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McMeekin P, James M, Price CI, Ford GA, White P. The impact of large core and late treatment trials: An update on the modelled annual thrombectomy eligibility of UK stroke patients. Eur Stroke J 2024; 9:566-574. [PMID: 38366958 DOI: 10.1177/23969873241232820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/19/2024] Open
Abstract
INTRODUCTION To support decisions about thrombectomy provision, we have previously estimated the annual UK population eligible for treatment as ∼10% of stroke admissions. Since then, eight further randomised trials that could alter the eligibility rate have reported in 2021-23. We updated our estimates of the eligible population from these trials and other recent studies. PATIENTS AND METHODS An updated decision tree describing the EVT eligible population for UK stroke admissions was produced. Decision criteria were derived from the highest level of evidence available. For nodes where no specific RCT data existed, evidence was obtained from the latest systematic review(s) or the highest quality observational data. RESULTS We estimate that 15,420 (approximately 15%) of admitted UK stroke patients are now eligible for thrombectomy, or 14,930 if advanced brain imaging using MRI/CT perfusion or collateral assessment were used in all patients. This is a 54% increase in our previous estimate in 2021. Over 50% of LAO strokes are now potentially eligible for thrombectomy. The increase in eligibility is principally due to a much larger cohort of later presenting and/or larger ischaemic core patients. CONCLUSION Most previously independent LAO stroke patients presenting within 24 h, even in the presence of a large ischaemic core on initial non-contrast CT, should be considered for thrombectomy with use of advanced brain imaging in those presenting beyond 12 h to identify salvageable penumbral brain tissue. Treatment in most patients remains critically time-dependent and our estimates should be interpreted with this in mind.
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Affiliation(s)
- Peter McMeekin
- Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Martin James
- Peninsula Applied Research Collaboration (PenARC), University of Exeter, Exeter, Devon, UK
| | - Christopher I Price
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Gary A Ford
- Oxford University Hospitals NHS Foundation Trust and Medical Sciences Division, University of Oxford, Oxford, UK
| | - Philip White
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
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2
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Scheldeman L, Sinnaeve P, Albers GW, Lemmens R, Van de Werf F. Acute myocardial infarction and ischaemic stroke: differences and similarities in reperfusion therapies-a review. Eur Heart J 2024; 45:2735-2747. [PMID: 38941344 DOI: 10.1093/eurheartj/ehae371] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Revised: 04/16/2024] [Accepted: 05/28/2024] [Indexed: 06/30/2024] Open
Abstract
Acute ST-elevation myocardial infarction (STEMI) and acute ischaemic stroke (AIS) share a number of similarities. However, important differences in pathophysiology demand a disease-tailored approach. In both conditions, fast treatment plays a crucial role as ischaemia and eventually infarction develop rapidly. Furthermore, in both fields, the introduction of fibrinolytic treatments historically preceded the implementation of endovascular techniques. However, in contrast to STEMI, only a minority of AIS patients will eventually be considered eligible for reperfusion treatment. Non-invasive cerebral imaging always precedes cerebral angiography and thrombectomy, whereas coronary angiography is not routinely preceded by non-invasive cardiac imaging in patients with STEMI. In the late or unknown time window, the presence of specific patterns on brain imaging may help identify AIS patients who benefit most from reperfusion treatment. For STEMI, a uniform time window for reperfusion up to 12 h after symptom onset, based on old placebo-controlled trials, is still recommended in guidelines and generally applied. Bridging fibrinolysis preceding endovascular treatment still remains the mainstay of reperfusion treatment in AIS, while primary percutaneous coronary intervention is the strategy of choice in STEMI. Shortening ischaemic times by fine-tuning collaboration networks between ambulances, community hospitals, and tertiary care hospitals, optimizing bridging fibrinolysis, and reducing ischaemia-reperfusion injury are important topics for further research. The aim of this review is to provide insights into the common as well as diverging pathophysiology behind current reperfusion strategies and to explore new ways to enhance their clinical benefit.
