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Scheldeman L, Sinnaeve P, Albers GW, Lemmens R, Van de Werf F. Acute myocardial infarction and ischaemic stroke: differences and similarities in reperfusion therapies-a review. Eur Heart J 2024; 45:2735-2747. [PMID: 38941344 DOI: 10.1093/eurheartj/ehae371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 04/16/2024] [Accepted: 05/28/2024] [Indexed: 06/30/2024] Open
Abstract
Acute ST-elevation myocardial infarction (STEMI) and acute ischaemic stroke (AIS) share a number of similarities. However, important differences in pathophysiology demand a disease-tailored approach. In both conditions, fast treatment plays a crucial role as ischaemia and eventually infarction develop rapidly. Furthermore, in both fields, the introduction of fibrinolytic treatments historically preceded the implementation of endovascular techniques. However, in contrast to STEMI, only a minority of AIS patients will eventually be considered eligible for reperfusion treatment. Non-invasive cerebral imaging always precedes cerebral angiography and thrombectomy, whereas coronary angiography is not routinely preceded by non-invasive cardiac imaging in patients with STEMI. In the late or unknown time window, the presence of specific patterns on brain imaging may help identify AIS patients who benefit most from reperfusion treatment. For STEMI, a uniform time window for reperfusion up to 12 h after symptom onset, based on old placebo-controlled trials, is still recommended in guidelines and generally applied. Bridging fibrinolysis preceding endovascular treatment still remains the mainstay of reperfusion treatment in AIS, while primary percutaneous coronary intervention is the strategy of choice in STEMI. Shortening ischaemic times by fine-tuning collaboration networks between ambulances, community hospitals, and tertiary care hospitals, optimizing bridging fibrinolysis, and reducing ischaemia-reperfusion injury are important topics for further research. The aim of this review is to provide insights into the common as well as diverging pathophysiology behind current reperfusion strategies and to explore new ways to enhance their clinical benefit.
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Affiliation(s)
- Lauranne Scheldeman
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
- Department of Neurosciences, Experimental Neurology KU Leuven - University of Leuven, Leuven, Belgium
| | - Peter Sinnaeve
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven, University of Leuven, Herestraat 49, B-3000 Leuven, Belgium
| | - Gregory W Albers
- Department of Neurology, Stanford University Medical Center, Palo Alto, USA
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
- Department of Neurosciences, Experimental Neurology KU Leuven - University of Leuven, Leuven, Belgium
| | - Frans Van de Werf
- Department of Cardiovascular Sciences, KU Leuven, University of Leuven, Herestraat 49, B-3000 Leuven, Belgium
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2
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Demeestere J, Qureshi MM, Vandewalle L, Wouters A, Strbian D, Nogueira RG, Nagel S, Yamagami H, Puetz V, Abdalkader M, Haussen DC, Mohammaden MH, Möhlenbruch MA, Olivé-Gadea M, Winzer S, Ribo M, Michel P, Marto JP, Tanaka K, Yoshimura S, Martinez-Majander N, Caparros F, Henon H, Tomppo L, Dusart A, Bellante F, Ramos JN, Jesser J, Sheth SA, Ortega-Gutiérrez S, Siegler JE, Nannoni S, Kaesmacher J, Dobrocky T, Salazar-Marioni S, Farooqui M, Virtanen P, Ventura R, Zaidi SF, Castonguay AC, Uchida K, Puri AS, Sakai N, Toyoda K, Farzin B, Masoud HE, Klein P, Bui J, Rizzo F, Kaiser DPO, Desfontaines P, Strambo D, Cordonnier C, Lin E, Ringleb PA, Roy D, Zaidat OO, Fischer U, Raymond J, Lemmens R, Nguyen TN. Outcomes of Bridging Intravenous Thrombolysis Versus Endovascular Therapy Alone in Late-Window Acute Ischemic Stroke. Stroke 2024; 55:1767-1775. [PMID: 38748598 DOI: 10.1161/strokeaha.124.046495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 04/26/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND Studies comparing bridging intravenous thrombolysis (IVT) with direct endovascular therapy (EVT) in patients with acute ischemic stroke who present late are limited. We aimed to compare the clinical outcomes and safety of bridging IVT in patients with acute ischemic stroke due to anterior circulation large vessel occlusion who underwent EVT 6 to 24 hours after time last known well. METHODS We enrolled patients with anterior circulation large vessel occlusion stroke and a National Institutes of Health Stroke Scale score of ≥6 from 20 centers across 10 countries in the multicenter retrospective CLEAR study (CT for Late Endovascular Reperfusion) between January 2014 and May 2022. We used inverse probability of treatment weighting modeling adjusted for clinical and imaging confounders to compare functional outcomes, reperfusion success, symptomatic intracranial hemorrhage, and mortality between EVT patients with and without prior IVT. RESULTS Of 5098 patients screened for eligibility, we included 2749 patients, of whom 549 received bridging IVT before EVT. The timing of IVT was not recorded. Witnessed stroke onset and transfer rates were higher in the bridging IVT group (25% versus 12% and 77% versus 55%, respectively, P value for both <0.0001), and time intervals between stroke onset and treatment were shorter (time last known well-start of EVT median 560 minutes [interquartile range, 432-791] versus 724 minutes [interquartile range, 544-912]; P<0.0001). After adjustment for confounders, there was no difference in functional outcome at 3 months (adjusted common odds ratio for modified Rankin Scale shift, 1.03 [95% CI, 0.89-1.19]; P=0.72) or successful reperfusion (adjusted odds ratio, 1.19 [95% CI, 0.81-1.75]; P=0.39). There were no safety concerns associated with bridging IVT versus direct EVT (symptomatic intracranial hemorrhage: adjusted odds ratio, 0.75 [95% CI, 0.38-1.48]; P=0.40; mortality: adjusted odds ratio, 1.14 [95% CI, 0.89-1.46]; P=0.31). Results were unchanged when the analysis was limited to patients who received IVT >6 hours after last known well. CONCLUSIONS In patients with an anterior circulation large vessel occlusion stroke who underwent EVT 6 to 24 hours from last known well, bridging IVT was not associated with a difference in outcomes compared with direct EVT. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04096248.
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Affiliation(s)
- Jelle Demeestere
- Laboratory for Neurobiology, KU Leuven, Belgium (J.D., L.V., A.W., R.L.)
- Neurology, UZ Leuven, Belgium (J.D., L.V., A.W., R.L.)
| | - Muhammad M Qureshi
- Radiology (M.M.Q., M.A., P.K., J.B., T.N.N.), Boston Medical Center, MA
- Radiation Oncology (M.M.Q.), Boston Medical Center, MA
- Boston University Chobanian & Avedisian School of Medicine, MA (M.M.Q., M.A., P.K., T.N.N.)
| | - Lieselotte Vandewalle
- Laboratory for Neurobiology, KU Leuven, Belgium (J.D., L.V., A.W., R.L.)
- Neurology, UZ Leuven, Belgium (J.D., L.V., A.W., R.L.)
| | - Anke Wouters
- Laboratory for Neurobiology, KU Leuven, Belgium (J.D., L.V., A.W., R.L.)
- Neurology, UZ Leuven, Belgium (J.D., L.V., A.W., R.L.)
| | - Daniel Strbian
- Neurology (D.S., N.M.-M., L.T.), Helsinki University Hospital, Finland
- University of Helsinki, Finland (D.S., N.M.-M., L.T., P.V.)
| | - Raul G Nogueira
- Neurology, Neurosurgery, University of Pittsburgh Medical Center, MA (R.G.N.)
- Neurology, Grady Memorial Hospital, Atlanta, GA (R.G.N., D.C.H., M.H.M.)
| | - Simon Nagel
- Neurology, Klinikum Ludwigshafen, Germany (S.N.)
- Neurology (S.N., P.A.R.), Heidelberg University Hospital, Germany
| | | | - Volker Puetz
- Neurology (V.P., S.W.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
- Dresden Neurovascular Center (V.P., S.W., D.P.O.K.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Mohamad Abdalkader
- Radiology (M.M.Q., M.A., P.K., J.B., T.N.N.), Boston Medical Center, MA
- Boston University Chobanian & Avedisian School of Medicine, MA (M.M.Q., M.A., P.K., T.N.N.)
| | - Diogo C Haussen
- Neurology, Grady Memorial Hospital, Atlanta, GA (R.G.N., D.C.H., M.H.M.)
| | | | | | - Marta Olivé-Gadea
- Neurology, Hospital Vall d'Hebron, Barcelona, Spain (M.O.G., M.R., F.R.)
| | - Simon Winzer
- Neurology (V.P., S.W.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
- Dresden Neurovascular Center (V.P., S.W., D.P.O.K.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Marc Ribo
- Neurology, Hospital Vall d'Hebron, Barcelona, Spain (M.O.G., M.R., F.R.)
| | - Patrik Michel
- Neurology, Lausanne University Hospital and University of Lausanne, Switzerland (P.M., D.S.)
| | - João Pedro Marto
- Neurology (J.P.M., R.V.), Hospital de Egas Moniz, Centro Hospitalar Lisboa Occidental, Lisbon, Portugal
| | - Kanta Tanaka
- Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan (K. Tanaka, K. Toyoda)
| | | | - Nicolas Martinez-Majander
- Neurology (D.S., N.M.-M., L.T.), Helsinki University Hospital, Finland
- University of Helsinki, Finland (D.S., N.M.-M., L.T., P.V.)
| | - Francois Caparros
- Neurology, Centre Hospitalier Universitaire de Lille, France (F.C., H.H., C.C.)
- Neurology, University of Lille, France (F.C., H.H., C.C.)
| | - Hilde Henon
- Neurology, Centre Hospitalier Universitaire de Lille, France (F.C., H.H., C.C.)
- Neurology, University of Lille, France (F.C., H.H., C.C.)
| | - Liisa Tomppo
- Neurology (D.S., N.M.-M., L.T.), Helsinki University Hospital, Finland
- University of Helsinki, Finland (D.S., N.M.-M., L.T., P.V.)
| | - Anne Dusart
- Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium (A.D., F.B.)
| | - Flavio Bellante
- Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium (A.D., F.B.)
| | - João Nuno Ramos
- Radiology (J.N.R.), Hospital de Egas Moniz, Centro Hospitalar Lisboa Occidental, Lisbon, Portugal
| | - Jessica Jesser
- Neuroradiology (M.A.M., J.J.), Heidelberg University Hospital, Germany
| | - Sunil A Sheth
- Neurology, UTHealth McGovern Medical School, Houston, TX (S.A.S., S.S.-M.)
| | | | | | - Stefania Nannoni
- Clinical Neurosciences, University of Cambridge, United Kingdom (S.N.)
| | - Johannes Kaesmacher
- Diagnostic and Interventional Neuroradiology, University Hospital Bern, Switzerland (J.K., T.D.)
| | - Tomas Dobrocky
- Diagnostic and Interventional Neuroradiology, University Hospital Bern, Switzerland (J.K., T.D.)
| | | | | | - Pekka Virtanen
- Radiology (P.V.), Helsinki University Hospital, Finland
- University of Helsinki, Finland (D.S., N.M.-M., L.T., P.V.)
| | - Rita Ventura
- Neurology (J.P.M., R.V.), Hospital de Egas Moniz, Centro Hospitalar Lisboa Occidental, Lisbon, Portugal
| | - Syed F Zaidi
- Neurology, University of Toledo, OH (S.F.Z., A.C.C.)
| | | | - Kazutaka Uchida
- Neurosurgery, Hyogo Medical University, Nishinomiya, Japan (S.Y., K.U.)
| | - Ajit S Puri
- Interventional Neuroradiology, University of Massachusetts Memorial Medical Center, Worcester (A.S.P.)
| | - Nobuyuki Sakai
- Neurovascular Research, Kobe City Medical Center General Hospital, Japan (N.S.)
| | - Kazunori Toyoda
- Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan (K. Tanaka, K. Toyoda)
| | - Behzad Farzin
- Interventional Neuroradiology, Centre Hospitalier de l'Universite de Montreal, Canada (B.F., D.R., J.R.)
| | | | - Piers Klein
- Radiology (M.M.Q., M.A., P.K., J.B., T.N.N.), Boston Medical Center, MA
- Boston University Chobanian & Avedisian School of Medicine, MA (M.M.Q., M.A., P.K., T.N.N.)
| | - Jenny Bui
- Radiology (M.M.Q., M.A., P.K., J.B., T.N.N.), Boston Medical Center, MA
| | - Federica Rizzo
- Neurology, Hospital Vall d'Hebron, Barcelona, Spain (M.O.G., M.R., F.R.)
| | - Daniel P O Kaiser
- Dresden Neurovascular Center (V.P., S.W., D.P.O.K.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
- Institute of Neuroradiology (D.P.O.K.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | | | - Davide Strambo
- Neurology, Lausanne University Hospital and University of Lausanne, Switzerland (P.M., D.S.)
| | - Charlotte Cordonnier
- Neurology, Centre Hospitalier Universitaire de Lille, France (F.C., H.H., C.C.)
- Neurology, University of Lille, France (F.C., H.H., C.C.)
| | - Eugene Lin
- Neuroscience and Stroke Program, Bon Secours Mercy Health St. Vincent Hospital, Toledo, OH (E.L., O.O.Z.)
| | - Peter A Ringleb
- Neurology (S.N., P.A.R.), Heidelberg University Hospital, Germany
| | - Daniel Roy
- Interventional Neuroradiology, Centre Hospitalier de l'Universite de Montreal, Canada (B.F., D.R., J.R.)
| | - Osama O Zaidat
- Neuroscience and Stroke Program, Bon Secours Mercy Health St. Vincent Hospital, Toledo, OH (E.L., O.O.Z.)
| | - Urs Fischer
- Neurology, University Hospital Basel, Switzerland (U.F.)
| | - Jean Raymond
- Interventional Neuroradiology, Centre Hospitalier de l'Universite de Montreal, Canada (B.F., D.R., J.R.)
| | - Robin Lemmens
- Laboratory for Neurobiology, KU Leuven, Belgium (J.D., L.V., A.W., R.L.)
- Neurology, UZ Leuven, Belgium (J.D., L.V., A.W., R.L.)
| | - Thanh N Nguyen
- Radiology (M.M.Q., M.A., P.K., J.B., T.N.N.), Boston Medical Center, MA
- Boston University Chobanian & Avedisian School of Medicine, MA (M.M.Q., M.A., P.K., T.N.N.)
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García-Alcántara G, Moreno-López C, López-Rebolledo R, Lorenzo-Barreto P, Garay-Albízuri P, Martínez-García B, Llanes A, Pérez-Gil D, Chico JL, Vera-Lechuga R, García-Madrona S, Matute-Lozano C, De Felipe-Mimbrera A, Masjuan J, Cruz-Culebras A. Clot migration in patients treated with tenecteplase versus alteplase before mechanical thrombectomy. Eur Stroke J 2024:23969873241263201. [PMID: 38915244 DOI: 10.1177/23969873241263201] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024] Open
Abstract
INTRODUCTION This study aimed to describe and analyze the rate of clot migration of vessel thrombosis to distal segments in patients with acute ischemic stroke (AIS) who received intravenous thrombolysis (IVT) with tenecteplase (TNK) and alteplase (ALT) before mechanical thrombectomy (MT). In addition, we aimed to determine the relationship between thrombus migration and functional prognosis. METHODS This study followed the STROBE reporting guidelines. We performed a retrospective analysis of a series of patients from November 2017 to April 2023 with an AIS with thrombosis on CT imaging, treated with IVT (TNK or ALT, split into two distinct groups) prior to mechanical thrombectomy. RESULTS Two hundred and fifty-six patients with large vessel occlusion (LVO) were included. Ninety-six had received TNK. One hundred and sixty had received ALT. Of the 96 TNK patients, 25 experienced either complete recanalization (n = 3) or thrombus migration (n = 22). Of the 160 ALT patients, 20 experienced either complete recanalization (n = 6) or thrombus migration (n = 14). The difference being statistically substantial for the thrombus migration rate (OR = 3.61, 95% confidence interval: 1.63; 7.98). Migration to an irretrievable very distal segment occurred in four (4%) patients with TNK and in three patients (2%) with ALT (p > 0.05). Thrombus migration was not significantly associated to a different functional prognosis, measured through Rankin scale after 3 months (OR = 0.44, 95% confidence interval: 0.17; 1.12). CONCLUSION The use of TNK over ALT as a fibrinolytic agent is associated with a higher thrombus migration rate. The migration of thrombi to distal segments, which are theoretically less accessible for mechanical thrombectomy, did not result in worse clinical outcomes.
