023] Open
Abstract
INTRODUCTION The benefit of endovascular treatment in large anterior circulation ischaemic strokes with low ASPECTS score (<6) is uncertain. Recent randomised studies have demonstrated the benefit of endovascular treatment (EVT) in large ischaemic strokes. The present meta-analysis aims to assess the combined effect of these studies on efficacy and safety of endovascular treatment in this group of patients. MATERIALS AND METHODS We conducted a systematic review and meta-analysis according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement. Databases MEDLINE, PubMed, EMBASE, SCOPUS, Google Scholar, Tripdatabase were searched for randomised controlled trials with at least 50 participants from inception until February 16, 2023. The primary efficacy outcome analysed was the relative risk of functional independence defined as mRS - 0-2 at 90 days. Secondary efficacy outcomes included early neurological improvement, death due to any cause at 90 days and proportion of patients requiring decompressive hemicraniectomy. The primary safety outcome was the risk of developing symptomatic intracerebral haemorrhage (sICH). RESULTS A total of three studies (RESCUE Japan-LIMIT, SELECT 2 and ANGEL ASPECTS) involving 1011 patients; 510 in the EVT arm and 501 in the medical management (MM) arm met the defined criteria (ASPECTS-3-5). The combined RR for the primary outcome of mRS 0-2 was 2.53 [1.84-3.47] (p = <0.0001) favouring EVT over MM. The primary safety outcome of sICH was not significant in the EVT arm with a combined RR of 1.84 [0.94-3.60] (p = 0.5157). Mortality rates were similar in both arms (26.67% in EVT arm vs 27.94% in MM arm) with a combined RR of 0.95 [0.78; 1.16] (p = 1.000). CONCLUSION In patients with Large vessel occlusion (LVO) and low ASPECTS (3-5), EVT was associated with higher likelihood of achieving functional independence and early neurologic improvement but did not provide any mortality benefit.
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Affiliation(s)
- Baikuntha Panigrahi
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | | | - Rohit Bhatia
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
| | - Partha Haldar
- Centre for Community Medicine, All India Institute of Medical Sciences, New Delhi, India
| | - Agrata Sharma
- Department of Neurology, All India Institute of Medical Sciences, New Delhi, India
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12
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Abdollahifard S, Taherifard E, Sadeghi A, Kiadeh PRH, Yousefi O, Mowla A. Endovascular therapy for acute stroke with a large infarct core: A systematic review and meta-analysis. J Stroke Cerebrovasc Dis 2023; 32:107427. [PMID: 37925765 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107427] [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: 08/09/2023] [Revised: 10/09/2023] [Accepted: 10/12/2023] [Indexed: 11/07/2023] Open
Abstract
OBJECTIVE In this meta-analysis, we aimed to investigate the efficacy and safety of endovascular treatment (EVT) for acute ischemic stroke (AIS) patients with large core infarct. METHODS Three online databases of Web of Science, PubMed and Scopus were systematically searched. Original studies which evaluated AIS participants with large core infarction who underwent EVT were included. R statistical software was used for statistical analyses. Effect sizes were presented with odds ratios (ORs) with their 95% confidence intervals (CIs). The effect sizes were pooled using random effects modeling. RESULTS Including 47 studies and 15,173 patients, this meta-analysis showed that compared with medical management (MM), EVT was significantly associated with decreased odds of mortality (0.67, 95% CI: 0.51-0.87) and increased odds of favorable outcomes, including a modified Rankin Scale of 0-3 (2.36, 95% CI: 1.69-3.291) and of 0-2 (3.54, 95% CI: 1.96-6.4) in 90 days and remarkable improvement in National Institutes of Health Stroke Scale within 48 h after the procedure (3.6, 95% CI:1.32-9.79). Besides, there was a higher chance of intracranial hemorrhage (ICH) development (1.88, 95% CI: 1.32-2.68) but not symptomatic ICH (1.34, 95% CI: 0.78-2.31) in those who underwent EVT. CONCLUSION Our study suggests that EVT might be an effective and relatively safe treatment option for the treatment of AIS patients with large vessel occlusion who have large core infarcts, although more large-scale trials are needed to consolidate the results and to make inclusion criteria and the patient selection process clearer.
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Affiliation(s)
| | - Erfan Taherifard
- School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran; MPH Department, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Alireza Sadeghi
- School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
| | | | - Omid Yousefi
- Trauma Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
| | - Ashkan Mowla
- Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California (USC), 1200 North State St., Suite 3300, Los Angeles, CA 90033, USA.
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13
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Pham J, Gan C, Dabboucy J, Stella DL, Dowling R, Yan B, Bush S, Williams C, Mitchell PJ, Desmond P, Thijs V, Asadi H, Brooks M, Maingard J, Jhamb A, Pavlin-Premrl D, Campbell BC, Ng FC. Occult contrast retention post-thrombectomy on 24-h follow-up dual-energy CT: Associations and impact on imaging analysis. Int J Stroke 2023; 18:1228-1237. [PMID: 37260232 DOI: 10.1177/17474930231182018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/02/2023]
Abstract
BACKGROUND Following reperfusion treatment in ischemic stroke, computed tomography (CT) imaging at 24 h is widely used to assess radiological outcomes. Even without visible hyperattenuation, occult angiographic contrast may persist in the brain and confound Hounsfield unit-based imaging metrics, such as net water uptake (NWU). AIMS We aimed to assess the presence and factors associated with retained contrast post-thrombectomy on 24-h imaging using dual-energy CT (DECT), and its impact on the accuracy of NWU as a measure of cerebral edema. METHODS Consecutive patients with anterior circulation large vessel occlusion who had post-thrombectomy DECT performed 24-h post-treatment from two thrombectomy stroke centers were retrospectively studied. NWU was calculated by interside comparison of HUs of the infarct lesion and its mirror homolog. Retained contrast was quantified by the difference in NWU values with and without adjustment for iodine. Patients with visible hyperdensities from hemorrhagic transformation or visible contrast retention and bilateral infarcts were excluded. Cerebral edema was measured by relative hemispheric volume (rHV) and midline shift (MLS). RESULTS Of 125 patients analyzed (median age 71 (IQR = 61-80), baseline National Institutes of Health Stroke Scale (NIHSS) 16 (IQR = 9.75-21)), reperfusion (defined as extended-Thrombolysis-In-Cerebral-Infarction 2b-3) was achieved in 113 patients (90.4%). Iodine-subtracted NWU was significantly higher than unadjusted NWU (17.1% vs 10.8%, p < 0.001). In multivariable median regression analysis, increased age (p = 0.024), number of passes (p = 0.006), final infarct volume (p = 0.023), and study site (p = 0.021) were independently associated with amount of retained contrast. Iodine-subtracted NWU correlated with rHV (rho = 0.154, p = 0.043) and MLS (rho = 0.165, p = 0.033) but unadjusted NWU did not (rHV rho = -0.035, p = 0.35; MLS rho = 0.035, p = 0.347). CONCLUSIONS Angiographic iodine contrast is retained in brain parenchyma 24-h post-thrombectomy, even without visually obvious hyperdensities on CT, and significantly affects NWU measurements. Adjustment for retained iodine using DECT is required for accurate NWU measurements post-thrombectomy. Future quantitative studies analyzing CT after thrombectomy should consider occult contrast retention.
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Affiliation(s)
- Jenny Pham
- Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Calvin Gan
- Department of Radiology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Jasmin Dabboucy
- Department of Neurology, Austin Health, Heidelberg, VIC, Australia
| | - Damien L Stella
- Department of Radiology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Richard Dowling
- Department of Radiology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Bernard Yan
- Department of Radiology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Radiology, Austin Health, Heidelberg, VIC, Australia
| | - Steven Bush
- Department of Radiology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Cameron Williams
- Department of Radiology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Peter J Mitchell
- Department of Radiology, The Royal Melbourne Hospital, Parkville, VIC, Australia
| | - Patricia Desmond
- Department of Radiology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- The University of Melbourne, Parkville, VIC, Australia
| | - Vincent Thijs
- Department of Neurology, Austin Health, Heidelberg, VIC, Australia
- Division of Stroke, Florey Institute of Neuroscience and Mental Health, Heidelberg, VIC, Australia
| | - Hamed Asadi
- Department of Radiology, Austin Health, Heidelberg, VIC, Australia
| | - Mark Brooks
- Department of Radiology, Austin Health, Heidelberg, VIC, Australia
| | - Julian Maingard
- Department of Radiology, Austin Health, Heidelberg, VIC, Australia
| | - Ash Jhamb
- Department of Radiology, Austin Health, Heidelberg, VIC, Australia
| | - Davor Pavlin-Premrl
- Department of Radiology, Austin Health, Heidelberg, VIC, Australia
- Melbourne Brain Centre, Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
| | - Bruce Cv Campbell
- Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- Melbourne Brain Centre, Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
| | - Felix C Ng
- Department of Neurology, The Royal Melbourne Hospital, Parkville, VIC, Australia
- Department of Neurology, Austin Health, Heidelberg, VIC, Australia
- Melbourne Brain Centre, Department of Medicine, Royal Melbourne Hospital, The University of Melbourne, Parkville, VIC, Australia
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14
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Faizy TD, Winkelmeier L, Mlynash M, Broocks G, Heitkamp C, Thaler C, van Horn N, Seners P, Kniep H, Stracke P, Zelenak K, Lansberg MG, Albers GW, Wintermark M, Fiehler J, Heit JJ. Brain edema growth after thrombectomy is associated with comprehensive collateral blood flow. J Neurointerv Surg 2023:jnis-2023-020921. [PMID: 37918909 DOI: 10.1136/jnis-2023-020921] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2023] [Accepted: 10/13/2023] [Indexed: 11/04/2023]
Abstract
BACKGROUND We determined whether a comprehensive assessment of cerebral collateral blood flow is associated with ischemic lesion edema growth in patients successfully treated by thrombectomy. METHODS This was a multicenter retrospective study of ischemic stroke patients who underwent thrombectomy treatment of large vessel occlusions. Collateral status was determined using the cerebral collateral cascade (CCC) model, which comprises three components: arterial collaterals (Tan Scale) and venous outflow profiles (Cortical Vein Opacification Score) on CT angiography, and tissue-level collaterals (hypoperfusion intensity ratio) on CT perfusion. Quantitative ischemic lesion net water uptake (NWU) was used to determine edema growth between admission and follow-up non-contrast head CT (ΔNWU). Three groups were defined: CCC+ (good pial collaterals, tissue-level collaterals, and venous outflow), CCC- (poor pial collaterals, tissue-level collaterals, and venous outflow), and CCCmixed (remainder of patients). Primary outcome was ischemic lesion edema growth (ΔNWU). Multivariable regression models were used to assess the primary and secondary outcomes. RESULTS 538 patients were included. 157 patients had CCC+, 274 patients CCCmixed, and 107 patients CCC- profiles. Multivariable regression analysis showed that compared with patients with CCC+ profiles, CCC- (β 1.99, 95% CI 0.68 to 3.30, P=0.003) and CCC mixed (β 1.65, 95% CI 0.75 to 2.56, P<0.001) profiles were associated with greater ischemic lesion edema growth (ΔNWU) after successful thrombectomy treatment. ΔNWU (OR 0.74, 95% CI 0.68 to 0.8, P<0.001) and CCC+ (OR 13.39, 95% CI 4.88 to 36.76, P<0.001) were independently associated with functional independence. CONCLUSION A comprehensive assessment of cerebral collaterals using the CCC model is strongly associated with edema growth and functional independence in acute stroke patients successfully treated by endovascular thrombectomy.
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Affiliation(s)
- Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laurens Winkelmeier
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Michael Mlynash
- Department of Neurology, Stanford Stroke Center, Stanford University, Stanford, California, USA
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Heitkamp
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Thaler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Paul Stracke
- Section of Interventional Neuroradiology, University Hospital Munster, Munster, Germany
| | - Kamil Zelenak
- Clinic of Radiology, Comenius University in Bratislava Jessenius Faculty of Medicine in Martin, Martin, Slovakia
- Clinic of Radiology, University Hospital Martin, Martin, Slovakia
| | - Maarten G Lansberg
- Department of Neurology, Stanford Stroke Center, Stanford University, Stanford, California, USA
| | - Gregory W Albers
- Stanford Stroke Center, Stanford Medicine, Stanford, California, USA
| | - Max Wintermark
- Department of Neuroradiology, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeremy J Heit
- Radiology, Neuroadiology and Neurointervention Division, Stanford University, Stanford, California, USA
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15
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Huang X, Chen C, Wang H, Cai Q, Li Z, Xu J, Yuan L, Xu X, Yang Q, Zhou Z, Liu X. The ACORNS grading scale: a novel tool for the prediction of malignant brain edema after endovascular thrombectomy. J Neurointerv Surg 2023; 15:e190-e197. [PMID: 36207112 PMCID: PMC10646923 DOI: 10.1136/jnis-2022-019404] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2022] [Accepted: 09/22/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND To develop and validate a novel tool for predicting the development of malignant brain edema (MBE) in large vessel occlusion stroke patients after endovascular thrombectomy (EVT). METHODS We used a prospectively registered population of EVT patients from three comprehensive stroke centers. The population was randomly divided into two subsets (7:3): a training cohort and an internal validation cohort. External validation was performed using the Endovascular Treatment for Acute Anterior Circulation Ischemic Stroke Registry in China (ACTUAL) database. MBE was defined as (1) hypodense parenchyma in at least 50% of the middle cerebral artery and signs of local brain swelling, and (2) a midline shift of ≥5 mm at the septum pellucidum or pineal gland with obliteration of the basal cisterns. The model was constructed using logistic regression analysis. The performance of the model was examined in terms of discrimination and calibration. RESULTS After adjusting for other confounders, baseline National Institutes of Health Stroke Scale (NIHSS) and Alberta Stroke Program Early CT (ASPECT) scores, a clinical history of hypertension, collateral status, intravenous thrombolysis before thrombectomy, fasting blood glucose, reperfusion status, and occlusion site were found to be independent predictors of MBE. These variables were combined to create the ACORNS grading scale. The areas under the curve in receiver operating curve analysis were 0.850 (95% CI 0.816 to 0.884), 0.874 (95% CI 0.821 to 0.926), and 0.785 (95% CI 0.740 to 0.829) for the training, internal validation, and external validation cohorts, respectively, indicating good discriminative performance in the validation cohorts. CONCLUSIONS The ACORNS grading scale is an accurate and easily applicable model for the prediction of the development of MBE after EVT.
