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Duan Q, Li W, Zhang Y, Zhuang W, Long J, Wu B, He J, Cheng H. Nomogram established on account of Lasso-logistic regression for predicting hemorrhagic transformation in patients with acute ischemic stroke after endovascular thrombectomy. Clin Neurol Neurosurg 2024; 243:108389. [PMID: 38870670 DOI: 10.1016/j.clineuro.2024.108389] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2024] [Revised: 05/26/2024] [Accepted: 06/09/2024] [Indexed: 06/15/2024]
Abstract
BACKGROUND Hemorrhagic transformation (HT) is a common and serious complication in patients with acute ischemic stroke (AIS) after endovascular thrombectomy (EVT). This study was performed to determine the predictive factors associated with HT in stroke patients with EVT and to establish and validate a nomogram that combines with independent predictors to predict the probability of HT after EVT in patients with AIS. METHODS All patients were randomly divided into development and validation cohorts at a ratio of 7:3. The least absolute shrinkage and selection operator (LASSO) regression was used to select the optimal factors, and multivariate logistic regression analysis was used to build a clinical prediction model. Calibration plots, decision curve analysis (DCA) and receiver operating characteristic curve (ROC) were generated to assess predictive performance. RESULTS LASSO regression analysis showed that Alberta Stroke Program Early CT Scores (ASPECTS), international normalized ratio (INR), uric acid (UA), neutrophils (NEU) were the influencing factors for AIS with HT after EVT. A novel prognostic nomogram model was established to predict the possibility of HT with AIS after EVT. The calibration curve showed that the model had good consistency. The results of ROC analysis showed that the AUC of the prediction model established in this study for predicting HT was 0.797 in the development cohort and 0.786 in the validation cohort. CONCLUSION This study proposes a novel and practical nomogram based on ASPECTS, INR, UA, NEU, which can well predict the probability of HT after EVT in patients with AIS.
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Affiliation(s)
- Qi Duan
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Wenlong Li
- Radiotherapy Center, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Ye Zhang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Weihao Zhuang
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Jingfang Long
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Beilan Wu
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Jincai He
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China.
| | - Haoran Cheng
- Department of Neurology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China.
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Kuang Y, Zhang L, Ye K, Jiang Z, Shi C, Luo L. Clinical and imaging predictors for hemorrhagic transformation of acute ischemic stroke after endovascular thrombectomy. J Neuroimaging 2024; 34:339-347. [PMID: 38296794 DOI: 10.1111/jon.13191] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 01/06/2024] [Accepted: 01/09/2024] [Indexed: 02/02/2024] Open
Abstract
BACKGROUND AND PURPOSE Hemorrhagic transformation (HT) is a common complication of endovascular thrombectomy (EVT) in patients with acute ischemic stroke (AIS). Our study aims to investigate the clinical and imaging predictors of HT and symptomatic intracranial hemorrhage (sICH) in patients who underwent EVT. METHODS A retrospective analysis of 118 patients undergoing EVT for acute anterior circulation stroke was performed. Potential clinical and imaging predictors of all patients were collected and multivariate logistic regression was performed. The risk prediction system was constructed according to the multivariate logistic regression results. RESULTS The incidence of HT and sICH after EVT were 46.6% and 15.3%, respectively. The multivariate logistic regression results showed that Alberta Stroke Program Early CT Score (ASPECTS) (p = .001, odds ratio [OR] = 0.367, 95% [confidence interval] CI, 0.201-0.670), collateral status (p<.001, OR = 0.117, 95% CI, 0.042-0.325), relative cerebral blood flow (CBF) ratio (p = .025, OR = 0.943, 95% CI, 0.895-0.993), and blood glucose on admission (p = .012, OR = 1.258, 95% CI, 1.053-1.504) were associated with HT. While for sICH, collateral circulation (p = .007, OR = 0.148, 95% CI, 0.037-0.589), ASPECTS (p = .033, OR = 0.510, 95% CI, 0.274-0.946), and blood glucose (p = .005, OR = 1.304, 95% CI, 1.082-1.573) were independent factors. The predictive model for HT after EVT was established, and the sensitivity and specificity of it were 90.9% and 79.4%, respectively, with the area under the curve of 90.0% (84.5%-95.4%). CONCLUSION Collateral status, ASPECTS, relative CBF ratio, and blood glucose on admission were predictors for HT in AIS patients, while collateral status, ASPECTS, and blood glucose on admission were also predictors for sICH. In addition, the established predictive model showed good diagnostic value for prediction of HT after EVT.
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Affiliation(s)
- Yongyao Kuang
- Department of Radiology, Shunde Hospital of Southern Medical University, Foshan, China
- Medical Imaging Center, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Lingtao Zhang
- Medical Imaging Center, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Kunlin Ye
- Medical Imaging Center, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Zijie Jiang
- Medical Imaging Center, Shenzhen Hospital of Southern Medical University, Shenzhen, China
| | - Changzheng Shi
- Medical Imaging Center, The First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Liangping Luo
- Medical Imaging Center, The First Affiliated Hospital of Jinan University, Guangzhou, China
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Shafique MA, Ali SMS, Mustafa MS, Aamir A, Khuhro MS, Arbani N, Raza RA, Abbasi MB, Lucke-Wold B. Meta-analysis of direct endovascular thrombectomy vs bridging therapy in the management of acute ischemic stroke with large vessel occlusion. Clin Neurol Neurosurg 2024; 236:108070. [PMID: 38071760 DOI: 10.1016/j.clineuro.2023.108070] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/03/2023] [Revised: 11/21/2023] [Accepted: 11/23/2023] [Indexed: 02/04/2024]
Abstract
BACKGROUND Debates persist when using intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) for acute ischemic stroke (AIS) due to large-vessel occlusion (LVO). This systematic review and meta-analysis synthesized evidence on outcomes in patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO), comparing bridging therapy (BT) with MT alone. METHOD We conducted searches of PubMed, Scopus, Web of Science, and the Cochrane Central Register of Controlled Trials from inception to July 2023 to identify pertinent clinical trials and observational studies. RESULT 76 studies, involving 37,658 patients, revealed no significant difference in 90-day functional independence between DEVT and BT. However, a trend favoring BT for achieving functional independence with a modified Rankin Scale (mRS) of 0-1 was observed, having Odds ratio (OR) of 0.75 (95% CI 0.66-0.86; p < 0.001). DEVT was associated with higher postprocedural mortality (OR 1.44;95% CI 1.25-1.65; p < 0.001), but a lower risk of symptomatic intracranial hemorrhage compared to BT (OR 0.855; 95% CI 0.621-1.177; p = 0.327). Successful recanalization rates favored BT, emphasizing the importance of individualized treatment decisions (OR 0.759; 95% CI 0.594-0.969; p = 0.027). Sensitivity analyses were conducted to identify key contributors to heterogeneity. CONCLUSION Our meta-analysis underscores the intricate equilibrium between functional efficacy and safety in the evaluation of DEVT and BT for ACS-LVO. Fundamentally, while BT appears more efficacious, concerns about safety arise due to the superior safety profile demonstrated by DEVT. Individualized treatment decisions are imperative, and further trials are warranted to enhance precision in clinical guidance.
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Affiliation(s)
| | | | | | - Ali Aamir
- Department of Medicine, Dow University of Health Sciences, Pakistan.
| | | | - Naeemullah Arbani
- Department of Medicine, Liaquat National Hospital and Medical College, Pakistan.
| | - Rana Ali Raza
- Department of Medicine, Liaquat National Hospital and Medical College, Pakistan.
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Deng Q, Zhang L, Liu Y, Zhou F, Yuan Z, Wang X, Gao J, Yang P, Zhang Y, Xing P, Li Z, Hong B, Han H, Shi H, Shi H, Liu J. Effect of Time Window on Endovascular Thrombectomy with or without Intravenous Thrombolysis in Acute Ischemic Stroke: Results from DIRECT-MT. Cerebrovasc Dis 2023; 53:176-183. [PMID: 37598670 DOI: 10.1159/000533231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2022] [Accepted: 05/12/2023] [Indexed: 08/22/2023] Open
Abstract
INTRODUCTION Whether time window affects the intravenous thrombolysis (IVT) effect before endovascular thrombectomy (EVT) is uncertain. We aimed to investigate the effect of different time windows (0-3 h and >3-4.5 h from stroke onset to randomization) on clinical outcomes of EVT with or without IVT in a subgroup analysis of DIRECT-MT. METHODS The primary outcome was the 90-day modified Rankin Scale (mRS) according to time window. Logistic regression models were used to analyze the effect of different treatments (EVT with or without IVT) on outcomes within 0-3 h or >3-4.5 h. RESULTS Among 656 patients who were included in the analysis, 282 (43.0%) were randomized within >3-4.5 h after stroke onset (125 without IVT and 157 with IVT), and 374 (57.0%) were randomized within 0-3 h (202 without IVT and 172 with IVT). We noted no significant difference in the thrombectomy-alone effect between the time window subgroups according to 90-day ordinal mRS (adjusted common odds ratio [acOR] in patients within 0-3 h: 1.06 [95% CI: 0.73-1.52], acOR in patients within >3-4.5 h: 1.19 [95% CI: 0.78-1.82]) and 90-day functional independence. Thrombectomy alone resulted in an increased proportion of patients with 90-day mRS 0-3 treated within >3-4.5 h (62.90 vs. 48.72%) but not within 0-3 h (65.84 vs. 63.95%). However, there was no interaction effect regarding all outcomes after the Bonferroni correction. CONCLUSIONS Our results did not support thrombectomy-alone administration within 3-4.5 h in patients with acute ischemic stroke from large-vessel occlusion in the subgroup analysis of DIRECT-MT.
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Affiliation(s)
- Qiwen Deng
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China,
| | - Lei Zhang
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | - Yukai Liu
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Feng Zhou
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Zhenhua Yuan
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Xixi Wang
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Jie Gao
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Pengfei Yang
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | - Yongwei Zhang
- Department of Neurology, Naval Medical University Changhai Hospital, Shanghai, China
| | - Pengfei Xing
- Department of Neurology, Naval Medical University Changhai Hospital, Shanghai, China
| | - Zifu Li
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | - Bo Hong
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
| | - Hongxing Han
- Department of Neurology, Linyi People's Hospital of Qingdao University, Linyi, China
| | - Huaizhang Shi
- Department of Neurosurgery, First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hongchao Shi
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Jianmin Liu
- Department of Neurosurgery, Naval Medical University Changhai Hospital, Shanghai, China
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Zheng M, Li L, Chen L, Li B, Feng C. Mechanical thrombectomy combined with intravenous thrombolysis for acute ischemic stroke: a systematic review and meta-analyses. Sci Rep 2023; 13:8597. [PMID: 37237159 DOI: 10.1038/s41598-023-35532-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Accepted: 05/19/2023] [Indexed: 05/28/2023] Open
Abstract
To assess the clinical value of mechanical thrombectomy (MT) combined with intravenous thrombolysis (IVT) in acute ischemic stroke (AIS) by comparing it with the MT alone. In this study, we conducted a comprehensive meta-analysis of both observational and randomized controlled studies (RCTs) to investigate various outcomes. Our search for relevant studies was conducted between January 2011 and June 2022 in four major databases: PubMed, Embase, WOS, and Cochrane Library. We collected data on several outcomes, including functional independence (FI; defined as modified Rankin Scale score of 0 to 2), excellent outcomes (mRS 0-1), successful recanalization (SR), symptomatic intracerebral hemorrhage (sICH), any intracerebral hemorrhage (aICH), and mortality at three months or discharge. The primary efficacy outcome and safety outcome were FI and sICH, respectively, whereas excellent outcomes and SR were considered secondary efficacy outcomes. Additionally, mortality and aICH were analyzed as secondary safety outcomes. We employed the Mantel-Haenszel fixed-effects model for RCTs when I2 < 50%, otherwise the random-effects model was utilized. For observational studies and subgroup analyses, we used the random-effects model to minimize potential bias. A total of 55 eligible studies (nine RCTs and 46 observational studies) were included. For RCTs, the MT + IVT group was superior in FI (OR: 1.27, 95% CI: 1.11-1.46), excellent outcomes (OR: 1.21, 95% CI: 1.03-1.43), SR (OR: 1.23, 95% CI: 1.05-1.45), mortality (OR: 0.72, 95% CI: 0.54-0.97) in crude analyses. In adjusted analyses, the MT + IVT group reduced the risk of mortality (OR: 0.65, 95% CI: 0.49-0.88). However, the difference in FI between the MT + IVT group and the MT alone group was not significant (OR: 1.17, 95% CI: 0.99-1.38, Fig. 3a). For observational studies, the results of FI (OR: 1.34, 95% CI: 1.16-1.33), excellent outcomes (OR: 1.30, 95% CI: 1.09-1.54), SR (OR: 1.23, 95% CI: 1.05-1.44), mortality (OR: 0.70, 95% CI: 0.64-0.77) in the MT + IVT group were better. Additionally, the MT + IVT group increased the risk of hemorrhagic transformation (HT) including sICH (OR: 1.16, 95% CI: 1.11-1.21) and aICH (OR: 1.24, 95% CI: 1.05-1.46) in crude analyses. In adjusted analyses, significant better outcomes were seen in the MT + IVT group on FI (OR: 1.36, 95% CI: 1.21-1.52), excellent outcomes (OR: 1.49, 95% CI: 1.26-1.75), and mortality (OR: 0.73, 95% CI: 0.56-0.94). The MT + IVT therapy did improve the prognosis for AIS patients and did not increase the risk of HT compared with MT alone therapy.
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Affiliation(s)
- Meiling Zheng
- Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing, 100010, People's Republic of China
| | - Li Li
- Department of Radiology, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, Sichuan Province, People's Republic of China.
| | - Lizhou Chen
- Department of Radiology, West China Hospital of Sichuan University, Chengdu, 610041, Sichuan Province, People's Republic of China.
| | - Bin Li
- Department of Geriatrics, Hospital of Chengdu University of Traditional Chinese Medicine, Chengdu, 610072, People's Republic of China.
| | - Cuiling Feng
- Peking University People's Hospital, Beijing, 100000, People's Republic of China.
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Kanamoto T, Tateishi Y, Yamashita K, Furuta K, Torimura D, Tomita Y, Hirayama T, Shima T, Nagaoka A, Yoshimura S, Miyazaki T, Ideguchi R, Morikawa M, Morofuji Y, Horie N, Izumo T, Tsujino A. Impact of width of susceptibility vessel sign on recanalization following endovascular therapy. J Neurol Sci 2023; 446:120583. [PMID: 36827810 DOI: 10.1016/j.jns.2023.120583] [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: 09/19/2022] [Revised: 02/05/2023] [Accepted: 02/09/2023] [Indexed: 02/14/2023]
Abstract
BACKGROUND AND PURPOSE We aimed to investigate the relationship between arterial recanalization following endovascular therapy and the susceptibility vessel sign (SVS) length and width on susceptibility-weighted imaging. METHODS We retrospectively evaluated consecutive patients with anterior circulation ischemic stroke who underwent magnetic resonance imaging preceded endovascular therapy, and measured the SVS length and width. Successful recanalization was defined as expanded thrombolysis in cerebral infarction grade of 2b to 3. Logistic regression analysis was executed to determine the independent predictors of successful recanalization and first-pass reperfusion (FPR) after endovascular therapy. RESULTS Among 100 patients, successful recanalization and FPR were observed in 77 and 34 patients, respectively. The median SVS length and width were 10.3 mm (interquartile range, 6.8-14.1 mm) and 4.2 mm (interquartile range, 3.1-5.2 mm), respectively. In multivariate logistic regression analysis, SVS width was associated with successful recanalization (odds ratio, 1.88; 95% confidence interval, 1.14-3.07; p = 0.005) and FPR (odds ratio, 1.38; 95% confidence interval, 1.01-1.89; p = 0.039). The optimal cutoff value for the SVS width to predict successful recanalization and FPR were 4.2 mm and 4.0 mm, respectively. CONCLUSIONS Larger SVS width may predict successful recanalization and FPR following endovascular therapy.
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Affiliation(s)
- Tadashi Kanamoto
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Yohei Tateishi
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Kairi Yamashita
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Kanako Furuta
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Daishi Torimura
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Yuki Tomita
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Takuro Hirayama
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Tomoaki Shima
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Atsushi Nagaoka
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Shunsuke Yoshimura
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Teiichiro Miyazaki
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Reiko Ideguchi
- Department of Radiology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Minoru Morikawa
- Department of Radiology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Yoichi Morofuji
- Department of Neurosurgery, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Nobutaka Horie
- Department of Neurosurgery, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan; Department of Neurosurgery, Hiroshima University, Kasumi 1-2-3 Minami-ku, Hiroshima 734-8551, Japan
| | - Tsuyoshi Izumo
- Department of Neurosurgery, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Akira Tsujino
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
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Kolahchi Z, Rahimian N, Momtazmanesh S, Hamidianjahromi A, Shahjouei S, Mowla A. Direct Mechanical Thrombectomy Versus Prior Bridging Intravenous Thrombolysis in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. LIFE (BASEL, SWITZERLAND) 2023; 13:life13010185. [PMID: 36676135 PMCID: PMC9863165 DOI: 10.3390/life13010185] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 11/14/2022] [Revised: 12/15/2022] [Accepted: 01/03/2023] [Indexed: 01/11/2023]
Abstract
BACKGROUND The current guideline recommends using an intravenous tissue-type plasminogen activator (IV tPA) prior to mechanical thrombectomy (MT) in eligible acute ischemic stroke (AIS) with emergent large vessel occlusion (ELVO). Some recent studies found no significant differences in the long-term functional outcomes between bridging therapy (BT, i.e., IV tPA prior to MT) and direct MT (dMT). METHODS We conducted a systematic review and meta-analysis to compare the safety and functional outcomes between BT and dMT in AIS patients with ELVO who were eligible for IV tPA administration. Based on the ELVO location, patients were categorized as the anterior group (occlusion of the anterior circulation), or the combined group (occlusion of the anterior and/or posterior circulation). A subgroup analysis was performed based on the study type, i.e., RCT and non-RCT. RESULTS Thirteen studies (3985 patients) matched the eligibility criteria. Comparing the BT and dMT groups, no significant differences in terms of mortality and good functional outcome were observed at 90 days. Symptomatic intracranial hemorrhagic (sICH) events were more frequent in BT patients in the combined group (OR = 0.73, p = 0.02); this result remained significant only in the non-RCT subgroup (OR = 0.67, p = 0.03). The RCT subgroup had a significantly higher rate of successful revascularization in BT patients (OR = 0.73, p = 0.02). CONCLUSIONS Our meta-analysis uncovered no significant differences in functional outcome and mortality rate at 90 days between dMT and BT in patients with AIS who had ELVO. Although BT performed better in terms of successful recanalization rate, there is a risk of increased sICH rate in this group.
