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Tanaka T, Kumono T, Itokawa H, Matsuno A. Early Detection of Hyperdense Basilar Artery Signs Through Comparison With Previous Images. Cureus 2024; 16:e66135. [PMID: 39229403 PMCID: PMC11370986 DOI: 10.7759/cureus.66135] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/04/2024] [Indexed: 09/05/2024] Open
Abstract
The presence of the hyperdense basilar artery (HDBA) sign, which indicates basilar artery occlusion (BAO), plays an important role in the early diagnosis and intervention in patients with acute ischemic stroke. However, qualitative and quantitative assessment of the HDBA sign is challenging. This case report describes a 60-year-old woman with a history of diabetes mellitus, hypertension, and cerebral infarction. She developed progressive loss of consciousness and ataxic respiration. A noncontrast-enhanced head computed tomography (CT) scan performed three hours after symptom onset revealed the HDBA sign compared with previously obtained CT images. Quantitative measurements revealed a significant increase in Hounsfield units (HUs) in the basilar artery. Subsequent three-dimensional CT angiography confirmed the occlusion of the vertebrobasilar artery. This case highlights the importance of comparing current and previous imaging findings in detecting the HDBA sign. Quantitative HU measurements may further aid diagnosis. Early detection of the HDBA sign on noncontrast-enhanced head CT is critical for expediting the diagnosis and treatment of BAO.
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Affiliation(s)
- Tatsuya Tanaka
- Department of Neurosurgery, International University of Health and Welfare, Narita Hospital, Narita, JPN
| | - Takahiro Kumono
- Department of Neurosurgery, International University of Health and Welfare, Narita Hospital, Narita, JPN
| | - Hiroshi Itokawa
- Department of Neurosurgery, International University of Health and Welfare, Narita Hospital, Narita, JPN
| | - Akira Matsuno
- Department of Neurosurgery, International University of Health and Welfare, Narita Hospital, Narita, JPN
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Räty S, Virtanen P, Ritvonen J, Georgiopoulos G, Sairanen T, Lindsberg PJ, Strbian D. IV Thrombolysis in Basilar Artery Occlusion: Outcomes and Comparison With Endovascular Thrombectomy. Neurology 2024; 102:e209249. [PMID: 38531004 DOI: 10.1212/wnl.0000000000209249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 01/08/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Recanalization is considered a prerequisite for favorable outcome in basilar artery occlusion (BAO). Intravenous thrombolysis (IVT) has been successfully used for eligible patients with BAO well beyond the 4.5-hour time window but has been largely underrepresented in the best medical management arms in recent randomized controlled trials of recanalization therapy in BAO. We aimed to analyze the outcomes of patients with BAO treated with IVT only and to compare IVT with endovascular thrombectomy (EVT). METHODS This observational single-center, retrospective cohort study included consecutive patients with BAO treated with IVT and/or EVT up to 48 hours of symptom onset during 1995-2022. The primary outcome was favorable functional outcome (modified Rankin Scale 0-3) at 3 months collected by a stroke physician by phone. In the first part, we described the outcomes and factors associated with functional outcome in the IVT-only cohort during 1995-2022. In the second part, we used doubly robust inverse probability-weighted regression adjustment models to compare functional outcome of patients treated with IVT vs EVT+/-IVT during 2010-2022. RESULTS In the whole cohort of 376 patients with acute BAO treated with recanalization therapy, 245 (65.2%) received only IVT. In the IVT-only cohort, most patients had moderate-to-severe clinical presentation (median NIH Stroke Scale 18) but no extensive early ischemic changes in the posterior circulation on admission. Half of them had onset-to-treatment time over 6 hours. 46.5% of the IVT-treated patients achieved 3-month favorable functional outcome, whereas mortality was 35.9%. sICH occurred in 11.1%. In a multivariable analysis, younger age, milder symptom severity, and less baseline ischemic changes predicted favorable functional outcome. In the 2010-2022 cohort, when compared with patients treated with EVT+/-IVT (n = 121), the IVT-only cohort (n = 122) had higher odds for favorable functional outcome (IVT 58.2% vs EVT 43.0% (aOR 2.82 [95% CI 1.31-6.05]). DISCUSSION IVT alone produced outcomes comparable with those in recent trials of endovascular BAO recanalization. Furthermore, in head-to-head comparison in our cohort, the IVT-only approach was more often associated with favorable outcome than EVT+/-IVT. Thus, it should not be overlooked as the first-line recanalization therapy in acute BAO, even in longer time windows. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that tPA is as effective as thrombectomy for basilar artery thrombosis.
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Affiliation(s)
- Silja Räty
- From the Departments of Neurology (S.R., J.R., T.S., P.J.L., D.S.) and Radiology (P.V.), Helsinki University Hospital and University of Helsinki, Finland; Department of Clinical Therapeutics (G.G.), National and Kapodistrian University of Athens, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College London; and Institute of Cardiovascular Science (G.G.), University College London, United Kingdom
| | - Pekka Virtanen
- From the Departments of Neurology (S.R., J.R., T.S., P.J.L., D.S.) and Radiology (P.V.), Helsinki University Hospital and University of Helsinki, Finland; Department of Clinical Therapeutics (G.G.), National and Kapodistrian University of Athens, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College London; and Institute of Cardiovascular Science (G.G.), University College London, United Kingdom
| | - Juhani Ritvonen
- From the Departments of Neurology (S.R., J.R., T.S., P.J.L., D.S.) and Radiology (P.V.), Helsinki University Hospital and University of Helsinki, Finland; Department of Clinical Therapeutics (G.G.), National and Kapodistrian University of Athens, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College London; and Institute of Cardiovascular Science (G.G.), University College London, United Kingdom
| | - Georgios Georgiopoulos
- From the Departments of Neurology (S.R., J.R., T.S., P.J.L., D.S.) and Radiology (P.V.), Helsinki University Hospital and University of Helsinki, Finland; Department of Clinical Therapeutics (G.G.), National and Kapodistrian University of Athens, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College London; and Institute of Cardiovascular Science (G.G.), University College London, United Kingdom
| | - Tiina Sairanen
- From the Departments of Neurology (S.R., J.R., T.S., P.J.L., D.S.) and Radiology (P.V.), Helsinki University Hospital and University of Helsinki, Finland; Department of Clinical Therapeutics (G.G.), National and Kapodistrian University of Athens, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College London; and Institute of Cardiovascular Science (G.G.), University College London, United Kingdom
| | - Perttu J Lindsberg
- From the Departments of Neurology (S.R., J.R., T.S., P.J.L., D.S.) and Radiology (P.V.), Helsinki University Hospital and University of Helsinki, Finland; Department of Clinical Therapeutics (G.G.), National and Kapodistrian University of Athens, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College London; and Institute of Cardiovascular Science (G.G.), University College London, United Kingdom
| | - Daniel Strbian
- From the Departments of Neurology (S.R., J.R., T.S., P.J.L., D.S.) and Radiology (P.V.), Helsinki University Hospital and University of Helsinki, Finland; Department of Clinical Therapeutics (G.G.), National and Kapodistrian University of Athens, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College London; and Institute of Cardiovascular Science (G.G.), University College London, United Kingdom
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Lima FO, Rocha FA, Silva HC, Puetz V, Dippel D, van den Wijngaard I, Majoie C, Yoo AJ, van Zwam W, de Lucena AF, Bandeira DDA, Arndt M, Barlinn K, Gerber JC, Langezaal LCM, Schonewille WJ, Pontes Neto OM, Dias FA, Martins SO, Mont’Alverne FJDA. Posterior circulation collaterals as predictors of outcome in basilar artery occlusion: a sub-analysis of the BASICS randomized trial. Front Neurol 2024; 15:1360335. [PMID: 38606280 PMCID: PMC11007200 DOI: 10.3389/fneur.2024.1360335] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Accepted: 03/13/2024] [Indexed: 04/13/2024] Open
Abstract
Introduction and purpose Basilar artery occlusion (BAO) is still one of the most devastating neurological conditions associated with high morbidity and mortality. In the present study, we aimed to assess the role of posterior circulation collaterals as predictors of outcome in the BASICS trial and to compare two grading systems (BATMAN score and PC-CS) in terms of prognostic value. Methods We performed a sub-analysis of the BASICS trial. Baseline clinical and imaging variables were analyzed. For the imaging analysis, baseline CT and CTA were analyzed by a central core lab. Only those patients with good or moderate quality of baseline CTA and with confirmed BAO were included. Multivariable binary logistic regression analysis was used to test the independent association of clinical and imaging characteristics with a favorable outcome at 3 months (defined as a modified Rankin Score of ≤3). ROC curve analysis was used to assess and compare accuracy between the two collateral grading systems. Results The mean age was 67.0 (±12.5) years, 196 (65.3%) patients were males and the median NIHSS was 21.5 (IQR 11-35). Median NCCT pc-ASPECTS was 10 (IQR10-10) and median collateral scores for BATMAN and PC-CS were 8 (IQR 7-9) and 7 (IQR 6-8) respectively. Collateral scores were associated with favorable outcome at 3 months for both BATMAN and PC-CS but only with a modest accuracy on ROC curve analysis (AUC 0.62, 95% CI [0.55-0.69] and 0.67, 95% CI [0.60-0.74] respectively). Age (OR 0.97, 95% CI [0.95-1.00]), NIHSS (OR 0.91, 95% CI [0.89-0.94]) and collateral score (PC-CS - OR 1.2495% CI [1.02-1.51]) were independently associated with clinical outcome. Conclusion The two collateral grading systems presented modest prognostic accuracy. Only the PC-CS was independently associated with a favorable outcome at 3 months.
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Affiliation(s)
- Fabricio O. Lima
- Neurology Service, Hospital Geral de Fortaleza, Fortaleza, Brazil
| | - Felipe A. Rocha
- Neurointerventional Service, Hospital Geral de Fortaleza, Fortaleza, Brazil
| | - Henrique C. Silva
- Neurointerventional Service, Hospital Geral de Fortaleza, Fortaleza, Brazil
| | - Volker Puetz
- Department of Neurology, Technical University Dresden, Dresden, Germany
- Dresden Neurovascular Center, Technical University Dresden, Dresden, Germany
| | - Diederik Dippel
- Erasmus MC University Medical Center, Rotterdam, Netherlands
| | | | | | | | - Wim van Zwam
- Interventional Radiology Department, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Adson F. de Lucena
- Neurointerventional Service, Hospital Geral de Fortaleza, Fortaleza, Brazil
| | | | - Martin Arndt
- Department of Neurology, Technical University Dresden, Dresden, Germany
- Dresden Neurovascular Center, Technical University Dresden, Dresden, Germany
| | - Kristian Barlinn
- Department of Neurology, Technical University Dresden, Dresden, Germany
- Dresden Neurovascular Center, Technical University Dresden, Dresden, Germany
| | - Johannes C. Gerber
- Dresden Neurovascular Center, Technical University Dresden, Dresden, Germany
- Institute of Neuroradiology, Dresden Neurovascular Center, Universitätsklinik Dresden, Dresden, Germany
| | | | | | - Octávio M. Pontes Neto
- Stroke Service, Neurology Division, Department of Neurosciences and Behavioral Sciences, Ribeirão Preto School of Medicine, University of São Paulo, Ribeirao Preto, Brazil
| | - Francisco Antunes Dias
- Stroke Service, Neurology Division, Department of Neurosciences and Behavioral Sciences, Ribeirão Preto School of Medicine, University of São Paulo, Ribeirao Preto, Brazil
| | - Sheila Ouriques Martins
- Department of Neurology, Hospital de Clinicas de Porto Alegre, Federal University of Rio Grande do Sul, Porto Alegre, Brazil
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Räty S, Nguyen TN, Nagel S, Puetz V, Alemseged F, Abdalkader M, Schonewille WJ, Strbian D. What Is the Evidence for Endovascular Thrombectomy in Posterior Circulation Stroke? Semin Neurol 2023; 43:345-355. [PMID: 37595603 DOI: 10.1055/s-0043-1771210] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Abstract
Posterior circulation infarcts comprise approximately 25% of ischemic strokes but are less often treated with recanalization therapy and have longer treatment delays compared with anterior circulation strokes. Among posterior circulation strokes, basilar artery occlusion is associated with the most severe deficits and the worst prognosis. Endovascular thrombectomy is a standard of care for patients with anterior circulation large vessel occlusion, but not until recently were the first randomized controlled trials on endovascular thrombectomy in basilar artery occlusion published. Two of the trials were neutral, whereas two others showed better functional outcome after thrombectomy up to 24 hours of symptom onset compared with best medical treatment, which in most cases had low rates of intravenous thrombolysis. According to observational data, thrombectomy seems to be safe also in isolated posterior cerebral artery occlusions and might be an option for selected patients, even if its outcome benefit is yet to be demonstrated.