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Affiliation(s)
- Xianjun Huang
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Chu Chen
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Huaiming Wang
- Department of Neurology, The 80th Group Army Hospital of the People's Liberation Army, Weifang, Shandong Province, China
- Department of Neurology, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
| | - Qiankun Cai
- Department of Neurology, The Second Affiliated Hospital of Fujian Medical University, Quanzhou, Fujian, China
| | - Zibao Li
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Junfeng Xu
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Lili Yuan
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Xiangjun Xu
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Qian Yang
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Zhiming Zhou
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui Province, China
| | - Xinfeng Liu
- Department of Neurology, Medical School of Nanjing University, Nanjing, Jiangsu Province, China
- Stroke Center & Department of Neurology, University of Science and Technology of China, Hefei, Anhui Province, China
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16
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Neuberger U, Vollherbst DF, Ulfert C, Schönenberger S, Herweh C, Nagel S, Ringleb PA, Möhlenbruch MA, Bendszus M, Vollmuth P. Location-specific ASPECTS does not improve Outcome Prediction in Large Vessel Occlusion compared to Cumulative ASPECTS. Clin Neuroradiol 2023; 33:661-668. [PMID: 36700986 PMCID: PMC10449666 DOI: 10.1007/s00062-022-01258-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Accepted: 12/18/2022] [Indexed: 01/27/2023]
Abstract
PURPOSE Individual regions of the Alberta Stroke Programme Early CT Score (ASPECTS) may contribute differently to the clinical symptoms in large vessel occlusion (LVO). Here, we investigated whether the predictive performance on clinical outcome can be increased by considering specific ASPECTS subregions. METHODS A consecutive series of patients with LVO affecting the middle cerebral artery territory and subsequent endovascular treatment (EVT) between January 2015 and July 2020 was analyzed, including affected ASPECTS regions. A multivariate logistic regression was performed to assess the individual impact of ASPECTS regions on good clinical outcome (defined as modified Rankin scale after 90 days of 0-2). Machine-learning-driven logistic regression models were trained (training = 70%, testing = 30%) to predict good clinical outcome using i) cumulative ASPECTS and ii) location-specific ASPECTS, and their performance compared using deLong's test. Furthermore, additional analyses using binarized as well as linear clinical outcomes using regression and machine-learning techniques were applied to thoroughly assess the potential predictive properties of individual ASPECTS regions and their combinations. RESULTS Of 1109 patients (77.3 years ± 11.6, 43.8% male), 419 achieved a good clinical outcome and a median NIHSS after 24 h of 12 (interquartile range, IQR 4-21). Individual ASPECTS regions showed different impact on good clinical outcome in the multivariate logistic regression, with strongest effects for insula (odds ratio, OR 0.56, 95% confidence interval, CI 0.42-0.75) and M5 (OR 0.53, 95% CI 0.29-0.97) regions. Accuracy (ACC) in predicting good clinical outcome of the test set did not differ between when considering i) cumulative ASPECTS and ii) location-specific ASPECTS (ACC = 0.619, 95% CI 0.58-0.64 vs. ACC = 0.629, 95% CI 0.60-0.65; p = 0.933). CONCLUSION Cumulative ASPECTS assessment in LVO remains a stable and reliable predictor for clinical outcome and is not inferior to a weighted (location-specific) ASPECTS assessment.
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Affiliation(s)
- Ulf Neuberger
- Dept. of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
| | - Dominik F Vollherbst
- Dept. of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Christian Ulfert
- Dept. of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | | | - Christian Herweh
- Dept. of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Simon Nagel
- Department of Neurology, Städtisches Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - Peter A Ringleb
- Dept. of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus A Möhlenbruch
- Dept. of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Martin Bendszus
- Dept. of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Philipp Vollmuth
- Dept. of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
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Pu M, Chen J, Chen Z, Li Z, Li Z, Tang Y, Li Q. Predictors and outcome of malignant cerebral edema after successful reperfusion in anterior circulation stroke. J Stroke Cerebrovasc Dis 2023; 32:107139. [PMID: 37105014 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107139] [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: 11/23/2022] [Revised: 04/08/2023] [Accepted: 04/12/2023] [Indexed: 04/29/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Risk factors and predictors of malignant cerebral edema (MCE) after successful endovascular thrombectomy (EVT) were not fully explored. This study aimed to evaluate the incidence and risk factors of MCE after successful reperfusion. METHODS We retrospectively analyzed consecutive ischemic stroke patients who underwent EVT in our institution from November 2015 to April 2022. Patients who failed to achieve successful reperfusion (modified thrombolysis in cerebral infarction [mTICI]<2b) were excluded. Based on multivariate logistic models, the best-fit monogram was established. The discriminative performance was assessed by the receiver operating characteristics curve (ROC). RESULTS A total of 307 patients were included and 48 (15.6%) were diagnosed with MCE after successful reperfusion. Patients with MCE after successful reperfusion had a lower 3-month favorable outcome (15.2% versus 59.6%; p<0.001), a lower 3-month good outcome (17.4% versus 68.4%; p<0.001), and a higher rate of mortality at 3-month (54.3% versus 8.8%; p<0.001) compared with patients without MCE. Predictors of MCE after successful reperfusion included admission glucose level, baseline National Institutes of Health Stroke Scale (NIHSS) score, stroke etiology, occlusion site and puncture-to-reperfusion (PTR) time>120 min. The area under the curve (AUC) of the nomogram was 0.805 (95% CI, 0.756-0.847). CONCLUSIONS MCE after successful reperfusion is associated with poor outcome and mortality. A nomogram containing admission glucose level, baseline NIHSS score, stroke etiology, occlusion site and PTR time>120 min may predict the risk of MCE after successful reperfusion in patients with acute ischemic stroke and treated successfully with EVT.
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Affiliation(s)
- Mingjun Pu
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China; Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang 621000, China
| | - Jun Chen
- Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang 621000, China
| | - Zhonglun Chen
- Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang 621000, China
| | - Zhaokun Li
- Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang 621000, China
| | - Zuoqiao Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China
| | - Yufeng Tang
- Mianyang Central Hospital, School of Medicine, University of Electronic Science and Technology of China, Mianyang 621000, China.
| | - Qi Li
- Department of Neurology, The First Affiliated Hospital of Chongqing Medical University, Chongqing 400016, China.
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18
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Doheim MF, Hagrass AI, Elrefaey M, Al-Bayati AR, Bhatt NR, Lang M, Starr M, Rocha M, Gross B, Nogueira RG. From therapeutic nihilism to armamentarium: A meta-analysis of randomized clinical trials assessing safety and efficacy of endovascular therapy for acute large ischemic strokes. Interv Neuroradiol 2023:15910199231170681. [PMID: 37082795 DOI: 10.1177/15910199231170681] [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: 04/22/2023] Open
Abstract
BACKGROUND Three recent randomized clinical trials (RCTs) investigated the potential benefit of endovascular therapy (EVT) in acute ischemic stroke patients presenting with large infarcts. We aimed to confirm the safety and efficacy of EVT in patients presenting with large infarcts and provide more precise estimations of the treatment effects using study-level meta-analysis. METHODS Comprehensive search of MEDLINE database through PubMed till February 2023 was performed including RCTs only. The data were then extracted from the selected studies and pooled as risk ratio (RR) with 95% confidence interval (95% CI). RESULTS There were a total of 1005 patients across the three qualifying RCTs. Regarding the functional outcomes assessed by modified Rankin Scale (mRS) score, the analyzed data demonstrated statistically significant differences in favor of thrombectomy for both independent ambulatory status (mRS 0-3: RR = 1.78, 95% CI [1.28, 2.48], p = 0.0006) and functional independence (mRS 0-2: RR = 2.54, 95% CI [1.85, 3.48], p < 0.001). The analyzed data did not demonstrate any statistically significant differences between EVT and medical management alone in terms of 90-day mortality (RR = 0.95, 95% CI [0.78, 1.16], p = 0.61), symptomatic intracranial hemorrhage (RR = 1.83, 95% CI [0.95, 3.55], p = 0.07), and need for hemicraniectomy (RR = 1.22, 95% CI [0.43, 3.41], p = 0.71). CONCLUSION This study confirms the benefit of EVT on functional outcomes of patients presenting with large ischemic infarcts without significant differences in the rates of symptomatic intracranial hemorrhage, hemicraniectomy, or 90-day mortality.
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Affiliation(s)
- Mohamed F Doheim
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | | | - Mohamed Elrefaey
- Department of Neurology, State University of New York Upstate Medical University, Syracuse, NY, USA
| | - Alhamza R Al-Bayati
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Nirav R Bhatt
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Michael Lang
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Neurosurgery, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Matthew Starr
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Marcelo Rocha
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Bradley Gross
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Neurosurgery, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Raul G Nogueira
- Department of Neurology, UPMC Stroke Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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19
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Alqahtani MS, Alharbi NF, Alghamdi BG, Asiri MA, Alwadai MM, Maghfuri AH, Alzahrani SS. Reversible CT Scan Hypodensity in Acute Ischemic Stroke Patient With Low Initial Alberta Stroke Program Early CT Score (ASPECTS) Following Endovascular Thrombectomy: A Case Report. Cureus 2023; 15:e36194. [PMID: 37065395 PMCID: PMC10104593 DOI: 10.7759/cureus.36194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/14/2023] [Indexed: 03/17/2023] Open
Abstract
According to current American and European guidelines, mechanical thrombectomy is recommended only for patients with an Alberta Stroke Program Early CT Score (ASPECTS) of 6 or higher. However, recent literature suggests that the potential benefits of reperfusion therapy should not be solely determined by baseline ASPECTS. In this case report, we present a young female patient with a low initial ASPECTS (4-5), who underwent mechanical thrombectomy and showed marked improvement in both CT imaging and clinical symptoms. Our findings potentially show that mechanical thrombectomy may be beneficial even for patients with an initial ASPECTS ≤ 5. These results may contribute to the growing evidence supporting the use of mechanical thrombectomy as a viable treatment option for acute ischemic stroke patients with low baseline ASPECTS.
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20
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Neurological Functional Independence After Endovascular Thrombectomy and Different Imaging Modalities for Large Infarct Core Assessment : A Systematic Review and Meta-analysis. Clin Neuroradiol 2023; 33:21-29. [PMID: 35920865 DOI: 10.1007/s00062-022-01202-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2022] [Accepted: 07/10/2022] [Indexed: 11/03/2022]
Abstract
PURPOSE To investigate the rate of neurological functional independence (NFI) at 90 days in patients with large infarct core (LIC), which was evaluated by different imaging modalities before endovascular thrombectomy (EVT). METHODS PubMed and EMBASE were searched for original studies on clinical functional outcomes at 90 days in LIC patients who received EVT treatment from inception to 28 September 2021. The pooled NFI rates were calculated using random effects model according to different imaging modalities and criteria. RESULTS We included 34 studies enrolling 2997 LIC patients. The NFI rates were 23% (95% confidence interval, CI 15-32%) and 24% (95% CI 10-38%) when LIC was defined as core volume ≥50 ml and ≥ 70 ml separately on computed tomography perfusion, 36% (95% CI 23-48%) and 21% (95% CI 17-25%) when LIC was defined as core volume ≥ 50 ml and ≥ 70 ml separately on magnetic resonance diffusion-weighted imaging (DWI), 28% (95% CI 24-32%) and 37% (95% CI 21-53%) when LIC was defined as DWI-ASPECTS ≤ 5 and ≤ 6 separately, 23% (95% CI 19-27%) and 32% (95% CI 18-46%) when LIC was defined as NCCT-ASPECTS ≤ 5 and ≤ 6 separately. CONCLUSION Similar NFI rates could be obtained after EVT in LIC patients if proper LIC criteria were select according to the imaging modality.
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21
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Broocks G, Meyer L, Elsayed S, McDonough R, Bechstein M, Faizy TD, Sporns P, Schön G, Minnerup J, Kniep HC, Hanning U, Barow E, Schramm P, Langner S, Nawabi J, Papanagiotou P, Wintermark M, Lansberg MG, Albers GW, Heit JJ, Fiehler J, Kemmling A. Association Between Net Water Uptake and Functional Outcome in Patients With Low ASPECTS Brain Lesions: Results From the I-LAST Study. Neurology 2023; 100:e954-e963. [PMID: 36414425 PMCID: PMC9990438 DOI: 10.1212/wnl.0000000000201601] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/14/2022] [Accepted: 10/10/2022] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND AND OBJECTIVES The effect of mechanical thrombectomy (MT) on functional outcome in patients with ischemic stroke with low ASPECTS is still uncertain. ASPECTS rating is based on the presence of ischemic hypoattenuation relative to normal; however, the degree of hypoattenuation, which directly reflects net uptake of water, is currently not considered an imaging biomarker in stroke triage. We hypothesized that the effect of thrombectomy on functional outcome in low ASPECTS patients depends on early lesion water uptake. METHODS For this multicenter observational study, patients with anterior circulation stroke with ASPECTS ≤5 were consecutively analyzed. Net water uptake (NWU) was assessed as a quantitative imaging biomarker in admission CT. The primary end point was the rate of favorable functional outcome defined as modified Rankin Scale score 0-3 at day 90. The effect of recanalization on functional outcome was analyzed according to the degree of NWU within the early infarct lesion. RESULTS A total of 254 patients were included, of which 148 (58%) underwent MT. The median ASPECTS was 4 (interquartile range [IQR] 3-5), and the median NWU was 11.4% (IQR 8.9%-15.1%). The rate of favorable outcome was 27.6% in patients with low NWU (<11.4%) vs 6.3% in patients with high NWU (≥11.4%; p < 0.0001). In multivariable logistic regression analysis, NWU was an independent predictor of outcome, whereas vessel recanalization (modified thrombolysis in cerebral infarction ≥2b) was only significantly associated with better outcomes if NWU was lower than 12.6%. In inverse-probability weighting analysis, recanalization was associated with 20.7% (p = 0.01) increase in favorable outcome in patients with low NWU compared with 9.1% (p = 0.06) in patients with high NWU. DISCUSSION Early NWU was independently associated with clinical outcome and might serve as an indicator of futile MT in low ASPECTS patients. NWU could be tested as a tool to select low ASPECTS patients for MT. TRIAL REGISTRATION INFORMATION The study is registered within the ClinicalTrials.gov Protocol Registration and Results System (NCT04862507).
