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Sequeiros JM, Rodriguez-Calienes A, Chavez-Malpartida SS, Morán-Mariños C, Alvarado-Gamarra G, Malaga M, Quincho-Lopez A, Hernadez-Fernandez W, Pacheco-Barrios K, Ortega-Gutierrez S, Hoit D, Arthur AS, Alexandrov AV, Alva-Diaz C, Elijovich L. Stroke imaging modality for endovascular therapy in the extended window: systematic review and meta-analysis. J Neurointerv Surg 2023; 15:e46-e53. [PMID: 35725306 DOI: 10.1136/neurintsurg-2022-018896] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 06/08/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND In anterior circulation large vessel occlusion (LVO) in the extended time window, the guidelines recommend advanced imaging (ADVI) to select patients for endovascular therapy (EVT). However, questions remain regarding its availability and applicability in the real world. It is unclear whether an approach to the extended window EVT that does not use ADVI would be equivalent. METHODS In April 2022, a literature search was performed to identified randomized controlled trials (RCT) and observational studies describing 90-day outcomes. We performed a meta-analysis of the proportion of aggregate using a random effect to estimate rates of functional independence, defined as modified Rankin Scale (mRS) score ≤2 at 90 days, mean mRS, mortality and symptomatic intracranial hemorrhage (sICH) stratified by imaging modality. RESULTS Four RCTs and 28 observational studies were included. The pooled proportion of functional independence among patients selected by ADVI was 44% (95% CI 39% to 48%; I2=80%) and 48% (95% CI 41% to 55%; I2=75%) with non-contrast CT/CT angiography (NCCT/CTA) (p=0.36). Mean mRS with ADVI was 2.88 (95% CI 2.36 to 3.41; I2=0.0%) and 2.79 (95% CI 2.31 to 3.27; I2=0.0%) with NCCT (p=0.79). Mortality in patients selected by ADVI was 13% (95% CI 10% to 17%; I2=81%) and 16% (95% CI 12% to 22%; I2=69%) with NCCT (p=0.29). sICH with ADVI was 4% (95% CI 3% to 7%; I2=73%) and 6% with NCCT/CTA (95% CI 4% to 8%; I2=6%, p=0.27). CONCLUSIONS Our study suggests that, in anterior circulation LVO, the rates of functional independence may be similar when patients are selected using ADVI or NCCT for EVT in the extended time window. A simplified triage protocol does not seem to increase mortality or sICH. PROTOCOL REGISTRATION NUMBER: (PROSPERO ID: CRD42021236092).
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Affiliation(s)
- Joel M Sequeiros
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Aaron Rodriguez-Calienes
- Grupo de Investigacion Neurociencia, Efectividad Clinica y Salud Publica, Universidad Científica del Sur, Lima, Peru
| | - Sandra S Chavez-Malpartida
- Facultad de Medicina Humana, Universidad Nacional Mayor de San Marcos, Lima, Peru
- Red de Eficacia Clínica y Sanitaria, REDECS, Lima, Peru
- Servicio de Neurologia, Departamento de Medicina y Oficina de Apoyo a la Docencia e Investigacion, Hospital Daniel Alcides Carrion, Callao, Peru
| | - Cristian Morán-Mariños
- Unidad de Investigacion en Bibliometria, Universidad San Ignacio de Loyola, Lima, Peru
- Servicio de Neumologia, Hospital Nacional Dos de Mayo, Lima, Peru
| | - Giancarlo Alvarado-Gamarra
- Red de Eficacia Clínica y Sanitaria, REDECS, Lima, Peru
- Departamento de Pediatria, Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru
- Departamento de Pediatria, Instituto de Investigación Nutricional, Lima, Peru
| | - Marco Malaga
- Red de Eficacia Clínica y Sanitaria, REDECS, Lima, Peru
| | - Alvaro Quincho-Lopez
- Facultad de Medicina Humana, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Wendy Hernadez-Fernandez
- Servicio de Neurologia, Departamento de Medicina y Oficina de Apoyo a la Docencia e Investigacion, Hospital Daniel Alcides Carrion, Callao, Peru
| | - Kevin Pacheco-Barrios
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Boston, Massachusetts, USA
- Vicerrectorado de Investigacion, Unidad de Investigacion para la Generacion y Síntesis de Evidencias en Salud, Universidad San Ignacio de Loyola, Lima, Peru
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Daniel Hoit
- Department of Neurosurgery, University of Tennessee Health Science Center - Semmens Murphy Clinic, Memphis, TN, USA
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center - Semmens Murphy Clinic, Memphis, TN, USA
