1
|
Mistry EA, Khoury JC, Kleindorfer DO, Kissela BM, Alwell KS, Jasne AS, Ferioli S, De Los Rios La Rosa F, Coleman E, Demel SL, Walsh KB, Slavin SJ, Star M, Haverbusch M, Mackey J, Woo D, Aziz YN, Heldner MR, Fischer U, Jadhav AP, Jovin TG, Albers GW, Nogueira RG, Khatri P. Projections of Endovascular Therapy-Eligible Patients With Stroke for the US Population. Stroke 2024; 55:2011-2019. [PMID: 38934124 DOI: 10.1161/strokeaha.123.045766] [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: 12/13/2023] [Accepted: 05/08/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND As stroke endovascular thrombectomy (EVT) treatment indications expand, understanding population-based EVT eligibility becomes critical for resource planning. We aimed to project current and future population-based EVT eligibility in the United States. METHODS We conducted a post hoc analysis of the physician-adjudicated GCNKSS (Greater Cincinnati Northern Kentucky Stroke Study; 2015 epoch), a population-based, cross sectional, observational study of stroke incidence, treatment, and outcomes across a 5-county region. All hospitalized patients ≥18 years of age with acute ischemic stroke were ascertained using the International Classification of Diseases, Ninth Revision codes 430-436 and Tenth Revision codes I60-I67 and G45-G46 and extrapolated to the US adult census 2020. We determined the rate of EVT eligibility within the GCNKSS population using time from last known well to presentation (0-5 versus 5-23 hours), presenting National Institutes of Health Stroke Scale, and prestroke modified Rankin Scale. Both conservative and liberal estimates of prevalence of large vessel occlusion and large core were then applied based on literature review (unavailable within the 2015 GCNKSS). This eligibility was then extrapolated to the 2020 US population. RESULTS Of the 1 057 183 adults within GCNKSS in 2015, 2741 had an ischemic stroke and 2176 had data available for analysis. We calculated that 8659 to 17 219 patients (conservative to liberal) meet the current guideline-recommended EVT criteria (nonlarge core, no prestroke disability, and National Institutes of Health Stroke Scale score ≥6) in the United States. Estimates (conservative to liberal) for expanded EVT eligibility subpopulations include (1) 5316 to 10 635 by large core; (2) 10 635 to 21 270 by mild presenting deficits with low National Institutes of Health Stroke Scale score; (3) 13 572 to 27 089 by higher prestroke disability; and (4) 7039 to 14 180 by >1 criteria. These expanded eligibility subpopulations amount to 36 562 to 73 174 patients. CONCLUSIONS An estimated 8659 to 17 219 adult patients in the United States met strict EVT eligibility criteria in 2020. A 4-fold increase in population-based EVT eligibility can be anticipated with incremental adoption of recent or future positive trials. US stroke systems need to be rapidly optimized to handle all EVT-eligible patients with stroke.
Collapse
Affiliation(s)
- Eva A Mistry
- Department of Neurology and Rehabilitation Medicine (E.A.M., B.M.K., K.S.A., S.F., S.L.D., M.H., D.W., Y.N.A., P.K.), University of Cincinnati, OH
| | - Jane C Khoury
- Division of Biostatistics and Epidemiology, Department of Pediatrics, Cincinnati Children's Hospital, University of Cincinnati Medical Center, OH (J.C.K.)
| | | | - Brett M Kissela
- Department of Neurology and Rehabilitation Medicine (E.A.M., B.M.K., K.S.A., S.F., S.L.D., M.H., D.W., Y.N.A., P.K.), University of Cincinnati, OH
| | - Kathleen S Alwell
- Department of Neurology and Rehabilitation Medicine (E.A.M., B.M.K., K.S.A., S.F., S.L.D., M.H., D.W., Y.N.A., P.K.), University of Cincinnati, OH
| | - Adam S Jasne
- Department of Neurology, Yale University, New Haven, CT (A.S.J.)
| | - Simona Ferioli
- Department of Neurology and Rehabilitation Medicine (E.A.M., B.M.K., K.S.A., S.F., S.L.D., M.H., D.W., Y.N.A., P.K.), University of Cincinnati, OH
| | | | | | - Stacie L Demel
- Department of Neurology and Rehabilitation Medicine (E.A.M., B.M.K., K.S.A., S.F., S.L.D., M.H., D.W., Y.N.A., P.K.), University of Cincinnati, OH
| | - Kyle B Walsh
- Department of Emergency Medicine (K.B.W.), University of Cincinnati, OH
| | - Sabreena J Slavin
- Department of Neurology, University of Kansas Medical Center (S.J.S.)
| | - Michael Star
- Department of Neurology, Soroka Medical Center, Beersheva, Israel (M.S.)
| | - Mary Haverbusch
- Department of Neurology and Rehabilitation Medicine (E.A.M., B.M.K., K.S.A., S.F., S.L.D., M.H., D.W., Y.N.A., P.K.), University of Cincinnati, OH
| | - Jason Mackey
- Department of Neurology, Indiana University School of Medicine, Indianapolis (J.M.)
| | - Daniel Woo
- Department of Neurology and Rehabilitation Medicine (E.A.M., B.M.K., K.S.A., S.F., S.L.D., M.H., D.W., Y.N.A., P.K.), University of Cincinnati, OH
| | - Yasmin N Aziz
- Department of Neurology and Rehabilitation Medicine (E.A.M., B.M.K., K.S.A., S.F., S.L.D., M.H., D.W., Y.N.A., P.K.), University of Cincinnati, OH
| | - Mirjam R Heldner
- Stroke Research Center Bern, University Hospital Bern and University of Bern, Switzerland (M.R.H.)
| | - Urs Fischer
- Department of Neurology, University Hospital Basel and University of Basel, Switzerland (U.F.)
| | | | - Tudor G Jovin
- Department of Neurology, Cooper University, Camden, NJ (T.G.J.)
| | | | - Raul G Nogueira
- Department of Neurology, University of Pittsburgh, PA (R.G.N.)
| | - Pooja Khatri
- Department of Neurology and Rehabilitation Medicine (E.A.M., B.M.K., K.S.A., S.F., S.L.D., M.H., D.W., Y.N.A., P.K.), University of Cincinnati, OH
| |
Collapse
|
2
|
Pei Y, Chen Y, Zhong W, He Y, Luo Z, Lou M, Chen Z. Effect of computed tomography vs. computed tomography perfusion on mechanical thrombectomy outcomes within 6 hours. Eur Radiol 2024; 34:5331-5338. [PMID: 38175220 DOI: 10.1007/s00330-023-10545-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2023] [Revised: 11/12/2023] [Accepted: 11/25/2023] [Indexed: 01/05/2024]
Abstract
OBJECTIVES It is unclear which selection strategy, plain CT vs. CT perfusion (CTP), is more powerful in predicting outcome after mechanical thrombectomy (MT). We aimed to compare the effect of plain CT and CTP in predicting outcome after MT within 6 h. METHODS We conducted a prospective analysis of a retrospective cohort from our single-center study, which had occlusion of the internal carotid artery and middle cerebral artery up to the proximal M2 segment and received MT within 6 h. According to the Alberta Stroke Program Early CT Score (ASPECTS), patients were divided into a high-ASPECTS group (≥ 6) and a low ASPECTS group (< 6). Similarly, patients were divided into mismatch and no-mismatch groups according to the DEFUSE3 criteria for CTP. A good outcome was defined as a 90-day modified Rankin Scale (mRS) score of ≤ 3. Univariate and binary logistic regression analyses were used to investigate the association between different imaging modality and 90-day mRS score, and mortalities, respectively. RESULTS The high ASPECTS group included 307 patients (89.2%). The mismatch group included 189 (54.9%) patients meeting the DEFUSE3 criterion. Compared to the low ASPECTS group, the high ASPECTS group had a good outcome (odds ratio (OR), 2.285; [95% confidence interval (CI) (1.106, 4.723)], p = 0.026) and lower mortality (OR, 0.350; [95% CI (0.163, 0.752)], p = 0.007). However, there were no significant differences in good outcomes and mortality between the mismatch and no-mismatch groups. CONCLUSIONS Compared with plain CT, CTP does not provide additional benefits in the selection of patients suitable for MT within 6 h. CLINICAL RELEVANCE STATEMENT CT perfusion is not superior to plain CT for the prediction of clinical outcomes when selecting patients for mechanical thrombectomy in the first 6 h. In that clinical setting, plain CT may be safe in the absence of perfusion data. KEY POINTS • The advantage of CT perfusion (CTP) over CT in pre-mechanical thrombectomy (MT) screening has not been proven for patients with a large infarct core. • CTP is not better than plain CT in predicting good outcome following MT within 6 h. • Plain CT is sufficient for selecting patients suitable for MT within 6 h of large artery occlusion.