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Affiliation(s)
- Zahra Kolahchi
- School of Medicine, Tehran University of Medical Sciences, Tehran 1417613151, Iran
| | - Nasrin Rahimian
- Department of Neurology, Creighton University Medical Center, Omaha, NE 68124, USA
| | - Sara Momtazmanesh
- School of Medicine, Tehran University of Medical Sciences, Tehran 1417613151, Iran
| | - Anahid Hamidianjahromi
- Department of Neurology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Shima Shahjouei
- Department of Neurology, Barrow Neurological Institute, St. Joseph’s Hospital and Medical Center, Phoenix, AZ 85013, USA
| | - Ashkan Mowla
- Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine, University of Southern California, Los Angeles, CA 90033, USA
- Correspondence: ; Tel.: +323-409-7422; Fax: +323-226-7833
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8
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Zhang LN, Chen QY, Wang M, Wang Y, Lei D, Chen SL. Analysis of the Therapeutic Effect of Multimode Mechanical Thrombectomy in the Treatment of Acute Ischemic Stroke. World Neurosurg 2022; 165:e488-e493. [PMID: 35750143 DOI: 10.1016/j.wneu.2022.06.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 06/15/2022] [Accepted: 06/16/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE We sought to observe the effectiveness and safety of multimode mechanical thrombectomy in the treatment of acute ischemic stroke. METHODS The data from patients with acute intracranial artery occlusion treated with multimode mechanical thrombectomy between November 2018 and December 2019 were collected, and the clinical features, imaging data, treatment, and clinical follow-up results 90 days after the operation were analyzed. Postoperative recanalization and the 90-day modified Rankin Scale score were used as clinically effective endpoints. The incidence of symptomatic intracranial hemorrhage within 72 hours and postoperative 90-day mortality were used to evaluate safety. RESULTS A total of 70 patients were enrolled, including 18 cases with bridging treatment, 11 cases with stent implantation, and 10 cases with balloon dilatation. During the 90 days of follow-up after surgery, 35.7% of (25/70) patients had a good prognosis (modified Rankin Scale score of 0-2). The incidence of postoperative symptomatic intracranial hemorrhage was 11.4% (8/70), and postoperative mortality was 34.3% (24/70). The onset-to-puncture time in the good-prognosis group and the poor-prognosis group was 270 (225-345) versus 330 (270-420) minutes, respectively, and the onset-to-recanalization time in the 2 groups was 350 (295-405) versus 410 (340-470) minutes, respectively. Successful recanalization in the good-prognosis group and the poor-prognosis group was 96.0% versus 57.8%, respectively, and the incidence of symptomatic intracranial hemorrhage in the 2 groups was 0% versus 17.8%, respectively. The difference between the 2 groups was statistically significant (P < 0.05). CONCLUSIONS Multimode mechanical thrombectomy is a safe and effective therapy for the intracranial occlusion of large vessels in patients with acute ischemic stroke.
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Affiliation(s)
- Li-Na Zhang
- Department of Neurology, ChongQing University Three Gorges Hospital, Chongqing, China
| | - Qi-Yan Chen
- Department of Neurology, ChongQing University Three Gorges Hospital, Chongqing, China
| | - Min Wang
- Department of Neurology, ChongQing University Three Gorges Hospital, Chongqing, China
| | - Yong Wang
- Department of Neurology, ChongQing University Three Gorges Hospital, Chongqing, China
| | - Da Lei
- Department of Neurology, ChongQing University Three Gorges Hospital, Chongqing, China
| | - Sheng-Li Chen
- Department of Neurology, ChongQing University Three Gorges Hospital, Chongqing, China.
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9
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Intravenous thrombolysis before mechanical thrombectomy for acute ischemic stroke due to large vessel occlusion; should we cross that bridge? A systematic review and meta-analysis of 36,123 patients. Neurol Sci 2022; 43:6243-6269. [DOI: 10.1007/s10072-022-06283-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 07/09/2022] [Indexed: 10/16/2022]
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10
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Efficacy and safety of endovascular treatment with or without intravenous alteplase in acute anterior circulation large vessel occlusion stroke: a meta-analysis of randomized controlled trials. Neurol Sci 2022; 43:3551-3563. [PMID: 35314911 DOI: 10.1007/s10072-022-06017-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 03/14/2022] [Indexed: 10/18/2022]
Abstract
OBJECTIVE The current meta-analysis aimed to investigate the efficacy and safety of direct endovascular treatment (EVT) and bridging therapy (EVT with prior intravenous thrombolysis (IVT)) in patients with acute anterior circulation large vessel occlusion (LVO) stroke. METHODS This meta-analysis followed PRISMA guidelines. Eligible RCTs were identified through a systemic search of electronic databases (PubMed, Ovid, Web of Science, and Cochrane Library) from the inception dates to January 10, 2022. The pooled analyses were performed using RevMan 5.3 software. The primary outcome was functional outcome on the modified Rankin Scale (mRS) (range 0 to 5) at 90 days. The secondary outcomes included successful reperfusion, intracranial hemorrhage, and mortality (mRS 6) within 90 days. RESULTS A total of 4 RCTs involving 1633 patients were finally included. Findings of pooled analyses indicated that neither the primary outcomes (no disability (mRS 0), no significant disability despite some symptoms (mRS 1), slight disability (mRS 2), moderate disability (mRS 3), moderately severe disability (mRS 4), severe disability (mRS 5), excellent outcome (mRS 0-1), functional independence outcome (mRS 0-2), and poor outcome (mRS 3-5)) nor the secondary outcomes (successful reperfusion, intracranial hemorrhage, and mortality) in the EVT groups were not statistically significant compared with the IVT plus EVT groups (P > 0.05). In addition, the outcomes of sensitivity analysis implied that the findings of meta-analysis were credible. CONCLUSIONS Among patients with acute ischemic stroke due to LVO of anterior circulation, EVT alone yielded efficacy and safety outcomes similar to IVT plus EVT.
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Jia ZY, Zhang YX, Cao YZ, Zhao LB, Shi HB, Zhang L, Li ZF, Shen HJ, Lou M, Zhang YW, Yin GC, Ye XF, Yang PF, Liu S, Liu JM, Direct-Mt Investigators T. Effect of baseline infarct size on endovascular thrombectomy with or without intravenous alteplase in stroke patients: a subgroup analysis of a randomized trial (DIRECT-MT). Eur J Neurol 2022; 29:1643-1651. [PMID: 35143095 DOI: 10.1111/ene.15276] [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: 10/27/2021] [Accepted: 02/03/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND DIRECT-MT showed that endovascular thrombectomy was non-inferior to thrombectomy preceded by intravenous alteplase with regard to functional outcome in patients with acute ischemic stroke. In this post-hoc analysis, we examined whether infarct size modified the effect of alteplase. METHODS All patients with baseline Alberta Stroke Program Early Computed Tomography Score (ASPECTS) grade were included. The primary outcome was the 90-day modified Rankin Scale (mRS) score. Multivariable ordinal logistic regression analysis was used to calculate the adjusted common odds ratio (OR) for better functional outcome based on the mRS for thrombectomy alone versus combination therapy. An interaction term was entered to test for an interaction with baseline ASPECTS subgroups: 0-4 versus 5-7 versus 8-10. RESULTS Of 649 patients, 323 (49.8%) were in the thrombectomy-alone group and 326 (50.2%) in the combination-therapy group. There was no significant treatment-by-trichotomized ASPECTS interaction with alteplase prior to endovascular treatment for the primary endpoint of ordinal mRS (p-value interaction term relative to ASPECTS 8-10: ASPECTS 0-4, p=0.386; ASPECTS 5-7, p=0.936). Adjusted common OR for improvement in the 90-day mRS with thrombectomy alone compared with combination therapy were 1.99 (95% confidence intervals, 0.72-5.46) for ASPECTS 0-4, 1.07 (0.62-1.86) for ASPECTS 5-7, and 1.03 (0.74-1.45) for ASPECTS 8-10. There was no significant difference in the safety outcomes between the two groups. CONCLUSIONS Baseline infarct size may not modify the effect of alteplase prior to endovascular thrombectomy with regard to favorable functional outcomes and adverse events.
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Affiliation(s)
- Zhen Yu Jia
- Department of Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Yong Xin Zhang
- Department of Neurosurgery, Naval Medical University Changhai hospital, Shanghai, China
| | - Yue Zhou Cao
- Department of Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Lin Bo Zhao
- Department of Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Hai Bin Shi
- Department of Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Lei Zhang
- Department of Neurosurgery, Naval Medical University Changhai hospital, Shanghai, China
| | - Zi Fu Li
- Department of Neurosurgery, Naval Medical University Changhai hospital, Shanghai, China
| | - Hong Jian Shen
- Department of Neurosurgery, Naval Medical University Changhai hospital, Shanghai, China
| | - Min Lou
- Department of Neurology, Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Yong Wei Zhang
- Department of Neurology, Naval Medical University Changhai Hospital, Shanghai, China
| | - Guo Cong Yin
- Department of Neurology, Hangzhou First People's Hospital of Zhejiang University, Hangzhou, China
| | - Xiao Fei Ye
- Department of Statistics, Naval Medical University, Shanghai, China
| | - Peng Fei Yang
- Department of Neurosurgery, Naval Medical University Changhai hospital, Shanghai, China
| | - Sheng Liu
- Department of Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Jian Min Liu
- Department of Neurosurgery, Naval Medical University Changhai hospital, Shanghai, China
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Du H, Lei H, Ambler G, Fang S, He R, Yuan Q, Werring DJ, Liu N. Intravenous Thrombolysis Before Mechanical Thrombectomy for Acute Ischemic Stroke: A Meta-Analysis. J Am Heart Assoc 2021; 10:e022303. [PMID: 34779235 PMCID: PMC9075352 DOI: 10.1161/jaha.121.022303] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
Background Whether intravenous thrombolysis before mechanical thrombectomy provides additional benefit for functional outcome in acute ischemic stroke remains uncertain. We performed a meta‐analysis to compare the outcomes of direct mechanical thrombectomy (dMT) to mechanical thrombectomy with bridging using intravenous thrombolysis (bridging therapy [BT]) in patients with acute ischemic stroke. Methods and Results We performed a literature search in the PubMed, Excerpta Medica database, and Cochrane Central Register of Controlled Trials from January 1, 2003, to April 26, 2021. We included randomized clinical trials and observational studies that reported the 90‐day functional outcome in patients with acute ischemic stroke undergoing dMT compared with BT. The 12 included studies (3 randomized controlled trials and 9 observational studies) yielded 3924 participants (mean age, 68.0 years [SD, 13.1 years]; women, 44.2%; 1887 participants who received dMT and 2037 participants who received BT). A meta‐analysis of randomized controlled trial and observational data revealed similar 90‐day functional independence (odds ratio [OR], 1.04; 95% CI, 0.90–1.19), mortality (OR, 1.03; 95% CI, 0.78–1.36), and successful recanalization (OR, 0.93; 95% CI, 0.76–1.14) for patients treated with dMT or BT. Compared with those in the BT group, patients in the dMT group were less likely to experience symptomatic intracranial hemorrhage (OR, 0.68; 95% CI, 0.51–0.91; P=0.008) or any intracranial hemorrhage (OR, 0.71; 95% CI, 0.61–0.84; P<0.001). Conclusions In this meta‐analysis of patients with acute ischemic stroke, we found no significant differences in 90‐day functional outcome or mortality between dMT and BT, but a lower rate of symptomatic intracranial hemorrhage for dMT. These findings support the use of dMT without intravenous thrombolysis bridging therapy. Registration URL: https://www.crd.york.ac.uk/prospero/; Unique identifier: 42021234664.
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Affiliation(s)
- Houwei Du
- Department of Neurology Stroke Research Center Fujian Medical University Union Hospital Fuzhou China.,Institute of Clinical Neurology Fujian Medical University Fuzhou China
| | - Hanhan Lei
- Department of Neurology Stroke Research Center Fujian Medical University Union Hospital Fuzhou China.,Institute of Clinical Neurology Fujian Medical University Fuzhou China
| | - Gareth Ambler
- Statistical Science University College London London United Kingdom
| | - Shuangfang Fang
- Department of Neurology Stroke Research Center Fujian Medical University Union Hospital Fuzhou China.,Institute of Clinical Neurology Fujian Medical University Fuzhou China
| | - Raoli He
- Department of Neurology Stroke Research Center Fujian Medical University Union Hospital Fuzhou China.,Institute of Clinical Neurology Fujian Medical University Fuzhou China
| | - Qilin Yuan
- Department of Neurology Stroke Research Center Fujian Medical University Union Hospital Fuzhou China.,Institute of Clinical Neurology Fujian Medical University Fuzhou China
| | - David J Werring
- University College London Queen Square Institute of Neurology London United Kingdom
| | - Nan Liu
- Department of Neurology Stroke Research Center Fujian Medical University Union Hospital Fuzhou China.,Department of Rehabilitation Fujian Medical University Union Hospital Fuzhou China
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13
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Jang KM, Choi HH, Jang MJ, Cho YD. Direct Endovascular Thrombectomy Alone vs. Bridging Thrombolysis for Patients with Acute Ischemic Stroke : A Meta-analysis. Clin Neuroradiol 2021; 32:603-613. [PMID: 34767050 DOI: 10.1007/s00062-021-01116-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 10/20/2021] [Indexed: 11/25/2022]
Abstract
PURPOSE Although the current guidelines recommend bridging thrombolysis (BT) therapy, which is intravenous thrombolysis (IVT) followed by endovascular thrombectomy (EVT), for patients with acute ischemic stroke from large vessel occlusion (AIS-LVO), the effectiveness and safety of IVT remain controversial. We performed a meta-analysis to demonstrate the non-inferiority of direct EVT alone (DEVT) compared to BT for the efficacy and safety in patients with AIS-LVO who were eligible for IVT. METHODS The literature was searched in big databases between 1 January 1990 and 1 April 2021. The search included both randomized clinical trials (RCTs) and nonrandomized studies (NRSs) that compared DEVT with BT for patients with AIS-LVO who were eligible for IVT (time from stroke onset ≤ 4.5 h). Only NRSs with good intergroup variable matching were included in the study. Outcomes measured included 90-day functional independence, mortality, symptomatic intracranial hemorrhage (sICH), and successful recanalization. The noninferiority margin for risk difference was set at 5% from the literature review. RESULTS Three RCTs (n = 1094) and four NRSs (n = 1366) were included in the meta-analysis. There were 1227 patients (49.9%) in the DEVT group and 1233 patients (50.1%) in the BT group. A statistically significant noninferiority of DEVT compared to BT was concluded in 90-day functional independence, mortality and successful reperfusion. Even in the sICH rate, DEVT group showed a superiority (risk difference, -2%; 95% confidence interval, -4 to -0.002%). CONCLUSION Evidence from RCTs and observational NRSs supports the use of DEVT (without IVT) as the first choice for treatment of patients with AIS-LVO within a time span of 4.5 h or less from stroke onset.
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Affiliation(s)
- Kyoung Min Jang
- Department of Neurosurgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea (Republic of)
| | - Hyun Ho Choi
- Department of Neurosurgery, Chung-Ang University Hospital, Chung-Ang University College of Medicine, Seoul, Korea (Republic of)
| | - Myoung-Jin Jang
- Medical Research Collaborating Center, Seoul National University Hospital, Seoul, Korea (Republic of)
| | - Young Dae Cho
- Department of Radiology, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, 03080, Seoul, Korea (Republic of).
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14
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Zhang J, Chen S, Shi S, Zhang Y, Kong D, Xie Y, Deng X, Tang J, Luo J, Liang Z. Direct endovascular treatment versus bridging therapy in patients with acute ischemic stroke eligible for intravenous thrombolysis: systematic review and meta-analysis. J Neurointerv Surg 2021; 14:321-325. [PMID: 34349014 DOI: 10.1136/neurintsurg-2021-017928] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2021] [Accepted: 07/26/2021] [Indexed: 01/17/2023]
Abstract
OBJECTIVE In this review and meta-analysis we sought to compare the efficacy and safety of direct endovascular thrombectomy (EVT) and bridging therapy for intravenous thrombolysis (IVT)-eligible patients with acute ischemic stroke caused by large vessel occlusions (AIS-LVO). METHODS We searched Medline, Embase, and the Cochrane Library for published randomized clinical trials (RCTs) and observational studies providing outcomes of patients with IVT-eligible AIS-LVO who have undergone EVT with or without IVT. The primary outcome was the proportion of patients achieving a modified Rankin Scale (mRS) score of 0-2 at 90 days. The secondary outcomes included the rates of (1) an excellent outcome defined as an mRS score of 0 or 1 at 90 days, (2) mortality at 90 days, (3) symptomatic intracranial hemorrhage (sICH), (4) any type of intracranial hemorrhage (ICH), (5) successful recanalization, and (6) clot migration. RESULTS We included three RCTs and six observational studies (4 of which were propensity score-adjusted studies) with a total of 3133 patients. In unadjusted and adjusted analyses, no differences in the rates of mRS scores 0-2, mRS scores 0-1, mortality at 90 days, sICH or successful recanalization were detected between patients with AIS-LVO who underwent direct EVT or bridging therapy. The patients treated with direct EVT had a lower risk ratio for any type of ICH and clot migration than did the patients treated with bridging therapy. CONCLUSION Compared with bridging therapy, direct EVT may be equally effective and yield a lower rate of ICH and clot migration in patients with AIS. TRAIL REGISTRATION NUMBER PROSPERO: CRD42021236691.