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Affiliation(s)
- Lauranne Scheldeman
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
- Department of Neurosciences, Experimental Neurology KU Leuven - University of Leuven, Leuven, Belgium
| | - Peter Sinnaeve
- Department of Cardiovascular Medicine, University Hospitals Leuven, Leuven, Belgium
- Department of Cardiovascular Sciences, KU Leuven, University of Leuven, Herestraat 49, B-3000 Leuven, Belgium
| | - Gregory W Albers
- Department of Neurology, Stanford University Medical Center, Palo Alto, USA
| | - Robin Lemmens
- Department of Neurology, University Hospitals Leuven, Leuven, Belgium
- Department of Neurosciences, Experimental Neurology KU Leuven - University of Leuven, Leuven, Belgium
| | - Frans Van de Werf
- Department of Cardiovascular Sciences, KU Leuven, University of Leuven, Herestraat 49, B-3000 Leuven, Belgium
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Shaw L, Burgess D, Dixit A, Gaude E, Lendrem C, McClelland G, White P, Williams C, Zhu G, Price C. Rapid Assay Diagnostic for Acute Stroke Recognition (RADAR): study protocol for a diagnostic accuracy study. BMJ Open 2024; 14:e087130. [PMID: 39122395 PMCID: PMC11331886 DOI: 10.1136/bmjopen-2024-087130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2024] [Accepted: 05/24/2024] [Indexed: 08/12/2024] Open
Abstract
INTRODUCTION Large-vessel occlusion (LVO) stroke is effectively treated by time-critical thrombectomy, a highly specialised procedure only available in a limited number of centres. Many patients with suspected stroke are admitted to their nearest hospital and require transfer to access treatment, with resulting delays. This study is evaluating the accuracy of a new rapid portable test for LVO stroke which could be used in the future to select patients for direct admission to a thrombectomy centre. METHODS AND ANALYSIS Rapid Assay Diagnostic for Acute Stroke Recognition (RADAR) is a prospective observational cohort study taking place in stroke units in England. Participants are adults with a new suspected stroke with at least one face, arm or speech (FAST) symptom(s) and known onset within 6 hours or last known to be well 6-24 hours ago. The index test ('LVOne test' (Upfront Diagnostics)), consists of two portable lateral flow assays which use fingerprick capillary blood to detect d-dimer and glial fibrillary acidic protein concentrations. Reference standards comprise independently adjudicated standard CT/MRI brain±CT/MR angiography with senior clinician opinion to establish: ischaemic stroke±LVO; intracerebral haemorrhage; transient ischaemic attack; stroke mimic. Analyses will report sensitivity, specificity and negative and positive predictive values for identification of LVO stroke. Powered using a primary analysis population (≥2 FAST symptoms and known onset within 6 hours), 276 participants will detect a test specificity of 92%. The broader total study population which allows evaluation of the test for milder symptoms and unknown onset times is estimated to be 552 participants. ETHICS AND DISSEMINATION Ethical (North East-Newcastle & North Tyneside 2 Research Ethics Committee (reference: 23/NE/0043), Health Research Authority and participating National Health Service Trust approvals are granted. Consent is required for enrolment. Dissemination of results will include presentations at conferences, publication in journals and plain English summaries. TRIAL REGISTRATION NUMBER ISRCTN12414986.