Collapse
Affiliation(s)
- Yingjian Pei
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, 310009, China
| | - Yuping Chen
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, 310009, China
| | - Wansi Zhong
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, 310009, China
| | - Yaode He
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, 310009, China
| | - Zhongyu Luo
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, 310009, China
| | - Min Lou
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, 310009, China.
| | - Zhicai Chen
- Department of Neurology, The Second Affiliated Hospital of Zhejiang University, School of Medicine, Hangzhou, 310009, China.
| |
Collapse
|
3
|
Ameen D, Dewey HM, Khalil H. Strategies to reduce delays in delivering mechanical thrombectomy for acute ischaemic stroke - an umbrella review. Front Neurol 2024; 15:1390482. [PMID: 38952471 PMCID: PMC11215205 DOI: 10.3389/fneur.2024.1390482] [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: 02/23/2024] [Accepted: 05/23/2024] [Indexed: 07/03/2024] Open
Abstract
Background Mechanical thrombectomy is a time-sensitive treatment, with rapid initiation and reduced delays being associated with better patient outcomes. Several systematic reviews reported on various interventions to address delays. Hence, we performed an umbrella review of systematic reviews to summarise the current evidence. Methods Medline, Embase, Cochrane Library and JBI were searched for published systematic reviews. Systematic Reviews that detailed outcomes related to time-to-thrombectomy or functional independence were included. Methodological quality was assessed using the JBI critical appraisal tool by two independent reviewers. Results A total of 17 systematic reviews were included in the review. These were all assessed as high-quality reviews. A total of 13 reviews reported on functional outcomes, and 12 reviews reported on time-to-thrombectomy outcomes. Various interventions were identified as beneficial. The most frequently reported beneficial interventions that improved functional and time-related outcomes included: direct-to-angio-suite and using a mothership model (compared to drip-and-ship). Only a few studies investigated other strategies including other pre-hospital and teamwork strategies. Conclusion Overall, there were various strategies that can be used to reduce delays in the delivery of mechanical thrombectomy with different effectiveness. The mothership model appears to be superior to the drip-and-ship model in reducing delays and improving functional outcomes. Additionally, the direct-to-angiosuite approach appears to be beneficial, but further research is required for broader implementation of this approach and to determine which groups of patients would benefit the most.
Collapse
Affiliation(s)
- D. Ameen
- Faculty of Medicine, Nursing and Health Sciences, School of Medicine, Monash University, Clayton, VIC, Australia
| | - H. M. Dewey
- Department of Neurosciences, Eastern Health and Eastern Health Clinical School, Monash University, Box Hill, VIC, Australia
| | - H. Khalil
- Department of Public Health, School of Psychology and Public Health, Latrobe University, Bundoora, VIC, Australia
| |
Collapse
|
4
|
Adwane G, Lapergue B, Piotin M, Gory B, Blanc R, Consoli A, Rodesch G, Mazighi M, Kyheng M, Labreuche J, Pico F. Frequency and predictors of decompressive craniectomy in ischemic stroke patients treated by mechanical thrombectomy in the ETIS registry. Rev Neurol (Paris) 2024; 180:177-181. [PMID: 37863718 DOI: 10.1016/j.neurol.2023.08.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Revised: 08/09/2023] [Accepted: 08/30/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND AND AIMS Mechanical thrombectomy (MT) for patients with acute ischemic stroke (AIS) is usually performed in a comprehensive stroke center with on-site neurosurgical expertise. The question of whether MT can be performed in a primary stroke center without a neurosurgical facility is debated. In this context, there is a need to determine the frequency, delay and predictors of neurosurgical procedures in patients treated by MT. This study aims to determine these factors. METHODS In total, 432 patients under 60years old, diagnosed with an acute ischemic stroke with a large vessel occlusion and treated by MT between January 2018 and December 2019 in six French stroke centers, were selected from the French clinical registry ETIS. Univariate and multivariate logistic regression models were used to identify predictive factors for decompressive craniectomy. RESULTS Among the 432 included patients, 43 (9.9%) patients with an anterior circulation infarct underwent decompressive craniectomy. Higher admission NIHSS (OR: 1.08 [95% CI: 1.02-1.16]), lower ASPECT (OR per 1 point of decrease 1.53 [1.31-1.79] P<0.001) and preadmission antiplatelet use (OR: 3.03 [1.31-7.01]) were independent risk factors for decompressive craniectomy. The risk of decompressive craniectomy increases to more than 30% with an ASPECT score<4, an NIHSS>16, and current antiplatelet use. CONCLUSION In this multicenter registry, 9% of acute ischemic stroke patients (<60years old) treated with MT, required decompressive craniectomy. Higher NIHSS score, lower ASPECT score, and preadmission antiplatelet use increase the risk of subsequent requirement for decompressive craniectomy.
Collapse
Affiliation(s)
- G Adwane
- Department of Neurology and Stroke Center, Centre Hospitalier de Versailles, Versailles, France; Departement of Neurology and Stroke Center, Rothschild Foundation, Paris ,Fance.
| | - B Lapergue
- Neurology Department and Stroke Center, Foch Hospital, Suresnes, France
| | - M Piotin
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - B Gory
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, Nancy, France
| | - R Blanc
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France
| | - A Consoli
- Department of Diagnostic and Interventional Neuroradiology, Hopital Foch, Suresnes, France
| | - G Rodesch
- Department of Diagnostic and Interventional Neuroradiology, Hopital Foch, Suresnes, France
| | - M Mazighi
- Department of Interventional Neuroradiology, Rothschild Foundation, Paris, France; Paris Denis-Diderot University, Paris, France
| | - M Kyheng
- Lille University, CHU de Lille, EA 2694 - Santé publique: épidémiologie et qualité des soins, 59000 Lille, France
| | - J Labreuche
- Lille University, CHU de Lille, EA 2694 - Santé publique: épidémiologie et qualité des soins, 59000 Lille, France
| | - F Pico
- Department of Neurology and Stroke Center, Centre Hospitalier de Versailles, Versailles, France; Versailles Saint-Quentin-en-Yvelines and Paris Saclay University, Versailles, France; INSERM, Laboratory for Vascular Translational Science (LVTS)-1148, Paris, France
| |
Collapse
|
5
|
Patel K, Hamedani AG, Taneja K, Koneru M, Wolfe J, Sprankle K, Patel P, Mullen MT, Siegler JE. Differential thrombectomy utilization across hospital classifications in the United States. J Stroke Cerebrovasc Dis 2023; 32:107401. [PMID: 37897885 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107401] [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: 06/21/2023] [Revised: 09/11/2023] [Accepted: 09/29/2023] [Indexed: 10/30/2023] Open
Abstract
OBJECTIVES To determine hospital-level factors associated with thrombectomy uptake. MATERIALS AND METHODS The Nationwide Emergency Department Sample was retrospectively queried to determine the total number of thrombectomies performed based on different hospital characteristics. Joint point analysis was used to determine which years were associated with significant increases in the number of high-volume thrombectomy centers (ostensibly defined as >50 thrombectomies/year), thrombectomy-capable centers (>15 thrombectomies/year), and total number of thrombectomies performed. Multivariable logistic regression was used to determine hospital factors associated with having an increased odds of performing thrombectomies, and of being classified as a high-volume thrombectomy or a thrombectomy-capable center. RESULTS Between 2007-2020 there was a stepwise increase in the number of thrombectomy-capable and high-volume thrombectomy centers in the United States. In 2020, there were a total of 15,705 thrombectomies performed, with 89 high-volume thrombectomy centers, and 359 thrombectomy-capable centers. The number of thrombectomy-capable centers significantly increased after 2011. After 2013 and 2016 there was a significant change in the growth rate of high-volume thrombectomy centers. There was also a significant increase in the total number of thrombectomies performed after 2016. Hospital characteristics that were associated with an increased likelihood of being classified as thrombectomy-capable or high-volume included trauma level 1 and 2 hospitals. CONCLUSIONS Between 2007 and 2020, there was a marked growth in thrombectomy utilization for acute ischemic stroke. This growth outpaced new diagnoses of ischemic stroke, and was driven largely by certain hospital types, with the greatest rises following seminal publications of positive randomized thrombectomy trials.
