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Bardutzky J, Kollmar R, Al-Rawi F, Lambeck J, Fazel M, Taschner C, Niesen WD. COmbination of Targeted temperature management and Thrombectomy after acute Ischemic Stroke (COTTIS): a pilot study. Stroke Vasc Neurol 2024; 9:258-267. [PMID: 37612052 PMCID: PMC11221305 DOI: 10.1136/svn-2023-002420] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 08/05/2023] [Indexed: 08/25/2023] Open
Abstract
BACKGROUND To evaluate the feasibility and safety of a fast initiation of cooling to a target temperature of 35°C by means of transnasal cooling in patients with anterior circulation large vessel occlusion (LVO) undergoing endovascular thrombectomy (EVT). METHODS Patients with an LVO onset of <24 hour who had an indication for EVT were included in the study. Transnasal cooling (RhinoChill) was initiated immediately after the patient was intubated for EVT and continued until an oesophageal target temperature of 35°C was reached. Hypothermia was maintained with surface cooling for 6-hour postrecanalisation, followed by active rewarming (+0.2°C/hour). The primary outcome was defined as the time required to reach 35°C, while secondary outcomes comprised clinical, radiological and safety parameters. RESULTS Twenty-two patients (median age, 77 years) were included in the study (14 received additional thrombolysis, 4 additional stenting of the proximal internal carotid artery). The median time intervals were 309 min for last-seen-normal-to-groin, 58 min for door-to-cooling-initiation, 65 min for door-to-groin and 123 min for door-to-recanalisation. The target temperature of 35°C was reached within 30 min (range 13-78 min), corresponding to a cooling rate of 2.6 °C/hour. On recanalisation, 86% of the patients had a body temperature of ≤35°C. The median National Institutes of Health Stroke Scale at admission was 15 and improved to 2 by day 7, and 68% of patients had a good outcome (modified Rankin Scale 0-2) at 3 months. Postprocedure complications included asymptomatic bradycardia (32%), pneumonia (18%) and asymptomatic haemorrhagic transformation (18%). CONCLUSION The combined application of hypothermia and thrombectomy was found to be feasible in sedated and ventilated patents. Adverse events were comparable to those previously described for EVT in the absence of hypothermia. The effect of this procedure will next be evaluated in the randomised COmbination of Targeted temperature management and Thrombectomy after acute Ischemic Stroke-2 trial.
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Affiliation(s)
- Jürgen Bardutzky
- Department of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Rainer Kollmar
- Neurology and Neurointensive Care, Darmstadt Hospital, Darmstadt, Germany
| | - Forat Al-Rawi
- Department of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Johann Lambeck
- Department of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | - Christian Taschner
- Department of Neuroradiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Wolf-Dirk Niesen
- Department of Neurology and Neurophysiology, Medical Center - University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg, Germany
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Schmidt-Pogoda A, Kaesmacher J, Bonberg N, Werring N, Strecker JK, Koecke MHM, Beuker C, Gralla J, Meier R, Wiendl H, Minnerup H, Fischer U, Minnerup J. The dilemma of neuroprotection trials in times of successful endovascular recanalization. Front Neurol 2024; 15:1383494. [PMID: 38654740 PMCID: PMC11035835 DOI: 10.3389/fneur.2024.1383494] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2024] [Accepted: 03/25/2024] [Indexed: 04/26/2024] Open
Abstract
Background The "translational roadblock" between successful animal stroke studies and neutral clinical trials is usually attributed to conceptual weaknesses. However, we hypothesized that rodent studies cannot inform the human disease due to intrinsic pathophysiological differences between rodents and humans., i.e., differences in infarct evolution. Methods To verify our hypothesis, we employed a mixed study design and compared findings from meta-analyses of animal studies and a retrospective clinical cohort study. For animal data, we systematically searched pubmed to identify all rodent studies, in which stroke was induced by MCAO and at least two sequential MRI scans were performed for infarct volume assessment within the first two days. For clinical data, we included 107 consecutive stroke patients with large artery occlusion, who received MRI scans upon admission and one or two days later. Results Our preclinical meta-analyses included 50 studies with 676 animals. Untreated animals had a median post-reperfusion infarct volume growth of 74%. Neuroprotective treatments reduced this infarct volume growth to 23%. A retrospective clinical cohort study showed that stroke patients had a median infarct volume growth of only 2% after successful recanalization. Stroke patients with unsuccessful recanalization, by contrast, experienced a meaningful median infarct growth of 148%. Conclusion Our study shows that rodents have a significant post-reperfusion infarct growth, and that this post-reperfusion infarct growth is the target of neuroprotective treatments. Stroke patients with successful recanalization do not have such infarct growth and thus have no target for neuroprotection.
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Affiliation(s)
- Antje Schmidt-Pogoda
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Nadine Bonberg
- Institute of Epidemiology and Social Medicine, University of Münster, Münster, Germany
| | - Nils Werring
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Jan-Kolja Strecker
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Mailin Hannah Marie Koecke
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Carolin Beuker
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Raphael Meier
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Heinz Wiendl
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
| | - Heike Minnerup
- Institute of Epidemiology and Social Medicine, University of Münster, Münster, Germany
| | - Urs Fischer
- Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Jens Minnerup
- Department of Neurology with Institute of Translational Neurology, University of Münster, Münster, Germany
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3
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Zhang Z, Pu Y, Yu L, Bai H, Duan W, Liu X, Nie X, Wen Z, Zheng L, Hu X, Leng X, Pan Y, Petersen NH, Liu L. Deviation From Personalized Blood Pressure Targets Correlates With Worse Outcome After Successful Recanalization. J Am Heart Assoc 2024; 13:e033633. [PMID: 38533955 PMCID: PMC11179781 DOI: 10.1161/jaha.123.033633] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/20/2023] [Accepted: 02/28/2024] [Indexed: 03/28/2024]
Abstract
BACKGROUND Personalized blood pressure (BP) management for patients with acute ischemic stroke after successful endovascular thrombectomy lacks evidence. We aimed to investigate whether the deviation of BP from cerebral autoregulation limits is associated with worse outcomes. METHODS AND RESULTS We determined autoregulation by measuring mean velocity index and calculated the percentage of time and the burden (defined as the time-BP area) with BP outside the autoregulatory limits of each subject within 48 hours after endovascular thrombectomy. In total, 91 patients with large vessel occlusion stroke who had achieved successful recanalization were prospectively enrolled between May 2020 and February 2022. The burden with BP outside the autoregulatory limits was associated with poor outcome (modified Rankin Scale score 3-6) at 90 days (adjusted odds ratio, 1.28 [95% CI, 1.03-1.59]). The percentage of time with BP out of the autoregulatory limits was correlated with early neurological deterioration (National Institute of Health Stroke Scale scores increased ≥2 at 7 days) (adjusted odds ratio, 1.38 [95% CI, 1.04-1.83]). The burden of BP that decreased below the autoregulatory lower limit was associated with significant infarct growth (volume of infarct growth >11.6 mL) at 7 days (adjusted odds ratio, 1.21 [95% CI, 1.01-1.44]). The percentage of time that BP exceeded the autoregulatory upper limit was associated with symptomatic intracranial hemorrhage within 48 hours (adjusted odds ratio, 1.55 [95% CI, 1.02-2.34]). CONCLUSIONS Both the percentage of time and the burden of BP that deviates from the autoregulation-preserved range are associated with unfavorable clinical outcomes. This study highlights the potential benefits of autoregulation-guided BP management strategy after successful recanalization.
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Affiliation(s)
- Zhe Zhang
- Neurocritical Care Unit, Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- Center for Data Science, Nell Hodgson Woodruff School of NursingEmory UniversityAtlantaGA
| | - Yuehua Pu
- Neurocritical Care Unit, Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Lei Yu
- Neurocritical Care Unit, Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- Department of Neurology, Beijing Anzhen HospitalCapital Medical UniversityBeijingChina
| | - Haiwei Bai
- Neurocritical Care Unit, Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- Department of NeurologyThe Forth Hospital of Hebei Medical UniversityShijiazhuangHebeiChina
| | - Wanying Duan
- Neurocritical Care Unit, Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Xin Liu
- Neurocritical Care Unit, Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Ximing Nie
- Neurocritical Care Unit, Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Zhixuan Wen
- Neurocritical Care Unit, Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
| | - Lina Zheng
- Neurocritical Care Unit, Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- Division of Neurology, Department of Medicine & TherapeuticsChinese University of Hong Kong, Prince of Wales HospitalShatinHong Kong SAR
| | - Xiao Hu
- Center for Data Science, Nell Hodgson Woodruff School of NursingEmory UniversityAtlantaGA
| | - Xinyi Leng
- Division of Neurology, Department of Medicine & TherapeuticsChinese University of Hong Kong, Prince of Wales HospitalShatinHong Kong SAR
| | - Yuesong Pan
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan HospitalBeijingChina
| | - Nils H. Petersen
- Divisions of Neurocritical Care and Stroke, Department of NeurologyYale New Haven Hospital, Yale School of MedicineNew HavenCT
| | - Liping Liu
- Neurocritical Care Unit, Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina
- China National Clinical Research Center for Neurological DiseasesBeijing Tiantan HospitalBeijingChina
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4
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Konduri P, Cavalcante F, van Voorst H, Rinkel L, Kappelhof M, van Kranendonk K, Treurniet K, Emmer B, Coutinho J, Wolff L, Hofmeijer J, Uyttenboogaart M, van Zwam W, Roos Y, Majoie C, Marquering H. Role of intravenous alteplase on late lesion growth and clinical outcome after stroke treatment. J Cereb Blood Flow Metab 2023; 43:116-125. [PMID: 37017421 PMCID: PMC10638991 DOI: 10.1177/0271678x231167755] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 01/24/2023] [Accepted: 03/03/2023] [Indexed: 04/06/2023]
Abstract
Several acute ischemic stroke mechanisms that cause lesion growth continue after treatment which is detrimental to long-term clinical outcome. The potential role of intravenous alteplase treatment (IVT), a standard in stroke care, in cessing the physiological processes causing post-treatment lesion development is understudied. We analyzed patients from the MR CLEAN-NO IV trial with good quality 24-hour and 1-week follow-up Non-Contrast CT scans. We delineated hypo- and hyper-dense regions on the scans as lesion. We performed univariable logistic and linear regression to estimate the influence of IVT on the presence (growth > 0 ml) and extent of late lesion growth. The association between late lesion growth and mRS was assessed using ordinal logistic regression. Interaction analysis was performed to evaluate the influence of IVT on this association. Of the 63/116 were randomized to included patients, IVT. Median growth was 8.4(-0.88-26) ml. IVT was not significantly associated with the presence (OR: 1.24 (0.57-2.74, p = 0.59) or extent (β = 5.1(-8.8-19), p = 0.47) of growth. Late lesion growth was associated with worse clinical outcome (aOR: 0.85(0.76-0.95), p < 0.01; per 10 ml). IVT did not influence this association (p = 0.18). We did not find evidence that IVT influences late lesion growth or the relationship between growth and worse clinical outcome. Therapies to reduce lesion development are necessary.