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Affiliation(s)
- Lisa Shaw
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - David Burgess
- Service user representative, Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Anand Dixit
- Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Edoardo Gaude
- Pockit Diagnostics Ltd trading as Upfront Diagnostics, Cambridge, UK
| | - Clare Lendrem
- NIHR Newcastle In Vitro Diagnostics Cooperative, Newcastle University and Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Graham McClelland
- Department of Nursing, Midwifery and Health, Faculty of Health and Life Sciences, Northumbria University, Newcastle upon Tyne, UK
| | - Phil White
- Stroke Research Group, Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Cameron Williams
- NIHR Newcastle In Vitro Diagnostics Cooperative, Newcastle University and Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - Gewei Zhu
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Christopher Price
- Stroke Research Group, Population Health Sciences Institute, Newcastle University, Newcastle upon Tyne, UK
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4
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Martín-Gutiérrez A, Leal-Vega L, Coco-Martín MB, Arenillas-Lara JF. A systematic review of the socioeconomic impact of mechanical thrombectomy for acute ischemic stroke. J Stroke Cerebrovasc Dis 2024; 33:107906. [PMID: 39127180 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107906] [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: 12/07/2023] [Revised: 07/25/2024] [Accepted: 07/29/2024] [Indexed: 08/12/2024] Open
Abstract
BACKGROUND Mechanical Thrombectomy (MT) is an efficacious treatment for severe acute ischemic stroke patients. However, access to MT is limited in many parts of the world, partly due to economic barriers. The purpose of this systematic review is to provide an updated frame about the socioeconomic impact of MT. METHODS To carry out this systematic review we used the PRISMA guidelines. We included scientific articles analyzing the socioeconomic impact of MT for acute ischemic stroke, in which MT was compared to best medical therapy (BMT). The online databases of Pubmed, Scopus and Web of Science were used as main sources of information. To carry out the comparative analysis, the incremental cost-effectiveness ratio (ICER) was used, relating the cost to quality-adjusted life-year (QALY). Risk of bias was assessed with the Consensus Health Economic Criteria (CHEC) and the Consolidated Health Economic Evaluation Reporting Standards (CHEERS). RESULTS Eight hundred thirty-two studies were identified in this systematic review. As a result, studies that used cost-effectiveness analysis show that MT saves costs in the long term and cost-utility analysis show that the cost per QALY is reasonable with a mean ICER value of $14242.36/QALY. CONCLUSIONS MT has a favorable socioeconomic impact, as derived from cost-effectiveness and cost-utility analyses. Therefore, public policies should encourage the implementation of MT for stroke patients around the world.
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Affiliation(s)
- Adrián Martín-Gutiérrez
- Group of Applied Clinical Neurosciences, Department of Medicine, Dermatology and Toxicology, University of Valladolid, Valladolid, Spain
| | - Luis Leal-Vega
- Group of Applied Clinical Neurosciences, Department of Medicine, Dermatology and Toxicology, University of Valladolid, Valladolid, Spain
| | - María Begoña Coco-Martín
- Group of Applied Clinical Neurosciences, Department of Medicine, Dermatology and Toxicology, University of Valladolid, Valladolid, Spain.
| | - Juan F Arenillas-Lara
- Group of Applied Clinical Neurosciences, Department of Medicine, Dermatology and Toxicology, University of Valladolid, Valladolid, Spain; Stroke Unit & Stroke Program, Department of Neurology, Hospital Clínico Universitario de Valladolid, Valladolid, Spain
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5
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Shen Y, You H, Yang Y, Tang R, Ji Z, Liu H, Du M, Zhou M. Predicting brain edema and outcomes after thrombectomy in stroke: Frontal delta/alpha ratio as an optimal quantitative EEG index. Clin Neurophysiol 2024; 164:149-160. [PMID: 38896932 DOI: 10.1016/j.clinph.2024.05.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 04/26/2024] [Accepted: 05/17/2024] [Indexed: 06/21/2024]
Abstract
OBJECTIVE We aimed to determine whether quantitative electroencephalography (QEEG) measures have predictive value for cerebral edema (CED) and clinical outcomes in acute ischemic stroke (AIS) patients with anterior circulation large vessel occlusion who underwent mechanical thrombectomy (MT). METHODS A total of 105 patients with AIS in the anterior circulation were enrolled in this prospective study. The occurrence and severity of CED were assessed through computed tomography conducted 24 h after MT. Clinical outcomes were evaluated based on early neurological deterioration (END) and 3-month functional status, as measured by the modified Rankin scale (mRS). Electroencephalography (EEG) recordings were performed 24 h after MT, and QEEG indices were calculated from the standard 16 electrodes and 2 frontal channels (F3-C3, F4-C4). The delta/alpha ratio (DAR), the (delta + theta) / (alpha + beta) ratio (DTABR), and relative delta power were averaged over all electrodes (global) and the F3-C3 and F4-C4 channels (frontal). The predictive effect and value of QEEG indices for CED and clinical outcomes were assessed using ordinal and logistic regression models, as well as receiver operating characteristic (ROC) curves. RESULTS Significantly, both global and frontal DAR were found to be associated with the severity of CED, END, and poor functional outcomes at 90 days, while global and frontal DTABR and relative delta power were not associated with outcomes. In ROC analysis, the best predictive effect was observed in frontal DAR, with an area under the curve of approximately 0.80. It exhibited approximately 75% sensitivity and 71% specificity for radiological and clinical outcomes when a threshold of 3.3 was used. CONCLUSIONS QEEG techniques may be considered an efficient bedside monitoring method for assessing treatment efficacy, identifying patients at higher risk of severe CED and END, and predicting long-term functional outcomes. SIGNIFICANCE QEEG can help identify patients at risk of severe neurological complications that can impact long-term functional recovery in AIS patients who underwent MT.