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Affiliation(s)
- Jian Zhang
- Department of Neurology, Guangxi Medical University First Affiliated Hospital, Nanning, China
| | - Shijian Chen
- Department of Neurology, Guangxi Medical University First Affiliated Hospital, Nanning, China
| | - Shengliang Shi
- Department of Neurology, Guangxi Medical University Second Affiliated Hospital, Nanning, China
| | - Yueling Zhang
- Department of Neurology, Guangxi Medical University Second Affiliated Hospital, Nanning, China
| | - Deyan Kong
- Department of Neurology, Guangxi Medical University Second Affiliated Hospital, Nanning, China
| | - Yiju Xie
- Department of Neurology, Guangxi Medical University First Affiliated Hospital, Nanning, China
| | - Xuhui Deng
- Department of Neurology, Guangxi Medical University First Affiliated Hospital, Nanning, China
| | - Jian Tang
- Department of Neurology, Guangxi Medical University Second Affiliated Hospital, Nanning, China
| | - Jinglian Luo
- Department of Neurology, Guangxi Medical University Second Affiliated Hospital, Nanning, China
| | - Zhijian Liang
- Department of Neurology, Guangxi Medical University First Affiliated Hospital, Nanning, China
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15
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Jian Y, Zhao L, Jia B, Tong X, Li T, Wu Y, Wang X, Gao Z, Gong Y, Zhang X, Wang H, Zhang R, Zhang L, Miao Z, Zhang G. Direct versus Bridging Mechanical Thrombectomy in Elderly Patients with Acute Large Vessel Occlusion: A Multicenter Cohort Study. Clin Interv Aging 2021; 16:1265-1274. [PMID: 34262266 PMCID: PMC8275117 DOI: 10.2147/cia.s313171] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 06/01/2021] [Indexed: 12/22/2022] Open
Abstract
Purpose Elderly people represent a growing stroke population with different pathophysiological states than younger. Whether intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) is beneficial for elderly patients remains unclear. This study compared the efficacy and safety between elderly patients treated with MT alone and those treated with both IVT and MT. Patients and Methods Patients aged ≥65 years who were eligible for IVT within 4.5 h from symptom onset were selected from the ANGEL-ACT (Endovascular Treatment Key Technique and Emergency Work Flow Improvement of Acute Ischemic Stroke) registry, a prospective registry program for patients with endovascular treatment from 111 Chinese stroke centers. The primary efficacy outcome was the 90-day modified Rankin Scale score. We compared efficacy and safety outcomes using ordinal or binary logistic regression or a generalized linear model. Results In total, 482 elderly patients were included: 187 (38.8%) received IVT and MT (bridging MT) and 295 (61.2%) received MT alone (direct MT). There was no significant difference in the 90-day modified Rankin Scale score between the two groups (median: 4 vs 4 points, respectively; adjusted β=−0.048, P=0.822). The direct MT group had a shorter onset-to-puncture time (225 vs 255 min, respectively; adjusted β=−55.074, P=0.002) and a lower rate of parenchymal hemorrhage type 2 within 24 h (2.80% vs 6.63%, respectively; adjusted odds ratio [OR]=0.287, 95% confidence interval [CI]=0.096–0.856, P=0.025). In addition, the direct MT group showed a trend toward a lower incidence of sICH (5.67% vs 10.06%, adjusted OR=0.453, P=0.061), procedure-related complications (7.12% vs 12.30%, adjusted OR=0.499, P=0.052) and distal or new territorial embolization (4.07% vs 6.95%, adjusted OR=0.450, P=0.093). Conclusion Direct MT had similar efficacy to bridging MT in terms of the 90-day functional outcome in elderly patients, whereas bridging MT had a longer onset-to-puncture time and increased risk of hemorrhagic transformation and procedure-related complications.
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Affiliation(s)
- Yating Jian
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, People's Republic of China
| | - Lili Zhao
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, People's Republic of China
| | - Baixue Jia
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xu Tong
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Tao Li
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, People's Republic of China
| | - Yulun Wu
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, People's Republic of China
| | - Xiaoya Wang
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, People's Republic of China
| | - Zhen Gao
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, People's Republic of China
| | - Yu Gong
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, People's Republic of China
| | - Xuelei Zhang
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Huqing Wang
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, People's Republic of China
| | - Ru Zhang
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, People's Republic of China
| | - Lei Zhang
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, People's Republic of China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Guilian Zhang
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, People's Republic of China
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16
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Chen ZJ, Li XF, Liang CY, Cui L, Yang LQ, Xia YM, Cao W, Gao BL. Comparison of Prior Bridging Intravenous Thrombolysis With Direct Endovascular Thrombectomy for Anterior Circulation Large Vessel Occlusion: Systematic Review and Meta-Analysis. Front Neurol 2021; 12:602370. [PMID: 33995238 PMCID: PMC8120007 DOI: 10.3389/fneur.2021.602370] [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: 09/03/2020] [Accepted: 03/15/2021] [Indexed: 12/23/2022] Open
Abstract
Background: Whether bridging treatment combining intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT) is superior to direct EVT alone for emergent large vessel occlusion (LVO) in the anterior circulation is unknown. A systematic review and a meta-analysis were performed to investigate and assess the effect and safety of bridging treatment vs. direct EVT in patients with LVO in the anterior circulation. Methods: PubMed, EMBASE, and the Cochrane library were searched to assess the effect and safety of bridging treatment and direct EVT in LVO. Functional independence, mortality, asymptomatic and symptomatic intracranial hemorrhage (aICH and sICH, respectively), and successful recanalization were evaluated. The risk ratio and the 95% CI were analyzed. Results: Among the eight studies included, there was no significant difference in the long-term functional independence (OR = 1.008, 95% CI = 0.845–1.204, P = 0.926), mortality (OR = 1.060, 95% CI = 0.840–1.336, P = 0.624), recanalization rate (OR = 1.015, 95% CI = 0.793–1.300, P = 0.905), and the incidence of sICH (OR = 1.320, 95% CI = 0.931–1.870, P = 0.119) between bridging therapy and direct EVT. After adjusting for confounding factors, bridging therapy showed a lower recanalization rate (effect size or ES = −0.377, 95% CI = −0.684 to −0.070, P = 0.016), but there was no significant difference in the long-term functional independence (ES = 0.057, 95% CI = −0.177 to 0.291, P = 0.634), mortality (ES = 0.693, 95% CI = −0.133 to 1.519, P = 0.100), and incidence of sICH (ES = −0.051, 95% CI = −0.687 to 0.585, P = 0.875) compared with direct EVT. Meanwhile, in the subgroup analysis of RCT, no significant difference was found in the long-term functional independence (OR = 0.927, 95% CI = 0.727–1.182, P = 0.539), recanalization rate (OR = 1.331, 95% CI = 0.948–1.867, P = 0.099), mortality (OR = 1.072, 95% CI = 0.776–1.481, P = 0.673), and sICH incidence (OR = 1.383, 95% CI = 0.806–2.374, P = 0.977) between patients receiving bridging therapy and those receiving direct DVT. Conclusion: For stroke patients with acute anterior circulation occlusion and who are eligible for intravenous thrombolysis, there is no significant difference in the clinical effect between direct EVT and bridging therapy, which needs to be verified by more randomized controlled trials.
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Affiliation(s)
- Zhao-Ji Chen
- The Third ward of Neurology Department, Affiliated Hospital of Hebei University, Baoding, China
| | - Xiao-Fang Li
- The Third ward of Neurology Department, Affiliated Hospital of Hebei University, Baoding, China
| | - Cheng-Yu Liang
- The Third ward of Neurology Department, Affiliated Hospital of Hebei University, Baoding, China
| | - Lei Cui
- The Third ward of Neurology Department, Affiliated Hospital of Hebei University, Baoding, China
| | - Li-Qing Yang
- The Third ward of Neurology Department, Affiliated Hospital of Hebei University, Baoding, China
| | - Yan-Min Xia
- The Third ward of Neurology Department, Affiliated Hospital of Hebei University, Baoding, China
| | - Wei Cao
- The Third ward of Neurology Department, Affiliated Hospital of Hebei University, Baoding, China
| | - Bu-Lang Gao
- The Third ward of Neurology Department, Affiliated Hospital of Hebei University, Baoding, China
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Cabrera-Maqueda JM, Alba-Isasi MT, Díaz-Pérez J, Albert-Lacal L, Morales A, Parrilla G. Bridging Therapy and Occlusion Site Influence Symptomatic Hemorrhage Rate after Thrombectomy: A Daily Practice Study in 623 Stroke Patients. Cerebrovasc Dis 2021; 50:279-287. [PMID: 33706319 DOI: 10.1159/000512604] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/21/2020] [Accepted: 10/21/2020] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Comparison of symptomatic intracranial hemorrhage (SICH) rates between stroke patients treated with bridging therapy (BT) and primary mechanical thrombectomy (PMT) are scarce and difficult to interpret due to baseline differences between both populations. METHODS Retrospective analysis of patients with acute ischemic stroke treated with endovascular therapy (BT or PMT) was performed at our center between January 2010 and June 2017. RESULTS Six hundred twenty-three patients were included. Global SICH rate was 9% overall: 6.8% in the PMT group and 12.6% in the BT group. The following factors significantly associated with SICH after multivariate analysis: MCA occlusion (p: 0.047), stroke of unknown origin (p: 0.025), BT (p: 0.024), and procedural time over 65 min (p: 0.027). The following variables presented a statistically significant higher frequency in patients treated with PMT: atrial fibrillation (p: 0.005), anticoagulant medication (p < 0.001), wake-up strokes (p < 0.001), atherothrombotic etiology (p < 0.05), combined thrombectomy technique (p: 0.008), longer procedural times (p: 0.025), and favorable outcome at 3 months (p: 0.011). The following variables presented a statistically significant higher frequency in patients treated with BT: antiplatelet medication (p: 0.048), MCA occlusions (p: 0.017), cardioembolic etiology (p < 0.05), stent retriever/aspiration technique (p: 0.008), and SICH (p: 0.013). Patients with MCA occlusions had twice the risk of SICH after BT than after PMT (16.4 and 8.6%, p: 0.038). CONCLUSIONS In this clinical series, the SICH rate was higher in patients treated with BT than in those treated with PMT. Relevant differences in baseline (related to IVT contraindications) were found between both groups. Randomized studies of BT versus PMT in populations with similar baseline characteristics might be of interest.
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Affiliation(s)
- Jose María Cabrera-Maqueda
- Department of Neurology, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain.,Instituto Murciano de Investigación Biosanitaria (IMIB-Arrixaca), Group of Experimental Opththalmology, Murcia, Spain
| | - Maria Teresa Alba-Isasi
- Department of Neurology, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain,
| | - Jose Díaz-Pérez
- Department of Neurointerventional Surgery, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Laura Albert-Lacal
- Department of Neurology, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Ana Morales
- Department of Neurology, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - Guillermo Parrilla
- Department of Neurointerventional Surgery, Hospital Clínico Universitario Virgen de la Arrixaca, Murcia, Spain
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Tong X, Wang Y, Fiehler J, Bauer CT, Jia B, Zhang X, Huo X, Luo G, Wang A, Pan Y, Ma N, Gao F, Mo D, Song L, Sun X, Liu L, Deng Y, Li X, Wang B, Ma G, Wang Y, Ren Z, Miao Z. Thrombectomy Versus Combined Thrombolysis and Thrombectomy in Patients With Acute Stroke: A Matched-Control Study. Stroke 2021; 52:1589-1600. [PMID: 33657849 DOI: 10.1161/strokeaha.120.031599] [Citation(s) in RCA: 38] [Impact Index Per Article: 12.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Xu Tong
- Department of Interventional Neuroradiology (X.T., B.J., X.Z., X.H., G.L., N.M., F.G., D.M., L.S., X.S., L.L., Y.D., X.L., B.W., G.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Yilong Wang
- Department of Neurology (Yilong Wang), Beijing Tiantan Hospital, Capital Medical University, China.,China National Clinical Research Center for Neurological Diseases (A.W., Y.P., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, China
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (J.F.)
| | - Clayton T Bauer
- Department of Neurosurgery, University of South Florida, Tampa (C.T.B., Z.R.)
| | - Baixue Jia
- Department of Interventional Neuroradiology (X.T., B.J., X.Z., X.H., G.L., N.M., F.G., D.M., L.S., X.S., L.L., Y.D., X.L., B.W., G.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Xuelei Zhang
- Department of Interventional Neuroradiology (X.T., B.J., X.Z., X.H., G.L., N.M., F.G., D.M., L.S., X.S., L.L., Y.D., X.L., B.W., G.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology (X.T., B.J., X.Z., X.H., G.L., N.M., F.G., D.M., L.S., X.S., L.L., Y.D., X.L., B.W., G.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Gang Luo
- Department of Interventional Neuroradiology (X.T., B.J., X.Z., X.H., G.L., N.M., F.G., D.M., L.S., X.S., L.L., Y.D., X.L., B.W., G.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases (A.W., Y.P., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, China
| | - Yuesong Pan
- China National Clinical Research Center for Neurological Diseases (A.W., Y.P., Yongjun Wang), Beijing Tiantan Hospital, Capital Medical University, China
| | - Ning Ma
- Department of Interventional Neuroradiology (X.T., B.J., X.Z., X.H., G.L., N.M., F.G., D.M., L.S., X.S., L.L., Y.D., X.L., B.W., G.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Feng Gao
- Department of Interventional Neuroradiology (X.T., B.J., X.Z., X.H., G.L., N.M., F.G., D.M., L.S., X.S., L.L., Y.D., X.L., B.W., G.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Dapeng Mo
- Department of Interventional Neuroradiology (X.T., B.J., X.Z., X.H., G.L., N.M., F.G., D.M., L.S., X.S., L.L., Y.D., X.L., B.W., G.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Ligang Song
- Department of Interventional Neuroradiology (X.T., B.J., X.Z., X.H., G.L., N.M., F.G., D.M., L.S., X.S., L.L., Y.D., X.L., B.W., G.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Xuan Sun
- Department of Interventional Neuroradiology (X.T., B.J., X.Z., X.H., G.L., N.M., F.G., D.M., L.S., X.S., L.L., Y.D., X.L., B.W., G.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Lian Liu
- Department of Interventional Neuroradiology (X.T., B.J., X.Z., X.H., G.L., N.M., F.G., D.M., L.S., X.S., L.L., Y.D., X.L., B.W., G.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Yiming Deng
- Department of Interventional Neuroradiology (X.T., B.J., X.Z., X.H., G.L., N.M., F.G., D.M., L.S., X.S., L.L., Y.D., X.L., B.W., G.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, China
| | | | | | | | | | - Zeguang Ren
- Department of Neurosurgery, University of South Florida, Tampa (C.T.B., Z.R.)
| | - Zhongrong Miao
- Department of Interventional Neuroradiology (X.T., B.J., X.Z., X.H., G.L., N.M., F.G., D.M., L.S., X.S., L.L., Y.D., X.L., B.W., G.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, China
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19
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Zi W, Qiu Z, Li F, Sang H, Wu D, Luo W, Liu S, Yuan J, Song J, Shi Z, Huang W, Zhang M, Liu W, Guo Z, Qiu T, Shi Q, Zhou P, Wang L, Fu X, Liu S, Yang S, Zhang S, Zhou Z, Huang X, Wang Y, Luo J, Bai Y, Zhang M, Wu Y, Zeng G, Wan Y, Wen C, Wen H, Ling W, Chen Z, Peng M, Ai Z, Guo F, Li H, Guo J, Guan H, Wang Z, Liu Y, Pu J, Wang Z, Liu H, Chen L, Huang J, Yang G, Gong Z, Shuai J, Nogueira RG, Yang Q. Effect of Endovascular Treatment Alone vs Intravenous Alteplase Plus Endovascular Treatment on Functional Independence in Patients With Acute Ischemic Stroke: The DEVT Randomized Clinical Trial. JAMA 2021; 325:234-243. [PMID: 33464335 PMCID: PMC7816099 DOI: 10.1001/jama.2020.23523] [Citation(s) in RCA: 297] [Impact Index Per Article: 99.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
IMPORTANCE For patients with large vessel occlusion strokes, it is unknown whether endovascular treatment alone compared with intravenous thrombolysis plus endovascular treatment (standard treatment) can achieve similar functional outcomes. OBJECTIVE To investigate whether endovascular thrombectomy alone is noninferior to intravenous alteplase followed by endovascular thrombectomy for achieving functional independence at 90 days among patients with large vessel occlusion stroke. DESIGN, SETTING, AND PARTICIPANTS Multicenter, randomized, noninferiority trial conducted at 33 stroke centers in China. Patients (n = 234) were 18 years or older with proximal anterior circulation intracranial occlusion strokes within 4.5 hours from symptoms onset and eligible for intravenous thrombolysis. Enrollment took place from May 20, 2018, to May 2, 2020. Patients were enrolled and followed up for 90 days (final follow-up was July 22, 2020). INTERVENTIONS A total of 116 patients were randomized to the endovascular thrombectomy alone group and 118 patients to combined intravenous thrombolysis and endovascular thrombectomy group. MAIN OUTCOMES AND MEASURES The primary end point was the proportion of patients achieving functional independence at 90 days (defined as score 0-2 on the modified Rankin Scale; range, 0 [no symptoms] to 6 [death]). The noninferiority margin was -10%. Safety outcomes included the incidence of symptomatic intracerebral hemorrhage within 48 hours and 90-day mortality. RESULTS The trial was stopped early because of efficacy when 234 of a planned 970 patients had undergone randomization. All 234 patients who were randomized (mean age, 68 years; 102 women [43.6%]) completed the trial. At the 90-day follow-up, 63 patients (54.3%) in the endovascular thrombectomy alone group vs 55 (46.6%) in the combined treatment group achieved functional independence at the 90-day follow-up (difference, 7.7%, 1-sided 97.5% CI, -5.1% to ∞)P for noninferiority = .003). No significant between-group differences were detected in symptomatic intracerebral hemorrhage (6.1% vs 6.8%; difference, -0.8%; 95% CI, -7.1% to 5.6%) and 90-day mortality (17.2% vs 17.8%; difference, -0.5%; 95% CI, -10.3% to 9.2%). CONCLUSIONS AND RELEVANCE Among patients with ischemic stroke due to proximal anterior circulation occlusion within 4.5 hours from onset, endovascular treatment alone, compared with intravenous alteplase plus endovascular treatment, met the prespecified statistical threshold for noninferiority for the outcome of 90-day functional independence. These findings should be interpreted in the context of the clinical acceptability of the selected noninferiority threshold. TRIAL REGISTRATION Chinese Clinical Trial Registry: ChiCTR-IOR-17013568.