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Carlos Alva-Diaz
- Grupo de Investigacion Neurociencia, Efectividad Clinica y Salud Publica, Universidad Científica del Sur, Lima, Peru
- Servicio de Neurologia, Departamento de Medicina y Oficina de Apoyo a la Docencia e Investigacion, Hospital Daniel Alcides Carrion, Callao, Peru
| | - Lucas Elijovich
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Department of Neurosurgery, University of Tennessee Health Science Center - Semmens Murphy Clinic, Memphis, TN, USA
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Hennebry J, Stoneman S, Jones B, Bambrick N, Stroiescu A, Crosbie I, Mulcahy R. Quality improvement project to improve patient outcomes by reducing door to CT and door to needle time and increasing appropriate referrals for endovascular thrombectomy. BMJ Open Qual 2022; 11:bmjoq-2021-001429. [PMID: 35017174 PMCID: PMC8753398 DOI: 10.1136/bmjoq-2021-001429] [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: 03/04/2021] [Accepted: 09/16/2021] [Indexed: 11/28/2022] Open
Abstract
This paper describes a stroke quality improvement (QI) project in a primary stroke centre in a 431-bed hospital serving a local population of 114 000 people. Approximately 170 acute strokes are treated each year in a seven-bed stroke unit managed by three geriatricians with a subspecialty interest in stroke. 24-hour CT radiology service is available. Endovascular thrombectomy (EVT) is performed by neuro-interventional radiology at one of two comprehensive stroke centres located 90–120 min away. In 2018, as part of a national collaborative QI initiative a new national thrombectomy referral pathway was introduced with an aim that all eligible patients be referred for EVT. This initiative included maximising timely access to CT and thrombolysis. Review of local data highlighted significant deficits in these areas. A local QI team convened and a multidisciplinary approach was employed to map the existing process for CT access and time to thrombolysis decision. We describe how focused timesaving interventions such as; new emergency and radiology department ‘pre-alerts’, dedicated acute stroke pagers, new ‘FAST’ registration by clerical staff, new CT ordering codes and new ‘FAST packs’ (including tissue plasminogen activator, paper National Institute of Health Stroke Scale scoring tools, consent forms and EVT patient selection tools) were created and incorporated into a multidisciplinary detailed clinical stroke care pathway. We describe how we achieved our SMART aims; to reduce our door to CT time and to reduce our door to needle time to the national target of less than 30 min. A third aim was to increase the number of patients referred for EVT from our centre. This project is an accurate description of how a multidisciplinary approach combined with teamwork and effective communication can create sustainable improved patient care and is generalisable to all institutions that require timely referral to external centres for EVT.
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Affiliation(s)
| | - Sinead Stoneman
- Gerontology, University Hospital Waterford, Waterford, Ireland
| | - Breda Jones
- Gerontology, University Hospital Waterford, Waterford, Ireland
| | - Nicola Bambrick
- Emergency, University Hospital Waterford, Waterford, Ireland
| | | | - Ian Crosbie
- Radiology, University Hospital Waterford, Waterford, Ireland
| | - Riona Mulcahy
- Gerontology, University Hospital Waterford, Waterford, Ireland
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3
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Zhongxing Y, Zhiqiang L, Jiangjie W, Qing C, Jinfeng Z, Chaoqun W, Feng L. Efficacy and Safety of Endovascular Treatment for Acute Large-Vessel Ischemic Stroke Beyond 6 h After Symptom Onset: A Meta-Analysis. Front Neurol 2021; 12:654816. [PMID: 34122303 PMCID: PMC8195613 DOI: 10.3389/fneur.2021.654816] [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: 01/17/2021] [Accepted: 03/22/2021] [Indexed: 11/23/2022] Open
Abstract