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Affiliation(s)
- Yeru Shen
- Department of Critical Care Medicine, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Heyang You
- Department of Critical Care Medicine, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Yanyan Yang
- Department of Critical Care Medicine, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Rui Tang
- Department of Critical Care Medicine, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Zongshu Ji
- Department of Critical Care Medicine, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Haiyan Liu
- Department of Critical Care Medicine, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Min Du
- Department of Critical Care Medicine, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China
| | - Min Zhou
- Department of Critical Care Medicine, The First Affiliated Hospital of University of Science and Technology of China, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, China.
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6
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Joiner L, Ryan J, Fiesta M. Including isolated aphasia improves sensitivity and negative predicative value for large vessel occlusion screening. J Stroke Cerebrovasc Dis 2024; 33:107840. [PMID: 38945416 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107840] [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: 05/07/2024] [Revised: 06/21/2024] [Accepted: 06/27/2024] [Indexed: 07/02/2024] Open
Abstract
BACKGROUND Large Vessel Occlusion (LVO) screening tools provide objective assessments to guide diagnostic decisions during acute stroke activations. The Stroke VAN screening tool includes weakness, vision, aphasia, and neglect; however, only screens positive if weakness is present regardless of presence of other symptoms including isolated aphasia. The purpose of this project was to evaluate wAve, a modified Stroke VAN screening tool. WAve includes components of VAN with emphasis on isolated aphasia. METHODS We conducted a retrospective cohort study on 376 persons who presented with stroke symptoms within 24 h of last known well (LKW) to the Emergency Department of an urban comprehensive stroke center in north central Texas between July 2019 and January 2020. Comparison of VAN and wAve predictive values was calculated using Chi square analysis. Sensitivity and specificity was checked by using MedCalc software. Data from the electronic medical record was obtained for analysis including a documented wAve score and a calculated VAN score. Results of CT angiogram diagnostic testing was used to determine congruence of screening results with evidence of LVO. Power analysis described by Hajian- Tilaki was used to estimate study size. RESULTS Results included 192 positive wAve screens and 184 negative wAve screens compared to 152 positive VAN screens and 224 negative VAN screens. The sensitivities for wAve and VAN were 89 % and 80 % respectively. Negative predictive values for wAve and VAN were 97 % and 95 % respectively. In isolated aphasic person, one of eight presented with a LVO and received intervention. CONCLUSION The team discovered more LVOs were identified with wAve than VAN in persons exhibiting isolated aphasia symptoms. Larger studies are needed to understand the role isolated aphasia plays in LVO detection.
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Affiliation(s)
- Leora Joiner
- Stroke Program Coordinator at Texas Health Fort Worth Hospital, 1301 Pennsylvania Ave, Fort Worth, TX 76104, United States.