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Affiliation(s)
- Wenjie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
| | - Zhongming Qiu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
- Department of Neurology, The 903rd Hospital of The Chinese People’s Liberation Army, Xihu District, Hangzhou, China
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
| | - Hongfei Sang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
- Department of Neurology, Affiliated Hangzhou First People’s Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Deping Wu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
- Huaian Medical District of Jingling Hospital, Medical School of Nanjing University, Huaian, China
| | - Weidong Luo
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
| | - Shuai Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
| | - Junjie Yuan
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
| | - Jiaxing Song
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
| | - Zhonghua Shi
- Department of Neurosurgery, The 904th Hospital of The Chinese People’s Liberation Army, Wuxi, China
| | - Wenguo Huang
- Department of Neurology, Maoming Traditional Chinese Medicine Hospital, Maonan District, Maoming, China
| | - Min Zhang
- Department of Neurology, Maoming Traditional Chinese Medicine Hospital, Maonan District, Maoming, China
| | - Wenhua Liu
- Department of Neurology, Wuhan No. 1 Hospital, Qiaokou District, Wuhan, China
| | - Zhangbao Guo
- Department of Neurology, Wuhan No. 1 Hospital, Qiaokou District, Wuhan, China
| | - Tao Qiu
- Department of Neurology, The First People’s Hospital of Zigong, Da'an District, Zigong, China
| | - Qiang Shi
- Department of Neurology, The First People’s Hospital of Zigong, Da'an District, Zigong, China
| | - Peiyang Zhou
- Department of Neurology, The First People’s Hospital of Xiangyang, Fancheng District, Xiangyang, China
| | - Li Wang
- Department of Neurology, The Third People’s Hospital of Zigong, Gongjing District, Zigong, China
| | - Xinmin Fu
- Department of Neurology, Xuzhou Central Hospital, Quanshan District, Xuzhou, China
| | - Shudong Liu
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing Key Laboratory of Cerebrovascular Disease Research, Yongchuan District, Chongqing, China
| | - Shiquan Yang
- Department of Neurology, The 902nd Hospital of The Chinese People’s Liberation Army, Yuhui District, Bengbu, China
| | - Shuai Zhang
- Department of Neurology, The Affiliated Hospital of Yangzhou University, Guangling District, Yangzhou, China
| | - Zhiming Zhou
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Xianjun Huang
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Yan Wang
- Department of Neurology, The Fifth People’s Hospital of Chengdu, Wenjiang District, Chengdu, China
| | - Jun Luo
- Department of Neurology, Sichuan Mianyang 404 Hospital, Fucheng District, Mianyang, China
| | - Yongjie Bai
- Department of Neurology, The First Affiliated Hospital of Henan Science and Technology University, Jianxi District, Luoyang, China
| | - Min Zhang
- Department of Neurology, Jiangmen Central Hospital, Pengjiang District, Jiangmen, China
| | - Youlin Wu
- Department of Neurology, Chongzhou People's Hospital, Chongzhou, China
| | - Guoyong Zeng
- Department of Neurology, Ganzhou People's Hospital, Zhanggong District, Ganzhou, China
| | - Yue Wan
- Department of Neurology, Yangluo District of Hubei Zhongshan Hospital, Qiaokou District, Wuhan, China
| | - Changming Wen
- Department of Neurology, Nanyang Central Hospital, Wolong District, Nanyang, China
| | - Hongbin Wen
- Department of Neurology, Xiangyang Central Hospital, Xiangcheng District, Xiangyang, China
| | - Wentong Ling
- Department of Neurology, Zhongshan People's Hospital, Zhongshan, China
| | - Zhuo Chen
- Department of Neurology, Mianzhu People's Hospital, Mianzhu, China
| | - Miao Peng
- Department of Neurology, Deyang People’s Hospital, Jingyang District, Deyang, China
| | - Zhibing Ai
- Department of Neurology, Taihe Affiliated Hospital of Shiyan, Shiyan, China
| | - Fuqiang Guo
- Department of Neurology, Sichuan Provincial People’s Hospital, Qingyang District, Chengdu, China
| | - Huagang Li
- Department of Neurology, Zhongnan Hospital of Wuhan University, Wuchang District, Wuhan, China
| | - Jing Guo
- Department of Neurology, Chongqing Three Gorges Central Hospital, Wanzhou District, Chongqing, China
| | - Haitao Guan
- Department of Neurology, The Third Affiliated Hospital of Guangzhou Medical University, Liwan District, Guangzhou, China
| | - Zhiyi Wang
- Department of Neurology, Huazhou People’s Hospital, Hexi District, Huazhou, China
| | - Yong Liu
- Department of Neurology, Lu'an People’s Hospital, Jin'an District, Lu'an, China
| | - Jie Pu
- Department of Neurology, Hubei Provincial People's Hospital, Wuchang District, Wuhan, China
| | - Zhen Wang
- Department of Neurology, Changsha Central Hospital, Yuhua District, Changsha, China
| | - Hansheng Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
| | - Luming Chen
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
| | - Jiacheng Huang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
| | - Guoqiang Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
| | - Zili Gong
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
| | - Jie Shuai
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
| | - Raul G. Nogueira
- Department of Neurology, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia
| | - Qingwu Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Shapingba District, Chongqing, China
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20
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Pienimäki JP, Ollikainen J, Sillanpää N, Protto S. In-Hospital Intravenous Thrombolysis Offers No Benefit in Mechanical Thrombectomy in Optimized Tertiary Stroke Center Setting. Cardiovasc Intervent Radiol 2020; 44:580-586. [PMID: 33354730 PMCID: PMC7987593 DOI: 10.1007/s00270-020-02727-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 11/25/2020] [Indexed: 12/29/2022]
Abstract
Purpose Mechanical thrombectomy (MT) is the first-line treatment in acute stroke patients presenting with large vessel occlusion (LVO). The efficacy of intravenous thrombolysis (IVT) prior to MT is being contested. The objective of this study was to evaluate the efficacy of MT without IVT in patients with no contraindications to IVT presenting directly to a tertiary stroke center with acute anterior circulation LVO. Materials and Methods We collected the data of 106 acute stroke patients who underwent MT in a single high-volume stroke center. Patients with anterior circulation LVO eligible for IVT and directly admitted to our institution who subsequently underwent MT were included. We recorded baseline clinical, laboratory, procedural, and imaging variables and technical, imaging, and clinical outcomes. The effect of intravenous thrombolysis on 3-month clinical outcome (mRS) was analyzed with univariate tests and binary and ordinal logistic regression analysis. Results Fifty-eight out of the 106 patients received IVT + MT. These patients had 2.6-fold higher odds of poorer clinical outcome in mRS shift analysis (p = 0.01) compared to MT-only patients who had excellent 3-month clinical outcome (mRS 0–1) three times more often (p = 0.009). There were no significant differences between the groups in process times, mTICI, or number of hemorrhagic complications. A trend of less distal embolization and higher number of device passes was observed among the MT-only patients. Conclusions MT without prior IVT was associated with an improved overall three-month clinical outcome in acute anterior circulation LVO patients. Supplementary Information The online version of this article (10.1007/s00270-020-02727-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Juha-Pekka Pienimäki
- Vascular and Interventional Radiology Center, Tampere University Hospital, Tampere, Finland.,Medical Imaging Center, Tampere University Hospital, PL2000, 33521, Tampere, Finland
| | - Jyrki Ollikainen
- Department of Neurology, Tampere University Hospital, Tampere, Finland
| | - Niko Sillanpää
- Vascular and Interventional Radiology Center, Tampere University Hospital, Tampere, Finland.,Medical Imaging Center, Tampere University Hospital, PL2000, 33521, Tampere, Finland
| | - Sara Protto
- Vascular and Interventional Radiology Center, Tampere University Hospital, Tampere, Finland. .,Medical Imaging Center, Tampere University Hospital, PL2000, 33521, Tampere, Finland.
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21
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Wang Y, Wu X, Zhu C, Mossa-Basha M, Malhotra A. Bridging Thrombolysis Achieved Better Outcomes Than Direct Thrombectomy After Large Vessel Occlusion: An Updated Meta-Analysis. Stroke 2020; 52:356-365. [PMID: 33302795 DOI: 10.1161/strokeaha.120.031477] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
The utility and necessity of pretreatment with intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) remains an issue of strong debate. This study aims to compare the outcomes of bridging thrombolysis (BT, IVT+MT) with direct MT (d-MT) after large vessel ischemic stroke based on the most up-to-date evidence. MEDLINE, EMBASE, Scopus, and the Cochrane Library from January 2017 to June 2020 were searched for studies that directly compared the outcomes of the 2 strategies. Methodological quality was assessed using the Quality in Prognostic Studies tool. Combined estimates of odds ratios (ORs) of BT versus d-MT were derived. Multiple subgroup analyses were performed, especially for IVT-eligible patients. Thirty studies involving 7191 patients in the BT group and 4891 patients in the d-MT group were included. Methodological quality was generally high. Compared with patients in the d-MT group, patients in the BT group showed significantly better functional independence (modified Rankin Scale score 0-2) at 90 days (OR=1.43 [95% CI, 1.28-1.61]), had lower mortality at 90 days (OR=0.67 [95% CI, 0.60-0.75]), and achieved higher successful recanalization (modified Thrombolysis in Cerebral Ischemia score 2b-3) rate (OR=1.23 [95% CI, 1.07-1.42]). No significant difference was detected in the occurrence of symptomatic intracranial hemorrhage between 2 groups (OR=1.01 [95% CI, 0.86-1.19]). Subgroup analysis showed that functional independence frequency remained significantly higher in BT group regardless of IVT eligibility or study design. Compared with d-MT, bridging with IVT led to better clinical outcomes, lower mortality at 90 days, and higher successful recanalization rates, without increasing the risk of near-term hemorrhagic complications. The benefits of BT based on this most recent literature evidence support the current guidelines of using BT.
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Affiliation(s)
- Yuting Wang
- Department of Radiology, Sichuan Provincial People's Hospital, University of Electronic Science and Technology of China, Chengdu (Y.W.)
| | - Xiao Wu
- Department of Radiology and Biomedical Imaging, University of California, San Francisco (X.W.)
| | - Chengcheng Zhu
- Department of Radiology, University of Washington School of Medicine, Seattle (C.Z., M.M.-B.)
| | - Mahmud Mossa-Basha
- Department of Radiology, University of Washington School of Medicine, Seattle (C.Z., M.M.-B.)
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale School of Medicine and Yale University, New Haven, CT (A.M.)
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22
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Du M, Li S, Huang X, Zhang S, Bai Y, Yan B, Guo H, Xu G, Liu X. Intravenous Thrombolysis before Thrombectomy may Increase the Incidence of Intracranial Hemorrhage inTreating Carotid T Occlusion. J Stroke Cerebrovasc Dis 2020; 30:105473. [PMID: 33276304 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105473] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2020] [Revised: 10/30/2020] [Accepted: 11/08/2020] [Indexed: 11/29/2022] Open
Abstract
BACKGROUND AND PURPOSE Current evidence does not agree on the merits of direct and bridging thrombectomy. This study aimed to compare the safety and efficacy of direct thrombectomy (DT) and bridging thrombectomy (BT) in treating patients with acute ischaemic stroke due to carotid T occlusion. METHODS Patients with stroke due to carotid T occlusion who were treated with DT or BT were retrospectively collected from four advanced stroke centres. Baseline characteristics and clinical outcomes were compared between the groups. Successful recanalization was defined by a modified thrombolysis in cerebral infarction (mTICI) score of 2b or 3. A favourable outcome was defined by a modified Rankin Scale (mRS) score of 0-2 at 90 days after stroke onset. Multivariable analysis was performed to control for potential confounders. RESULTS Of the 111 enrolled patients, 57 (51.4%) patients were treated with DT, and 54 (48.6%) were treated with BT. Patients treated with DT had a shorter imaging to puncture (ITP) time (53 min versus 92 min, P<0.001) and symptom onset to puncture (OTP) time (198 min versus 218 min, P=0.045) than patients treated with BT. No significant difference was detected concerning the rate of successful recanalization (80.7% versus 77.8%, P=0.704) or a favourable outcome between patients treated with DT and BT (35.1% versus 33.3%, P=0.846). Patients treated with DT had a lower intracranial haemorrhage (ICH) rate (40.4% versus 59.3%, P=0.046), but the difference was not significant for symptomatic ICH (sICH, 12.3% versus 16.7%, P=0.511) or asymptomatic ICH (aICH, 28.1% versus 42.6%, P=0.109). After adjusting for potential confounding factors, the ratio of favorable prognosis, successful reperfusion, sICH and mortality did not differ between the two groups. However, there was a higher rate of ICH (OR=2.492, 95% CI 1.005 to 6.180, p=0.049) in the BT group as compared with the DT group. CONCLUSIONS DT seems equivalent to BT in treating stroke due to carotid T occlusion in favorable outcome, successful recanalization, 90-day morality and sICH. However, BT may increase the incidence of ICH in this specific type stroke.
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Affiliation(s)
- Mingyang Du
- Department of Neurology, Jinling Hospital, Nanjing Medical University, Nanjing 210002, Jiangsu, China; Depatment of Cerebrovascular Disease Treatment Center, Nanjing Brain Hospital Affiliated to Nanjing Medical University, Nanjing 210002, Jiangsu, China
| | - Shun Li
- Depatment of Cerebrovascular Disease Treatment Center, Nanjing Brain Hospital Affiliated to Nanjing Medical University, Nanjing 210002, Jiangsu, China; Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing 210002, Jiangsu, China
| | - Xianjun Huang
- Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing 210002, Jiangsu, China
| | - Shuai Zhang
- Department of Neurology, the Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou 225001, Jiangsu, China
| | - Yongjie Bai
- Department of Neurology, First Affiliated Hospital, College of Clinical Medicine of Henan University of Science and Technology, Luoyang 471003, Henan, China
| | - Bin Yan
- Department of Neurology, Jinling Hospital, Nanjing Medical University, Nanjing 210002, Jiangsu, China
| | - Hongquan Guo
- Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing 210002, Jiangsu, China
| | - Gelin Xu
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing 210002, Jiangsu, China
| | - Xinfeng Liu
- Department of Neurology, Jinling Hospital, Nanjing Medical University, Nanjing 210002, Jiangsu, China; Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing 210002, Jiangsu, China.
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23
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Bridge mechanical thrombectomy may be a better choice for acute large vessel occlusions. J Thromb Thrombolysis 2020; 52:291-300. [PMID: 33079378 DOI: 10.1007/s11239-020-02307-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/05/2020] [Indexed: 10/23/2022]
Abstract
Direct mechanical thrombectomy (DMT) was confirmed non-inferior to bridge mechanical thrombectomy (BMT, MT preceded by intravenous alteplase within 4.5 h after symptom onset) for acute ischemic stroke with large vessel occlusions (AIS-LVO) in mothership patients. However, the noninferiority of DMT in the general population (including drip and ship mode) is controversial, and the impact of thrombolysis on retrieval attempts remains uncertain. This was a post-hoc analysis of a multi-center, prospective enrolled study. Patients were divided into the BMT group and the DMT group. Baseline characteristics and clinical outcomes were compared by using univariate analysis, multivariable analysis, and propensity score matching analysis, respectively. Of all 245 patients enrolled in this study, 79 (32.2%) patients underwent BMT. In the multivariable analysis, the ratio of excellent prognosis (defined as modified Rankin Scale [mRS] score 0-1 at 90 days) was significantly higher in the BMT group compared with the DMT group (odds ratio, 2.731; 95% confidence interval, 1.238-6.023; P = 0.013). The ratio of good prognosis (mRS score 0-2 at 90 days), successful recanalization rate [modified Thrombolysis In Cerebral Ischemia (mTICI) score 2b-3] and mortality rate were similar between the two groups. The excellent prognosis rate was significantly higher in the BMT group after propensity score matching (P = 0.023). BMT was associated with a higher ratio of excellent prognosis (mRS 0-1) and a similar successful recanalization rate without increasing peri-operation complications compared with DMT in AIS-LVO patients. It is prudent to continue BMT until further data is available.
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Safety of Mechanical Thrombectomy with Combined Intravenous Thrombolysis in Stroke Treatment 4.5 to 9 Hours from Symptom Onset. J Stroke Cerebrovasc Dis 2020; 29:105204. [PMID: 33066886 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105204] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 07/15/2020] [Accepted: 07/22/2020] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND An extended time window for intravenous thrombolysis (IVT) for acute stroke patients up to 9 hours from symptom onset has been established in recent trials, excluding patients who received mechanical thrombectomy (MT). We therefore investigated whether combined therapy with IVT and MT (IVT+MT) is safe in patients with ischemic stroke and large vessel occlusion (LVO) in an extended time window. METHODS We retrospectively analyzed patients with anterior circulation ischemic stroke and LVO who were treated within 4.5 to 9 hours after symptom onset using MT with or without IVT. Primary endpoint was the occurrence of any intracranial hemorrhage (ICH). Multivariable logistic regression was used to adjust for potential confounders. RESULTS In total, 168 patients were included in the study, 44 (26%) were treated with IVT+ MT. 133 (79%) patients had a M1-/distal carotid artery occlusion. Median ASPECT-Score was 8 (IQR 7-10) and complete reperfusion (mTICI 2b-3) was achieved in 132 (79%) patients. 18 (41%) of the patients in the IVT+MT group developed any ICH vs. 45 (36%) patients in the direct MT group (p=0.587). Symptomatic ICH occurred in 5 (11%) patients with IVT+MT vs. 8 (6%) patients receiving direct MT (p=0.295). In multivariable analysis, IVT+MT was not an independent predictor of ICH (adjusted for NIHSS, degree of reperfusion, symptom-onset-to-treatment time and therapy with tirofiban; OR 0.95 [95% CI 0.43-2.08], p=0.896). CONCLUSION Mechanical thrombectomy in stroke patients seems to be safe with combined intravenous thrombolysis within 4.5 to 9 hours after onset as it did not significantly increase the risk for intracranial hemorrhage.
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Flint AC, Avins AL, Eaton A, Uong S, Cullen SP, Hsu DP, Edwards NJ, Reddy PA, Klingman JG, Rao VA, Chan SL, Hartman J, Zrelak PA, Nguyen-Huynh MN. Risk of Distal Embolization From tPA (Tissue-Type Plasminogen Activator) Administration Prior to Endovascular Stroke Treatment. Stroke 2020; 51:2697-2704. [PMID: 32757749 DOI: 10.1161/strokeaha.120.029025] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
BACKGROUND AND PURPOSE In large artery occlusion stroke, both intravenous (IV) tPA (tissue-type plasminogen activator) and endovascular stroke treatment (EST) are standard-of-care. It is unknown how often tPA causes distal embolization, in which a procedurally accessible large artery occlusion is converted to a more distal and potentially inaccessible occlusion. METHODS We analyzed data from a decentralized stroke telemedicine program in an integrated healthcare delivery system covering 21 hospitals, with 2 high-volume EST centers. We captured all cases sent for EST and examined the relationship between IV tPA administration and the rate of distal embolization, the rate of target recanalization (modified Treatment in Cerebral Infarction scale 2b/3), clinical improvement before EST, and short-term and long-term clinical outcomes. RESULTS Distal embolization before EST was quite common (63/314 [20.1%]) and occurred more often after IV tPA before EST (57/229 [24.9%]) than among those not receiving IV tPA (6/85 [7.1%]; P<0.001). Distal embolization was associated with an inability to attempt EST: after distal embolization, 26/63 (41.3%) could not have attempted EST because of the new clot location, while in cases without distal embolization, only 8/249 (3.2%) were unable to have attempted EST (P<0.001). Among patients who received IV tPA, 13/242 (5.4%) had sufficient symptom improvement that a catheter angiogram was not performed; 6/342 (2.5%) had improvement to within 2 points of their baseline NIHSS. At catheter angiogram, 2/229 (0.9%) of patients who had received tPA had complete recanalization without distal embolization. Both IV tPA and EST recanalization were associated with improved long-term outcome. CONCLUSIONS IV tPA administration before EST for large artery occlusion is associated with distal embolization, which in turn may reduce the chance that EST can be attempted and recanalization achieved. At the same time, some IV tPA-treated patients show symptomatic improvement and complete recanalization. Because IV tPA is associated with both distal embolization and improved long-term clinical outcome, there is a need for prospective clinical trials testing the net benefit or harm of IV tPA before EST.