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Affiliation(s)
| | - Cristina Moreno-López
- Neurology Department and Stroke Unit, Ramón y Cajal University Hospital, Madrid, Spain
| | | | - Pablo Lorenzo-Barreto
- Neurology Department and Stroke Unit, Ramón y Cajal University Hospital, Madrid, Spain
| | | | | | - Ana Llanes
- Neurology Department and Stroke Unit, Ramón y Cajal University Hospital, Madrid, Spain
| | - Daniel Pérez-Gil
- Neurology Department and Stroke Unit, Ramón y Cajal University Hospital, Madrid, Spain
| | - Juan Luis Chico
- Neurology Department and Stroke Unit, Ramón y Cajal University Hospital, Madrid, Spain
| | - Rocío Vera-Lechuga
- Neurology Department and Stroke Unit, Ramón y Cajal University Hospital, Madrid, Spain
| | | | | | | | - Jaime Masjuan
- Neurology Department and Stroke Unit, Ramón y Cajal University Hospital, Madrid, Spain
| | - Antonio Cruz-Culebras
- Neurology Department and Stroke Unit, Ramón y Cajal University Hospital, Madrid, Spain
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4
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Arrarte Terreros N, Stolp J, Bruggeman AAE, Swijnenburg ISJ, Lopes RR, van Meenen LCC, Groot AED, Kappelhof M, Coutinho JM, Roos YBWEM, Emmer BJ, Beenen LFM, Dippel DWJ, van Zwam WH, van Bavel E, Marquering HA, Majoie CBLM. Thrombus Imaging Characteristics to Predict Early Recanalization in Anterior Circulation Large Vessel Occlusion Stroke. J Cardiovasc Dev Dis 2024; 11:107. [PMID: 38667725 PMCID: PMC11050543 DOI: 10.3390/jcdd11040107] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2024] [Revised: 03/23/2024] [Accepted: 03/25/2024] [Indexed: 04/28/2024] Open
Abstract
The early management of transferred patients with a large vessel occlusion (LVO) stroke could be improved by identifying patients who are likely to recanalize early. We aim to predict early recanalization based on patient clinical and thrombus imaging characteristics. We included 81 transferred anterior-circulation LVO patients with an early recanalization, defined as the resolution of the LVO or the migration to a distal location not reachable with endovascular treatment upon repeated radiological imaging. We compared their clinical and imaging characteristics with all (322) transferred patients with a persistent LVO in the MR CLEAN Registry. We measured distance from carotid terminus to thrombus (DT), thrombus length, density, and perviousness on baseline CT images. We built logistic regression models to predict early recanalization. We validated the predictive ability by computing the median area-under-the-curve (AUC) of the receiver operating characteristics curve for 100 5-fold cross-validations. The administration of intravenous thrombolysis (IVT), longer transfer times, more distal occlusions, and shorter, pervious, less dense thrombi were characteristic of early recanalization. After backward elimination, IVT administration, DT and thrombus density remained in the multivariable model, with an AUC of 0.77 (IQR 0.72-0.83). Baseline thrombus imaging characteristics are valuable in predicting early recanalization and can potentially be used to optimize repeated imaging workflow.
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Affiliation(s)
- Nerea Arrarte Terreros
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (E.v.B.)
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Jeffrey Stolp
- Department of Neurology, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (J.S.)
| | - Agnetha A. E. Bruggeman
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Isabella S. J. Swijnenburg
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (E.v.B.)
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Ricardo R. Lopes
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (E.v.B.)
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Laura C. C. van Meenen
- Department of Neurology, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (J.S.)
| | - Adrien E. D. Groot
- Department of Neurology, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (J.S.)
| | - Manon Kappelhof
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (E.v.B.)
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Jonathan M. Coutinho
- Department of Neurology, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (J.S.)
| | - Yvo B. W. E. M. Roos
- Department of Neurology, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands; (J.S.)
| | - Bart J. Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Ludo F. M. Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | | | - Wim H. van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, 6229 HX Maastricht, The Netherlands;
| | - Ed van Bavel
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (E.v.B.)
| | - Henk A. Marquering
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, Location University of Amsterdam, Meibergdreef 9, 1105 AZ Amsterdam, The Netherlands (E.v.B.)
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
| | - Charles B. L. M. Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, Location University of Amsterdam, 1105 AZ Amsterdam, The Netherlands
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Li Z, Zhou Y, Zhang X, Zhang L, Zhang Y, Xing P, Zhang Y, Huang Q, Li Q, Zuo Q, Ye X, Liu J, Yang P. Effect of Clot Burden Score on Safety and Efficacy of Intravenous Alteplase Prior to Mechanical Thrombectomy in Acute Ischemic Stroke: A Subgroup Analysis of a Randomized Phase 3 Trial. AJNR Am J Neuroradiol 2024; 45:296-301. [PMID: 38388688 DOI: 10.3174/ajnr.a8134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2023] [Accepted: 12/04/2023] [Indexed: 02/24/2024]
Abstract
BACKGROUND AND PURPOSE Whether thrombus burden in acute ischemic stroke modify the effect of intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) remains uncertain. We aim to investigate the treatment effect of stratified clot burden score (CBS) on the efficacy and safety of direct versus bridging MT. MATERIALS AND METHODS This is an exploratory subgroup analysis of a randomized trial evaluating the effect of CBS on clinical outcome in the DIRECT-MT trial. CBS was divided into 3 groups (0-3, 4-6, and 7-10) based on preoperative CTA, where higher scores indicated a lower clot burden. We report the adjusted common odds ratio for a shift toward better outcomes on the mRS after thrombectomy alone compared with combination treatment by stratified CBS groups. RESULTS No modification effect of mRS distribution was observed by CBS subgroups (CBS 0-3: adjusted common ratio odds 1.519 [95% CI, 0.928-2.486]; 4-6: 0.924 [0.635-1.345]; 7-10: 1.040 [0.481-2.247]). Patients with CBS 4-6 had a higher rate of early reperfusion (adjusted OR (aOR), 0.3 [95% CI, 0.1-0.9]), final reperfusion (aOR 0.5 [95% CI, 0.3-0.9]), and fewer thrombectomy attempts (aOR 0.4 [95% CI, 0.1-0.7]). Patients with CBS 7-10 had a higher rate of asymptomatic intracranial hemorrhage (14.9% versus 36.8%, P = .0197) for bridging MT. No significant difference was observed in other safety outcomes by trichotomized CBS. CONCLUSIONS The subgroup analysis of DIRECT-MT suggested that thrombus burden did not alter the treatment effect of IVT before MT on functional outcomes in CBS subgroups.
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Affiliation(s)
- Zifu Li
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yu Zhou
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xiaoxi Zhang
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Lei Zhang
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yongwei Zhang
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Pengfei Xing
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Yongxin Zhang
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qinghai Huang
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qiang Li
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Qiao Zuo
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Xiaofei Ye
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Jianmin Liu
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
| | - Pengfei Yang
- From the Neurovascular Center, Changhai Hospital, Naval Medical University, Shanghai, China
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6
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Pikija S, Killer-Oberpfalzer M, Pfaff JAR, Griessenauer CJ, Sonnberger M, Vosko M, Mutzenbach JS, Schwarzenhofer D, Constantin H. Thrombus migration in emergent M1 middle cerebral artery occlusion. Clin Neurol Neurosurg 2024; 237:108132. [PMID: 38310761 DOI: 10.1016/j.clineuro.2024.108132] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2023] [Revised: 12/17/2023] [Accepted: 01/22/2024] [Indexed: 02/06/2024]
Abstract
BACKGROUND AND PURPOSE Thrombus migration (TM) is a well-established phenomenon in patients with intracranial vessel occlusion, particularly in those who receive alteplase. However, the relationship between TM, reperfusion success, and clinic-radiological outcomes is still being determined. This study aimed to describe the various outcomes in the event of TM in patients with M1 middle cerebral artery (M1 MCA) occlusion. MATERIALS AND METHODS The study involved a retrospective analysis of patients undergoing endovascular thrombectomy (EVT) due to M1 MCA occlusion from two tertiary centers between January 2015 and December 2020. The proximal positions of thrombi were measured using a curve tool on CT or MR angiography before EVT. Subsequently, measurements were taken on angiographic imaging. Patients were grouped based on the amount of difference between the two measurements: growth (≤ - 10 mm), stability (> -10 mm and ≤ 10 mm), migration (> 10 mm), and resolution. RESULTS A total of 463 patients (266 [57%] females, median 76 [interquartile range IQR: 65-83] years) were analyzed. Of them, 106 (22.8%) expressed any degree of TM. In multivariate ordinal regression analysis, the alteplase was significantly associated with TM (t = 2.192, p = 0.028), as was the greater interval from first imaging to angiography (t = 2.574, p = 0.010). In multivariate logistical regression analysis, the good clinical outcome measured by the modified Rankin scale (0-2) was not associated with TM status. CONCLUSIONS Thrombus migration within the M1 MCA segment occurs in almost a quarter of patients, is associated with alteplase administration, and is mainly irrelevant to radiological and clinical outcome.
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Affiliation(s)
- Slaven Pikija
- Department of Neurology, University Hospital Salzburg, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria.
| | - Monika Killer-Oberpfalzer
- Department of Neurology, University Hospital Salzburg, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria; Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
| | - Johannes A R Pfaff
- Department of Neuroradiology, University Hospital Salzburg, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Christoph J Griessenauer
- Department of Neurosurgery, University Hospital Salzburg, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Michael Sonnberger
- Department of Neuroradiology, Neuromed Campus, Johannes Kepler University, Linz, Austria
| | - Milan Vosko
- Department of Neurology, Neuromed Campus, Johannes Kepler University, Linz, Austria
| | - Johannes S Mutzenbach
- Department of Neurology, University Hospital Salzburg, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | | | - Hecker Constantin
- Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria; Department of Neurosurgery, University Hospital Salzburg, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
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7
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Morsi RZ, Zhang Y, Carrión-Penagos J, Desai H, Tannous E, Kothari S, Khamis A, Darzi AJ, Tarabichi A, Bastin R, Hneiny L, Thind S, Coleman E, Brorson JR, Mendelson S, Mansour A, Prabhakaran S, Kass-Hout T. Endovascular Thrombectomy With or Without Thrombolysis for Stroke: A Systematic Review and Meta-Analysis of Randomized Controlled Trials. Neurohospitalist 2024; 14:23-33. [PMID: 38235037 PMCID: PMC10790620 DOI: 10.1177/19418744231200046] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2024] Open
Abstract
Background To this date, whether to administer intravenous thrombolysis (IVT) prior to endovascular thrombectomy (EVT) for stroke patients still stirs some debate. We aimed to systematically update the evidence from randomized trials comparing EVT alone vs EVT with bridging IVT. Methods We searched MEDLINE, EMBASE, and the Cochrane Library to identify randomized controlled trials (RCTs) comparing EVT with or without IVT in patients presenting with stroke secondary to a large vessel occlusion. We conducted meta-analyses using random-effects models to compare functional independence, mortality, and symptomatic intracranial hemorrhage (sICH), between EVT and EVT with IVT. We assessed risk of bias using the Cochrane risk-of-bias tool and certainty of evidence for each outcome using the GRADE approach. Results Of 11,111 citations, we included 6 studies with a total of 2336 participants. We found low-certainty evidence of possibly a small decrease in the proportion of patients with functional independence (risk difference [RD] -2.0%, 95% CI -5.9% to 2.0%), low-certainty evidence that there is possibly a small increase in mortality (RD 1.0%, 95% CI -2.2% to 4.7%), and moderate-certainty evidence that there is probably a decrease in sICH (RD -1.0%, 95% CI -1.6% to .7%) for patients with EVT alone compared to EVT plus IVT, respectively. Conclusion Low-certainty evidence shows that there is possibly a small decrease in functional independence, low-certainty evidence shows that there is possibly a small increase in mortality, and moderate-certainty evidence that there is probably a decrease in sICH for patients with EVT alone compared to EVT plus IVT.
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Affiliation(s)
- Rami Z. Morsi
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Yuan Zhang
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | | | - Harsh Desai
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Elie Tannous
- Department of Pathology, Albany Medical Center, Albany, NY, USA
| | - Sachin Kothari
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Assem Khamis
- Wolfson Palliative Care Research Centre, Hull York Medical School, University of Hull, Hull, UK
| | - Andrea J. Darzi
- Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, ON, Canada
| | - Ammar Tarabichi
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Reena Bastin
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Layal Hneiny
- Wegner Health Sciences Information Center, University of South Dakota, Sioux Falls, SD, USA
| | - Sonam Thind
- Section of Neurosurgery, Department of Surgery, University of Chicago, Chicago, IL, USA
| | - Elisheva Coleman
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - James R. Brorson
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Scott Mendelson
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | - Ali Mansour
- Department of Neurology, University of Chicago, Chicago, IL, USA
| | | | - Tareq Kass-Hout
- Department of Neurology, University of Chicago, Chicago, IL, USA
- Section of Neurosurgery, Department of Surgery, University of Chicago, Chicago, IL, USA
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8
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Riegler C, Siebert E, Kleine JF, Nolte CH. Thrombus migration in ischemic stroke due to large vessel occlusion: a question of time. J Neurointerv Surg 2023; 15:e216-e222. [PMID: 36319085 PMCID: PMC10646911 DOI: 10.1136/jnis-2022-019365] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 10/08/2022] [Indexed: 05/20/2023]
Abstract
BACKGROUND Thrombus migration (TM) is frequently observed in large vessel occlusion (LVO) ischemic stroke to be treated by endovascular thrombectomy (EVT). TM may impede complete recanalization and hereby worsen clinical outcomes. This study aimed to delineate factors associated with TM and clarify its impact on technical and functional outcome. METHODS All patients undergoing EVT due to LVO in the anterior circulation at two tertiary stroke centers between October 2015 and December 2020 were included. Source imaging data of all individuals were assessed regarding occurrence of TM by raters blinded to clinical data. Patient data were gathered as part of the German Stroke Registry, a multicenter, prospective registry assessing real-world outcomes. Technical outcome was assessed by modified Thrombolysis in Cerebral Infarction scale (mTICI). Functional outcome was assessed by modified Rankin Scale (mRS) at 3 months. RESULTS The study consisted of 512 individuals, of which 71 (13.8%) displayed TM. In adjusted analyses, TM was associated with longer time from primary imaging to reassessment in the angio suite (aOR 2.37 (1.47 to 3.84) per logarithmic step) and intravenous thrombolysis (IVT; aOR 4.07 (2.17 to 7.65)). In individuals with IVT, a needle-to-groin time >1 hour was associated with higher odds for TM (aOR 2.60 (1.20 to 5.99)). TM was associated with lack of complete recanalization (aORmTICI3 0.46 (0.24 to 0.90)) but TM did not worsen odds for good clinical outcome (aORmRS≤2_d90 0.89 (0.47 to 1.68)). CONCLUSIONS TM is associated with IVT and longer time between sequential assessments of thrombus location. Consequently, TM may be of high relevance in patients with drip-and-ship treatment.
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Affiliation(s)
- Christoph Riegler
- Klinik und Hochschulambulanz für Neurologie, Charite Universitatsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Eberhard Siebert
- Institut für Neuroradiologie, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Justus F Kleine
- Institut für Neuroradiologie, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Klinik und Hochschulambulanz für Neurologie, Charite Universitatsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charite Universitatsmedizin Berlin, Berlin, Germany
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9
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Le Floch A, Clarençon F, Rouchaud A, Kyheng M, Labreuche J, Sibon I, Boulouis G, Gory B, Richard S, Caroff J, Blanc R, Seners P, Eker OF, Cho TH, Consoli A, Bourcier R, Guillon B, Dargazanli C, Arquizan C, Denier C, Eugene F, Vannier S, Gentric JC, Gauberti M, Naggara O, Rosso C, Turc G, Ozkul-Wermester O, Cognard C, Albucher JF, Timsit S, Bourdain F, Le Bras A, Richter S, Moulin S, Pop R, Heck O, Moreno R, L'Allinec V, Lapergue B, Marnat G. Influence of prior intravenous thrombolysis in patients treated with mechanical thrombectomy for M2 occlusions: insight from the Endovascular Treatment in Ischemic Stroke (ETIS) registry. J Neurointerv Surg 2023; 15:e289-e297. [PMID: 36460462 DOI: 10.1136/jnis-2022-019672] [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: 09/22/2022] [Accepted: 11/16/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Intravenous thrombolysis (IVT) for patients treated with mechanical thrombectomy (MT) for proximal occlusions has recently been questioned through randomized trials. However, few patients with M2 occlusions were included. We investigated the influence of prior IVT for patients presenting M2 occlusions treated with MT in comparison with MT alone. METHODS We conducted a retrospective analysis of the Endovascular Treatment in Ischemic Stroke (ETIS) registry, a multicenter observational study. Data from consecutive patients treated with MT for M2 occlusions between January 2015 and January 2022 at 26 comprehensive stroke centers were analyzed. The primary endpoint was 90-day modified Rankin Scale score of 0-2. Outcomes were compared using propensity score approaches. We also performed sensitivity analysis in relevant subgroups of patients. RESULTS Among 1132 patients with M2 occlusions treated with MT, 570 received prior IVT. The two groups were comparable after propensity analysis. The rate of favorable functional outcome was significantly higher in the IVT+MT group compared with the MT alone group (59.8% vs 44.7%; adjusted OR 1.38, 95% CI 1.10 to 1.75, P=0.008). Hemorrhagic and procedural complications were similar in both groups. In sensitivity analysis excluding patients with anticoagulation treatment, favorable recanalization was more frequent in the IVT+MT group (OR 1.37, 95% CI 1.11 to 1.70, P=0.004). CONCLUSIONS In cases of M2 occlusions, prior IVT combined with MT resulted in better functional outcome than MT alone, without increasing the rate of hemorrhagic or procedural complications. These results suggest the benefit of IVT in patients undergoing MT for M2 occlusions.