Background: There is considerable evidence on the benefits of endovascular thrombectomy (EVT) for acute ischemic stroke (AIS) within 6 h after symptom onset. However, uncertainties remain regarding EVT efficacy beyond 6 h after symptom onset. We undertook a meta-analysis to assess the efficacy and safety of EVT in patients with AIS >6 h after symptom onset. Methods: We searched PubMed, EMBASE, and Chinese Biomedical through July 2019. We included studies involving early (≤6 h) vs. delayed (>6 h) EVT in selected patients with AIS, based on radiological evaluation criteria. Functional independence, successful recanalization, mortality, and symptomatic intracranial hemorrhage (sICH) rates were assessed. Results: Eight articles, with 3,265 patients who had undergone early EVT and 1,078 patients who had received delayed EVT, were included in the meta-analysis. Patients treated with early EVT showed a similar proportion of functional independence at 90 days [odds ratio (OR) = 1.14, 95% confidence interval (CI) = 0.926–1.397, P = 0.219; I2 = 36.2%, P = 0.128] as those treated with delayed EVT. Delayed EVT was also associated with no significant difference in mortality (OR = 1.015, 95% CI = 0.852–1.209; P = 0.871; I2 = 0.0%, P = 0.527), successful recanalization (OR = 1.255, 95% CI = 0.923–1.705; P = 0.147; I2 = 60.5%, P = 0.009), and sICH (OR = 0.976, 95% CI = 0.737–1.293; P = 0.871; I2 = 0.0%, P = 0.742) rates compared with early EVT. Conclusions: Among selected patients with AIS, delayed EVT showed comparable outcomes in functional independence, recanalization, mortality, and sICH rates compared with early EVT.
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Affiliation(s)
- Ye Zhongxing
- Department of Neurosurgery, Fujian Sanbo Funeng Brain Hospital, Fuzhou, China
| | - Liu Zhiqiang
- Department of Neurosurgery, Fujian Sanbo Funeng Brain Hospital, Fuzhou, China
| | - Wang Jiangjie
- Department of Neurosurgery, Linyi Central Hospital, Linyi, China
| | - Chen Qing
- Department of Pathology, Linyi Central Hospital, Linyi, China
| | - Zhang Jinfeng
- Department of Neurosurgery, Fujian Sanbo Funeng Brain Hospital, Fuzhou, China
| | - Weng Chaoqun
- Department of Neurosurgery, Fujian Sanbo Funeng Brain Hospital, Fuzhou, China
| | - Li Feng
- Department of Neurosurgery, Fujian Medical University Union Hospital, Fuzhou, China
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Ito Y, Kojima T, Sato N, Oinuma M, Horiuchi K, Ichikawa T, Oda K, Maeda T, Saito K. Results of Mechanical Thrombectomy 6 Hours after Stroke Onset: Analysis of Multiple Stroke Centers in Fukushima Prefecture. JOURNAL OF NEUROENDOVASCULAR THERAPY 2020; 15:220-227. [PMID: 37501691 PMCID: PMC10370929 DOI: 10.5797/jnet.oa.2020-0007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 08/18/2020] [Indexed: 07/29/2023]
Abstract
Objective The purpose of this study was to examine the efficacy and safety of mechanical thrombectomy in patients with acute occlusion of a large cerebral artery in the anterior circulation beyond 6 hours of the time last known to be well using the real-world clinical data collected from non-urban areas of Japan. Methods We analyzed a retrospective multicenter database collected at 10 thrombectomy capable primary stroke centers in Fukushima Prefecture. In all, 188 patients were presenting a large cerebral artery occlusion in the anterior circulation, that is, internal carotid and middle cerebral artery (M1 and M2 segment). In all, 158 patients received mechanical thrombectomy within 6 hours from symptom onset (early time window), and 30 patients exceeded 6 hours (late time window). We compared the patient background, outcomes, and safety variables between the two groups. The modified Rankin Scale (mRS) score of 0-2 at 90 days after treatment and the incidence of symptomatic intracranial hemorrhage were compared between groups to evaluate treatment efficacy and safety. Results There was no significant difference in the proportion of mRS score 0-2 at 90 days after treatment (51.3 vs. 46.7%: P = 0.644). However, symptomatic intracranial hemorrhage was more frequent in the late time window group (7.0 vs. 16.7%: P = 0.081). Symptomatic intracranial hemorrhage was a significant factor of a poor functional outcome in the late time window group (P = 0.022). Conclusion This study reflects the real-world results of mechanical thrombectomy in the non-urban areas of Japan. The treatment efficacy in the late time window patients was equivalent to that in the early time window patients. On the other hand, the incidence of symptomatic intracranial hemorrhage showed a trend to high in patients beyond 6 hours, which was a significant factor related to a poor functional outcome.