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Affiliation(s)
- Alexander C Flint
- Division of Research, Kaiser Permanente Northern California, Oakland (A.C.F., A.L.A, A.E., S.U., M.N.N.-H.).,Department of Neuroscience, Kaiser Permanente, Redwood City, CA (A.C.F., S.P.C., D.P.H., V.A.R., N.J.E., P.A.R., S.L.C.)
| | - Andrew L Avins
- Division of Research, Kaiser Permanente Northern California, Oakland (A.C.F., A.L.A, A.E., S.U., M.N.N.-H.)
| | - Abigail Eaton
- Division of Research, Kaiser Permanente Northern California, Oakland (A.C.F., A.L.A, A.E., S.U., M.N.N.-H.)
| | - Stephen Uong
- Division of Research, Kaiser Permanente Northern California, Oakland (A.C.F., A.L.A, A.E., S.U., M.N.N.-H.)
| | - Sean P Cullen
- Department of Neuroscience, Kaiser Permanente, Redwood City, CA (A.C.F., S.P.C., D.P.H., V.A.R., N.J.E., P.A.R., S.L.C.)
| | - Daniel P Hsu
- Department of Neuroscience, Kaiser Permanente, Redwood City, CA (A.C.F., S.P.C., D.P.H., V.A.R., N.J.E., P.A.R., S.L.C.)
| | - Nancy J Edwards
- Department of Neuroscience, Kaiser Permanente, Redwood City, CA (A.C.F., S.P.C., D.P.H., V.A.R., N.J.E., P.A.R., S.L.C.)
| | - Prasad A Reddy
- Department of Neuroscience, Kaiser Permanente, Redwood City, CA (A.C.F., S.P.C., D.P.H., V.A.R., N.J.E., P.A.R., S.L.C.)
| | | | - Vivek A Rao
- Department of Neuroscience, Kaiser Permanente, Redwood City, CA (A.C.F., S.P.C., D.P.H., V.A.R., N.J.E., P.A.R., S.L.C.)
| | - Sheila L Chan
- Department of Neuroscience, Kaiser Permanente, Redwood City, CA (A.C.F., S.P.C., D.P.H., V.A.R., N.J.E., P.A.R., S.L.C.)
| | | | | | - Mai N Nguyen-Huynh
- Division of Research, Kaiser Permanente Northern California, Oakland (A.C.F., A.L.A, A.E., S.U., M.N.N.-H.).,Kaiser Permanente, Sacramento, CA (J.G.K., M.N.N.-H.)
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Kurminas M, Berūkštis A, Misonis N, Blank K, Tamošiūnas AE, Jatužis D. Intravenous r-tPA Dose Influence on Outcome after Middle Cerebral Artery Ischemic Stroke Treatment by Mechanical Thrombectomy. ACTA ACUST UNITED AC 2020; 56:medicina56070357. [PMID: 32708971 PMCID: PMC7404734 DOI: 10.3390/medicina56070357] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2020] [Revised: 07/07/2020] [Accepted: 07/13/2020] [Indexed: 01/01/2023]
Abstract
Background and Objectives: Pretreatment with intravenous thrombolysis (IVT) is still recommended in all eligible acute ischemic stroke patients with large-vessel occlusion before mechanical thrombectomy (MTE). However, the added value and safety of bridging therapy versus direct MTE remains controversial. We aimed at evaluating the influence of r-tPA dose level in patients with middle cerebral artery (MCA) occlusion treated with MTE. Materials and Methods: We prospectively compared clinical and radiological outcomes in 38 bridging patients, with 65 receiving direct MTE for MCA stroke admitted to Vilnius University Hospital Santaros Clinics. Following our protocol, r-tPA infusion was stopped just before MTE in the operating room. Therefore, we divided all bridging patients into three groups according to the amount of r-tPA they received: bolus, partial dose or full dose. Functional independence at 90 days was assessed by a modified Rankin Scale score, i.e., from 0–2. The safety outcomes included 90-day mortality and any intracerebral hemorrhage (ICH). Results: Baseline characteristics and functional outcome at 90 days did not differ between the bridging and direct MTE groups. Shorter MTE procedure and hospitalization time (p = 0.025 and p = 0.036, respectively) were observed in the direct MTE group. An IVT treatment subgroup analysis showed higher rates of symptomatic ICH (p < 0.001) and longer intervals between imaging to MTE (p = 0.005) in the full r-tPA dose group. Conclusions: In patients with an MCA stroke, direct MTE seems to be a safe and equally effective as bridging therapy. The optimal r-tPA dose remains unclear. Randomized trials are needed to accurately evaluate the added value of r-tPA in patients treated with MTE.
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Affiliation(s)
- Marius Kurminas
- Department of Radiology and Nuclear Medicine, Faculty of Medicine, Vilnius University, Santariškių str. 2, LT-08661 Vilnius, Lithuania; (A.B.); (N.M.); (A.E.T.)
- Correspondence:
| | - Andrius Berūkštis
- Department of Radiology and Nuclear Medicine, Faculty of Medicine, Vilnius University, Santariškių str. 2, LT-08661 Vilnius, Lithuania; (A.B.); (N.M.); (A.E.T.)
| | - Nerijus Misonis
- Department of Radiology and Nuclear Medicine, Faculty of Medicine, Vilnius University, Santariškių str. 2, LT-08661 Vilnius, Lithuania; (A.B.); (N.M.); (A.E.T.)
| | - Karmela Blank
- Faculty of Medicine, Vilnius University, M. K. Čiurlionio str. 21/27, LT-03101 Vilnius, Lithuania;
| | - Algirdas Edvardas Tamošiūnas
- Department of Radiology and Nuclear Medicine, Faculty of Medicine, Vilnius University, Santariškių str. 2, LT-08661 Vilnius, Lithuania; (A.B.); (N.M.); (A.E.T.)
| | - Dalius Jatužis
- Centre of Neurology, Faculty of Medicine, Vilnius University, Santariškių str. 2, LT-08661 Vilnius, Lithuania;
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27
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Siegler JE, Jovin TG. Thrombolysis Before Thrombectomy in Acute Large Vessel Occlusion: a Risk/Benefit Assessment and Review of the Evidence. Curr Treat Options Neurol 2020. [DOI: 10.1007/s11940-020-00633-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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28
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Qiu Z, Liu H, Li F, Luo W, Wu D, Shi Z, Liu W, Huang W, Fu X, Qiu T, Wang L, Yang S, Zhang S, Wang Y, Bai Y, Liu X, Li H, Liu Y, Li W, Wan Y, Ai Z, Yao X, Luo J, Pu J, Zhou Z, Wang S, Wen C, Ling W, Liu S, Yang W, Zeng G, Wu Y, Guo F, Chen S, Huang J, Wang Z, Peng M, Zhang M, Zhou P, Chen L, Liu S, Yue C, Yang J, Gong Z, Shuai J, Sang H, Nogueira RG, Zi W, Yang Q. DEVT: A randomized, controlled, multicenter trial of direct endovascular treatment versus standard bridging therapy for acute stroke patients with large vessel occlusion in the anterior circulation - Protocol. Int J Stroke 2020; 16:229-235. [PMID: 32448089 DOI: 10.1177/1747493020925349] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Eight randomized controlled trials have consistently shown that endovascular treatment plus best medical treatment improves outcome after acute anterior proximal intracranial large vessel occlusion strokes. Whether intravenous thrombolysis prior to endovascular treatment in patients with anterior circulation, large vessel occlusion is of any additional benefits remains unclear. OBJECTIVE This study compares the safety and efficacy of direct endovascular treatment versus intravenous recombinant tissue-type plasminogen activator bridging with endovascular treatment (bridging therapy) in acute stroke patients with intracranial internal carotid artery or middle cerebral artery-M1 occlusion within 4.5 h of symptom onset. METHODS AND DESIGN The DEVT study is a randomized, controlled, multicenter trial with blinded outcome assessment. This trial uses a five-look group-sequential non-inferiority design. Up to 194 patients in each interim analysis will be consecutively randomized to direct endovascular treatment or bridging therapy group in 1:1 ratio over three years from about 30 hospitals in China. OUTCOMES The primary end-point is the proportion of independent neurological function defined as modified Rankin scale score of 0 to 2 at 90 days. The primary safety measure is symptomatic intracerebral hemorrhage at 48 h and mortality at 90 days. TRIAL REGISTRY NUMBER ChiCTR-IOR-17013568 (www.chictr.org.cn).
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Affiliation(s)
- Zhongming Qiu
- Department of Neurology, 105785Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China.,Department of Neurology, The 903th Hospital of The People's Liberation Army, Hangzhou, China
| | - Hansheng Liu
- Department of Neurology, 105785Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Fengli Li
- Department of Neurology, 105785Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Weidong Luo
- Department of Neurology, 105785Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Deping Wu
- Department of Neurology, 105785Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Zhonghua Shi
- Department of Neurosurgery, The 904th Hospital of The People's Liberation Army, Wuxi, China
| | - Wenhua Liu
- Department of Neurology, Wuhan No. 1 Hospital, Wuhan, China
| | - Wenguo Huang
- Department of Neurology, Chinese Medical Hospital of Maoming, Maoming, China
| | - Xinmin Fu
- Department of Neurology, Xuzhou Central Hospital, Xuzhou, China
| | - Tao Qiu
- Department of Neurology, The First People's Hospital of Zigong, Zigong, China
| | - Li Wang
- Department of Neurology, The Third People's Hospital of Zigong, Zigong, China
| | - Shiquan Yang
- Department of Neurology, The 902th Hospital of The People's Liberation Army, Bengbu, China
| | - Shuai Zhang
- Department of Neurology, The First People's Hospital of Yangzhou, 38043Yangzhou University, Yangzhou, China
| | - Yan Wang
- Department of Neurology, The Fifth People's Hospital of Chengdu, Chengdu, China
| | - Yongjie Bai
- Department of Neurology, The First Affiliated Hospital of Henan Science and Technology University, Luoyang, China
| | - Xuan Liu
- Department of Neurology, 74731Xiangyang Central Hospital, Hubei Arts and Science University, Xiangyang, China
| | - Huagang Li
- Department of Neurology, Zhongnan Hospital, Wuhan University, Wuhan, China
| | - Yong Liu
- Department of Neurology, Lu'an Affiliated Hospital of Anhui Medical University, Lu'an, China
| | - Wei Li
- Department of Neurology, The Third Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Yue Wan
- Department of Neurology, Hubei Zhongshan Hospital, Wuhan, China
| | - Zhibing Ai
- Department of Neurology, Taihe Affiliated Hospital of Hubei Medical University, Shiyan, China
| | - Xiaoxi Yao
- Department of Neurology, The First People's Hospital of Chenzhou, Chenzhou, China
| | - Jun Luo
- Department of Neurology, The 404th hospital of Mianyang, Mianyang, China
| | - Jie Pu
- Department of Neurology, Hubei Province People's Hospital, Wuhan, China
| | - Zhiming Zhou
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, China
| | - Shouchun Wang
- Department of Neurology, The First Affiliated Hospital of Jilin University, Changchun, China
| | - Changming Wen
- Department of Neurology, Nanyang Central Hospital, Nanyang, China
| | - Wentong Ling
- Department of Neurology, Zhongshan People's Hospital, Zhongshan, China
| | - Shudong Liu
- Department of Neurology, 531595Yongchuan Hospital of Chongqing Medical University, Chongqing Key Laboratory of Cerebrovascular Disease Research, Chongqing, China
| | - Weimin Yang
- Department of Neurology, the 36639First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Guoyong Zeng
- Department of Neurology, Ganzhou People's Hospital, Ganzhou, China
| | - Youlin Wu
- Department of Neurology, Chongzhou People's Hospital, Chongzhou, China
| | - Fuqiang Guo
- Department of Neurology, Sichuan Provincial People's Hospital, Chengdu, China
| | - Shengli Chen
- Department of Neurology, Chongqing Three Gorges Central Hospital, Chongqing, China
| | - Junjie Huang
- Department of Neurosurgery, The Second People's Hospital of Huaiyuan, Huaiyuan, China
| | - Zhen Wang
- Department of Neurology, Changsha Central Hospital, Changsha, China
| | - Miao Peng
- Department of Neurology, Deyang People's Hospital, Deyang, China
| | - Min Zhang
- Department of Neurology, 71537Jiangmen Central Hospital, Jiangmen, China
| | - Peiyang Zhou
- Department of Neurology, The First People's Hospital of Xiangyang, Hubei Medical University, Xiangyang, China
| | - Luming Chen
- Department of Neurology, 105785Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Shuai Liu
- Department of Neurology, 105785Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Chengsong Yue
- Department of Neurology, 105785Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jun Yang
- Department of Neurology, 105785Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Zili Gong
- Department of Neurology, 105785Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jie Shuai
- Department of Neurology, 105785Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Hongfei Sang
- Department of Neurology, 105785Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China.,Department of Neurology, The First People's Hospital of Hangzhou; Zhejiang University School of Medicine, Hangzhou, China
| | - Raul G Nogueira
- Marcus Stroke & Neuroscience Center, 71741Grady Memorial Hospital, Emory University School of Medicine, Atlanta, GA, USA
| | - Wenjie Zi
- Department of Neurology, 105785Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Qingwu Yang
- Department of Neurology, 105785Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
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Smaal JA, de Ridder IR, Heshmatollah A, van Zwam WH, Dippel D, Majoie CB, Brown S, Goyal M, Campbell B, Muir KW, Demchuck AM, Davalos A, Jovin TG, Mitchell PJ, White P, Saver JL, Hill MD, Roos YB, van der Lugt A, van Oostenbrugge RJ. Effect of atrial fibrillation on endovascular thrombectomy for acute ischemic stroke. A meta-analysis of individual patient data from six randomised trials: Results from the HERMES collaboration. Eur Stroke J 2020; 5:245-251. [PMID: 33072878 PMCID: PMC7538768 DOI: 10.1177/2396987320923447] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Accepted: 04/03/2020] [Indexed: 12/22/2022] Open
Abstract
Background Atrial fibrillation is an important risk factor for ischemic stroke, and is
associated with an increased risk of poor outcome after ischemic stroke.
Endovascular thrombectomy is safe and effective in acute ischemic stroke
patients with large vessel occlusion of the anterior circulation. This
meta-analysis aims to investigate whether there is an interaction between
atrial fibrillation and treatment effect of endovascular thrombectomy, and
secondarily whether atrial fibrillation is associated with worse outcome in
patients with ischemic stroke due to large vessel occlusion. Methods Individual patient data were from six of the recent randomised clinical
trials (MR CLEAN, EXTEND-IA, REVASCAT, SWIFT PRIME, ESCAPE, PISTE) in which
endovascular thrombectomy plus standard care was compared to standard care
alone. Primary outcome measure was the shift on the modified Rankin scale
(mRS) at 90 days. Secondary outcomes were functional independence (mRS 0–2)
at 90 days, National Institutes of Health Stroke Scale score at 24 h,
symptomatic intracranial hemorrhage and mortality at 90 days. The primary
effect parameter was the adjusted common odds ratio, estimated with ordinal
logistic regression (shift analysis); treatment effect modification of
atrial fibrillation was assessed with a multiplicative interaction term. Results Among 1351 patients, 447 patients had atrial fibrillation, 224 of whom were
treated with endovascular thrombectomy. We found no interaction of atrial
fibrillation with treatment effect of endovascular thrombectomy for both
primary (p-value for interaction: 0.58) and secondary
outcomes. Regardless of treatment allocation, we found no difference in
primary outcome (mRS at 90 days: aOR 1.11 (95% CI 0.89–1.38) and secondary
outcomes between patients with and without atrial fibrillation. Conclusion We found no interaction of atrial fibrillation on treatment effect of
endovascular thrombectomy, and no difference in outcome between large vessel
occlusion stroke patients with and without atrial fibrillation.
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Affiliation(s)
- J A Smaal
- Maastricht University Medical Center, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - I R de Ridder
- Maastricht University Medical Center, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - A Heshmatollah
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - W H van Zwam
- Maastricht University Medical Center, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Dwj Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - C B Majoie
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - S Brown
- Altair Biostatistics, St Louis Park, MN, USA
| | - M Goyal
- Department of Radiology, University of Calgary, Foothills Hospital, Calgary, AB, Canada
| | - Bcv Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - K W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK
| | - A M Demchuck
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, Calgary, AB, Canada
| | - A Davalos
- Department of Neuroscience, University Autònoma de Barcelona, Spain
| | - T G Jovin
- Stroke Institute, Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - P J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - P White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | - J L Saver
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - M D Hill
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Foothills Hospital, Calgary, AB, Canada
| | - Y B Roos
- Department of Neurology, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands
| | - A van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - R J van Oostenbrugge
- Maastricht University Medical Center, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
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30
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Fan L, Zang L, Liu X, Wang J, Qiu J, Wang Y. Outcomes of mechanical thrombectomy with pre-intravenous thrombolysis: a systematic review and meta-analysis. J Neurol 2020; 268:2420-2428. [PMID: 32140863 DOI: 10.1007/s00415-020-09778-4] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2020] [Revised: 02/25/2020] [Accepted: 02/26/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Whether pre-intravenous thrombolysis (IVT) provides any extra benefits to mechanical thrombectomy (MT) remains controversial. We conducted a systematic review and meta-analysis to compare MT with pre-IVT (IVT + MT) and MT without pre-IVT (MT) for acute ischemic stroke of large vessel occlusion. METHODS We systematically searched PubMed, EMBASE and Cochrane Library to identify studies comparing outcomes between IVT + MT and MT from inception to Jan 24, 2019. Random effects mode was used to pool relative risk (RR) with confidence intervals (CI) to compare functional independence in terms of modified Rankin Scale (mRS) 0-2, favorable outcome (mRS 0-1) and mortality at three-months, symptomatic intracerebral hemorrhage, successful reperfusion, and complete reperfusion between the two treatments groups. RESULTS We included 30 studies enrolling 8970 patients with acute ischemic stroke of large vessel occlusion. Compared with MT, IVT + MT significantly increased the rate of 3-month functional independence (RR 1.20, 95% CI 1.12-1.30; P < 0.0001) and favorable outcome (RR 1.28; 95% CI 1.16-1.40; P < 0.0001), increased the rate of successful reperfusion (RR 1.04,95% CI 1.01-1.08; P = 0.013) and complete reperfusion (RR 1.10; 95% CI 1.01-1.19; P = 0.024), reduced the rate of mortality (RR 0.74, 95% CI 0.67-0.82; P < 0.0001), without significantly increasing the rate of symptomatic intracerebral hemorrhage (RR 0.98,95% CI 0.82-1.17; P = 0.833). The results remained stable in sensitivity analyses and adjusting for publication bias. CONCLUSIONS Pre-IVT provides extra benefits to MT on clinical and imaging outcomes without increasing symptomatic intracerebral hemorrhage in acute ischemic stroke of large vessel occlusion.