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Affiliation(s)
- Gabriel Broocks
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany.
| | - Lukas Meyer
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Sarah Elsayed
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Rosalie McDonough
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Matthias Bechstein
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Tobias Djamsched Faizy
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Peter Sporns
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Gerhard Schön
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Jens Minnerup
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Helge C Kniep
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Uta Hanning
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Ewgenia Barow
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Peter Schramm
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Soenke Langner
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Jawed Nawabi
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Panagiotis Papanagiotou
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Max Wintermark
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Maarten G Lansberg
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Gregory W Albers
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Jeremy J Heit
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Jens Fiehler
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
| | - Andre Kemmling
- From the Departments of Diagnostic and Interventional Neuroradiology (G.B., L.M., S.E., R.M., M.B., T.D.F., P. Sporns, H.C.K., U.H., J.F.) and Neuroradiology (S.L.), and Institute of Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf, Germany; Departments of Clinical Neuroscience and Radiology (R.M.), Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Alberta, Canada; Department of Neuroradiology (T.D.F.), Stanford University, CA; Department of Neuroradiology (P. Sporns), Universitätsspital Basel, Switzerland; Department of Neurology with Institute of Translational Neurology (J.M.), University Hospital Münster; Department of Neuroradiology (P. Schramm), University Hospital Schleswig-Holstein, Luebeck; Department of Neuroradiology (S.L.), University Greifswald; Department of Neuroradiology (S.L.), University Medical Center Rostock; Department of Neuroradiology (J.N.), Charité University Medicine, Berlin; Department of Neuroradiology (P.P.), Hospital Bremen-Mitte, Germany; Department of Neuroradiology (M.W.), MD Anderson, Houston, TX; Departments of Neurology and Neurological Sciences (M.G.L., G.W.A.) and Radiology (J.J.H.), Stanford University School of Medicine, CA; and Department of Neuroradiology (A.K.), University Hospital Marburg, Germany
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Shao Y, Chen X, Wang H, Shang Y, Xu J, Zhang J, Wang P, Geng Y. Large mismatch profile predicts rapidly progressing brain edema in acute anterior circulation large vessel occlusion patients undergoing endovascular thrombectomy. Front Neurol 2023; 13:982911. [PMID: 36686510 PMCID: PMC9846046 DOI: 10.3389/fneur.2022.982911] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Accepted: 12/05/2022] [Indexed: 01/05/2023] Open
Abstract
Background Brain edema is a severe complication in patients with large vessel occlusion (LVO) that can reduce the effectiveness of endovascular therapy (EVT). This study aimed to investigate the association of the perfusion profile at baseline computed tomography (CT) perfusion with rapidly progressing brain edema (RPBE) after EVT in patients with acute anterior LVO. Methods We retrospectively reviewed consecutive data collected from 149 patients with anterior LVO who underwent EVT at our center. Brain edema was measured by the swelling score (0-6 score), and RPBE was defined as the swelling score increased by more than 2 scores within 24 h after EVT. We investigated the effect of RPBE on poor outcomes [National Institute of Health Stroke Scale (NIHSS) score and modified Rankin scale (mRS) score at discharge, the occurrence of hemorrhagic transformation, and mortality rate in the hospital] using the Mann-Whitney U-test and chi-square test. A multivariate logistic regression model was used to assess the relationship between perfusion imaging parameters and RPBE occurrence. Results Overall, 39 patients (26.2%) experienced RPBE after EVT. At discharge, RPBE was associated with higher NIHSS scores (Z = 3.52, 95% CI 2.0-12.0, P < 0.001) and higher mRS scores (Z = 3.67, 95% CI 0.0-1.0, P < 0.001) including the more frequent occurrence of hemorrhagic transformation (χ2 = 22.17, 95% CI 0.29-0.59, P < 0.001) and higher mortality rates in hospital (χ2 = 9.54, 95% CI 0.06-0.36, P = 0.002). Univariate analysis showed that intravenous thrombolysis, baseline ischemic core volume, and baseline mismatch ratio correlated with RPBE (all P < 0.05). After dividing the mismatch ratio into quartiles and performing a chi-square test between quartiles, we found that the occurrence of RPBE in Q4 (mismatch ratio > 11.3) was significantly lower than that in Q1 (mismatch ratio ≤ 3.0) (P < 0.05). The result of multivariate logistic regression analysis showed that compared with baseline mismatch ratio <5.1, baseline mismatch ratio between 5.1 and 11.3 (OR:3.85, 95% CI 1.06-14.29, P = 0.040), and mismatch ratio >11.3 (OR:5.26, 95% CI 1.28-20.00, P = 0.021) were independent protective factors for RPBE. Conclusion In patients with anterior circulation LVO stroke undergoing successful EVT, a large mismatch ratio at baseline is a protective factor for RPBE, which is associated with poor outcomes.
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Affiliation(s)
- Yanqi Shao
- Department of Neurology, Center for Rehabilitation Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Xinyi Chen
- Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Huiyuan Wang
- Department of Neurology, Center for Rehabilitation Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China,Department of Clinical Medicine, Bengbu Medical College, Bengbu, China
| | - Yafei Shang
- Department of Neurology, Center for Rehabilitation Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China,Department of Clinical Medicine, Bengbu Medical College, Bengbu, China
| | - Jie Xu
- Department of Neurology, Center for Rehabilitation Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China,Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, China
| | - Jinshi Zhang
- Department of Nephrology, Urology and Nephrology Center, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Peng Wang
- Department of Neurology, Center for Rehabilitation Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China
| | - Yu Geng
- Department of Neurology, Center for Rehabilitation Medicine, Zhejiang Provincial People's Hospital, Affiliated People's Hospital, Hangzhou Medical College, Hangzhou, Zhejiang, China,*Correspondence: Yu Geng ✉
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23
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Lu SS, Wu RR, Cao YZ, Xu XQ, Jia ZY, Shi HB, Liu S, Wu FY. Automated Estimation of Quantitative Lesion Water Uptake as a Prognostic Biomarker for Patients with Ischemic Stroke and Large-Vessel Occlusion. AJNR Am J Neuroradiol 2023; 44:33-39. [PMID: 36549850 PMCID: PMC9835911 DOI: 10.3174/ajnr.a7741] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Accepted: 11/11/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE Net water uptake is qualified as an imaging marker of brain edema. We aimed to investigate the ability of net water uptake to predict 90-day functional outcome in patients with acute ischemic stroke and large-vessel occlusion. MATERIALS AND METHODS A total of 295 consecutive patients were retrospectively enrolled. Automated ASPECTS-net water uptake was calculated on the admission CT. The relationship between ASPECTS-net water uptake and 90-day neurologic outcome was assessed. The independent predictors of favorable outcome (mRS score ≤2) were assessed using multivariate logistic regression analysis and receiver operating characteristic curves and stratified by the ASPECTS. RESULTS Favorable 90-day outcomes were observed in 156 (52.9%) patients. ASPECTS-net water uptake (OR, 0.79; 95% CI, 0.70-0.90), NIHSS scores (OR, 0.91; 95% CI, 0.87-0.96), age (OR, 0.96; 95% CI, 0.94-0.99), and vessel recanalization (OR, 7.78; 95% CI, 3.96-15.29) were independently associated with favorable outcomes at 90 days (all, P < .01). A lower ASPECTS-net water uptake independently predicted a good prognosis, even in the subgroup of patients with low ASPECTS (≤5) (P < .05). An outcome-prediction model based on these variables yielded an area under the receiver operating characteristic curve of 0.856 (95% CI, 0.814-0.899; sensitivity, 76.3%; specificity, 81.3%). CONCLUSIONS ASPECTS-net water uptake could independently predict 90-day neurologic outcomes in patients with acute ischemic stroke and large-vessel occlusion. Integrating ASPECTS-net water uptake with clinical models could improve the efficiency of outcome stratification.
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Affiliation(s)
- S S Lu
- From the Departments of Radiology (S.S.L., R.R.W., X.Q.X., F.Y.W.)
| | - R R Wu
- From the Departments of Radiology (S.S.L., R.R.W., X.Q.X., F.Y.W.)
| | - Y Z Cao
- Interventional Radiology (Y.Z.C., Z.Y.J., H.B.S., S.L.), The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - X Q Xu
- From the Departments of Radiology (S.S.L., R.R.W., X.Q.X., F.Y.W.)
| | - Z Y Jia
- Interventional Radiology (Y.Z.C., Z.Y.J., H.B.S., S.L.), The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - H B Shi
- Interventional Radiology (Y.Z.C., Z.Y.J., H.B.S., S.L.), The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - S Liu
- Interventional Radiology (Y.Z.C., Z.Y.J., H.B.S., S.L.), The First Affiliated Hospital of Nanjing Medical University, Nanjing, Jiangsu Province, China
| | - F Y Wu
- From the Departments of Radiology (S.S.L., R.R.W., X.Q.X., F.Y.W.)
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24
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Broocks G, McDonough R, Bechstein M, Hanning U, Brekenfeld C, Flottmann F, Kniep H, Nawka MT, Deb-Chatterji M, Thomalla G, Sporns P, Yeo LL, Tan BY, Gopinathan A, Kastrup A, Politi M, Papanagiotou P, Kemmling A, Fiehler J, Meyer L. Benefit and risk of intravenous alteplase in patients with acute large vessel occlusion stroke and low ASPECTS. J Neurointerv Surg 2023; 15:8-13. [PMID: 35078927 DOI: 10.1136/neurintsurg-2021-017986] [Citation(s) in RCA: 15] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2021] [Accepted: 12/10/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND The benefit of best medical treatment including intravenous alteplase (IVT) before mechanical thrombectomy (MT) in patients with acute ischemic stroke and extensive early ischemic changes on baseline CT remains uncertain. The purpose of this study was to evaluate the benefit of IVT for patients with low ASPECTS (Alberta Stroke Programme Early CT Score) compared with patients with or without MT. METHODS This multicenter study pooled consecutive patients with anterior circulation acute stroke and ASPECTS≤5 to analyze the impact of IVT on functional outcome, and to compare bridging IVT with direct MT. Functional endpoints were the rates of good (modified Rankin Scale (mRS) score ≤2) and very poor (mRS ≥5) outcome at day 90. Safety endpoint was the occurrence of symptomatic intracranial hemorrhage (sICH). RESULTS 429 patients were included. 290 (68%) received IVT and 168 (39%) underwent MT. The rate of good functional outcome was 14.4% (95% CI 7.1% to 21.8%) for patients who received bridging IVT and 24.4% (95% CI 16.5% to 32.2%) for those who underwent direct MT. The rate of sICH was significantly higher in patients with bridging IVT compared with direct MT (17.8% vs 6.4%, p=0.004). In multivariable logistic regression analysis, IVT was significantly associated with very poor outcome (OR 2.22, 95% CI 1.05 to 4.73, p=0.04) and sICH (OR 3.44, 95% CI 1.18 to 10.07, p=0.02). Successful recanalization, age, and ASPECTS were associated with good functional outcome. CONCLUSIONS Bridging IVT in patients with low ASPECTS was associated with very poor functional outcome and an increased risk of sICH. The benefit of this treatment should therefore be carefully weighed in such scenarios. Further randomized controlled trials are required to validate our findings.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marie Teresa Nawka
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Sporns
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Diagnostic and Interventional Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Leonard Ll Yeo
- National University Health System and Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Benjamin Yq Tan
- National University Health System and Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Anil Gopinathan
- National University Health System and Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Andreas Kastrup
- Department of Neurology, Klinikum Bremen-Mitte gGmbH, Bremen, Germany
| | - Maria Politi
- Department of Neuroradiology, Klinikum Bremen-Mitte GmbH, Bremen, Germany
| | - Panagiotis Papanagiotou
- Department of Neuroradiology, Klinikum Bremen-Mitte GmbH, Bremen, Germany.,National and Kapodistrian University of Athens, Aretaiio Hospital, Athens, Greece
| | | | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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25
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Sporns PB, Rusche T, Lee S, Hanning U, Meyer L, Faizy T, Fiehler J, Psychogios M, Kemmling A, Broocks G. Impact of edema formation on functional outcome in pediatric stroke patients. Eur J Neurol 2023; 30:150-154. [PMID: 36168926 DOI: 10.1111/ene.15576] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2022] [Accepted: 09/09/2022] [Indexed: 11/27/2022]
Abstract
BACKGROUND Quantitative lesion net water uptake (NWU) has been described as an imaging biomarker reflecting vasogenic edema as an early indicator of infarct progression. We hypothesized that edema formation measured by NWU is higher in children compared to adults but despite this functional outcome may be better in children. METHODS This study analyzed children enrolled in the Save ChildS Study who had baseline and follow-up computed tomography available and the data were compared to adult patients. RESULTS Some 207 patients, of whom 13 were children and 194 were adults, were analyzed. Median NWU at baseline was 7.8% (IQR: 4.3-11.3), and there were no significant differences between children and adults (7.5% vs. 7.8%; p = 0.87). The early edema progression rate was 3.0%/h in children and 2.3%/h in adults. Median ΔNWU was 15.1% in children and 10.5% in adults. Children had significantly more often excellent (mRS 0-1; children 10/13 = 77% vs. adults 28/196 = 14%; p < 0.0001) and favorable clinical outcomes (mRS 0-2, 12/13 = 92% vs. 39/196 = 20%; p < 0.0001). CONCLUSIONS In this study, clinical outcomes in children with large vessel occlusion strokes were better than in adults despite similar clinical and imaging characteristics and similar edema formation. This may be impacted by the generally better outcomes of children after strokes but may demonstrate that the degree of early ischemic changes using Alberta Stroke Program Early Computed Tomography Score (ASPECTS) and edema progression rate may not be a reason for exclusion from endovascular thrombectomy.