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Affiliation(s)
- Agathe Le Floch
- Neuroradiology, CHU Bordeaux GH Pellegrin, Bordeaux, Aquitaine, France
| | - Frédéric Clarençon
- Interventional neuroradiology, University Hospital Pitié Salpêtrière, Paris, France
| | - Aymeric Rouchaud
- Interventional neuroradiology, Centre Hospitalier Universitaire de Limoges, Limoges, France
- CNRS, XLIM, UMR 7252, Université de Limoges, Limoges, Nouvelle-Aquitaine, France
| | - Maeva Kyheng
- Biostatistics, CHU Lille, Lille, Hauts-de-France, France
| | | | - Igor Sibon
- Neurology, CHU de Bordeaux, Bordeaux, France
| | | | - Benjamin Gory
- Diagnostic and Interventional Neuroradiology, Centre Hospitalier Universitaire de Nancy, Nancy, France
| | - Sébastien Richard
- Neurology Stroke Unit, University Hospital Centre Nancy, Nancy, France
| | - Jildaz Caroff
- Department of Interventional Neuroradiology - NEURI Brain Vascular Center, Bicêtre Hospital, APHP, Le Kremlin Bicêtre, France
| | - Raphaël Blanc
- Departement of interventional neuroradiology, Fondation Rothschild, Paris, Île-de-France, France
| | - Pierre Seners
- Neurology, Fondation Rothschild, Paris, Île-de-France, France
| | - Omer F Eker
- Neuroradiology, Hospices Civils de Lyon, Bron, France
| | - Tae-Hee Cho
- Neurology, CHU Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Arturo Consoli
- Interventional Neuroradiologie, Hopital Foch, Suresnes, Ile-de-France, France
| | | | - Benoit Guillon
- Stroke unit, CHU Nantes, Nantes, Pays de la Loire, France
| | - Cyril Dargazanli
- Department of Neuroradiology, University Hospital Centre Montpellier, Montpellier, Occitanie, France
| | - Caroline Arquizan
- Neurology, CHU Montpellier, Montpellier, Languedoc-Roussillon, France
| | | | | | | | | | | | - Olivier Naggara
- Neuroradiology, GHU Paris Pôle Neuro Sainte-Anne, Paris, Île-de-France, France
| | - Charlotte Rosso
- Neurology, Hôpital Universitaire Pitié Salpêtrière, Paris, Île-de-France, France
| | - Guillaume Turc
- Neurology, GHU Paris Pôle Neuro Sainte-Anne, Paris, Île-de-France, France
| | | | - Christophe Cognard
- Diagnostic and Therapeutic Neuroradiology, CHU Toulouse, Toulouse, Occitanie, France
| | | | | | - Frederic Bourdain
- Neurology, Centre Hospitalier de la Cote Basque, Bayonne, Aquitaine, France
| | - Anthony Le Bras
- Department of Radiology, Centre Hospitalier Bretagne Atlantique, Vannes, Bretagne, France
- Neuroradiology, CHU Rennes Service de radiologie et d'imagerie médicale, Rennes, France
| | | | - Solène Moulin
- Neurology, University Hospital Centre Reims, Reims, Champagne-Ardenne, France
| | - Raoul Pop
- Neuroradiolology, CHU Strasbourg, Strasbourg, Alsace, France
| | - Olivier Heck
- Neurology, CHU Grenoble Alpes, Grenoble, Auvergne-Rhone-Alpes, France
| | - Ricardo Moreno
- Department Of Neuroradiology, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | | | | | - Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, CHU Bordeaux GH Pellegrin, Bordeaux, Aquitaine, France
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10
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Liu W, Zhao J, Liu H, Li T, Zhou T, He Y, Zhu L, Ding Y, Hui FK, He Y. Safety and Efficacy of Direct Thrombectomy Versus Bridging Therapy in Patients with Acute Ischemic Stroke Eligible for Intravenous Thrombolysis: A Meta-Analysis of Randomized Controlled Trials. World Neurosurg 2023; 175:113-121.e3. [PMID: 37040841 DOI: 10.1016/j.wneu.2023.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2023] [Accepted: 04/05/2023] [Indexed: 04/13/2023]
Abstract
OBJECTIVE In the present study, we conducted a meta-analysis of reported randomized controlled trials (RCTs) comparing the safety and efficacy of direct thrombectomy (DT) and bridging therapy (BT) for patients eligible for intravenous thrombolysis (IVT). METHODS A comprehensive search of PubMed, Cochrane Library, EMBASE, and Web of Science up to July 11, 2022 was performed. RCTs comparing DT and BT were included. The relative risk or rate difference and their 95% confidence intervals in a Mantel-Haenszel fixed effects model were used as the effect index of each outcome. The noninferior margin was specified as 80% for the relative risk or -10% for the rate difference. The primary outcome was the proportion of patients with a favorable functional outcome, defined as a modified Rankin scale (mRS) score of 0-2 or a return to baseline at 90 days. Additional efficacy and safety outcomes included successful recanalization at the end of thrombectomy, excellent clinical outcomes (defined as an mRS score of 0-1), death within 90 ± 14 days, symptomatic intracerebral hemorrhage, any type of intracerebral hemorrhage, and clot migration. RESULTS Six RCTs with 2334 patients were pooled for the meta-analysis. The results showed the noninferiority of DT for favorable functional outcomes, higher successful recanalization rates, and any intracerebral hemorrhage in the BT group, with no statistically significant differences for other outcomes. The risk of bias for all RCTs in our analysis was low. CONCLUSIONS DT achieved noninferiority to BT for favorable functional outcomes. Patient-level pooled analysis and subgroup analysis are needed to provide more information to distinguish which patients will benefit more from which therapy.
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Affiliation(s)
- Wenbo Liu
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, China
| | - Jingge Zhao
- Clinical Research Center, Zhengzhou University People's Hospital, Henan Provincial People's Hospital, Zhengzhou, China
| | - Huan Liu
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, China
| | - Tianxiao Li
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, China
| | - Tengfei Zhou
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, China
| | - Yanyan He
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, China
| | - Liangfu Zhu
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, China
| | - Yonghong Ding
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Ferdinand K Hui
- University of Hawaii, Queen's Medical Center, Honolulu, Hawaii, USA
| | - Yingkun He
- Department of Cerebrovascular Disease, Zhengzhou University People's Hospital, Henan University People's Hospital, Henan Provincial People's Hospital, Henan Provincial Neurointerventional Engineering Research Center, Henan International Joint Laboratory of Cerebrovascular Disease and Henan Engineering Research Center of Cerebrovascular Intervention, Zhengzhou, China.
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11
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Direct Mechanical Thrombectomy vs. Bridging Therapy in Stroke Patients in A “Stroke Belt” Region of Southern Europe. J Pers Med 2023; 13:jpm13030440. [PMID: 36983622 PMCID: PMC10058874 DOI: 10.3390/jpm13030440] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Revised: 02/25/2023] [Accepted: 02/27/2023] [Indexed: 03/03/2023] Open
Abstract
The aim of this 4-year observational study is to analyze the outcomes of stroke patients treated with direct mechanical thrombectomy (dMT) compared to bridging therapy (BT) (intravenous thrombolysis [IVT] + BT) based on 3-month outcomes, in real clinical practice in the "Stroke Belt" of Southern Europe. In total, 300 patients were included (41.3% dMT and 58.6% BT). The frequency of direct referral to the stroke center was similar in the dMT and BT group, whereas the time from onset to groin was longer in the BT group (median 210 [IQR 160–303] vs. 399 [IQR 225–675], p = 0.001). Successful recanalization (TICI 2b-3) and hemorrhagic transformation were similar in both groups. The BT group more frequently showed excellent outcomes at 3 months (32.4% vs. 15.4%, p = 0.004). Multivariate analysis showed that BT was independently associated with excellent outcomes (OR 2.7. 95% CI,1.2–5.9, p = 0.02) and lower mortality (OR 0.36. 95% CI 0.16–0.82, p = 015). Conclusions: Compared with dMT, BT was associated with excellent functional outcomes and lower 3-month mortality in this real-world clinical practice study conducted in a region belonging to the “Stroke Belt” of Southern Europe. Given the disparity of results on the benefit of BT in the current evidence, it is of vital importance to analyze the convenience of its use in each health area.
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12
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Cheng Y, Wang Q, Niu G, Luo C. Correlation of Atherosclerotic Dyslipidemia with Long-Term Stroke Recurrence in Patients Undergoing Intravenous Thrombolysis for Acute Ischemic Stroke. Int J Gen Med 2023; 16:1621-1629. [PMID: 37159580 PMCID: PMC10163887 DOI: 10.2147/ijgm.s407971] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Accepted: 04/21/2023] [Indexed: 05/11/2023] Open
Abstract
Background Atherosclerotic dyslipidemia (AD) is associated with an increased risk of cardiovascular diseases and stroke events, but the effect of AD among acute ischemic stroke (AIS) patients undergoing intravenous thrombolysis is unclear. This study aimed to investigate the relationship between AD and long-term stroke recurrence in AIS patients undergoing intravenous thrombolysis. Methods This prospective cohort study included 499 AIS patients treated with intravenous thrombolysis. Stroke subtype was classified according to the Trial of ORG 10172 in Acute Stroke Treatment (TOAST) criteria, patients' clinical characteristics, and results from multiple diagnostic tests. The primary endpoint event was ischemic stroke recurrence; the time to first AIS recurrence was estimated using Kaplan‒Meier analysis and compared using the two-sided Log rank test. Cox univariate and multivariate regression analyses were used to assess the association between AD and long-term stroke recurrence. Results Of the 499 patients with AIS treated with rt-PA intravenous thrombolysis, 80 (16.0%) had AD, and 60 (12.0%) had a stroke recurrence event. Kaplan‒Meier analysis showed that the stroke recurrence rate was significantly higher in patients with AD than in those without AD (p = 0.035, log rank test) and in the large-artery disease (LAD) subtype (p = 0.006, log rank test). Multivariate Cox regression analysis showed that AD (HR = 2.363, 95% CI: 1.294-4.314, P = 0.005) and atrial fibrillation (HR = 2.325, 95% CI: 1.007-5.366, P = 0.048) were associated with an increased risk of long-term stroke recurrence in AIS patients who underwent intravenous thrombolysis. Furthermore, AD was associated with an increased risk of stroke recurrence in patients undergoing intravenous thrombolysis in the LAD subtype (HR = 3.122, 95% CI: 1.304-7.437, P = 0.011). Conclusion We found that AD increases the risk of long-term stroke recurrence in AIS patients undergoing intravenous thrombolysis. This association may be stronger in the LAD subtype.
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Affiliation(s)
- Yuan Cheng
- Medical School, Fuyang Normal University, Fuyang, Anhui, People’s Republic of China
| | - Qingqing Wang
- Department of Neurology, The Affiliated Fuyang People’s Hospital of Anhui Medical University, Fuyang, Anhui, People’s Republic of China
| | - Guihong Niu
- Medical School, Fuyang Normal University, Fuyang, Anhui, People’s Republic of China
- Correspondence: Guihong Niu, Medical School, Fuyang Normal University, Fuyang, Anhui, 236300, People’s Republic of China, Email
| | - Chun Luo
- Department of Pediatric Surgery, Fuyang Women and Children’s Hospital, Fuyang, People’s Republic of China
- Chun Luo, Department of Pediatric Surgery, Fuyang Women and Children’s Hospital, Fuyang, Anhui, 236300, People’s Republic of China, Email
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13
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Intravenous thrombolysis before thrombectomy in acute ischemic stroke: a dual centre retrospective cohort study. Sci Rep 2022; 12:21071. [PMID: 36473938 PMCID: PMC9726865 DOI: 10.1038/s41598-022-25696-z] [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: 09/06/2022] [Accepted: 12/02/2022] [Indexed: 12/12/2022] Open
Abstract
First pass effect (FPE) is a successful recanalization (mTICI ≥ 2b) after the first trial of thrombectomy. It is associated with good functional outcomes. Few studies discussed the effect of BT (bridging therapy: combined I.V. thrombolysis and mechanical thrombectomy) on FPE and clinical outcomes. In our study, we would like to report the effect of MT with or without preceding IVT on FPE and the functional outcome of AIS (Acute Ischemic Stroke) of anterior circulation in real practice. A dual-center retrospective cohort study enrolled 201 patients with AIS of anterior circulation and was divided into a bridging therapy (BT) group of 150 patients who received alteplase preceding thrombectomy, and a direct mechanical thrombectomy (dMT) group of 51 patients. Comparisons between both groups regarding the clinical and radiological outcome. Early better clinical outcome (mRS ≤ 2) at day seven with BT group (39.3%) rather than dMT (23.5%) with P value = 0.044. No significant differences as regard puncture to revascularization time, successful revascularization (mTICI) ≥ 2b and FPE between both groups (P value: 0.328, 0.538, and 0.708, respectively). No differences as regards hemorrhagic transformation, mortality rate, and 90-day favorable outcome between both groups (P value 0.091, 0.089, and 0.192, respectively). BT might have better early outcome than dMT but no difference as regards 90-day favorable outcomes, mortality, sICH, FPE, recanalization rate and procedure time. It might be reasonable to go directly to mechanical thrombectomy without IVT for AIS with large vessel occlusion.
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14
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Kohli GS, Schartz D, Whyte R, Akkipeddi SM, Ellens NR, Bhalla T, Mattingly TK, Bender MT. Endovascular thrombectomy with or without intravenous thrombolysis in acute basilar artery occlusion ischemic stroke: A meta-analysis. J Stroke Cerebrovasc Dis 2022; 31:106847. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 10/16/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022] Open
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15
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Kargiotis O, Psychogios K, Safouris A, Spiliopoulos S, Karapanayiotides T, Bakola E, Mantatzis M, Dardiotis E, Ellul J, Giannopoulos S, Magoufis G, Tsivgoulis G. Diagnosis and treatment of acute isolated proximal internal carotid artery occlusions: a narrative review. Ther Adv Neurol Disord 2022; 15:17562864221136335. [PMID: 36437850 PMCID: PMC9685148 DOI: 10.1177/17562864221136335] [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: 05/04/2022] [Accepted: 10/16/2022] [Indexed: 07/27/2023] Open
Abstract
The clinical manifestations of proximal (extracranial) internal carotid artery occlusions (pICAOs) may range from asymptomatic to acute, large, and devastating ischemic strokes. The etiology and pathophysiology of the occlusion, intracranial collateral status and patient's premorbid status are among the factors determining the clinical presentation and outcome of pICAOs. Rapid and accurate diagnosis is crucial and may be assisted by the combination of carotid and transcranial duplex sonography, or a computed tomography/magnetic resonance angiography (CTA/MRA). It should be noted that with either imaging modalities, the discrimination of a pseudo-occlusion of the extracranial internal carotid artery (ICA) from a true pICAO may not be straightforward. In the absence of randomized data, the management of acute, symptomatic pICAOs remains individualized and relies largely on expert opinion. Administration of intravenous thrombolysis is reasonable and probably beneficial in the settings of acute ischemic stroke with early presentation. Unfortunately, rates of recanalization are rather low and acute interventional reperfusion therapies emerge as a potentially powerful therapeutic option for patients with persistent and severe symptoms. However, none of the pivotal clinical trials on mechanical thrombectomy for acute ischemic stroke randomized patients with isolated extracranial large vessel occlusions. On the contrary, several lines of evidence from non-randomized studies have shown that acute carotid endarterectomy, or endovascular thrombectomy/stenting of the ICA are feasible and safe, and pοtentially beneficial. The heterogeneity in the pathophysiology and clinical presentation of acute pICAOs renders patient selection for an acute interventional treatment a complicated decision-making process. The present narrative review will outline the pathophysiology, clinical presentation, diagnostic challenges, and possible treatment options for pICAOs.
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Affiliation(s)
| | | | - Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus,
Greece
- Second Department of Neurology, National and
Kapodistrian University of Athens, School of Medicine, ‘Attikon’ University
General Hospital, Athens, Greece
- Aktios Rehabilitation Center, Koropi,
Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional
Radiology Unit, ‘Attikon’ University General Hospital, Athens, Greece
| | - Theodore Karapanayiotides
- Second Department of Neurology, School of
Medicine, Faculty of Health Sciences, AHEPA University General Hospital,
Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Eleni Bakola
- Second Department of Neurology, National and
Kapodistrian University of Athens, School of Medicine, ‘Attikon’ University
General Hospital, Athens, Greece
| | - Michail Mantatzis
- Department of Radiology, Interventional
Neuroradiology Unit, AHEPA University General Hospital, Aristotle University
of Thessaloniki, Thessaloniki, Greece
| | - Efthimios Dardiotis
- Department of Neurology, University Hospital
of Larissa, School of Medicine, University of Thessaly, Larissa,
Greece
| | - John Ellul
- Department of Neurology, University General
Hospital of Patras, Patras, Greece
| | - Sotirios Giannopoulos
- Second Department of Neurology, National and
Kapodistrian University of Athens, School of Medicine, ‘Attikon’ University
General Hospital, Athens, Greece
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16
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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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17
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Trifan G, Biller J, Testai FD. Mechanical Thrombectomy vs Bridging Therapy for Anterior Circulation Large Vessel Occlusion Stroke: Systematic Review and Meta-analysis. Neurology 2022; 98:e1361-e1373. [PMID: 35173017 DOI: 10.1212/wnl.0000000000200029] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2021] [Accepted: 01/03/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND and Purpose: Current guidelines recommend the use of mechanical thrombectomy (MT) plus intravenous thrombolysis (aka bridging therapy, [BT]) for patients with anterior circulation large vessel occlusion (LVO) stroke. However, clinical equipoise exists in relation to the use of BT versus MT alone. Our objective is to compare the efficacy and safety of BT to MT for anterior circulation LVO. METHODS A systematic search of biomedical literature databases was performed from inception to October 29, 2021 to identify prospective and retrospective studies comparing the rates for functional independence (modified Rankin Scale score 0-2) and mortality at 90 days, symptomatic hemorrhage (sICH), and successful recanalization rates for MT and BT. Effect size was represented by odds ratio (OR) and analysis was done using random effects meta-analysis. Heterogeneity was assessed by I2 and Cochrane's Q statistics. RESULTS Overall, 41 studies with 14885 patients were included. Mean age ± standard deviation (years) was 69±11 for BT and 70±11 for MT. All studies used alteplase as thrombolytic agent. BT group had 29% higher odds for functional independence (OR=1.29, 95% CI 1.16-1.44, I2=42%), 25% higher odds of successful reperfusion (OR=1.25, 95% CI=1.08-1.44, I2=42%) and a 31% decrease in odds for mortality (OR=.69, 95% CI .60-.80, I2=47%) compared with MT. sICH prevalence was similar between groups (OR=1.10, 95% CI=.95-1.28, I2=0%). Six of the studies were randomized clinical trials (RCT) with intention-to-treat analysis done in patients presenting directly to MT-capable centers. When analysis was restricted to these six RCT (n= 2333), no differences were observed in functional independence (OR=1.08, 95% CI=.91-1.27, I2=0%), sICH (OR=1.37, 95% CI=.95-1.97, I2=0%) or mortality (OR=.93, 95% CI=.74-1.16, I2=0%) between groups. However, successful reperfusion favored BT group (OR=1.35, 95% CI=1.06-1.73, I2=0%). DISCUSSION The odds for functional independence, successful reperfusion and mortality for the entire dataset favored the use of BT over MT (medium heterogeneity and low quality of the evidence). When analysis was restricted to RCT, both treatments had similar functional and safety outcomes (no heterogeneity), but recanalization rates favored BT group (no heterogeneity). Because these findings may differ in patients that present to non-MT-capable centers or with the use of other thrombolytic agents, further RCTs are needed.