Collapse
Affiliation(s)
- Karan Patel
- Cooper Medical School of Rowan University, Camden, NJ, USA.
| | - Ali G Hamedani
- Departments of Neurology and Ophthalmology and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kamil Taneja
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Manisha Koneru
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Jared Wolfe
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | | | - Pratit Patel
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
| | - Michael T Mullen
- Department of Neurology, Lewis Katz School of Medicine at Temple University, USA
| | - James E Siegler
- Cooper Medical School of Rowan University, Camden, NJ, USA; Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
| |
Collapse
|
6
|
Zhan Z, Gu F, Ji Y, Zhang Y, Ge Y, Wang Z. Thrombectomy with and without computed tomography perfusion imaging for large-vessel occlusion stroke in the extended time window: a meta-analysis of randomized clinical trials. Front Neurol 2023; 14:1185554. [PMID: 37669248 PMCID: PMC10470654 DOI: 10.3389/fneur.2023.1185554] [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: 03/13/2023] [Accepted: 07/27/2023] [Indexed: 09/07/2023] Open
Abstract
Objective In recent years, several studies have used computed tomography perfusion (CTP) to assess whether mechanical thrombectomy can be performed in patients with large-vessel occlusion (LVO) stroke in an extended time window. However, it has the disadvantage of being time-consuming and expensive. This study aimed to compare the impact of the CTP group with the non-CTP group [non-contrast CT (NCCT) ± CT angiography (CTA)] on the prognosis of this patient population. Methods A search of PubMed, EMBASE, and the Cochrane Library databases was conducted to collect randomized controlled trials (RCTs) comparing the two strategies. Outcome indicators and factors influencing prognosis were summarized by standardized mean differences, ratios, and relative risks with 95% confidence intervals using a random-effects model. Results A total of two RCTs were included in the combined analysis. There were no significant differences in the main outcome indicators (modified Rankin Scale score at 90 days, successful postoperative reperfusion rate) or the incidence of adverse events (90-day mortality and symptomatic intracranial hemorrhage) between the NCCT ± CTA and CTP groups. The time from the last puncture appeared to be significantly shorter in the NCCT ± CTA group than in the CTP group (SMD: -0.14; 95% CI: -0.24, -0.04). Among them, age (OR: 0.96; 95% CI: 0.94, 0.98), ASPECTS (OR: 1.18; 95% CI: 1.12, 1.24), NIHSS score (OR: 0.90; 95% CI: 0.89, 0.91), and diabetes (OR: 0.69; 95% CI: 0.54, 0.88) were associated with a 90-day independent functional outcome. Conclusion These findings suggest that the choice of NCCT ± CTA (without CTP) for the assessment of mechanical thrombectomy within 6-24 h after LVO in the anterior circulation is not significantly different from CTP; instead, the choice of NCCT ± CTA significantly reduces the time from onset to arterial puncture.
Collapse
Affiliation(s)
- Zheng Zhan
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Feng Gu
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yi Ji
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yu Zhang
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| | - Yi Ge
- Department of Neurology, The Affiliated Changzhou Second People's Hospital of Nanjing Medical University, Changzhou, Jiangsu, China
| | - Zhong Wang
- Department of Neurosurgery and Brain and Nerve Research Laboratory, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China
| |
Collapse
|
7
|
Moving from traditional to more advanced treatments in stroke care is cost-effective: A case study from Greece. J Stroke Cerebrovasc Dis 2022; 31:106764. [PMID: 36095859 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106764] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2022] [Accepted: 09/04/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES Stroke is the most common cause of disability in high-income countries. Several countries offer a limited range of advanced treatments with implications for outcomes, disability and costs. This study estimates the burden of disability that could have been avoided through the transition from traditional (no intravenous thrombolytic therapy (IVT), or endovascular thrombectomy (EVT)) to modern stroke treatments (treatment in stroke units, IVT and EVT). We perform a cost-effectiveness analysis comparing best practice with traditional stroke care, using Greece as a case study. MATERIALS AND METHODS A Markov model was used to calculate costs and Quality Adjusted Life Years (QALYs) for each treatment strategy, using a lifetime horizon. Data for model inputs were derived from meta-analyses of trials, and national and international cost databases. Sensitivity analyses were also performed to address potential uncertainty and test the robustness of the findings. RESULTS Incremental effectiveness comprised 0.22 QALYs per patient and year. Best practice was cost-effective for more than 90% of all iterations (ICER for the baseline scenario: €2,109.25/QALY). Sensitivity analysis demonstrated that the findings remain robust. Considering the stroke incidence in Greece, the annual additional cost to implement best practice was calculated to be between 0.07%-0.15% of the total health expenditure. CONCLUSION Best practice stroke treatment was cost-effective and affordable in a case study based on Greece. The results could be leveraged by including effects of preventive policies and rehabilitation. They also highlight the importance of adopting modern treatment strategies from a cost-effectiveness perspective, apart from the improved clinical outcomes.
Collapse
|
8
|
Lemmerman LR, Harris HN, Balch MHH, Rincon-Benavides MA, Higuita-Castro N, Arnold DW, Gallego-Perez D. Transient Middle Cerebral Artery Occlusion with an Intraluminal Suture Enables Reproducible Induction of Ischemic Stroke in Mice. Bio Protoc 2022; 12:e4305. [PMID: 35284595 PMCID: PMC8857907 DOI: 10.21769/bioprotoc.4305] [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: 11/24/2021] [Revised: 09/03/2021] [Accepted: 12/01/2021] [Indexed: 01/11/2023] Open
Abstract
Ischemic stroke is a leading cause of mortality and chronic disability worldwide, underscoring the need for reliable and accurate animal models to study this disease's pathology, molecular mechanisms of injury, and treatment approaches. As most clinical strokes occur in regions supplied by the middle cerebral artery (MCA), several experimental models have been developed to simulate an MCA occlusion (MCAO), including transcranial MCAO, micro- or macro-sphere embolism, thromboembolisation, photothrombosis, Endothelin-1 injection, and - the most common method for ischemic stroke induction in murine models - intraluminal MCAO. In the intraluminal MCAO model, the external carotid artery (ECA) is permanently ligated, after which a partially-coated monofilament is inserted and advanced proximally to the common carotid artery (CCA) bifurcation, before being introduced into the internal carotid artery (ICA). The coated tip of the monofilament is then advanced to the origin of the MCA and secured for the duration of occlusion. With respect to other MCAO models, this model offers enhanced reproducibility regarding infarct volume and cognitive/functional deficits, and does not require a craniotomy. Here, we provide a detailed protocol for the surgical induction of unilateral transient ischemic stroke in mice, using the intraluminal MCAO model. Graphic abstract: Overview of the intraluminal monofilament method for transient middle cerebral artery occlusion (MCAO) in mouse.
Collapse
Affiliation(s)
- Luke R. Lemmerman
- Department of Biomedical Engineering, The Ohio State University, Columbus, USA
| | - Hallie N. Harris
- Department of Neurology, The Ohio State University, Columbus, USA
| | | | - Maria A. Rincon-Benavides
- Department of Biomedical Engineering, The Ohio State University, Columbus, USA
,Biophysics Graduate Program, The Ohio State University, Columbus, USA
| | - Natalia Higuita-Castro
- Department of Biomedical Engineering, The Ohio State University, Columbus, USA
,Department of Surgery, The Ohio State University, Columbus, USA
| | - David W. Arnold
- Department of Neurology, The Ohio State University, Columbus, USA
| | - Daniel Gallego-Perez
- Department of Biomedical Engineering, The Ohio State University, Columbus, USA
,Department of Surgery, The Ohio State University, Columbus, USA
,*For correspondence:
| |
Collapse
|
9
|
Bulwa Z, Chen M. Stroke Center Designations, Neurointerventionalist Demand, and the Finances of Stroke Thrombectomy in the United States. Neurology 2021; 97:S17-S24. [PMID: 34785600 DOI: 10.1212/wnl.0000000000012780] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 11/24/2020] [Indexed: 11/15/2022] Open
Abstract
PURPOSE OF THE REVIEW This article aims to provide an update on the designation of stroke centers, neurointerventionalist demand, and cost-effectiveness of stroke thrombectomy in the United States. RECENT FINDINGS There are now more than 1,660 stroke centers certified by national accrediting bodies in the United States, 306 of which are designated as thrombectomy-capable or comprehensive stroke centers. Considering the amount of nationally certified centers and the number of patients with acute stroke eligible for thrombectomy, each center would be responsible for 64 to 104 thrombectomies per year. As a result, there is a growing demand placed on neurointerventionalists, who have the ability to alter the trajectory of large vessel occlusive strokes. Numbers needed to achieve functional independence after stroke thrombectomy at 90 days range from 3.2 to 7.4 patients in the early time window and 2.8 to 3.6 patients in the extended time window in appropriately selected candidates. With the low number needed to treat, in a variety of valued-based calculations and cost-effectiveness analyses, stroke thrombectomy has proved to be both clinically effective and cost-effective. SUMMARY Advancements in the early recognition and treatment of stroke have been paralleled by a remodeling of health care systems to ensure best practices in a timely manner. Stroke center-accrediting bodies provide oversight to safeguard these standards. As successful trial data from high volume centers transform into real-world experience, we must continue to re-evaluate cost-effectiveness, strike a balance between sufficient case volumes to maintain clinical excellence vs the burden and burnout associated with call responsibilities, and improve access to care for all.