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Affiliation(s)
- Peter B Sporns
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland.,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thilo Rusche
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Sarah Lee
- Division of Child Neurology, Department of Neurology & Neurological Sciences, Stanford University School of Medicine, Stanford, California, USA
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marios Psychogios
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Andre Kemmling
- Department of Neuroradiology, University Hospital Marburg, Marburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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26
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Ni H, Lu GD, Hang Y, Jia ZY, Cao YZ, Shi HB, Liu S, Zhao LB. Association between Infarct Location and Hemorrhagic Transformation of Acute Ischemic Stroke following Successful Recanalization after Mechanical Thrombectomy. AJNR Am J Neuroradiol 2023; 44:54-59. [PMID: 36521961 PMCID: PMC9835909 DOI: 10.3174/ajnr.a7742] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 11/16/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE The association between infarct location and hemorrhagic transformation of acute ischemic stroke after mechanical thrombectomy is not understood. We aimed to evaluate the association between CTP-based ischemic core variables at admission and hemorrhagic transformation after a successful thrombectomy. MATERIALS AND METHODS We retrospectively analyzed patients who underwent endovascular thrombectomy for acute anterior circulation large-vessel occlusion between October 2019 and June 2021. We enrolled 146 patients with visible ischemic core on pretreatment CTP who had successful reperfusion. The ischemic core infarct territories were classified into the cortical and subcortical areas and then qualitatively and quantitatively analyzed by CTP. Logistic regression and receiver operating characteristic curve analyses were performed to determine the association between ischemic core variables and hemorrhagic transformation. RESULTS Of the 146 patients analyzed, 72 (49.3%) had hemorrhagic transformation and 23 (15.8%) had symptomatic intracerebral hemorrhage. Multivariate analysis showed that subcortical infarcts were independently associated with hemorrhagic transformation (OR, 8.06; 95% CI, 2.31-28.10; P = .001) and subcortical infarct volume was independently linked to symptomatic intracerebral hemorrhage (OR, 1.05; 95% CI, 1.01-1.09; P = .039). The receiver operating characteristic curve indicated that subcortical infarcts can predict hemorrhagic transformation accurately (area under the curve = 0.755; 95% CI, 0.68-0.82; P < .001) and subcortical infarct volume can predict symptomatic intracerebral hemorrhage (area under the curve = 0.694; 95% CI, 0.61-0.77; P = .002). CONCLUSIONS Subcortical infarcts seen on CTP at admission are associated with hemorrhagic transformation in patients after successful thrombectomy, and subcortical infarct volume may influence the risk of symptomatic intracerebral hemorrhage.
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Affiliation(s)
- H Ni
- From the Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - G-D Lu
- From the Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Y Hang
- From the Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Z-Y Jia
- From the Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Y-Z Cao
- From the Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - H-B Shi
- From the Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - S Liu
- From the Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - L-B Zhao
- From the Department of Interventional Radiology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
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27
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Panni P, Lapergue B, Maïer B, Finitsis S, Clarençon F, Richard S, Marnat G, Bourcier R, Sibon I, Dargazanli C, Blanc R, Consoli A, Eugène F, Vannier S, Spelle L, Denier C, Boulanger M, Gauberti M, Saleme S, Macian F, Rosso C, Naggara O, Turc G, Ozkul-Wermester O, Papagiannaki C, Albucher JF, Darcourt J, Le Bras A, Evain S, Wolff V, Pop R, Timsit S, Gentric JC, Bourdain F, Veunac L, Arquizan C, Gory B. Clinical Impact and Predictors of Diffusion Weighted Imaging (DWI) Reversal in Stroke Patients with Diffusion Weighted Imaging Alberta Stroke Program Early CT Score 0-5 Treated by Thrombectomy : Diffusion Weighted Imaging Reversal in Large Volume Stroke. Clin Neuroradiol 2022; 32:939-950. [PMID: 35412044 DOI: 10.1007/s00062-022-01156-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 03/02/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE To determine whether reversal of DWI lesions (DWIr) on the DWI-ASPECTS (diffusion weighted imaging Alberta Stroke Program CT Score) template should serve as a predictor of 90-day clinical outcome in acute ischemic stroke (AIS) patients with pretreatment diffusion-weighted imaging (DWI)-ASPECTS 0-5 treated with thrombectomy, and to determine its predictors in current practice. METHODS We analyzed data of all consecutive patients included in the prospective multicenter national Endovascular Treatment in Ischemic Stroke Registry between 1 January 2015 and 31 December 2020 with a premorbid mRS ≤ 2, who presented with a pretreatment DWI-ASPECTS 0-5 score, underwent thrombectomy and had an available 24 h post-interventional MRI follow-up. Multivariable analyses were performed to evaluate the clinical impact of DWIr on early neurological improvement (ENI), 3‑month modified Rankin scale (mRS) score distribution (shift analysis) and to define independent predictors of DWIr. RESULTS Early neurological improvement was detected in 82/211 (41.7%) of patients while 3‑month functional independence was achieved by 75 (35.5%) patients. The DWI reversal (39/211, 18.9%) resulted an independent predictor of both ENI (aOR 3.6, 95% CI 1.2-7.7; p 0.018) and 3‑month clinical outcome (aOR for mRS shift: 2.2, 95% CI 1-4.6; p 0.030). Only successful recanalization (mTICI 2c-3) independently predicted DWIr in the studied population (aOR 3.3, 95% CI 1.3-7.9; p 0.009). CONCLUSION The DWI reversal occurs in a non-negligible proportion of DWI-ASPECTS 0-5 patients subjected to thrombectomy and significantly influences clinical outcome. The mTICI 2c-3 recanalization emerged as an independent DWIr predictor.
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Affiliation(s)
- Pietro Panni
- Department of Neuroradiology, Division of Interventional Neuroradiology, Department of Neurosurgery, San Raffaele University Hospital, Milan, Italy.
| | - Bertrand Lapergue
- Department of Neurology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - Benjamin Maïer
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - Stephanos Finitsis
- AHEPA Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | | | - Sébastien Richard
- CHRU-Nancy, Department of Neurology, Stroke Unit, Université de Lorraine, 54000, Nancy, France.,CIC-P 1433, INSERM U1116, CHRU-Nancy, 54000, Nancy, France
| | - Gaultier Marnat
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
| | - Romain Bourcier
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - Igor Sibon
- Neurology, University Hospital of Bordeaux, Bordeaux, France
| | - Cyril Dargazanli
- Department of Interventional Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
| | - Raphaël Blanc
- Department of Neuroradiology, University Hospital of Nantes, Nantes, France
| | - Arturo Consoli
- Diagnostic and Interventional Neuroradiology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - François Eugène
- Department of Neuroradiology, University Hospital of Rennes, Rennes, France
| | | | | | | | | | | | | | | | - Charlotte Rosso
- Department of Neurology, CHU Pitié-Salpétrière, Paris, France
| | | | - Guillaume Turc
- Department of Neurology, Hôpital Saint-Anne, Paris, France
| | | | | | | | | | - Anthony Le Bras
- Department of Neuroradiology, CHBA Bretagne Atlantique, Vannes, France
| | - Sarah Evain
- Neurology, CHBA Bretagne Atlantique, Vannes, France
| | - Valérie Wolff
- Department of Neurology, CHU Strasbourg, Strasbourg, France
| | - Raoul Pop
- Neuroradiology, CHU Strasbourg, Strasbourg, France
| | - Serge Timsit
- Department of Neurology, CHU Brest, Brest, France
| | | | | | | | | | - Benjamin Gory
- CHRU-Nancy, Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, 54000, Nancy, France.,IADI, INSERM U1254, Université de Lorraine, 54000, Nancy, France
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28
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Safouris A, Palaiodimou L, Szikora I, Kargiotis O, Magoufis G, Psychogios K, Paraskevas G, Spiliopoulos S, Brountzos E, Nardai S, Goyal N, De Sousa DA, Strbian D, Caso V, Alexandrov A, Tsivgoulis G. Endovascular treatment for anterior circulation large-vessel occlusion ischemic stroke with low ASPECTS: a systematic review and meta-analysis. Ther Adv Neurol Disord 2022; 15:17562864221139632. [PMID: 36467113 PMCID: PMC9716457 DOI: 10.1177/17562864221139632] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2022] [Accepted: 10/31/2022] [Indexed: 08/30/2023] Open
Abstract
BACKGROUND Endovascular treatment (EVT) for acute ischemic stroke (AIS) patients presenting with Alberta Stroke Program Early CT Score (ASPECTS) 0-5 has not yet proven safe and effective by clinical trials. OBJECTIVES The aim of the study was to assess whether EVT in AIS patients presenting with low ASPECTS is beneficial. DESIGN Systematic review and meta-analysis of available studies in accordance with the PRISMA statement. DATA SOURCES AND METHODS We have searched MEDLINE, the Cochrane Central Register of Controlled Trials, and reference lists of articles published until 28 May 2022 with the aim to calculate (1) modified Rankin scale (mRS) score 0-3 at 3 months, (2) mRS score 0-2 at 3 months, (3) symptomatic intracranial hemorrhage (sICH), and (3) mortality at 3 months. RESULTS Overall, 24 eligible studies were included in the meta-analysis, comprising a total of 2539 AIS patients with ASPECTS 0-5 treated with EVT. The pooled proportion of EVT-treated patients achieving mRS 0-3 at 3 months was calculated at 38.4%. The pooled proportion of EVT-treated patients achieving mRS 0-2 at 3 months was 25.7%. Regarding safety outcomes, sICH occurred in 12.8% of patients. The 3-month pooled mortality was 30%. In pairwise meta-analysis, patients treated with EVT had a higher likelihood of achieving mRS 0-3 at 3 months compared with patients treated with best medical therapy (BMT, OR: 2.41). sICH occurred more frequently in EVT-treated patients compared with the BMT-treated patients (OR: 2.30). Mortality at 3 months was not different between the two treatment groups (OR: 0.71). CONCLUSION EVT may be beneficial for AIS patients with low baseline ASPECTS despite an increased risk for sICH. Further data from randomized-controlled clinical trials are needed to elucidate the role of EVT in this subgroup of AIS patients. REGISTRATION The protocol has been registered in the International Prospective Register of Ongoing Systematic Reviews PROSPERO; Registration Number: CRD42022334417.
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Affiliation(s)
- Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus,
Greece
- Second Department of Neurology, Attikon
University Hospital, Athens, Greece
- School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
- Aktios Rehabilitation Center, Athens,
Greece
- Department of Neurointerventions, National
Institute of Mental Health, Neurology and Neurosurgery, Section of
Neurointervention, Department of Neurosurgery, Semmelweis University,
Budapest, Hungary
| | - Lina Palaiodimou
- Second Department of Neurology, Attikon
University Hospital, Athens, Greece
- School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
| | - István Szikora
- Department of Neurointerventions, National
Institute of Mental Health, Neurology and Neurosurgery, Section of
Neurointervention, Department of Neurosurgery, Semmelweis University,
Budapest, Hungary
| | | | - George Magoufis
- Neuroradiology Department, Metropolitan
Hospital, Piraeus, Greece
| | | | - Georgios Paraskevas
- Second Department of Neurology, Attikon
University Hospital, Athens, Greece
- School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
| | - Stavros Spiliopoulos
- Interventional Radiology Department, Attikon
University Hospital, Athens, Greece
| | - Elias Brountzos
- Interventional Radiology Department, Attikon
University Hospital, Athens, Greece
| | - Sándor Nardai
- Department of Neurointerventions, National
Institute of Mental Health, Neurology and Neurosurgery, Section of
Neurointervention, Department of Neurosurgery, Semmelweis University,
Budapest, Hungary
| | - Nitin Goyal
- Department of Neurology, The University of
Tennessee Health Science Center, Memphis, TN, USA
- Department of Neurosurgery, The University of
Tennessee Health Science Center and Semmes Murphey Neurologic and Spine
Clinic. Memphis, TN, USA
| | - Diana Aguiar De Sousa
- Stroke Center, Lisbon Central University
Hospital and Faculty of Medicine, University of Lisbon, Lisbon,
Portugal
| | - Daniel Strbian
- Neurological Research Unit, University Medical
Center Hamburg-Eppendorf, Hamburg, Germany
| | - Valeria Caso
- Neurology Unit, ‘M. Bufalini’ Hospital-AUSL
Romagna, Cesena, Italy
| | - Andrei Alexandrov
- Department of Neurology, The University of
Tennessee Health Science Center, Memphis, TN, USA
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon
University Hospital, Rimini 1, Chaidari, 124 62 Athens, Greece
- School of Medicine, National and Kapodistrian
University of Athens, Athens, Greece
- Department of Neurology, The University of
Tennessee Health Science Center, Memphis, TN, USA
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29
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Broocks G, Hanning U, Bechstein M, Elsayed S, Faizy TD, Brekenfeld C, Flottmann F, Kniep H, Deb-Chatterji M, Schön G, Thomalla G, Kemmling A, Fiehler J, Meyer L. Association of Thrombectomy With Functional Outcome for Patients With Ischemic Stroke Who Presented in the Extended Time Window With Extensive Signs of Infarction. JAMA Netw Open 2022; 5:e2235733. [PMID: 36239941 PMCID: PMC9568804 DOI: 10.1001/jamanetworkopen.2022.35733] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
IMPORTANCE Only limited data are available about a potential benefit associated with endovascular treatment (EVT) for patients with ischemic stroke presenting in the extended time window who also show signs of extensive infarction. OBJECTIVE To assess the association of recanalization after EVT with functional outcomes for patients with ischemic stroke presenting in the extended time window who also show signs of extensive infarction. DESIGN, SETTING, AND PARTICIPANTS This retrospective, multicenter cohort study included patients enrolled in the German Stroke Registry-Endovascular Treatment with an Alberta Stroke Program Early CT Score (ASPECTS) of 5 or less who presented between 6 and 24 hours after stroke onset and underwent computed tomography and subsequent EVT between July 1, 2015, and December 31, 2019. MAIN OUTCOMES AND MEASURES The primary end point was a modified Rankin Scale (mRS) score of 3 or less at day 90. The association between recanalization (defined as the occurrence of a modified Thrombolysis in Cerebral Infarction Scale score of 2b or 3) and outcome was assessed using logistic regression and inverse probability weighting analysis. INTERVENTION Endovascular treatment. RESULTS Of 5853 patients, 285 (5%; 146 men [51%]; median age, 73 years [IQR, 62-81 years]) met the inclusion criteria and were analyzed. Of these 285 patients, 79 (27.7%) had an mRS score of 3 or less at day 90. The rate of successful recanalization was 75% (215 of 285) and was independently associated with a higher probability of reaching an mRS score of 3 or less (adjusted odds ratio, 4.39; 95% CI, 1.79-10.72; P < .001). In inverse probability weighting analysis, a modified Thrombolysis in Cerebral Infarction Scale score of 2b or 3 was associated with a 19% increase (95% CI, 9%-29%; P < .001) in the probability for an mRS score of 3 or more. Multivariable logistic regression analysis suggested a significant treatment benefit associated with vessel recanalization in a time window of up to 17.6 hours and ASPECTS of 3 to 5. The rate of secondary symptomatic intracerebral hemorrhage was 6.3% (18 of 285). CONCLUSIONS AND RELEVANCE In this cohort study reflecting daily clinical practice, vessel recanalization for patients with a low ASPECTS and extended time window was associated with better functional outcomes in a time window up to 17.6 hours and ASPECTS of 3 to 5. The results of this study encourage current randomized clinical trials to enroll patients with a low ASPECTS, even within the extended time window.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sarah Elsayed
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D. Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - André Kemmling
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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ASPECTS-based net water uptake predicts poor reperfusion and poor clinical outcomes in patients with ischemic stroke. Eur Radiol 2022; 32:7026-7035. [PMID: 35980434 DOI: 10.1007/s00330-022-09077-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2022] [Revised: 07/27/2022] [Accepted: 08/01/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE To investigate the value of automated Alberta Stroke Program Early CT Score (ASPECTS)-based net water uptake (NWU) to predict tissue-level reperfusion status and 90-day functional outcomes in acute ischemic stroke (AIS) patients after reperfusion therapy. METHODS One hundred and twelve patients with AIS who received reperfusion therapy were enrolled. ASPECTS-NWU was calculated from admission CT (NWUadmission) and follow-up CT (NWUFCT), and the difference (ΔNWU) was calculated. Tissue-level reperfusion status was evaluated via follow-up arterial spin labeling imaging. The relationship between ASPECTS-NWU and tissue-level reperfusion was evaluated. Predictors of 90-day unfavorable outcomes (modified Rankin Scale score > 2) were assessed by multivariate logistic regression analysis and receiver operating characteristic (ROC) curves. RESULTS Poor reperfusion was observed in 40 patients (35.7%) after therapy. Those patients had significantly elevated NWUFCT (median, 14.15% vs. 8.08%, p = 0.018) and higher ΔNWU (median, 4.12% vs. -2.03%, p < 0.001), compared to patients with good reperfusion. High ΔNWU was a significant marker of poor reperfusion despite successful recanalization. National Institutes of Health Stroke Scale score at admission (odds ratio [OR], 1.11; 95% confidence interval [CI] 1.03-1.20, p = 0.007) and ΔNWU (OR, 1.07; 95% CI 1.02-1.13, p = 0.008) were independently associated with unfavorable outcomes. An outcome prediction model including both parameters yields an area under the curve of 0.762 (sensitivity 70.3%, specificity, 84.2%). CONCLUSIONS Elevated NWUFCT and higher ΔNWU were associated with poor tissue-level reperfusion after therapy. Higher ΔNWU was an independent predictor of poor reperfusion and unfavorable neurological outcomes despite successful recanalization. KEY POINTS • ASPECTS-NWU may provide pathophysiological information about tissue-level reperfusion status and offer prognostic benefits for patients with AIS after reperfusion therapy. • Elevated NWUFCT and higher ΔNWU were correlated with poor tissue-level reperfusion after therapy. • A higher ΔNWU is an independent predictor of poor reperfusion and 90-day unfavorable outcomes despite successful recanalization.