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18
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Turc G, Tsivgoulis G, Audebert HJ, Boogaarts H, Bhogal P, De Marchis GM, Fonseca AC, Khatri P, Mazighi M, Pérez de la Ossa N, Schellinger PD, Strbian D, Toni D, White P, Whiteley W, Zini A, van Zwam W, Fiehler J. European Stroke Organisation (ESO)-European Society for Minimally Invasive Neurological Therapy (ESMINT) expedited recommendation on indication for intravenous thrombolysis before mechanical thrombectomy in patients with acute ischemic stroke and anterior circulation large vessel occlusion. J Neurointerv Surg 2022; 14:209. [PMID: 35115395 DOI: 10.1136/neurintsurg-2021-018589] [Citation(s) in RCA: 61] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 01/09/2022] [Indexed: 12/30/2022]
Abstract
Six randomized controlled clinical trials have assessed whether mechanical thrombectomy (MT) alone is non-inferior to intravenous thrombolysis (IVT) plus MT within 4.5 hours of symptom onset in patients with anterior circulation large vessel occlusion (LVO) ischemic stroke and no contraindication to IVT. An expedited recommendation process was initiated by the European Stroke Organisation (ESO) and conducted with the European Society of Minimally Invasive Neurological Therapy (ESMINT) according to ESO standard operating procedure based on the GRADE system. We identified two relevant Population, Intervention, Comparator, Outcome (PICO) questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote evidence-based recommendations. Expert opinion was provided if insufficient evidence was available to provide recommendations based on the GRADE approach.For stroke patients with anterior circulation LVO directly admitted to a MT-capable center ('mothership') within 4.5 hours of symptom onset and eligible for both treatments, we recommend IVT plus MT over MT alone (moderate evidence, strong recommendation). MT should not prevent the initiation of IVT, nor should IVT delay MT. In stroke patients with anterior circulation LVO admitted to a center without MT facilities and eligible for IVT ≤4.5 hours and MT, we recommend IVT followed by rapid transfer to a MT capable-center ('drip-and-ship') in preference to omitting IVT (low evidence, strong recommendation). Expert consensus statements on ischemic stroke on awakening from sleep are also provided. Patients with anterior circulation LVO stroke should receive IVT in addition to MT if they have no contraindications to either treatment.
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Affiliation(s)
- Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Université de Paris, INSERM U1266, FHU NeuroVasc, Paris, France
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Heinrich J Audebert
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin & Center for Stroke Research Berlin, Berlin, Germany
| | - Hieronymus Boogaarts
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pervinder Bhogal
- Department of Interventional Neuroradiology, Royal London Hospital, Barts NHS Trust, London, UK
| | - Gian Marco De Marchis
- Neurology and Stroke Center, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Ana Catarina Fonseca
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria-CHLN, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Mikaël Mazighi
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France.,Stroke Unit, Lariboisière Hospital AP-HP-Nord, FHU NeuroVasc, Université de Paris, Paris, France
| | | | - Peter D Schellinger
- Departments of Neurology and Neurogeriatrics, Johannes Wesling Medical Center Minden, University hospitals of the Ruhr-University of Bochum, Bochum, Germany
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Danilo Toni
- Hospital Policlinico Umberto I, Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Philip White
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - William Whiteley
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Wim van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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19
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Turc G, Tsivgoulis G, Audebert H, Boogaarts H, Bhogal P, De Marchis GM, Fonseca AC, Khatri P, Mazighi M, Pérez de la Ossa N, Schellinger PD, Strbian D, Toni D, White P, Whiteley W, Zini A, van Zwam W, Fiehler J. EXPRESS: European Stroke Organisation (ESO) – European Society for Minimally Invasive Neurological Therapy (ESMINT) expedited recommendation on indication for intravenous thrombolysis before mechanical thrombectomy in patients with acute ischaemic stroke and anterior circulation large vessel occlusion. Eur Stroke J 2022; 7:I-XXVI. [PMID: 35300256 PMCID: PMC8921785 DOI: 10.1177/23969873221076968] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 01/13/2022] [Indexed: 11/15/2022] Open
Abstract
Six randomized controlled clinical trials have assessed whether mechanical thrombectomy (MT) alone is non-inferior to intravenous thrombolysis (IVT) plus MT within 4.5 hours of symptom onset in patients with anterior circulation large vessel occlusion (LVO) ischaemic stroke and no contraindication to IVT. An expedited recommendation process was initiated by the European Stroke Organisation (ESO) and conducted with the European Society of Minimally Invasive Neurological Therapy (ESMINT) according to ESO standard operating procedure based on the GRADE system. We identified two relevant Population, Intervention, Comparator, Outcome (PICO) questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote evidence-based recommendations. Expert opinion was provided if insufficient evidence was available to provide recommendations based on the GRADE approach.
For stroke patients with anterior circulation LVO directly admitted to a MT-capable centre (“mothership”) within 4.5 hours of symptom onset and eligible for both treatments, we recommend IVT plus MT over MT alone (moderate evidence, strong recommendation). MT should not prevent the initiation of IVT, nor should IVT delay MT. In stroke patients with anterior circulation LVO admitted to a centre without MT facilities and eligible for IVT ≤4.5 hrs and MT, we recommend IVT followed by rapid transfer to a MT capable-centre (“drip-and-ship”) in preference to omitting IVT (low evidence, strong recommendation). Expert consensus statements on ischaemic stroke on awakening from sleep are also provided. Patients with anterior circulation LVO stroke should receive IVT in addition to MT if they have no contraindications to either treatment.
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Affiliation(s)
| | - Georgios Tsivgoulis
- Department of Neuology, University Hospital of AlexandroupolisDemocritus University of Thrace
| | | | | | | | | | | | - Pooja Khatri
- NeurologyUniversity of Cincinnati Medical Center
| | | | | | | | | | - Danilo Toni
- Human NeurosciencesSapienza University of Rome
| | - Phil White
- Institute of Neuroscience (Stroke Research Group)Newcastle University
| | | | | | - Wim van Zwam
- NeurologyMaastricht University Faculty of Health Medicine and Life Sciences
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20
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Pilato F, Valente I, Calandrelli R, Alexandre A, Arena V, Dell'Aquila M, Broccolini A, Della Marca G, Morosetti R, Frisullo G, Brunetti V, Distefano M, Pedicelli A, Colosimo C, Di Lazzaro V. Clot evaluation and distal embolization risk during mechanical thrombectomy in anterior circulation stroke. J Neurol Sci 2022; 432:120087. [PMID: 34933250 DOI: 10.1016/j.jns.2021.120087] [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: 10/03/2021] [Revised: 11/22/2021] [Accepted: 12/07/2021] [Indexed: 12/14/2022]
Abstract
INTRODUCTION Clot features along with patients' clinical features may influence thrombus compactness predisposing at distal embolization during thrombectomy. The aim of this study was to evaluate thrombus features assessed by radiological and histopathological analysis along with patient-related features to predict distal embolization during thrombectomy. METHODS We performed a retrospective analysis of a prospectively maintained dataset of a tertiary stroke center inclusive of all cases of endovascular treatment for acute ischemic stroke involving anterior circulation occlusion. All patients underwent head and neck CT-angiography (CTA) at baseline. Patients were enrolled if thrombus material was suitable for histopathologic analyses. RESULTS A total of 327 patients underwent mechanical thrombectomy between March 2017 and May 2020. Among them, 133 (40.7%) had thrombus material suitable for histopathological analysis but 11 patients were excluded due to posterior circulation occlusion. A total of 122 patients were included in the analysis. A distal embolism was documented in 27 patients (28.4%). Multivariable analysis with distal embolism as dependent variable showed an adjusted OR of 2.64 (95%CI: 0.9-7.73; p-value: 0.08) for anticoagulant therapy, an adjusted OR of 1.38 (95%CI: 1.01-1.91; p-value 0.05) each 5-mm increasing of thrombus length at CTA. No association was found with age, sex, thrombolysis and first thrombectomy technique used. CONCLUSION The combined effect of anticoagulant therapy and thrombus length may have a potentially harmful effect on reperfusion during mechanical recanalization, causing distal embolization and this aspect should be taken into account in patient's risk assessment and when planning treatment strategy.
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Affiliation(s)
- Fabio Pilato
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, University Campus Bio-Medico of Rome, via Álvaro del Portillo, 21, 00128 Rome, Italy.
| | - Iacopo Valente
- UOC Radiologia e Neuroradiologia, Polo Diagnostica Per Immagini, Radioterapia, Oncologia ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma - Area Diagnostica Per Immagini, 00168 Rome, Italy
| | - Rosalinda Calandrelli
- UOC Radiologia e Neuroradiologia, Polo Diagnostica Per Immagini, Radioterapia, Oncologia ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma - Area Diagnostica Per Immagini, 00168 Rome, Italy
| | - Andrea Alexandre
- UOC Radiologia e Neuroradiologia, Polo Diagnostica Per Immagini, Radioterapia, Oncologia ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma - Area Diagnostica Per Immagini, 00168 Rome, Italy
| | - Vincenzo Arena
- Istituto di Anatomia Patologica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica -Area Anatomia Patologica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Marco Dell'Aquila
- Istituto di Anatomia Patologica, Dipartimento Scienze della Salute della Donna, del Bambino e di Sanità Pubblica -Area Anatomia Patologica, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma, Italy
| | - Aldobrando Broccolini
- UOC Neurologia, Dipartimento Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Giacomo Della Marca
- UOC Neurologia, Dipartimento Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Roberta Morosetti
- UOC Neurologia, Dipartimento Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Giovanni Frisullo
- UOC Neurologia, Dipartimento Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Valerio Brunetti
- UOC Neurologia, Dipartimento Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Marisa Distefano
- UOC Neurologia, Dipartimento Scienze dell'invecchiamento, Neurologiche, Ortopediche e della Testa-Collo, Fondazione Policlinico Universitario A. Gemelli IRCCS, 00168 Rome, Italy
| | - Alessandro Pedicelli
- UOC Radiologia e Neuroradiologia, Polo Diagnostica Per Immagini, Radioterapia, Oncologia ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma - Area Diagnostica Per Immagini, 00168 Rome, Italy
| | - Cesare Colosimo
- UOC Radiologia e Neuroradiologia, Polo Diagnostica Per Immagini, Radioterapia, Oncologia ed Ematologia, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, Roma - Area Diagnostica Per Immagini, 00168 Rome, Italy; Dipartimento di Diagnostica per Immagini, Università Cattolica del Sacro Cuore, Istituto di Radiologia, 00168 Rome, Italy
| | - Vincenzo Di Lazzaro
- Unit of Neurology, Neurophysiology, Neurobiology, Department of Medicine, University Campus Bio-Medico of Rome, via Álvaro del Portillo, 21, 00128 Rome, Italy
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21
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Gropen TI, Ivankova NV, Beasley M, Hess EP, Mittman B, Gazi M, Minor M, Crawford W, Floyd AB, Varner GL, Lyerly MJ, Shoemaker CC, Owens J, Wilson K, Gray J, Kamal S. Trauma Communications Center Coordinated Severity-Based Stroke Triage: Protocol of a Hybrid Type 1 Effectiveness-Implementation Study. Front Neurol 2021; 12:788273. [PMID: 34938265 PMCID: PMC8686821 DOI: 10.3389/fneur.2021.788273] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2021] [Accepted: 11/15/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Mechanical thrombectomy (MT) can improve the outcomes of patients with large vessel occlusion (LVO), but a minority of patients with LVO are treated and there are disparities in timely access to MT. In part, this is because in most regions, including Alabama, the emergency medical service (EMS) transports all patients with suspected stroke, regardless of severity, to the nearest stroke center. Consequently, patients with LVO may experience delayed arrival at stroke centers with MT capability and worse outcomes. Alabama's trauma communications center (TCC) coordinates EMS transport of trauma patients by trauma severity and regional hospital capability. Our aims are to develop a severity-based stroke triage (SBST) care model based on Alabama's trauma system, compare the effectiveness of this care pathway to current stroke triage in Alabama for improving broad, equitable, and timely access to MT, and explore stakeholder perceptions of the intervention's feasibility, appropriateness, and acceptability. Methods: This is a hybrid type 1 effectiveness-implementation study with a multi-phase mixed methods sequential design and an embedded observational stepped wedge cluster trial. We will extend TCC guided stroke severity assessment to all EMS regions in Alabama; conduct stakeholder interviews and focus groups to aid in development of region and hospital specific prehospital and inter-facility stroke triage plans for patients with suspected LVO; implement a phased rollout of TCC Coordinated SBST across Alabama's six EMS regions; and conduct stakeholder surveys and interviews to assess context-specific perceptions of the intervention. The primary outcome is the change in proportion of prehospital stroke system patients with suspected LVO who are treated with MT before and after implementation of TCC Coordinated SBST. Secondary outcomes include change in broad public health impact before and after implementation and stakeholder perceptions of the intervention's feasibility, appropriateness, and acceptability using a mixed methods approach. With 1200 to 1300 total observations over 36 months, we have 80% power to detect a 15% improvement in the primary endpoint. Discussion: This project, if successful, can demonstrate how the trauma system infrastructure can serve as the basis for a more integrated and effective system of emergency stroke care.
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Affiliation(s)
- Toby I Gropen
- Division of Cerebrovascular Disease, The University of Alabama at Birmingham, Birmingham, AL, United States
| | | | - Mark Beasley
- The University of Alabama at Birmingham, Birmingham, AL, United States
| | - Erik P Hess
- Vanderbilt University Medical Center, Nashville, TN, United States
| | - Brian Mittman
- Kaiser Permanente Southern California, Pasadena, CA, United States
| | - Melissa Gazi
- The University of Alabama at Birmingham, Birmingham, AL, United States
| | - Michael Minor
- The University of Alabama at Birmingham, Birmingham, AL, United States
| | - William Crawford
- The Office of Emergency Medical Services, Alabama Department of Public Health, Montgomery, AL, United States
| | - Alice B Floyd
- The Office of Emergency Medical Services, Alabama Department of Public Health, Prattville, AL, United States
| | - Gary L Varner
- The Office of Emergency Medical Services, Alabama Department of Public Health, Montgomery, AL, United States
| | - Michael J Lyerly
- The University of Alabama at Birmingham, Birmingham, AL, United States
| | | | - Jackie Owens
- Mobile Infirmary Medical Center, Mobile, AL, United States
| | - Kent Wilson
- The Office of Emergency Medical Services, Alabama Department of Public Health, Prattville, AL, United States
| | - Jamie Gray
- The Office of Emergency Medical Services, Alabama Department of Public Health, Montgomery, AL, United States
| | - Shaila Kamal
- The University of Alabama at Birmingham, Birmingham, AL, United States
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22
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Nguyen TN, Fischer U. Treatment Effect of Intravenous Thrombolysis Bridging to Mechanical Thrombectomy on Vessel Occlusion Site. Stroke 2021; 53:17-19. [PMID: 34915740 DOI: 10.1161/strokeaha.121.037603] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Thanh N Nguyen
- Department of Neurology and Radiology, Boston Medical Center, Boston University School of Medicine, MA (T.N.N.)
| | - Urs Fischer
- Department of Neurology, University Hospital Bern, University of Bern, Switzerland (U.F.).,Department of Neurology, University Hospital Basel, University of Basel, Switzerland (U.F.)