| | - James Ryan
- Clinical Workflow Specialist, Viz.ai, United States
| | - Matthew Fiesta
- Radiology Associates of North Texas and on the Medical Staff at Texas Health Fort Worth Hospital, United States; Study Completed at Texas Health Fort Worth Hospital Fort Worth, TX, United States
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7
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Li J, Zhang J, Li C, Li J, Wu X, Wang S. Nomogram to predict prognosis in patients with posterior circulation acute ischemic stroke after mechanical thrombectomy. Front Neurol 2024; 15:1406882. [PMID: 38903172 PMCID: PMC11188432 DOI: 10.3389/fneur.2024.1406882] [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: 03/27/2024] [Accepted: 05/23/2024] [Indexed: 06/22/2024] Open
Abstract
Purpose This study aimed to investigate the risk factors of prognosis and hemorrhagic transformation after mechanical thrombectomy (MT) in patients with posterior circulation acute ischemic stroke (PC-AIS) caused by large vessel occlusion. We sought to develop a nomogram for predicting the risk of poor prognosis and symptomatic intracerebral hemorrhage (sICH) in patients with PC-AIS. Methods A retrospective analysis was conducted on 81 patients with PC-AIS who underwent MT treatment. We collected clinical information from the patients to assessed sICH and prognosis based on CT results and National Institutes of Health Stroke Scale (NIHSS) scores. Subsequently, they were followed up for 3 months, and their prognosis was assessed using the Modified Rankin Scale. We used the least absolute shrinkage and selection operator (LASSO) and multivariate logistic regression to determine the factors affecting prognosis to construct a nomogram. The nomogram's performance was assessed through receiver operating characteristic curves, calibration curves, decision curve analysis, and clinical impact curves. Results Among the 81 patients with PC-AIS, 33 had a good prognosis, 48 had a poor prognosis, 19 presented with sICH, and 62 did not present with sICH. The results of the LASSO regression indicated that variables, including HPT, baseline NIHSS score, peak SBP, SBP CV, SBP SD, peak SBP, DBP CV, HbA1c, and BG SD, were predictors of patient prognosis. Variables such as AF, peak SBP, and peak DBP predicted the risk of sICH. Multivariate logistic regression revealed that baseline NIHSS score (OR = 1.115, 95% CI 1.002-1.184), peak SBP (OR = 1.060, 95% CI 1.012-1.111), SBP CV (OR = 1.296, 95% CI 1.036-1.621) and HbA1c (OR = 3.139, 95% CI 1.491-6.609) were independent risk factors for prognosis. AF (OR = 6.823, 95% CI 1.606-28.993), peak SBP (OR = 1.058, 95% CI 1.013-1.105), and peak DBP (OR = 1.160, 95% CI 1.036-1.298) were associated with the risk of sICH. In the following step, nomograms were developed, demonstrating good discrimination, calibration, and clinical applicability. Conclusion We constructed nomograms to predict poor prognosis and risk of sICH in patients with PC-AIS undergoing MT. The model exhibited good discrimination, calibration, and clinical applicability.
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Affiliation(s)
| | | | | | | | | | - Shaoshuai Wang
- Department of Neurology, First Hospital of Shanxi Medical University, Taiyuan, China
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Dallas J, Nguyen VN, Sequeiros JM, Graham S, Burns-Martin J, Goyal N, Khatibi K. Distal mechanical thrombectomy using beveled tip aspiration zoom catheters: A preliminary study. Interv Neuroradiol 2024:15910199241258289. [PMID: 38831628 DOI: 10.1177/15910199241258289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024] Open
Abstract
INTRODUCTION Distal medium vessel occlusion (DVO) thrombectomy has been shown to be efficacious with safety profiles comparable to large vessel occlusion (LVO) thrombectomy. A novel, highly-trackable, bevel-tipped Zoom 35 catheter can be used as an aspiration catheter for DVO thrombectomy. METHODS This is a retrospective, single-arm, multi-institutional observational study evaluating the efficacy and safety of aspiration thrombectomy for DVO using the Zoom 35 catheter. Patient demographics, presenting and discharge NIHSS, primary and rescue thrombectomy, site of occlusion, TICI score, and intracranial hemorrhage were chart abstracted. Descriptive statistics were used to evaluate the efficacy and safety of thrombectomy. RESULTS Fourteen patients (mean age 66.64 ± 13.75 years) were included. The mean NIHSS at presentation was 10.79 ± 5.48, and the mean ASPECTS was 9.00 ± 0.89. Nine patients (64.3%) received tPA. Primary occlusion location was M3 in nine cases (64.3%), M2/M3 junction in two cases (14.3%), A2 in one case (7.1%), A3 in one case (7.1%), and P1 in one case (7.1%). TICI scores were 3 in seven cases (50.0%), 2C in three cases (21.4%), and 2B in four cases (28.6%). There was one postoperative SAH (7.1%) and one asymptomatic ICH (7.1%). Mean discharge NIHSS was 3.38 ± 4.44, with a mean decrease of 7.31 from presentation (p < 0.0001, t-test). CONCLUSION Zoom 35 beveled-tip aspiration microcatheters are highly trackable and associated with improved radiographic and clinical outcomes for the treatment of DVO with a good safety profile.