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Affiliation(s)
- Silja Räty
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Simon Nagel
- Department of Neurology, Klinikum Ludwigshafen, Ludwigshafen/Rhein, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Volker Puetz
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Dresden Neurovascular Center, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Fana Alemseged
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Mohamad Abdalkader
- Department of Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | | | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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5
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Feil K, Berndt MT, Wunderlich S, Maegerlein C, Bernkopf K, Zimmermann H, Herzberg M, Tiedt S, Küpper C, Wischmann J, Schönecker S, Dimitriadis K, Liebig T, Dieterich M, Zimmer C, Kellert L, Boeckh-Behrens T, Boeckh-Behrens T, Wunderlich S, Ludolph A, Henn KH, Reich A, Nikoubashman O, Wiesmann M, Ernemann U, Poli S, Nolte CH, Siebert E, Zweynert S, Bohner G, Solymosi L, Petzold G, Pfeilschifter W, Keil F, Röther J, Eckert B, Berrouschot J, Bormann A, Alegiani A, Fiehler J, Gerloff C, Thomalla G, Thonke S, Bangard C, Kraemer C, Dichgans M, Psychogios M, Liman J, Petersen M, Stögbauer F, Kraft P, Pham M, Braun M, Hamann GF, Roth C, Gröschel K, Uphaus T, Limmroth V. Endovascular thrombectomy for basilar artery occlusion stroke: Analysis of the German Stroke Registry-Endovascular Treatment. Eur J Neurol 2023; 30:1293-1302. [PMID: 36692229 DOI: 10.1111/ene.15694] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Revised: 01/05/2023] [Accepted: 01/09/2023] [Indexed: 01/25/2023]
Abstract
BACKGROUND AND PURPOSE Acute ischemic stroke due to basilar artery occlusion (BAO) causes the most severe strokes and has a poor prognosis. Data regarding efficacy of endovascular thrombectomy in BAO are sparse. Therefore, in this study, we performed an analysis of the therapy of patients with BAO in routine clinical practice. METHODS Patients enrolled between June 2015 and December 2019 in the German Stroke Registry-Endovascular Treatment (GSR-ET) were analyzed. Primary outcomes were successful reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] score of 2b-3), substantial neurological improvement (≥8-point National Institute of Health Stroke Scale [NIHSS] score reduction from admission to discharge or NIHSS score at discharge ≤1), and good functional outcome at 3 months (modified Rankin Scale [mRS] score of 0-2). RESULTS Out of 6635 GSR-ET patients, 640 (9.6%) patients (age 72.2 ± 13.3, 43.3% female) experienced BAO (median [interquartile range] NIHSS score 17 [8, 27]). Successful reperfusion was achieved in 88.4%. Substantial neurological improvement at discharge was reached by 45.5%. At 3-month follow-up, good clinical outcome was observed in 31.1% of patients and the mortality rate was 39.2%. Analysis of mTICI3 versus mTICI2b groups showed considerable better outcome in those with mTICI3 (38.9% vs. 24.4%; p = 0.005). The strongest predictors of good functional outcome were intravenous thrombolysis (IVT) treatment (odds ratio [OR] 3.04, 95% confidence interval [CI] 1.76-5.23) and successful reperfusion (OR 4.92, 95% CI 1.15-21.11), while the effect of time between symptom onset and reperfusion seemed to be small. CONCLUSIONS Acute reperfusion strategies in BAO are common in daily practice and can achieve good rates of successful reperfusion, neurological improvement and good functional outcome. Our data suggest that, in addition to IVT treatment, successful and, in particular, complete reperfusion (mTICI3) strongly predicts good outcome, while time from symptom onset seemed to have a lower impact.
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Affiliation(s)
- Katharina Feil
- Department of Neurology, Ludwig Maximilians Universität (LMU), Munich, Germany.,Department of Neurology and Stroke, Eberhard-Karls University Tübingen/Universitätsklinikum Tübingen (UKT), Tübingen, Germany
| | - Maria Teresa Berndt
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Silke Wunderlich
- Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Kathleen Bernkopf
- Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | | | - Moriz Herzberg
- Institute of Neuroradiology, LMU, Munich, Germany.,Department of Radiology, University Hospital, Würzburg, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany
| | - Clemens Küpper
- Department of Neurology, Ludwig Maximilians Universität (LMU), Munich, Germany
| | - Johannes Wischmann
- Department of Neurology, Ludwig Maximilians Universität (LMU), Munich, Germany
| | - Sonja Schönecker
- Department of Neurology, Ludwig Maximilians Universität (LMU), Munich, Germany
| | - Konstantin Dimitriadis
- Institute for Stroke and Dementia Research (ISD), University Hospital, LMU Munich, Munich, Germany
| | | | - Marianne Dieterich
- Department of Neurology, Ludwig Maximilians Universität (LMU), Munich, Germany.,Munich Cluster for Systems Neurology (SyNergy), Munich, Germany.,German Center for Vertigo and Balance Disorders, LMU, Munich, Germany
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Lars Kellert
- Department of Neurology, Ludwig Maximilians Universität (LMU), Munich, Germany
| | - Tobias Boeckh-Behrens
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
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6
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Hu J, He W, Zheng B, Huang F, Lv K, Liao J, Chen Z, Jiang H, Wang K, Wang H, Lei Y, Liao J, Sang H, Liu S, Luo W, Sun R, Yang J, Huang J, Song J, Li F, Zi W, Long C, Yang Q. Hyperdense Artery Sign and Clinical Outcomes After Endovascular Treatment in Acute Basilar Artery Occlusion. Front Neurol 2022; 13:830705. [PMID: 35547375 PMCID: PMC9081764 DOI: 10.3389/fneur.2022.830705] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2021] [Accepted: 03/23/2022] [Indexed: 11/13/2022] Open
Abstract
Background This study aimed to investigate the association between the hyperdense basilar artery sign (HBAS) on non-enhanced computed tomography (CT) and clinical outcomes in patients with acute basilar artery occlusion (BAO) who underwent endovascular treatment (EVT). Methods Eligible patients who underwent EVT due to acute BAO between January 2014 and May 2019 were divided into two groups based on HBAS. HBAS was assessed by two neuroradiologists using five grades on nonenhanced CT. The primary outcome was a favorable functional outcome (defined as a modified Rankin Scale [mRS] of 0-3) at 90 days. Secondary outcomes included successful recanalization and mortality within 90 days. Results Among 829 patients with BAO as assessed with CT angiography, magnetic resonance angiography, or digital subtraction angiography, 643 patients were treated with EVT. Of these, 51.32% (330/643) had HBAS. Patients with HBAS were older and had more severe neurological deficits and a higher frequency of atrial fibrillation than those without HBAS. There was no significant difference in favorable outcome (adjusted odds ratio [aOR]: 1.354, 95% confidence interval [CI]: 0.906-2.024; p = 0.14), successful recanalization (aOR: 0.926, 95% CI: 0.616--1.393; p = 0.71), and mortality (aOR: 1.193, 95% CI: 0.839-1.695; p = 0.33) between patients with or without HBAS. Subgroup analysis showed that the HBAS predicted a favorable outcome in patients aged <60 years (aOR: 2.574, 95% CI: 1.234-5.368; p = 0.01) and patients with vertebral artery-V4 segment occlusion (aOR: 3.738, 95% CI: 1.212-11.530; p = 0.02). In patients with HBAS, the baseline National Institutes of Health Stroke Scale (NIHSS) score, posterior circulation-Acute Stroke Prognosis Early Computed Tomography Score (pc-ASPECTS), and stent retriever were associated with successful recanalization. Conclusions Our study did not find a significant association between HBAS and favorable outcomes and successful recanalization in patients with BAO who underwent EVT. Moreover, large prospective studies are warranted to further investigate this relationship.
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Affiliation(s)
- Jinrong Hu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Wencheng He
- Department of Neurology, Guiping People's Hospital, Guiping, China
| | - Bo Zheng
- Department of Neurology, Yaan Peoples's Hospital, Yaan, China
| | - Fang Huang
- Department of Neurology, People's Hospital of Yuxi City, Yuxi, China
| | - Kefeng Lv
- Department of Neurology, Dongguan People's Hospital of Southern Medical University, Dongguan, China
| | - Jiasheng Liao
- Department of Neurology, Suining No.1 People's Hospital, Suining, China
| | - Zhao Chen
- Department of Neurology, Yaan Peoples's Hospital, Yaan, China
| | - He Jiang
- Department of Neurology, The First People's Hospital of Neijiang, Neijiang, China
| | - Kuiyun Wang
- Department of Neurology, The Jintang First People's Hospital, Jintang, China
| | - Hongjun Wang
- Department of Neurology, Fengdu People's Hospital, Fengdu, China
| | - Yang Lei
- Department of Neurology, Wulong District People's Hospital, Chongqing, China
| | - Jiachuan Liao
- Department of Neurology, Santai County People's Hospital of North Sichuan Medical College, Santai, China
| | - Hongfei Sang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Shuai Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Weidong Luo
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Ruidi Sun
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jie Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jiacheng Huang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Jiaxing Song
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Fengli Li
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Wenjie Zi
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Chen Long
- Department of Emergency, Xiangtan Central Hospital, Chongqing, China
| | - Qingwu Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
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7
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Jahan R, Saver JL. Endovascular Treatment of Acute Ischemic Stroke. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00067-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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8
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Focal brainstem infarction in the adult rat. Lab Anim (NY) 2021; 50:97-107. [PMID: 33564191 DOI: 10.1038/s41684-021-00722-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2020] [Accepted: 01/12/2021] [Indexed: 11/08/2022]
Abstract
Animal models are required to study the pathogenesis of brainstem ischemia and to develop new therapeutic approaches to promote functional recovery after ischemia in humans. Few models of brainstem ischemia are available, and they show great variability or cause early lethality. New, reliable animal models are therefore needed. By selectively ligating four points of the lower basilar artery, we developed a new focal basilar artery occlusion model that causes a localized brainstem ischemic lesion in female Sprague-Dawley rats. Analysis of ischemic lesion volume and neurological deficits over a period of 28 d showed that the rats present symptoms specific to this type of stroke while the ischemic lesion remains relatively unchanged over time. This procedure allows higher survival rates and extended observation periods compared with other models of brainstem ischemia. The procedure takes ~40 min, can be performed by researchers with basic surgical skills and does not require specialized surgical equipment. This protocol is highly reliable and will be useful to evaluate new therapeutic approaches to promote functional recovery in patients with brainstem ischemia.
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Abstract
Basilar artery occlusion is a relatively uncommon but neurologically devastating condition. If revascularization is not achieved, the potential for death and disability is substantial. During the last several years, there have been positive endovascular stroke trials for the treatment of large vessel occlusion; however, all of them excluded patients with basilar artery occlusion. The current treatment of basilar artery occlusion is still founded on small observational studies or meta-analyses. As case selection for revascularization and treatment protocols often vary widely across institutions, sample sizes remain limited. In this article, we aim to review some of the larger observational studies in stroke due to basilar artery occlusion, considering potential treatment strategies and resultant outcomes.
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Affiliation(s)
- Zuolu Liu
- Department of Neurology and UCLA Stroke Center, University of California, Los Angeles, Los Angeles, California
| | - David S Liebeskind
- Department of Neurology and UCLA Stroke Center, University of California, Los Angeles, Los Angeles, California.,Neurovascular Imaging Research Core, University of California, Los Angeles, Los Angeles, California
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10
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Zhong X, Tong X, Sun X, Gao F, Mo D, Wang Y, Miao Z. Early Neurological Deterioration Despite Recanalization in Basilar Artery Occlusion Treated by Endovascular Therapy. Front Neurol 2020; 11:592003. [PMID: 33329341 PMCID: PMC7710936 DOI: 10.3389/fneur.2020.592003] [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: 08/06/2020] [Accepted: 10/15/2020] [Indexed: 12/12/2022] Open
Abstract
Background: We aim to identify the risk factors of early neurological deterioration (END) despite successful recanalization and explore the association of END with 90-day outcomes in acute basilar artery occlusion (BAO) treated by endovascular therapy (EVT). Methods: A prospectively registered consecutive cohort of BAO patients with successful recanalization by EVT in a tertiary stroke center during a 6-year period was reviewed. END was defined as an National Institutes of Health Stroke Scale (NIHSS) score increase ≥4 points, or death, from baseline to 24 h after EVT. Multivariate logistic regression analysis was used to identify the risk factors of END. The 90-day outcomes between END and non-END groups were compared by Pearson's χ2 test. Results: END was observed in 21 of 148 patients included in this study. Multivariate logistic regression analysis showed that patients with progressive or fluctuating symptoms had a higher risk of END than those with symptoms of acute attack (OR 5.52, 95% CI 1.73–17.63), and NIHSS score and puncture-to-recanalization time (PTR), as continuous variables, were also significantly associated with END. Using a generalized additive model with spline smoothing function, we observed a linear relationship between PTR (increased by 1 h) and END (OR 2.57, 95% CI 1.45–4.57), and a non-linear relationship between NIHSS score and END. Only when the NIHSS score was ≥23 points was it related to END (OR 0.7, 95% CI 0.6–0.9). In addition, patients with END had a lower proportion of 90-day favorable outcome (19.0 vs. 59.1%, p < 0.01) and higher mortality (33.3 vs. 13.4%, p = 0.048) than those with non-END. Conclusion: Mode of stroke onset, NIHSS score, and PTR may help to identify BAO patients with a higher risk of END after EVT. Moreover, END may affect the 90-day outcomes of these patients.