Collapse
Affiliation(s)
- Zachary Bulwa
- From the Departments of Neurology (Z.B.) and Neurosurgery (M.C.), Rush University Medical Center, Chicago, IL.
| | - Michael Chen
- From the Departments of Neurology (Z.B.) and Neurosurgery (M.C.), Rush University Medical Center, Chicago, IL
| |
Collapse
|
10
|
Inam ME, Lekka E, Sheriff FG, Sanzgiri AA, Lopez-Rivera V, Barreto AD, Sheth SA, Artime C, Engstrom AC, Ambrocik A, Pedroza C, Savitz SI, Chen PR. Disparities among neurointerventionalists suggest further investigation of conscious sedation versus general anesthesia during thrombectomy for acute stroke. Brain Circ 2021; 7:201-206. [PMID: 34667904 PMCID: PMC8459687 DOI: 10.4103/bc.bc_19_21] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2021] [Revised: 05/12/2021] [Accepted: 06/11/2021] [Indexed: 11/25/2022] Open
Abstract
INTRODUCTION: Prior retrospective and case-control studies have shown that the use of general anesthesia (GA) during endovascular therapy (EVT) for acute ischemic stroke with large vessel occlusion (AIS-LVO) was independently associated with poor clinical outcomes compared with cases performed under conscious sedation (CS). Conversely, recent small randomized clinical trials (RCT) demonstrated a trend toward better outcome in cases performed under GA. METHODS: We submitted an online survey to 193 Society of Vascular Interventional Neurology and 78 American Association of Neurological Surgeons and Congress of Neurological Surgeons – Cerebrovascular Section neuroendovascular practitioners. Questions were aimed at understanding the current state of anesthesia practice during EVT, and to determine if there is clinical equipoise for a large multicenter RCT comparing GA versus CS during EVT. RESULTS: Between March and May of 2017, we received 116 (43%) responses. Anesthesiologists were responsible for managing 96% of the GA cases as compared to only 51% of the CS cases (P < 0.0001). Notable 56% of providers reported performing less than a quarter of their cases under GA. Only 7% performed all cases under GA compared with 17% who used solely CS (P = 0.048). More than half of respondents thought a new RCT was necessary, of whom 61% were interested in participating. Among interested responders, 59% were located in centers with 3 or more neurointerventionalists. CONCLUSION: The significant variation among neuroendovascular providers, added with the lack of consensus among recent trials and meta-analyses, demonstrate clinical equipoise for further studies to explore the effects of anesthesia during EVT in AIS-LVO.
Collapse
Affiliation(s)
- Mehmet Enes Inam
- Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA.,Department of Neurology, McGovern Medical School, Texas Institute for Restorative Neurotechnologies, University of Texas Health Science Center at Houston, TX, USA.,Department of Biomedical Informatics, School of Biomedical Informatics, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Elvira Lekka
- Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Faheem G Sheriff
- Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Aditya A Sanzgiri
- Research Operations and Conduct, University of Chicago, Chicago, Illinois, USA
| | - Victor Lopez-Rivera
- Department of Neurology, McGovern Medical School, Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Andrew D Barreto
- Department of Neurology, McGovern Medical School, Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Sunil A Sheth
- Department of Neurology, McGovern Medical School, Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Carlos Artime
- Department of Anesthesiology, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Allison C Engstrom
- Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Alexander Ambrocik
- Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Claudia Pedroza
- Department of Pediatrics, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Sean I Savitz
- Department of Neurology, McGovern Medical School, Institute for Stroke and Cerebrovascular Disease, University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Peng Roc Chen
- Department of Neurosurgery, McGovern Medical School, University of Texas Health Science Center at Houston, Houston, TX, USA
| |
Collapse
|
11
|
Ren Z, Ma G, Mokin M, Jadhav AP, Jia B, Tong X, Bauer C, Liu R, Wang A, Zhang X, Mo D, Ma N, Gao F, Song L, Sun X, Huo X, Deng Y, Liu L, Luo G, Luo X, Peng Y, Gui L, Song C, Wu J, Wang L, Li C, Jovin TG, Wang Y, Wang Y, Miao Z. Non-contrast head CT alone for thrombectomy in acute ischemic stroke: analysis of the ANGEL-ACT registry. J Neurointerv Surg 2021; 14:868-874. [PMID: 34599086 DOI: 10.1136/neurintsurg-2021-017940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/25/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUD The goal of this study was to determine if the choice of imaging paradigm performed in the emergency department influences the procedural or clinical outcomes after mechanical thrombectomy (MT). METHODS This is a retrospective comparative outcome study which was conducted from the ANGEL-ACT registry. Comparisons were made between baseline characteristics and clinical outcomes of patients with acute ischemic stroke undergoing MT with non-contrast head computed tomography (NCHCT) alone versus patients undergoing NCHCT plus non-invasive vessel imaging (NVI) (including CT angiography (with or without CT perfusion) and magnetic resonance angiography). The primary outcome was the modified Rankin Scale (mRS) score at 90 days. Secondary outcomes included change in mRS score from baseline to 90 days, the proportions of mRS 0-1, 0-2, and 0-3, and dramatic clinical improvement at 24 hours. The safety outcomes were any intracranial hemorrhage (ICH), symptomatic ICH, and mortality within 90 days. RESULTS A total of 894 patients met the inclusion criteria; 476 (53%) underwent NCHCT alone and 418 (47%) underwent NCHCT + NVI. In the NCHCT alone group, the door-to-reperfusion time was shorter by 47 min compared with the NCHCT + NVI group (219 vs 266 min, P<0.001). Patients in the NCHCT alone group showed a smaller increase in baseline mRS score at 90 days (median 3 vs 2 points; P=0.004) after adjustment. There were no significant differences between groups in the remaining clinical outcomes. CONCLUSIONS In patients selected for MT using NCHCT alone versus NCHCT + NVI, there were improved procedural outcomes and smaller increases in baseline mRS scores at 90 days.
Collapse
Affiliation(s)
- Zeguang Ren
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Gaoting Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Maxim Mokin
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | | | - Baixue Jia
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Clayton Bauer
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Raynald Liu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xuelei Zhang
- Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - 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
| | - Ligang Song
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xuan Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yiming Deng
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Lian Liu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gang Luo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiang Luo
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ya Peng
- Neurosurgery, The First People's Hospital of Changzhou,The Third Affiliated Hospital of Soochow University, Changzhou, China
| | - Liqiang Gui
- Interventional Neuroradiology, Langfang Changzheng Hospital, Langfang, Hebei, China
| | - Cunfeng Song
- Department of Interventional Neuroradiology, The Third People's Hospital of Liaocheng City, Liaocheng, China
| | - Jin Wu
- Neurology, Nanjing Medical University Second Affiliated Hospital, Nanjing, Jiangsu, China
| | - Leyuan Wang
- Interventional Neuroradiology Center, Changle People's Hospital, Weifang, China
| | - Chunlei Li
- Department of Neurology, The Second People's Hospital of Dongying City, Dongying, China
| | - Tudor G Jovin
- Cooper Neurologic Institute, Cooper University Hospital, Camden, New Jersey, USA
| | - Yilong Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | | |
Collapse
|
12
|
Martinez G, Katz JM, Pandya A, Wang JJ, Boltyenkov A, Malhotra A, Mushlin AI, Sanelli PC. Cost-Effectiveness Study of Initial Imaging Selection in Acute Ischemic Stroke Care. J Am Coll Radiol 2021; 18:820-833. [PMID: 33387454 PMCID: PMC8186007 DOI: 10.1016/j.jacr.2020.12.013] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/12/2020] [Revised: 12/04/2020] [Accepted: 12/06/2020] [Indexed: 12/18/2022]
Abstract
PURPOSE National guidelines recommend prompt identification of candidates for acute ischemic stroke (AIS) treatment, requiring timely neuroimaging with CT and/or MRI. CT is often preferred because of its widespread availability and rapid acquisition. Despite higher diagnostic accuracy of MRI, it commonly involves complex workflows that could potentially cause treatment time delays. The purpose of this study was to analyze the impact on outcomes of imaging utilization before treatment decisions at comprehensive stroke centers for patients presenting with suspected AIS in the anterior circulation with last-known-well-to-arrival time 0 to 24 hours. METHODS A decision simulation model based on the American Heart Association's recommendations for AIS care pathways was developed from a health care perspective to compare initial imaging strategies: (1) stepwise-CT: noncontrast CT (NCCT) at the time of presentation, with CT angiography (CTA) ± CT perfusion (CTP) only in select patients (initial imaging to exclude hemorrhage and extensive ischemia) for mechanical thrombectomy (MT) evaluation; (2) stepwise-hybrid: NCCT at the time of presentation, with MR angiography (MRA) ± MR perfusion (MRP) only for MT evaluation; (3) stepwise-advanced: NCCT + CTA at presentation, with MR diffusion-weighted imaging (MR DWI) + MRP only for MT evaluation; (4) comprehensive-CT: NCCT + CTA + CTP at the time of presentation; and (5) comprehensive-MR: MR DWI + MRA + MRP at the time of presentation. Model parameters were defined using evidence-based data. Cost-effectiveness and sensitivity analyses were performed. RESULTS The cost-effectiveness analyses revealed that comprehensive-CT and comprehensive-MR yield the highest lifetime quality-adjusted life-years (QALYs) (4.81 and 4.82, respectively). However, the incremental cost-effectiveness ratio of comprehensive-MR is $233,000/QALY compared with comprehensive-CT. Stepwise-CT, stepwise-hybrid, and stepwise-advanced strategies are dominated, yielding lower QALYs and higher costs compared with comprehensive-CT. CONCLUSIONS Performing comprehensive-CT at presentation is the most cost-effective initial imaging strategy at comprehensive stroke centers.