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Affiliation(s)
- Jonathan Dallas
- Department of Neurological Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - Vincent N Nguyen
- Department of Neurological Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - Joel M Sequeiros
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Shelby Graham
- University of Tennessee Health Science Center College of Medicine, Memphis, TN, USA
| | - Jared Burns-Martin
- New York Institute of Technology College of Medicine, Glen Head, NY, USA
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kasra Khatibi
- Department of Neurological Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
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9
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Alton A, Flynn D, Burgess D, Ford GA, Price C, James M, McMeekin P, Allen M, Shaw L, White P. Stroke survivor views on ambulance redirection as a strategy to increase access to thrombectomy in England. Br Paramed J 2024; 9:1-9. [PMID: 38946738 PMCID: PMC11210583 DOI: 10.29045/14784726.2024.6.9.1.1] [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] [Indexed: 07/02/2024] Open
Abstract
Introduction Intravenous thrombolysis and mechanical thrombectomy are effective time-sensitive treatments for selected cases of acute ischaemic stroke. While thrombolysis is widely available, thrombectomy can only be provided at facilities with the necessary equipment and interventionists. Suitable patients admitted to other hospitals require secondary transfer, causing delays to treatment. Pre-hospital ambulance redirection to thrombectomy facilities may improve access but treatment eligibility cannot be confirmed pre-hospital. Some redirected patients would travel further and be displaced without receiving thrombectomy. This study aimed to elicit stroke survivor and carer/relative views about the possible consequences of introducing a conceptual, idealised ambulance redirection pathway. Methods Focus groups were undertaken using a topic guide describing four hypothetical ambulance redirection scenarios and their possible consequences: earlier treatment with thrombectomy; delayed diagnosis of non-stroke 'mimic' conditions; delayed thrombolysis treatment; and delayed diagnosis of haemorrhagic stroke. Meetings were audio recorded, transcribed verbatim and data analysed thematically using emergent coding. Results Fifteen stroke survivors and carers/relatives participated in three focus groups. There was wide acceptance of possible low-risk consequences of ambulance redirection, including extended travel time, being further from home and experiencing longer hospital stays. Participants were more uncertain about higher-risk consequences, including delays in diagnosis/treatment for patients unsuitable for thrombectomy, but remained positive about ambulance redirection overall. Participants rationalised acceptance of higher-risk consequences by recognising that redirected patients would still access appropriate treatment, even if delayed. In addition, acceptance of ambulance redirection would be increased if there were robust clinical evidence showing net benefit over secondary transfer pathways. Conclusions Participant views were generally supportive of ambulance redirection to facilitate access to thrombectomy. Further research is needed to demonstrate overall benefit in an NHS context.
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Affiliation(s)
- Abigail Alton
- Newcastle University ORCID iD: https://orcid.org/0000-0002-9983-080X
| | - Darren Flynn
- Northumbria University ORCID iD: https://orcid.org/0000-0001-7390-632X
| | - David Burgess
- North East and North Cumbria Stroke Patient & Carer Panel, CRN North East and North Cumbria ORCID iD: https://orcid.org/0009-0003-3248-4601
| | - Gary A Ford
- University of Oxford ORCID iD: https://orcid.org/0000-0001-8719-4968
| | - Chris Price
- Newcastle University ORCID iD: https://orcid.org/0000-0003-3566-3157
| | - Martin James
- Royal Devon & Exeter Hospital/University of Exeter Medical School; NIHR South West Peninsula Applied Research Collaboration ORCID iD: https://orcid.org/0000-0001-6065-6018
| | - Peter McMeekin
- Northumbria University ORCID iD: https://orcid.org/0000-0003-0946-7224
| | - Michael Allen
- University of Exeter Medical School & NIHR South West Peninsula Applied Research Collaboration ORCID iD: https://orcid.org/0000-0002-8746-9957
| | - Lisa Shaw
- Newcastle University ORCID iD: https://orcid.org/0000-0002-9931-7774
| | - Phil White
- Newcastle University ORCID iD: https://orcid.org/0000-0001-6007-6013
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10