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Affiliation(s)
- Xi Zhong
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Peking University Shougang Hospital, Beijing, China
| | - Xu Tong
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,Department of Neurology, Tangshan Gongren Hospital, Hebei Medical University, Tangshan, China
| | - Xuan Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Center of Stroke, Beijing Institute for Brain Disorders, Beijing, China
| | - Zhongrong Miao
- Department of Neurology, Peking University Shougang Hospital, Beijing, China
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11
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Deguchi I, Osada T, Kimura H, Hayashi T, Takahashi S, Takao M. Clinical outcomes of mechanical thrombectomy following intravenous administration of recombinant tissue-type plasminogen activator for basilar artery occlusion. Clin Neurol Neurosurg 2020; 194:105796. [PMID: 32247170 DOI: 10.1016/j.clineuro.2020.105796] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2019] [Revised: 01/19/2020] [Accepted: 03/17/2020] [Indexed: 11/26/2022]
Abstract
OBJECTIVE Mechanical thrombectomy (MT) following intravenous administration of recombinant tissue-type plasminogen activator (IV-rt-PA) is considered an effective treatment for the occlusion of the internal carotid artery or the M1 segment of the middle cerebral artery. However, its efficacy in treating basilar artery (BA) occlusion is still unclear. In order to evaluate the efficacy of MT in treating BA occlusion, we aimed to analyzed the clinical outcomes of those patients who had undergone MT following IV-rt-PA administration. PATIENTS AND METHODS We retrospectively analyzed the clinical outcomes of 11 patients with BA occlusion who had undergone MT following IV-rt-PA administration between January 1, 2015, and March 31, 2019. RESULTS The patients consisted of 8 men and 3 women. The mean (±standard deviation) age was 73 ± 9.4 years. Stroke subtypes were found to be atherothrombosis in 2 patients, cardiogenic embolism in 6, arterial dissection in 1, and an unknown cause in 2. The median pretreatment scores were 9 on the Glasgow Coma Scale (GCS) and 25 on the National Institutes of Health Stroke Scale. The time elapsed from onset of the stroke to reperfusion was 281 min. Successful reperfusion, characterized by a modified Thrombolysis in Cerebral Infarction grade ≥ 2b, was achieved in all patients. The 3-month outcomes were good [modified Rankin Scale (mRS) 0-2] in 5 patients and poor (mRS 3-6) in 6 patients. The pretreatment median GCS scores were significantly higher in patients with a good outcome compared to that in those with a poor outcome with scores of 11 and 7.5, respectively (P = 0.044). The receiver operating characteristic (ROC) curve analysis showed that the optimal cut-off score on the GCS was 9.5 [area under the curve (AUC), 0.867; sensitivity, 0.8; specificity, 1.0]. Complications occurred in 1 patient with arterial dissection who had developed a subarachnoid hemorrhage and later died. CONCLUSION The results of the present study suggests that the pretreatment GCS score might affect the clinical outcomes in patients with BA occlusion who underwent MT following IV-rt-PA therapy.
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Affiliation(s)
- Ichiro Deguchi
- Department of Neurology, Saitama Medical University International Medical Center, 1397-1, Yamane, Hidaka, Saitama, Japan.
| | - Takashi Osada
- Department of Neurology, Saitama Medical University International Medical Center, 1397-1, Yamane, Hidaka, Saitama, Japan.
| | - Hiroaki Kimura
- Department of Neurology, Saitama Medical University International Medical Center, 1397-1, Yamane, Hidaka, Saitama, Japan.
| | - Takeshi Hayashi
- Department of Neurology, Saitama Medical University International Medical Center, 1397-1, Yamane, Hidaka, Saitama, Japan.
| | - Shinichi Takahashi
- Department of Neurology, Saitama Medical University International Medical Center, 1397-1, Yamane, Hidaka, Saitama, Japan.
| | - Masaki Takao
- Department of Neurology, Saitama Medical University International Medical Center, 1397-1, Yamane, Hidaka, Saitama, Japan.
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12
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Namioka A, Namioka T, Sasaki M, Kataoka-Sasaki Y, Oka S, Nakazaki M, Onodera R, Suzuki J, Sasaki Y, Nagahama H, Kocsis JD, Honmou O. Intravenous infusion of mesenchymal stem cells for protection against brainstem infarction in a persistent basilar artery occlusion model in the adult rat. J Neurosurg 2019; 131:1308-1316. [PMID: 30485204 DOI: 10.3171/2018.4.jns173121] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2017] [Accepted: 04/05/2018] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Morbidity and mortality in patients with posterior circulation stroke remains an issue despite advances in acute stroke therapies. The intravenous infusion of mesenchymal stem cells (MSCs) elicits therapeutic efficacy in experimental supratentorial stroke models. However, since there are few reliable animal models of ischemia in the posterior circulation, the therapeutic approach with intravenous MSC infusion has not been tested. The objective of this study was to test the hypothesis that intravenously infused MSCs provide functional recovery in a newly developed model of brainstem infarction in rats. METHODS Basilar artery (BA) occlusion (BAO) was established in rats by selectively ligating 4 points of the proximal BA with 10-0 nylon monofilament suture. The intravenous infusion of MSCs was performed 1 day after BAO induction. MRI and histological examinations were performed to assess ischemic lesion volume, while multiple behavioral tests were performed to evaluate functional recovery. RESULTS The MSC-treated group exhibited a greater reduction in ischemic lesion volume, while behavioral testing indicated that the MSC-infused group had greater improvement than the vehicle group 28 days after the MSC infusion. Accumulated infused MSCs were observed in the ischemic brainstem lesion. CONCLUSIONS Infused MSCs may provide neuroprotection to facilitate functional outcomes and reduce ischemic lesion volume as evaluated in a newly developed rat model of persistent BAO.
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Affiliation(s)
- Ai Namioka
- 1Department of Neural Regenerative Medicine, Research Institute for Frontier Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Takahiro Namioka
- 1Department of Neural Regenerative Medicine, Research Institute for Frontier Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Masanori Sasaki
- 1Department of Neural Regenerative Medicine, Research Institute for Frontier Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
- 3Center for Neuroscience and Regeneration Research, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Yuko Kataoka-Sasaki
- 1Department of Neural Regenerative Medicine, Research Institute for Frontier Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Shinichi Oka
- 1Department of Neural Regenerative Medicine, Research Institute for Frontier Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Masahito Nakazaki
- 1Department of Neural Regenerative Medicine, Research Institute for Frontier Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Rie Onodera
- 1Department of Neural Regenerative Medicine, Research Institute for Frontier Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Junpei Suzuki
- 1Department of Neural Regenerative Medicine, Research Institute for Frontier Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Yuichi Sasaki
- 1Department of Neural Regenerative Medicine, Research Institute for Frontier Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Hiroshi Nagahama
- 1Department of Neural Regenerative Medicine, Research Institute for Frontier Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
| | - Jeffery D Kocsis
- 2Department of Neurology, Yale University School of Medicine, New Haven; and
- 3Center for Neuroscience and Regeneration Research, VA Connecticut Healthcare System, West Haven, Connecticut
| | - Osamu Honmou
- 1Department of Neural Regenerative Medicine, Research Institute for Frontier Medicine, Sapporo Medical University School of Medicine, Sapporo, Japan
- 3Center for Neuroscience and Regeneration Research, VA Connecticut Healthcare System, West Haven, Connecticut
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13
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Ravindren J, Aguilar Pérez M, Hellstern V, Bhogal P, Bäzner H, Henkes H. Predictors of Outcome After Endovascular Thrombectomy in Acute Basilar Artery Occlusion and the 6hr Time Window to Recanalization. Front Neurol 2019; 10:923. [PMID: 31608001 PMCID: PMC6773802 DOI: 10.3389/fneur.2019.00923] [Citation(s) in RCA: 33] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2019] [Accepted: 08/09/2019] [Indexed: 12/20/2022] Open
Abstract
Background and Purpose: Decision algorithms for large vessel occlusions in the anterior circulation remain unconfirmed for acute basilar artery occlusion (aBAO). The aim of this study was to investigate procedural parameters, patient characteristics, functional outcome, and survival in dependency of the time window to recanalization from symptom onset. Furthermore predictors of outcome were identified. Materials and Methods: Retrospectively 231 patients with aBAO treated with endovascular treatment (EVT) between November 2008 and February 2019 were identified in a prospectively maintained single center stroke database. Baseline characteristics such as age, cardiovascular risk factors, NIHSS at admission, pre-interventional PC-ASPECTS, periprocedural parameters such as time to recanalization, duration of treatment, extent of reperfusion, collateral status, and occlusion patterns, as well as post-interventional 24 h NIHSS and post-interventional ICH were evaluated. Target variables were mRS at 90 days and mortality over 90 days. Results: Good outcome (mRS 0–2) was attained in 29.5% (n = 68) of patients, overall mortality was 36.8% (n = 85). In mulitivariate analyses patients with time to reperfusion beyond 6 h had a more than half fold decreased chance of good outcome [OR 0.47 95% CI (0.23–0.95) p < 0.05]. The odds for good outcome were reduced by almost 2/3 if post-interventional imaging revealed intracerebral hemorrhage [OR 0.28 95% CI (0.08–0.98)]. Unfavorable outcome was noted in 100% (n = 14) of patients with symptomatic ICH. Risk for death was reduced by more than 80% if collaterals were present [0.16 95% CI (0.03–0.87)] and if recanalization was successful (TICI 2b-3) [OR 0.19 95% CI (0.05–0.78)]. The odds for survival were 5-fold higher in patients with no post-interventional hemorrhages present [OR 5.35 95% CI (2.2–1.58)]. Conclusion: This study might contribute to explaining the ambiguous findings regarding the validity of the 6 h time window in aBAO, suggesting that collateral status impacts the odds of survival in the time window to recanalization beyond 6 h. In our study recanalization within 6 h from symptom onset was associated with good outcome. Successful recanalization (TICI 2b-3a) was necessary for good outcome and survival, post-interventional ICH was highly associated with unfavorable outcome. This might ease the decision making for EVT.
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Affiliation(s)
- Johannes Ravindren
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany.,Neurological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Marta Aguilar Pérez
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Victoria Hellstern
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Pervinder Bhogal
- Department of Neuroradiology, St Bartholomew's Hospital, London, United Kingdom
| | - Hansjörg Bäzner
- Neurological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany
| | - Hans Henkes
- Neuroradiological Clinic, Neurocenter, Klinikum Stuttgart, Stuttgart, Germany.,Medical Faculty, University Duisburg-Essen, Essen, Germany
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14
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Abstract
Purpose: This study aims to analyse the efficacy of different treatment methods for acute basilar artery occlusion, with an emphasis placed on evaluating the latest treatment methods. Method: A systematic review and meta-analysis was performed to analyse the current data on the therapies available for treating acute basilar artery occlusion. Results: A total of 102 articles were included. The weighted pooled rate of mortality was 43.16% (95% CI 38.35-48.03%) in the intravenous thrombolysis group, 45.56% (95% CI 39.88-51.28) in the intra-arterial thrombolysis group, and 31.40% (95% CI 28.31-34.56%) for the endovascular thrombectomy group. The weighted pooled rate of Modified Ranking Score (mRS) 0-2 at 3 months was 31.40 (95% CI 28.31-34.56%) in the IVT group, 28.29% (95% CI 23.16-33.69%) in the IAT group, and 35.22% (95% CI 32.39-38.09%) for the EVT group. Meta-analyses were also done for the secondary outcomes of recanalization and symptomatic haemorrhage. There was no difference between stent retriever and thrombo-aspiration thrombectomy on subgroup analysis in both clinical outcome and safety profile. Limitations: The included studies were observational in nature. There was significant heterogeneity in some of the outcomes. Conclusions: Superior outcomes and better recanalization rates for acute basilar occlusion were seen with patients managed with endovascular thrombectomy when compared with either intravenous and/or intraarterial thrombolysis. No superiority of stent-retrievers over thrombo-aspiration thrombectomy was seen.
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Affiliation(s)
- Kevin Sheng
- Faculty of Medicine, Macquarie University, Macquarie Park, NSW, 2109, Australia
- Concord Hospital, Concord, NSW, 2137, Australia
| | - Marcus Tong
- Faculty of Medicine, Macquarie University, Macquarie Park, NSW, 2109, Australia
- Sir Charles Gairdner Hospital, Nedlands, Nedlands, WA, 6009, Australia
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15
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Boeckh-Behrens T, Pree D, Lummel N, Friedrich B, Maegerlein C, Kreiser K, Kirschke J, Berndt M, Lehm M, Wunderlich S, Mosimann PJ, Fischer U, Zimmer C, Kaesmacher J. Vertebral Artery Patency and Thrombectomy in Basilar Artery Occlusions. Stroke 2019; 50:389-395. [DOI: 10.1161/strokeaha.118.022466] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
Factors influencing recanalization success in basilar artery occlusions are largely unknown. Preliminary evidence has suggested that flow arrest in the vertebral artery contralateral to the catheter bearing vertebral artery may facilitate recanalization. The aim of this analysis was to assess the impact of anatomic variations and flow conditions on recanalization success in basilar artery occlusion treated with mechanical thrombectomy.
Methods—
Consecutive basilar artery occlusions treated with second-generation thrombectomy devices at a single-center were retrospectively analyzed. Baseline patients’ characteristics, occlusion length, collateral circulation, underlying stenosis, incomplete occlusions, and patency of the vertebral arteries were analyzed with regards to recanalization success. Aplastic or hypoplastic vertebral artery contralateral to the catheter position was defined as contralateral low flow condition. Logistic regression analysis was used to examine the association between anatomic variations and flow conditions in relation to complete recanalization and the modified Rankin Scale score while controlling for several potentially confounding variables. Clinical impact was evaluated using the modified Rankin Scale score of ≤3.
Results—
One hundred fifteen patients were included (mean age 71.5±12.8, m:f=2:1, median National Institutes of Health Stroke Scale =15, interquartile range =10–22). Complete recanalization was more often observed in patients with contralateral low flow conditions (80.6% versus 50.0%), which remained an independent predictor of complete recanalization in multivariable analysis (adjusted odds ratio, 5.81; 95% CI, 1.97–17.19). Patients with complete posterior recanalization had lower in-hospital mortality (16.4% versus 41.7%) and more often achieved modified Rankin Scale score of ≤3 (49.4% versus 8.3%), even after adjusting for potential confounders (adjusted odds ratio, 15.93; 95% CI, 1.42–179.00).