Collapse
Affiliation(s)
- Gabriela Martinez
- Siemens Healthineers, Malvern, Pennsylvania; Department of Radiology, Northwell Health, Manhasset, New York; Feinstein Institutes for Medical Research, Manhasset, New York.
| | - Jeffrey M Katz
- Chief, Neurovascular Services and Director Comprehensive Stroke Center at North Shore University Hospital, Department of Neurology, North Shore University Hospital, Manhasset, New York; Director of Neuroendovascular surgery, Neurology Service Line, Northwell Health, Manhasset, New York; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Ankur Pandya
- T. H. Trustee (unpaid), Society for Medical Decision Making, T.H Chan School of Public Health, Harvard University, Boston, Massachusetts
| | - Jason J Wang
- Feinstein Institutes for Medical Research, Manhasset, New York; Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| | - Artem Boltyenkov
- Siemens Healthineers, Malvern, Pennsylvania; Department of Radiology, Northwell Health, Manhasset, New York; Feinstein Institutes for Medical Research, Manhasset, New York
| | - Ajay Malhotra
- Radiology & Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut
| | - Alvin I Mushlin
- Healthcare Policy and Research, Weill Cornell Medical College, New York, New York
| | - Pina C Sanelli
- Department of Radiology, Northwell Health, Manhasset, New York; Feinstein Institutes for Medical Research, Manhasset, New York; Radiology & Biomedical Imaging, Yale School of Medicine, New Haven, Connecticut; Healthcare Policy and Research, Weill Cornell Medical College, New York, New York; Vice Chair of Research, Department of Radiology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Hempstead, New York
| |
Collapse
|
13
|
Sporns PB, Fiehler J, Ospel J, Safouris A, Hanning U, Fischer U, Goyal M, McTaggart R, Brehm A, Psychogios M. Expanding indications for endovascular thrombectomy-how to leave no patient behind. Ther Adv Neurol Disord 2021; 14:1756286421998905. [PMID: 33796144 PMCID: PMC7970189 DOI: 10.1177/1756286421998905] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 01/18/2021] [Indexed: 01/01/2023] Open
Abstract
Endovascular thrombectomy (EVT) has become standard of care for large vessel occlusion strokes but current guidelines exclude a large proportion of patients from this highly effective treatment. This review therefore focuses on expanding indications for EVT in several borderline indications such as patients in the extended time window, patients with extensive signs of infarction on admission imaging, elderly patients and patients with pre-existing deficits. It also discusses the current knowledge on intravenous thrombolysis as an adjunct to EVT and EVT as primary therapy for distal vessel occlusions, for tandem occlusions, for basilar artery occlusions and in pediatric patients. We provide clear recommendations based on current guidelines and further literature.
Collapse
Affiliation(s)
- Peter B. Sporns
- Department of Neuroradiology, Clinic for
Radiology & Nuclear Medicine, University Hospital Basel, Petersgraben 4,
Basel, 4031, Switzerland
- 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
| | - Johanna Ospel
- Department of Neuroradiology, Clinic for
Radiology & Nuclear Medicine, University Hospital Basel, Basel,
Switzerland
| | | | - Uta Hanning
- Department of Diagnostic and Interventional
Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg,
Germany
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern
University Hospital, University of Bern, Bern, Switzerland
| | - Mayank Goyal
- Department of Radiology, University of Calgary,
Calgary, AB, Canada
| | - Ryan McTaggart
- Department of Interventional Radiology, Warren
Alpert Medical School of Brown University, Providence, RI, USA
| | - Alex Brehm
- Department of Neuroradiology, Clinic for
Radiology & Nuclear Medicine, University Hospital Basel, Basel,
Switzerland
| | - Marios Psychogios
- Department of Neuroradiology, Clinic for
Radiology & Nuclear Medicine, University Hospital Basel, Basel,
Switzerland
| |
Collapse
|
14
|
Nogueira RG, Haussen DC, Liebeskind D, Jovin TG, Gupta R, Jadhav A, Budzik RF, Baxter B, Krajina A, Bonafe A, Malek A, Narata AP, Shields R, Zhang Y, Morgan P, Bartolini B, English J, Frankel MR, Veznedaroglu E. Stroke Imaging Selection Modality and Endovascular Therapy Outcomes in the Early and Extended Time Windows. Stroke 2021; 52:491-497. [PMID: 33430634 DOI: 10.1161/strokeaha.120.031685] [Citation(s) in RCA: 39] [Impact Index Per Article: 13.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Advanced imaging has been increasingly used for patient selection in endovascular stroke therapy. The impact of imaging selection modality on endovascular stroke therapy clinical outcomes in extended time window remains to be defined. We aimed to study this relationship and compare it to that noted in early-treated patients. METHODS Patients from a prospective multicentric registry (n=2008) with occlusions involving the intracranial internal carotid or the M1- or M2-segments of the middle cerebral arteries, premorbid modified Rankin Scale score 0 to 2 and time to treatment 0 to 24 hours were categorized according to treatment times within the early (0-6 hour) or extended (6-24 hour) window as well as imaging modality with noncontrast computed tomography (NCCT)±CT angiography (CTA) or NCCT±CTA and CT perfusion (CTP). The association between imaging modality and 90-day modified Rankin Scale, analyzed in ordinal (modified Rankin Scale shift) and dichotomized (functional independence, modified Rankin Scale score 0-2) manner, was evaluated and compared within and across the extended and early windows. RESULTS In the early window, 332 patients were selected with NCCT±CTA alone while 373 also underwent CTP. After adjusting for identifiable confounders, there were no significant differences in terms of 90-day functional disability (ordinal shift: adjusted odd ratio [aOR], 0.936 [95% CI, 0.709-1.238], P=0.644) or independence (aOR, 1.178 [95% CI, 0.833-1.666], P=0.355) across the CTP and NCCT±CTA groups. In the extended window, 67 patients were selected with NCCT±CTA alone while 180 also underwent CTP. No significant differences in 90-day functional disability (aOR, 0.983 [95% CI, 0.81-1.662], P=0.949) or independence (aOR, 0.640 [95% CI, 0.318-1.289], P=0.212) were seen across the CTP and NCCT±CTA groups. There was no interaction between the treatment time window (0-6 versus 6-24 hours) and CT selection modality (CTP versus NCCT±CTA) in terms of functional disability at 90 days (P=0.45). CONCLUSIONS CTP acquisition was not associated with better outcomes in patients treated in the early or extended time windows. While confirmatory data is needed, our data suggests that extended window endovascular stroke therapy may remain beneficial even in the absence of advanced imaging.