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Affiliation(s)
- Yuhei Ito
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Fukushima, Japan
| | - Takao Kojima
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Fukushima, Japan
| | - Naoki Sato
- Department of Neurosurgery, Masu Memorial Hospital, Nihonmatsu, Fukushima, Japan
| | - Masahiro Oinuma
- Department of Neurosurgery, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku Hospital, Koriyama, Fukushima, Japan
| | - Kazuomi Horiuchi
- Department of Neurosurgery, Southern Tohoku Research Institute for Neuroscience, Southern Tohoku Hospital, Koriyama, Fukushima, Japan
| | - Tsuyoshi Ichikawa
- Department of Neurosurgery, Japanese Red Cross Society Fukushima Hospital, Fukushima, Fukushima, Japan
| | - Keiko Oda
- Department of Neurosurgery, Minamisoma Municipal General Hospital, Minamisoma, Fukushima, Japan
| | - Takuya Maeda
- Department of Neurosurgery, Ohta-Nishinouchi Hospital, Koriyama, Fukushima, Japan
| | - Kiyoshi Saito
- Department of Neurosurgery, Fukushima Medical University, Fukushima, Fukushima, Japan
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Lawner BJ, Szabo K, Daly J, Foster K, McCoy P, Poliner D, Poremba M, Nawrocki PS, Rahangdale R. Challenges Related to the Implementation of an EMS-Administered, Large Vessel Occlusion Stroke Score. West J Emerg Med 2019; 21:441-448. [PMID: 32191202 PMCID: PMC7081843 DOI: 10.5811/westjem.2019.9.43127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 09/09/2019] [Indexed: 12/22/2022] Open
Abstract
Introduction There is considerable interest in triaging victims of large vessel occlusion (LVO) strokes to comprehensive stroke centers. Timely access to interventional therapy has been linked to improved stroke outcomes. Accurate triage depends upon the use of a validated screening tool in addition to several emergency medical system (EMS)-specific factors. This study examines the integration of a modified Rapid Arterial oCcclusion Evaluation (mRACE) score into an existing stroke treatment protocol. Methods We performed a retrospective review of EMS and hospital charts of patients transported to a single comprehensive stroke center. Adult patients with an EMS provider impression of “stroke/TIA,” “CVA,” or “neurological problem” were included for analysis. EMS protocols mandated the use of the Cincinnati Prehospital Stroke Score (CPSS). The novel protocol authorized the use of the mRACE score to identify candidates for triage directly to the comprehensive stroke center. We calculated specificity and sensitivity for various stroke screens (CPSS and a mRACE exam) for the detection of LVO stroke. The score’s metrics were evaluated as a surrogate marker for a successful EMS triage protocol. Results We included 312 prehospital charts in the final analysis. The CPSS score exhibited reliable sensitivity at 85%. Specificity of CPSS for an LVO was calculated at 73%. For an mRACE score of five or greater, the sensitivity was 25%. Specificity for mRACE was calculated at 75%. The positive predictive value of the mRACE score for an LVO was estimated at 12.50%. Conclusion In this retrospective study of patients triaged to a single comprehensive stroke center, the addition of an LVO-specific screening tool failed to improve accuracy. Reliable triage of LVO strokes in the prehospital setting is a challenging task. In addition to statistical performance of a particular stroke score, a successful EMS protocol should consider system-based factors such as provider education and training. Study limitations can inform future iterations of LVO triage protocols.