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23
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Nie X, Wang D, Pu Y, Wei Y, Lu Q, Yan H, Liu X, Zheng L, Liu J, Yang X, Ding Y, Liu D, Duan W, Zhang Z, Yang Z, Wen M, Gu W, Hou X, Leng X, Pan Y, Miao Z, Liu L. Endovascular treatment with or without intravenous alteplase for acute ischaemic stroke due to basilar artery occlusion. Stroke Vasc Neurol 2021; 7:190-199. [PMID: 34880112 PMCID: PMC9240464 DOI: 10.1136/svn-2021-001242] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 11/01/2021] [Indexed: 12/14/2022] Open
Abstract
Background and purpose It remains controversial if endovascular treatment (EVT) can improve the outcome of patients with acute basilar artery occlusion (BAO). This study aims to compare the functional outcomes between EVT with and without intravenous thrombolysis (IVT) first in patients who had acute ischaemic stroke (AIS) due to BAO. Methods Patients who had AIS with BAO who underwent EVT within 24 hours of onset were enrolled in this multicentre cohort study, and the efficacy and safety were compared between IVT+EVT and direct EVT. The primary outcome was 90-day functional independence. All outcomes were assessed with adjusted OR (aOR) from the multivariable logistic regression. In addition, a meta-analysis was performed on all recently published pivotal studies on functional independence after EVT in patients with BAO. Results Of 310 enrolled patients with BAO, 241 (78%) were treated with direct EVT and 69 (22%) with IVT+EVT. Direct EVT was associated with a worse functional outcome (aOR, 0.46 (95% CI 0.24 to 0.85), p=0.01). IVT+EVT was associated with a lower percentage of patients who needed ≥3 passes of stent retriever (10.14% vs 20.75%). The meta-analysis regression revealed a potential positive correlation between bridging with IVT first and functional independence (r=0.14 (95% CI 0.05 to 0.24), p<0.01). Conclusions This study showed that compared with direct EVT, EVT with IVT first was associated with better functional outcomes in patients with BAO treated within 24 hours of onset. The meta-analysis demonstrated similar favourable efficacy of IVT first followed by EVT in patients with BAO.
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Affiliation(s)
- Ximing Nie
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - David Wang
- Neurovascular Division, Department of Neurology, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Yuehua Pu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yufei Wei
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Qixuan Lu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Hongyi Yan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xin Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Lina Zheng
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong, China
| | - Jingyi Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xinxuan Yang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yarong Ding
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Dacheng Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Wanying Duan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhe Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhonghua Yang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Miao Wen
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Weibin Gu
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinyi Hou
- Department of Radiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xinyi Leng
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Hong Kong, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China .,China National Clinical Research Center for Neurological Diseases, Beijing, China
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Higashida T, Kanazawa R, Uchida T, Takahashi Y, Suzuki K, Kimura K. Difference of Thrombus Location between Initial Noninvasive Vascular Image and First DSA Findings in Mechanical Thrombectomy for Intracranial Large Vessel Occlusion: Post Hoc Analysis of the SKIP Study. Neurol Med Chir (Tokyo) 2021; 61:640-646. [PMID: 34421095 PMCID: PMC8592813 DOI: 10.2176/nmc.oa.2021-0137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
In patients who undergo mechanical thrombectomy for intracranial large vessel occlusion, the occluded site is sometimes distal to the site shown in the initial vascular imaging. We investigated the factors related to the change in the occluded site between the sequential imagings. The 203 patients in the SKIP study were reviewed retrospectively. Magnetic resonance angiography (MRA) or computed tomography angiography (CTA) was used to assess the occluded site. The occluded site shown in the cerebral angiography appeared to be distal to the occluded site shown in the initial vascular imaging in 55 patients (group A). The location of the occluded site in the remaining 148 patients did not change between the sequential imagings (group B). MRA was used more often than CTA in group A (54 MRA, 1 CTA; P <0.01). Patients with middle cerebral artery (M1) occlusion were more likely to show change of the occluded site than patients with internal carotid artery (ICA) occlusion (M1: 38%, ICA: 9%; P <0.01). The number of patients who received intravenous recombinant tissue plasminogen activator did not differ between the two groups (group A: 54%, group B: 49%; P = 0.5). In patients with acute intracranial large vessel occlusion who require mechanical thrombectomy, physicians should be aware that the location of the thrombus may be distal to the occluded site shown in the initial vascular imaging, particularly in patients with M1 occlusion shown by MRA.
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25
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Kappelhof M, Tolhuisen ML, Treurniet KM, Dutra BG, Alves H, Zhang G, Brown S, Muir KW, Dávalos A, Roos YBWEM, Saver JL, Demchuk AM, Jovin TG, Bracard S, Campbell BCV, van der Lugt A, Guillemin F, White P, Hill MD, Dippel DWJ, Mitchell PJ, Goyal M, Marquering HA, Majoie CBLM. Endovascular Treatment Effect Diminishes With Increasing Thrombus Perviousness: Pooled Data From 7 Trials on Acute Ischemic Stroke. Stroke 2021; 52:3633-3641. [PMID: 34281377 PMCID: PMC8547583 DOI: 10.1161/strokeaha.120.033124] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose: Thrombus perviousness estimates residual flow along a thrombus in acute ischemic stroke, based on radiological images, and may influence the benefit of endovascular treatment for acute ischemic stroke. We aimed to investigate potential endovascular treatment (EVT) effect modification by thrombus perviousness. Methods: We included 443 patients with thin-slice imaging available, out of 1766 patients from the pooled HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke trials) data set of 7 randomized trials on EVT in the early window (most within 8 hours). Control arm patients (n=233) received intravenous alteplase if eligible (212/233; 91%). Intervention arm patients (n=210) received additional EVT (prior alteplase in 178/210; 85%). Perviousness was quantified by thrombus attenuation increase on admission computed tomography angiography compared with noncontrast computed tomography. Multivariable regression analyses were performed including multiplicative interaction terms between thrombus attenuation increase and treatment allocation. In case of significant interaction, subgroup analyses by treatment arm were performed. Our primary outcome was 90-day functional outcome (modified Rankin Scale score), resulting in an adjusted common odds ratio for a one-step shift towards improved outcome. Secondary outcomes were mortality, successful reperfusion (extended Thrombolysis in Cerebral Infarction score, 2B–3), and follow-up infarct volume (in mL). Results: Increased perviousness was associated with improved functional outcome. After adding a multiplicative term of thrombus attenuation increase and treatment allocation, model fit improved significantly (P=0.03), indicating interaction between perviousness and EVT benefit. Control arm patients showed significantly better outcomes with increased perviousness (adjusted common odds ratio, 1.2 [95% CI, 1.1–1.3]). In the EVT arm, no significant association was found (adjusted common odds ratio, 1.0 [95% CI, 0.9–1.1]), and perviousness was not significantly associated with successful reperfusion. Follow-up infarct volume (12% [95% CI, 7.0–17] per 5 Hounsfield units) and chance of mortality (adjusted odds ratio, 0.83 [95% CI, 0.70–0.97]) decreased with higher thrombus attenuation increase in the overall population, without significant treatment interaction. Conclusions: Our study suggests that the benefit of best medical care including alteplase, compared with additional EVT, increases in patients with more pervious thrombi.
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Affiliation(s)
- Manon Kappelhof
- Radiology and Nuclear Medicine, Amsterdam University Medical Center, University of Amsterdam, the Netherlands. (M.K., M.L.T., K.M.T., B.G.D., H.A., G.Z., H.A.M., C.B.L.M.M.)
| | - Manon L Tolhuisen
- Radiology and Nuclear Medicine, Amsterdam University Medical Center, University of Amsterdam, the Netherlands. (M.K., M.L.T., K.M.T., B.G.D., H.A., G.Z., H.A.M., C.B.L.M.M.).,Biomedical Engineering and Physics, Amsterdam University Medical Center, University of Amsterdam, the Netherlands. (M.L.T., B.G.D., H.A., H.A.M.)
| | - Kilian M Treurniet
- Radiology and Nuclear Medicine, Amsterdam University Medical Center, University of Amsterdam, the Netherlands. (M.K., M.L.T., K.M.T., B.G.D., H.A., G.Z., H.A.M., C.B.L.M.M.)
| | - Bruna G Dutra
- Radiology and Nuclear Medicine, Amsterdam University Medical Center, University of Amsterdam, the Netherlands. (M.K., M.L.T., K.M.T., B.G.D., H.A., G.Z., H.A.M., C.B.L.M.M.).,Biomedical Engineering and Physics, Amsterdam University Medical Center, University of Amsterdam, the Netherlands. (M.L.T., B.G.D., H.A., H.A.M.)
| | - Heitor Alves
- Radiology and Nuclear Medicine, Amsterdam University Medical Center, University of Amsterdam, the Netherlands. (M.K., M.L.T., K.M.T., B.G.D., H.A., G.Z., H.A.M., C.B.L.M.M.).,Biomedical Engineering and Physics, Amsterdam University Medical Center, University of Amsterdam, the Netherlands. (M.L.T., B.G.D., H.A., H.A.M.)
| | - Guang Zhang
- Radiology and Nuclear Medicine, Amsterdam University Medical Center, University of Amsterdam, the Netherlands. (M.K., M.L.T., K.M.T., B.G.D., H.A., G.Z., H.A.M., C.B.L.M.M.)
| | - Scott Brown
- Altair Biostatistics, St Louis Park, MN (S. Brown)
| | - Keith W Muir
- Neuroscience & Psychology, University of Glasgow, Queen Elizabeth University Hospital, United Kingdom (K.W.M.)
| | - Antoni Dávalos
- Neuroscience, Hospital Germans Trias i Pujol, Universitat Autònoma de Barcelona, Spain (A.D.)
| | - Yvo B W E M Roos
- Neurology, Amsterdam University Medical Center, University of Amsterdam, the Netherlands. (Y.B.W.E.M.R.)
| | - Jeffrey L Saver
- Neurology, Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles (UCLA) (J.L.S.)
| | - Andrew M Demchuk
- Clinical Neurosciences, University of Calgary, Alberta, Canada. (A.M.D., M.D.H.)
| | - Tudor G Jovin
- Neurology, University of Pittsburgh Medical Center, PA (T.G.J.)
| | - Serge Bracard
- Diagnostic and Interventional Neuroradiology, University of Lorraine, University Hospital of Nancy, France. (S. Bracard)
| | - Bruce C V Campbell
- Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (B.C.V.C.)
| | - Aad van der Lugt
- Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, the Netherlands. (A.v.d.L.)
| | - Francis Guillemin
- Epidemiology, University of Lorraine, University Hospital of Nancy, France. (F.G.)
| | - Philip White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom (P.W.)
| | - Michael D Hill
- Clinical Neurosciences, University of Calgary, Alberta, Canada. (A.M.D., M.D.H.)
| | | | - Peter J Mitchell
- Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia. (P.J.M.)
| | - Mayank Goyal
- Radiology, University of Calgary, Alberta, Canada.(M.G.)
| | - Henk A Marquering
- Radiology and Nuclear Medicine, Amsterdam University Medical Center, University of Amsterdam, the Netherlands. (M.K., M.L.T., K.M.T., B.G.D., H.A., G.Z., H.A.M., C.B.L.M.M.).,Biomedical Engineering and Physics, Amsterdam University Medical Center, University of Amsterdam, the Netherlands. (M.L.T., B.G.D., H.A., H.A.M.)
| | - Charles B L M Majoie
- Radiology and Nuclear Medicine, Amsterdam University Medical Center, University of Amsterdam, the Netherlands. (M.K., M.L.T., K.M.T., B.G.D., H.A., G.Z., H.A.M., C.B.L.M.M.)
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26
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Ospel JM, McDonough R, Kunz WG, Goyal M. Is concurrent intravenous alteplase in patients undergoing endovascular treatment for large vessel occlusion stroke cost-effective even if the cost of alteplase is only US$1? J Neurointerv Surg 2021; 14:568-572. [PMID: 34187871 DOI: 10.1136/neurintsurg-2021-017817] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2021] [Accepted: 06/08/2021] [Indexed: 01/17/2023]
Abstract
BACKGROUND The added value of intravenous (IV) alteplase in large vessel occlusion (LVO) stroke over and beyond endovascular treatment (EVT) is controversial. We compared the long-term costs and cost-effectiveness of a direct-to-EVT paradigm in LVO stroke patients presenting directly to the mothership hospital to concurrent EVT and IV alteplase. METHODS We used a decision model consisting of a short-run model to analyze costs and functional outcomes within 90 days after the index stroke and a long-run Markov state transition model (cycle length of 12 months) to estimate expected lifetime costs and outcomes. Outcome data were from the DIRECT-MT trial (NCT03469206). Incremental cost-effectiveness ratios and net monetary benefits were calculated and probabilistic sensitivity analysis was performed. Analysis was performed from a healthcare perspective and a societal perspective using both a minimal assumed alteplase cost of US$1 and true alteplase cost. RESULTS When assuming a minimal cost of alteplase of $1, EVT with concurrent IV alteplase resulted in incremental lifetime cost of $5664 (healthcare perspective)/$4804 (societal perspective) and a decrement of 0.25 quality-adjusted life years (QALYs) compared with EVT only, indicating dominance of the EVT only approach. Net monetary benefits were consistently higher for EVT only compared with EVT with concurrent alteplase. Probabilistic sensitivity analysis showed increased costs without an increase in QALYs for EVT and concurrent IV alteplase compared with EVT only. Results were even more in favor of EVT when the true cost of alteplase was used for analysis. CONCLUSION EVT without concurrent alteplase is the preferred strategy from a health economic standpoint.
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Affiliation(s)
- Johanna Maria Ospel
- Radiology, Universitatsspital Basel, Basel, Switzerland.,Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Rosalie McDonough
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada.,Diagnostic and Interventional Neuroradiology, Department of Diagnostic and Interventional Neuroradiology, University Hospital Hamburg Eppendorf, Hamburg, Germany
| | | | - Mayank Goyal
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada .,Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
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27
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Magoufis G, Safouris A, Raphaeli G, Kargiotis O, Psychogios K, Krogias C, Palaiodimou L, Spiliopoulos S, Polizogopoulou E, Mantatzis M, Finitsis S, Karapanayiotides T, Ellul J, Bakola E, Brountzos E, Mitsias P, Giannopoulos S, Tsivgoulis G. Acute reperfusion therapies for acute ischemic stroke patients with unknown time of symptom onset or in extended time windows: an individualized approach. Ther Adv Neurol Disord 2021; 14:17562864211021182. [PMID: 34122624 PMCID: PMC8175833 DOI: 10.1177/17562864211021182] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 05/10/2021] [Indexed: 02/05/2023] Open
Abstract
Recent randomized controlled clinical trials (RCTs) have revolutionized acute ischemic stroke care by extending the use of intravenous thrombolysis and endovascular reperfusion therapies in time windows that have been originally considered futile or even unsafe. Both systemic and endovascular reperfusion therapies have been shown to improve outcome in patients with wake-up strokes or symptom onset beyond 4.5 h for intravenous thrombolysis and beyond 6 h for endovascular treatment; however, they require advanced neuroimaging to select stroke patients safely. Experts have proposed simpler imaging algorithms but high-quality data on safety and efficacy are currently missing. RCTs used diverse imaging and clinical inclusion criteria for patient selection during the dawn of this novel stroke treatment paradigm. After taking into consideration the dismal prognosis of nonrecanalized ischemic stroke patients and the substantial clinical benefit of reperfusion therapies in selected late presenters, we propose rescue reperfusion therapies for acute ischemic stroke patients not fulfilling all clinical and imaging inclusion criteria as an option in a subgroup of patients with clinical and radiological profiles suggesting low risk for complications, notably hemorrhagic transformation as well as local or remote parenchymal hemorrhage. Incorporating new data to treatment algorithms may seem perplexing to stroke physicians, since treatment and imaging capabilities of each stroke center may dictate diverse treatment pathways. This narrative review will summarize current data that will assist clinicians in the selection of those late presenters that will most likely benefit from acute reperfusion therapies. Different treatment algorithms are provided according to available neuroimaging and endovascular treatment capabilities.
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Affiliation(s)
- Georgios Magoufis
- Interventional Neuroradiology Unit, Metropolitan Hospital, Piraeus, Greece
| | - Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
- Interventional Neuroradiology Unit, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Guy Raphaeli
- Interventional Neuroradiology Unit, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
| | | | - Klearchos Psychogios
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Lina Palaiodimou
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional Radiology Unit, “ATTIKON” University General Hospital, Athens, Greece
| | - Eftihia Polizogopoulou
- Emergency Medicine Clinic, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Michael Mantatzis
- Department of Radiology, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Stephanos Finitsis
- Department of Interventional Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodore Karapanayiotides
- Second Department of Neurology, Aristotle University of Thessaloniki, School of Medicine, Faculty of Health Sciences, AHEPA University Hospital, Thessaloniki, Greece
| | - John Ellul
- Department of Neurology, University Hospital of Patras, School of Medicine, University of Patras, Patras, Greece
| | - Eleni Bakola
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Elias Brountzos
- Second Department of Radiology, Interventional Radiology Unit, “ATTIKON” University General Hospital, Athens, Greece
| | - Panayiotis Mitsias
- Department of Neurology Medical School, University of Crete, Heraklion, Crete, Greece
| | - Sotirios Giannopoulos
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian, University of Athens, School of Medicine, “Attikon” University Hospital, Iras 39, Gerakas Attikis, Athens, 15344, Greece
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA
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28
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Arrarte Terreros N, Bruggeman AAE, Swijnenburg ISJ, van Meenen LCC, Groot AE, Coutinho JM, Roos YBWEM, Emmer BJ, Beenen LFM, van Bavel E, Marquering HA, Majoie CBLM. Early recanalization in large-vessel occlusion stroke patients transferred for endovascular treatment. J Neurointerv Surg 2021; 14:neurintsurg-2021-017441. [PMID: 33986112 PMCID: PMC9016237 DOI: 10.1136/neurintsurg-2021-017441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/24/2021] [Accepted: 04/29/2021] [Indexed: 11/25/2022]
Abstract
Background We performed an exploratory analysis to identify patient and thrombus characteristics associated with early recanalization in large-vessel occlusion (LVO) stroke patients transferred for endovascular treatment (EVT) from a primary (PSC) to a comprehensive stroke center (CSC). Methods We included patients with an LVO stroke of the anterior circulation who were transferred to our hospital for EVT and underwent repeated imaging between January 2016 and June 2019. We compared patient characteristics, workflow time metrics, functional outcome (modified Rankin Scale at 90 days), and baseline thrombus imaging characteristics, which included: occlusion location, thrombus length, attenuation, perviousness, distance from terminus of intracranial carotid artery to the thrombus (DT), and clot burden score (CBS), between early-recanalized LVO (ER-LVO), and non-early-recanalized LVO (NER-LVO) patients. Results One hundred and forty-nine patients were included in the analysis. Early recanalization occurred in 32% of patients. ER-LVO patients less often had a medical history of hypertension (31% vs 49%, P=0.04), and more often had clinical improvement between PSC and CSC (ΔNIHSS −5 vs 3, P<0.01), compared with NER-LVO patients. Thrombolysis administration was similar in both groups (88% vs 78%, P=0.18). ER-LVO patients had no ICA occlusions (0% vs 27%, P<0.01), more often an M2 occlusion (35% vs 17%, P=0.01), longer DT (27 mm vs 12 mm, P<0.01), shorter thrombi (17 mm vs 27 mm, P<0.01), and higher CBS (8 vs 6, P<0.01) at baseline imaging. ER-LVO patients had lower mRS scores (1 vs 3, P=0.02). Conclusions Early recanalization is associated with clinical improvement between PSC and CSC admission, more distal occlusions and shorter thrombi at baseline imaging, and better functional outcome.