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Chen L, Xu Z, Zhang C, Ji Y, Huang X, Yang W, Zhou Z, Wang S, Wang K, Luo B, Wang J. Post-ASPECTS based on hyperdensity in NCCT immediately after thrombectomy is an ultra-early predictor of hemorrhagic transformation and prognosis. Front Neurol 2022; 13:887277. [PMID: 36034273 PMCID: PMC9399794 DOI: 10.3389/fneur.2022.887277] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2022] [Accepted: 07/13/2022] [Indexed: 11/13/2022] Open
Abstract
Background and PurposeAlmost half of the patients exhibit futile recanalization after thrombectomy; however, the early postoperative predictors of futile recanalization remain unclear. We analyzed the relationship of post-thrombectomy ASPECTS (Post-ASPECTS) with 90-day prognosis and hemorrhagic transformation (HT).MethodsWe collected data from patients with acute ischemic stroke (AIS) with anterior-circulation large vessel occlusion (ACLVO) who were treated via thrombectomy within 10 h in 3 hospitals. Successful endovascular recanalization was achieved (modified thrombolysis in cerebral ischemia [mTICI] 2b/3). Non-contrast computed tomography (NCCT) examination was performed immediately (within 1 h) after thrombectomy. Post-ASPECTS were scored based on the brain parenchymal hyperdensity in NCCT according to the ASPECTS scoring method. HT was defined according to the ECASS II classification criteria. Linear correlation, logistic regression, and receiver operating characteristic curve analyses were used to determine the influencing factors and best predictive value of 90-day prognosis, 90-day death, and HT.ResultsA total of 231 patients were enrolled. The good prognosis rate, mortality rate, and HT rate were 57.1, 9.5, and 38.3%, respectively. The Post-ASPECTS affected poor prognosis, death, and HT. The best predictive value of Post-ASPECTS for poor prognosis, death, and HT was 7. The specificities of Post-ASPECTS for predicting HT, poor prognosis, and death were 87.6% (AUC, 0.811; P < 0.001), 87.1% (AUC, 0.768; P < 0.001), and 73.7% (AUC, 0.748; P < 0.001), with positive predictive values of 74.2, 75.7, and 21.4%, respectively.ConclusionPost-ASPECTS predicted 90-day prognosis, death, and HT with high specificity and high positive predictive value in patients with AIS with ACLVO. Post-ASPECTS may be an ultra-early predictor of prognosis after thrombectomy.
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Affiliation(s)
- Lulu Chen
- Department of Neurology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Ziqi Xu
- Department of Neurology, Brain Medical Centre, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Chen Zhang
- Department of Neurology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yachen Ji
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Xianjun Huang
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Weimin Yang
- Department of Neurology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zhiming Zhou
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Shuiping Wang
- Department of Neurology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Kai Wang
- Department of Neurology, First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Benyan Luo
- Department of Neurology, Brain Medical Centre, First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Jingye Wang
- Department of Neurology, First Affiliated Hospital of Anhui Medical University, Hefei, China
- *Correspondence: Jingye Wang
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Pan J, Wu H, Wu T, Geng Y, Yuan R. Association Between Post-procedure Cerebral Blood Flow Velocity and Severity of Brain Edema in Acute Ischemic Stroke With Early Endovascular Therapy. Front Neurol 2022; 13:906377. [PMID: 35923831 PMCID: PMC9339960 DOI: 10.3389/fneur.2022.906377] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Accepted: 06/17/2022] [Indexed: 11/13/2022] Open
Abstract
ObjectivesWe aimed to investigate the association between post-procedure cerebral blood flow velocity (CBFV) and severity of brain edema in patients with acute ischemic stroke (AIS) who received early endovascular therapy (EVT).MethodsWe retrospectively included patients with AIS who received EVT within 24 h of onset between February 2016 and November 2021. Post-procedure CBFV of the middle cerebral artery was measured in the affected and the contralateral hemispheres using transcranial Doppler ultrasound. The severity of brain edema was measured using the three-level cerebral edema grading from the Safe Implementation of Thrombolysis in Stroke-Monitoring Study, with grades 2–3 indicating severe brain edema. The Association between CBFV parameters and severity of brain edema was analyzed.ResultsA total of 101 patients (mean age 64.2 years, 65.3% male) were included, of whom 56.3% (57/101) suffered brain edema [grade 1, 23 (22.8%); grade 2, 10 (9.9%); and grade 3, 24 (23.8%)]. Compared to patients with non-severe brain edema, patients with severe brain edema had lower affected/contralateral ratios of systolic CBFV (median 1 vs. 1.2, P = 0.020) and mean CBFV (median 0.9 vs. 1.3, P = 0.029). Multivariate logistic regression showed that severe brain edema was independently associated with affected/contralateral ratios of systolic CBFV [odds ratio (OR) = 0.289, 95% confidence interval (CI): 0.069–0.861, P = 0.028] and mean CBFV (OR = 0.278, 95% CI: 0.084–0.914, P = 0.035) after adjusting for potential confounders.ConclusionPost-procedure affected/contralateral ratio of CBFV may be a promising predictor of brain edema severity in patients with AIS who received early EVT.
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Affiliation(s)
- Jie Pan
- Suzhou Medical College of Soochow University, Suzhou, China
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China
| | - Huadong Wu
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China
| | - Tingting Wu
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China
| | - Yu Geng
- Suzhou Medical College of Soochow University, Suzhou, China
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China
- *Correspondence: Ruozhen Yuan
| | - Ruozhen Yuan
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China
- Yu Geng
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Abstract
Our Japanese colleagues deserve much praise for finishing the first randomized clinical trial of thrombectomy in Alberta Stroke Program Early CT Score 3 to 5 patients showing an impressive therapy effect of thrombectomy. The predominant use of magnetic resonance imaging for patient selection, the low rate of alteplase therapy and its low dose limit direct comparisons with patients treated outside of Japan. Another limitation is the lack of benefit when using the traditional metric–modified Rankin Scale score 0–2. We consider the results of RESCUE-Japan LIMIT encouraging and a clear motivation to continue and complete other studies.
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Affiliation(s)
- Diogo C. Haussen
- Emory University School of Medicine/Grady Memorial Hospital, Atlanta, GA. (D.C.H.)
| | - Jens Fiehler
- Department of Neuroradiology, University Center Hamburg-Eppendorf, Germany (J.F.)
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Faizy TD, Mlynash M, Kabiri R, Christensen S, Kuraitis GM, Mader MM, Flottmann F, Broocks G, Lansberg MG, Albers GW, Marks MP, Fiehler J, Wintermark M, Heit JJ. The Cerebral Collateral Cascade: Comprehensive Blood Flow in Ischemic Stroke. Neurology 2022; 98:e2296-e2306. [PMID: 35483902 DOI: 10.1212/wnl.0000000000200340] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2021] [Accepted: 02/21/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Robust cerebral collaterals are associated with favorable outcomes in patients with acute ischemic stroke due to large vessel occlusion treated by thrombectomy. However, collateral status assessment mostly relies on single imaging biomarkers and a more comprehensive holistic approach may provide deeper insights into the biology of collateral perfusion on medical imaging. Comprehensive collateralization is defined as blood flow of cerebral arteries through the brain tissue and into draining veins. We hypothesized that a comprehensive analysis of the cerebral collateral cascade (CCC) on an arterial, tissue, and venous level would predict clinical and radiologic outcomes. METHODS This was a multicenter retrospective cohort study of patients with acute stroke undergoing thrombectomy triage. CCC was determined by quantifying pial arterial collaterals, tissue-level collaterals, and venous outflow (VO). Pial arterial collaterals were determined by CT angiography; tissue-level collaterals were assessed on CT perfusion. VO was assessed on CT angiography using the cortical vein opacification score. Three groups were defined: CCC+ (good pial collaterals, tissue-level collaterals, and VO), CCC- (poor pial collaterals, tissue-level collaterals, and VO), and CCCmixed (the remainder of the patients). Primary outcome was functional independence (modified Rankin Scale score 0-2) at 90 days. Secondary outcome was final infarct volume. RESULTS A total of 647 patients met inclusion criteria: 176 CCC+, 345 CCCmixed, and 126 CCC-. Multivariable ordinal logistic regression showed that CCC+ predicted good functional outcomes (odds ratio [OR] 18.9 [95% CI 8-44.5]; p < 0.001) compared with CCC- and CCCmixed. CCCmixed patients likely had better functional outcomes compared with CCC- patients (OR 2.5 [95% CI 1.2-5.4]; p = 0.014). Quantile regression analysis (50th percentile) showed that CCC+ (β -78.5, 95% CI -96.0 to -61.1; p < 0.001) and CCCmixed (β -64.0, 95% CI -82.4 to -45.6; p < 0.001) profiles were associated with considerably lower final infarct volumes compared with CCC- profiles. DISCUSSION Comprehensive assessment of the collateral blood flow cascade in patients with acute stroke is a strong predictor of clinical and radiologic outcomes in patients treated by thrombectomy.
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Affiliation(s)
- Tobias Djamsched Faizy
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Michael Mlynash
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Reza Kabiri
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Soren Christensen
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Gabriella Marie Kuraitis
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Marius M Mader
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Fabian Flottmann
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Gabriel Broocks
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Maarten G Lansberg
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Gregory W Albers
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Michael P Marks
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Jens Fiehler
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Max Wintermark
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Jeremy J Heit
- From the Departments of Radiology (T.D.F., R.K., G.M.K., M.P.M., M.W., J.J.H.) and Neurology and Neurological Sciences (M.M., S.C., M.G.L., G.W.A.), Stanford University School of Medicine, CA; and Departments of Neuroradiology (T.D.F., R.K., F.F., G.B., J.F.) and Neurosurgery (M.M.M.), University Medical Center Hamburg-Eppendorf, Germany.
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Pellegrino MP, Guerra FBD, Perissinotti IN. Decision-making strategies for reperfusion therapies: navigating through stroke trials gaps. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:60-71. [PMID: 35976313 PMCID: PMC9491414 DOI: 10.1590/0004-282x-anp-2022-s123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 04/29/2022] [Indexed: 06/15/2023]
Abstract
Despite there being a robust amount of literature and numerous randomized clinical trials regarding acute ischemic stroke treatment, the trials have not included some frequent controversial situations for which decision-making strategies are an urgent and unmet need in clinical practice. This article tries to summarize the current evidence about some selected situations (mechanical thrombectomy in low ASPECTS, low NIHSS with proximal occlusion, acute basilar occlusion, distal and medium vessel occlusion, among others), make suggestions on how to approach them in clinical practice and show what to expect in acute stroke research in the near future.