Collapse
Affiliation(s)
- Raul G Nogueira
- Department of Neurology, Emory University School of Medicine, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, GA (R.G.N., D.C.H., M.R.F.)
| | - Diogo C Haussen
- Department of Neurology, Emory University School of Medicine, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, GA (R.G.N., D.C.H., M.R.F.)
| | | | - Tudor G Jovin
- Department of Neurology, Cooper University Hospital Neurological Institute, Camden, NJ (T.G.J.)
| | - Rishi Gupta
- Department of Neurosciences, Wellstar Health System, Atlanta, GA (R.G.)
| | - Ashutov Jadhav
- Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center, PA (A.J.)
| | - Ron F Budzik
- Department of Interventional Neuroradiology, Riverside Methodist Hospital/Ohio Health Research Institute, Columbus (R.F.B.)
| | - Blaise Baxter
- Department of Radiology, Erlanger Hospital, Chattanooga, TN (B. Baxter)
| | - Antonin Krajina
- Department of Radiology, University Hospital Hradec Kralove, Czech Republic (A.K.)
| | - Alain Bonafe
- Department of Neuroradiology, CHU Montpellier, France (A.B.)
| | - Ali Malek
- St. Mary's Medical Center, West Palm Beach, FL (A.M.)
| | | | - Ryan Shields
- Stryker Neurovascular, Fremont, CA (R.S., Y.Z., P.M.)
| | | | | | - Bruno Bartolini
- Department of Interventional Radiology, La Pitie Salpetriere, Paris, France (B. Bartolini)
| | - Joey English
- Department of Neurology, California Pacific Medical Center, San Francisco (J.E.)
| | - Michael R Frankel
- Department of Neurology, Emory University School of Medicine, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, GA (R.G.N., D.C.H., M.R.F.)
| | - Erol Veznedaroglu
- Department of Neurosciences, Drexel Neurosciences Institute, Philadelphia, PA (E.V.)
| | | |
Collapse
|
15
|
Abstract
Endovascular therapy (EVT) has become the standard treatment for large-vessel occlusion (LVO) acute ischemic stroke (AIS). EVT is now indicated in patients up to 24h from their last known well, provided that the patient meets specific clinical and imaging criteria. Improvements in thrombectomy devices, techniques, and operator experience have allowed successful EVT of ICA terminus, M1-MCA occlusions as well as proximal M2-MCA, basilar artery occlusions, and revascularization of tandem lesions. Mechanical thrombectomy failures still occur due to several factors, however, highlighting the need for further device and technical improvements. An ongoing debate exists regarding the need for pre-EVT thrombolytic agents, thrombectomy techniques, distal occlusions, anesthesia methods, the role of advanced neuroimaging, the treatment of patients with larger infarct core, and those presenting with milder stroke symptoms. Many of these questions are the subject of current or upcoming clinical trials. This review aims to provide an outline and discussion about the established recommendations and emerging topics regarding EVT for LVO AIS.
Collapse
Affiliation(s)
- Fabio Settecase
- Neuroradiology Division, Department of Radiology, University of British Columbia, Vancouver, BC, Canada; Diagnostic and Interventional Neuroradiology Division, Department of Radiology, Vancouver General Hospital, Vancouver, BC, Canada; Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, United States.
| |
Collapse
|
16
|
Kunz WG, Hunink MG, Almekhlafi MA, Menon BK, Saver JL, Dippel DWJ, Majoie CBLM, Jovin TG, Davalos A, Bracard S, Guillemin F, Campbell BCV, Mitchell PJ, White P, Muir KW, Brown S, Demchuk AM, Hill MD, Goyal M. Public health and cost consequences of time delays to thrombectomy for acute ischemic stroke. Neurology 2020; 95:e2465-e2475. [PMID: 32943483 DOI: 10.1212/wnl.0000000000010867] [Citation(s) in RCA: 38] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 06/12/2020] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine public health and cost consequences of time delays to endovascular thrombectomy (EVT) for patients, health care systems, and society, we estimated quality-adjusted life-years (QALYs) of EVT-treated patients and associated costs based on times to treatment. METHODS The Markov model analysis was performed from US health care and societal perspectives over a lifetime horizon. Contemporary data from 7 trials within the Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials (HERMES) collaboration served as data source. Aside from cumulative lifetime costs, we calculated the net monetary benefit (NMB) to determine the economic value of care. We used a contemporary willingness-to-pay threshold of $100,000 per QALY for NMB calculations. RESULTS Every 10 minutes of earlier treatment resulted in an average gain of 39 days (95% prediction interval 23-53 days) of disability-free life. Overall, the cumulative lifetime costs for patients with earlier or later treatment were similar. Patients with later treatment had higher morbidity-related costs but over a shorter time span due to their shorter life expectancy, resulting in similar lifetime costs as in patients with early treatment. Regarding the economic value of care, every 10 minutes of earlier treatment increased the NMB by $10,593 (95% prediction interval $5,549-$14,847) and by $10,915 (95% prediction interval $5,928-$15,356) taking health care and societal perspectives, respectively. CONCLUSIONS Any time delay to EVT reduces QALYs and decreases the economic value of care provided by this intervention. Health care policies to implement efficient prehospital triage and to accelerate in-hospital workflow are urgently needed.
Collapse
Affiliation(s)
- Wolfgang G Kunz
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Myriam G Hunink
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Mohammed A Almekhlafi
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Bijoy K Menon
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Jeffrey L Saver
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Diederik W J Dippel
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Charles B L M Majoie
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Tudor G Jovin
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Antoni Davalos
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Serge Bracard
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Francis Guillemin
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Bruce C V Campbell
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Peter J Mitchell
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Philip White
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Keith W Muir
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Scott Brown
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Andrew M Demchuk
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Michael D Hill
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN
| | - Mayank Goyal
- From the University of Calgary (W.G.K., M.A.A., B.K.M., A.M.D., M.D.H., M.G.), Alberta, Canada; Department of Radiology (W.G.K.), University Hospital, LMU Munich, Germany; Harvard T.H. Chan School of Public Health (M.G.H.), Boston, MA; Erasmus MC (M.G.H., D.W.J.D.), University Medical Center Rotterdam, the Netherlands; Faculty of Medicine (M.A.A.), King Abdulaziz University, Jeddah, Saudi Arabia; David Geffen School of Medicine (J.L.S.), University of California-Los Angeles; Academic Medical Center (C.B.L.M.M.), Amsterdam, the Netherlands; University of Pittsburgh Medical Center (T.G.J.), PA; Hospital Germans Trias i Pujol (A.D.), Barcelona, Spain; University Hospital of Nancy (S. Bracard, F.G.), France; University of Melbourne (B.C.V.C., P.J.M.), Australia; Newcastle University (P.W.), UK; University of Glasgow (K.W.M.), UK; and Altair Biostatistics (S. Brown), St. Louis Park, MN.
| | | |
Collapse
|
17
|
Schreier DR, Di Lorenzo F, Iodice F, Shribman S. Do you want to perform endovascular therapy? Perspectives from neurology trainees across Europe. Eur J Neurol 2020; 27:2646-2650. [PMID: 32918361 DOI: 10.1111/ene.14519] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 08/31/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE Endovascular therapy (EVT) has become standard care for acute ischaemic stroke caused by large-vessel occlusion in the anterior circulation. However, access to this treatment in Europe remains poor. The lack of operators is a contributing factor and there is on-going discussion as to whether other specialists, including neurologists, could contribute to the EVT workforce. The question remains whether the next generation of neurologists want to become 'interventional neurologists'. The aim of this study was to address this question. METHODS We conducted a short survey within the National Representatives Network (a division of the Resident and Research Fellow Section, European Academy of Neurology) in order to determine the interest of future neurologists in performing EVT. RESULTS A total of 1218 responses from 27 European countries were received, with some variation in the number of respondents and results among individual countries. In total, 568 neurology trainees (47%) stated that they would want to be an 'interventional neurologist'. CONCLUSION Our findings suggest that neurologists could make a significant contribution to the workforce performing EVT and have important implications for the development and uptake of training programmes in Europe.