Conclusions—
Contralateral low flow condition (vertebral artery aplasia or hypoplasia) seems to be an independent factor for fewer distal emboli and complete recanalization in basilar artery occlusion patients treated by modern endovascular devices. Complete recanalization reflecting the absence of peri-interventional clot fragmentation brings clear clinical benefit. Further studies are warranted to evaluate the need for contralateral flow modulation or ipsilateral balloon guide catheter during posterior circulation thrombectomy in patients with bilaterally patent vertebral arteries.
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Affiliation(s)
- Tobias Boeckh-Behrens
- From the Department of Diagnostic and Interventional Neuroradiology (T.B.-B., D.P., N.L., B.F., C.M., K.K., J.K., M.B., M.L., C.Z., J.K.), Klinikum Rechts der Isar, Technical University Munich, Germany
| | - David Pree
- From the Department of Diagnostic and Interventional Neuroradiology (T.B.-B., D.P., N.L., B.F., C.M., K.K., J.K., M.B., M.L., C.Z., J.K.), Klinikum Rechts der Isar, Technical University Munich, Germany
| | - Nina Lummel
- From the Department of Diagnostic and Interventional Neuroradiology (T.B.-B., D.P., N.L., B.F., C.M., K.K., J.K., M.B., M.L., C.Z., J.K.), Klinikum Rechts der Isar, Technical University Munich, Germany
| | - Benjamin Friedrich
- From the Department of Diagnostic and Interventional Neuroradiology (T.B.-B., D.P., N.L., B.F., C.M., K.K., J.K., M.B., M.L., C.Z., J.K.), Klinikum Rechts der Isar, Technical University Munich, Germany
| | - Christian Maegerlein
- From the Department of Diagnostic and Interventional Neuroradiology (T.B.-B., D.P., N.L., B.F., C.M., K.K., J.K., M.B., M.L., C.Z., J.K.), Klinikum Rechts der Isar, Technical University Munich, Germany
| | - Kornelia Kreiser
- From the Department of Diagnostic and Interventional Neuroradiology (T.B.-B., D.P., N.L., B.F., C.M., K.K., J.K., M.B., M.L., C.Z., J.K.), Klinikum Rechts der Isar, Technical University Munich, Germany
| | - Jan Kirschke
- From the Department of Diagnostic and Interventional Neuroradiology (T.B.-B., D.P., N.L., B.F., C.M., K.K., J.K., M.B., M.L., C.Z., J.K.), Klinikum Rechts der Isar, Technical University Munich, Germany
| | - Maria Berndt
- From the Department of Diagnostic and Interventional Neuroradiology (T.B.-B., D.P., N.L., B.F., C.M., K.K., J.K., M.B., M.L., C.Z., J.K.), Klinikum Rechts der Isar, Technical University Munich, Germany
| | - Manuel Lehm
- From the Department of Diagnostic and Interventional Neuroradiology (T.B.-B., D.P., N.L., B.F., C.M., K.K., J.K., M.B., M.L., C.Z., J.K.), Klinikum Rechts der Isar, Technical University Munich, Germany
| | | | - Pascal J. Mosimann
- Department of Neurology (P.J.M., J.K.), Klinikum Rechts der Isar, Technical University Munich, Germany
- Institute of Diagnostic and Interventional Neuroradiology (P.J.M., J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Urs Fischer
- Department of Neurology (U.F., J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Claus Zimmer
- From the Department of Diagnostic and Interventional Neuroradiology (T.B.-B., D.P., N.L., B.F., C.M., K.K., J.K., M.B., M.L., C.Z., J.K.), Klinikum Rechts der Isar, Technical University Munich, Germany
| | - Johannes Kaesmacher
- From the Department of Diagnostic and Interventional Neuroradiology (T.B.-B., D.P., N.L., B.F., C.M., K.K., J.K., M.B., M.L., C.Z., J.K.), Klinikum Rechts der Isar, Technical University Munich, Germany
- Department of Neurology (P.J.M., J.K.), Klinikum Rechts der Isar, Technical University Munich, Germany
- Institute of Diagnostic and Interventional Neuroradiology (P.J.M., J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland
- Department of Neurology (U.F., J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland
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16
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Giorgianni A, Biraschi F, Piano M, Mardighian D, Gasparotti R, Frigerio M, Pero G, Quilici L, Crispino M, Pellegrino C, Pavia M, Peroni R, Longoni M, Cellerini M, Lafe E, Remida P, Faragò G, Reganati P, Strocchi S, Valvassori L. Endovascular Treatment of Acute Basilar Artery Occlusion: Registro Endovascolare Lombardo Occlusione Basilar Artery (RELOBA) Study Group Experience. J Stroke Cerebrovasc Dis 2018; 27:2367-2374. [DOI: 10.1016/j.jstrokecerebrovasdis.2018.04.022] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2018] [Revised: 04/11/2018] [Accepted: 04/20/2018] [Indexed: 11/25/2022] Open
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17
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Impact of smoking on stroke outcome after endovascular treatment. PLoS One 2018; 13:e0194652. [PMID: 29718909 PMCID: PMC5931491 DOI: 10.1371/journal.pone.0194652] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 03/07/2018] [Indexed: 12/21/2022] Open
Abstract
Background Recent studies suggest a paradoxical association between smoking status and clinical outcome after intravenous thrombolysis (IVT). Little is known about relationship between smoking and stroke outcome after endovascular treatment (EVT). Methods We analyzed data of all stroke patients treated with EVT at the tertiary stroke centre of Berne between January 2005 and December 2015. Using uni- and multivariate modeling, we assessed whether smoking was independently associated with excellent clinical outcome (modified Rankin Scale (mRS) 0–1) and mortality at 3 months. In addition, we also measured the occurrence of symptomatic intracranial hemorrhage (sICH) and recanalization. Results Of 935 patients, 204 (21.8%) were smokers. They were younger (60.5 vs. 70.1 years of age, p<0.001), more often male (60.8% vs. 52.5%, p = 0.036), had less often from hypertension (56.4% vs. 69.6%, p<0.001) and were less often treated with antithrombotics (35.3% vs. 47.7%, p = 0.004) as compared to nonsmokers. In univariate analyses, smokers had higher rates of excellent clinical outcome (39.1% vs. 23.1%, p<0.001) and arterial recanalization (85.6% vs. 79.4%, p = 0.048), whereas mortality was lower (15.6% vs. 25%, p = 0.006) and frequency of sICH similar (4.4% vs. 4.1%, p = 0.86). After correcting for confounders, smoking still independently predicted excellent clinical outcome (OR 1.758, 95% CI 1.206–2.562; p<0.001). Conclusion Smoking in stroke patients may be a predictor of excellent clinical outcome after EVT. However, these data must not be misinterpreted as beneficial effect of smoking due to the observational study design. In view of deleterious effects of cigarette smoking on cardiovascular health, cessation of smoking should still be strongly recommended for stroke prevention.
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18
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Lee WJ, Jung KH, Ryu YJ, Kim JM, Lee ST, Chu K, Kim M, Lee SK, Sohn CH, Roh JK. Impact of stroke mechanism in acute basilar occlusion with reperfusion therapy. Ann Clin Transl Neurol 2018; 5:357-368. [PMID: 29560380 PMCID: PMC5846447 DOI: 10.1002/acn3.536] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Revised: 12/13/2017] [Accepted: 12/30/2017] [Indexed: 12/27/2022] Open
Abstract
Objective We aimed to evaluate the impact of underlying mechanism of basilar artery (BA) occlusion on the outcomes after endovascular therapy (EVT) for reperfusion and the outcome factors associated with each mechanism, and to identify radiologic parameters enabling to distinguish the underlying mechanism. Methods From a registry database, 194 consecutive patients with acute BA occlusion who underwent EVT were analyzed. Stroke mechanism, classified into in situ atherosclerotic thrombosis (ISAT) and embolism, clot sign location profiles in pre‐angiography magnetic resonance image (MRI), parameters of angiography and EVT, and reperfusion were assessed. Poor outcome was defined as a modified Rankin‐Scale score at 90 days of 3–6. Results The mean age was 68.8±11.8 years (range 21–92 years) and seventy‐eight (40.2%) were female patients. 102 (52.6%) patients were classified into an embolism mechanism and 92 (47.4%) into an ISAT mechanism. Overall, ISAT mechanism compared with embolism was significantly associated with poor outcomes (P = 0.002), along with the NIHSS scores, reperfusion status, and collateral status. In the embolism group, reperfusion (P = 0.001), NIHSS scores (P < 0.001), and onset‐to‐treatment time (P = 0.030) were significant outcome factors. However, in the ISAT group, baseline collateral status (P = 0.001) and NIHSS scores (P < 0.001) were significant outcome factors. A clot sign at the distal BA segment on pre‐angiography MRI was strongly associated with embolism mechanism (P < 0.001). Interpretation Stroke mechanism has a major influence on outcomes, and outcome predictors differ according to the underlying mechanism in acute BA occlusion with EVT. Clot sign profile on pre‐angiography MRI might be useful to determine the underlying mechanism.
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Affiliation(s)
- Woo-Jin Lee
- Department of Neurology Seoul National University Hospital Seoul South Korea
| | - Keun-Hwa Jung
- Department of Neurology Seoul National University Hospital Seoul South Korea.,Program in Neuroscience Neuroscience Research Institute of SNUMRC College of Medicine Seoul National University Seoul South Korea
| | - Young Jin Ryu
- Department of Radiology Seoul National University Hospital Seoul South Korea
| | - Jeong-Min Kim
- Department of Neurology Chung-Ang University Hospital Seoul South Korea
| | - Soon-Tae Lee
- Department of Neurology Seoul National University Hospital Seoul South Korea.,Program in Neuroscience Neuroscience Research Institute of SNUMRC College of Medicine Seoul National University Seoul South Korea
| | - Kon Chu
- Department of Neurology Seoul National University Hospital Seoul South Korea.,Program in Neuroscience Neuroscience Research Institute of SNUMRC College of Medicine Seoul National University Seoul South Korea
| | - Manho Kim
- Department of Neurology Seoul National University Hospital Seoul South Korea.,Program in Neuroscience Neuroscience Research Institute of SNUMRC College of Medicine Seoul National University Seoul South Korea
| | - Sang Kun Lee
- Department of Neurology Seoul National University Hospital Seoul South Korea.,Program in Neuroscience Neuroscience Research Institute of SNUMRC College of Medicine Seoul National University Seoul South Korea
| | - Chul-Ho Sohn
- Department of Radiology Seoul National University Hospital Seoul South Korea
| | - Jae-Kyu Roh
- Department of Neurology Seoul National University Hospital Seoul South Korea.,Department of Neurology Armed Forces Capital Hospital Sungnam South Korea
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19
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Wyszomirski A, Szczyrba S, Tomaka D, Karaszewski B. Treatment of acute basilar artery occlusion: Systematic review and meta-analysis. Neurol Neurochir Pol 2017; 51:486-496. [DOI: 10.1016/j.pjnns.2017.07.012] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2017] [Revised: 07/13/2017] [Accepted: 07/17/2017] [Indexed: 10/19/2022]
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20
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Hu SY, Yi HJ, Lee DH, Hong JT, Sung JH, Lee SW. Effectiveness and Safety of Mechanical Thrombectomy with Stent Retrievers in Basilar Artery Occlusion: Comparison with Anterior Circulation Occlusions. J Korean Neurosurg Soc 2017; 60:635-643. [PMID: 29142622 PMCID: PMC5678059 DOI: 10.3340/jkns.2017.0404.008] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2017] [Revised: 06/04/2017] [Accepted: 08/02/2017] [Indexed: 11/27/2022] Open
Abstract
Objective Acute basilar artery occlusion (BAO) is associated with severe neurological dysfunction and high mortality rates. The benefits of mechanical thrombectomy in BAO have not been explored in recent clinical trials. Therefore, we analyzed outcomes of stent retriever mechanical thrombectomy for BAO, and compared with anterior circulation occlusions (ACO). Methods In total, 161 consecutive patients (24 BAO, 137 ACO) who underwent mechanical thrombectomy with the stent retriever between January 2013 and August 2016 enrolled in our study. All patients underwent clinical assessment with the National Institutes of Health Stroke Scale (NIHSS) and modified Rankin scale (mRS). Radiological results were used to evaluate thrombolysis in cerebral infarction (TICI) scores and successful recanalization was defined by TICI 2b or 3. Results Mean NIHSS scores at 24 hours and 30 days were significantly higher in the BAO group than the ACO group (p=0.021, p=0.001). mRS at 90 days was significantly higher in the BAO group (4.2) compared with the ACO group (3.0) (p=0.003). The BAO group (2.0) performed fewer stent retriever passages than the ACO group (2.7) (p=0.049). There were no significant differences between the two groups in terms of complications, but the BAO patients experienced a higher mortality (16.6%) rate than ACO patients (5.8%) (p=0.001). In subgroup analysis of BAO, patients with short procedure times achieved successful recanalization (p=0.001) and successfully recanalized patients exhibited more favorable mRS at 90 days (p=0.027). Conclusion In our study, mechanical thrombectomy of BAO patients showed worse clinical outcome and higher mortality rate than ACO patients. However, mechanical thrombectomy with a stent retriever in BAO is an effective treatment, because successfully recanalized patients showed good clinical outcome in BAO patients.