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Affiliation(s)
- Benjamin J Lawner
- Allegheny General Hospital, Department of Emergency Medicine, Pittsburgh, Pennsylvania.,Temple University School of Medicine, Department of Emergency Medicine, Philadelphia, Pennsylvania
| | - Kelly Szabo
- Allegheny General Hospital, Department of Emergency Medicine, Pittsburgh, Pennsylvania
| | - Jonathan Daly
- Allegheny General Hospital, Department of Emergency Medicine, Pittsburgh, Pennsylvania
| | - Krista Foster
- University of Pittsburgh, Joseph M Katz Graduate School of Business, Pittsburgh, Pennsylvania
| | - Philip McCoy
- Allegheny General Hospital, Department of Emergency Medicine, Pittsburgh, Pennsylvania
| | - David Poliner
- Penn Medicine, Division of Traumatology, Surgical Critical Care, and Emergency Surgery, Department of Surgery, Philadelphia, Pennsylvania
| | - Matthew Poremba
- Allegheny General Hospital, Department of Emergency Medicine, Pittsburgh, Pennsylvania.,Temple University School of Medicine, Department of Emergency Medicine, Philadelphia, Pennsylvania
| | - Philip S Nawrocki
- Allegheny General Hospital, Department of Emergency Medicine, Pittsburgh, Pennsylvania
| | - Rahul Rahangdale
- University of Minnesota School of Medicine, Department of Neurology, Minneapolis, Minnesota
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Adams NC, Griffin E, Motyer R, Farrell T, Carmody E, O'Shea A, Murphy B, O'Hare A, Looby S, Power S, Brennan P, Doyle KM, Thornton J. Review of external referrals to a regional stroke centre: it is not just about thrombectomy. Clin Radiol 2019; 74:950-955. [PMID: 31521325 DOI: 10.1016/j.crad.2019.07.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2018] [Accepted: 07/26/2019] [Indexed: 02/02/2023]
Abstract
AIMS To determine the experience of a regional stroke referral centre of external referrals for endovascular thrombectomy (EVT) in patients with symptoms of acute ischaemic stroke (AIS) and large vessel occlusion (LVO). MATERIALS AND METHODS Data were collected prospectively over two 4-month periods (2017-2018) on consecutive external referrals for EVT. Baseline demographics, imaging findings, and key time parameters were recorded. Reasons for not transferring patients and for not performing EVT were recorded. Key time intervals were calculated and compared between the transferred and non-transferred group with and without intracranial occlusion and between the transferred patients who underwent thrombectomy and those who did not. RESULTS Two hundred and sixty-two patients were referred. Sixty-one percent (n=159) were accepted and transferred for treatment. Of those transferred, 86% (n=136) had EVT. Fourteen percent (n=23) were unsuitable for EVT on arrival due to no vessel occlusion (48% n=11), poor Alberta Stroke Program Early CT Score (ASPECTS)/established infarct (30%, n=7) haemorrhage (9%, n=2), and clinical recovery (13% n=3). One hundred and three patients (39%) were ineligible for EVT following phone discussion due to absence of intracranial occlusion (59%, n=61), low ASPECTS (22%, n=23), distal occlusion (4%, n=4), low/improving National Institutes of Health Stroke Scale (NIHSS; 10.7%, n=11), and poor modified Rankin Scale (mRS) at baseline (3%, n=3). Patients with LVO but not transferred had longer onset to hospital arrival time compared with those transferred 151.5 versus 91 minutes (p<0.005), with a trend also toward a longer door to CT/CTA 40 minutes versus 30 minutes (p=0.142). CONCLUSION These data provide valuable insights into the service provision of a comprehensive stroke network. The present rates of EVT and futile transfers are modest compared to published data. Access to neuroradiology and specialised stroke assessment is crucial to optimise time to treatment.
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Affiliation(s)
- N C Adams
- Interventional Neuroradiology Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland.
| | - E Griffin
- Interventional Neuroradiology Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - R Motyer
- Department of Radiology, Tallaght Hospital, Tallaght, Dublin 24, Ireland
| | - T Farrell
- Interventional Neuroradiology Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - E Carmody
- Interventional Neuroradiology Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - A O'Shea
- Interventional Neuroradiology Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - B Murphy
- Interventional Neuroradiology Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - A O'Hare
- Interventional Neuroradiology Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - S Looby
- Interventional Neuroradiology Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - S Power
- Interventional Neuroradiology Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - P Brennan
- Interventional Neuroradiology Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland
| | - K M Doyle
- Department of Physiology, School of Medicine, National University of Ireland, Galway, Ireland
| | - J Thornton
- Interventional Neuroradiology Service, Department of Radiology, Beaumont Hospital, Dublin, Ireland; Honorary Clinical Associate Professor, Royal College of Surgeons, 123 St Stephens Green, Dublin, Ireland