Collapse
Affiliation(s)
- D R Schreier
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - F Di Lorenzo
- Non Invasive Brain Stimulation Unit, Department of Behavioral and Clinical Neurology, Santa Lucia Foundation IRCCS, Rome, Italy
| | - F Iodice
- Institute of Neurology, Catholic University of the Sacred Heart, Fondazione Policlinico Gemelli IRCCS, Rome, Italy
| | - S Shribman
- Reta Lila Weston Institute of Neurological Studies, UCL Queen Square Institute of Neurology, London, UK
| | | |
Collapse
|
18
|
Jadhav AP, Mokin M, Ortega-Gutierrez S, Haussen D, Liebeskind D, Nogueira R, Jovin T, Linfante I. An Appraisal of the 2018 Guidelines for the Early Management of Patients with Acute Ischemic Stroke. INTERVENTIONAL NEUROLOGY 2020; 8:55-59. [PMID: 32231695 DOI: 10.1159/000495041] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/17/2018] [Accepted: 10/24/2018] [Indexed: 01/01/2023]
Affiliation(s)
- Ashutosh P Jadhav
- Department of Neurology and Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Maxim Mokin
- Department of Neurology and Neurosurgery, University of South Florida, Tampa, Florida, USA
| | | | - Diogo Haussen
- Department of Neurology and Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - David Liebeskind
- Department of Neurology, University of California Los Angeles, Los Angeles, California, USA
| | - Raul Nogueira
- Department of Neurology and Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Tudor Jovin
- Department of Neurology and Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Italo Linfante
- Miami Cardiac and Vascular Institute and Baptist Neuroscience Center, Miami, Florida, USA
| |
Collapse
|
19
|
Waqas M, Mokin M, Primiani CT, Gong AD, Rai HH, Chin F, Rai AT, Levy EI, Siddiqui AH. Large Vessel Occlusion in Acute Ischemic Stroke Patients: A Dual-Center Estimate Based on a Broad Definition of Occlusion Site. J Stroke Cerebrovasc Dis 2019; 29:104504. [PMID: 31761735 DOI: 10.1016/j.jstrokecerebrovasdis.2019.104504] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Revised: 10/25/2019] [Accepted: 10/27/2019] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Accurate assessment of the frequency of large vessel occlusion (LVO) is important to determine needs for neurointerventionists and thrombectomy-capable stroke facilities. Current estimates vary from 13% to 52%, depending on acute ischemic stroke (AIS) definition and methods for AIS and LVO determination. We sought to estimate LVO prevalence among confirmed and suspected AIS patients at 2 comprehensive US stroke centers using a broad occlusion site definition: internal carotid artery (ICA), first and second segments of the middle cerebral artery (MCA M1,M2), the anterior cerebral artery, vertebral artery, basilar artery, or the proximal posterior cerebral artery. METHODS We analyzed prospectively maintained stroke databases of patients presenting to the centers between January and December 2017. ICD-10 coding was used to determine the number of patients discharged with an AIS diagnosis. Computed tomography angiography (CTA) or magnetic resonance angiography (MRA) was reviewed to determine LVO presence and site. Percentages of patients with LVO among the confirmed AIS population were reported. RESULTS Among 2245 patients with an AIS discharge diagnosis, 418 (18.6%:95% confidence interval [CI] 17.3%-20.0%) had LVO documented on CTA or MRA. Most common occlusion site was M1 (n=139 [33.3%]), followed by M2 (n=114 [27.3%]), ICA (n=69[16.5%]), and tandem ICA-MCA lesions (n=44 [10.5%]). Presentation National Institutes of Health Stroke Scale scores were significantly different for different occlusion sites (P=.02). CONCLUSIONS The LVO prevalence in our large series of consecutive AIS patients was 18.6% (95% CI 17.3%-20.0%). Despite the use of a broad definition, this estimate is less than that reported in most previous studies.
Collapse
Affiliation(s)
- Muhammad Waqas
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Maxim Mokin
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida
| | - Christopher T Primiani
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida
| | - Andrew D Gong
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Hamid H Rai
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Felix Chin
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York
| | - Ansaar T Rai
- Department of Neurosurgery, West Virginia University Hospital, Morgantown, West Virginia
| | - Elad I Levy
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York; Jacobs Institute, Buffalo, New York
| | - Adnan H Siddiqui
- Department of Neurosurgery, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York; Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo, New York; Department of Radiology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Buffalo, New York; Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York; Jacobs Institute, Buffalo, New York.
| |
Collapse
|
20
|
Rai AT, Crivera C, Kottenmeier E, Kalsekar I, Kumari R, Patino N, Chekani F, Khanna R. Outcomes associated with endovascular treatment among patients with acute ischemic stroke in the USA. J Neurointerv Surg 2019; 12:422-426. [PMID: 31649206 DOI: 10.1136/neurintsurg-2019-015378] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2019] [Revised: 10/02/2019] [Accepted: 10/03/2019] [Indexed: 11/04/2022]
Abstract
BACKGROUND Few studies have examined the trends in clinical and economic outcomes of patients with acute ischemic stroke (AIS) who receive endovascular therapy (ET) in the real-world setting. OBJECTIVE To evaluate characteristics and trends in clinical and economic outcomes among commercially insured patients with AIS undergoing ET between 2011 and 2017. METHODS Patients with AIS undergoing ET from January 1, 2011 to June 30, 2017 were identified from administrative claims contained in the IBM MarketScan Commercial and Medicare Supplemental databases. The Mann-Kendall trend test was performed to examine clinical and economic trends.Between 2011 and 2017, 3411 patients (mean age 62.85±15 years) with a primary diagnosis of AIS underwent ET (coverage: Commercial 59%, n=2008; Medicare Supplemental 41%, n=1403). In the Commercial cohort, discharge to home increased significantly (from 29.54% to 39.18%, p<0.05). Length of stay declined significantly among the overall cohort (from 10.96 to 9.05 days, p<0.01) and the Medicare Supplemental cohort (from 10.03 to 8.43 days, p<0.05). All-cause 365-day readmission decreased significantly among the overall cohort (from 47.5% to 36.7%, p<0.05) and the Commercial cohort (from 51.54% to 36.43%, p<0.05) but remained unchanged in the Medicare Supplemental cohort. While index procedure cost did not change significantly ($93 955 to $87 906, p=0.8806), total cost significantly declined in the overall cohort (from $166 922 to $130 678, p<0.05). CONCLUSIONS Although with some variation across the samples studied, outcomes including discharge to home, length of stay, readmission, and total cost associated with endovascular stroke therapy seemed to have improved between 2011 and 2017. Index admission cost remained unchanged.
Collapse
Affiliation(s)
- Ansaar T Rai
- Interventional Neuroradiology, West Virginia University Hospital, Morgantown, West Virginia, USA
| | - Concetta Crivera
- Janssen Pharmaceutical Companies of Johnson and Johnson, Titusville, New Jersey, USA
| | - Emilie Kottenmeier
- Franchise Health Economics and Outcomes Research, Biosense Webster Inc, Irvine, California, USA
| | - Iftekhar Kalsekar
- Medical Device Epidemiology, Johnson and Johnson Medical Devices, New Brunswick, New Jersey, USA
| | - Rashmi Kumari
- Mu Sigma Business Solutions Private Ltd, Bangalore, Karnataka, India
| | - Nataly Patino
- Medical Device Epidemiology, Johnson and Johnson Medical Devices, New Brunswick, New Jersey, USA
| | - Farid Chekani
- Medical Device Epidemiology, Johnson and Johnson Medical Devices, New Brunswick, New Jersey, USA
| | - Rahul Khanna
- Medical Device Epidemiology, Johnson and Johnson Medical Devices, New Brunswick, New Jersey, USA
| |
Collapse
|
21
|
Rocha M, Jadhav AP, Jovin TG. Endovascular therapy for large vessel occlusion stroke: an update on the most recent clinical trials. J Cereb Blood Flow Metab 2019; 39:1661-1663. [PMID: 30351184 PMCID: PMC6727133 DOI: 10.1177/0271678x18805926] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Marcelo Rocha
- Department of Neurology, UPMC Stroke Institute, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Ashutosh P Jadhav
- Department of Neurology, UPMC Stroke Institute, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurosurgery, UPMC Stroke Institute, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| | - Tudor G Jovin
- Department of Neurology, UPMC Stroke Institute, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
- Department of Neurosurgery, UPMC Stroke Institute, School of Medicine, University of Pittsburgh, Pittsburgh, PA, USA
| |
Collapse
|
22
|
Affiliation(s)
- Raul G. Nogueira
- From the Department of Neurology, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA (R.G.N.)
| | - Marc Ribó
- Department of Neurology, Hospital Vall d’Hebron, Barcelona, Spain (M.R.)
| |
Collapse
|
23
|
Waqas M, Rai AT, Vakharia K, Chin F, Siddiqui AH. Effect of definition and methods on estimates of prevalence of large vessel occlusion in acute ischemic stroke: a systematic review and meta-analysis. J Neurointerv Surg 2019; 12:260-265. [DOI: 10.1136/neurintsurg-2019-015172] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2019] [Revised: 07/12/2019] [Accepted: 07/15/2019] [Indexed: 11/04/2022]
Abstract
IntroductionAccurate estimation of the incidence of large vessel occlusion (LVO) is critical for planning stroke systems of care and approximating workforce requirements. This systematic review aimed to estimate the prevalence of LVO among patients with acute ischemic stroke (AIS), with emphasis on definitions and methods used by different studies.MethodsA systematic literature review was performed to search for articles on the prevalence of LVO and AIS. All articles describing the frequency of LVO frequency among AIS patients were included. Studies without consecutive recruitment or confirmation of LVO with CT angiography or MR angiography were excluded. Heterogeneity of the studies was assessed; meta-regression was performed to estimate the effect of LVO definition and study methods on LVO prevalence.Results18 articles met the inclusion criteria: 5 studies presented population based estimates; 13 provided single hospital experiences (5 prospective, 8 retrospective). The AIS denominator (number of all AIS) from which LVO rates were generated was variable. Nine different definitions were used, based on occlusion site. Significant heterogeneity existed among the studies (I2=99%, P<0.001). The prevalence of LVO among patients with suspected AIS ranged from 13% to 52%. Overall prevalence was 30.0% (95% CI 25.0% to 35.0%). Pooled prevalence of LVO among suspected AIS patients was 21% (95% CI 19% to 30%). Based on meta-regression, the method of AIS denominator determination significantly influenced heterogeneity (P=0.018).ConclusionThe heterogeneity of LVO estimates was remarkably high. The method of AIS denominator determination was the most significant predictor of LVO estimates. Studies with a standardized LVO definition and methods of AIS estimation are necessary to estimate the true prevalence of LVO among patients with AIS.