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Affiliation(s)
- Praneeta Konduri
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Fabiano Cavalcante
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Henk van Voorst
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Leon Rinkel
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Katinka van Kranendonk
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Kilian Treurniet
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Department of Radiology, Haaglanden MC, The Hague, The Netherlands
| | - Bart Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Jonathan Coutinho
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Lennard Wolff
- Department of Radiology & Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Jeanette Hofmeijer
- Department of Neurology, Rijnstate Hospital, Arnhem, the Netherlands
- Department of Clinical Neurophysiology, University of Twente, Enschede, the Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, University Medical Center Groningen, Groningen, the Netherlands
| | - Wim van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
| | - Yvo Roos
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Charles Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - Henk Marquering
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
| | - on behalf of the MR CLEAN-NO IV Trial Investigators (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands)
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Department of Neurology, Amsterdam UMC, location University of Amsterdam, Amsterdam, the Netherlands
- Department of Radiology, Haaglanden MC, The Hague, The Netherlands
- Department of Radiology & Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands
- Department of Neurology, Rijnstate Hospital, Arnhem, the Netherlands
- Department of Clinical Neurophysiology, University of Twente, Enschede, the Netherlands
- Department of Neurology, University Medical Center Groningen, Groningen, the Netherlands
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, the Netherlands
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Mohammaden MH, Haussen DC, Pisani L, Al-Bayati AR, Bhatt NR, Jillella DV, Bianchi NA, Belagaje SR, Frankel MR, Nogueira RG. Characterizing Fast and Slow Progressors in Anterior Circulation Large Vessel Occlusion Strokes. Interv Neuroradiol 2023; 29:379-385. [PMID: 35379038 PMCID: PMC10399496 DOI: 10.1177/15910199221083100] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/31/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND AND PURPOSE Infarct growth rate (IGR) in acute ischemic stroke is highly variable. We sought to evaluate impact of symptom-reperfusion time on outcomes in patients undergoing mechanical thrombectomy (MT). METHODS A prospectively maintained database from January,2012-August,2020 was reviewed. All patients with isolated MCA-M1 occlusion who achieved complete reperfusion(mTICI2C-3), had a witnessed symptom onset and follow-up MRI were included. IGR was calculated as final infarct volume (FIV)(ml)/symptom onset to reperfusion time(hours) and was dichotomized according to the median value into slow-(SP) versus fast-progressors (FP). The primary analysis aimed to evaluate the impact of symptom-reperfusion time on 90-day mRS in SP and FP. Secondary analysis was performed to identify predictors of IGR. RESULTS A total of 137 patients were eligible for analysis. Mean age was 63 ± 15.4 years and median IGR was 5.13ml/hour. SP(n = 69) had higher median ASPECTS, lower median rCBF<30% lesion volume, higher proportion of favorable collaterals and hypoperfusion intensity ratio (HIR)<0.4, higher minimal mean arterial blood pressure before reperfusion, and lower rates of general anesthesia compared to FP(n = 68). Symptom-reperfusion time was comparable between both groups. SP had higher rates of 90-day mRS0-2(71.9%vs.38.9%,aOR;7.226,95%CI[2.431-21.482],p < 0.001) and lower median FIV. Symptom-reperfusion time was associated with 90-day mRS0-2 in FP (aOR;0.541,95%CI[0.309-0.946],p = 0.03) but not in SP (aOR;0.874,95%CI[0.742-1.056],p = 0.16). On multivariable analysis, high ASPECTS and favorable collaterals in the NCCT/CTA model, and low rCBF<30% and HIR<0.4 in the CTP model were independent predictors of SP. CONCLUSIONS The impact of symptom-reperfusion time on outcomes significantly varies across slow-versus fast-progressors. ASPECTS, collateral score, rCBF<30%, and HIR define stroke progression profile.
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Affiliation(s)
- Mahmoud H Mohammaden
- Department of Neurology, Marcus Stroke & Neuroscience Center, Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Diogo C Haussen
- Department of Neurology, Marcus Stroke & Neuroscience Center, Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Leonardo Pisani
- Department of Neurology, Marcus Stroke & Neuroscience Center, Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Alhamza R Al-Bayati
- Department of Neurology, Marcus Stroke & Neuroscience Center, Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Nirav R Bhatt
- Department of Neurology, Marcus Stroke & Neuroscience Center, Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Dinesh V Jillella
- Department of Neurology, Marcus Stroke & Neuroscience Center, Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Nicolas A Bianchi
- Department of Neurology, Marcus Stroke & Neuroscience Center, Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Samir R Belagaje
- Department of Neurology, Marcus Stroke & Neuroscience Center, Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Michael R Frankel
- Department of Neurology, Marcus Stroke & Neuroscience Center, Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Raul G Nogueira
- University of Pittsburg Medical Center, UPMC Stroke Institute, Pittsburg, PA, USA
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6
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Hong L, Ling Y, Zhang Y, Yang L, Li S, Liu X, Dong Q, Cheng X. Reperfusion measurements, treatment time, and outcomes in patients receiving endovascular treatment within 24 hours of last known well. CNS Neurosci Ther 2023; 29:1067-1074. [PMID: 36601659 PMCID: PMC10018078 DOI: 10.1111/cns.14080] [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: 07/08/2022] [Revised: 12/17/2022] [Accepted: 12/21/2022] [Indexed: 01/06/2023] Open
Abstract
AIMS The aim of this study was to explore the interaction between reperfusion and treatment time on the outcomes of patients undergoing endovascular treatment presenting within 24 h of last known well, and to compare the predictive ability of different reperfusion measurements on outcomes. METHODS Eligible patients from a single-center cohort were enrolled in this study. Reperfusion was assessed using reperfusion index (decreased volume of hypoperfusion lesion compared with baseline) measured by repeated perfusion imaging, and modified treatment in cerebral ischemia score measured by digital subtraction angiography, respectively. The interactions between reperfusion measurements and treatment time on outcomes were explored using multivariate-adjusted logistic and linear regression models. The predictive abilities of reperfusion measurements on outcomes were compared using area under the receiver operating characteristic curve (ROC-AUC) and values of R-square. RESULTS Reperfusion index and treatment time had significant interactions on 3-month modified Rankin Scale (mRS) 0-2 and infarct growth (p for interaction <0.05). Although the AUCs were statistically similar (AUCs of mRS 0-2 prediction, mTICI≥2b:0.63, mTICI≥2c:0.59, reperfusion index≥0.5:0.66, reperfusion index ≥0.9:0.73, P value of any of the two AUCs >0.05), reperfusion index≥0.9 showed the highest R-square values in outcome prediction (R-square values of 3-month mRS 0-2 and infarct growth = 0.21) among all the reperfusion measurements. CONCLUSION Treatment time mitigated the effect of reperfusion on outcomes of patients receiving endovascular treatment within 24 h of last known well. Reperfusion index≥0.9 might serve as a better proxy of good outcomes compared with other reperfusion measurements.
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Affiliation(s)
- Lan Hong
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Yifeng Ling
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Yiran Zhang
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Lumeng Yang
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Siyuan Li
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Xinyu Liu
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Qiang Dong
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Xin Cheng
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
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7
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Bani-Sadr A, Pavie D, Mechtouff L, Cappucci M, Hermier M, Ameli R, Derex L, De Bourguignon C, Cho TH, Eker O, Nighoghossian N, Berthezene Y. Brush sign and collateral supply as potential markers of large infarct growth after successful thrombectomy. Eur Radiol 2023; 33:4502-4509. [PMID: 36633674 DOI: 10.1007/s00330-022-09387-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 12/13/2022] [Accepted: 12/22/2022] [Indexed: 01/13/2023]
Abstract
OBJECTIVES To investigate the relationships between brush sign and cerebral collateral status on infarct growth after successful thrombectomy. METHODS HIBISCUS-STROKE cohort includes acute ischemic stroke patients treated with thrombectomy after MRI triage and undergoing a day-6 MRI including FLAIR images to quantify final infarct volume (FIV). Successful reperfusion was defined as a modified thrombolysis in cerebral infarction score ≥ 2B. Infarct growth was calculated by subtracting FIV from baseline ischemic core after co-registration and considered large (LIG) when > 11.6 mL. Brush sign was assessed on T2*-weighted-imaging and collaterals were assessed using the hypoperfusion intensity ratio, which is the volume of Time-To-Tmax (Tmax) ≥ 10 s divided by the volume of Tmax ≥ 6 s. Good collaterals were defined by a hypoperfusion intensity ratio < 0.4. RESULTS One hundred and twenty-nine patients were included, of whom 45 (34.9%) had a brush sign and 63 (48.8%) good collaterals. Brush sign was associated with greater infarct growth (p = 0.01) and larger FIV (p = 0.02). Good collaterals were associated with a smaller baseline ischemic core (p < 0.001), larger penumbra (p = 0.04), and smaller FIV (p < 0.001). Collateral status was not significantly associated with brush sign (p = 0.20) or with infarct growth (p = 0.67). Twenty-eight (22.5%) patients experienced LIG. Univariate regressions indicated that brush sign (odds ratio (OR) = 4.8; 95% confidence interval (CI): [1.9;13.3]; p = 0.004) and hemorrhagic transformation (OR = 1.7; 95%CI: [1.2;2.6]; p = 0.04) were predictive of LIG. In multivariate regression, only the brush sign remained predictive of LIG (OR = 5.2; 95%CI: [1.8-16.6], p = 0.006). CONCLUSIONS Brush sign is a predictor of LIG after successful thrombectomy and cerebral collateral status is not. KEY POINTS • Few predictors of ischemic growth are known in ischemic stroke patients achieving successful mechanical thrombectomy. • Our results suggest that the brush sign-a surrogate marker of severe hypoperfusion-is independently associated with large ischemic growth (> 11.6 mL) after successful thrombectomy whereas cerebral collateral status does not.