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Affiliation(s)
- Nerea Arrarte Terreros
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location AMC, Amsterdam, the Netherlands .,Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Agnetha A E Bruggeman
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Isabella S J Swijnenburg
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location AMC, Amsterdam, the Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Laura C C van Meenen
- Department of Neurology, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Adrien E Groot
- Department of Neurology, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Bart J Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Ludo F M Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Ed van Bavel
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Henk A Marquering
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location AMC, Amsterdam, the Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
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29
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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: 2] [Impact Index Per Article: 0.7] [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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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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Ohara T, Menon BK, Al-Ajlan FS, Horn M, Najm M, Al-Sultan A, Puig J, Dowlatshahi D, Calleja Sanz AI, Sohn SI, Ahn SH, Poppe AY, Mikulik R, Asdaghi N, Field TS, Jin A, Asil T, Boulanger JM, Letteri F, Dey S, Evans JW, Goyal M, Hill MD, Almekhlafi M, Demchuk AM. Thrombus Migration and Fragmentation After Intravenous Alteplase Treatment: The INTERRSeCT Study. Stroke 2020; 52:203-212. [PMID: 33317416 DOI: 10.1161/strokeaha.120.029292] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE There is interest in what happens over time to the thrombus after intravenous alteplase. We study the effect of alteplase on thrombus structure and its impact on clinical outcome in patients with acute stroke. METHODS Intravenous alteplase treated stroke patients with intracranial internal carotid artery or middle cerebral artery occlusion identified on baseline computed tomography angiography and with follow-up vascular imaging (computed tomography angiography or first run of angiography before endovascular therapy) were enrolled from INTERRSeCT study (Identifying New Approaches to Optimize Thrombus Characterization for Predicting Early Recanalization and Reperfusion With IV Alteplase and Other Treatments Using Serial CT Angiography). Thrombus movement after intravenous alteplase was classified into complete recanalization, thrombus migration, thrombus fragmentation, and no change. Thrombus migration was diagnosed when occlusion site moved distally and graded according to degrees of thrombus movement (grade 0-3). Thrombus fragmentation was diagnosed when a new distal occlusion in addition to the primary occlusion was identified on follow-up imaging. The association between thrombus movement and clinical outcome was also evaluated. RESULTS Among 427 patients in this study, thrombus movement was seen in 54% with a median time of 123 minutes from alteplase administration to follow-up imaging, and sub-classified as marked (thrombus migration grade 2-3 + complete recanalization; 27%) and mild to moderate thrombus movement (thrombus fragmentation + thrombus migration grade 0-1; 27%). In patients with proximal M1/internal carotid artery occlusion, marked thrombus movement was associated with a higher rate of good outcome (90-day modified Rankin Scale, 0-2) compared with mild to moderate movement (52% versus 27%; adjusted odds ratio, 5.64 [95% CI, 1.72-20.10]). No difference was seen in outcomes between mild to moderate thrombus movement and no change. In M1 distal/M2 occlusion, marked thrombus movement was associated with improved 90-day good outcome compared with no change (70% versus 56%; adjusted odds ratio, 2.54 [95% CI, 1.21-5.51]). CONCLUSIONS Early thrombus movement is common after intravenous alteplase. Marked thrombus migration leads to good clinical outcomes. Thrombus dynamics over time should be further evaluated in clinical trials of acute reperfusion therapy.
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Affiliation(s)
- Tomoyuki Ohara
- Calgary Stroke Program, Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (T.O., B.K.M., M.H., M.N., A.A.-S., M.G., M.D.H., M.A., A.M.D.).,Department of Neurology, Kyoto Prefectural University of Medicine, Kyoto, Japan (T.O.)
| | - Bijoy K Menon
- Calgary Stroke Program, Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (T.O., B.K.M., M.H., M.N., A.A.-S., M.G., M.D.H., M.A., A.M.D.)
| | - Fahad S Al-Ajlan
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia (F.S.A.-A.)
| | - MacKenzie Horn
- Calgary Stroke Program, Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (T.O., B.K.M., M.H., M.N., A.A.-S., M.G., M.D.H., M.A., A.M.D.)
| | - Mohamed Najm
- Calgary Stroke Program, Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (T.O., B.K.M., M.H., M.N., A.A.-S., M.G., M.D.H., M.A., A.M.D.)
| | - Abdulaziz Al-Sultan
- Calgary Stroke Program, Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (T.O., B.K.M., M.H., M.N., A.A.-S., M.G., M.D.H., M.A., A.M.D.)
| | - Josep Puig
- IDI-IDIBGI, Dr Josep Trueta University Hospital, Girona, Spain (J.P.)
| | - Dar Dowlatshahi
- Department of Medicine, University of Ottawa and Ottawa Hospital Research Institute, Canada (D.D.)
| | - Ana I Calleja Sanz
- Department of Neurology, Universitary Clinical Hospital of Valladolid, Spain (A.I.C.-S.)
| | - Sung-Il Sohn
- Department of Neurology, Keimyung University, Daegu, Republic of Korea (S.-I.S.)
| | - Seong H Ahn
- Gwangju Institute of Science and Technology, Republic of Korea (S.H.A.)
| | - Alexandre Y Poppe
- Department of Neurosciences, University of Montreal, Canada (A.Y.P.)
| | - Robert Mikulik
- International Clinical Research Center, Department of Neurology, St Anne's University Hospital, Masaryk University, Brno, Czech Republic (R.M.)
| | | | - Thalia S Field
- Division of Neurology, University of British Columbia, Vancouver, British Columbia, Canada (T.S.F.)
| | - Albert Jin
- Department of Medicine (Neurology), Queen's University, Kingston, Ontario, Canada (A.J.)
| | - Talip Asil
- Bezmialem Vakif Univesitesi Noroloji, Istanbul, Turkey (T.A.)
| | | | - Federica Letteri
- Istituto Don Calabria, IRCCS Sacro Cuore Hospital, Negrar, Italy (F.L.)
| | | | | | - Mayank Goyal
- Calgary Stroke Program, Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (T.O., B.K.M., M.H., M.N., A.A.-S., M.G., M.D.H., M.A., A.M.D.)
| | - Michael D Hill
- Calgary Stroke Program, Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (T.O., B.K.M., M.H., M.N., A.A.-S., M.G., M.D.H., M.A., A.M.D.)
| | - Mohammed Almekhlafi
- Calgary Stroke Program, Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (T.O., B.K.M., M.H., M.N., A.A.-S., M.G., M.D.H., M.A., A.M.D.)
| | - Andrew M Demchuk
- Calgary Stroke Program, Hotchkiss Brain Institute, Departments of Clinical Neurosciences and Radiology, Cumming School of Medicine, University of Calgary, Canada (T.O., B.K.M., M.H., M.N., A.A.-S., M.G., M.D.H., M.A., A.M.D.)
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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: 45] [Impact Index Per Article: 11.3] [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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Chang A, Beheshtian E, Llinas EJ, Idowu OR, Marsh EB. Intravenous Tissue Plasminogen Activator in Combination With Mechanical Thrombectomy: Clot Migration, Intracranial Bleeding, and the Impact of "Drip and Ship" on Effectiveness and Outcomes. Front Neurol 2020; 11:585929. [PMID: 33424741 PMCID: PMC7794010 DOI: 10.3389/fneur.2020.585929] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2020] [Accepted: 11/16/2020] [Indexed: 01/19/2023] Open
Abstract
Purpose: Intravenous tissue plasminogen activator (tPA) is indicated prior to mechanical thrombectomy (MT) to treat large vessel occlusion (LVO). However, administration takes time, and rates of clot migration complicating successful retrieval and hemorrhagic transformation may be higher. Given time-to-effectiveness, the benefit of tPA may vary significantly based on whether administration occurs at a thrombectomy-capable center or transferring hospital. Methods: We prospectively evaluated 170 individuals with LVO involving the anterior circulation who underwent MT at our Comprehensive Stroke Center over a 3.5 year period. Two thirds (n = 114) of patients were admitted through our Emergency Department (ED). The other 33% were transferred from outside hospitals (OSH). Patients meeting criteria were bridged with IV tPA; the others were treated with MT alone. Clot migration, recanalization times, TICI scores, and hemorrhage rates were compared for those bridged vs. treated with MT alone, along with modified Rankin scores (mRS) at discharge and 90-day follow-up. Multivariable regression was used to determine the relationship between site of presentation and effect of tPA on outcomes. Results: Patients presenting to an OSH had longer mean discovery to puncture/recanalization times, but were actually more likely to receive IV tPA prior to MT (70 vs. 42%). The rate of clot migration was low (11%) and similar between groups, though slightly higher for those receiving IV tPA. There was no difference in symptomatic ICH rate after tPA. TICI scores were also not significantly different; however, more patients achieved TICI 2b or higher reperfusion (83 vs. 67%, p = 0.027) after tPA, and TICI 0 reperfusion was seen almost exclusively in patients who were not treated with tPA. Those bridged at an OSH required fewer passes before successful recanalization (2.4 vs. 1.6, p = 0.037). Overall, mean mRS scores on discharge and at 90 days were significantly better for those receiving IV tPA (3.9 vs. 4.6, 3.4 vs. 4.4 respectively, p ~ 0.01) and differences persisted when comparing only patients recanalized in under 6 h. Conclusion: Independent of site of presentation, IV tPA before MT appears to lead to better radiographic outcomes, without increased rates of clot migration or higher intracranial hemorrhage risk, and overall better functional outcomes.
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Affiliation(s)
- Adam Chang
- Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Elham Beheshtian
- Department of Radiology, The Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Edward J. Llinas
- Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Oluwatoyin R. Idowu
- Department of Radiology, The Johns Hopkins School of Medicine, Baltimore, MD, United States
| | - Elisabeth B. Marsh
- Department of Neurology, The Johns Hopkins School of Medicine, Baltimore, MD, United States
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Lee SJ, Lee TK, Kim BT, Shin DS. Clinical Implications of Preinterventional Thrombus Migration in Patients with Emergent Large Vessel Occlusion. World Neurosurg 2020; 146:e1012-e1020. [PMID: 33227529 DOI: 10.1016/j.wneu.2020.11.080] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2020] [Revised: 11/11/2020] [Accepted: 11/12/2020] [Indexed: 11/24/2022]
Abstract
BACKGROUND In patients treated with thrombectomy, thrombus migration (TM) to distal arterial segments is occasionally observed. We investigated the incidence of TM, factors associated with TM, and association between TM and clinical outcomes. METHODS The study population consisted of 164 patients with anterior circulation stroke who underwent pretreatment brain computed tomography angiography and digital subtraction angiography before undergoing thrombectomy. TM was defined as a thrombus shift to a more distal arterial segment observed on digital subtraction angiography than that on computed tomography angiography. Successful and complete recanalization was defined as cerebral infarction perfusion scale scores of 2b-3 and 3, respectively. Good functional outcomes were defined as scores of ≤2 on the modified Rankin Scale at 3 months. The results are presented as adjusted odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS Thirty-two patients (19.5%) had TM. Intravenous thrombolysis (IVT) (OR, 5.238; 95% CI, 1.653-16.603) and female sex (OR, 2.874; 95% CI, 1.135-7.277) were associated with TM. IVT-related TM was not significantly associated with thrombus inaccessibility (P = 0.304). In addition, TM was not associated with successful (P = 0.960) or complete (P = 0.612) recanalization. However, TM (OR, 2.777; 95% CI, 1.019-7.569), together with IVT (OR, 2.982; 95% CI, 1.332-6.676), a low National Institutes of Health Stroke Scale score (OR, 0.906; 95% CI, 0.845-0.972), and successful recanalization (OR, 4.878; 95% CI, 1.940-12.266), were independently associated with good functional outcomes. CONCLUSIONS TM is common, particularly after IVT. In addition, TM is associated with better functional outcomes, irrespective of the angiographic outcomes.
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Affiliation(s)
- Seung-Jae Lee
- Department of Neurology, Soonchunhyang University Bucheon Hospital, Bucheon, South Korea.
| | - Tae-Kyeong Lee
- Department of Neurology, Soonchunhyang University Bucheon Hospital, Bucheon, South Korea
| | - Bum-Tae Kim
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, South Korea
| | - Dong-Seong Shin
- Department of Neurosurgery, Soonchunhyang University Bucheon Hospital, Bucheon, South Korea
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35
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Hassan AE, Ringheanu VM, Preston L, Tekle W, Qureshi AI. IV tPA is associated with increase in rates of intracerebral hemorrhage and length of stay in patients with acute stroke treated with endovascular treatment within 4.5 hours: should we bypass IV tPA in large vessel occlusion? J Neurointerv Surg 2020; 13:114-118. [PMID: 32620575 DOI: 10.1136/neurintsurg-2020-016045] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2020] [Revised: 05/26/2020] [Accepted: 05/29/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Endovascular treatment (EVT) is a widely proved method to treat patients diagnosed with intracranial large vessel occlusions (LVOs); however, there has been controversy about the safety and efficacy of incorporating intravenous tissue plasminogen activator (IV tPA) as pretreatment for EVT. OBJECTIVE To compare the outcomes of all patients with LVO treated with IV tPA +EVT versus EVT alone within 4.5 hours of stroke onset. METHODS A prospectively collected endovascular database at a comprehensive stroke center between 2012 and 2019 was used to examine variables such as demographics, comorbid conditions, symptomatic/asymptomatic intracerebral hemorrhage (ICH), mortality rate, and good/poor outcomes as shown by the modified Thrombolysis in Cerebral Infarction score and modified Rankin Scale (mRS) assessment at discharge. The outcomes between patients receiving IV tPA+EVT on admission and patients who underwent EVT alone were compared. RESULTS Of 588 patients with acute ischemic stroke treated with EVT, a total of 189 met the criteria for the study (average age 70.44±12.90 years, 42.9% women). Analysis of 109 patients from the group receiving EVT+IV tPA (average age 68.17±14.28 years, 41.3% women), and 80 patients from the EVT alone group was performed (average age 73.54±9.84 years, 45.0% women). Four patients (5.0%) in the EVT alone group experienced symptomatic ICH versus 15 patients (13.8%) in the IV tPA+EVT group (p=0.0478); significant increases were also noted in the length of stay for patients treated with IV tPA (8.2 days vs 11.0 days; p=0.0056). CONCLUSION IV tPA in addition to EVT was associated with an increase in the rate of ICH in patients with LVO treated within 4.5 hours and in patients' length of stay. Further research is required to determine whether EVT treatment alone in patients with LVO treated within 4.5 hours is a more effective option.
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Affiliation(s)
- Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley School of Medicine, Edinburg, Texas, USA .,Department of Clinical Research, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA.,Neuroscience Department, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA
| | - Victor M Ringheanu
- Department of Clinical Research, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA
| | - Laurie Preston
- Department of Clinical Research, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA.,Neuroscience Department, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA
| | - Wondwossen Tekle
- Department of Neurology, University of Texas Rio Grande Valley School of Medicine, Edinburg, Texas, USA.,Neuroscience Department, Valley Baptist Medical Center - Harlingen, Harlingen, Texas, USA
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute, St. Cloud, Minnesota, USA.,Department of Neurology, University of Missouri School of Medicine, Columbia, Missouri, USA
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36
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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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37
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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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38
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Seners P, Turc G, Lion S, Cottier JP, Cho TH, Arquizan C, Bracard S, Ozsancak C, Legrand L, Naggara O, Debiais S, Berthezene Y, Costalat V, Richard S, Magni C, Nighoghossian N, Narata AP, Dargazanli C, Gory B, Mas JL, Oppenheim C, Baron JC. Relationships between brain perfusion and early recanalization after intravenous thrombolysis for acute stroke with large vessel occlusion. J Cereb Blood Flow Metab 2020; 40:667-677. [PMID: 30890074 PMCID: PMC7026851 DOI: 10.1177/0271678x19836288] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
In large vessel occlusion (LVO) stroke, it is unclear whether severity of ischemia is involved in early post-thrombolysis recanalization over and above thrombus site and length. Here we assessed the relationships between perfusion parameters and early recanalization following intravenous thrombolysis administration in LVO patients. From a multicenter registry, we identified 218 thrombolysed LVO patients referred for thrombectomy with both (i) pre-thrombolysis MRI, including diffusion-weighted imaging (DWI), T2*-imaging, MR-angiography and dynamic susceptibility-contrast perfusion-weighted imaging (PWI); and (ii) evaluation of recanalization on first angiographic run or non-invasive imaging ≤ 3 h from thrombolysis start. Infarct core volume on DWI, PWI-DWI mismatch volume and hypoperfusion intensity ratio (HIR; defined as Tmax ≥ 10 s volume/ Tmax ≥ 6 s volume, low HIR indicating milder hypoperfusion) were determined using a commercially available software. Early recanalization occurred in 34 (16%) patients, and multivariable analysis was associated with lower HIR (P = 0.006), shorter thrombus on T2*-imaging (P < 0.001) and more distal occlusion (P = 0.006). However, the relationship between HIR and early recanalization was robust only for thrombus length <14 mm. In summary, the present study disclosed an association between lower HIR and early post-thrombolysis recanalization. Early post-thrombolysis recanalization is therefore determined not only by thrombus site and length but also by severity of ischemia.