Collapse
|
24
|
Rocha M, Desai SM, Jadhav AP, Jovin TG. Prevalence and Temporal Distribution of Fast and Slow Progressors of Infarct Growth in Large Vessel Occlusion Stroke. Stroke 2019; 50:2238-2240. [DOI: 10.1161/strokeaha.118.024035] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Fast and slow progressors of infarct growth due to anterior circulation large vessel occlusion are commonly observed in clinical practice. We aimed to estimate the prevalence and temporal distribution of fast and slow progressors among anterior circulation large vessel occlusion patients diagnosed within 24 hours of stroke onset.
Methods—
Single-center retrospective study of all patients with anterior circulation large vessel occlusion who underwent baseline computed tomographic perfusion or magnetic resonance imaging within 24 hours of stroke onset. Prevalence was determined for fast progressors (ischemic core >70 mL, <6 hours of stroke onset) and slow progressors (ischemic core ≤30 mL, >6–24 hours of stroke onset).
Results—
One hundred eighty-five patients were included. The median time interval from stroke onset to baseline core imaging was 7.6 hours (interquartile range, 3.9–13.2), and median core volume was 17 mL (range, 0–405). Patients had core volume ≤70 mL in 72% of cases in the overall cohort. The prevalence of fast progressors was 25% (95% CI, 17%–37%) and reached 40% (95% CI, 24%–59%) between 3 and 4.5 hours after stroke onset. The prevalence of slow progressors was 55% (95% CI, 46%–64%) and was similar across time intervals beyond 6 hours after stroke onset.
Conclusions—
Most anterior circulation large vessel occlusion patients had small-to-moderate ischemic core volume, irrespective of early or delayed presentation within 24 hours of stroke onset. Fast progressors were highly prevalent between 3 and 4.5 hours after stroke onset.
Collapse
Affiliation(s)
- Marcelo Rocha
- From the Department of Neurology (M.R., S.M.D., A.P.J.), University of Pittsburgh Medical Center, PA
| | - Shashvat M. Desai
- From the Department of Neurology (M.R., S.M.D., A.P.J.), University of Pittsburgh Medical Center, PA
| | - Ashutosh P. Jadhav
- From the Department of Neurology (M.R., S.M.D., A.P.J.), University of Pittsburgh Medical Center, PA
- Department of Neurosurgery (A.P.J.), University of Pittsburgh Medical Center, PA
| | - Tudor G. Jovin
- Department of Neurology, Cooper University Hospital Neurological Institute, Camden, NJ (T.G.J.)
| |
Collapse
|
25
|
Albers GW, Molina CA, Selim MH, Jovin TG. Advanced Brain Imaging in Late-Arriving Drip and Ship Patients With Known Large Vessel Occlusion. Stroke 2019; 50:1940-1943. [PMID: 31216963 DOI: 10.1161/strokeaha.118.020574] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Gregory W Albers
- From the Department of Neurology, Stanford University, Palo Alto, CA (G.W.A.)
| | - Carlos A Molina
- Vall d'Hebron Stroke Unit, Hospital Universitari Vall d'Hebron, Barcelona (C.A.M.)
| | - Magdy H Selim
- Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.S.)
| | - Tudor G Jovin
- Cooper Neurological Institute, Cooper Medical School of Rowan University, Camden, NJ (T.G.J.)
| |
Collapse
|
26
|
Mokin M, Ansari SA, McTaggart RA, Bulsara KR, Goyal M, Chen M, Fraser JF. Indications for thrombectomy in acute ischemic stroke from emergent large vessel occlusion (ELVO): report of the SNIS Standards and Guidelines Committee. J Neurointerv Surg 2019; 11:215-220. [DOI: 10.1136/neurintsurg-2018-014640] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 12/11/2018] [Indexed: 11/04/2022]
|
27
|
Mokin M, Abou-Chebl A, Castonguay AC, Nogueira RG, English JD, Farid H, Gupta R, Martin C, Holloway WE, Haussen DC, Mueller-Kronast N, Zaidat OO. Real-world stent retriever thrombectomy for acute ischemic stroke beyond 6 hours of onset: analysis of the NASA and TRACK registries. J Neurointerv Surg 2018; 11:334-337. [DOI: 10.1136/neurintsurg-2018-014272] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2018] [Revised: 08/17/2018] [Accepted: 08/21/2018] [Indexed: 11/03/2022]
Abstract
BackgroundThe DEFUSE 3 and DAWN trials have shown the benefit of thrombectomy beyond 6 hours of stroke symptom onset in carefully selected patients.ObjectiveTo evaluate the real-world outcomes of stent retriever thrombectomy beyond 6 hours of stroke onset using combined individual patient data from the North American Solitaire Stent Retriever Acute Stroke (NASA) and Trevo Stent-Retriever Acute Stroke (TRACK) registries.MethodsPooled analysis of individual patient data of all cases of anterior circulation acute ischemic stroke (AIS) from NASA and TRACK was performed to compare outcomes of patients presenting within the first hours 6 or beyond 6 hours of stroke symptom onset.ResultsOf 830 patients with anterior circulation AIS from the NASA and TRACK registries, 32.7% (271 patients) underwent thrombectomy beyond the first 6 hours of symptom onset. The rates of good clinical outcome (modified Rankin scale score of 0–2 at 90 days), mortality, and symptomatic intracranial hemorrhage were similar: 48.1%, 20.6%, and 8.0% within 0–6 hours, 46.2%, 21.6%, and 10.9% within 6–16 hours, and 38.9%, 33.3%, and 5% within 16–24 hours (p=0.8, 0.6, and 0.5, respectively). The rates of successful recanalization (Thrombolysis in Cerebral Infarction 2b/3) were 79.4% in patients with stroke within 0–6 hours, 72.6% within 6–16 hours, and 85.0% within 16–24 hours (p=0.04).ConclusionsReal-world experience with patients with anterior circulation AIS treated with the Solitaire and Trevo thrombectomy devices beyond the first 6 hours of symptom onset proved to be equally safe and effective as for patients with symptom onset within the first 6 hours.
Collapse
|
28
|
Predictors of Endovascular Treatment Among Stroke Codes Activated Within 6 Hours From Symptom Onset. Stroke 2018; 49:2116-2121. [DOI: 10.1161/strokeaha.118.021316] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
|
29
|
Egger K, Strecker C, Kellner E, Urbach H. [Imaging in acute ischemic stroke using automated postprocessing algorithms]. DER NERVENARZT 2018; 89:885-894. [PMID: 29947938 DOI: 10.1007/s00115-018-0535-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Abstract
There are several automated analytical methods to detect thromboembolic vascular occlusions, the infarct core and the potential infarct-endangered tissue (tissue at risk) by means of multimodal computed tomography (CT) and magnetic resonance imaging (MRI). The infarct core is more reliably visualized by diffusion-weighted imaging (DWI) MRI or CT perfusion than by native CT. The extent of tissue at risk and endangerment can only be estimated; however, it seems essential whether "tissue at risk" actually exists. To ensure consistent patient care, uniform imaging protocols should be acquired in the referring hospital and thrombectomy center and the collected data should be standardized and automatically evaluated and presented. Whether patients with a large infarct core and with or without tissue at risk or patients with large vessel occlusion (LVO) but low NIHSS benefit from thrombectomy has to be evaluated in controlled clinical trials using standardized imaging protocols. A promising, potentially time-saving approach is also native CT and CT angiography using a flat-panel detector angiography system for assessment of vessel occlusion and leptomeningeal collaterals.
Collapse
Affiliation(s)
- K Egger
- Neurozentrum, Klinik für Neuroradiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Breisacher Str. 64, 79106, Freiburg, Deutschland.
| | - C Strecker
- Klinik für Neurologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
| | - E Kellner
- Abteilung Medizinische Physik Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg, Deutschland
| | - H Urbach
- Neurozentrum, Klinik für Neuroradiologie, Universitätsklinikum Freiburg, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Breisacher Str. 64, 79106, Freiburg, Deutschland
| |
Collapse
|