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Affiliation(s)
- Lu Fan
- Cerebrovascular Disease Center, Department of Neurology, People's Hospital, China Medical University, 33 Wenyi Road, Shenyang, 110016, Shenhe District, People's Republic of China.,Dalian Medical University, 9 Western Sections, Lvshun South Street, Dalian, 116044, Lvshunkou District, People's Republic of China
| | - Lin Zang
- Cerebrovascular Disease Center, Department of Neurology, People's Hospital, China Medical University, 33 Wenyi Road, Shenyang, 110016, Shenhe District, People's Republic of China.,Dalian Medical University, 9 Western Sections, Lvshun South Street, Dalian, 116044, Lvshunkou District, People's Republic of China
| | - Xiaodong Liu
- Cerebrovascular Disease Center, Department of Neurology, People's Hospital, China Medical University, 33 Wenyi Road, Shenyang, 110016, Shenhe District, People's Republic of China.,Dalian Medical University, 9 Western Sections, Lvshun South Street, Dalian, 116044, Lvshunkou District, People's Republic of China
| | - Jian Wang
- Cerebrovascular Disease Center, Department of Neurology, People's Hospital, China Medical University, 33 Wenyi Road, Shenyang, 110016, Shenhe District, People's Republic of China.,Neurosurgery Department, The First Hospital of China Medical University, 155 Nanjing North Road, Shenyang, 110001, Heping District, People's Republic of China
| | - Jianting Qiu
- Cerebrovascular Disease Center, Department of Neurology, People's Hospital, China Medical University, 33 Wenyi Road, Shenyang, 110016, Shenhe District, People's Republic of China
| | - Yujie Wang
- Cerebrovascular Disease Center, Department of Neurology, People's Hospital, China Medical University, 33 Wenyi Road, Shenyang, 110016, Shenhe District, People's Republic of China.
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Xiao L, Ma M, Gu M, Han Y, Wang H, Zi W, Yang D, Hao Y, Lv Q, Ye R, Sun W, Zhu W, Xu G, Liu X. Renal impairment on clinical outcomes following endovascular recanalization. Neurology 2019; 94:e464-e473. [PMID: 31857435 DOI: 10.1212/wnl.0000000000008748] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Accepted: 07/31/2019] [Indexed: 01/21/2023] Open
Abstract
OBJECTIVE To determine the influence of renal impairment (RI) on clinical outcomes at 3 months and the risk of recurrent stroke in patients presenting with emergent large vessel occlusion (ELVO) treated with emergent endovascular treatment (EVT). METHODS Consecutive patients with anterior circulation stroke due to ELVO treated with EVT in 21 endovascular centers were included. Multivariate regressions were used to evaluate the association of RI with mortality, functional independence (modified Rankin Scale [mRS] score 0-2), and functional improvement (shift in mRS score) at 3 months. The association between RI and the risk of recurrent stroke was evaluated with multivariate competing-risk regression analyses. RESULTS A total of 628 patients with ELVO (mean age 64.7 ± 12.5 years, median NIH Stroke Scale score 17 points, 99 [15.8%] with RI) who underwent EVT were enrolled. After adjustment for other relevant variables, multivariate regression analysis indicated that RI was independently associated with functional independence (adjusted odds ratio 0.53, 95% confidence interval [CI] 0.29-0.96, p = 0.035) at 3 months but not with mortality or functional improvement. Multivariate competing-risk regression analysis showed that patients with RI who received EVT had a significantly higher risk of recurrent stroke (adjusted hazard ratio 2.56, 95% CI 1.27-5.18, p = 0.009) compared to those with normal renal function. CONCLUSION Our results suggest that RI is an independent predictor of functional independence at 3 months and long-term risk of recurrent stroke in patients with ELVO treated with EVT.
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Affiliation(s)
- Lulu Xiao
- From the Department of Neurology (L.X., M.M., Y. Han, H.W., D.Y., Q.L., R.Y., W. Zhu, G.X., X.L.), Jinling Hospital, Medical School of Nanjing University; Department of Neurology (M.G.), Nanjing First Hospital, Nanjing Medical University; Department of Neurology (H.W.), 89th Hospital of the People's Liberation Army, Weifang; Department of Neurology (W. Zi), Xinqiao Hospital, Third Military Medical University; Department of Neurology (Y. Hao), Sir Run Run Shaw Hospital, affiliated with the Zhejiang University School of Medicine, Hangzhou; and Stroke Center and Department of Neurology (W.S.), First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Minmin Ma
- From the Department of Neurology (L.X., M.M., Y. Han, H.W., D.Y., Q.L., R.Y., W. Zhu, G.X., X.L.), Jinling Hospital, Medical School of Nanjing University; Department of Neurology (M.G.), Nanjing First Hospital, Nanjing Medical University; Department of Neurology (H.W.), 89th Hospital of the People's Liberation Army, Weifang; Department of Neurology (W. Zi), Xinqiao Hospital, Third Military Medical University; Department of Neurology (Y. Hao), Sir Run Run Shaw Hospital, affiliated with the Zhejiang University School of Medicine, Hangzhou; and Stroke Center and Department of Neurology (W.S.), First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Mengmeng Gu
- From the Department of Neurology (L.X., M.M., Y. Han, H.W., D.Y., Q.L., R.Y., W. Zhu, G.X., X.L.), Jinling Hospital, Medical School of Nanjing University; Department of Neurology (M.G.), Nanjing First Hospital, Nanjing Medical University; Department of Neurology (H.W.), 89th Hospital of the People's Liberation Army, Weifang; Department of Neurology (W. Zi), Xinqiao Hospital, Third Military Medical University; Department of Neurology (Y. Hao), Sir Run Run Shaw Hospital, affiliated with the Zhejiang University School of Medicine, Hangzhou; and Stroke Center and Department of Neurology (W.S.), First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Yunfei Han
- From the Department of Neurology (L.X., M.M., Y. Han, H.W., D.Y., Q.L., R.Y., W. Zhu, G.X., X.L.), Jinling Hospital, Medical School of Nanjing University; Department of Neurology (M.G.), Nanjing First Hospital, Nanjing Medical University; Department of Neurology (H.W.), 89th Hospital of the People's Liberation Army, Weifang; Department of Neurology (W. Zi), Xinqiao Hospital, Third Military Medical University; Department of Neurology (Y. Hao), Sir Run Run Shaw Hospital, affiliated with the Zhejiang University School of Medicine, Hangzhou; and Stroke Center and Department of Neurology (W.S.), First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Huaiming Wang
- From the Department of Neurology (L.X., M.M., Y. Han, H.W., D.Y., Q.L., R.Y., W. Zhu, G.X., X.L.), Jinling Hospital, Medical School of Nanjing University; Department of Neurology (M.G.), Nanjing First Hospital, Nanjing Medical University; Department of Neurology (H.W.), 89th Hospital of the People's Liberation Army, Weifang; Department of Neurology (W. Zi), Xinqiao Hospital, Third Military Medical University; Department of Neurology (Y. Hao), Sir Run Run Shaw Hospital, affiliated with the Zhejiang University School of Medicine, Hangzhou; and Stroke Center and Department of Neurology (W.S.), First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Wenjie Zi
- From the Department of Neurology (L.X., M.M., Y. Han, H.W., D.Y., Q.L., R.Y., W. Zhu, G.X., X.L.), Jinling Hospital, Medical School of Nanjing University; Department of Neurology (M.G.), Nanjing First Hospital, Nanjing Medical University; Department of Neurology (H.W.), 89th Hospital of the People's Liberation Army, Weifang; Department of Neurology (W. Zi), Xinqiao Hospital, Third Military Medical University; Department of Neurology (Y. Hao), Sir Run Run Shaw Hospital, affiliated with the Zhejiang University School of Medicine, Hangzhou; and Stroke Center and Department of Neurology (W.S.), First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Dong Yang
- From the Department of Neurology (L.X., M.M., Y. Han, H.W., D.Y., Q.L., R.Y., W. Zhu, G.X., X.L.), Jinling Hospital, Medical School of Nanjing University; Department of Neurology (M.G.), Nanjing First Hospital, Nanjing Medical University; Department of Neurology (H.W.), 89th Hospital of the People's Liberation Army, Weifang; Department of Neurology (W. Zi), Xinqiao Hospital, Third Military Medical University; Department of Neurology (Y. Hao), Sir Run Run Shaw Hospital, affiliated with the Zhejiang University School of Medicine, Hangzhou; and Stroke Center and Department of Neurology (W.S.), First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Yonggang Hao
- From the Department of Neurology (L.X., M.M., Y. Han, H.W., D.Y., Q.L., R.Y., W. Zhu, G.X., X.L.), Jinling Hospital, Medical School of Nanjing University; Department of Neurology (M.G.), Nanjing First Hospital, Nanjing Medical University; Department of Neurology (H.W.), 89th Hospital of the People's Liberation Army, Weifang; Department of Neurology (W. Zi), Xinqiao Hospital, Third Military Medical University; Department of Neurology (Y. Hao), Sir Run Run Shaw Hospital, affiliated with the Zhejiang University School of Medicine, Hangzhou; and Stroke Center and Department of Neurology (W.S.), First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Qiushi Lv
- From the Department of Neurology (L.X., M.M., Y. Han, H.W., D.Y., Q.L., R.Y., W. Zhu, G.X., X.L.), Jinling Hospital, Medical School of Nanjing University; Department of Neurology (M.G.), Nanjing First Hospital, Nanjing Medical University; Department of Neurology (H.W.), 89th Hospital of the People's Liberation Army, Weifang; Department of Neurology (W. Zi), Xinqiao Hospital, Third Military Medical University; Department of Neurology (Y. Hao), Sir Run Run Shaw Hospital, affiliated with the Zhejiang University School of Medicine, Hangzhou; and Stroke Center and Department of Neurology (W.S.), First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Ruidong Ye
- From the Department of Neurology (L.X., M.M., Y. Han, H.W., D.Y., Q.L., R.Y., W. Zhu, G.X., X.L.), Jinling Hospital, Medical School of Nanjing University; Department of Neurology (M.G.), Nanjing First Hospital, Nanjing Medical University; Department of Neurology (H.W.), 89th Hospital of the People's Liberation Army, Weifang; Department of Neurology (W. Zi), Xinqiao Hospital, Third Military Medical University; Department of Neurology (Y. Hao), Sir Run Run Shaw Hospital, affiliated with the Zhejiang University School of Medicine, Hangzhou; and Stroke Center and Department of Neurology (W.S.), First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Wen Sun
- From the Department of Neurology (L.X., M.M., Y. Han, H.W., D.Y., Q.L., R.Y., W. Zhu, G.X., X.L.), Jinling Hospital, Medical School of Nanjing University; Department of Neurology (M.G.), Nanjing First Hospital, Nanjing Medical University; Department of Neurology (H.W.), 89th Hospital of the People's Liberation Army, Weifang; Department of Neurology (W. Zi), Xinqiao Hospital, Third Military Medical University; Department of Neurology (Y. Hao), Sir Run Run Shaw Hospital, affiliated with the Zhejiang University School of Medicine, Hangzhou; and Stroke Center and Department of Neurology (W.S.), First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China.
| | - Wusheng Zhu
- From the Department of Neurology (L.X., M.M., Y. Han, H.W., D.Y., Q.L., R.Y., W. Zhu, G.X., X.L.), Jinling Hospital, Medical School of Nanjing University; Department of Neurology (M.G.), Nanjing First Hospital, Nanjing Medical University; Department of Neurology (H.W.), 89th Hospital of the People's Liberation Army, Weifang; Department of Neurology (W. Zi), Xinqiao Hospital, Third Military Medical University; Department of Neurology (Y. Hao), Sir Run Run Shaw Hospital, affiliated with the Zhejiang University School of Medicine, Hangzhou; and Stroke Center and Department of Neurology (W.S.), First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Gelin Xu
- From the Department of Neurology (L.X., M.M., Y. Han, H.W., D.Y., Q.L., R.Y., W. Zhu, G.X., X.L.), Jinling Hospital, Medical School of Nanjing University; Department of Neurology (M.G.), Nanjing First Hospital, Nanjing Medical University; Department of Neurology (H.W.), 89th Hospital of the People's Liberation Army, Weifang; Department of Neurology (W. Zi), Xinqiao Hospital, Third Military Medical University; Department of Neurology (Y. Hao), Sir Run Run Shaw Hospital, affiliated with the Zhejiang University School of Medicine, Hangzhou; and Stroke Center and Department of Neurology (W.S.), First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China
| | - Xinfeng Liu
- From the Department of Neurology (L.X., M.M., Y. Han, H.W., D.Y., Q.L., R.Y., W. Zhu, G.X., X.L.), Jinling Hospital, Medical School of Nanjing University; Department of Neurology (M.G.), Nanjing First Hospital, Nanjing Medical University; Department of Neurology (H.W.), 89th Hospital of the People's Liberation Army, Weifang; Department of Neurology (W. Zi), Xinqiao Hospital, Third Military Medical University; Department of Neurology (Y. Hao), Sir Run Run Shaw Hospital, affiliated with the Zhejiang University School of Medicine, Hangzhou; and Stroke Center and Department of Neurology (W.S.), First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, China.
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Yang P, Treurniet KM, Zhang L, Zhang Y, Li Z, Xing P, Zhang Y, Zhang P, Wang H, Hong B, Dippel DW, Roos YB, Majoie CB, Deng B, Liu J. Direct Intra-arterial thrombectomy in order to Revascularize AIS patients with large vessel occlusion Efficiently in Chinese Tertiary hospitals: A Multicenter randomized clinical Trial (DIRECT-MT)-Protocol. Int J Stroke 2019; 15:689-698. [PMID: 31663831 DOI: 10.1177/1747493019882837] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
RATIONALE Intravenous thrombolysis combined with mechanical thrombectomy (MT) has been proven safe and clinical effective in patients with acute ischemic stroke of anterior circulation large vessel occlusion. However, despite reperfusion, a considerable proportion of patients do not recover. Incidence of symptomatic intracerebral hemorrhage was similar between patients treated with the combination of intravenous thrombolysis and MT, as compared to intravenous thrombolysis alone, suggesting that this complication should be attributed to pre-treatment with intravenous thrombolysis. Conversely, intravenous thrombolysis may be beneficial in patients with small clots occluding intracranial arteries with underlying intracranial atherosclerotic disease, not accessible for MT. AIM To assess whether direct MT is non-inferior compared to combined intravenous thrombolysis plus MT in patients with AIS due to an anterior circulation large vessel occlusion, and to assess treatment effect modification by presence of intracranial atherosclerotic disease. SAMPLE SIZE Aim to randomize 636 patients 1:1 to receive direct MT (intervention) or combined intravenous thrombolysis plus MT (control). DESIGN This is a multicenter, prospective, open label parallel group trial with blinded outcome assessment (PROBE design) assessing non-inferiority of direct MT compared to combined intravenous thrombolysis plus MT. OUTCOMES The primary outcome is the score on the modified Rankin Scale assessed blindly at 90 (±14) days. An common odds ratio, adjusted for the prognostic factors (age, NIHSS, collateral score), representing the shift on the 6-category mRS scale measured at three months, estimated with ordinal logistic regression, will be the primary effect parameter. Non-inferiority is established if the lower boundary of the 95% confidence interval does not cross 0.8. DISCUSSION DIRECT-MT could result in improved therapeutic efficiency and cost reduction in treatment of anterior circulation large vessel occlusion stroke.
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Affiliation(s)
- Pengfei Yang
- Neurosurgery, Changhai Hospital - Naval Medical University, Shanghai, China
| | - Kilian M Treurniet
- Radiology & Nuclear Medicine, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Lei Zhang
- Neurosurgery, Changhai Hospital - Naval Medical University, Shanghai, China
| | - Yongwei Zhang
- Neurology, Changhai Hospital - Naval Medical University, Shanghai, China
| | - Zifu Li
- Neurosurgery, Changhai Hospital - Naval Medical University, Shanghai, China
| | - Pengfei Xing
- Neurology, Changhai Hospital - Naval Medical University, Shanghai, China
| | - Yongxin Zhang
- Neurosurgery, Changhai Hospital - Naval Medical University, Shanghai, China
| | - Ping Zhang
- Neurology, Changhai Hospital - Naval Medical University, Shanghai, China
| | - Hao Wang
- Neurosurgery, Changhai Hospital - Naval Medical University, Shanghai, China
| | - Bo Hong
- Neurosurgery, Changhai Hospital - Naval Medical University, Shanghai, China
| | - Diederik Wj Dippel
- Erasmus MC University Medical Center, Neurology and Stroke Center, Rotterdam, The Netherlands
| | - Yvo Bwem Roos
- Neurology, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Charles Blm Majoie
- Radiology & Nuclear Medicine, Amsterdam University Medical Centers, Location AMC, Amsterdam, The Netherlands
| | - Benqiang Deng
- Neurology, Changhai Hospital - Naval Medical University, Shanghai, China
| | - Jianmin Liu
- Neurosurgery, Changhai Hospital - Naval Medical University, Shanghai, China
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Is intravenous thrombolysis still necessary in patients who undergo mechanical thrombectomy? Curr Opin Neurol 2019; 32:3-12. [PMID: 30461464 DOI: 10.1097/wco.0000000000000633] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW To summarize available evidence on the potential utility of pretreatment with intravenous thrombolysis (IVT) using recombinant tissue-plasminogen activator (rt-PA) in acute ischemic stroke (AIS) patients with large vessel occlusions (LVO) who are treated with mechanical thrombectomy. RECENT FINDINGS Despite theoretical concerns of a higher bleeding risk with IVT pretreatment, there are no data showing increased risk of symptomatic intracerebral hemorrhage (sICH) in patients with LVO receiving bridging therapy (IVT and mechanical thrombectomy) compared with direct mechanical thrombectomy (dMT). Additionally, evidence from observational studies suggest lower rates of infarctions in previously unaffected territories and higher rates of successful reperfusion, with lower number of device passes, in patients receiving bridging therapy. There are substantial discrepancies in studies comparing clinical outcomes between dMT and bridging therapy that are directly related to the inclusion of patients with contraindications to IVT in the dMT group. Ongoing clinical trials will provide definitive answers on the potential additional benefit of IVT in LVO patients receiving mechanical thrombectomy. SUMMARY IVT and mechanical thrombectomy are two effective reperfusion therapies that should be used in a swift and noncompeting fashion in AIS patients. AIS patients with LVO and no contraindications for IVT should receive promptly rt-PA bolus followed by immediate initiation of mechanical thrombectomy as indicated by current international recommendations, unless future randomized controlled trials provide evidence to proceed differently.
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Sawyer RN. Intravenous Tissue Plasminogen Activator for Large Vessel Ischemic Stroke - Is There Still a Role? Neurosurgery 2019; 85:S34-S37. [PMID: 31197340 DOI: 10.1093/neuros/nyz083] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Accepted: 02/24/2019] [Indexed: 01/01/2023] Open
Abstract
While the efficacy of Intravenous tissue plasminogen activator (tPA) is well established, its impact on large vessel occlusion (LVO) is controversial. Whether IV tPA should be bypassed in favor of endovascular thrombectomy (MT) will be addressed. Compelling evidence exists to suggest tPA administration might be bypassed in tPA eligible patients in favor of MT for LVO. A trial of MT with patients randomized for IV tPA within the 4.5-h time window should conducted at comprehensive stroke centers demonstrating equipoise between time to tPA or MT with time to treatment from ED arrival of 45 min. We may do well to consider the systems pathway taken by interventional cardiologists 15 years ago.