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Affiliation(s)
- Soo Young Hu
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Ho Jun Yi
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Dong Hoon Lee
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Jae Taek Hong
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Jae Hoon Sung
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
| | - Sang Won Lee
- Department of Neurosurgery, St. Vincent's Hospital, College of Medicine, The Catholic University of Korea, Suwon, Korea
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21
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Abbott AL, Silvestrini M, Topakian R, Golledge J, Brunser AM, de Borst GJ, Harbaugh RE, Doubal FN, Rundek T, Thapar A, Davies AH, Kam A, Wardlaw JM. Optimizing the Definitions of Stroke, Transient Ischemic Attack, and Infarction for Research and Application in Clinical Practice. Front Neurol 2017; 8:537. [PMID: 29104559 PMCID: PMC5654955 DOI: 10.3389/fneur.2017.00537] [Citation(s) in RCA: 39] [Impact Index Per Article: 5.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2017] [Accepted: 09/25/2017] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND AND PURPOSE Until now, stroke and transient ischemic attack (TIA) have been clinically based terms which describe the presence and duration of characteristic neurological deficits attributable to intrinsic disorders of particular arteries supplying the brain, retina, or (sometimes) the spinal cord. Further, infarction has been pathologically defined as death of neural tissue due to reduced blood supply. Recently, it has been proposed we shift to definitions of stroke and TIA determined by neuroimaging results alone and that neuroimaging findings be equated with infarction. METHODS We examined the scientific validity and clinical implications of these proposals using the existing published literature and our own experience in research and clinical practice. RESULTS We found that the proposals to change to imaging-dominant definitions, as published, are ambiguous and inconsistent. Therefore, they cannot provide the standardization required in research or its application in clinical practice. Further, we found that the proposals are scientifically incorrect because neuroimaging findings do not always correlate with the clinical status or the presence of infarction. In addition, we found that attempts to use the proposals are disrupting research, are otherwise clinically unhelpful and do not solve the problems they were proposed to solve. CONCLUSION We advise that the proposals must not be accepted. In particular, we explain why the clinical focus of the definitions of stroke and TIA should be retained with continued sub-classification of these syndromes depending neuroimaging results (with or without other information) and that infarction should remain a pathological term. We outline ways the established clinically based definitions of stroke and TIA, and use of them, may be improved to encourage better patient outcomes in the modern era.
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Affiliation(s)
- Anne L. Abbott
- Department of Epidemiology and Preventive Medicine, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- The Neurology Department, The Alfred Hospital, Melbourne, VIC, Australia
| | | | - Raffi Topakian
- Department of Neurology, Academic Teaching Hospital Wels-Grieskirchen, Wels, Austria
| | - Jonathan Golledge
- Queensland Research Centre for Peripheral Vascular Disease, College of Medicine and Dentistry, James Cook University, Townsville, QLD, Australia
- Department of Vascular and Endovascular Surgery, The Townsville Hospital, Townsville, QLD, Australia
| | - Alejandro M. Brunser
- Cerebrovascular Program, Neurology Service, Department of Medicine, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana – Universidad del Desarrollo, Santiago, Chile
| | - Gert J. de Borst
- Department of Vascular Surgery, University Medical Centre of Utrecht, Utrecht, Netherlands
| | - Robert E. Harbaugh
- Department of Neurosurgery, Penn State University, State College, PA, United States
| | - Fergus N. Doubal
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kingdom
- Department of Medicine, Elderly Royal Infirmary of Edinburgh, Edinburgh, United Kingdom
| | - Tatjana Rundek
- Department of Neurology, Miller School of Medicine, Miami, FL, United States
| | - Ankur Thapar
- Imperial College Healthcare NHS Trust, London, United Kingdom
- Imperial College, London, United Kingdom
| | - Alun H. Davies
- Academic Section of Vascular Surgery, Department of Surgery and Cancer, Imperial College School of Medicine, Charing Cross Hospital, London, United Kingdom
| | - Anthony Kam
- Department of Radiology, Alfred Health, Melbourne, VIC, Australia
| | - Joanna M. Wardlaw
- Division of Neuroimaging Sciences, Centre for Clinical Brain Sciences, UK Dementia Research Institute at the University of Edinburgh, Edinburgh, United Kingdom
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Wen WL, Li ZF, Zhang YW, Yang PF, Simfukwe K, Fang YB, Zhang TY, Deng BQ, Hong B, Liu JM, Huang QH. Effect of Baseline Characteristics on the Outcome of Stent Retriever–Based Thrombectomy in Acute Basilar Artery Occlusions: A Single-Center Experience and Pooled Data Analysis. World Neurosurg 2017; 104:1-8. [DOI: 10.1016/j.wneu.2017.04.015] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2016] [Revised: 04/02/2017] [Accepted: 04/05/2017] [Indexed: 11/25/2022]
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23
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Garg R, Biller J. Neuroimaging Predictors of Clinical Outcome in Acute Basilar Artery Occlusion. Front Neurol 2017; 8:293. [PMID: 28674517 PMCID: PMC5474464 DOI: 10.3389/fneur.2017.00293] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2017] [Accepted: 06/06/2017] [Indexed: 11/13/2022] Open
Abstract
Certain early neuroimaging findings are independent predictors of clinical outcome in acute basilar artery occlusion. These imaging findings may serve as important baseline imaging characteristics as well as subgroups in future randomized controlled trials. The purpose of this review is to review and compare early neuroimaging findings seen on non-invasive cranial imaging that predict clinical outcome in acute basilar artery occlusion.
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Affiliation(s)
- Ravi Garg
- Department of Neurology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, United States
| | - José Biller
- Department of Neurology, Stritch School of Medicine, Loyola University Chicago, Maywood, IL, United States
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24
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van der Hoeven EJ, Algra A, Vos JA, Mattle HP, Weimar C, Schonewille WJ, Kappelle J. Clot length predicts recanalisation but not outcome after basilar artery occlusion. Eur Stroke J 2016; 1:330-336. [PMID: 31008295 DOI: 10.1177/2396987316673265] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2016] [Accepted: 09/06/2016] [Indexed: 11/15/2022] Open
Abstract
Introduction The aim of our study was to evaluate the effect of clot length on both recanalisation and outcome in acute basilar artery occlusion (BAO). Patients and methods One hundred forty-nine patients with an acute basilar artery occlusion from the Basilar Artery International Cooperation Study (BASICS) were included. Clot length was assessed on computed tomographic angiography. Thrombus length was divided in tertiles and was related to recanalisation and outcome at 1 month, with Poisson regression. Modified Rankin scale scores of 4 or 5, or death were considered poor outcomes. Additionally, clot length was analysed as a continuous variable. Results Forty-nine patients (33%) had a short (4-11 mm), 50 (34%) an intermediate (12-22 mm), and 50 (34%) a long clot (≥23 mm). Multivariable analyses showed a significantly lower probability of recanalisation but no statistically significant difference in poor outcome for patients with a long clot compared with patients with a short clot (RR 0.64, 95% CI: 0.42-0.98 and RR 1.10, 95% CI: 0.88-1.37, respectively). No statistically significant differences were found for patients with an intermediate clot length compared with patients with a short clot length (RR 0.97, 95% CI: 0.75-1.25 and RR 1.11, 95% CI: 0.88-1.40, respectively). Analyses of clot length as a continuous variable showed a 10% reduction in chance of recanalisation and a 2% increase in risk of poor outcome with every centimeter increase in clot length (RR 0.90, 95% CI: 0.78-1.04 and RR 1.02, 95% CI: 0.98-1.05, respectively). Conclusions Clot length predicted recanalisation but not outcome at 1 month in patients with a BAO. We found 2% more poor outcome and 10% less recanalisation with every centimeter increase in clot length.
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Affiliation(s)
| | - Ale Algra
- Brain Center Rudolf Magnus, Department Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands.,Julius Center for Health Sciences and Patient Care, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Jan Albert Vos
- Department of Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Heinrich P Mattle
- Department of Neurology, Inselspital, University of Bern, Bern, Switzerland
| | - Christian Weimar
- Department of Neurology, University Hospital Essen, Essen, Germany
| | | | - Jaap Kappelle
- Brain Center Rudolf Magnus, Department Neurology and Neurosurgery, University Medical Center Utrecht, Utrecht, The Netherlands
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25
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Pallesen LP, Khomenko A, Dzialowski I, Barlinn J, Barlinn K, Zerna C, van der Hoeven EJRJ, Algra A, Kapelle LJ, Michel P, Bodechtel U, Demchuk AM, Schonewille W, Puetz V. CT-angiography source images indicate less fatal outcome despite coma of patients in the Basilar Artery International Cooperation Study. Int J Stroke 2016; 12:145-151. [DOI: 10.1177/1747493016669886] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background Coma is associated with poor outcome in patients with basilar artery occlusion. Aims We sought to assess whether the posterior circulation Acute Stroke Prognosis Early CT Score and the Pons-Midbrain Index applied to CT angiography source images predict the outcome of comatose patients in the Basilar Artery International Cooperation Study. Methods Basilar Artery International Cooperation Study was a prospective, observational registry of patients with acute basilar artery occlusion with 48 recruiting centers worldwide. We applied posterior circulation Acute Stroke Prognosis Early CT Score and Pons-Midbrain Index to CT angiography source images of Basilar Artery International Cooperation Study patients who presented with coma. We calculated adjusted risk ratios to assess the association of dichotomized posterior circulation Acute Stroke Prognosis Early CT Score (≥8 vs. <8) and Pons-Midbrain Index (<3 vs. ≥3) with mortality and favourable outcome (modified Rankin Scale score 0–3) at one month. Results Of 619 patients in the Basilar Artery International Cooperation Study registry, CT angiography source images were available for review in 158 patients. Among these, 78 patients (49%) presented with coma. Compared to non-comatose patients, comatose patients were more likely to die (risk ratios 2.34; CI 95% 1.56–3.52) and less likely to have a favourable outcome (risk ratios 0.44; CI 95% 0.24–0.80). Among comatose patients, a Pons-Midbrain Index < 3 was related to reduced mortality (adjusted RR 0.66; 95% CI 0.46–0.96), but not to favourable outcome (adjusted RR 1.19; 95% CI 0.39–3.62). Posterior circulation Acute Stroke Prognosis Early CT Score dichotomized at ≥ 8 vs. <8 was not significantly associated with death (adjusted RR 0.70; 95% CI 0.46–1.05). Conclusion In comatose patients with basilar artery occlusion, the extent of brainstem ischemia appears to be related to mortality but not to favourable outcome.
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Affiliation(s)
- Lars P Pallesen
- Department of Neurology, University of Technology Dresden, Dresden, Germany
| | - Andrei Khomenko
- Department of Neurology, University of Regensburg, Regensburg, Germany
| | | | - Jessica Barlinn
- Department of Neurology, University of Technology Dresden, Dresden, Germany
| | - Kristian Barlinn
- Department of Neurology, University of Technology Dresden, Dresden, Germany
| | - Charlotte Zerna
- Department of Neurology, University of Technology Dresden, Dresden, Germany
- Calgary Stroke Program, University of Calgary, Calgary, Canada
| | | | - Ale Algra
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center, Utrecht, The Netherlands
- Julius Center for Health Sciences and Primary Care, University Medical Center, Utrecht, The Netherlands
| | - L Jaap Kapelle
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center, Utrecht, The Netherlands
| | - Patrik Michel
- Centre Hospitalier Universitaire Vaudois, Centre Cérébrovasculaire, Lausanne, Switzerland
| | - Ulf Bodechtel
- Department of Neurology, University of Technology Dresden, Dresden, Germany
| | | | - Wouter Schonewille
- St. Antonius Hospital Nieuwegein, Nieuwegein, The Netherlands
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center, Utrecht, The Netherlands
| | - Volker Puetz
- Department of Neurology, University of Technology Dresden, Dresden, Germany
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26
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van der Hoeven EJRJ, McVerry F, Vos JA, Algra A, Puetz V, Kappelle LJ, Schonewille WJ. Collateral flow predicts outcome after basilar artery occlusion: The posterior circulation collateral score. Int J Stroke 2016; 11:768-75. [DOI: 10.1177/1747493016641951] [Citation(s) in RCA: 68] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2015] [Accepted: 02/14/2016] [Indexed: 11/16/2022]
Abstract
Background and Aim Our aim was to assess the prognostic value of a semiquantitative computed tomography angiography-based grading system, for the prediction of outcome in patients with acute basilar artery occlusion, based on the presence of potential collateral pathways on computed tomography angiography: the posterior circulation collateral score (PC-CS). Methods One hundred forty-nine patients with acute basilar artery occlusion from the Basilar Artery International Cooperation Study were included. We related poor outcome at one month, defined as a modified Rankin scale score of 4 or 5, or death to collateral flow with Poisson regression. We used a 10 points grading system to quantify the potential for collateral flow in the posterior communicating arteries and the cerebellar arteries. Additionally, the relation between the presence and size of posterior communicating arteries and outcome was analyzed. Results Thirty-six patients had poor (PC-CS: 0–3), 59 patients intermediate (PC-CS: 4–5), and 54 patients good (PC-CS: 6–10) collaterals. Multivariable analyses showed a statistically significant lower risk of poor outcome in patients with a good PC-CS than in patients with a poor PC-CS (risk ratio (RR): 0.74, 95% confidence interval (CI): 0.58–0.96), but not for patients with an intermediate PC-CS compared with patients with a poor PC-CS (RR: 0.95, 95% CI: 0.78–1.15). Multivariable analyses showed a statistically significant lower risk of poor outcome for the presence of at least one posterior communicating artery and for larger caliber of posterior communicating arteries (RR: 0.79, 95% CI: 0.66–0.95 and 0.76, 95% CI: 0.61–0.96, respectively). Conclusions The PC-CS predicted poor outcome at one month. In a separate analysis, both the absence and smaller caliber of posterior communicating arteries predicted poor outcome.