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Affiliation(s)
- Alexandre Bani-Sadr
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon. 59 Bd Pinel, 69500, Bron, France. .,CREATIS Laboratory, CNRS UMR 5220, INSERM U 5220, Claude Bernard Lyon I University. 7 Avenue Jean Capelle O, 69100, Villeurbanne, France.
| | - Dylan Pavie
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon. 59 Bd Pinel, 69500, Bron, France
| | - Laura Mechtouff
- Stroke Department, East Group Hospital, Hospices Civils de Lyon. 59 Bd Pinel, 69500, Bron, France.,CarMeN Laboratory, INSERM U1060, Claude Bernard Lyon I University, 59 Bd Pinel, 69500, Bron, France
| | - Matteo Cappucci
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon. 59 Bd Pinel, 69500, Bron, France
| | - Marc Hermier
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon. 59 Bd Pinel, 69500, Bron, France
| | - Roxana Ameli
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon. 59 Bd Pinel, 69500, Bron, France
| | - Laurent Derex
- Stroke Department, East Group Hospital, Hospices Civils de Lyon. 59 Bd Pinel, 69500, Bron, France.,Research On Healthcare Performance (RESHAPE), INSERM U 1290, Claude Bernard Lyon I University. Domaine Rockfeller, 8 Avenue Rockfeller, 69373 Cedex 08, Lyon, France
| | | | - Tae-Hee Cho
- Stroke Department, East Group Hospital, Hospices Civils de Lyon. 59 Bd Pinel, 69500, Bron, France.,CarMeN Laboratory, INSERM U1060, Claude Bernard Lyon I University, 59 Bd Pinel, 69500, Bron, France
| | - Omer Eker
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon. 59 Bd Pinel, 69500, Bron, France.,CREATIS Laboratory, CNRS UMR 5220, INSERM U 5220, Claude Bernard Lyon I University. 7 Avenue Jean Capelle O, 69100, Villeurbanne, France
| | - Norbert Nighoghossian
- Stroke Department, East Group Hospital, Hospices Civils de Lyon. 59 Bd Pinel, 69500, Bron, France.,CarMeN Laboratory, INSERM U1060, Claude Bernard Lyon I University, 59 Bd Pinel, 69500, Bron, France
| | - Yves Berthezene
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon. 59 Bd Pinel, 69500, Bron, France.,CREATIS Laboratory, CNRS UMR 5220, INSERM U 5220, Claude Bernard Lyon I University. 7 Avenue Jean Capelle O, 69100, Villeurbanne, France
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8
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Konduri P, Bucker A, Boers A, Dutra B, Samuels N, Treurniet K, Berkhemer O, Yoo A, van Zwam W, van Oostenbrugge R, van der Lugt A, Dippel D, Roos Y, Bot J, Majoie C, Marquering H. Risk factors of late lesion growth after acute ischemic stroke treatment. Front Neurol 2022; 13:977608. [PMID: 36277932 PMCID: PMC9581245 DOI: 10.3389/fneur.2022.977608] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 09/01/2022] [Indexed: 11/13/2022] Open
Abstract
Background Even days after treatment of acute ischemic stroke due to a large vessel occlusion, the infarct lesion continues to grow. This late, subacute growth is associated with unfavorable functional outcome. In this study, we aim to identify patient characteristics that are risk factors of late, subacute lesion growth. Methods Patients from the MR CLEAN trial cohort with good quality 24 h and 1-week follow up non-contrast CT scans were included. Late Lesion growth was defined as the difference between the ischemic lesion volume assessed after 1-week and 24-h. To identify risk factors, patient characteristics associated with lesion growth (categorized in quartiles) in univariable ordinal analysis (p < 0.1) were included in a multivariable ordinal regression model. Results In the 226 patients that were included, the median lesion growth was 22 (IQR 10–45) ml. In the multivariable model, lower collateral capacity [aOR: 0.62 (95% CI: 0.44–0.87); p = 0.01], longer time to treatment [aOR: 1.04 (1–1.08); p = 0.04], unsuccessful recanalization [aOR: 0.57 (95% CI: 0.34–0.97); p = 0.04], and larger midline shift [aOR: 1.18 (95% CI: 1.02–1.36); p = 0.02] were associated with late lesion growth. Conclusion Late, subacute, lesion growth occurring between 1 day and 1 week after ischemic stroke treatment is influenced by lower collateral capacity, longer time to treatment, unsuccessful recanalization, and larger midline shift. Notably, these risk factors are similar to the risk factors of acute lesion growth, suggesting that understanding and minimizing the effects of the predictors for late lesion growth could be beneficial to mitigate the effects of ischemia.
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Affiliation(s)
- Praneeta Konduri
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
- *Correspondence: Praneeta Konduri
| | - Amber Bucker
- Department of Radiology, University Medical Center Groningen, Groningen, Netherlands
| | - Anna Boers
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
- Nico-Lab, Amsterdam, Netherlands
| | - Bruna Dutra
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
| | - Noor Samuels
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
- Department of Public Health, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Kilian Treurniet
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
- Department of Radiology, Haaglanden Medisch Centrum, The Hague, Netherlands
| | - Olvert Berkhemer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Albert Yoo
- Department of Radiology, Texas Stroke Institute, Dallas-Fort Worth, Dallas, TX, United States
| | - Wim van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands
| | - Robert van Oostenbrugge
- Department of Neurology, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Diederik Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Yvo Roos
- Department of Neurology, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
| | - Joost Bot
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Vrije Universiteit van Amsterdam, Amsterdam, Netherlands
| | - Charles Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
| | - Henk Marquering
- Department of Biomedical Engineering and Physics, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Location AMC, Amsterdam, Netherlands
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9
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Tan Z, Parsons M, Bivard A, Sharma G, Mitchell P, Dowling R, Bush S, Churilov L, Xu A, Yan B. Comparison of Computed Tomography Perfusion and Multiphase Computed Tomography Angiogram in Predicting Clinical Outcomes in Endovascular Thrombectomy. Stroke 2022; 53:2926-2934. [PMID: 35748291 DOI: 10.1161/strokeaha.122.038576] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND In patients with acute stroke who undergo endovascular thrombectomy, the relative prognostic power of computed tomography perfusion (CTP) parameters compared with multiphase CT angiogram (mCTA) is unknown. We aimed to compare the predictive accuracy of mCTA and CTP parameters on clinical outcomes. METHODS We included patients with acute ischemic stroke who had anterior circulation large vessel occlusion within 24 hours of onset in Melbourne Brain Centre at the Royal Melbourne Hospital. All patients underwent CTP for endovascular thrombectomy, and the mCTA collateral score was determined using CTP-reconstructed mCTA images. The primary outcome was 90-day functional outcomes defined by modified Rankin Scale. Multivariable logistic regression models analyzed associations between mCTA and CTP parameters and 90-day functional outcomes. The ability to discriminate 90 days-functional outcomes was compared between mCTA collateral score and CTP parameters using receiver operating curve analysis and C statistics. RESULTS One hundred and twenty patients were included. The median age was 69 years (interquartile range, 60-79), the median baseline National Institutes of Health Stroke Scale score was 14 (interquartile range, 9-19). The baseline ischemic core volume, defined by CTP-based relative cerebral blood flow <30%, was associated with excellent functional outcome (modified Rankin Scale score 0-1; odds ratio, 0.942 [-0.897 to -0.989]; P=0.015) and poor functional outcome (modified Rankin Scale score 5-6; odds ratio, 1.032 [1.007-1.056]; P=0.010) at 90 days in the analysis of multivariable regression. There was no significant association between the mCTA score and excellent functional outcome (P=0.58) or poor functional outcome (P=0.155). The relative cerebral blood flow <30%-based regression model best fit the data for the 90-day poor functional outcome (C statistic, 0.834). CONCLUSIONS The CTP-based ischemic core volume may provide better discrimination for 90-day functional outcomes for patients with acute stroke undergoing endovascular thrombectomy than the mCTA collateral score.
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Affiliation(s)
- Zefeng Tan
- Department of Neurology, the First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, China (Z.T., A.X.).,Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Australia (Z.T., M.P., A.B., G.S., L.C., B.Y.).,Department of Neurology, the First People's Hospital of Foshan, China (Z.T.)
| | - Mark Parsons
- Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Australia (Z.T., M.P., A.B., G.S., L.C., B.Y.).,Neurointervention Service, Department of Radiology, Royal Melbourne Hospital, Australia (P.M., R.D., S.B., B.Y.)
| | - Andrew Bivard
- Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Australia (Z.T., M.P., A.B., G.S., L.C., B.Y.)
| | - Gagan Sharma
- Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Australia (Z.T., M.P., A.B., G.S., L.C., B.Y.)
| | - Peter Mitchell
- Neurointervention Service, Department of Radiology, Royal Melbourne Hospital, Australia (P.M., R.D., S.B., B.Y.)
| | - Richard Dowling
- Neurointervention Service, Department of Radiology, Royal Melbourne Hospital, Australia (P.M., R.D., S.B., B.Y.)
| | - Steven Bush
- Neurointervention Service, Department of Radiology, Royal Melbourne Hospital, Australia (P.M., R.D., S.B., B.Y.)
| | - Leonid Churilov
- Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Australia (Z.T., M.P., A.B., G.S., L.C., B.Y.)
| | - Anding Xu
- Department of Neurology, the First Affiliated Hospital, Jinan University, Guangzhou, Guangdong, China (Z.T., A.X.)
| | - Bernard Yan
- Melbourne Brain Centre at Royal Melbourne Hospital, University of Melbourne, Australia (Z.T., M.P., A.B., G.S., L.C., B.Y.).,Neurointervention Service, Department of Radiology, Royal Melbourne Hospital, Australia (P.M., R.D., S.B., B.Y.)