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Affiliation(s)
- Pierre Seners
- Neurology Department, Sainte-Anne Hospital, Université Paris Descartes, INSERM UMR 1266, Paris, France
| | - Guillaume Turc
- Neurology Department, Sainte-Anne Hospital, Université Paris Descartes, INSERM UMR 1266, Paris, France
| | - Stéphanie Lion
- Radiology Department, Sainte-Anne Hospital, Université Paris Descartes, INSERM UMR 1266, Paris, France
| | - Jean-Philippe Cottier
- Department of Neuroradiology, Bretonneau Hospital, University of Tours, Tours, France
| | - Tae-Hee Cho
- Department of Stroke Medicine, Hospices Civils de Lyon, Université Lyon 1, CREATIS, CNRS UMR 5220-INSERM U1044, INSALyon, Lyon, France
| | | | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, INSERM U 947, Nancy, France
| | | | - Laurence Legrand
- Radiology Department, Sainte-Anne Hospital, Université Paris Descartes, INSERM UMR 1266, Paris, France
| | - Olivier Naggara
- Radiology Department, Sainte-Anne Hospital, Université Paris Descartes, INSERM UMR 1266, Paris, France
| | - Séverine Debiais
- Department of Neurology, Bretonneau Hospital, University of Tours, Tours, France
| | - Yves Berthezene
- Neuroradiology Department, Hospices Civils de Lyon, Lyon, France
| | - Vincent Costalat
- Department of Interventional Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
| | | | | | - Norbert Nighoghossian
- Department of Stroke Medicine, Hospices Civils de Lyon, Université Lyon 1, CREATIS, CNRS UMR 5220-INSERM U1044, INSALyon, Lyon, France
| | - Ana-Paula Narata
- Department of Neuroradiology, Bretonneau Hospital, University of Tours, Tours, France
| | - Cyril Dargazanli
- Department of Interventional Neuroradiology, CHRU Gui de Chauliac, Montpellier, France
| | - Benjamin Gory
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, INSERM U 947, Nancy, France
| | - Jean-Louis Mas
- Neurology Department, Sainte-Anne Hospital, Université Paris Descartes, INSERM UMR 1266, Paris, France
| | - Catherine Oppenheim
- Radiology Department, Sainte-Anne Hospital, Université Paris Descartes, INSERM UMR 1266, Paris, France
| | - Jean-Claude Baron
- Neurology Department, Sainte-Anne Hospital, Université Paris Descartes, INSERM UMR 1266, Paris, France
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39
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Ospel JM, Kashani N, Fischer U, Menon BK, Almekhlafi M, Wilson AT, Foss MM, Saposnik G, Goyal M, Hill MD. How Do Physicians Approach Intravenous Alteplase Treatment in Patients with Acute Ischemic Stroke Who Are Eligible for Intravenous Alteplase and Endovascular Therapy? Insights from UNMASK-EVT. AJNR Am J Neuroradiol 2020; 41:262-267. [PMID: 31974081 DOI: 10.3174/ajnr.a6396] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/23/2019] [Accepted: 12/11/2019] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE With increasing use of endovascular therapy, physicians' attitudes toward intravenous alteplase in endovascular therapy-eligible patients may be changing. We explored current intravenous alteplase treatment practices of physicians in endovascular therapy- and alteplase-eligible patients with acute stroke using prespecified case scenarios and compared how their current local treatment practices differ compared with an assumed ideal environment. MATERIALS AND METHODS In an international multidisciplinary survey, 607 physicians involved in acute stroke care were randomly assigned 10 of 22 case scenarios, among them 14 with guideline-based alteplase recommendations (9 with level 1A and 5 with level 2B recommendation) and were asked how they would treat the patient: A) under their current local resources, and B) under assumed ideal conditions. Answer options were the following: 1) anticoagulation/antiplatelet therapy, 2) endovascular therapy, 3) endovascular therapy plus intravenous alteplase, and 4) intravenous alteplase. Decision rates were calculated, and multivariable regression analysis was performed to determine variables associated with the decision to abandon intravenous alteplase. RESULTS In cases with guideline recommendations for alteplase, physicians favored alteplase in 82.0% under current local resources and in 79.3% under assumed ideal conditions (P < .001). Under assumed ideal conditions, interventional neuroradiologists would refrain from intravenous alteplase most often (6.28%, OR = 2.40; 95% CI, 1.01-5.71). When physicians' current and ideal decisions differed, most would like to add endovascular therapy to intravenous alteplase in an ideal setting (196/3861 responses, 5.1%). CONCLUSIONS In patients eligible for endovascular therapy and intravenous alteplase, we observed a slightly lower decision rate in favor of intravenous alteplase under assumed ideal conditions compared with the decision rate under current local resources.
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Affiliation(s)
- J M Ospel
- From the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
- Division of Neuroradiology (J.M.O.), Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Basel, Switzerland
| | - N Kashani
- Radiology (N.K., B.K.M., M.A., M.G., M.D.H.), University of Calgary, Calgary, Alberta, Canada
| | - U Fischer
- University Hospital Bern (U.F.), Inselspital, University of Bern, Bern, Switzerland
| | - B K Menon
- From the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
- Radiology (N.K., B.K.M., M.A., M.G., M.D.H.), University of Calgary, Calgary, Alberta, Canada
| | - M Almekhlafi
- From the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
- Radiology (N.K., B.K.M., M.A., M.G., M.D.H.), University of Calgary, Calgary, Alberta, Canada
| | - A T Wilson
- From the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
| | - M M Foss
- From the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
| | - G Saposnik
- Division of Neurology (G.S.), Department of Medicine, St. Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - M Goyal
- From the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
- Radiology (N.K., B.K.M., M.A., M.G., M.D.H.), University of Calgary, Calgary, Alberta, Canada
| | - M D Hill
- From the Departments of Clinical Neurosciences (J.M.O., B.K.M., M.A., A.T.W., M.M.F., M.G., M.D.H.)
- Radiology (N.K., B.K.M., M.A., M.G., M.D.H.), University of Calgary, Calgary, Alberta, Canada
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40
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Kaminsky AL, Mione G, Omorou Y, Humbertjean L, Bonnerot M, Lacour JC, Riou-Comte N, Anadani M, Gory B, Richard S. Outcome of patients with large vessel occlusion stroke after first admission in telestroke spoke versus comprehensive stroke center. J Neurointerv Surg 2019; 12:753-757. [DOI: 10.1136/neurintsurg-2019-015342] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/02/2019] [Revised: 10/29/2019] [Accepted: 11/06/2019] [Indexed: 11/04/2022]
Abstract
IntroductionWhile telestroke allows early intravenous thrombolysis (IVT) for ischemic strokes in spoke centers, mechanical thrombectomy (MT) for large vessel occlusion (LVO) is mainly performed at comprehensive stroke centers (CSCs). We aimed to compare 3 month outcome in patients with LVO after admission to a spoke center using telestroke compared with first CSC admission in our large regional stroke network, irrespective of final treatment decision.MethodsAll consecutive LVO patients who were admitted to one of six spoke centers or to the regional CSC within 6 hours of symptom onset were prospectively included from September 1, 2015 to August 31, 2017. All patients admitted to spoke centers were assessed on site with cerebral and vessel imaging. Primary outcome was 3 month favorable outcome (modified Rankin Scale score of 0–2).ResultsDistances between spoke centers and CSC ranged from 36 to 77 miles. Among 207 included patients, 132 (63.8%) were first admitted to CSCs and 75 (36.2%) to spoke centers. IVT was administered more in spoke centers (81.3% vs 53.8%, p<0.0001) while MT was performed less (26.7% vs 49.2%, p=0.001) and with a longer time from onset (303 vs 200 min, p<0.0001). No difference was found in 3 month favorable outcome between spoke centers compared with CSCs (32.0% and 35.1%, respectively; OR=0.68; 95% CI 0.42 to 1.10; p=0.12).ConclusionsDespite different distribution of reperfusion therapies for LVO patients managed by telemedicine, we could not demonstrate a difference in functional outcome according to admission location in a large area with long distances between centers.
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41
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Alves HC, Treurniet KM, Jansen IGH, Yoo AJ, Dutra BG, Zhang G, Yo L, van Es ACGM, Emmer BJ, van den Berg R, van den Wijngaard IR, Lycklama À Nijeholt GJ, Vos JA, Roos YBWEM, Schonewille W, Marquering HA, Majoie CBLM. Thrombus Migration Paradox in Patients With Acute Ischemic Stroke. Stroke 2019; 50:3156-3163. [PMID: 31597552 PMCID: PMC6824579 DOI: 10.1161/strokeaha.119.026107] [Citation(s) in RCA: 69] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Supplemental Digital Content is available in the text. The location of the thrombus as observed on first digital subtraction angiography during endovascular treatment may differ from the initial observation on initial noninvasive imaging. We studied the incidence of thrombus dynamics, its impact on patient outcomes, and its association with intravenous thrombolytics.
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Affiliation(s)
- Heitor C Alves
- From the Departments of Radiology and Nuclear Medicine (H.C.A., K.M.T, I.G.H.J., B.G.D., G.Z., B.J.E., R.v.d.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands.,Biomedical Engineering and Physics (H.C.A., B.G.D., H.A.M.), Academic Medical Center, Amsterdam, the Netherlands.,Department of Radiology, Irmandade Santa Casa de Misericórdia de São Paulo, Brazil (H.C.A., B.G.D.)
| | - Kilian M Treurniet
- From the Departments of Radiology and Nuclear Medicine (H.C.A., K.M.T, I.G.H.J., B.G.D., G.Z., B.J.E., R.v.d.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands
| | - Ivo G H Jansen
- From the Departments of Radiology and Nuclear Medicine (H.C.A., K.M.T, I.G.H.J., B.G.D., G.Z., B.J.E., R.v.d.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands
| | - Albert J Yoo
- Division of Interventional Neuroradiology, Department of Radiology, Texas Stroke Institute, Plano (A.J.Y.)
| | - Bruna G Dutra
- From the Departments of Radiology and Nuclear Medicine (H.C.A., K.M.T, I.G.H.J., B.G.D., G.Z., B.J.E., R.v.d.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands.,Biomedical Engineering and Physics (H.C.A., B.G.D., H.A.M.), Academic Medical Center, Amsterdam, the Netherlands.,Department of Radiology, Irmandade Santa Casa de Misericórdia de São Paulo, Brazil (H.C.A., B.G.D.)
| | - Guang Zhang
- From the Departments of Radiology and Nuclear Medicine (H.C.A., K.M.T, I.G.H.J., B.G.D., G.Z., B.J.E., R.v.d.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands
| | - Lonneke Yo
- Department of Radiology, Catharina Ziekenhuis, Eindhoven, the Netherlands (L.Y.)
| | - Adriaan C G M van Es
- Department of Radiology, Erasmus MC University Medical Center, Rotterdam, the Netherlands (A.C.G.M.v.E.)
| | - Bart J Emmer
- From the Departments of Radiology and Nuclear Medicine (H.C.A., K.M.T, I.G.H.J., B.G.D., G.Z., B.J.E., R.v.d.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands
| | - René van den Berg
- From the Departments of Radiology and Nuclear Medicine (H.C.A., K.M.T, I.G.H.J., B.G.D., G.Z., B.J.E., R.v.d.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands
| | | | | | - Jan-Albert Vos
- Department of Radiology, St Antonius Ziekenhuis, Nieuwegein, the Netherlands (J.A.V)
| | - Yvo B W E M Roos
- Neurology (Y.B.W.E.M.R.), Academic Medical Center, Amsterdam, the Netherlands
| | - Wouter Schonewille
- Department of Neurology, University Medical Center, Utrecht, the Netherlands (W.S.)
| | - Henk A Marquering
- Biomedical Engineering and Physics (H.C.A., B.G.D., H.A.M.), Academic Medical Center, Amsterdam, the Netherlands
| | - Charles B L M Majoie
- From the Departments of Radiology and Nuclear Medicine (H.C.A., K.M.T, I.G.H.J., B.G.D., G.Z., B.J.E., R.v.d.B., C.B.L.M.M.), Academic Medical Center, Amsterdam, the Netherlands
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Seners P, Roca P, Legrand L, Turc G, Cottier JP, Cho TH, Arquizan C, Bracard S, Ozsancak C, Ben Hassen W, Naggara O, Lion S, Debiais S, Berthezene Y, Costalat V, Richard S, Magni C, Mas JL, Baron JC, Oppenheim C. Better Collaterals Are Independently Associated With Post-Thrombolysis Recanalization Before Thrombectomy. Stroke 2019; 50:867-872. [DOI: 10.1161/strokeaha.118.022815] [Citation(s) in RCA: 28] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
In acute stroke patients with large vessel occlusion, the goal of intravenous thrombolysis (IVT) is to achieve early recanalization (ER). Apart from occlusion site and thrombus length, predictors of early post-IVT recanalization are poorly known. Better collaterals might also facilitate ER, for instance, by improving delivery of the thrombolytic agent to both ends of the thrombus. In this proof-of-concept study, we tested the hypothesis that good collaterals independently predict post-IVT recanalization before thrombectomy.
Methods—
Patients from the registries of 6 French stroke centers with the following criteria were included: (1) acute stroke with large vessel occlusion treated with IVT and referred for thrombectomy between May 2015 and March 2017; (2) pre-IVT brain magnetic resonance imaging, including diffusion-weighted imaging, T2*, MR angiography, and dynamic susceptibility contrast perfusion-weighted imaging; and (3) ER evaluated ≤3 hours from IVT start on either first angiographic run or noninvasive imaging. A collateral flow map derived from perfusion-weighted imaging source data was automatically generated, replicating a previously validated method. Thrombus length was measured on T2*-based susceptibility vessel sign.
Results—
Of 224 eligible patients, 37 (16%) experienced ER. ER occurred in 10 of 83 (12%), 17 of 116 (15%), and 10 of 25 (40%) patients with poor/moderate, good, and excellent collaterals, respectively. In multivariable analysis, better collaterals were independently associated with ER (
P
=0.029), together with shorter thrombus (
P
<0.001) and more distal occlusion site (
P
=0.010).
Conclusions—
In our sample of patients with stroke imaged with perfusion-weighted imaging before IVT and intended for thrombectomy, better collaterals were independently associated with post-IVT recanalization, supporting our hypothesis. These findings strengthen the idea that advanced imaging may play a key role for personalized medicine in identifying patients with large vessel occlusion most likely to benefit from IVT in the thrombectomy era.