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Affiliation(s)
| | - Ferghal McVerry
- Department of Neurology, Altnagelvin Area Hospital, Derry, Northern Ireland
| | - Jan Albert Vos
- Department of Radiology, St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Ale Algra
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
- Julius Center for Health Sciences and Patient Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Volker Puetz
- Department of Neurology, Dresden University Stroke Center, University Clinics Carl Gustav Carus, Technical University Dresden, Dresden, Germany
| | - L Jaap Kappelle
- Department of Neurology and Neurosurgery, Brain Center Rudolf Magnus, University Medical Center Utrecht, Utrecht, the Netherlands
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27
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Glycoprotein IIb/IIIa Inhibitor Bridging and Subsequent Endovascular Therapy in Vertebrobasilar Occlusion in 120 Patients. Clin Neuroradiol 2016; 26:169-75. [DOI: 10.1007/s00062-014-0341-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2014] [Accepted: 08/14/2014] [Indexed: 10/24/2022]
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28
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A case of successful interventional treatment in acute basilar artery occlusion. COR ET VASA 2016. [DOI: 10.1016/j.crvasa.2016.01.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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29
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Bhole R, Goyal N, Nearing K, Belayev A, Doss VT, Elijovich L, Hoit DA, Tsivgoulis G, Alexandrov AV, Arthur AS, Alexandrov AW. Implications of limiting mechanical thrombectomy to patients with emergent large vessel occlusion meeting top tier evidence criteria. J Neurointerv Surg 2016; 9:225-228. [PMID: 26932801 DOI: 10.1136/neurintsurg-2015-012206] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2015] [Revised: 02/02/2016] [Accepted: 02/05/2016] [Indexed: 11/04/2022]
Abstract
BACKGROUND Recent guidelines for endovascular management of emergent large vessel occlusion (ELVO) award top tier evidence to the same selective criteria in recent trials. We aimed to understand how guideline adherence would have impacted treatment numbers and outcomes in a cohort of patients from a comprehensive stroke center. METHODS A retrospective observational study was conducted using consecutive emergent endovascular patients. Mechanical thrombectomy (MT) was performed with stent retrievers or large bore clot aspiration catheters. Procedural outcomes were compared between patients meeting, and those failing to meet, top tier evidence criteria. RESULTS 126 patients receiving MT from January 2012 to June 2015 were included (age 31-89 years, National Institutes of Health Stroke Scale (NIHSS) score 2-38); 62 (49%) patients would have been excluded if top tier criteria were upheld: pretreatment NIHSS score <6 (10%), Alberta Stroke Program Early CT score <6 (6.5%), premorbid modified Rankin Scale (mRS) score ≥2 (27%), M2 occlusion (10%), posterior circulation (32%), symptom to groin puncture >360 min (58%). 26 (42%) subjects had more than one top tier exclusion. Symptomatic intracerebral hemorrhage (sICH) and systemic hemorrhage rates were similar between the groups. 3 month mortality was 45% in those lacking top tier evidence compared with 26% (p=0.044), and 3 month mRS score 0-2 was 33% versus 46%, respectively (NS). After adjusting for potential confounders, top tier treatment was not associated with neurological improvement during hospitalization (β -8.2; 95% CI -24.6 to -8.2; p=0.321), 3 month mortality (OR=0.38; 95% CI 0.08 to 1.41), or 3 month favorable mRS (OR=0.97; 95% CI 0.28 to 3.35). CONCLUSIONS Our study showed that with strict adherence to top tier evidence criteria, half of patients may not be considered for MT. Our data indicate no increased risk of sICH and a potentially higher mortality that is largely due to treatment of patients with basilar occlusions and those treated at an extended time window. Despite this, good functional recovery is possible, and consideration of MT in patients not meeting top tier evidence criteria may be warranted.
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Affiliation(s)
- Rohini Bhole
- Stroke Team, Methodist University Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Nitin Goyal
- Stroke Team, Methodist University Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Katherine Nearing
- Stroke Team, Methodist University Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Andrey Belayev
- Stroke Team, Methodist University Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Department of Neurosurgery, Semmes-Murphey Brain and Spine Institute, Memphis, Tennessee, USA
| | - Vinodh T Doss
- Stroke Team, Methodist University Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Department of Neurosurgery, Semmes-Murphey Brain and Spine Institute, Memphis, Tennessee, USA
| | - Lucas Elijovich
- Stroke Team, Methodist University Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Department of Neurosurgery, Semmes-Murphey Brain and Spine Institute, Memphis, Tennessee, USA
| | - Daniel A Hoit
- Stroke Team, Methodist University Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Department of Neurosurgery, Semmes-Murphey Brain and Spine Institute, Memphis, Tennessee, USA
| | - Georgios Tsivgoulis
- Stroke Team, Methodist University Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Second Department of Neurology, 'Attikon University Hospital', School of Medicine, University of Athens, Athens, Greece.,Australian Catholic University, Sydney, Australia
| | - Andrei V Alexandrov
- Stroke Team, Methodist University Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Adam S Arthur
- Stroke Team, Methodist University Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Department of Neurosurgery, Semmes-Murphey Brain and Spine Institute, Memphis, Tennessee, USA
| | - Anne W Alexandrov
- Stroke Team, Methodist University Hospital, University of Tennessee Health Science Center, Memphis, Tennessee, USA.,Australian Catholic University, Sydney, Australia
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30
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Werner M, Lopez-Rueda A, Zarco F, Román LS, Blasco J, Amaro S, Carrero E, Fontanals J, Oleaga L, Macho J, Bargallo N. Mechanical thrombectomy in acute basilar artery occlusion: A safety and efficacy single centre study. Interv Neuroradiol 2016; 22:310-7. [PMID: 26908588 DOI: 10.1177/1591019916631145] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2015] [Accepted: 01/13/2016] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVES The objective of this study was to add more evidence about the efficacy and safety of mechanical thrombectomy in patients with basilar artery occlusion and secondarily to identify prognostic factors. METHODS Twenty-two consecutive patients (mean age 60.5 years, 15 men) with basilar artery occlusion treated with mechanical thrombectomy were included. Clinical, procedure and radiological data were collected. Primary outcomes were the modified Rankin scale score with a good outcome defined by a modified Rankin scale score of 0-2 and mortality rate at three months. RESULTS The median National Institutes of Health stroke scale at admission was 24 (interquartile range 11.5-31.25). Twelve patients (54.5%) required tracheal intubation due to a decreased level of consciousness. Successful recanalisation (modified treatment in cerebral ischaemia scale 2b-3) was achieved in 20 patients (90.9%). A favourable clinical outcome (modified Rankin scale score 0-2) was observed in nine patients (40.9%) and the overall mortality rate was 40.9% (nine patients). Haemorrhagic events were observed in three patients (13.63%). A decreased level of consciousness requiring intubation in the acute setting was more frequent in patients with poor outcomes (84.6%) than in patients with favourable outcomes (11.1%), and in patients who died (100%) compared with those who survived (23.1%), with a statistically significant difference (P = 0.002 and P = 0.001, respectively). CONCLUSION Mechanical thrombectomy is feasible and effective in patients with acute basilar artery occlusion. A decreased level of consciousness requiring tracheal intubation seems to be a prognostic factor and is associated with a poor clinical outcome and higher mortality rate. These initial results must be confirmed by further prospective studies with a larger number of patients.
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Affiliation(s)
- Mariano Werner
- Hospital Clínic, Department of Radiology, University of Barcelona, Spain
| | | | - Federico Zarco
- Hospital Clínic, Department of Radiology, University of Barcelona, Spain
| | - Luis San Román
- Hospital Clínic, Department of Radiology, University of Barcelona, Spain
| | - Jordi Blasco
- Hospital Clínic, Department of Radiology, University of Barcelona, Spain
| | - Sergio Amaro
- Hospital Clínic, Department of Neurology, University of Barcelona, Spain
| | - Enrique Carrero
- Hospital Clínic, Department of Anaesthesia, University of Barcelona, Spain
| | - Jaume Fontanals
- Hospital Clínic, Department of Anaesthesia, University of Barcelona, Spain
| | - Laura Oleaga
- Hospital Clínic, Department of Radiology, University of Barcelona, Spain
| | - Juan Macho
- Hospital Clínic, Department of Radiology, University of Barcelona, Spain
| | - Nuria Bargallo
- Hospital Clínic, Department of Radiology, University of Barcelona, Spain
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31
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Gilberti N, Gamba M, Premi E, Costa A, Vergani V, Delrio I, Spezi R, Mardighian D, Frigerio M, Gasparotti R, Padovani A, Magoni M. Endovascular mechanical thrombectomy in basilar artery occlusion: variables affecting recanalization and outcome. J Neurol 2016; 263:707-13. [DOI: 10.1007/s00415-016-8047-x] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2015] [Revised: 01/21/2016] [Accepted: 01/21/2016] [Indexed: 11/28/2022]
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Da Ros V, Meschini A, Gandini R, Del Giudice C, Garaci F, Stanzione P, Rizzato B, Diomedi M, Simonetti G, Floris R, Sallustio F. Proposal for a Vascular Computed Tomography-Based Grading System in Posterior Circulation Stroke: A Single-Center Experience. J Stroke Cerebrovasc Dis 2016; 25:368-77. [DOI: 10.1016/j.jstrokecerebrovasdis.2015.10.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2015] [Revised: 09/17/2015] [Accepted: 10/10/2015] [Indexed: 10/22/2022] Open
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Haridy J, Churilov L, Mitchell P, Dowling R, Yan B. Is there association between hyperdense middle cerebral artery sign on CT scan and time from stroke onset within the first 24-hours? BMC Neurol 2015; 15:101. [PMID: 26133766 PMCID: PMC4489032 DOI: 10.1186/s12883-015-0358-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2015] [Accepted: 06/19/2015] [Indexed: 11/10/2022] Open
Abstract
Background The hyperdense artery sign (HAS) on CT brain scan is an assumed radiological marker of acute intra-arterial thrombotic occlusion. However, the relationship between HAS between time of stroke onset has not been adequately investigated, leading to uncertainty regarding its validity as a marker of acute ischaemia. We attempted to determine if the presence of the hyperdense artery sign is associated with time from stroke onset. Methods Retrospective cross-sectional study conducted in a tertiary referral centre. Consecutive patients with acute ischaemic stroke and confirmed middle cerebral arterial occlusion on initial CT angiogram from 2007–2011 were included. Visual estimation and manual measurement of Hounsfield units of affected and corresponding non-affected artery on non-contrast CT was completed and mean density was calculated from four separate readings. Primary outome measures were Time from stroke onset and HAS on both visual estimation and the ratio of mean value in Hounsfield Units (HU) of affected to non-affected artery. Results One hundred and fifty-four subjects with confirmed arterial occlusion on CT Angiogram were included in the study. There were no significant differences in age distribution or vascular risk factor presence between subjects with or without HAS. Subjects with HAS were less likely to be male (50.9 % vs 70.8 %, p = 0.02).) HAS was found in 106 (68.8 %) of all subjects. Median NIHSS score at presentation was significantly higher in the HAS group (17 vs 12, p = 0.02). No statistically significant association between HAS and stroke onset time or density ratio between affected and non-affected artery was detected overall within either the first 24-h or on subgroup analysis of those in the first 4.5-h. A small subgroup of three patients with stroke onset greater than 24-h all had absent HAS. Conclusions No evidence of a correlation between time of stroke onset and presence of a HAS within the first 24-h post acute ischaemic stroke was identified. The HAS was associated with a higher NIHSS score at presentation.
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Affiliation(s)
| | - Leonid Churilov
- Florey Institute of Neuroscience and Mental Health, Melbourne, Australia.
| | - Peter Mitchell
- Department of Radiology, Neurointervention Service, Royal Melbourne Hospital, Parkville, Victoria, 3050, Australia.
| | - Richard Dowling
- Department of Radiology, Neurointervention Service, Royal Melbourne Hospital, Parkville, Victoria, 3050, Australia.
| | - Bernard Yan
- Department of Radiology, Neurointervention Service, Royal Melbourne Hospital, Parkville, Victoria, 3050, Australia. .,Department of Medicine, Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Australia.