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10
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Giammello F, De Martino SRM, Simonetti L, Agati R, Battaglia S, Cirillo L, Gentile M, Migliaccio L, Forlivesi S, Romoli M, Princiotta C, Tonon C, Stagni S, Galluzzo S, Lodi R, Trimarchi G, Toscano A, Musolino RF, Zini A. Predictive value of Tmax perfusion maps on final core in acute ischemic stroke: an observational single-center study. LA RADIOLOGIA MEDICA 2022; 127:414-425. [PMID: 35226245 DOI: 10.1007/s11547-022-01467-8] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/20/2021] [Accepted: 02/01/2022] [Indexed: 12/30/2022]
Abstract
PURPOSE To assess utility of computed tomography perfusion (CTP) protocols for selection of patients with acute ischemic stroke (AIS) for reperfusive treatments and compare the diagnostic accuracy (ACC) in predicting follow-up infarction, using time-to-maximum (Tmax) maps. METHODS We retrospectively reviewed consecutive AIS patients evaluated for reperfusive treatments at comprehensive stroke center, employing a multimodal computed tomography. To assess prognostic accuracy of CTP summary maps in predicting final infarct area (FIA) in AIS patients, we assumed the best correlation between non-viable tissue (NVT) and FIA in early and fully recanalized patients and/or in patients with favorable clinical response (FCR). On the other hand, the tissue at risk (TAR) should better correlate with FIA in untreated patients and in treatment failure. RESULTS We enrolled 158 patients, for which CTP maps with Tmax thresholds of 9.5 s and 16 s, presented sensitivity of 82.5%, specificity of 74.6%, and ACC of 75.9%. In patients selected for perfusion deficit in anterior circulation territory, CTP-Tmax > 16 s has proven relatively reliable to identify NVT in FCR patients, with a tendency to overestimate NVT. Similarly, CTP-Tmax > 9.5 s was reliable for TAR, but it was overestimated comparing to FIA, in patients with unfavorable outcomes. CONCLUSIONS In our experience, Tmax thresholds have proven sufficiently reliable to identify global hypoperfusion, with tendency to overestimate both NVT and TAR, not yielding satisfactory differentiation between true penumbra and benign oligoemia. In particular, the overestimation of NVT could have serious consequences in not selecting potential candidates for a reperfusion treatment.
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Affiliation(s)
- Fabrizio Giammello
- International PhD Translational Molecular Medicine and Surgery, Department of Biomedical, Dental Science and Morphological and Functional Images, University of Messina, Polyclinic Hospital, Via Consolare Valeria 1, 98125, Messina, Italy.
- Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy.
| | - Sara Rosa Maria De Martino
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neuroradiology Unit, Bellaria Hospital, Bologna, Italy
| | - Luigi Simonetti
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neuroradiology Unit, Maggiore Hospital, Bologna, Italy
| | - Raffaele Agati
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Programma Neuroradiologia Con Tecniche Ad Elevata Complessità, Bellaria Hospital, Bologna, Italy
| | - Stella Battaglia
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Programma Neuroradiologia Con Tecniche Ad Elevata Complessità, Bellaria Hospital, Bologna, Italy
| | - Luigi Cirillo
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neuroradiology Unit, Bellaria Hospital, Bologna, Italy
- DIMES, Department of Specialty, Diagnostic and Experimental Medicine, University of Bologna, Bologna, Italy
| | - Mauro Gentile
- Department of Neurology and Stroke Center, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Maggiore Hospital, Bologna, Italy
| | - Ludovica Migliaccio
- Department of Neurology and Stroke Center, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Maggiore Hospital, Bologna, Italy
| | - Stefano Forlivesi
- Department of Neurology and Stroke Center, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Maggiore Hospital, Bologna, Italy
| | - Michele Romoli
- Department of Neurology and Stroke Center, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Maggiore Hospital, Bologna, Italy
| | - Ciro Princiotta
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neuroradiology Unit, Bellaria Hospital, Bologna, Italy
| | - Caterina Tonon
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
- Functional and Molecular Neuroimaging Unit, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
| | - Silvia Stagni
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neuroradiology Unit, Maggiore Hospital, Bologna, Italy
| | - Simone Galluzzo
- IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Neuroradiology Unit, Maggiore Hospital, Bologna, Italy
| | - Raffaele Lodi
- Department of Biomedical and Neuromotor Sciences, University of Bologna, Bologna, Italy
- Functional and Molecular Neuroimaging Unit, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Bologna, Italy
| | | | - Antonio Toscano
- Unit of Neurology and Neuromuscular Diseases, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Rosa Fortunata Musolino
- Stroke Unit, Department of Clinical and Experimental Medicine, University of Messina, Messina, Italy
| | - Andrea Zini
- Department of Neurology and Stroke Center, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Maggiore Hospital, Bologna, Italy
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11
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Konduri P, van Voorst H, Bucker A, van Kranendonk K, Boers A, Treurniet K, Berkhemer O, Yoo AJ, van Zwam W, van Oostenbrugge R, van der Lugt A, Dippel D, Roos Y, Bot J, Majoie C, Marquering H. Posttreatment Ischemic Lesion Evolution Is Associated With Reduced Favorable Functional Outcome in Patients With Stroke. Stroke 2021; 52:3523-3531. [PMID: 34289708 DOI: 10.1161/strokeaha.120.032331] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND AND PURPOSE Ischemic lesion volume can increase even 24 hours after onset of an acute ischemic stroke. In this study, we investigated the association of lesion evolution with functional outcome and the influence of successful recanalization on this association. METHODS We included patients from the MR CLEAN trial (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands) who received good quality noncontrast CT images 24 hours and 1 week after stroke onset. The ischemic lesion delineations included infarct, edema, and hemorrhagic transformation. Lesion evolution was defined as the difference between the volumes measured on the 1-week and 24-hour noncontrast CTs. The association of lesion evolution with functional outcome was evaluated using unadjusted and adjusted logistic regression. Adjustments were made for baseline, clinical, and imaging parameters that were associated P<0.10) in univariate analysis with favorable functional outcome, defined as modified Rankin Scale score of ≤2. Interaction analysis was performed to evaluate the influence of successful recanalization, defined as modified Arterial Occlusion Lesion score of 3 points, on this association. RESULTS Of the 226 patients who were included, 69 (31%) patients achieved the favorable functional outcome. Median lesion evolution was 22 (interquartile range, 10-45) mL. Lesion evolution was significantly inversely correlated with favourable functional outcome: unadjusted odds ratio, 0.76 (95% CI, 0.66-0.86; per 10 mL of lesion evolution; P<0.01) and adjusted odds ratio: 0.85 (95% CI, 0.72-0.97; per 10 mL of lesion evolution; P=0.03). There was no significant interaction of successful recanalization on the association of lesion evolution and favorable functional outcome (odds ratio, 1.01 [95% CI, 0.77-1.36]; P=0.94). CONCLUSIONS In our population, subacute ischemic lesion evolution is associated with unfavorable functional outcome. This study suggests that even 24 hours after onset of stroke, deterioration of the brain continues, which has a negative effect on functional outcome. This finding may warrant additional treatment in the subacute phase.
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Affiliation(s)
- Praneeta Konduri
- Department of Biomedical Engineering and Physics (P.K., H.v.V., A.B., H.M.), Amsterdam UMC, location AMC, the Netherlands
- Department of Radiology and Nuclear Medicine (P.K., H.v.V., H.v.V., K.v.K., K.T., O.B., C.M., H.M.), Amsterdam UMC, location AMC, the Netherlands
| | - Henk van Voorst
- Department of Biomedical Engineering and Physics (P.K., H.v.V., A.B., H.M.), Amsterdam UMC, location AMC, the Netherlands
- Department of Radiology and Nuclear Medicine (P.K., H.v.V., H.v.V., K.v.K., K.T., O.B., C.M., H.M.), Amsterdam UMC, location AMC, the Netherlands
| | - Amber Bucker
- Department of Biomedical Engineering and Physics (P.K., H.v.V., A.B., H.M.), Amsterdam UMC, location AMC, the Netherlands
| | - Katinka van Kranendonk
- Department of Radiology and Nuclear Medicine (P.K., H.v.V., H.v.V., K.v.K., K.T., O.B., C.M., H.M.), Amsterdam UMC, location AMC, the Netherlands
| | - Anna Boers
- Department of Radiology, University Medical Center Groningen, the Netherlands (A.B.)
- Nico-lab, Amsterdam, Netherlands (A.B.)
| | - Kilian Treurniet
- Department of Radiology and Nuclear Medicine (P.K., H.v.V., H.v.V., K.v.K., K.T., O.B., C.M., H.M.), Amsterdam UMC, location AMC, the Netherlands
- Department of Radiology, Haaglanden Medisch Centrum, The Hague, the Netherlands (K.T.)
| | - Olvert Berkhemer
- Department of Radiology and Nuclear Medicine (P.K., H.v.V., H.v.V., K.v.K., K.T., O.B., C.M., H.M.), Amsterdam UMC, location AMC, the Netherlands
- Department of Neurology (O.B., D.D.), Erasmus MC University Medical Center, Rotterdam, Netherlands
- Department of Radiology & Nuclear Medicine (O.B., A.v.d.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Albert J Yoo
- Department of Radiology, Texas Stroke Institute, Dallas-Fort Worth (A.J.Y.)
| | - Wim van Zwam
- Department of Radiology (W.v.Z.), Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM)
| | - Robert van Oostenbrugge
- Department of Neurology (R.v.O.), Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM)
| | - Aad van der Lugt
- Department of Radiology & Nuclear Medicine (O.B., A.v.d.L.), Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Diederik Dippel
- Department of Neurology (O.B., D.D.), Erasmus MC University Medical Center, Rotterdam, Netherlands
| | - Yvo Roos
- Department of Neurology (Y.R.), Amsterdam UMC, location AMC, the Netherlands
| | - Joost Bot
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, Vrije Universiteit van Amsterdam (J.B.)