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Affiliation(s)
- Mateus Paquesse Pellegrino
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto de Radiologia, São Paulo, SP, Brazil
| | | | - Iago Navas Perissinotti
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto do Câncer do Estado de São Paulo, São Paulo, SP, Brazil
- Universidade de São Paulo, Faculdade de Medicina, Hospital das Clínicas, Instituto Central, Departamento de Neurologia, São Paulo, SP, Brazil
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Su M, Chen Z, Chen X, Huang J, Li Z, Zhou Y, Xu G. Venous Flow Profiles on Perfusion CT are Associated with Futile Recanalization After Thrombectomy. Neuropsychiatr Dis Treat 2022; 18:933-942. [PMID: 35515078 PMCID: PMC9064056 DOI: 10.2147/ndt.s360626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2022] [Accepted: 04/09/2022] [Indexed: 11/23/2022] Open
Abstract
Background and Purpose Robust venous outflow (VO) reflects favourable tissue reperfusion in acute ischaemic stroke (AIS) patients with large vessel occlusion (LVO). We aimed to investigate the association of the venous outflow profile on computed tomographic perfusion (CTP) and futile recanalization in anterior circulation AIS patients with LVO after thrombectomy. Methods This was a retrospective study of consecutive AIS patients due to anterior circulation LVO who underwent CTP before thrombectomy. Patients who achieved successful recanalization defined as a modified Thrombolysis in Cerebral Infarction (mTICI) score of 2b or 3 after thrombectomy were included. Based on the venous time-intensity curve of CTP, the peak time of venous outflow (PTV), total venous outflow time (TVT), and difference value of arteriovenous peak time (D-value) were recorded. A modified mRS score of 3-6 at 3 months was regarded as futile recanalization (FR). Logistic regression analysis was applied to assess risk factors for FR. We used receiver operating characteristic curves (ROCs) to evaluate the predictive value of venous outflow time parameters based on VO for FR. Results Eighty patients were included; 35 (43.8%) achieved good functional outcomes, and 45 (56.3%) had unfavourable functional outcomes, that is, FR. Adjusting confounding factors, binary stepwise logistic regression analysis showed that delayed PTV was independently associated with FR (odds ratio, 1.374 [95% CI, 1.093-1.726], P = 0.007). ROCs indicated that PTV effectively predicted unfavourable outcomes at 3 months (area under the curve (AUC) = 0.729, p< 0.001). The combined model was a powerful predictor of FR with an AUC of 0.824 and a cut-off value of 0.631 (p< 0.001). Conclusion Delayed PTV is independently related to FR in anterior circulation AIS patients with LVO achieving successful recanalization after thrombectomy. Our results highlight that the time of VO may be a potential marker for FR.
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Affiliation(s)
- Mouxiao Su
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, 510000, People’s Republic of China
- Department of Neurology, School of Medicine, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, 621000, People’s Republic of China
| | - Zhonglun Chen
- Department of Neurology, School of Medicine, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, 621000, People’s Republic of China
| | - Xinyue Chen
- CT Collaboration, Siemens Healthineers, Chengdu, 610000, People’s Republic of China
| | - Jiaxing Huang
- Department of Radiology, School of Medicine, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, 621000, People’s Republic of China
| | - Zhaokun Li
- Department of Neurology, School of Medicine, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, 621000, People’s Republic of China
| | - Ying Zhou
- Department of Radiology, School of Medicine, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, 621000, People’s Republic of China
| | - Gelin Xu
- The First School of Clinical Medicine, Southern Medical University, Guangzhou, 510000, People’s Republic of China
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, People's Republic of China
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van Horn N, Broocks G, Kabiri R, Kraemer MC, Christensen S, Mlynash M, Meyer L, Lansberg MG, Albers GW, Sporns P, Guenego A, Fiehler J, Wintermark M, Heit JJ, Faizy TD. Cerebral Hypoperfusion Intensity Ratio Is Linked to Progressive Early Edema Formation. J Clin Med 2022; 11:jcm11092373. [PMID: 35566500 PMCID: PMC9105689 DOI: 10.3390/jcm11092373] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 04/09/2022] [Accepted: 04/16/2022] [Indexed: 11/16/2022] Open
Abstract
The hypoperfusion intensity ratio (HIR) is associated with collateral status and reflects the impaired microperfusion of brain tissue in patients with acute ischemic stroke and large vessel occlusion (AIS-LVO). As a deterioration in cerebral blood flow is associated with brain edema, we aimed to investigate whether HIR is correlated with the early edema progression rate (EPR) determined by the ischemic net water uptake (NWU) in a multicenter retrospective analysis of AIS-LVO patients anticipated for thrombectomy treatment. HIR was automatically calculated as the ratio of time-to-maximum (TMax) > 10 s/(TMax) > 6 s. HIRs < 0.4 were regarded as favorable (HIR+) and ≥0.4 as unfavorable (HIR−). Quantitative ischemic lesion NWU was delineated on baseline NCCT images and EPR was calculated as the ratio of NWU/time from symptom onset to imaging. Multivariable regression analysis was used to assess the association of HIR with EPR. This study included 731 patients. HIR+ patients exhibited a reduced median NWU upon admission CT (4% (IQR: 2.1−7.6) versus 8.2% (6−10.4); p < 0.001) and less median EPR (0.016%/h (IQR: 0.007−0.04) versus 0.044%/h (IQR: 0.021−0.089; p < 0.001) compared to HIR− patients. Multivariable regression showed that HIR+ (β: 0.53, SE: 0.02; p = 0.003) and presentation of the National Institutes of Health Stroke Scale (β: 0.2, SE: 0.0006; p = 0.001) were independently associated with EPR. In conclusion, favorable HIR was associated with lower early edema progression and decreased ischemic edema formation on baseline NCCT.
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Affiliation(s)
- Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (N.v.H.); (G.B.); (R.K.); (M.C.K.); (L.M.); (J.F.)
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (N.v.H.); (G.B.); (R.K.); (M.C.K.); (L.M.); (J.F.)
| | - Reza Kabiri
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (N.v.H.); (G.B.); (R.K.); (M.C.K.); (L.M.); (J.F.)
| | - Michel C. Kraemer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (N.v.H.); (G.B.); (R.K.); (M.C.K.); (L.M.); (J.F.)
| | - Soren Christensen
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA 94305, USA; (S.C.); (M.M.); (M.G.L.); (G.W.A.)
| | - Michael Mlynash
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA 94305, USA; (S.C.); (M.M.); (M.G.L.); (G.W.A.)
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (N.v.H.); (G.B.); (R.K.); (M.C.K.); (L.M.); (J.F.)
| | - Maarten G. Lansberg
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA 94305, USA; (S.C.); (M.M.); (M.G.L.); (G.W.A.)
| | - Gregory W. Albers
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA 94305, USA; (S.C.); (M.M.); (M.G.L.); (G.W.A.)
| | - Peter Sporns
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Basel, 4031 Basel, Switzerland;
| | - Adrien Guenego
- Department of Interventional Neuroradiology, Erasme University Hospital, 1070 Brussels, Belgium;
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (N.v.H.); (G.B.); (R.K.); (M.C.K.); (L.M.); (J.F.)
| | - Max Wintermark
- Department of Radiology, Stanford University School of Medicine, Stanford, CA 94305, USA; (M.W.); (J.J.H.)
| | - Jeremy J. Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, CA 94305, USA; (M.W.); (J.J.H.)
| | - Tobias D. Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany; (N.v.H.); (G.B.); (R.K.); (M.C.K.); (L.M.); (J.F.)
- Correspondence: ; Tel.: +49-0-152-2283-5161
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Ng FC, Yassi N, Sharma G, Brown SB, Goyal M, Majoie CBLM, Jovin TG, Hill MD, Muir KW, Saver JL, Guillemin F, Demchuk AM, Menon BK, San Roman L, White P, van der Lugt A, Ribo M, Bracard S, Mitchell PJ, Davis SM, Sheth KN, Kimberly WT, Campbell BCV. Correlation Between Computed Tomography-Based Tissue Net Water Uptake and Volumetric Measures of Cerebral Edema After Reperfusion Therapy. Stroke 2022; 53:2628-2636. [PMID: 35450438 DOI: 10.1161/strokeaha.121.037073] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Cerebral edema after large hemispheric infarction is associated with poor functional outcome and mortality. Net water uptake (NWU) quantifies the degree of hypoattenuation on unenhanced-computed tomography (CT) and is increasingly used to measure cerebral edema in stroke research. Hemorrhagic transformation and parenchymal contrast staining after thrombectomy may confound NWU measurements. We investigated the correlation of NWU measured postthrombectomy with volumetric markers of cerebral edema and association with functional outcomes. METHODS In a pooled individual patient level analysis of patients presenting with anterior circulation large hemispheric infarction (core 80-300 mL or Alberta Stroke Program Early CT Score ≤5) in the HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke trials) data set, cerebral edema was defined as the volumetric expansion of the ischemic hemisphere expressed as a ratio to the contralateral hemisphere(rHV). NWU and midline-shift were compared with rHV as the reference standard on 24-hour follow-up CT, adjusted for hemorrhagic transformation and the use of thrombectomy. Association between edema markers and day 90 functional outcomes (modified Rankin Scale) was assessed using ordinal logistic regression. RESULTS Overall (n=144), there was no correlation between NWU and rHV (rs=0.055, P=0.51). In sub-group analyses, a weak correlation between NWU with rHV was observed after excluding patients with any degree of hemorrhagic transformation (rs=0.211, P=0.015), which further improved after excluding thrombectomy patients (rs=0.453, P=0.001). Midline-shift correlated strongly with rHV in all sub-group analyses (rs>0.753, P=0.001). Functional outcome at 90 days was negatively associated with rHV (adjusted common odds ratio, 0.46 [95% CI, 0.32-0.65]; P<0.001) and midline-shift (adjusted common odds ratio, 0.85 [95% CI, 0.78-0.92]; P<0.001) but not NWU (adjusted common odds ratio, 1.00 [95% CI, 0.97-1.03]; P=0.84), adjusted for age, baseline National Institutes of Health Stroke Scale, and thrombectomy. Prognostic performance of NWU improved after excluding patients with hemorrhagic transformation and thrombectomy (adjusted odds ratio, 0.90 [95% CI, 0.80-1.02]; P=0.10). CONCLUSIONS NWU correlated poorly with conventional markers of cerebral edema and was not associated with clinical outcome in the presence of hemorrhagic transformation and thrombectomy. Measuring NWU postthrombectomy requires validation before implementation into clinical research. At present, the use of NWU should be limited to baseline CT, or follow-up CT only in patients without hemorrhagic transformation or treatment with thrombectomy.
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Affiliation(s)
- Felix C Ng
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (F.C.N., N.Y., G.S., S.M.D., B.C.V.C.).,Austin Health, Heidelberg, Australia (F.C.N.)
| | - Nawaf Yassi
- Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Australia (N.Y.)
| | - Gagan Sharma
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (F.C.N., N.Y., G.S., S.M.D., B.C.V.C.)
| | | | - Mayank Goyal
- Department of Radiology, University of Calgary, Foothills Hospital, AB, Canada (M.G.)
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location AMC, the Netherlands (C.B.L.M.M.)
| | - Tudor G Jovin
- Cooper Neurological Institute, Cooper University Health Care, Camden, NJ (T.G.J.)
| | - Michael D Hill
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, AB, Canada (M.D.H., A.M.D., B.K.M.)
| | - Keith W Muir
- Institute of Neuroscience & Psychology, University of Glasgow, Queen Elizabeth University Hospital, United Kingdom (K.W.M.)
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine at the University of California, Los Angeles, California Stanford Stroke Center, Stanford University (J.L.S.)
| | - Francis Guillemin
- Clinical Investigation Centre-Clinical Epidemiology INSERM 1433, University of Lorraine and University Hospital of Nancy, France (F.G.)
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, AB, Canada (M.D.H., A.M.D., B.K.M.)
| | - Bijoy K Menon
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, AB, Canada (M.D.H., A.M.D., B.K.M.)
| | - Luis San Roman
- Department of Radiology, Hospital Clínic, Barcelona, Spain (L.S.R.)
| | - Philip White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom (P.W.)
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands (A.v.d.L.)
| | - Marc Ribo
- Department of Neurology, Hospital Vall d'Hebron, Barcelona, Spain (M.R.)
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, Université de Lorraine, Inserm, IADI, CHRU Nancy, France (S.B.)
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (P.J.M.)
| | - Stephen M Davis
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (F.C.N., N.Y., G.S., S.M.D., B.C.V.C.)
| | - Kevin N Sheth
- Department of Neurology, Yale New Haven Hospital, CT (K.N.S.)
| | - W Taylor Kimberly
- Center for Genomic Medicine and Department of Neurology, Massachusetts General Hospital, Boston (W.T.K.)
| | - Bruce C V Campbell
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (F.C.N., N.Y., G.S., S.M.D., B.C.V.C.)
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Derraz I, Ahmed R, Mourand I, Dargazanli C, Cagnazzo F, Gaillard N, Gascou G, Riquelme C, Lefevre PH, Bonafe A, Arquizan C, Costalat V. FLAIR vascular hyperintensities predict functional outcome after endovascular thrombectomy in patients with large ischemic cores. Eur Radiol 2022; 32:6136-6144. [PMID: 35394187 DOI: 10.1007/s00330-022-08683-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Revised: 02/03/2022] [Accepted: 02/20/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVES To establish whether collateral circulation was associated with functional outcome in stroke patients with large infarct size (Alberta Stroke Program Early CT Score [ASPECTS] ≤ 5) undergoing endovascular thrombectomy (EVT) METHODS: Consecutive patients with acute ischemic stroke due to large-vessel occlusion in the anterior circulation and an ASPECTS of ≤ 5 were analyzed. Quantification of collateral circulation was performed using a fluid-attenuated inversion recovery vascular hyperintensity (FVH)-ASPECTS rating system (score ranging from 0 [no FVH] to 7 [FVHs abutting all ASPECTS cortical areas]) by two independent neuroradiologists. Good functional outcome was defined by modified Rankin Scale (mRS) score of 0 to 3 at 3 months. We determined the association between FVH score and clinical outcome using multivariable regression analyses. RESULTS A total of 139 patients (age, 63.1 ± 20.8 years; men, 51.8%) admitted between March 2012 and December 2017 were included. Good functional outcome (mRS 0-3) was observed in 65 (46.8%) patients, functional independence (mRS 0-2) was achieved in 43 (30.9%) patients, and 33 (23.7%) patients died at 90 days. The median FVH score was 4 (IQR, 3-5). FVH score was independently correlated with good outcome (adjusted OR = 1.41 [95% CI, 1.03-1.92]; p = 0.03 per 1-point increase). CONCLUSIONS In stroke patients with large-volume infarcts, good collaterals as measured by the FVH-ASPECTS rating system are associated with improved outcomes and may help select patients for reperfusion therapy. KEY POINTS • Endovascular thrombectomy can allow almost 1 in 2 patients with large infarct cores to achieve good functional outcome (modified Rankin Scale [mRS] of 0-3) and 1 in 3 patients to regain functional independence (mRS 0-2) at 3 months. • The extent of FVH score (as reflected by FLAIR vascular hyperintensity [FVH]-Alberta Stroke Program Early CT Score [ASPECTS] values) is associated with functional outcome at 3 months in this patient group.