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Hlavica M, Diepers M, Garcia-Esperon C, Ineichen BV, Nedeltchev K, Kahles T, Remonda L. Pharmacological recanalization therapy in acute ischemic stroke – Evolution, current state and perspectives of intravenous and intra-arterial thrombolysis. J Neuroradiol 2015; 42:30-46. [DOI: 10.1016/j.neurad.2014.11.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2014] [Accepted: 11/07/2014] [Indexed: 10/24/2022]
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Singer OC, Berkefeld J, Nolte CH, Bohner G, Haring HP, Trenkler J, Gröschel K, Müller-Forell W, Niederkorn K, Deutschmann H, Neumann-Haefelin T, Hohmann C, Bussmeyer M, Mpotsaris A, Stoll A, Bormann A, Brenck J, Schlamann MU, Jander S, Turowski B, Petzold GC, Urbach H, Liebeskind DS. Mechanical recanalization in basilar artery occlusion: The ENDOSTROKE study. Ann Neurol 2015; 77:415-24. [DOI: 10.1002/ana.24336] [Citation(s) in RCA: 225] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2014] [Revised: 11/28/2014] [Accepted: 12/07/2014] [Indexed: 02/04/2023]
Affiliation(s)
| | | | | | - Georg Bohner
- Institute of Diagnostic and Interventional Radiology and Nuclear Medicine; Charité Hospital; Berlin Germany
| | | | | | - Klaus Gröschel
- Department of Neurology; Mainz University Hospital; Mainz Germany
| | | | - Kurt Niederkorn
- Department of Neurology; Division of Neuroradiology, Medical University of Graz; Graz Austria
| | - Hannes Deutschmann
- Department of Radiology; Division of Neuroradiology, Medical University of Graz; Graz Austria
| | | | - Carina Hohmann
- Departments of Neurology and Pharmacy; Fulda Hospital; Fulda Germany
| | | | - Anastasios Mpotsaris
- Institute of Radiology and Neuroradiology; Vest Hospital; Recklinghausen Germany
- Institute of Radiology; Division of Neuroradiology, Cologne University Hospital; Cologne Germany
| | - Anett Stoll
- Department of Neurology; Altenburger Land Hospital; Altenburg Germany
| | - Albrecht Bormann
- Institute of Radiology; Altenburger Land Hospital; Altenburg Germany
| | - Johannes Brenck
- Department of Neurology; Essen University Hospital; Essen Germany
| | - Marc U. Schlamann
- Institute of Diagnostic and Interventional Radiology and Neuroradiology; Essen University Hospital; Essen Germany
| | - Sebastian Jander
- Department of Neurology; Medical Faculty, Heinrich Heine University; Düsseldorf Germany
| | - Bernd Turowski
- Institute of Diagnostic and Interventional Radiology; Medical Faculty, Heinrich Heine University; Düsseldorf Germany
| | - Gabor C. Petzold
- German Center for Neurodegenerative Diseases and Department of Neurology; Bonn University Hospital; Bonn Germany
| | - Horst Urbach
- Department of Neuroradiology; Freiburg University Hospital; Freiburg Germany
| | - David S. Liebeskind
- UCLA Stroke Center and Department of Neurology; University of California, Los Angeles; Los Angeles CA
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Dornak T, Herzig R, Sanak D, Skoloudik D. Management of acute basilar artery occlusion: Should any treatment strategy prevail? Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2014; 158:528-34. [DOI: 10.5507/bp.2013.075] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2013] [Accepted: 09/20/2013] [Indexed: 11/23/2022] Open
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Eom YI, Hwang YH, Hong JM, Choi JW, Lim YC, Kang DH, Kim YW, Kim YS, Kim SY, Lee JS. Forced arterial suction thrombectomy with the penumbra reperfusion catheter in acute basilar artery occlusion: a retrospective comparison study in 2 Korean university hospitals. AJNR Am J Neuroradiol 2014; 35:2354-9. [PMID: 25034774 DOI: 10.3174/ajnr.a4045] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE A performance of forced arterial suction thrombectomy was not reported for the treatment of acute basilar artery occlusion. This study compared revascularization performance between intra-arterial fibrinolytic treatment and forced arterial suction thrombectomy with a Penumbra reperfusion catheter in patients with acute basilar artery occlusion. MATERIALS AND METHODS Fifty-seven patients with acute basilar artery occlusion were treated with intra-arterial fibrinolysis (n = 25) or forced arterial suction thrombectomy (n = 32). Baseline characteristics, successful revascularization rate, and clinical outcomes were compared between the groups. RESULTS Baseline characteristics, the frequency of patients receiving intravenous recombinant tissue plasminogen activator, and mean time interval between symptom onset and femoral puncture did not differ between groups. The forced arterial suction thrombectomy group had a shorter procedure duration (75.5 minutes versus 113.3 minutes, P = .016) and higher successful revascularization rate (88% versus 60%, P = .017) than the fibrinolysis group. Fair outcome, indicated by a modified Rankin Scale 0-3, at 3 months was achieved in 34% of patients undergoing forced arterial suction thrombectomy and 8% of patients undergoing fibrinolysis (P = .019), and the mortality rate was significantly higher in the fibrinolysis group (25% versus 68%, P = .001). Multiple logistic regression analysis identified the forced arterial suction thrombectomy method as an independent predictor of fair outcome with adjustment for age, sex, initial NIHSS score, and the use of intravenous recombinant tissue plasminogen activator (odds ratio, 7.768; 95% CI, 1.246-48.416; P = .028). CONCLUSIONS In acute basilar artery occlusion, forced arterial suction thrombectomy demonstrated a higher revascularization rate and improved clinical outcome compared with traditional intra-arterial fibrinolysis. Further clinical trials with the newer Penumbra catheter are warranted.
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Affiliation(s)
- Y-I Eom
- From the Departments of Neurology (Y.-I.E., J.M.H., J.S.L.)
| | - Y-H Hwang
- Departments of Neurology (Y.-H.H., Y.-W.K.)
| | - J M Hong
- From the Departments of Neurology (Y.-I.E., J.M.H., J.S.L.)
| | - J W Choi
- Radiology (J.W.C., S.Y.K.), Ajou University Medical Center, Suwon, South Korea
| | - Y C Lim
- Department of Neurosurgery (Y.C.L.), Ajou University Hospital, Daegu, South Korea
| | - D-H Kang
- Neurosurgery (D.-H.K.) Radiology (D.-H.K., Y.-W.K., Y.-S.K.), Kyungpook National University Hospital, Daegu, South Korea
| | - Y-W Kim
- Departments of Neurology (Y.-H.H., Y.-W.K.) Radiology (D.-H.K., Y.-W.K., Y.-S.K.), Kyungpook National University Hospital, Daegu, South Korea
| | - Y-S Kim
- Radiology (D.-H.K., Y.-W.K., Y.-S.K.), Kyungpook National University Hospital, Daegu, South Korea
| | - S Y Kim
- Radiology (J.W.C., S.Y.K.), Ajou University Medical Center, Suwon, South Korea
| | - J S Lee
- From the Departments of Neurology (Y.-I.E., J.M.H., J.S.L.)
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Gerber JC, Miaux YJ, von Kummer R. Scoring flow restoration in cerebral angiograms after endovascular revascularization in acute ischemic stroke patients. Neuroradiology 2014; 57:227-40. [PMID: 25407716 DOI: 10.1007/s00234-014-1460-x] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2014] [Accepted: 10/30/2014] [Indexed: 12/18/2022]
Abstract
Endovascular revascularization techniques are increasingly used to treat arterial occlusions in patients with acute ischemic stroke. To monitor and communicate treatment results, a valid, reproducible, and clinically relevant, yet easy to use grading scheme of arterial recanalization and tissue reperfusion for digital subtraction angiography is needed. An ideal scoring system would consider the target arterial lesion, the perfusion deficit, and the collateral status before treatment and measure recanalization, reperfusion, early venous shunting, vasospasm, as well as distal embolization after flow restoration. Currently, a variety of different flow restoration scales are in use, including the Thrombolysis in Myocardial Infarction scoring system, the Thrombolysis in Cerebral Infarction score, and the Arterial Occlusive Lesion score, which describe the local recanalization result. These scores are not used homogeneously throughout the literature, are often modified and not fully documented, which make them inept to compare treatment effects across studies. In addition, none of these scores cover all of the above-mentioned aspects, nor are they able to describe satisfactorily all relevant angiographic findings, and data on their reliability and predictive power regarding clinical outcome are sparse. We aimed to review and illustrate the different revascularization scales, discuss their advantages and limitations as well as the available data regarding standardization, reliability testing, and outcome prediction. In addition, we give examples for the use of the scales and show potential pitfalls.
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Affiliation(s)
- Johannes C Gerber
- Neuroradiology, Medizinische Fakultät Carl Gustav Carus, Technische Universität Dresden, Fetscherstrasse 74, 01307, Dresden, Germany,
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Strbian D, Sairanen T, Silvennoinen H, Salonen O, Lindsberg PJ. Intravenous thrombolysis of basilar artery occlusion: thrombus length versus recanalization success. Stroke 2014; 45:1733-8. [PMID: 24781081 DOI: 10.1161/strokeaha.114.004884] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE In middle cerebral artery occlusion, probability of recanalization after intravenous tissue-type plasminogen activator thrombolysis (IVT) was reported to drop <1% for thrombi exceeding 8 mm. We aimed to evaluate the effect of thrombus length and location on success of recanalization after IVT in basilar artery occlusion. METHODS We evaluated 164 consecutive patients with angiography-proven basilar artery occlusion and available thrombus length. We excluded 24 patients who underwent endovascular treatment. All included patients (n=140) received IVT. Thrombolysis in myocardial infarction 2 to 3 was considered as successful recanalization. RESULTS Of the 140 included patients, 37 (26.4%) lacked post-treatment angiography, mostly because of early death. Of the remaining 103 patients, those with recanalization had shorter thrombi (median, 5.5 mm and mean, 9.7 mm) when compared with those with nonrecanalized (median, 15.0 mm and mean, 16.6 mm; P<0.001). Thrombi shorter than 10 mm had 70% to 80% probability of recanalization, whereas 10 to 20 mm, 20 to 30 mm, and >30 mm long thrombi had probabilities of 50% to 70%, 30% to 50%, and 20% to 30%, respectively. Patients with thrombi <10 mm (n=52) and recanalization had more frequently top-of-the basilar (92.5%) and less frequently caudal or midbasilar (7.5%) clot location (P=0.01). In multivariable analysis, thrombus length was independently associated with recanalization (P=0.001). Their relationship remained linear across all lengths. CONCLUSIONS Although recanalization of basilar artery occlusion with IVT depends on thrombus length, its probability even in patients with thrombi >30 mm (20%-30%) was substantially higher than minimal recanalization of middle cerebral artery thrombi exceeding 8 mm. There was no threshold length, beyond which basilar artery occlusion recanalization with IVT could ad hoc be deemed hopeless.
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Affiliation(s)
- Daniel Strbian
- From the Department of Neurology (D.S., T.S., P.J.L.) and Helsinki Medical Imaging Center (H.S., O.S.), Helsinki University Central Hospital, Helsinki, Finland; and Molecular Neurology, Research Program Unit, Biomedicum Helsinki, and Department of Clinical Neurosciences, University of Helsinki, Helsinki, Finland (P.J.L.).
| | - Tiina Sairanen
- From the Department of Neurology (D.S., T.S., P.J.L.) and Helsinki Medical Imaging Center (H.S., O.S.), Helsinki University Central Hospital, Helsinki, Finland; and Molecular Neurology, Research Program Unit, Biomedicum Helsinki, and Department of Clinical Neurosciences, University of Helsinki, Helsinki, Finland (P.J.L.)
| | - Heli Silvennoinen
- From the Department of Neurology (D.S., T.S., P.J.L.) and Helsinki Medical Imaging Center (H.S., O.S.), Helsinki University Central Hospital, Helsinki, Finland; and Molecular Neurology, Research Program Unit, Biomedicum Helsinki, and Department of Clinical Neurosciences, University of Helsinki, Helsinki, Finland (P.J.L.)
| | - Oili Salonen
- From the Department of Neurology (D.S., T.S., P.J.L.) and Helsinki Medical Imaging Center (H.S., O.S.), Helsinki University Central Hospital, Helsinki, Finland; and Molecular Neurology, Research Program Unit, Biomedicum Helsinki, and Department of Clinical Neurosciences, University of Helsinki, Helsinki, Finland (P.J.L.)
| | - Perttu J Lindsberg
- From the Department of Neurology (D.S., T.S., P.J.L.) and Helsinki Medical Imaging Center (H.S., O.S.), Helsinki University Central Hospital, Helsinki, Finland; and Molecular Neurology, Research Program Unit, Biomedicum Helsinki, and Department of Clinical Neurosciences, University of Helsinki, Helsinki, Finland (P.J.L.)
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Mourand I, Machi P, Nogué E, Arquizan C, Costalat V, Picot MC, Bonafé A, Milhaud D. Diffusion-weighted imaging score of the brain stem: A predictor of outcome in acute basilar artery occlusion treated with the Solitaire FR device. AJNR Am J Neuroradiol 2014; 35:1117-23. [PMID: 24524920 DOI: 10.3174/ajnr.a3870] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND PURPOSE The prognosis for ischemic stroke due to acute basilar artery occlusion is very poor: Early recanalization remains the main factor that can improve outcomes. The baseline extent of brain stem ischemic damage can also influence outcomes. We evaluated the validity of an easy-to-use DWI score to predict clinical outcome in patients with acute basilar artery occlusion treated by mechanical thrombectomy. MATERIALS AND METHODS We analyzed the baseline clinical and DWI parameters of 31 patients with acute basilar artery occlusion, treated within 24 hours of symptom onset by using a Solitaire FR device. The DWI score of the brain stem was assessed with a 12-point semiquantitative score that separately considered each side of the medulla, pons, and midbrain. Clinical outcome was assessed at 180 days by using the mRS. According to receiver operating characteristic analyses, the cutoff score determined the optimal positive predictive value for outcome. The Spearman rank correlation coefficient assessed the correlation between the DWI brain stem score and baseline characteristics. RESULTS Successful recanalization (Thrombolysis in Cerebral Infarction 3-2b) was achieved in 23 patients (74%). A favorable outcome (mRS ≤ 2) was observed in 11 patients (35%). An optimal DWI brain stem score of <3 predicted a favorable outcome. The probability of a very poor outcome (mRS ≥ 5) if the DWI brain stem score was ≥5 reached 80% (positive predictive value) and 100% if this score was ≥6. Interobserver reliability of the DWI brain stem score was excellent, with an intraclass correlation coefficient of 0.97 (95% CI, 0.96-0.99). The DWI brain stem score was significantly associated with baseline tetraplegia (P = .001) and coma (P = .005). CONCLUSIONS In patients with acute basilar artery occlusion treated by mechanical thrombectomy, the baseline DWI brain lesion score seems to predict clinical outcome.