| | - Charles Majoie
- Department of Radiology and Nuclear Medicine (P.K., H.v.V., H.v.V., K.v.K., K.T., O.B., C.M., H.M.), Amsterdam UMC, location AMC, the Netherlands
| | - Henk Marquering
- Department of Biomedical Engineering and Physics (P.K., H.v.V., A.B., H.M.), Amsterdam UMC, location AMC, the Netherlands
- Department of Radiology and Nuclear Medicine (P.K., H.v.V., H.v.V., K.v.K., K.T., O.B., C.M., H.M.), Amsterdam UMC, location AMC, the Netherlands
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12
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Ben Hassen W, Touloupas C, Benzakoun J, Boulouis G, Bretzner M, Bricout N, Legrand L, Rodriguez C, Le Berre A, Seners P, Turc G, Cordonnier C, Oppenheim C, Henon H, Naggara O. Impact of Repeated Clot Retrieval Attempts on Infarct Growth and Outcome After Ischemic Stroke. Neurology 2021; 97:e444-e453. [PMID: 34162721 DOI: 10.1212/wnl.0000000000012321] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2020] [Accepted: 04/23/2021] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To determine whether the association between increasing number of clot retrieval attempts (CRA) and unfavorable outcome is due to an increase in emboli to new territory (ENT) and greater infarct growth (IG) in successfully recanalized patients with acute ischemic stroke due to large vessel occlusion (AIS-LVO). METHODS Data were extracted from 2 pooled multicentric prospective registries of consecutive patients with anterior AIS-LVO treated with mechanical thrombectomy (MT) between January 2016 and 2019. Patients with pretreatment and 24-hour posttreatment diffusion-weighted imaging (DWI) achieving successful recanalization, defined as expanded Thrombolysis in Cerebral Infarction Scale score of 2B, 2C, or 3, were included. ENT were assessed and IG was measured by voxel-based segmentation after DWI coregistration. Associations between number of CRA, ENT, IG, and 3-month outcome were analyzed. RESULTS Four hundred nineteen patients achieving successful recanalization were included. ENT occurrence was strongly correlated with increasing CRA (ρ = 0.73, p = 10-4). In multivariable linear analysis, IG was independently associated with CRA (β = 1.6 per retrieval attempt, 95% confidence interval [CI] 0.97-9.74, p = 0.03) and ENT (β = 2.7 [95% CI 1.21-4.1], p = 0.03). Unfavorable functional outcome (3-month modified Rankin Scale score >2) increased with each additional CRA. IG was an independent predictor of unfavorable outcome (odds ratio 1.05 [95% CI 1.02-1.07] per 1-mL IG increase, p = 10-4) in binary logistic regression analysis. CONCLUSIONS Increasing number of CRA in acute stroke is correlated with an increased ENT rate and increased IG volume, affecting functional outcome even when successful recanalization is achieved. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that, for patients with acute stroke undergoing successful recanalization, an increasing number of CRA is associated with poorer functional outcome.
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Affiliation(s)
- Wagih Ben Hassen
- From GHU Paris (W.B.H., C.T., J.B., G.B., L.L., C.R., P.S., G.T., C.O., O.N.), Université de Paris, INSERM UMR 1266, Department of Neuroradiology; Department of Interventional Neuroradiology (M.B., N.B.), CHU Lille; Hôpital Saint Joseph (A.L.B.), Department of Radiology, Paris; and Department of Neurology (C.C., H.H.), Université Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, France.
| | - Caroline Touloupas
- From GHU Paris (W.B.H., C.T., J.B., G.B., L.L., C.R., P.S., G.T., C.O., O.N.), Université de Paris, INSERM UMR 1266, Department of Neuroradiology; Department of Interventional Neuroradiology (M.B., N.B.), CHU Lille; Hôpital Saint Joseph (A.L.B.), Department of Radiology, Paris; and Department of Neurology (C.C., H.H.), Université Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, France
| | - Joseph Benzakoun
- From GHU Paris (W.B.H., C.T., J.B., G.B., L.L., C.R., P.S., G.T., C.O., O.N.), Université de Paris, INSERM UMR 1266, Department of Neuroradiology; Department of Interventional Neuroradiology (M.B., N.B.), CHU Lille; Hôpital Saint Joseph (A.L.B.), Department of Radiology, Paris; and Department of Neurology (C.C., H.H.), Université Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, France
| | - Gregoire Boulouis
- From GHU Paris (W.B.H., C.T., J.B., G.B., L.L., C.R., P.S., G.T., C.O., O.N.), Université de Paris, INSERM UMR 1266, Department of Neuroradiology; Department of Interventional Neuroradiology (M.B., N.B.), CHU Lille; Hôpital Saint Joseph (A.L.B.), Department of Radiology, Paris; and Department of Neurology (C.C., H.H.), Université Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, France
| | - Martin Bretzner
- From GHU Paris (W.B.H., C.T., J.B., G.B., L.L., C.R., P.S., G.T., C.O., O.N.), Université de Paris, INSERM UMR 1266, Department of Neuroradiology; Department of Interventional Neuroradiology (M.B., N.B.), CHU Lille; Hôpital Saint Joseph (A.L.B.), Department of Radiology, Paris; and Department of Neurology (C.C., H.H.), Université Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, France
| | - Nicolas Bricout
- From GHU Paris (W.B.H., C.T., J.B., G.B., L.L., C.R., P.S., G.T., C.O., O.N.), Université de Paris, INSERM UMR 1266, Department of Neuroradiology; Department of Interventional Neuroradiology (M.B., N.B.), CHU Lille; Hôpital Saint Joseph (A.L.B.), Department of Radiology, Paris; and Department of Neurology (C.C., H.H.), Université Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, France
| | - Laurence Legrand
- From GHU Paris (W.B.H., C.T., J.B., G.B., L.L., C.R., P.S., G.T., C.O., O.N.), Université de Paris, INSERM UMR 1266, Department of Neuroradiology; Department of Interventional Neuroradiology (M.B., N.B.), CHU Lille; Hôpital Saint Joseph (A.L.B.), Department of Radiology, Paris; and Department of Neurology (C.C., H.H.), Université Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, France
| | - Christine Rodriguez
- From GHU Paris (W.B.H., C.T., J.B., G.B., L.L., C.R., P.S., G.T., C.O., O.N.), Université de Paris, INSERM UMR 1266, Department of Neuroradiology; Department of Interventional Neuroradiology (M.B., N.B.), CHU Lille; Hôpital Saint Joseph (A.L.B.), Department of Radiology, Paris; and Department of Neurology (C.C., H.H.), Université Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, France
| | - Alice Le Berre
- From GHU Paris (W.B.H., C.T., J.B., G.B., L.L., C.R., P.S., G.T., C.O., O.N.), Université de Paris, INSERM UMR 1266, Department of Neuroradiology; Department of Interventional Neuroradiology (M.B., N.B.), CHU Lille; Hôpital Saint Joseph (A.L.B.), Department of Radiology, Paris; and Department of Neurology (C.C., H.H.), Université Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, France
| | - Pierre Seners
- From GHU Paris (W.B.H., C.T., J.B., G.B., L.L., C.R., P.S., G.T., C.O., O.N.), Université de Paris, INSERM UMR 1266, Department of Neuroradiology; Department of Interventional Neuroradiology (M.B., N.B.), CHU Lille; Hôpital Saint Joseph (A.L.B.), Department of Radiology, Paris; and Department of Neurology (C.C., H.H.), Université Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, France
| | - Guillaume Turc
- From GHU Paris (W.B.H., C.T., J.B., G.B., L.L., C.R., P.S., G.T., C.O., O.N.), Université de Paris, INSERM UMR 1266, Department of Neuroradiology; Department of Interventional Neuroradiology (M.B., N.B.), CHU Lille; Hôpital Saint Joseph (A.L.B.), Department of Radiology, Paris; and Department of Neurology (C.C., H.H.), Université Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, France
| | - Charlotte Cordonnier
- From GHU Paris (W.B.H., C.T., J.B., G.B., L.L., C.R., P.S., G.T., C.O., O.N.), Université de Paris, INSERM UMR 1266, Department of Neuroradiology; Department of Interventional Neuroradiology (M.B., N.B.), CHU Lille; Hôpital Saint Joseph (A.L.B.), Department of Radiology, Paris; and Department of Neurology (C.C., H.H.), Université Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, France
| | - Catherine Oppenheim
- From GHU Paris (W.B.H., C.T., J.B., G.B., L.L., C.R., P.S., G.T., C.O., O.N.), Université de Paris, INSERM UMR 1266, Department of Neuroradiology; Department of Interventional Neuroradiology (M.B., N.B.), CHU Lille; Hôpital Saint Joseph (A.L.B.), Department of Radiology, Paris; and Department of Neurology (C.C., H.H.), Université Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, France
| | - Hilde Henon
- From GHU Paris (W.B.H., C.T., J.B., G.B., L.L., C.R., P.S., G.T., C.O., O.N.), Université de Paris, INSERM UMR 1266, Department of Neuroradiology; Department of Interventional Neuroradiology (M.B., N.B.), CHU Lille; Hôpital Saint Joseph (A.L.B.), Department of Radiology, Paris; and Department of Neurology (C.C., H.H.), Université Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, France
| | - Olivier Naggara
- From GHU Paris (W.B.H., C.T., J.B., G.B., L.L., C.R., P.S., G.T., C.O., O.N.), Université de Paris, INSERM UMR 1266, Department of Neuroradiology; Department of Interventional Neuroradiology (M.B., N.B.), CHU Lille; Hôpital Saint Joseph (A.L.B.), Department of Radiology, Paris; and Department of Neurology (C.C., H.H.), Université Lille, Inserm U1171, Degenerative and Vascular Cognitive Disorders, CHU Lille, France
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13
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Regenhardt RW, Etherton MR, Das AS, Schirmer MD, Hirsch JA, Stapleton CJ, Patel AB, Leslie-Mazwi TM, Rost NS. Infarct Growth despite Endovascular Thrombectomy Recanalization in Large Vessel Occlusive Stroke. J Neuroimaging 2021; 31:155-164. [PMID: 33119954 PMCID: PMC8365346 DOI: 10.1111/jon.12796] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2020] [Revised: 09/14/2020] [Accepted: 09/18/2020] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND PURPOSE Endovascular thrombectomy (EVT) has revolutionized large vessel occlusion stroke care. However, not all patients with good endovascular results achieve good outcomes. We sought to understand the clinical significance of magnetic resonance imaging defined infarct growth despite adequate reperfusion and identify associated clinical and radiographic variables. METHODS History, presentation, treatments, and outcomes for consecutive EVT patients at a referral center were collected. Adequate reperfusion was defined as thrombolysis in cerebral infarction (TICI) score 2b-3. Region-specific infarct volumes in white matter, cortex, and basal ganglia were determined on diffusion-weighted imaging. Infarct growth was defined as post-EVT minus pre-EVT volume. Good outcome was defined as 90-day modified Rankin Scale ≤2. RESULTS Forty-four patients with adequate reperfusion were identified with median age 72 years; 64% were women. Each region showed infarct growth: white matter (median pre-EVT 7 cubic centimeters [cc], post-EVT 16 cc), cortex (4 cc, 15 cc), basal ganglia (2 cc, 4 cc), total (20 cc, 39 cc). In multivariable regression, total infarct growth independently decreased the odds of good outcome (odds ratio = .946, 95% CI = .897, .998). Further multivariable analyses for determinants of infarct growth identified female sex was associated with less total growth (β = -.294, P = .042), TICI 3 was associated with less white matter growth (β = -.277, P = .048) and cortical growth (β = -.335, P = .017), and both female sex (β = -.332, P = .015) and coronary disease (β = -.337, P = .015) were associated with less cortical growth. CONCLUSIONS Infarct growth occurred despite adequate reperfusion, disproportionately in the cortex, and independently decreased the odds of good outcome. Infarct growth occurred while patients were hospitalized and may represent a therapeutic target. Potential determinants of region-specific infarct growth were identified that require confirmation in larger studies.