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Glynn RW, Teljeur C, Harbison J, Williams DJ, Harrington P, Ryan M. A systematic review of the clinical effectiveness of emergency endovascular therapy using mechanical thrombectomy in acute ischaemic stroke: implications for service delivery. Ir J Med Sci 2018; 188:689-698. [PMID: 30218291 DOI: 10.1007/s11845-018-1899-6] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2018] [Accepted: 09/05/2018] [Indexed: 11/29/2022]
Abstract
BACKGROUND Twelve randomised controlled trials (RCTs) comparing mechanical thrombectomy against traditional treatment options for patients experiencing acute ischaemic stroke (AIS) have been published. AIMS To evaluate whether this technology is more effective and/or safer than traditional treatment options and to assess the potential for implementation of this technology as a treatment strategy for acute ischaemic stroke in Ireland. METHODS RCTs published up to February 2017 were included. Meta-analysis was performed for two primary (mortality at 90 days, mRS at 90 days) and four secondary outcomes. Cumulative meta-analysis was used to investigate the point at which a consistent treatment effect was observed for outcomes that had a statistically significant pooled effect. RESULTS Mechanical thrombectomy was associated with higher likelihood of being independent (mRS, p < 0.01; Barthel index, p < 0.01) at 90 days post-AIS (p < 0.001). Cumulative meta-analysis demonstrated a consistent treatment effect in favour of mechanical thrombectomy after each trial was added to the analysis. There was no evidence of a difference in mortality rates (p = 0.21) or rates of SICH (p = 0.71) between patients randomised to intervention and control arms. Although the intervention appears to be associated with higher rates of any cerebral haemorrhage (p < 0.01) and recurrent ischaemic stroke (p = 0.03), considerable uncertainty remains as to these treatment effects. CONCLUSIONS The trials published most recently have acted as a 'watershed' for mechanical thrombectomy, and while there are significant caveats, the data suggests that mechanical thrombectomy needs to be factored into the planning and delivery of services for the management of patients with acute ischaemic stroke in Ireland.
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Affiliation(s)
- Ronan W Glynn
- Health Technology Assessment Directorate, Health Information and Quality Authority, George's Court, Dublin 7, Ireland.
| | - Conor Teljeur
- Health Technology Assessment Directorate, Health Information and Quality Authority, George's Court, Dublin 7, Ireland
| | | | - David J Williams
- Geriatric Medicine, Royal College of Surgeons in Ireland (RCSI) and Beaumont Hospital, Dublin, Ireland
| | - Patricia Harrington
- Health Technology Assessment Directorate, Health Information and Quality Authority, George's Court, Dublin 7, Ireland
| | - Mairin Ryan
- Health Technology Assessment Directorate, Health Information and Quality Authority, George's Court, Dublin 7, Ireland
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Motyer R, Thornton J, Power S, Brennan P, O’Hare A, Looby S, Williams DJ, Moynihan B, Murphy S. Endovascular thrombectomy beyond 12 hours of stroke onset: a stroke network’s experience of late intervention. J Neurointerv Surg 2018; 10:1043-1046. [DOI: 10.1136/neurintsurg-2017-013575] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2017] [Revised: 01/29/2018] [Accepted: 02/02/2018] [Indexed: 11/04/2022]
Abstract
BackgroundSelected patients with proximal anterior circulation ischemic stroke who demonstrate limited infarct and sufficient penumbra may benefit from endovascular thrombectomy (EVT) beyond conventional time limits.ObjectiveTo perform a retrospective review of all cases of EVT performed at our institution for proximal anterior circulation acute ischemic stroke with onset >12 hours.Materials and methodsPatients were assessed with non-contrast CT brain and multiphase CT angiography, with Alberta Stroke Program Early CT Score (ASPECTS) and collateral grade informing patient selection. Data, including patient demographics, workflow, neuroimaging findings, procedural details, recanalization rates, and 90-day functional outcomes, were collected.ResultsOf the 542 consecutive endovascular thrombectomy cases performed during the study period, 25 (4.6%) were >12 hours from stroke onset. Median age was 69 years (IQR 55–80), median National Institute of Health Stroke Scale score on presentation was 14 (IQR 11–18.5), median ASPECTS was 8 (IQR 8–9), and rate of moderate–good collateral status was 96% (n=24). Median time to groin puncture was 14 hours 40 min (IQR 12 hours 36 min – 16 hours 18 min). Rate of successful recanalization (modified Thrombolysis in Cerebral infarction 2b–3) was 88% (n=22). Rate of functional independence (90-day modified Rankin Scale score 0–2) was 52% (n=13). There were no cases of symptomatic intracranial haemorrhage and 90-day mortality rate was 12% (n=3).ConclusionWith the use of ASPECTS and collateral grade to guide patient selection, good functional outcome with acceptable safety parameters may be achieved in patients undergoing EVT beyond 12 hours from stroke onset.