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Paxton JH, Keenan KJ, Wilburn JM, Wise SL, Klausner HA, Ball MT, Dunne RB, Kreitel KD, Morgan LF, Fales WD, Madhok D, Barazangi N, McLean ST, Cross K, Distenfield L, Sykes J, Lovoi P, Johnson B, Smith WS. Headpulse measurement can reliably identify large-vessel occlusion stroke in prehospital suspected stroke patients: Results from the EPISODE-PS-COVID study. Acad Emerg Med 2024. [PMID: 38643419 DOI: 10.1111/acem.14919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2023] [Revised: 02/26/2024] [Accepted: 03/12/2024] [Indexed: 04/22/2024]
Abstract
BACKGROUND Large-vessel occlusion (LVO) stroke represents one-third of acute ischemic stroke (AIS) in the United States but causes two-thirds of poststroke dependence and >90% of poststroke mortality. Prehospital LVO stroke detection permits efficient emergency medical systems (EMS) transport to an endovascular thrombectomy (EVT)-capable center. Our primary objective was to determine the feasibility of using a cranial accelerometry (CA) headset device for prehospital LVO stroke detection. Our secondary objective was development of an algorithm capable of distinguishing LVO stroke from other conditions. METHODS We prospectively enrolled consecutive adult patients suspected of acute stroke from 11 study hospitals in four different U.S. geographical regions over a 21-month period. Patients received device placement by prehospital EMS personnel. Headset data were matched with clinical data following informed consent. LVO stroke diagnosis was determined by medical chart review. The device was trained using device data and Los Angeles Motor Scale (LAMS) examination components. A binary threshold was selected for comparison of device performance to LAMS scores. RESULTS A total of 594 subjects were enrolled, including 183 subjects who received the second-generation device. Usable data were captured in 158 patients (86.3%). Study subjects were 53% female and 56% Black/African American, with median age 69 years. Twenty-six (16.4%) patients had LVO and 132 (83.6%) were not LVO (not-LVO AIS, 33; intracerebral hemorrhage, nine; stroke mimics, 90). COVID-19 testing and positivity rates (10.6%) were not different between groups. We found a sensitivity of 38.5% and specificity of 82.7% for LAMS ≥ 4 in detecting LVO stroke versus a sensitivity of 84.6% (p < 0.0015 for superiority) and specificity of 82.6% (p = 0.81 for superiority) for the device algorithm (CA + LAMS). CONCLUSIONS Obtaining adequate recordings with a CA headset is highly feasible in the prehospital environment. Use of the device algorithm incorporating both CA and LAMS data for LVO detection resulted in significantly higher sensitivity without reduced specificity when compared to the use of LAMS alone.
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Affiliation(s)
- James H Paxton
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Kevin J Keenan
- Department of Neurology, University of California, Davis, Sacramento, California, USA
| | - John M Wilburn
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Stefanie L Wise
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Howard A Klausner
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Matthew T Ball
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - Robert B Dunne
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | - K Derek Kreitel
- Department of Radiology, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA
| | - Larry F Morgan
- Department of Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA
| | - William D Fales
- Department of Emergency Medicine, Western Michigan University Homer Stryker MD School of Medicine, Kalamazoo, Michigan, USA
| | - Debbie Madhok
- Department of Emergency Medicine, University of California, San Francisco, California, USA
| | - Nobl Barazangi
- Department of Neurology, California Pacific Medical Center, San Francisco, California, USA
| | - Steven T McLean
- Department of Emergency Medicine, Ascension St. Mary's Hospital, Saginaw, Michigan, USA
| | - Katherine Cross
- Department of Emergency Medicine, Wayne State University School of Medicine, Detroit, Michigan, USA
| | | | | | - Paul Lovoi
- MindRhythm, Inc., Cupertino, California, USA
| | | | - Wade S Smith
- Department of Neurology, University of California, Davis, Sacramento, California, USA
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11
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Zafar AS, Shahid R, Albakr AI, Aljaafari DT, Alkhamis FA, Shariff EM, Alabdali MM, Nazish S, Alshamrani FJ, Alamri AS, Hadhiah KM, Alsulaiman AA, Alkhaldi NA, Al-Suhibani SS, Al-Jehani HM. Characteristics and outcomes of large artery occlusion-related stroke due to intracranial atherostenosis: An experience from a single center in Saudi Arabia. J Family Community Med 2024; 31:140-147. [PMID: 38800790 PMCID: PMC11114875 DOI: 10.4103/jfcm.jfcm_313_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Revised: 02/05/2024] [Accepted: 02/17/2024] [Indexed: 05/29/2024] Open