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Affiliation(s)
- I Mourand
- From the Departments of Neurology (I.M., C.A., D.M.)
| | - P Machi
- Neuroradiology (P.M., V.C., A.B.), University Hospital Center of Montpellier, Gui de Chauliac Hospital, Montpellier, France
| | - E Nogué
- Unit of Clinical Research and Epidemiology (E.N., M.-C.P.), Department of Medical Information, University Hospital Center of Montpellier, Lapeyronie Hospital, Montpellier, France
| | - C Arquizan
- From the Departments of Neurology (I.M., C.A., D.M.)
| | - V Costalat
- Neuroradiology (P.M., V.C., A.B.), University Hospital Center of Montpellier, Gui de Chauliac Hospital, Montpellier, France
| | - M-C Picot
- Unit of Clinical Research and Epidemiology (E.N., M.-C.P.), Department of Medical Information, University Hospital Center of Montpellier, Lapeyronie Hospital, Montpellier, France
| | - A Bonafé
- Neuroradiology (P.M., V.C., A.B.), University Hospital Center of Montpellier, Gui de Chauliac Hospital, Montpellier, France
| | - D Milhaud
- From the Departments of Neurology (I.M., C.A., D.M.)
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Quinn TJ, Dawson J, Lees KR. Past, present and future of alteplase for acute ischemic stroke. Expert Rev Neurother 2014; 8:181-92. [DOI: 10.1586/14737175.8.2.181] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
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Lee WI, Mitchell P, Dowling R, Yan B. Clinical factors are significant predictors of outcome post intra-arterial therapy for acute ischaemic stroke: a review. J Neuroradiol 2013; 40:315-25. [PMID: 24239412 DOI: 10.1016/j.neurad.2013.09.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2013] [Revised: 08/16/2013] [Accepted: 09/17/2013] [Indexed: 11/28/2022]
Abstract
Intra-arterial therapy (IAT) provides superior recanalisation rates, approaching 80% for the current generation of endovascular devices. Furthermore, IAT may allow for an extended therapeutic window beyond that which is permissible for intravenous thrombolysis. However, the improved recanalisation rates are not matched by concordant clinical outcomes, leading to an invigorated search for predictors of clinical outcome. There is emerging evidence that younger age, mild-moderate stroke, and shorter vessel occlusion time are associated with better clinical outcome after IAT. This review aims to critically appraise current evidence that may inform changes in the selective inclusion of clinical factors in the future design and trial of IAT.
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Affiliation(s)
- Wei-I Lee
- Austin Hospital, 145 Studley Road, Heidelberg, Victoria 3084, Australia
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Zaidat OO, Yoo AJ, Khatri P, Tomsick TA, von Kummer R, Saver JL, Marks MP, Prabhakaran S, Kallmes DF, Fitzsimmons BFM, Mocco J, Wardlaw JM, Barnwell SL, Jovin TG, Linfante I, Siddiqui AH, Alexander MJ, Hirsch JA, Wintermark M, Albers G, Woo HH, Heck DV, Lev M, Aviv R, Hacke W, Warach S, Broderick J, Derdeyn CP, Furlan A, Nogueira RG, Yavagal DR, Goyal M, Demchuk AM, Bendszus M, Liebeskind DS. Recommendations on angiographic revascularization grading standards for acute ischemic stroke: a consensus statement. Stroke 2013; 44:2650-63. [PMID: 23920012 PMCID: PMC4160883 DOI: 10.1161/strokeaha.113.001972] [Citation(s) in RCA: 1166] [Impact Index Per Article: 106.0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Affiliation(s)
- Osama O Zaidat
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, USA.
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Brekenfeld C, Remonda L, Nedeltchev K, v Bredow F, Ozdoba C, Wiest R, Arnold M, Mattle HP, Schroth G. Endovascular neuroradiological treatment of acute ischemic stroke: techniques and results in 350 patients. Neurol Res 2013; 27 Suppl 1:S29-35. [PMID: 16197821 DOI: 10.1179/016164105x35549] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
BACKGROUND AND OBJECTIVES Randomized trials have demonstrated the benefit of intra-arterial thrombolysis (IAT) for treatment of acute ischemic stroke, if performed within 6 hours of symptom onset. METHODS We report our experience with 350 acute stroke patients who were treated with IAT using urokinase at a single center. Predictors of favorable outcome were low National Institute of Health Stroke Scale (NIHSS) at admission (p<0.001), good collaterals (p<0.001) and successful endovascular recanalization (p<0.001). Recanalization rates of more than 75% could be achieved, when additional endovascular techniques such as mechanical fragmentation of the thrombus, thromboaspiration, percutaneous transluminal angioplasty, and implantation of stents were used. RESULTS AND CONCLUSIONS Predictors of unfavorable outcome were diabetes mellitus (p<0.001) and symptomatic hemorrhages (p<0.001). The latter occurred in 5% of our population. Preliminary results of new techniques including sonothrombolysis, angiojet aspiration, and laser recanalization of thromboembolic occlusions are discussed.
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Affiliation(s)
- Caspar Brekenfeld
- Institute of Diagnostic and Interventional Neuroradiology, University of Bern, Inselspital, Switzerland
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Leker RR, Grigoriadis S, Cohen JE. Endovascular reperfusion therapy for acute ischemic stroke: a meta-analysis. Neurol Res 2013; 32:787-91. [DOI: 10.1179/174313209x382430] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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van der Hoeven EJRJ, Schonewille WJ, Vos JA, Algra A, Audebert HJ, Berge E, Ciccone A, Mazighi M, Michel P, Muir KW, Obach V, Puetz V, Wijman CAC, Zini A, Kappelle JL. The Basilar Artery International Cooperation Study (BASICS): study protocol for a randomised controlled trial. Trials 2013; 14:200. [PMID: 23835026 PMCID: PMC3728222 DOI: 10.1186/1745-6215-14-200] [Citation(s) in RCA: 108] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2013] [Accepted: 07/02/2013] [Indexed: 11/13/2022] Open
Abstract
Background Despite recent advances in acute stroke treatment, basilar artery occlusion (BAO) is associated with a death or disability rate of close to 70%. Randomised trials have shown the safety and efficacy of intravenous thrombolysis (IVT) given within 4.5 h and have shown promising results of intra-arterial thrombolysis given within 6 h of symptom onset of acute ischaemic stroke, but these results do not directly apply to patients with an acute BAO because only few, if any, of these patients were included in randomised acute stroke trials. Recently the results of the Basilar Artery International Cooperation Study (BASICS), a prospective registry of patients with acute symptomatic BAO challenged the often-held assumption that intra-arterial treatment (IAT) is superior to IVT. Our observations in the BASICS registry underscore that we continue to lack a proven treatment modality for patients with an acute BAO and that current clinical practice varies widely. Design BASICS is a randomised controlled, multicentre, open label, phase III intervention trial with blinded outcome assessment, investigating the efficacy and safety of additional IAT after IVT in patients with BAO. The trial targets to include 750 patients, aged 18 to 85 years, with CT angiography or MR angiography confirmed BAO treated with IVT. Patients will be randomised between additional IAT followed by optimal medical care versus optimal medical care alone. IVT has to be initiated within 4.5 h from estimated time of BAO and IAT within 6 h. The primary outcome parameter will be favourable outcome at day 90 defined as a modified Rankin Scale score of 0–3. Discussion The BASICS registry was observational and has all the limitations of a non-randomised study. As the IAT approach becomes increasingly available and frequently utilised an adequately powered randomised controlled phase III trial investigating the added value of this therapy in patients with an acute symptomatic BAO is needed (clinicaltrials.gov: NCT01717755).
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Mourand I, Machi P, Milhaud D, Picot MC, Lobotesis K, Arquizan C, Costalat V, Héroum C, Sablot D, Bouly S, Lalu T, Bonafé A. Mechanical thrombectomy with the Solitaire device in acute basilar artery occlusion. J Neurointerv Surg 2013; 6:200-4. [PMID: 23645572 DOI: 10.1136/neurintsurg-2012-010629] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
AIMS To evaluate the efficacy and safety of mechanical thrombectomy with the Solitaire FR device in revascularization of patients with acute basilar artery occlusion (ABAO) and to identify the predictive factors for clinical outcome. METHODS This prospective single-center study included 31 patients with acute ischemic stroke attributable to ABAO treated within the first 24 h after onset of symptoms with the Solitaire device. Nineteen patients simultaneously received intravenous thrombolysis. Recanalization rates after stent retrieval were determined and the clinical outcome and mortality rate were assessed 180 days after treatment. RESULTS The mean ±SD age of the patients was 61±17 years, the median prethrombectomy NIH Stroke Scale score was 38 (IQR 9-38) and the median Glasgow Coma Scale (GCS) score was 7 (IQR 4-14). Successful recanalization (TICI 3 or 2b) was achieved in 23 patients (74%). Five symptomatic intracranial hemorrhages were related to the procedure. Ten symptomatic distal migrations of thrombotic material occurred. A favorable outcome, defined as a modified Rankin Score (mRS) of 0-2, was observed in 35% of patients (11/31). Overall mortality rate was 32% (10/31). In the univariate analysis, elevated baseline glucose (p=0.008) was significantly associated with a poor outcome (mRS >2), whereas a tendency towards significance was observed with age (p=0.06), GCS on admission (p=0.07) and symptom-related lesions on T2 sequences (p=0.10). Patients with successful recanalization tended to have a better outcome (p=0.20). CONCLUSION Mechanical thrombectomy with the Solitaire FR device can rapidly and effectively contribute to a high rate of recanalization and improve functional outcome in patients with ABAO and has an acceptable complication rate.
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Affiliation(s)
- Isabelle Mourand
- Neurology Department, University Hospital Center of Montpellier, Gui de Chauliac Hospital, Montpellier, France
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Lagman-Bartolome AM, Pontigon AM, Moharir M, MacGregor DL, Askalan R, Yau I, Deveber G. Basilar artery strokes in children: good outcomes with conservative medical treatment. Dev Med Child Neurol 2013; 55:434-9. [PMID: 23398238 DOI: 10.1111/dmcn.12092] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2012] [Accepted: 11/09/2012] [Indexed: 12/20/2022]
Abstract
AIM To describe outcomes and outcome predictors in childhood basilar artery stroke (BAS). METHOD We prospectively enrolled children with BAS with or without basilar artery occlusion (BAO) in the Toronto Children's Stroke Registry from 1992 to 2009. We assessed presenting features and outcomes including Pediatric Stroke Outcome Measure scores. RESULTS Among 578 children with acute arterial ischemic stroke, 27 had BAS (4.6% including neonates, 6% excluding neonates). Twenty-four (14 males, 10 females) children met study criteria (mean age at stroke was 8 y 10 mo; range 0-17 y). Eleven children had BAO. Aspirin or anticoagulation was given to 15 children. None received tissue plasminogen activator or endovascular treatments. At mean follow-up (3 y 2 mo, range 1 mo-11 y 8 mo), 12 had a 'good outcome' (seven normal, five insignificant deficit) and 12 had 'poor outcome' (10 moderate or severe deficit, two acute deaths). Larger infarct size (≥50% of axial brainstem diameter) independently predicted poor outcome (p=0.02; odds ratio 21.2, 95% confidence interval 1.6-274.9) but not BAO, altered level of consciousness, or age. INTERPRETATION Compared with adults, in childhood BAS death is rare and survivors frequently have good outcomes. Aggressive endovascular interventions may not be justifiable in this population.
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Titomanlio L, Zanin A, Sachs P, Khaled J, Elmaleh M, Blanc R, Piotin M. Pediatric ischemic stroke: acute management and areas of research. J Pediatr 2013; 162:227-35.e1. [PMID: 23153863 DOI: 10.1016/j.jpeds.2012.09.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/06/2012] [Revised: 08/08/2012] [Accepted: 09/10/2012] [Indexed: 11/28/2022]
Affiliation(s)
- Luigi Titomanlio
- Pediatric Emergency Department, APHP, Robert Debré Hospital, Paris Diderot University, Paris, France.
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Jauch EC, Saver JL, Adams HP, Bruno A, Connors JJB, Demaerschalk BM, Khatri P, McMullan PW, Qureshi AI, Rosenfield K, Scott PA, Summers DR, Wang DZ, Wintermark M, Yonas H. Guidelines for the early management of patients with acute ischemic stroke: a guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2013; 44:870-947. [PMID: 23370205 DOI: 10.1161/str.0b013e318284056a] [Citation(s) in RCA: 3227] [Impact Index Per Article: 293.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND PURPOSE The authors present an overview of the current evidence and management recommendations for evaluation and treatment of adults with acute ischemic stroke. The intended audiences are prehospital care providers, physicians, allied health professionals, and hospital administrators responsible for the care of acute ischemic stroke patients within the first 48 hours from stroke onset. These guidelines supersede the prior 2007 guidelines and 2009 updates. METHODS Members of the writing committee were appointed by the American Stroke Association Stroke Council's Scientific Statement Oversight Committee, representing various areas of medical expertise. Strict adherence to the American Heart Association conflict of interest policy was maintained throughout the consensus process. Panel members were assigned topics relevant to their areas of expertise, reviewed the stroke literature with emphasis on publications since the prior guidelines, and drafted recommendations in accordance with the American Heart Association Stroke Council's Level of Evidence grading algorithm. RESULTS The goal of these guidelines is to limit the morbidity and mortality associated with stroke. The guidelines support the overarching concept of stroke systems of care and detail aspects of stroke care from patient recognition; emergency medical services activation, transport, and triage; through the initial hours in the emergency department and stroke unit. The guideline discusses early stroke evaluation and general medical care, as well as ischemic stroke, specific interventions such as reperfusion strategies, and general physiological optimization for cerebral resuscitation. CONCLUSIONS Because many of the recommendations are based on limited data, additional research on treatment of acute ischemic stroke remains urgently needed.
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