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Affiliation(s)
- Robert W Regenhardt
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School
| | - Mark R Etherton
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School
| | - Alvin S Das
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School
| | - Markus D Schirmer
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School
| | - Joshua A Hirsch
- Department of Radiology, Massachusetts General Hospital, Harvard Medical School
| | | | - Aman B Patel
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School
| | - Thabele M Leslie-Mazwi
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School
- Department of Neurosurgery, Massachusetts General Hospital, Harvard Medical School
| | - Natalia S Rost
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School
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14
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Yaghi S, Dehkharghani S, Raz E, Jayaraman M, Tanweer O, Grory BM, Henninger N, Lansberg MG, Albers GW, Havenon AD. The Effect of Hyperglycemia on Infarct Growth after Reperfusion: An Analysis of the DEFUSE 3 trial. J Stroke Cerebrovasc Dis 2020; 30:105380. [PMID: 33166769 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105380] [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: 07/08/2020] [Revised: 09/24/2020] [Accepted: 09/29/2020] [Indexed: 12/21/2022] Open
Abstract
BACKGROUND AND PURPOSE Brain infarct growth, despite successful reperfusion, decreases the likelihood of good functional outcome after ischemic stroke. In patients undergoing reperfusion, admission glucose is associated with poor outcome but the effect of glucose level on infarct growth is not well studied. MATERIALS AND METHODS This is a secondary analysis of the DEFUSE 3 trial. The primary predictor was baseline glucose level and the primary outcome is the change of the ischemic core volume from the baseline to 24-hour follow-up imaging (∆core), transformed as a cube root to reduce right skew. We included DEFUSE 3 patients who were randomized to endovascular therapy, had perfusion imaging data at baseline, an MRI at 24 hours, and who achieved TICI 2b or 3. Linear regression models, both unadjusted and adjusted, were fit to the primary outcome and all models included the baseline core volume as a covariate to normalize ∆core. RESULTS We identified 62 patients who met our inclusion criteria. The mean age was 68.1±13.1 (years), 48.4% (30/62) were men, and the median (IQR) cube root of ∆core was 2.8 (2.0-3.8) mL. There was an association between baseline glucose level and normalized ∆core in unadjusted analysis (beta coefficient 0.010, p = 0.01) and after adjusting for potential confounders (beta coefficient 0.008, p = 0.03). CONCLUSION In acute ischemic stroke patients with large vessel occlusion undergoing successful endovascular reperfusion, baseline hyperglycemia is associated with infarction growth. Further study is needed to establish potential neuroprotective benefits of aggressive glycemic control prior to and after reperfusion.
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Affiliation(s)
- Shadi Yaghi
- Department of Neurology, NYU Langone Health, 150 55th St Suite 3667, Brooklyn, NY 11220, USA.
| | - Seena Dehkharghani
- Department of Radiology, NYU Langone Health, New York, NY, United States.
| | - Eytan Raz
- Department of Radiology, NYU Langone Health, New York, NY, United States.
| | - Mahesh Jayaraman
- Department of Neurology, Brown University, Providence, RI, United States; Department of Radiology, Brown University, Providence, RI, United States; Department of Neuorosurgery, Brown University, Providence, RI, United States.
| | - Omar Tanweer
- Department of Neurosurgery, NYU Langone Health, New York, NY, United States.
| | - Brian Mac Grory
- Department of Neurology, Duke University, Durham, NC, United States.
| | - Nils Henninger
- Department of Neurology, University of Massachusetts, Worcester, MA, United States; Department of Psychiatry, University of Massachusetts, Worcester, MA, United States.
| | - Maarten G Lansberg
- Department of Neurology, Stanford University, San Francisco, CA, United States.
| | - Gregory W Albers
- Department of Neurology, Stanford University, San Francisco, CA, United States.
| | - Adam de Havenon
- Department of Neurology, University of Utah Medical Center, Salt Lake City, UT, United States.
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15
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Ben Hassen W, Tordjman M, Boulouis G, Bretzner M, Bricout N, Legrand L, Benzakoun J, Edjlali M, Seners P, Cordonnier C, Oppenheim C, Turc G, Henon H, Naggara O. Benefit of first-pass complete reperfusion in thrombectomy is mediated by limited infarct growth. Eur J Neurol 2020; 28:124-131. [PMID: 32896067 DOI: 10.1111/ene.14490] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2020] [Accepted: 08/18/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND AND PURPOSE The number of clot retrieval attempts required to achieve complete reperfusion by mechanical thrombectomy impacts functional outcome in acute ischaemic stroke (AIS). Complete reperfusion [expanded Treatment In Cerebral Infarction (eTICI) score = 3] at first pass (FP), is associated with the highest rates of favorable outcome compared to complete reperfusion by multiple passes. The aim of the present study was to investigate the relationship between FP complete reperfusion and infarct growth (IG). METHODS Anterior AIS patients with baseline and 24-h diffusion-weighted magnetic resonance imaging were included from two prospective registries. IG was measured by voxel-based segmentation of initial and 24-h diffusion-weighted imaging lesions. IG and favorable 3-month modified Rankin Scale (mRS) score (≤ 2) were compared between patients in whom complete reperfusion (eTICI 3) was achieved with a single pass (FP group) and those for whom multiple passes were required (MP group), after matching for confounding factors. Mediation analysis was performed to examine the association between FP and 3-month mRS score, with IG as mediating variable. RESULTS A total of 200 patients were included, of whom 118 (28.9%) had FP complete reperfusion. In case-control analysis, the FP group had lower IG than the MP group [8.7 (5.4-12.9) ml vs. 15.2 (11-22.6) ml, respectively; P = 0.03). Favorable outcome was higher in the FP population compared to a matched MP population (70.9% vs. 53.2%, respectively; P = 0.04). FP compete reperfusion (eTICI 3) was independently associated with favorable outcome in multivariable regression analysis [odds ratio 1.86, 95% confidence interval (CI) 1.01-4.39; P = 0.04]. The effect of complete reperfusion at FP on functional outcome was explained by limited IG in mediation analysis [indirect effect: -0.32 (95% CI -0.47 to -0.09)]. CONCLUSION Complete reperfusion at FP is independently associated with significant decrease in IG compared to complete reperfusion by multiple attempts, explaining better functional outcomes.
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Affiliation(s)
- W Ben Hassen
- INSERM UMR 1266, Department of Neuroradiology, Université de Paris, Paris, France
| | - M Tordjman
- INSERM UMR 1266, Department of Neuroradiology, Université de Paris, Paris, France
| | - G Boulouis
- INSERM UMR 1266, Department of Neuroradiology, Université de Paris, Paris, France
| | - M Bretzner
- Department of Interventional Neuroradiology, University of Lille, CHU Lille, Lille, France
| | - N Bricout
- Department of Interventional Neuroradiology, University of Lille, CHU Lille, Lille, France
| | - L Legrand
- INSERM UMR 1266, Department of Neuroradiology, Université de Paris, Paris, France
| | - J Benzakoun
- INSERM UMR 1266, Department of Neuroradiology, Université de Paris, Paris, France
| | - M Edjlali
- INSERM UMR 1266, Department of Neuroradiology, Université de Paris, Paris, France
| | - P Seners
- Department of Neurology, CH Sainte-Anne, Paris, France
| | - C Cordonnier
- Department of Vascular Neurology, Stroke Unit, University of Lille, CHU Lille, Lille, France
| | - C Oppenheim
- INSERM UMR 1266, Department of Neuroradiology, Université de Paris, Paris, France
| | - G Turc
- Department of Neurology, CH Sainte-Anne, Paris, France
| | - H Henon
- Department of Vascular Neurology, Stroke Unit, University of Lille, CHU Lille, Lille, France
| | - O Naggara
- INSERM UMR 1266, Department of Neuroradiology, Université de Paris, Paris, France
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16
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Dehkharghani S, Yaghi S, Bowen MT, Pisani L, Scher E, Haussen DC, Nogueira RG. Mild fever as a catalyst for consumption of the ischaemic penumbra despite endovascular reperfusion. Brain Commun 2020; 2:fcaa116. [PMID: 33033801 PMCID: PMC7532660 DOI: 10.1093/braincomms/fcaa116] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2020] [Revised: 05/18/2020] [Accepted: 06/23/2020] [Indexed: 11/26/2022] Open
Abstract
Cerebrovascular ischaemia is potentiated by hyperthermia, and even mild temperature elevation has proved detrimental to ischaemic brain. Infarction progression following endovascular reperfusion relates to multiple patient-specific and procedural variables; however, the potential influence of mild systemic temperature fluctuations is not fully understood. This study aims to assess the relationship between systemic temperatures in the early aftermath of acute ischaemic stroke and the loss of at-risk penumbral tissues, hypothesizing consumption of the ischaemic penumbra as a function of systemic temperatures, irrespective of reperfusion status. A cross-sectional, retrospective evaluation of a single-institution, prospectively collected endovascular therapy registry was conducted. Patients with anterior circulation, large vessel occlusion acute ischaemic stroke who underwent initial CT perfusion, and in whom at least four-hourly systemic temperatures were recorded beginning from presentation and until the time of final imaging outcome were included. Initial CT perfusion core and penumbra volumes and final MRI infarction volumes were computed. Systemic temperature indices including temperature maxima were recorded, and pre-defined temperature thresholds varying between 37°C and 38°C were examined in unadjusted and adjusted regression models which included glucose, collateral status, reperfusion status, CT perfusion-to-reperfusion delay, general anaesthesia and antipyretic exposure. The primary outcome was the relative consumption of the penumbra, reflecting normalized growth of the at-risk tissue volume ≥10%. The final study population comprised 126 acute ischaemic stroke subjects (mean 63 ± 14.5 years, 63% women). The primary outcome of penumbra consumption ≥10% occurred in 51 (40.1%) subjects. No significant differences in baseline characteristics were present between groups, with the exception of presentation glucose (118 ± 26.6 without versus 143.1 ± 61.6 with penumbra consumption, P = 0.009). Significant differences in the likelihood of penumbra consumption relating to systemic temperature maxima were observed [37°C (interquartile range 36.5 − 37.5°C) without versus 37.5°C (interquartile range 36.8 − 38.2°C) with penumbra consumption, P = 0.001]. An increased likelihood of penumbra consumption was observed for temperature maxima in unadjusted (odds ratio 3.57, 95% confidence interval 1.65 − 7.75; P = 0.001) and adjusted (odds ratio 3.06, 95% confidence interval 1.33 − 7.06; P = 0.009) regression models. Significant differences in median penumbra consumption were present at a pre-defined temperature maxima threshold of 37.5°C [4.8 ml (interquartile range 0 − 11.5 ml) versus 21.1 ml (0 − 44.7 ml) for subjects not reaching or reaching the threshold, respectively, P = 0.007]. Mild fever may promote loss of the ischaemic penumbra irrespective of reperfusion, potentially influencing successful salvage of at-risk tissue volumes following acute ischaemic stroke.