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Affiliation(s)
- Robert N Sawyer
- Department of Neurology/UBMD Neurology, Jacobs School of Medicine and Biomedical Sciences, University at Buffalo, Gates Stroke Center, Kaleida Hospitals, Buffalo, New York
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Gamba M, Gilberti N, Premi E, Costa A, Frigerio M, Mardighian D, Vergani V, Spezi R, Delrio I, Morotti A, Poli L, De Giuli V, Caria F, Pezzini A, Gasparotti R, Padovani A, Magoni M. Intravenous fibrinolysis plus endovascular thrombectomy versus direct endovascular thrombectomy for anterior circulation acute ischemic stroke: clinical and infarct volume results. BMC Neurol 2019; 19:103. [PMID: 31142273 PMCID: PMC6540520 DOI: 10.1186/s12883-019-1341-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 05/23/2019] [Indexed: 01/01/2023] Open
Abstract
Background endovascular therapy (ET) is the standard of care for anterior circulation acute ischemic stroke (AIS) caused by large vessel occlusion (LVO). The role of adjunctive intravenous thrombolysis (IVT) in these patients remains unclear. The present study aims to investigate whether IVT followed by ET (CoT, combined therapy) provides additional benefits over direct ET for anterior circulation AIS with LVO. Methods we achieved a single center retrospective study of patients with AIS caused by anterior circulation LVO, referred to our center between January 2014 and January 2017 and treated with ET. Functional recovery (modified Rankin at 3-months follow-up), recanalization rate (thrombolysis in cerebral infarction [TICI] score) and time, early follow-up brain CT scan infarct volume (EFIV) (for recanalized patients only), symptomatic intracerebral hemorrhage (sICH) and 3-month mortality were the outcomes of interests. Independent predictors of the outcomes were explored with multivariable logistic regression. Results 145 subjects were included in the study, of whom 70 underwent direct ET and 75 were treated with CoT. Functional independence at 3-months was more frequent in CoT subjects compared to patients who received direct ET (mRS score 0–1: 48.5% vs 18.6%; P < 0.001. mRS score 0–2: 67.1% vs 37.3%; P < 0.001); CoT patients had also higher first-pass success rate (62.7% vs 38.6%, P < 0.05), higher recanalization rate (84.3% vs 65.3%; P = 0.009) and, in recanalized subjects, smaller EFIV (16.4 ml vs 62.3 ml; P = 0.003). Mortality and intracranial bleeding did not differ between the two groups. In multivariable regression analysis, low baseline NIHSS score (P < 0.05), vessel recanalization (P = 0.05) and CoT (P = 0.03) were independent predictors of favorable outcome at three months. Conclusions CoT appears more effective than ET alone for anterior circulation AIS with LVO, with similar safety profile.
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Affiliation(s)
- Massimo Gamba
- Stroke Unit, Neurologia Vascolare, ASST Spedali Civili di Brescia, Piazzale Spedali Civili 1, Brescia 25123, Brescia, Italy.
| | - Nicola Gilberti
- Stroke Unit, Neurologia Vascolare, ASST Spedali Civili di Brescia, Piazzale Spedali Civili 1, Brescia 25123, Brescia, Italy
| | - Enrico Premi
- Stroke Unit, Neurologia Vascolare, ASST Spedali Civili di Brescia, Piazzale Spedali Civili 1, Brescia 25123, Brescia, Italy
| | - Angelo Costa
- Stroke Unit, Neurologia Vascolare, ASST Spedali Civili di Brescia, Piazzale Spedali Civili 1, Brescia 25123, Brescia, Italy
| | - Michele Frigerio
- Servizio di Neuroradiologia, Università degli Studi di Brescia, Brescia, Italy
| | - Dikran Mardighian
- Servizio di Neuroradiologia, Università degli Studi di Brescia, Brescia, Italy
| | - Veronica Vergani
- Stroke Unit, Neurologia Vascolare, ASST Spedali Civili di Brescia, Piazzale Spedali Civili 1, Brescia 25123, Brescia, Italy
| | - Raffaella Spezi
- Stroke Unit, Neurologia Vascolare, ASST Spedali Civili di Brescia, Piazzale Spedali Civili 1, Brescia 25123, Brescia, Italy
| | - Ilenia Delrio
- Stroke Unit, Neurologia Vascolare, ASST Spedali Civili di Brescia, Piazzale Spedali Civili 1, Brescia 25123, Brescia, Italy
| | - Andrea Morotti
- Stroke Unit, IRCCS Fondazione Istituto Neurologico Nazionale "C. Mondino", Pavia, Italy
| | - Loris Poli
- Dipartimento di Scienze Mediche e Chirurgiche, Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italy
| | - Valeria De Giuli
- Dipartimento di Scienze Mediche e Chirurgiche, Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italy
| | - Filomena Caria
- Dipartimento di Scienze Mediche e Chirurgiche, Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italy
| | - Alessandro Pezzini
- Dipartimento di Scienze Mediche e Chirurgiche, Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italy
| | - Roberto Gasparotti
- Servizio di Neuroradiologia, Università degli Studi di Brescia, Brescia, Italy
| | - Alessandro Padovani
- Dipartimento di Scienze Mediche e Chirurgiche, Clinica Neurologica, Università degli Studi di Brescia, Brescia, Italy
| | - Mauro Magoni
- Stroke Unit, Neurologia Vascolare, ASST Spedali Civili di Brescia, Piazzale Spedali Civili 1, Brescia 25123, Brescia, Italy
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Casetta I, Pracucci G, Saletti A, Saia V, Padroni M, De Vito A, Inzitari D, Zini A, Vallone S, Bergui M, Cerrato P, Bracco S, Tassi R, Gandini R, Sallustio F, Piano M, Motto C, Spina PL, Vinci SL, Causin F, Baracchini C, Gasparotti R, Magoni M, Castellan L, Serrati C, Mangiafico S, Toni D. Combined intravenous and endovascular treatment versus primary mechanical thrombectomy. The Italian Registry of Endovascular Treatment in Acute Stroke. Int J Stroke 2019; 14:898-907. [DOI: 10.1177/1747493019851279] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background Whether mechanical thrombectomy alone may achieve better or at least equal clinical outcome than mechanical thrombectomy combined with intravenous thrombolysis is a matter of debate. Methods From the Italian Registry of Endovascular Stroke Treatment, we extracted all cases treated with intravenous thrombolysis followed by mechanical thrombectomy or with primary mechanical thrombectomy for anterior circulation stroke due to proximal vessel occlusion. We included only patients who would have qualified for intravenous thrombolysis. We compared outcomes of the two groups by using multivariate regression analysis and propensity score method. Results We included 1148 patients, treated with combined intravenous thrombolysis and mechanical thrombectomy therapy (n = 635; 55.3%), or with mechanical thrombectomy alone (n = 513; 44.7%). Demographic and baseline clinical characteristics did not differ between the two groups, except for a shorter onset to groin puncture time (p < 0.05) in the mechanical thrombectomy group. A shift in the 90-day modified Rankin Scale distributions toward a better outcome was found in favor of the combined treatment (adjusted common odds ratio = 1.3; 95% confidence interval: 1.04–1.66). Multivariate analyses on binary outcome show that subjects who underwent combined treatment had higher probability to survive with modified Rankin Scale 0–3 (odds ratio = 1.42; 95% confidence interval: 1.04–1.95) and lower case fatality rate (odds ratio = 0.6; 95% confidence interval: 0.44–0.9). Hemorrhagic transformation did not differ between the two groups. Conclusion These data seem to indicate that combined intravenous thrombolysis and mechanical thrombectomy could be associated with lower probability of death or severe dependency after three months from stroke due to large vessel occlusion, supporting the current guidelines of treating eligible patients with intravenous thrombolysis before mechanical thrombectomy.
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Affiliation(s)
- Ilaria Casetta
- Neurological Clinic, S. Anna University Hospital of Ferrara, Italy
| | | | - Andrea Saletti
- Interventional Neuroradiology, S. Anna University Hospital of Ferrara, Italy
| | - Valentina Saia
- Neurology and Stroke Unit, Santa Corona Hospital, Pietra Ligure
| | - Marina Padroni
- Stroke Unit, S. Anna University Hospital of Ferrara, Italy
| | | | | | - Andrea Zini
- Stroke Unit, Ospedale Civile “S.Agostino-Estense”, Modena
| | - Stefano Vallone
- Neuroradiological Unit, Ospedale Civile “S.Agostino-Estense”, Modena
| | - Mauro Bergui
- Interventional Neuroradiology Unit, Ospedale “Molinette”, Torino
| | - Paolo Cerrato
- Stroke Unit, Ospedale “Molinette”, Torino
- Ospedale “Molinette”, Torino
| | - Sandra Bracco
- Interventional Neuroradiology Unit, Siena University Hospital
| | | | - Roberto Gandini
- Interventional Neuroradiology Unit, Policlinico Tor Vergata, Rome
| | | | - Mariangela Piano
- NEUROFARBA Department, Neuroscience Section, University of Florence
- Interventional Neuroradiology Unit, Niguarda Cà Granda” Hospital, Milan
| | | | | | - Sergio L Vinci
- Interventional Neuroradiology Unit, Policlinico G. Martino, Messina
| | | | | | | | | | - Lucio Castellan
- Interventional Neuroradiology Unit, IRCCS S. Martino-IST, Genova
| | | | | | - Danilo Toni
- Stroke Unit, University Hospital “Umberto I”, Rome
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Effectiveness of Low-Dose Intravenous Tissue Plasminogen Activator before Stent Retriever or Aspiration Mechanical Thrombectomy. J Vasc Interv Radiol 2019; 30:134-140. [PMID: 30717945 DOI: 10.1016/j.jvir.2018.11.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2018] [Revised: 10/31/2018] [Accepted: 11/05/2018] [Indexed: 12/14/2022] Open
Abstract
PURPOSE To determine whether thrombolysis with a lower dose of intravenous recombinant tissue plasminogen activator before mechanical thrombectomy is beneficial for functional outcomes compared with mechanical thrombectomy alone. MATERIALS AND METHODS Data for 100 Japanese patients who underwent mechanical thrombectomy between July 2014 and November 2017 were retrospectively reviewed. These patients were divided into groups according to whether they received intravenous thrombolysis before mechanical thrombectomy, and outcomes were compared. Favorable outcome was defined as a modified Rankin scale score ≤ 2 at 3 months after treatment. RESULTS Thirty-four patients for the thrombolysis group and 66 patients for the thrombectomy-only group were identified. The thrombolysis and nonthrombolysis groups did not differ significantly in baseline characteristics (mean age, 74.3 y vs 75.7 y [P = .485]; mean preoperative National Institute Health Stroke Scale score, 19.8 vs 19.6 [P = .825]). There were no significant differences in the times required for, or the rates of, successful recanalization. However, the thrombolysis group had a higher rate of complete recanalization (67.6% vs 43.9%; P = .041). Postoperative symptomatic intracranial hemorrhage was not significantly different between groups. Favorable outcomes were observed in 73.5% of patients in the thrombolysis group and 51.5% in the nonthrombolysis group (P = .028). CONCLUSIONS This single-center retrospective study shows that lower-dose intravenous thrombolysis improves the outcomes of mechanical thrombectomy for Japanese patients with acute anterior-circulation stroke treated within 4.5 hours of onset.
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Pan X, Liu G, Wu B, Liu X, Fang Y. Comparative efficacy and safety of bridging strategies with direct mechanical thrombectomy in large vessel occlusion: A systematic review and meta-analysis. Medicine (Baltimore) 2019; 98:e14956. [PMID: 30946319 PMCID: PMC6456029 DOI: 10.1097/md.0000000000014956] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Whether bridging strategies[intravenous thrombolysis (IVT) + mechanical thrombectomy (MT)] are superior to mechanical thrombectomy alone for large vessel occlusion(LVO) is still uncertain. A systematic review and meta-analysis was conducted to investigate and evaluate comparative efficacy and safety of bridging strategies vs direct MT in patients with LVO. METHODS The PubMed, EMBASE and Cochrane library databases were searched to evaluate the efficacy and safety of bridging strategies with direct MT in LVO. Functional independence, mortality, symptomatic intracranial hemorrhage (sICH) and successful recanalization were assessed. The risk ratio (RR) and its 95% confidence interval (CI) were calculated. RESULTS The proportion of patients who received MT + IVT was significantly higher in functional independence and successful recanalization rate than MT alone patients. However, pooled results showed that the mortality of patients who received MT + IVT was significantly lower than that of MT alone patients. Moreover, no significant differences were observed in the incidence of sICH between the 2 groups. CONCLUSION The findings of our meta-analysis confirmed that bridging strategies improved functional outcomes, successful recanalization rate and reduced mortality rates. Moreover, the incidence of sICH showed no differences between the bridging strategies and MT alone treatments. However, the conduct of high-quality randomized clinical trials that directly compare both strategies is warranted.
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Affiliation(s)
- Xiaohua Pan
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan
- Department of Neurology, Baotou Central Hospital, Baotou, Inner Mongolia, China
| | - Guorong Liu
- Department of Neurology, Baotou Central Hospital, Baotou, Inner Mongolia, China
| | - Bo Wu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, Sichuan
| | - Xiuzhen Liu
- Department of Neurology, Baotou Central Hospital, Baotou, Inner Mongolia, China
| | - Yong Fang
- Department of Neurology, Baotou Central Hospital, Baotou, Inner Mongolia, China
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Xiong Y, Manwani B, Fisher M. Management of Acute Ischemic Stroke. Am J Med 2019; 132:286-291. [PMID: 30832769 DOI: 10.1016/j.amjmed.2018.10.019] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2018] [Revised: 10/05/2018] [Accepted: 10/06/2018] [Indexed: 11/29/2022]
Abstract
The treatment of acute ischemic stroke includes both intravenous (IV) thrombolysis and mechanical thrombectomy. Important advances regarding both treatment modalities have occurred recently that all physicians who see patients at risk for or who have had a stroke should be aware of. This review will focus on recent clinical trials of IV thrombolysis both positive and negative. Additionally, the results of a large number of early and late time window thrombectomy trials will be presented that demonstrate the remarkable efficacy of this treatment for appropriately selected patients.
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Affiliation(s)
- Yunyun Xiong
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass
| | - Bharti Manwani
- Department of Neurology and Neuroscience, University of Texas, Houston
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Mass.
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Guimarães Rocha M, Carvalho A, Rodrigues M, Cunha A, Figueiredo S, Martins de Campos A, Gregório T, Paredes L, Veloso M, Barros P, Castro S, Ribeiro M, Costa H. Primary Thrombectomy Versus Combined Mechanical Thrombectomy and Intravenous Thrombolysis in Large Vessel Occlusion Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2019; 28:627-631. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.11.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2018] [Revised: 10/03/2018] [Accepted: 11/03/2018] [Indexed: 11/26/2022] Open
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Kaesmacher J, Mordasini P, Arnold M, López-Cancio E, Cerdá N, Boeckh-Behrens T, Kleine JF, Goyal M, Hill MD, Pereira VM, Saver JL, Gralla J, Fischer U. Direct mechanical thrombectomy in tPA-ineligible and -eligible patients versus the bridging approach: a meta-analysis. J Neurointerv Surg 2019; 11:20-27. [PMID: 29705773 PMCID: PMC6327861 DOI: 10.1136/neurintsurg-2018-013834] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Revised: 03/26/2018] [Accepted: 04/03/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND Whether pretreatment with intravenous thrombolysis prior to mechanical thrombectomy (IVT+MTE) adds additional benefit over direct mechanical thrombectomy (dMTE) in patients with large vessel occlusions (LVO) is a matter of debate. METHODS This study-level meta-analysis was presented in accord with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Pooled effect sizes were calculated using the inverse variance heterogeneity model and displayed as summary Odds Ratio (sOR) and corresponding 95% confidence interval (95% CI). Sensitivity analysis was performed by distinguishing between studies including dMTE patients eligible for IVT (IVT-E) or ineligible for IVT (IVT-IN). Primary outcome measures were functional independence (modified Rankin Scale≤2) and mortality at day 90, successful reperfusion, and symptomatic intracerebral hemorrhage. RESULTS Twenty studies, incorporating 5279 patients, were included. There was no evidence that rates of successful reperfusion differed in dMTE and IVT+MTE patients (sOR 0.93, 95% CI 0.68 to 1.28). In studies including IVT-IN dMTE patients, patients undergoing dMTE tended to have lower rates of functional independence and had higher odds for a fatal outcome as compared with IVT+MTE patients (sOR 0.78, 95% CI 0.61 to 1.01 and sOR 1.45, 95% CI 1.22 to 1.73). However, no such treatment group effect was found when analyses were confined to cohorts with a lower risk of selection bias (including IVT-E dMTE patients). CONCLUSION The quality of evidence regarding the relative merits of IVT+MTE versus dMTE is low. When considering studies with lower selection bias, the data suggest that dMTE may offer comparable safety and efficacy as compared with IVT+MTE. The conduct of randomized-controlled clinical trials seems justified.
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Affiliation(s)
- Johannes Kaesmacher
- Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Elena López-Cancio
- Department of Neurology, Stroke Unit Hospital Universitario Central de Asturias (HUCA), Oviedo, Spain
| | - Neus Cerdá
- Biostatistics Unit, Bioclever CRO, Barcelona, Spain
| | - Tobias Boeckh-Behrens
- Institute of Diagnostic and Interventional Neuroradiology, Technical University Munich, Klinikum rechts der Isar, München, Germany
| | | | - Mayank Goyal
- Department of Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Vitor Mendes Pereira
- Division of Neuroradiology, Department of Medical Imaging and Division of Neurosurgery, Department of Surgery, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Jeffrey L Saver
- Comprehensive Stroke Center, Geffen School of Medicine, University of California, Los Angeles, California, USA
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
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Schapira AHV. Progress in neurology 2017-2018. Eur J Neurol 2018; 25:1389-1397. [DOI: 10.1111/ene.13846] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- A. H. V. Schapira
- Department of Clinical and Movement Neurosciences; UCL Queen Square Institute of Neurology; London UK
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Phan K, Dmytriw AA, Lloyd D, Maingard JM, Kok HK, Chandra RV, Brooks M, Thijs V, Moore JM, Chiu AHY, Selim M, Goyal M, Pereira VM, Thomas AJ, Hirsch JA, Asadi H, Wang N. Direct endovascular thrombectomy and bridging strategies for acute ischemic stroke: a network meta-analysis. J Neurointerv Surg 2018; 11:443-449. [PMID: 30291209 DOI: 10.1136/neurintsurg-2018-014260] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2018] [Revised: 09/04/2018] [Accepted: 09/07/2018] [Indexed: 12/14/2022]
Abstract
OBJECTIVES The present Bayesian network meta-analysis aimed to compare the various strategies for acute ischemic stroke: direct endovascular thrombectomy within the thrombolysis window in patients with no contraindications to thrombolysis (DEVT); (2) direct endovascular thrombectomy secondary to contraindications to thrombolysis (DEVTc); (3) endovascular thrombectomy in addition to thrombolysis (IVEVT); and (4) thrombolysis without thrombectomy (IVT). METHODS Six electronic databases were searched from their dates of inception to May 2017 to identify randomized controlled trials (RCTs) comparing IVT versus IVEVT, and prospective registry studies comparing IVEVT versus DEVT or IVEVT versus DEVTc. Network meta-analyses were performed using ORs and 95% CIs as the summary statistic. RESULTS We identified 12 studies (5 RCTs, 7 prospective cohort) with a total of 3161 patients for analysis. There was no significant difference in good functional outcome at 90 days (modified Rankin Scale score ≤2) between DEVT and IVEVT. There was no significant difference in mortality between all treatment groups. DEVT was associated with a 49% reduction in intracranial hemorrhage (ICH) compared with IVEVT (OR 0.51; 95% CI 0.33 to 0.79), due to reduction in rates of asymptomatic ICH (OR 0.47; 95% CI 0.29 to 0.76). Patients treated with DEVT had higher rates of reperfusion compared with IVEVT (OR 1.73; 95% CI 1.04 to 2.94). CONCLUSIONS To our knowledge, this is the first network meta-analysis to be performed in the era of contemporary mechanical thrombectomy comparing DEVT and DEVTc. Our analysis suggests the addition of thrombolysis prior to thrombectomy for large vessel occlusions may not be associated with improved outcomes.