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Affiliation(s)
- Pierre Seners
- From the Department of Neurology (P.S., G.T., J.-L.M., J.-C.B.), Sainte-Anne Hospital, INSERM U894, University Paris Descartes, France
| | - Pauline Roca
- Department of Radiology (P.R., L.L., W.B.H., O.N., S.L., C. Oppenheim), Sainte-Anne Hospital, INSERM U894, University Paris Descartes, France
| | - Laurence Legrand
- Department of Radiology (P.R., L.L., W.B.H., O.N., S.L., C. Oppenheim), Sainte-Anne Hospital, INSERM U894, University Paris Descartes, France
| | - Guillaume Turc
- From the Department of Neurology (P.S., G.T., J.-L.M., J.-C.B.), Sainte-Anne Hospital, INSERM U894, University Paris Descartes, France
| | - Jean-Philippe Cottier
- Department of Neuroradiology (J.-P.C.), Bretonneau Hospital, University of Tours, France
| | - Tae-Hee Cho
- Department of Stroke Medicine (T.-H.C.), Hospices Civils de Lyon, Université Lyon 1, CREATIS, CNRS UMR 5220-INSERM U1044, France
| | - Caroline Arquizan
- Department of Neurology (C.A.), CHRU Gui de Chauliac, Montpellier, France
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Nancy, INSERM U947, France (S.B.)
| | - Canan Ozsancak
- Department of Neurology (C. Ozsancak), Orleans Hospital, France
| | - Wagih Ben Hassen
- Department of Radiology (P.R., L.L., W.B.H., O.N., S.L., C. Oppenheim), Sainte-Anne Hospital, INSERM U894, University Paris Descartes, France
| | - Olivier Naggara
- Department of Radiology (P.R., L.L., W.B.H., O.N., S.L., C. Oppenheim), Sainte-Anne Hospital, INSERM U894, University Paris Descartes, France
| | - Stéphanie Lion
- Department of Radiology (P.R., L.L., W.B.H., O.N., S.L., C. Oppenheim), Sainte-Anne Hospital, INSERM U894, University Paris Descartes, France
| | - Séverine Debiais
- Department of Neurology (S.D.), Bretonneau Hospital, University of Tours, France
| | - Yves Berthezene
- Department of Neuroradiology (Y.B.), Hospices Civils de Lyon, Université Lyon 1, CREATIS, CNRS UMR 5220-INSERM U1044, France
| | - Vincent Costalat
- Department of Interventional Neuroradiology (V.C.), CHRU Gui de Chauliac, Montpellier, France
| | - Sébastien Richard
- Department of Neurology, University Hospital of Nancy, France (S.R.)
| | | | - Jean-Louis Mas
- From the Department of Neurology (P.S., G.T., J.-L.M., J.-C.B.), Sainte-Anne Hospital, INSERM U894, University Paris Descartes, France
| | - Jean-Claude Baron
- From the Department of Neurology (P.S., G.T., J.-L.M., J.-C.B.), Sainte-Anne Hospital, INSERM U894, University Paris Descartes, France
| | - Catherine Oppenheim
- Department of Radiology (P.R., L.L., W.B.H., O.N., S.L., C. Oppenheim), Sainte-Anne Hospital, INSERM U894, University Paris Descartes, France
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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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45
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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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46
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Seners P, Turc G, Naggara O, Henon H, Piotin M, Arquizan C, Cho TH, Narata AP, Lapergue B, Richard S, Legrand L, Bricout N, Blanc R, Dargazanli C, Gory B, Debiais S, Tisserand M, Bracard S, Leclerc X, Obadia M, Costalat V, Berner LP, Cottier JP, Consoli A, Ducrocq X, Mas JL, Oppenheim C, Baron JC, Abrivard M, Alamowitch S, Ben Hassen W, Berthezene Y, Blanc-Lasserre K, Boulin A, Boulouis G, Bouly S, Bourdain F, Calvet D, Charron V, Chbicheb M, Condette-Auliac S, Corabianu O, Cordonnier C, Coskun O, De Broucker T, Decroix JP, Di Maria F, Evrard S, Fissellier M, Girard I, Lalu T, Le Coz P, Le Guen M, Ille O, Leys D, Magni C, Manchon E, Mazighi M, Mounier-Vehier F, Moynier M, Muresan IP, Nighoghossian N, Ong E, Ozsancak C, Philippeau F, Pico F, Rodesch G, Rosolacci T, Sabben C, Sablot D, Tassan P, Tchikviladze M, Turjman F, Vallet AE, Wang A, Zins M, Zuber M. Post-Thrombolysis Recanalization in Stroke Referrals for Thrombectomy. Stroke 2018; 49:2975–2982. [DOI: 10.1161/strokeaha.118.022335] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Background and Purpose—
Whether all acute stroke patients with large vessel occlusion need to undergo intravenous thrombolysis before mechanical thrombectomy (MT) is debated as (1) the incidence of post-thrombolysis early recanalization (ER) is still unclear; (2) thrombolysis may be harmful in patients unlikely to recanalize; and, conversely, (3) transfer for MT may be unnecessary in patients highly likely to recanalize. Here, we determined the incidence and predictors of post-thrombolysis ER in patients referred for MT and derive ER prediction scores for trial design.
Methods—
Registries from 4 MT-capable centers gathering patients referred for MT and thrombolyzed either on site (mothership) or in a non MT-capable center (drip-and-ship) after magnetic resonance– or computed tomography–based imaging between 2015 and 2017. ER was identified on either first angiographic run or noninvasive imaging. In the magnetic resonance imaging subsample, thrombus length was determined on T2*-based susceptibility vessel sign. Independent predictors of no-ER were identified using multivariable logistic regression models, and scores were developed according to the magnitude of regression coefficients. Similar registries from 4 additional MT-capable centers were used as validation cohort.
Results—
In the derivation cohort (N=633), ER incidence was ≈20%. In patients with susceptibility vessel sign (n=498), no-ER was independently predicted by long thrombus, proximal occlusion, and mothership paradigm. A 6-point score derived from these variables showed strong discriminative power for no-ER (C statistic, 0.854) and was replicated in the validation cohort (n=353; C statistic, 0.888). A second score derived from the whole sample (including negative T2* or computed tomography–based imaging) also showed good discriminative power and was similarly validated. Highest grades on both scores predicted no-ER with >90% specificity, whereas low grades did not reliably predict ER.
Conclusions—
The substantial ER rate underlines the benefits derived from thrombolysis in bridging populations. Both prediction scores afforded high specificity for no-ER, but not for ER, which has implications for trial design.
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Affiliation(s)
- Pierre Seners
- From the Neurology Department (P.S., G.T., J.-L.M., J.-C.B.), INSERM U894, Sainte-Anne Hospital, Université Paris Descartes, Paris, France
| | - Guillaume Turc
- From the Neurology Department (P.S., G.T., J.-L.M., J.-C.B.), INSERM U894, Sainte-Anne Hospital, Université Paris Descartes, Paris, France
| | - Olivier Naggara
- Radiology Department (O.N., L.L., C.O.), INSERM U894, Sainte-Anne Hospital, Université Paris Descartes, Paris, France
| | - Hilde Henon
- Stroke Unit, Neurology Department (H.H.), Roger Salengro Hospital, Lille, France
| | - Michel Piotin
- Interventional Neuroradiology Department (M.P., R.B.), Fondation Adolphe de Rothschild, Paris, France
| | - Caroline Arquizan
- Neurology Department (C.A.), CHRU Gui de Chauliac, Montpellier, France
| | - Tae-Hee Cho
- Stroke Medicine Department (T.-H.C.), Hospices Civils de Lyon, France
| | - Ana-Paula Narata
- Neuroradiology Department (A.-P.N., J.-P.C.), Bretonneau Hospital, Tours, France
| | | | | | - Laurence Legrand
- Radiology Department (O.N., L.L., C.O.), INSERM U894, Sainte-Anne Hospital, Université Paris Descartes, Paris, France
| | - Nicolas Bricout
- Neuroradiology Department (N.B., X.L.), Roger Salengro Hospital, Lille, France
- Neuroradiology Department, CHU Lille, France (N.B., X.L.)
| | - Raphaël Blanc
- Interventional Neuroradiology Department (M.P., R.B.), Fondation Adolphe de Rothschild, Paris, France
| | - Cyril Dargazanli
- Neuroradiology Department (C.D., V.C.), CHRU Gui de Chauliac, Montpellier, France
| | - Benjamin Gory
- Stroke Medicine Department (T.-H.C.), Hospices Civils de Lyon, France
- Neuroradiology Department (B.G., S.B.), University Hospital of Nancy, France
| | | | - Marie Tisserand
- Neuroradiology Department (A.C., M.T.), Foch Hospital, Suresnes, France
| | - Serge Bracard
- Stroke Medicine Department (T.-H.C.), Hospices Civils de Lyon, France
- Neuroradiology Department (B.G., S.B.), University Hospital of Nancy, France
| | - Xavier Leclerc
- Neuroradiology Department (N.B., X.L.), Roger Salengro Hospital, Lille, France
- Neurology Department (C.A.), CHRU Gui de Chauliac, Montpellier, France
| | - Michael Obadia
- Neurology Department (M.O.), Fondation Adolphe de Rothschild, Paris, France
| | - Vincent Costalat
- Neuroradiology Department (C.D., V.C.), CHRU Gui de Chauliac, Montpellier, France
| | - Lise-Prune Berner
- Neuroradiology Department (L.-P.B.), Hospices Civils de Lyon, France
| | | | - Arturo Consoli
- Neuroradiology Department (A.C., M.T.), Foch Hospital, Suresnes, France
| | - Xavier Ducrocq
- Neurology Department, Metz-Thionville Hospital, France (X.D.)
| | - Jean-Louis Mas
- From the Neurology Department (P.S., G.T., J.-L.M., J.-C.B.), INSERM U894, Sainte-Anne Hospital, Université Paris Descartes, Paris, France
| | - Catherine Oppenheim
- From the Neurology Department (P.S., G.T., J.-L.M., J.-C.B.), INSERM U894, Sainte-Anne Hospital, Université Paris Descartes, Paris, France
- Radiology Department (O.N., L.L., C.O.), INSERM U894, Sainte-Anne Hospital, Université Paris Descartes, Paris, France
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Kaesmacher J, Giarrusso M, Zibold F, Mosimann PJ, Dobrocky T, Piechowiak E, Bellwald S, Arnold M, Jung S, El-Koussy M, Mordasini P, Gralla J, Fischer U. Rates and Quality of Preinterventional Reperfusion in Patients With Direct Access to Endovascular Treatment. Stroke 2018; 49:1924-1932. [DOI: 10.1161/strokeaha.118.021579] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Johannes Kaesmacher
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., F.Z., P.J.M., T.D., E.P., M.E.-K., P.M., J.G.)
- Department of Neurology (J.K., M.G., S.B., M.A., S.J., U.F.), University Hospital Bern, University of Bern, Inselspital, Switzerland
| | - Mattia Giarrusso
- Department of Neurology (J.K., M.G., S.B., M.A., S.J., U.F.), University Hospital Bern, University of Bern, Inselspital, Switzerland
| | - Felix Zibold
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., F.Z., P.J.M., T.D., E.P., M.E.-K., P.M., J.G.)
| | - Pascal J. Mosimann
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., F.Z., P.J.M., T.D., E.P., M.E.-K., P.M., J.G.)
| | - Tomas Dobrocky
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., F.Z., P.J.M., T.D., E.P., M.E.-K., P.M., J.G.)
| | - Eike Piechowiak
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., F.Z., P.J.M., T.D., E.P., M.E.-K., P.M., J.G.)
| | - Sebastian Bellwald
- Department of Neurology (J.K., M.G., S.B., M.A., S.J., U.F.), University Hospital Bern, University of Bern, Inselspital, Switzerland
| | - Marcel Arnold
- Department of Neurology (J.K., M.G., S.B., M.A., S.J., U.F.), University Hospital Bern, University of Bern, Inselspital, Switzerland
| | - Simon Jung
- Department of Neurology (J.K., M.G., S.B., M.A., S.J., U.F.), University Hospital Bern, University of Bern, Inselspital, Switzerland
| | - Marwan El-Koussy
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., F.Z., P.J.M., T.D., E.P., M.E.-K., P.M., J.G.)
| | - Pasquale Mordasini
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., F.Z., P.J.M., T.D., E.P., M.E.-K., P.M., J.G.)
| | - Jan Gralla
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., F.Z., P.J.M., T.D., E.P., M.E.-K., P.M., J.G.)
| | - Urs Fischer
- Department of Neurology (J.K., M.G., S.B., M.A., S.J., U.F.), University Hospital Bern, University of Bern, Inselspital, Switzerland
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Goyal N, Tsivgoulis G, Frei D, Turk A, Baxter B, Froehler MT, Mocco J, Pandhi A, Zand R, Malhotra K, Hoit D, Elijovich L, Loy D, Turner RD, Mascitelli J, Espaillat K, Katsanos AH, Alexandrov AW, Alexandrov AV, Arthur AS. Comparative safety and efficacy of combined IVT and MT with direct MT in large vessel occlusion. Neurology 2018; 90:e1274-e1282. [PMID: 29549221 DOI: 10.1212/wnl.0000000000005299] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2017] [Accepted: 12/27/2017] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE In this multicenter study, we sought to evaluate comparative safety and efficacy of combined IV thrombolysis (IVT) and mechanical thrombectomy (MT) vs direct MT in emergent large vessel occlusion (ELVO) patients. METHODS Consecutive ELVO patients treated with MT at 6 high-volume endovascular centers were evaluated. Standard safety and efficacy outcomes (successful reperfusion [modified Thrombolysis in Cerebral Infarction IIb/III], functional independence [FI] [modified Rankin Scale (mRS) score of 0-2 at 3 months], favorable functional outcome [mRS of 0-1 at 3 months], functional improvement [mRS shift by 1-point decrease in mRS score]) were compared between patients who underwent combined IVT and MT vs MT alone. Additional propensity score-matched analyses were performed. RESULTS A total of 292 and 277 patients were treated with combination therapy and direct MT, respectively. The combination therapy group had greater functional improvement (p = 0.037) at 3 months. After propensity score matching, 104 patients in the direct MT group were matched to 208 patients in the combination therapy group. IVT pretreatment was independently (p < 0.05) associated with higher odds of FI (odds ratio [OR] 1.75; 95% confidence interval [CI] 1.02-2.99) and functional improvement (common OR 1.64; 95% CI 1.05-2.56). Combination therapy was independently (p < 0.05) related to lower likelihood of 3-month mortality (0.50; 95% CI 0.26-0.96). CONCLUSIONS This observational study provides preliminary evidence that IVT pretreatment may improve outcomes in ELVO patients treated with MT. The question of the potential effect of IVT on ELVO patients treated with MT should be addressed with a randomized controlled trial. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that for stroke patients with emergent large vessel occlusion, combined IVT and MT is superior to direct MT in improving functional outcomes.
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Affiliation(s)
- Nitin Goyal
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Georgios Tsivgoulis
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Donald Frei
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Aquilla Turk
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Blaise Baxter
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Michael T Froehler
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - J Mocco
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Abhi Pandhi
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Ramin Zand
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Konark Malhotra
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Daniel Hoit
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Lucas Elijovich
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - David Loy
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Raymond D Turner
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Justin Mascitelli
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Kiersten Espaillat
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Aristeidis H Katsanos
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Anne W Alexandrov
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Andrei V Alexandrov
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis
| | - Adam S Arthur
- From the Department of Neurology (N.G., G.T., A.P., R.Z., L.E., A.W.A., A.V.A.), University of Tennessee Health Science Center, Memphis; Second Department of Neurology (G.T., A.H.K.), "Attikon University Hospital," School of Medicine, University of Athens, Greece; International Clinical Research Center (G.T.), St. Anne's Hospital, Brno, Czech Republic; Department of Interventional Neuroradiology (D.F., D.L.), Radiology Imaging Associates, Englewood, CO; Department of Neurosurgery (A.T., R.D.T.), Medical University of South Carolina, Charleston; Department of Interventional Neuroradiology (B.B.), Erlanger Hospital, Chattanooga; Cerebrovascular Program (M.T.F., K.E.), Vanderbilt University, Nashville, TN; Department of Neurosurgery (J. Mocco, J. Mascitelli), Mount Sinai Medical Center, New York, NY; Charleston Area Medical Center (K.M.), West Virginia University; and Department of Neurosurgery (D.H., L.E., A.S.A.), University of Tennessee Health Science Center and Semmes-Murphey Clinic, Memphis.
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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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Bellwald S, Weber R, Dobrocky T, Nordmeyer H, Jung S, Hadisurya J, Mordasini P, Mono ML, Stracke CP, Sarikaya H, Bernasconi C, Berger K, Arnold M, Chapot R, Gralla J, Fischer U. Direct Mechanical Intervention Versus Bridging Therapy in Stroke Patients Eligible for Intravenous Thrombolysis: A Pooled Analysis of 2 Registries. Stroke 2017; 48:3282-3288. [PMID: 29114095 DOI: 10.1161/strokeaha.117.018459] [Citation(s) in RCA: 70] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2017] [Revised: 09/11/2017] [Accepted: 09/15/2017] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Randomized controlled trials have shown that mechanical thrombectomy (MT) plus best medical treatment improves outcome in stroke patients with large-vessel occlusion in the anterior circulation. Whether direct MT is equally effective as bridging thrombolysis (intravenous thrombolysis plus MT) in intravenous thrombolysis eligible patients remains unclear. METHODS We compared clinical and radiological outcomes at 3 months in 249 bridging patients with 111 patients receiving direct MT for large-vessel occlusion anterior circulation stroke from 2 prospective registries (study period Essen: June 2012 to August 2013, Bern February 2009 to August 2014). We matched all patients from the direct MT group who would have qualified for intravenous thrombolysis with controls from the bridging group, using multivariate and propensity score methods. Subgroup analyses for internal carotid artery occlusions were performed. RESULTS Baseline characteristics did not differ between the direct MT group and bridging cohort, except for higher rates of coronary heart disease (P=0.029) and shorter intervals from onset to endovascular therapy (P<0.001) in the MT group. Functional outcome, mortality, and intracerebral hemorrhage did not differ, neither in univariate nor after multivariate and propensity score matching. However, in patients with internal carotid artery occlusion, mortality in the direct cohort was significantly lower. CONCLUSIONS In this matched-pair analysis, there was no difference in outcome in patients with large-vessel occlusion anterior circulation stroke treated with direct MT compared with those treated with bridging thrombolysis; however, mortality in patients with internal carotid artery occlusion treated with direct MT was significantly lower than after bridging thrombolysis. Randomized trials comparing direct MT with bridging therapy are needed.
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Affiliation(s)
- Sebastian Bellwald
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.)
| | - Ralph Weber
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.)
| | - Tomas Dobrocky
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.)
| | - Hannes Nordmeyer
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.)
| | - Simon Jung
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.)
| | - Jeffrie Hadisurya
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.)
| | - Pasquale Mordasini
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.)
| | - Marie-Luise Mono
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.)
| | - Christian P Stracke
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.)
| | - Hakan Sarikaya
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.)
| | - Corrado Bernasconi
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.)
| | - Klaus Berger
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.)
| | - Marcel Arnold
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.)
| | - René Chapot
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.)
| | - Jan Gralla
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.)
| | - Urs Fischer
- From the Department of Neurology (S.B., S.J., M.-L.M., H.S., C.B., M.A., U.F.) and Department of Diagnostic and Interventional Neuroradiology (S.B., T.D., P.M., J.G.), Inselspital, University Hospital Bern and University of Bern, Switzerland; Department of Neurology (R.W., J.H.) and Department of Radiology and Neuroradiology (H.N., C.P.S., R.C.), Alfried Krupp Krankenhaus Essen, Germany; and Institute of Epidemiology and Social Medicine, University of Münster, Germany (K.B.).
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