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Affiliation(s)
- Seena Dehkharghani
- Department of Radiology, New York University Langone Health, New York, NY, USA
| | - Shadi Yaghi
- Department of Neurology, New York University Langone Health, New York, NY, USA
| | - Meredith T Bowen
- Department of Neurology, Johns Hopkins University, Baltimore, MD, USA
| | - Leonardo Pisani
- Department of Neurology, Emory University Hospital, Atlanta, GA, USA
| | - Erica Scher
- Department of Neurology, New York University Langone Health, New York, NY, USA
| | - Diogo C Haussen
- Department of Neurology, Emory University Hospital, Atlanta, GA, USA.,Department of Neurology, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA 30303, USA
| | - Raul G Nogueira
- Department of Neurology, Emory University Hospital, Atlanta, GA, USA.,Department of Neurology, Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA 30303, USA
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17
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Dehkharghani S, Qiu D. MR Thermometry in Cerebrovascular Disease: Physiologic Basis, Hemodynamic Dependence, and a New Frontier in Stroke Imaging. AJNR Am J Neuroradiol 2020; 41:555-565. [PMID: 32139425 DOI: 10.3174/ajnr.a6455] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2019] [Accepted: 01/02/2020] [Indexed: 01/20/2023]
Abstract
The remarkable temperature sensitivity of the brain is widely recognized and has been studied for its role in the potentiation of ischemic and other neurologic injuries. Pyrexia frequently complicates large-vessel acute ischemic stroke and develops commonly in critically ill neurologic patients; the profound sensitivity of the brain even to minor intraischemic temperature changes, together with the discovery of brain-to-systemic as well as intracerebral temperature gradients, has thus compelled the exploration of cerebral thermoregulation and uncovered its immutable dependence on cerebral blood flow. A lack of pragmatic and noninvasive tools for spatially and temporally resolved brain thermometry has historically restricted empiric study of cerebral temperature homeostasis; however, MR thermometry (MRT) leveraging temperature-sensitive nuclear magnetic resonance phenomena is well-suited to bridging this long-standing gap. This review aims to introduce the reader to the following: 1) fundamental aspects of cerebral thermoregulation, 2) the physical basis of noninvasive MRT, and 3) the physiologic interdependence of cerebral temperature, perfusion, metabolism, and viability.
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Affiliation(s)
- S Dehkharghani
- From the Department of Radiology (S.D.), New York University Langone Health, New York, New York
| | - D Qiu
- Department of Radiology (D.Q.), Emory University Hospital, Atlanta, Georgia
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18
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Khalil AA, Villringer K, Filleböck V, Hu JY, Rocco A, Fiebach JB, Villringer A. Non-invasive monitoring of longitudinal changes in cerebral hemodynamics in acute ischemic stroke using BOLD signal delay. J Cereb Blood Flow Metab 2020; 40:23-34. [PMID: 30334657 PMCID: PMC6928563 DOI: 10.1177/0271678x18803951] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Relative delays in blood-oxygen-level-dependent (BOLD) signal oscillations can be used to assess cerebral perfusion without using contrast agents. However, little is currently known about the utility of this method in detecting clinically relevant perfusion changes over time. We investigated the relationship between longitudinal BOLD delay changes, vessel recanalization, and reperfusion in 15 acute stroke patients with vessel occlusion examined within 24 h of symptom onset (D0) and one day later (D1). We created BOLD delay maps using time shift analysis of resting-state functional MRI data and quantified perfusion lesion volume changes (using the D1/D0 volume ratio) and severity changes (using a linear mixed model) over time. Between baseline and follow-up, BOLD delay lesions shrank (median D1/D0 ratio = 0.2, IQR = 0.03-0.7) and BOLD delay severity decreased (b = -4.4 s) in patients with recanalization, whereas they grew (median D1/D0 ratio = 1.47, IQR = 1.1-1.7) and became more severe (b = 4.3 s) in patients with persistent vessel occlusion. Clinically relevant changes in cerebral perfusion in early stroke can be detected using BOLD delay, making this non-invasive method a promising option for detecting tissue at risk of infarction and monitoring stroke patients following recanalization therapy.
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Affiliation(s)
- Ahmed A Khalil
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany.,Mind, Brain, Body Institute, Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Kersten Villringer
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Vivien Filleböck
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jiun-Yiing Hu
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Andrea Rocco
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Jochen B Fiebach
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Arno Villringer
- Center for Stroke Research Berlin, Charité - Universitätsmedizin Berlin, Berlin, Germany.,Department of Neurology, Max Planck Institute for Human Cognitive and Brain Sciences, Leipzig, Germany.,Mind, Brain, Body Institute, Berlin School of Mind and Brain, Humboldt-Universität zu Berlin, Berlin, Germany
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19
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Deng W, Teng J, Liebeskind D, Miao W, Du R. Predictors of Infarct Growth Measured by Apparent Diffusion Coefficient Quantification in Patients with Acute Ischemic Stroke. World Neurosurg 2019; 123:e797-e802. [DOI: 10.1016/j.wneu.2018.12.051] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2018] [Revised: 12/12/2018] [Accepted: 12/13/2018] [Indexed: 11/25/2022]
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20
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Di Giuliano F, Picchi E, Sallustio F, Ferrazzoli V, Alemseged F, Greco L, Minosse S, Da Ros V, Diomedi M, Garaci F, Marziali S, Floris R. Accuracy of advanced CT imaging in prediction of functional outcome after endovascular treatment in patients with large-vessel occlusion. Neuroradiol J 2018; 32:62-70. [PMID: 30303448 DOI: 10.1177/1971400918805710] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND PURPOSE Computed tomography perfusion (CTP) and multiphase CT angiography (mCTA) help selection for endovascular treatment (EVT) in anterior ischemic stroke (AIS). Our aim was to investigate the ability of perfusion maps and collateral score to predict functional outcome after EVT. PATIENTS AND METHODS Patients with M1-middle cerebral artery occlusion, evaluated by mCTA and CTP and treated with EVT within six hours of onset, were enrolled. Perfusion parametric maps of cerebral blood flow (CBF), cerebral blood volume (CBV) and time to maximum of tissue residue function ( Tmax) were generated; areas of altered perfusion were manually outlined to obtain volumes CBFv, CBVv, Tmax,v16-25s and Tmax,v9.5-25s . Diffusion-weighted imaging (DWI) at 24-36 hours was used to manually outline the ischemic core (volume: DWIv). Collateral vessels were assessed on mCTA considering extent and delay of maximal enhancement (six-point scale). Functional outcome was evaluated by modified Rankin Scale score at three months. Volumes in good and poor outcome groups were compared by Wilcoxon rank-sum test t, and their discriminative ability for outcome was determined by receiver operating characteristic analysis. A logistic regression model, including Tmax, CBF and collaterals, was used to differentiate good and poor outcome. RESULTS Seventy-one patients (mean age 75 ± 11 years, range 45-99 years) were included. Tmax,v16-25s , Tmax,v9.5-25s , CBVv, CBFv and DWIv were statistically different between the two groups. CBF had the best discriminative value for good and poor outcome (area under the curve (AUC) 0.73; 64.5% sensitivity; 74.4% specificity); the logistic regression model might be promising (AUC 0.79, 64.5% sensitivity, 82.1% specificity). CONCLUSIONS In patients with AIS, the combined use of CTP and mCTA predicts functional outcome of EVT and might allow better selection.