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Affiliation(s)
- Kevin Phan
- NeuroSpine Surgery Research Group (NSURG), Prince of Wales Private Hospital, Sydney, New South Wales, Australia.,Faculty of Medicine, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
| | - Adam A Dmytriw
- Neurosurgery Service, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA.,Division of Neuroradiology, Department of Medical Imaging, University of Toronto, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Declan Lloyd
- School of Medicine, The University of Notre Dame, Sydney, New South Wales, Australia
| | - Julian M Maingard
- Interventional Neuroradiology Service, Department of Radiology, Austin Hospital, Melbourne, Victoria, Australia.,Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Victoria, Australia
| | - Hong Kuan Kok
- Department of Interventional Radiology, Guy's and St Thomas' NHS Foundation Trust, London, UK
| | - Ronil V Chandra
- Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Victoria, Australia
| | - Mark Brooks
- Interventional Neuroradiology Service, Department of Radiology, Austin Hospital, Melbourne, Victoria, Australia
| | - Vincent Thijs
- Stroke Division, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Belgium.,Department of Neurology, Austin Health, Melbourne, Victoria, Australia
| | - Justin M Moore
- Neurosurgery Service, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Albert Ho Yuen Chiu
- Department of Interventional Neuroradiology, Institute of Neurological Sciences, Prince of Wales Hospital and Community Health Services, Prince of Wales Clinical School, University of New South Wales, Randwick, New South Wales, Australia
| | - Magdy Selim
- Stroke Division, Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Mayank Goyal
- Diagnostic and Interventional Neuroradiology, University of Calgary, Calgary, Alberta, Canada
| | - Vitor Mendes Pereira
- Division of Neuroradiology, Department of Medical Imaging, University of Toronto, Toronto Western Hospital, University Health Network, Toronto, Ontario, Canada
| | - Ajith J Thomas
- Neurosurgery Service, Department of Surgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | | | - Hamed Asadi
- Interventional Neuroradiology Service, Department of Radiology, Austin Hospital, Melbourne, Victoria, Australia.,Interventional Neuroradiology Unit, Monash Imaging, Monash Health, Melbourne, Victoria, Australia
| | - Nelson Wang
- Faculty of Medicine, Sydney Medical School, University of Sydney, Sydney, New South Wales, Australia
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Gariel F, Lapergue B, Bourcier R, Berge J, Barreau X, Mazighi M, Kyheng M, Labreuche J, Fahed R, Blanc R, Gory B, Duhamel A, Saleme S, Costalat V, Bracard S, Desal H, Detraz L, Consoli A, Piotin M, Marnat G. Mechanical Thrombectomy Outcomes With or Without Intravenous Thrombolysis. Stroke 2018; 49:2383-2390. [DOI: 10.1161/strokeaha.118.021500] [Citation(s) in RCA: 44] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Intravenous thrombolysis (IVT) within 4.5 hours of symptom onset is currently recommended before mechanical thrombectomy (MT). We compared functional outcome, neurological recovery, reperfusion, and adverse events according to the use or not of IVT before MT.
Methods—
This is a post hoc analysis of the ASTER trial (Contact Aspiration Versus Stent Retriever for Successful Revascularization). The primary outcome was favorable 90-day functional outcome defined as a modified Rankin Scale of ≤2. Secondary outcomes were successful reperfusion following all procedures and after the first-line procedure, number of device passes, and change in National Institutes of Health Stroke Scale score at 24 hours. Safety outcomes included 90-day mortality and any symptomatic intracerebral hemorrhage.
Results—
Three hundred eighty-one patients were included, 250 of whom received IVT before MT (IVT+MT group). There were no significant differences between IVT+MT and MT-alone groups in 90-day favorable functional outcome, in successful reperfusion rate (modified Thrombolysis In Cerebral Infarction 2b or 3), in National Institutes of Health Stroke Scale score improvement at 24 hours, or in hemorrhagic complication rate. The 90-day mortality rate in the IVT+MT group was lower than after MT alone (fully-adjusted risk ratio, 0.59; 95% CI, 0.39–0.88). In a subgroup of patients without anticoagulant medication before stroke onset, we observed in the IVT+MT group a better functional outcome (fully-adjusted risk ratio, 1.38; 95% CI, 1.02–1.89), a higher successful recanalization rate after first-line strategy (fully-adjusted risk ratio, 1.26; 95% CI, 1.05–1.50), and a lower mortality rate (fully-adjusted risk ratio, 0.58; 95% CI, 0.36–0.93).
Conclusions—
Our results show that IVT+MT patients in the ASTER trial have lower 90-day mortality compared with those receiving MT alone. In a selected population of patients without prestroke anticoagulation, we demonstrated that IVT associated with MT might improve functional outcome and recanalization while reducing mortality rates.
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Affiliation(s)
- Florent Gariel
- From the Department of Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, France (F.G., J.B., X.B., G.M.)
| | - Bertrand Lapergue
- Department of Stroke Center, University of Versailles and Saint-Quentin-en-Yvelines, Foch Hospital, Suresnes, France (B.L., A.C.)
| | - Romain Bourcier
- Department of Diagnostic and Interventional Neuroradiology, Guillaume et René Laennec University Hospital, Nantes, France (R.B., H.D., L.D.)
| | - Jérôme Berge
- From the Department of Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, France (F.G., J.B., X.B., G.M.)
| | - Xavier Barreau
- From the Department of Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, France (F.G., J.B., X.B., G.M.)
| | - Mikael Mazighi
- Department of Diagnostic and Interventional Neuroradiology, Rothschild Foundation, Paris, France (M.M., R.F., R.B., M.P.)
| | - Maéva Kyheng
- Department of Biostatistics, University Lille, CHU Lille, EA2694-Santé Publique: Epidémiologie et Qualité des Soins, France (M.K., J.L., A.D.)
| | - Julien Labreuche
- Department of Biostatistics, University Lille, CHU Lille, EA2694-Santé Publique: Epidémiologie et Qualité des Soins, France (M.K., J.L., A.D.)
| | - Robert Fahed
- Department of Diagnostic and Interventional Neuroradiology, Rothschild Foundation, Paris, France (M.M., R.F., R.B., M.P.)
| | - Raphael Blanc
- Department of Diagnostic and Interventional Neuroradiology, Rothschild Foundation, Paris, France (M.M., R.F., R.B., M.P.)
| | | | - Alain Duhamel
- Department of Biostatistics, University Lille, CHU Lille, EA2694-Santé Publique: Epidémiologie et Qualité des Soins, France (M.K., J.L., A.D.)
| | - Suzana Saleme
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Limoges, France (S.S.)
| | - Vincent Costalat
- Department of Diagnostic and Interventional Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France (V.C.)
| | | | - Hubert Desal
- Department of Diagnostic and Interventional Neuroradiology, Guillaume et René Laennec University Hospital, Nantes, France (R.B., H.D., L.D.)
| | - Lili Detraz
- Department of Diagnostic and Interventional Neuroradiology, Guillaume et René Laennec University Hospital, Nantes, France (R.B., H.D., L.D.)
| | - Arturo Consoli
- Department of Stroke Center, University of Versailles and Saint-Quentin-en-Yvelines, Foch Hospital, Suresnes, France (B.L., A.C.)
| | - Michel Piotin
- Department of Diagnostic and Interventional Neuroradiology, Rothschild Foundation, Paris, France (M.M., R.F., R.B., M.P.)
| | - Gaultier Marnat
- From the Department of Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, France (F.G., J.B., X.B., G.M.)
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Abstract
The most feared complication after acute ischemic stroke is symptomatic or asymptomatic hemorrhagic conversion. Neuroimaging and clinical criteria are used to predict development of hemorrhage. Seizures after acute ischemic stroke or stroke-like symptoms from seizures are not common but may lead to confusion in the peristroke period, especially if seizures are repetitive or evolve into status epilepticus, which could affect neuroimaging findings. Malignant infarction develops when cytotoxic edema is large enough to lead to herniation and death. Post-stroke neuroimaging prognosticators have been described and should be assessed early so that appropriate treatment is offered before herniation leads to additional tissue injury.
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Leker RR, Cohen JE, Tanne D, Orion D, Telman G, Raphaeli G, Amsalem J, Streifler JY, Hallevi H, Gavriliuc P, Bornstein NM, Horev A, Yaghmour NE. Direct Thrombectomy versus Bridging for Patients with Emergent Large-Vessel Occlusions. INTERVENTIONAL NEUROLOGY 2018; 7:403-412. [PMID: 30410518 DOI: 10.1159/000489575] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 04/24/2018] [Indexed: 11/19/2022]
Abstract
Background and Aims Patients with emergent large-vessel occlusion (ELVO) that present earlier than 4 h from onset are usually treated with bridging systemic thrombolysis followed by endovascular thrombectomy (EVT). Whether direct EVT (dEVT) could improve the chances of favorable outcome remains unknown. Methods Consecutively, prospectively enrolled patients with ELVO presenting within 4 h of onset were entered into a National Acute Stroke Registry of patients undergoing revascularization. Patients treated with bridging were compared to those treated with dEVT. Excellent outcome was defined as having a modified Rankin Scale score ≤1 at 90 days following stroke. Results Out of 392 patients that underwent thrombectomy, 270 (68%) presented within 4 h and were included. Of those, 159 (59%) underwent bridging and 111 (41%) underwent dEVT. Atrial fibrillation and congestive heart failure were more common in the dEVT group (43 vs. 30%, p = 0.04 and 20 vs. 8%, p = 0.009, respectively), but other risk factors, demographics, stroke severity and subtypes as well as baseline vessel patency state and time metrics did not differ. Excellent target vessel recanalization defined as TICI 3 (thrombolysis in cerebral infarction score) was more common in the dEVT group (75 vs. 61%, p = 0.03), but in-hospital mortality, discharge destinations, short- and long-term excellent outcome rates did not differ. On multivariate regression analysis, treatment modality did not significantly modify the chances of excellent outcome at discharge (OR 0.7; 95% CI 0.3-1.5) or at 3 months (OR 0.78 95% CI 0.4-1.4). Conclusions The chances of attaining excellent functional outcomes are similar in ELVO patients undergoing dEVT or bridging.
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Affiliation(s)
- Ronen R Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Jose E Cohen
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - David Tanne
- Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | - David Orion
- Chaim Sheba Medical Center, Tel-Hashomer, Israel
| | | | | | | | | | - Hen Hallevi
- Tel-Aviv Sourasky Medical Center, Tel Aviv, Israel
| | - Pavel Gavriliuc
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | | | - Anat Horev
- Soroka Medical Center, Beer Sheva, Israel
| | - Nour Eddine Yaghmour
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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Ferrigno M, Bricout N, Leys D, Estrade L, Cordonnier C, Personnic T, Kyheng M, Henon H. Intravenous Recombinant Tissue-Type Plasminogen Activator: Influence on Outcome in Anterior Circulation Ischemic Stroke Treated by Mechanical Thrombectomy. Stroke 2018; 49:1377-1385. [PMID: 29748424 DOI: 10.1161/strokeaha.118.020490] [Citation(s) in RCA: 34] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Revised: 03/24/2018] [Accepted: 04/17/2018] [Indexed: 12/15/2022]
Abstract
BACKGROUND AND PURPOSE Intravenous thrombolysis (IVT) followed by mechanical thrombectomy (MT) improves functional outcome in patients with ischemic stroke related to proximal-vessel occlusion in the anterior circulation. Whether MT alone is as effective as IVT/MT remains controversial. We aimed at evaluating the influence of IVT in patients with large anterior circulation artery occlusion treated with MT. METHODS We did a prospective observational cohort study in patients with stroke related to large anterior circulation artery occlusion treated by MT who were admitted to Lille University Hospital, Lille, France. We evaluated the influence of IVT on favorable functional outcome (defined as a modified Rankin Scale score 0-2 or similar to the prestroke modified Rankin Scale) and on mortality at month 3. Between-group comparisons in outcomes were adjusted for prespecified confoundors by using a propensity score-adjusted approach. RESULTS From January 2012 to January 2017, we included 485 patients (median age, 68 years; 46% men; 348 [72%] in the IVT/MT group; 137 [28%] in the MT group). In MT group, 22% of patients had a favorable outcome versus 35% in IVT/MT group (adjusted relative risk, 1.76; 95% confidence interval, 1.23-2.55). Mortality within 3 months occurred less frequently in IVT/MT group (14% versus 32%; adjusted relative risk, 0.46; 95% confidence interval, 0.31-0.70). Successful reperfusion (Thrombolysis in Cerebral Infarction scale 2b-3) was more frequent in IVT/MT group (75% versus 60%; adjusted relative risk, 1.30; 95% confidence interval, 1.11-1.53). There was no difference between groups on hemorrhagic complications. CONCLUSIONS In this population, previous IVT improved functional outcome and survival at 3 months in patients treated by MT. While waiting for randomized controlled trials, this result encourages not to avoid IVT before MT.
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Affiliation(s)
- Marc Ferrigno
- From the Stroke Unit, Department of Neurology, CHU Lille, INSERM, U1171-Degenerative and Vascular Cognitive Disorders (M.F., D.L., C.C., H.H.)
| | - Nicolas Bricout
- Department of Neuroradiology, Lille University Hospital, France (N.B., L.E., T.P.)
| | - Didier Leys
- From the Stroke Unit, Department of Neurology, CHU Lille, INSERM, U1171-Degenerative and Vascular Cognitive Disorders (M.F., D.L., C.C., H.H.)
| | - Laurent Estrade
- Department of Neuroradiology, Lille University Hospital, France (N.B., L.E., T.P.)
| | - Charlotte Cordonnier
- From the Stroke Unit, Department of Neurology, CHU Lille, INSERM, U1171-Degenerative and Vascular Cognitive Disorders (M.F., D.L., C.C., H.H.)
| | - Thomas Personnic
- Department of Neuroradiology, Lille University Hospital, France (N.B., L.E., T.P.)
| | - Maeva Kyheng
- Department of Biostatistics, CHRU Lille (M.K.), University of Lille, France
| | - Hilde Henon
- From the Stroke Unit, Department of Neurology, CHU Lille, INSERM, U1171-Degenerative and Vascular Cognitive Disorders (M.F., D.L., C.C., H.H.)
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Zussman B, Weiner G, Ducruet A. Addressing the Role of Intravenous Tissue-Plasminogen Activator in Patients with Large Vessel Occlusions. Neurosurgery 2018; 82:E109-E110. [DOI: 10.1093/neuros/nyy040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Fischer U, Kaesmacher J, Molina CA, Selim MH, Alexandrov AV, Tsivgoulis G. Primary Thrombectomy in tPA (Tissue-Type Plasminogen Activator) Eligible Stroke Patients With Proximal Intracranial Occlusions. Stroke 2018; 49:265-269. [DOI: 10.1161/strokeaha.117.018564] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Urs Fischer
- From the Department of Neurology (U.F.) and Department of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, University Hospital Bern, University of Bern, Switzerland; Vall d´Hebron Stroke Unit, Hospital Universitari Vall d´Hebron Passeig Vall d´Hebron, Barcelona, Spain (C.A.M.); Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA (M.H.S.); Department of Neurology, University of Tennessee Health Science Center, Memphis (A.V.A., G.T.); and Second Department of
| | - Johannes Kaesmacher
- From the Department of Neurology (U.F.) and Department of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, University Hospital Bern, University of Bern, Switzerland; Vall d´Hebron Stroke Unit, Hospital Universitari Vall d´Hebron Passeig Vall d´Hebron, Barcelona, Spain (C.A.M.); Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA (M.H.S.); Department of Neurology, University of Tennessee Health Science Center, Memphis (A.V.A., G.T.); and Second Department of
| | - Carlos A. Molina
- From the Department of Neurology (U.F.) and Department of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, University Hospital Bern, University of Bern, Switzerland; Vall d´Hebron Stroke Unit, Hospital Universitari Vall d´Hebron Passeig Vall d´Hebron, Barcelona, Spain (C.A.M.); Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA (M.H.S.); Department of Neurology, University of Tennessee Health Science Center, Memphis (A.V.A., G.T.); and Second Department of
| | - Magdy H. Selim
- From the Department of Neurology (U.F.) and Department of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, University Hospital Bern, University of Bern, Switzerland; Vall d´Hebron Stroke Unit, Hospital Universitari Vall d´Hebron Passeig Vall d´Hebron, Barcelona, Spain (C.A.M.); Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA (M.H.S.); Department of Neurology, University of Tennessee Health Science Center, Memphis (A.V.A., G.T.); and Second Department of
| | - Andrei V. Alexandrov
- From the Department of Neurology (U.F.) and Department of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, University Hospital Bern, University of Bern, Switzerland; Vall d´Hebron Stroke Unit, Hospital Universitari Vall d´Hebron Passeig Vall d´Hebron, Barcelona, Spain (C.A.M.); Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA (M.H.S.); Department of Neurology, University of Tennessee Health Science Center, Memphis (A.V.A., G.T.); and Second Department of
| | - Georgios Tsivgoulis
- From the Department of Neurology (U.F.) and Department of Diagnostic and Interventional Neuroradiology (J.K.), Inselspital, University Hospital Bern, University of Bern, Switzerland; Vall d´Hebron Stroke Unit, Hospital Universitari Vall d´Hebron Passeig Vall d´Hebron, Barcelona, Spain (C.A.M.); Harvard Medical School, Beth Israel Deaconess Medical Center, Boston, MA (M.H.S.); Department of Neurology, University of Tennessee Health Science Center, Memphis (A.V.A., G.T.); and Second Department of
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