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Bai W, Li W, Ning YL, Li P, Zhao Y, Yang N, Jiang YL, Liang ZP, Jiang DP, Wang Y, Zhang M, Zhou YG. Blood Glutamate Levels Are Closely Related to Acute Lung Injury and Prognosis after Stroke. Front Neurol 2018; 8:755. [PMID: 29403427 PMCID: PMC5785722 DOI: 10.3389/fneur.2017.00755] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2017] [Accepted: 12/29/2017] [Indexed: 11/13/2022] Open
Abstract
Background Acute lung injury (ALI) is a serious complication of stroke that occurs with a high incidence. Our preclinical results indicated that ALI might be related to blood glutamate levels after brain injury. The purpose of this study was to assess dynamic changes in blood glutamate levels in patients with stroke and to determine the correlation between blood glutamate levels, ALI, and long-term prognosis after stroke. Methods Venous blood samples were collected from controls and patients with stroke at admission and on the third and seventh day after the onset of stroke. Patients were followed for 3 months. The correlations among blood glutamate levels, severities of stroke and ALI, and long-term outcomes were analyzed, and the predictive values of blood glutamate levels and severity scores for ALI were assessed. Results In this study, a total of 384 patients with stroke were enrolled, with a median age of 59 years. Patients showed significantly increased blood glutamate levels within 7 days of stroke onset (p < 0.05), and patients with more severe injuries showed higher blood glutamate levels. Moreover, blood glutamate levels were closely related to the occurrence (adjusted odds ratio, 3.022, p = 0.003) and severity (p < 0.001) of ALI and the long-term prognosis after stroke (p < 0.05), and they were a more accurate predictor of ALI than the more commonly used severity scores (p < 0.01). Conclusion These results indicated that an increased blood glutamate level was closely related to the development of ALI and a poor prognosis after stroke. Clinical Trial Registration http://www.chictr.org.cn, identifier ChiCTR-RPC-15006770.
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Affiliation(s)
- Wei Bai
- Molecular Biology Center, State Key Laboratory of Trauma, Burn, and Combined Injury, Research Institute of Surgery and Daping Hospital, Third Military Medical University, Chongqing, China
| | - Wei Li
- Department of Neurology, Research Institute of Surgery and Daping Hospital, Third Military Medical University, Chongqing, China
| | - Ya-Lei Ning
- Molecular Biology Center, State Key Laboratory of Trauma, Burn, and Combined Injury, Research Institute of Surgery and Daping Hospital, Third Military Medical University, Chongqing, China
| | - Ping Li
- Molecular Biology Center, State Key Laboratory of Trauma, Burn, and Combined Injury, Research Institute of Surgery and Daping Hospital, Third Military Medical University, Chongqing, China
| | - Yan Zhao
- Molecular Biology Center, State Key Laboratory of Trauma, Burn, and Combined Injury, Research Institute of Surgery and Daping Hospital, Third Military Medical University, Chongqing, China
| | - Nan Yang
- Molecular Biology Center, State Key Laboratory of Trauma, Burn, and Combined Injury, Research Institute of Surgery and Daping Hospital, Third Military Medical University, Chongqing, China
| | - Yu-Lin Jiang
- Molecular Biology Center, State Key Laboratory of Trauma, Burn, and Combined Injury, Research Institute of Surgery and Daping Hospital, Third Military Medical University, Chongqing, China
| | - Ze-Ping Liang
- Department of ICU, Research Institute of Surgery and Daping Hospital, Third Military Medical University, Chongqing, China
| | - Dong-Po Jiang
- Department of ICU, Research Institute of Surgery and Daping Hospital, Third Military Medical University, Chongqing, China
| | - Ying Wang
- Department of Neurology, Research Institute of Surgery and Daping Hospital, Third Military Medical University, Chongqing, China
| | - Meng Zhang
- Department of Neurology, Research Institute of Surgery and Daping Hospital, Third Military Medical University, Chongqing, China
| | - Yuan-Guo Zhou
- Molecular Biology Center, State Key Laboratory of Trauma, Burn, and Combined Injury, Research Institute of Surgery and Daping Hospital, Third Military Medical University, Chongqing, China
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