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Affiliation(s)
| | - Eliseo Picchi
- 1 Department of Biomedicine and Prevention, University of Tor Vergata, Italy
| | - Fabrizio Sallustio
- 2 Department of Neuroscience, Comprehensive Stroke Center, University of Tor Vergata, Italy
| | | | - Fana Alemseged
- 2 Department of Neuroscience, Comprehensive Stroke Center, University of Tor Vergata, Italy.,3 Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Australia
| | - Laura Greco
- 1 Department of Biomedicine and Prevention, University of Tor Vergata, Italy
| | - Silvia Minosse
- 1 Department of Biomedicine and Prevention, University of Tor Vergata, Italy
| | - Valerio Da Ros
- 1 Department of Biomedicine and Prevention, University of Tor Vergata, Italy
| | - Marina Diomedi
- 2 Department of Neuroscience, Comprehensive Stroke Center, University of Tor Vergata, Italy.,4 I.R.C.C.S., Santa Lucia Foundation, Italy
| | - Francesco Garaci
- 1 Department of Biomedicine and Prevention, University of Tor Vergata, Italy
| | - Simone Marziali
- 1 Department of Biomedicine and Prevention, University of Tor Vergata, Italy
| | - Roberto Floris
- 1 Department of Biomedicine and Prevention, University of Tor Vergata, Italy
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Kim T, Chung JW, Jang MS, Yang MH, Lee SH, Kim BJ, Han MK, Kim JH, Jung C, Lim JS, Bae HJ. The Role of the Signal Intensity Ratio on Fluid-Attenuated Inversion Recovery in Stroke Patients Achieving Successful Recanalization with Endovascular Treatment. J Stroke Cerebrovasc Dis 2017; 26:1528-1534. [DOI: 10.1016/j.jstrokecerebrovasdis.2017.02.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2016] [Revised: 01/26/2017] [Accepted: 02/22/2017] [Indexed: 10/19/2022] Open
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22
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Dehkharghani S, Andre J. Imaging Approaches to Stroke and Neurovascular Disease. Neurosurgery 2017; 80:681-700. [DOI: 10.1093/neuros/nyw108] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Accepted: 12/02/2016] [Indexed: 11/14/2022] Open
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Dehkharghani S, Bowen M, Haussen DC, Gleason T, Prater A, Cai Q, Kang J, Nogueira RG. Body Temperature Modulates Infarction Growth following Endovascular Reperfusion. AJNR Am J Neuroradiol 2017; 38:46-51. [PMID: 27758774 DOI: 10.3174/ajnr.a4969] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 08/23/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE The neuronal substrate is highly sensitive to temperature elevation; however, its impact on the fate of the ischemic penumbra has not been established. We analyzed interactions between temperature and penumbral expansion among successfully reperfused patients with acute ischemic stroke, hypothesizing infarction growth and worse outcomes among patients with fever who achieve full reperfusion. MATERIALS AND METHODS Data from 129 successfully reperfused (modified TICI 2b/3) patients (mean age, 65 ± 15 years) presenting within 12 hours of onset were examined from a prospectively collected acute ischemic stroke registry. CT perfusion was analyzed to produce infarct core, hypoperfusion, and penumbral mismatch volumes. Final DWI infarction volumes were measured, and relative infarction growth was computed. Systemic temperatures were recorded throughout hospitalization. Correlational and logistic regression analyses assessed the associations between fever (>37.5°C) and both relative infarction growth and favorable clinical outcome (90-day mRS of ≤2), corrected for NIHSS score, reperfusion times, and age. An optimized model for outcome prediction was computed by using the Akaike Information Criterion. RESULTS The median presentation NIHSS score was 18 (interquartile range, 14-22). Median (interquartile range) CTP-derived volumes were: core = 9.6 mL (1.5-25.3 mL); hypoperfusion = 133 mL (84.2-204 mL); and final infarct volume = 9.6 mL (8.3-45.2 mL). Highly significant correlations were observed between temperature of >37.5°C and relative infarction growth (Kendall τ correlation coefficient = 0.24, P = .002). Odds ratios for favorable clinical outcome suggested a trend toward significance for fever in predicting a 90-day mRS of ≤2 (OR = 0.31, P = .05). The optimized predictive model for favorable outcomes included age, NIHSS score, procedure time to reperfusion, and fever. Likelihood ratios confirmed the superiority of fever inclusion (P < .05). Baseline temperature, range, and maximum temperature did not meet statistical significance. CONCLUSIONS These findings suggest that imaging and clinical outcomes may be affected by systemic temperature elevations, promoting infarction growth despite reperfusion.
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Affiliation(s)
- S Dehkharghani
- From the Department of Radiology and Imaging Sciences (S.D., M.B., T.G., A.P.), Emory University Hospital, Atlanta, Georgia
- Department of Neurology (S.D., D.C.H., R.G.N.), Marcus Stroke and Neuroscience Center, Grady Memorial Hospital and Emory University Hospital, Atlanta, Georgia
| | - M Bowen
- From the Department of Radiology and Imaging Sciences (S.D., M.B., T.G., A.P.), Emory University Hospital, Atlanta, Georgia
| | - D C Haussen
- Department of Neurology (S.D., D.C.H., R.G.N.), Marcus Stroke and Neuroscience Center, Grady Memorial Hospital and Emory University Hospital, Atlanta, Georgia
| | - T Gleason
- From the Department of Radiology and Imaging Sciences (S.D., M.B., T.G., A.P.), Emory University Hospital, Atlanta, Georgia
| | - A Prater
- From the Department of Radiology and Imaging Sciences (S.D., M.B., T.G., A.P.), Emory University Hospital, Atlanta, Georgia
| | - Q Cai
- Department of Biostatistics (Q.C.), Emory University, Atlanta, Georgia
| | - J Kang
- Department of Biostatistics (J.K.), University of Michigan, Ann Arbor, Michigan
| | - R G Nogueira
- Department of Neurology (S.D., D.C.H., R.G.N.), Marcus Stroke and Neuroscience Center, Grady Memorial Hospital and Emory University Hospital, Atlanta, Georgia
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24
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Nogueira RG, Zaidat OO, Castonguay AC, Haussen DC, Martin CO, Holloway WE, Mueller-Kronast N, English J, Linfante I, Dabus G, Malisch TW, Marden FA, Bozorgchami H, Xavier A, Rai AT, Froehler MT, Badruddin A, Nguyen TN, Taqi MA, Abraham MG, Janardhan V, Yoo AJ, Shaltoni H, Abou-Chebl A, Chen PR, Britz GW, Novakovic R, Nanda A, Kaushal R, Issa MA, Frankel MR, Gupta R. Rescue Thrombectomy in Large Vessel Occlusion Strokes Leads to Better Outcomes than Intravenous Thrombolysis Alone: A 'Real World' Applicability of the Recent Trials. INTERVENTIONAL NEUROLOGY 2016; 5:101-110. [PMID: 27781037 DOI: 10.1159/000445809] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/23/2015] [Accepted: 02/03/2016] [Indexed: 01/17/2023]
Abstract
BACKGROUND The Interventional Management of Stroke III (IMS-III) trial demonstrated no benefit for intravenous recombinant tissue plasminogen activator (IV rt-PA) followed by endovascular therapy versus IV rt-PA alone. However, IMS-III mostly included earlier generation devices. The recent thrombectomy trials have incorporated the stent-retriever technology, but their generalizability remains unknown. METHODS The North American Solitaire Acute Stroke (NASA) registry recruited patients treated with the Solitaire FR™ device between March 2012 and February 2013. The NASA-IMS-III-Like Group (NILG baseline NIHSS score ≥10 who received IV rt-PA) was compared to the IV rt-PA and IV + intra-arterial (IA)-IMS-III groups and the MR CLEAN, ESCAPE, SWIFT Prime, and REVASCAT trial controls to assess the stent-retriever treatment in the 'real-world' setting. The NILG was also compared to non-IV rt-PA NASA patients to evaluate the impact of IV rt-PA on thrombectomy. RESULTS A total of 136 of the 354 NASA patients fulfilled criteria for the NILG. Baseline characteristics were well balanced across groups. Time from onset to puncture was higher in NILG than IV+IA-IMS-III patients (274 ± 112 vs. 208 ± 47 min, p < 0.0001). Occlusions involving the intracranial ICA, MCA-M1, or basilar arteries were more common in NILG than IV+IA-IMS-III patients (91.2 vs. 47.2%, p < 0.00001). Modified thrombolysis in cerebral infarction ≥2b reperfusion was higher in NILG than IV+IA-IMS-III patients (74.3 vs. 39.6%, p < 0.00001). A 90-day modified Rankin Scale score ≤2 was more frequent in the NILG than IV+IA-IMS-III patients (51.9 vs. 40.8%, p = 0.03) and MR CLEAN (51.9 vs. 19.1%, p < 0.00001), ESCAPE (51.9 vs. 29.3%, p = 0.0002), SWIFT Prime (51.9 vs. 35.5%, p = 0.02), and REVASCAT (51.9 vs. 28.2%, p = 0.0003) controls. Symptomatic intracranial hemorrhage definitions varied across the different studies with rates ranging from 2.7% (ESCAPE) to 11.9% (NILG). The NILG 90-day mortality (24.4%) was higher than in SWIFT Prime but comparable to all other groups. IV rt-PA was an independent predictor of good outcome in NASA (OR = 2.3, 95% CI 1.2-4.7). CONCLUSION Our results support the 'real-world' applicability of the recent thrombectomy trials.
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Affiliation(s)
- Raul G Nogueira
- Department of Neurology, Emory University School of Medicine, Atlanta, Ga., USA
| | - Osama O Zaidat
- Department of Neurology, Medical College of Wisconsin, Milwaukee, Wis., USA
| | | | - Diogo C Haussen
- Department of Neurology, Emory University School of Medicine, Atlanta, Ga., USA
| | | | | | | | - Joey English
- California Pacific Medical Center, San Francisco, Calif., USA
| | - Italo Linfante
- Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, Fla., USA
| | - Guilherme Dabus
- Division of Interventional Neuroradiology, Baptist Cardiac and Vascular Institute, Miami, Fla., USA
| | - Tim W Malisch
- Alexian Brothers Medical Center, Elk Grove Village, Ill., USA
| | | | | | - Andrew Xavier
- Department of Neurology, Wayne State University School of Medicine, Detroit, Mich., USA
| | - Ansaar T Rai
- Department of Radiology, West Virginia University Hospital, Morgantown, W.Va., USA
| | - Michael T Froehler
- Department of Neurology, Neurosurgery, and Radiology, Vanderbilt University Medical Center, Nashville, Tenn., USA
| | - Aamir Badruddin
- Department of Neurosurgery, Presence Saint Joseph Medical Center, Joliet, Ill., USA
| | - Thanh N Nguyen
- Department of Neurology, Boston University School of Medicine, Boston, Mass., USA
| | - M Asif Taqi
- Desert Regional Medical Center, Palm Springs, Calif., USA
| | | | | | - Albert J Yoo
- Texas Stroke Institute, Dallas Fort-Worth Metroplex, Tex., USA
| | | | - Alex Abou-Chebl
- Department of Neurology, University of Louisville Medical School, Louisville, Ky., USA
| | - Peng R Chen
- Department of Neurosurgery, University of Texas, Houston, Tex., USA
| | - Gavin W Britz
- Department of Neurosurgery, Methodist Neurological Institute, Houston, Tex., USA
| | - Roberta Novakovic
- Department of Radiology and Neurology, UT Southwestern Medical Center, Dallas, Tex., USA
| | | | | | - Mohammad A Issa
- Department of Neurology, Medical College of Wisconsin, Milwaukee, Wis., USA
| | - Michael R Frankel
- Department of Neurology, Emory University School of Medicine, Atlanta, Ga., USA
| | - Rishi Gupta
- Department of Neurosurgery, Wellstar Medical Group, Marietta., USA
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