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Affiliation(s)
- Imad Derraz
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France.
| | - Raed Ahmed
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Isabelle Mourand
- Department of Neurology, Hôpital Gui de Chauliac, Montpellier University Medical Center, Montpellier, France
| | - Cyril Dargazanli
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Federico Cagnazzo
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Nicolas Gaillard
- Department of Neurology, Hôpital Gui de Chauliac, Montpellier University Medical Center, Montpellier, France
| | - Gregory Gascou
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Carlos Riquelme
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Pierre-Henri Lefevre
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Alain Bonafe
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
| | - Caroline Arquizan
- Department of Neurology, Hôpital Gui de Chauliac, Montpellier University Medical Center, Montpellier, France
| | - Vincent Costalat
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier University Medical Center, 80, Avenue Augustin Fliche, Montpellier, France
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40
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New imaging score for outcome prediction in basilar artery occlusion stroke. Eur Radiol 2022; 32:4491-4499. [PMID: 35333974 DOI: 10.1007/s00330-022-08684-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2021] [Revised: 01/13/2022] [Accepted: 02/20/2022] [Indexed: 11/04/2022]
Abstract
OBJECTIVE In ischemic posterior circulation stroke, the utilization of standardized image scores is not established in daily clinical practice. We aimed to test a novel imaging score that combines the collateral status with the rating of the posterior circulation Acute Stroke Prognosis Early CT score (pcASPECTS). We hypothesized that this score (pcASCO) predicts functional outcome and malignant cerebellar edema (MCE). METHODS Ischemic stroke patients with acute BAO who received multimodal-CT and underwent thrombectomy on admission at two comprehensive stroke centers were analyzed. The posterior circulation collateral score by van der Hoeven et al was added to the pcASPECTS to define pcASCO as a 20-point score. Multivariable logistic regression analyses were performed to predict functional independence at day 90, assessed using modified Rankin Scale scores, and occurrence of MCE in follow-up CT using the established Jauss scale score as endpoints. RESULTS A total of 118 patients were included, of which 84 (71%) underwent successful thrombectomy. Based on receiver operating characteristic curve analysis, pcASCO ≥ 14 classified functional independence with higher discriminative power (AUC: 0.83, 95%CI: 0.71-0.91) than pcASPECTS (AUC: 0.74). In multivariable logistic regression analysis, pcASCO was significantly and independently associated with functional independence (aOR: 1.91, 95%CI: 1.25-2.92, p = 0.003), and MCE (aOR: 0.71, 95%CI: 0.53-0.95, p = 0.02). CONCLUSION The pcASCO could serve as a simple and feasible imaging tool to assess BAO stroke patients on admission and might be tested as a complementary tool to select patients for thrombectomy in uncertain situations, or to predict clinical outcome. KEY POINTS • The neurological assessment of basilar artery occlusion stroke patients can be challenging and there are yet no validated imaging scores established in daily clinical practice. • The pcASCO combines the rating of early ischemic changes with the status of the intracranial posterior circulation collaterals. • The pcASCO showed high diagnostic accuracy to predict functional outcome and malignant cerebellar edema and could serve as a simple and feasible imaging tool to support treatment selection in uncertain situations, or to predict clinical outcome.
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Broocks G, Meyer L, Ruppert C, Haupt W, Faizy TD, Van Horn N, Bechstein M, Kniep H, Elsayed S, Kemmling A, Barow E, Fiehler J, Hanning U. Effect of Intravenous Alteplase on Functional Outcome and Secondary Injury Volumes in Stroke Patients with Complete Endovascular Recanalization. J Clin Med 2022; 11:jcm11061565. [PMID: 35329891 PMCID: PMC8949925 DOI: 10.3390/jcm11061565] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2022] [Revised: 03/04/2022] [Accepted: 03/08/2022] [Indexed: 11/22/2022] Open
Abstract
Intravenous thrombolytic therapy with alteplase (IVT) is a standard of care in ischemic stroke, while recent trials investigating direct endovascular thrombectomy (EVT) approaches showed conflicting results. Yet, the effect of IVT on secondary injury volumes in patients with complete recanalization has not been analyzed. We hypothesized that IVT is associated with worse functional outcome and aggravated secondary injury volumes when administered to patients who subsequently attained complete reperfusion after EVT. Anterior circulation ischemic stroke patients with complete reperfusion after thrombectomy defined as thrombolysis in cerebral infarctions (TICI) scale 3 after thrombectomy admitted between January 2013–January 2021 were analyzed. Primary endpoints were the proportion of patients with functional independence defined as modified Rankin Scale (mRS) score 0–2 at day 90, and secondary injury volumes: Edema volume in follow-up imaging measured using quantitative net water uptake (NWU), and the rate of symptomatic intracerebral hemorrhage (sICH). A total of 219 patients were included and 128 (58%) patients received bridging IVT before thrombectomy. The proportion of patients with functional independence was 28% for patients with bridging IVT, and 34% for patients with direct thrombectomy (p = 0.35). The rate of sICH was significantly higher after bridging IVT (20% versus 7.7%, p = 0.01). Multivariable logistic and linear regression analysis confirmed the independent association of bridging IVT with sICH (aOR: 2.78, 95% CI: 1.02–7.56, p = 0.046), and edema volume (aOR: 8.70, 95% CI: 2.57–14.85, p = 0.006). Bridging IVT was associated with increased edema volume and risk for sICH as secondary injury volumes. The results of this study encourage direct EVT approaches, particularly in patients with higher likelihood of successful EVT.
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Affiliation(s)
- Gabriel Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
- Correspondence:
| | - Lukas Meyer
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Celine Ruppert
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Wolfgang Haupt
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Tobias D. Faizy
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Noel Van Horn
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Matthias Bechstein
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Helge Kniep
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Sarah Elsayed
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Andre Kemmling
- Department of Neuroradiology, Philipps-University Marburg, 35037 Marburg, Germany;
- Department of Neuroradiology, University Medical Center Schleswig-Holstein, Campus Lübeck, 23538 Lübeck, Germany
| | - Ewgenia Barow
- Department of Neurology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany;
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Uta Hanning
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
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Review of net water uptake in the management of acute ischemic stroke. Eur Radiol 2022; 32:5517-5524. [DOI: 10.1007/s00330-022-08658-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2021] [Revised: 01/24/2022] [Accepted: 02/12/2022] [Indexed: 12/15/2022]
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Wassélius J, Arnberg F, von Euler M, Wester P, Ullberg T. Endovascular thrombectomy for acute ischemic stroke. J Intern Med 2022; 291:303-316. [PMID: 35172028 DOI: 10.1111/joim.13425] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
This review describes the evolution of endovascular treatment for acute ischemic stroke, current state of the art, and the challenges for the next decade. The rapid development of endovascular thrombectomy (EVT), from the first attempts into standard of care on a global scale, is one of the major achievements in modern medicine. It was possible thanks to the establishment of a scientific framework for patient selection, assessment of stroke severity and outcome, technical development by dedicated physicians and the MedTech industry, including noninvasive imaging for patient selection, and radiological outcome evaluation. A series of randomized controlled trials on EVT in addition to intravenous thrombolytics, with overwhelmingly positive results for anterior circulation stroke within 6 h of onset regardless of patient characteristics with a number needed to treat of less than 3 for any positive shift in outcome, paved the way for a rapid introduction of EVT into clinical practice. Within the "extended" time window of 6-24 h, the effect has been even greater for patients with salvageable brain tissue according to perfusion imaging with a number needed to treat below 2. Even so, EVT is only available for a small portion of stroke patients, and successfully recanalized EVT patients do not always achieve excellent functional outcome. The major challenges in the years to come include rapid prehospital detection of stroke symptoms, adequate clinical and radiological diagnosis of severe ischemic stroke cases, enabling effective recanalization by EVT in dedicated angiosuites, followed by personalized post-EVT stroke care.
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Affiliation(s)
- Johan Wassélius
- Department of Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Lund University, Lund, Sweden
| | - Fabian Arnberg
- Department of Neuroradiology, Karolinska University Hospital, Solna, Sweden
| | - Mia von Euler
- School of Medicine, Örebro University, Örebro, SE-70182, Sweden
| | - Per Wester
- Department of Public Health and Clinical Science, Umeå University, Umeå, Sweden.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Teresa Ullberg
- Department of Medical Imaging and Physiology, Skåne University Hospital, Lund, Sweden.,Department of Clinical Sciences, Lund University, Lund, Sweden
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Fiehler J, Nawka MT, Meyer L. Persistent challenges in endovascular treatment decision-making for acute ischaemic stroke. Curr Opin Neurol 2022; 35:18-23. [PMID: 34812746 DOI: 10.1097/wco.0000000000001006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Although endovascular treatment (EVT) is the gold standard for treating acute stroke patients with large vessel occlusion (LVO), multiple challenges in decision-making for specific conditions persist. Recent evidence on a selection of patient subgroups will be discussed in this narrative review. RECENT FINDINGS Two randomized controlled trials (RCTs) have been published in EVT of basilar artery occlusion (BAO). Large single arm studies showed promising results in Patients with low Alberta stroke program early CT score (ASPECTS) and more distal vessel occlusions. Recent data confirm patients with low National Institutes of Health Stroke Scale (NIHSS) despite LVO to represent a heterogeneous and challenging patient group. SUMMARY The current evidence does not justify withholding EVT from BAO patients as none of the RCTs showed any signal of superiority of BMT alone vs. EVT. Patients with low ASPECTS, more distal vessel occlusions and patients with low NIHSS scores should be included into RCTs if possible. Without participation in a RCT, patients should be selected for EVT based on age, severity and type of neurological impairment, time since symptom onset, location of the ischaemic lesion and perhaps also results of advanced imaging.
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Affiliation(s)
- Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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45
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Sun PZ. Consistent depiction of the acidic ischemic lesion with APT MRI-Dual RF power evaluation of pH-sensitive image in acute stroke. Magn Reson Med 2022; 87:850-858. [PMID: 34590730 PMCID: PMC8627494 DOI: 10.1002/mrm.29029] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2021] [Revised: 07/31/2021] [Accepted: 09/09/2021] [Indexed: 02/03/2023]
Abstract
PURPOSE Amide proton transfer-weighted (APTw) MRI provides a non-invasive pH-sensitive image, complementing perfusion and diffusion imaging for refined stratification of ischemic tissue. Although the commonly used magnetization transfer (MT) asymmetry (MTRasym ) calculation reasonably corrects the direct RF saturation effect, it is susceptible to the concomitant semisolid macromolecular MT contribution. Therefore, this study aimed to compare the performance of MTRasym and magnetization transfer and relaxation-normalized APT (MRAPT) analyses under 2 representative experimental conditions. METHODS Multiparametric MRI scans were performed in a rodent model of acute stroke, including relaxation, diffusion, and Z spectral images under 2 representative RF levels of 0.75 and 1.5 µT. Both MTRasym and MRAPT values in the ischemic diffusion lesion and the contralateral normal areas were compared using correlation and Bland-Altman tests. In addition, the acidic lesion volumes were compared. RESULTS MRAPT measurements from the diffusion lesion under the 2 conditions were highly correlated (R2 = 0.97) versus MTRasym measures (R2 = 0.58). The pH lesion sizes determined from MRAPT analysis were in good agreement (178 ± 43 mm3 vs. 186 ± 55 mm3 for B1 of 0.75 and 1.5 µT, respectively). CONCLUSIONS The study demonstrated that MRAPT analysis could be generalized to moderately different RF amplitudes, providing a more consistent depiction of acidic lesions than the MTRasym analysis.
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Affiliation(s)
- Phillip Zhe Sun
- Athinoula A Martinos Center for Biomedical Imaging, Department of Radiology, Massachusetts General Hospital, Harvard Medical School, Boston, MA,Yerkes Imaging Center, Yerkes National Primate Research Center, Emory University, Atlanta GA,Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta GA,Corresponding Author: Phillip Zhe Sun, Ph.D., Department of Radiology and Imaging Sciences, Emory University School of Medicine, 954 Gatewood Road NE, Atlanta, GA 30329, Phone: (404) 727-7786; (404) 712-1667,
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Kunz WG, Sporns PB, Psychogios MN, Fiehler J, Chapot R, Dorn F, Grams A, Morotti A, Musolino P, Lee S, Kemmling A, Henkes H, Nikoubashman O, Wiesmann M, Jensen-Kondering U, Möhlenbruch M, Schlamann M, Marik W, Schob S, Wendl C, Turowski B, Götz F, Kaiser D, Dimitriadis K, Gersing A, Liebig T, Ricke J, Reidler P, Wildgruber M, Mönch S. Cost-Effectiveness of Endovascular Thrombectomy in Childhood Stroke: An Analysis of the Save ChildS Study. J Stroke 2022; 24:138-147. [PMID: 35135067 PMCID: PMC8829473 DOI: 10.5853/jos.2021.01606] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2021] [Accepted: 09/23/2021] [Indexed: 12/02/2022] Open
Abstract
Background and Purpose The Save ChildS Study demonstrated that endovascular thrombectomy (EVT) is a safe treatment option for pediatric stroke patients with large vessel occlusions (LVOs) with high recanalization rates. Our aim was to determine the long-term cost, health consequences and cost-effectiveness of EVT in this patient population.
Methods In this retrospective study, a decision-analytic Markov model estimated lifetime costs and quality-adjusted life years (QALYs). Early outcome parameters were based on the entire Save ChildS Study to model the EVT group. As no randomized data exist, the Save ChildS patient subgroup with unsuccessful recanalization was used to model the standard of care group. For modeling of lifetime estimates, pediatric and adult input parameters were obtained from the current literature. The analysis was conducted in a United States setting applying healthcare and societal perspectives. Probabilistic sensitivity analyses were performed. The willingness-to-pay threshold was set to $100,000 per QALY.
Results The model results yielded EVT as the dominant (cost-effective as well as cost-saving) strategy for pediatric stroke patients. The incremental effectiveness for the average age of 11.3 years at first stroke in the Save ChildS Study was determined as an additional 4.02 lifetime QALYs, with lifetime cost-savings that amounted to $169,982 from a healthcare perspective and $254,110 when applying a societal perspective. Acceptability rates for EVT were 96.60% and 96.66% for the healthcare and societal perspectives.
Conclusions EVT for pediatric stroke patients with LVOs resulted in added QALY and reduced lifetime costs. Based on the available data in the Save ChildS Study, EVT is very likely to be a cost-effective treatment strategy for childhood stroke.
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Affiliation(s)
- Wolfgang G. Kunz
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
- Correspondence: Wolfgang G. Kunz Department of Radiology, University Hospital, LMU Munich, Marchioninistr 15, 81377 Munich, Germany Tel: +49-89-4400-73630 Fax: +49-89-4400-78832 E-mail:
| | - Peter B. Sporns
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Switzerland
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marios N. Psychogios
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Switzerland
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - René Chapot
- Department of Neuroradiology, Alfried-Krupp Hospital, Essen, Germany
| | - Franziska Dorn
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Astrid Grams
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Andrea Morotti
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, Brescia, Italy
| | - Patricia Musolino
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Sarah Lee
- Division of Child Neurology, Department of Neurology, Stanford University, Stanford, CA, USA
| | - André Kemmling
- Department for Neuroradiology, University Hospital Marburg, Marburg, Germany
| | - Hans Henkes
- Department of Neuroradiology, Klinikum Stuttgart, Stuttgart, Germany
| | | | - Martin Wiesmann
- Department of Neuroradiology, Aachen University, Aachen, Germany
| | - Ulf Jensen-Kondering
- Department of Radiology and Neuroradiology, University Hospital of Schleswig-Holstein, Kiel, Germany
| | - Markus Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Marc Schlamann
- Department of Neuroradiology, University Hospital of Cologne, Cologne, Germany
| | - Wolfgang Marik
- Division of Neuroradiology and Musculoskeletal Radiology, Department of Biomedical Imaging and Image-guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Stefan Schob
- Department for Neuroradiology, University Hospital Leipzig, Leipzig, Germany
| | - Christina Wendl
- Department of Radiology, University Hospital Regensburg, Regensburg, Germany
| | - Bernd Turowski
- Institute of Neuroradiology, University Hospital Duesseldorf, Duesseldorf, Germany
| | - Friedrich Götz
- Department of Diagnostic and Interventional Neuroradiology, Hannover Medical School, Hannover, Germany
| | - Daniel Kaiser
- Department of Neuroradiology, University Hospital Carl Gustav Carus, Dresden, Germany
| | | | - Alexandra Gersing
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital, LMU Munich, Munich, Germany
| | - Thomas Liebig
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital, LMU Munich, Munich, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Paul Reidler
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Moritz Wildgruber
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
| | - Sebastian Mönch
- Department of Radiology, University Hospital, LMU Munich, Munich, Germany
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47
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Kim BK, Kim B, You SH. Clinical Relevance of Computed Tomography Perfusion-Estimated Infarct Volume in Acute Ischemic Stroke Patients within the 6-h Therapeutic Time Window. Cerebrovasc Dis 2022; 51:438-446. [PMID: 35066495 DOI: 10.1159/000519901] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2021] [Accepted: 09/24/2021] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Although the estimated infarct volume on baseline computed tomography perfusion (CTP) can identify patients who are likely to benefit from endovascular thrombectomy (EVT) in late time window strokes, the role of CTP imaging in early time windows has not been established. We assessed the clinical impact of CTP-estimated infarct volume on long-term prognosis after EVT, particularly in patients with early time window stroke. METHODS We retrospectively reviewed patients who underwent pretreatment CTP and EVT for large vessel occlusion in the anterior circulation within 6 h after symptom onset between March 2014 and February 2019. The infarct volume at baseline CTP was estimated using commercially available software (RAPID, iSchemaView, Menlo Park, CA, USA) with a cerebral blood flow threshold <30% of the normal brain. Risk factors for poor outcome after EVT were evaluated, and a receiver operating characteristic (ROC) curve analysis was used to identify CTP-estimated infarct volumes that optimally predicted the development of symptomatic intracranial hemorrhage (sICH) and poor outcomes (modified Rankin Scale [mRS] 3-6) at 90 days. RESULTS Of 120 patients, successful recanalization was achieved in 89 (74.2%) patients, while 61 (50.8%) showed poor outcomes at 90 days. Among 89 patients with successful recanalization after EVT, age, diabetes, clinical stroke severity, CTP-estimated infarct volume, and sICH development were independently associated with 90-day clinical outcomes. ROC analysis identified infarct volumes of ≥88.5 mL and ≥74 mL as the optimal thresholds for predicting poor outcome and development of sICH, respectively. Patients with large infarct volumes showed poorer outcomes (odds ratio [OR], 7.704; 95% confidence interval [CI], 1.528-38.839) and higher rates of sICH development (OR, 10.857; 95% CI, 1.835-64.235). Among patients with large infarction volumes (≥88.5 mL), the 90-day mRS demonstrated a shift toward better outcomes in patients with successful recanalization. CONCLUSION Larger initial infarct volumes are significantly associated with worse clinical outcomes in patients who underwent EVT because of early time window stroke. Furthermore, our study of 6-h data demonstrated that an initial infarction of more than a certain volume might be an independent risk factor for sICH development and poor outcomes even in patients with successful recanalization. However, we still observed benefits of EVT in patients with large ischemic cores. The CTP-estimated infarct volume might be an important prognostic factor after EVT rather than a biomarker predicting treatment effectiveness.
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Affiliation(s)
- Bo Kyu Kim
- Department of Radiology, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Byungjun Kim
- Department of Radiology, Korea University Anam Hospital, Seoul, Republic of Korea
| | - Sung-Hye You
- Department of Radiology, Korea University Anam Hospital, Seoul, Republic of Korea
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48
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Broocks G, Meyer L, McDonough R, Bechstein M, Hanning U, Fiehler J, Kemmling A. The Benefit of Thrombectomy in Patients With Low ASPECTS Is a Matter of Shades of Gray—What Current Trials May Have Missed. Front Neurol 2022; 12:718046. [PMID: 35095708 PMCID: PMC8795604 DOI: 10.3389/fneur.2021.718046] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 12/06/2021] [Indexed: 11/13/2022] Open
Abstract
Randomized trials supporting the benefit of endovascular treatment in acute ischemic stroke patients with a large early infarction are not yet available. Few retrospective studies exist that suggest a potential positive treatment effect on functional outcome, as well as procedural safety. However, potential benefit or harm of MT in patients with low initial ASPECTS is still a subject of current debate, and in particular, how to select these patients for treatment. The purpose of this pilot study was to evaluate how early tissue water uptake in acute ischemic brain might determine lesion fate and functional outcome in low ASPECTS patients undergoing MT. We observed that the degree of early water uptake measured by quantitative NWU was significantly associated with functional outcome in low ASPECTS patients, yielding a higher diagnostic power compared to other parameters such as ASPECTS, age, or NIHSS. No conclusive evidence of a beneficial effect of successful reperfusion was observed in patients with low ASPECTS and high NWU, which highlights the potential of NWU as a tool to specify patient selection.
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Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- *Correspondence: Gabriel Broocks
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andre Kemmling
- Department of Neuroradiology, University Hospital Schleswig-Holstein, Lübeck, Germany
- Department of Neuroradiology, University of Marburg, Marburg, Germany
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49
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van Horn N, Heit JJ, Kabiri R, Broocks G, Christensen S, Mlynash M, Meyer L, Schoenfeld MH, Lansberg MG, Albers GW, Fiehler J, Wintermark M, Faizy TD. Venous outflow profiles are associated with early edema progression in ischemic stroke. Int J Stroke 2022; 17:1078-1084. [PMID: 34983276 DOI: 10.1177/17474930211065635] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND In patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO), development of extensive early ischemic brain edema is associated with poor functional outcomes, despite timely treatment. Robust cortical venous outflow (VO) profiles correlate with favorable tissue perfusion. We hypothesized that favorable VO profiles (VO+) correlate with a reduced early edema progression rate (EPR) and good functional outcomes. METHODS Multicenter, retrospective analysis to investigate AIS-LVO patients treated by mechanical thrombectomy between May 2013 and December 2020. Baseline computed tomography angiography (CTA) was used to determine VO using the cortical vein opacification score (COVES); VO+ was defined as COVES ⩾ 3 and unfavorable as COVES ⩽ 2. EPR was determined as the ratio of net water uptake (NWU) on baseline non-contrast CT and time from symptom onset to admission imaging. Multivariable regression analysis was performed to assess primary (EPR) and secondary outcome (good functional outcomes defined as 0-2 points on the modified Rankin scale). RESULTS A total of 728 patients were included. Primary outcome analysis showed VO+ (β: -0.03, SE: 0.009, p = 0.002), lower presentation National Institutes of Health Stroke Scale (NIHSS; β: 0.002, SE: 0.001, p = 0.002), and decreased time from onset to admission imaging (β: -0.00002, SE: 0.00004, p < 0.001) were independently associated with reduced EPR. VO+ also predicted good functional outcomes (odds ratio (OR): 5.07, 95% CI: 2.839-9.039, p < 0.001), while controlling for presentation NIHSS, time from onset to imaging, general vessel reperfusion, baseline Alberta Stroke Program Early CT Score, infarct core volume, EPR, and favorable arterial collaterals. CONCLUSIONS Favorable VO profiles were associated with slower infarct edema progression and good long-term functional outcomes as well as better neurological status and ischemic brain alterations at admission.
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Affiliation(s)
- Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Reza Kabiri
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Soren Christensen
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Michael Mlynash
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Maarten G Lansberg
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Gregory W Albers
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, Stanford, CA, USA
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Max Wintermark
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
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50
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Ng FC, Churilov L, Yassi N, Kleinig TJ, Thijs V, Wu TY, Shah DG, Dewey HM, Sharma G, Desmond PM, Yan B, Parsons MW, Donnan GA, Davis SM, Mitchell PJ, Leigh R, Campbell BCV. Microvascular Dysfunction in Blood-Brain Barrier Disruption and Hypoperfusion Within the Infarct Posttreatment Are Associated With Cerebral Edema. Stroke 2021; 53:1597-1605. [PMID: 34937423 DOI: 10.1161/strokeaha.121.036104] [Citation(s) in RCA: 37] [Impact Index Per Article: 12.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Factors contributing to cerebral edema in the post-hyperacute period of ischemic stroke (first 24-72 hours) are poorly understood. Blood-brain barrier (BBB) disruption and postischemic hyperperfusion reflect microvascular dysfunction and are associated with hemorrhagic transformation. We investigated the relationships between BBB integrity, cerebral blood flow, and space-occupying cerebral edema in patients who received acute reperfusion therapy. METHODS We performed a pooled analysis of patients treated for anterior circulation large vessel occlusion in the EXTEND-IA TNK and EXTEND-IA TNK part 2 trials who had MRI with dynamic susceptibility contrast-enhanced perfusion-weighted imaging 24 hours after treatment. We investigated the associations between BBB disruption and cerebral blood flow within the infarct with cerebral edema assessed using 2 metrics: first midline shift (MLS) trichotomized as an ordinal scale of negligible (<1 mm), mild (≥1 to <5 mm), or severe (≥5 mm), and second relative hemispheric volume (rHV), defined as the ratio of the 3-dimensional volume of the ischemic hemisphere relative to the contralateral hemisphere. RESULTS Of 238 patients analyzed, 133 (55.9%) had negligible, 93 (39.1%) mild, and 12 (5.0%) severe MLS at 24 hours. The associated median rHV was 1.01 (IQR, 1.00-1.028), 1.03 (IQR, 1.01-1.077), and 1.15 (IQR, 1.08-1.22), respectively. MLS and rHV were associated with poor functional outcome at 90 days (P<0.002). Increased BBB permeability was independently associated with more edema after adjusting for age, occlusion location, reperfusion, parenchymal hematoma, and thrombolytic agent used (MLS cOR, 1.12 [95% CI, 1.03-1.20], P=0.005; rHV β, 0.39 [95% CI, 0.24-0.55], P<0.0001), as was reduced cerebral blood flow (MLS cOR, 0.25 [95% CI, 0.10-0.58], P=0.001; rHV β, -2.95 [95% CI, -4.61 to -11.29], P=0.0006). In subgroup analysis of patients with successful reperfusion (extended Treatment in Cerebral Ischemia 2b-3, n=200), reduced cerebral blood flow remained significantly associated with edema (MLS cOR, 0.37 [95% CI, 0.14-0.98], P=0.045; rHV β, -2.59 [95% CI, -4.32 to -0.86], P=0.004). CONCLUSIONS BBB disruption and persistent hypoperfusion in the infarct after reperfusion treatment is associated with space-occupying cerebral edema. Further studies evaluating microvascular dysfunction during the post-hyperacute period as biomarkers of poststroke edema and potential therapeutic targets are warranted.
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Affiliation(s)
- Felix C Ng
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.D., S.M.D., B.C.V.C.).,The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia (F.C.N., V.T.)
| | - Leonid Churilov
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.D., S.M.D., B.C.V.C.).,Department of Neurology, Austin Hospital, Austin Health, Heidelberg, Australia (L.C., V.T., B.C.V.C.).,Melbourne Medical School, The University of Melbourne, Heidelberg, Australia (L.C.)
| | - Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.D., S.M.D., B.C.V.C.).,Population Health and Immunity Division. The Walter and Eliza Hall Institute of Medical Research. Parkville, Australia (N.Y.)
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Australia (T.J.K.)
| | - Vincent Thijs
- The Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia (F.C.N., V.T.).,Department of Neurology, Austin Hospital, Austin Health, Heidelberg, Australia (L.C., V.T., B.C.V.C.)
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, New Zealand (T.Y.W.)
| | - Darshan G Shah
- Department of Neurology, Princess Alexandra Hospital, Brisbane, Australia (D.G.S.)
| | - Helen M Dewey
- Eastern Health and Eastern Health Clinical School, Department of Neurosciences, Monash University, Clayton, Australia (H.M.D.)
| | - Gargan Sharma
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.D., S.M.D., B.C.V.C.)
| | - Patricia M Desmond
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (P.M.D., B.Y., P.J.M.)
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.D., S.M.D., B.C.V.C.).,Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (P.M.D., B.Y., P.J.M.)
| | - Mark W Parsons
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.D., S.M.D., B.C.V.C.)
| | - Geoffrey A Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.D., S.M.D., B.C.V.C.)
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.D., S.M.D., B.C.V.C.)
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (P.M.D., B.Y., P.J.M.)
| | - Richard Leigh
- Department of Neurology, John Hopkins University, Baltimore, MD (R.L.)
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Australia (F.C.N., L.C., N.Y., G.S., B.Y., M.W.P., G.A.D., S.M.D., B.C.V.C.).,Department of Neurology, Austin Hospital, Austin Health, Heidelberg, Australia (L.C., V.T., B.C.V.C.)
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