Abstract
BACKGROUND Literature on the frequency, response to treatment, and outcomes of acute ischemic stroke (AIS) due to intracranial atherostenosis (ICAS)-related intracranial large artery occlusion (ILAO) from Saudi Arabia is scarce. The aim of this study was to identify the percentage, describe the characteristics, and observe the treatment response in patients with AIS attributed to ICAS-related ILAO. MATERIALS AND METHODS This cross-sectional study included all adult patients from 2017-2021 who fulfilled the inclusion criteria for the diagnosis of ICAS-related AIS. Patients were dichotomized based on ILAO. Mortality and functional outcomes (FOCs) based on 90 days' dependence level were compared between the two groups. The association between ILAO and other variables was assessed using the Chi-squared test, odds ratios (OR), and 95% confidence interval (CI). RESULTS ILAO was found in 38.7% of patients with ICAS-related AIS. Men comprised three-fourths of the cohort and were more frequent in the ILAO group. Smoking was associated with increased (P = 0.04) likelihood of ILAO. Patients with ILAO had more severe strokes (P ≤ 0.001) than patients without. Middle cerebral artery was the most common occluded vessel (52%). Functional dependence (P = 0.003, OR = 2.87, CI = 1.42-5.77), malignant transformation (P = 0.001, OR = 8.0, CI = 1.82-35.9), and mortality (P ≤ 0.001, OR = 7.67, CI = 2.40-24.5) were significantly higher among ILAO group. Patients with ILAO with unfavorable FOC were older than those who achieved better FOC (P ≤ 0.001). Thrombolysis (P = 0.02, OR = 2.50, CI = 1.15-5.41) and mechanical thrombectomy (MT) improved FOC in patients with ILAO (P = 0.04, OR = 2.33, CI = 1.10-4.92). CONCLUSION ILAO is common in patients with ICAS-related AIS. Timely hyperacute stroke treatment can help improve the FOC of otherwise disabling stroke due to ILAO. Raising awareness of the community about stroke is needed, so that a higher number of patients can arrive at hospital within the golden hours. Further data from the region are required to recognize the efficacy of MT in ICAS-related ILAO.
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Affiliation(s)
- Azra S. Zafar
- Department of Neurology, College of Medicine and King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Rizwana Shahid
- Department of Neurology, College of Medicine and King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Aishah I. Albakr
- Department of Neurology, College of Medicine and King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Danah T. Aljaafari
- Department of Neurology, College of Medicine and King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Fahd A. Alkhamis
- Department of Neurology, College of Medicine and King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Erum M. Shariff
- Department of Neurology, College of Medicine and King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Majed M. Alabdali
- Department of Neurology, College of Medicine and King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Saima Nazish
- Department of Neurology, College of Medicine and King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Foziah J.G. Alshamrani
- Department of Neurology, College of Medicine and King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Abdullah S. Alamri
- Department of Neurology, College of Medicine and King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Kawther M. Hadhiah
- Department of Neurology, College of Medicine and King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Abdulla A. Alsulaiman
- Department of Neurology, College of Medicine and King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Norah A. Alkhaldi
- Department of Neurology, College of Medicine and King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Sari S. Al-Suhibani
- Department of Radiology, College of Medicine and King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Hosam M. Al-Jehani
- Department of Neurosurgery, Critical Care Medicine and Interventional Radiology, King Fahd Hospital of the University, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
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12
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Xiong Y, Campbell BCV, Fisher M, Schwamm LH, Parsons M, Li H, Pan Y, Meng X, Zhao X, Wang Y. Rationale and design of Tenecteplase Reperfusion Therapy in Acute Ischaemic Cerebrovascular Events III (TRACE III): a randomised, phase III, open-label, controlled trial. Stroke Vasc Neurol 2024; 9:82-89. [PMID: 37247876 PMCID: PMC10956103 DOI: 10.1136/svn-2023-002310] [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: 01/16/2023] [Accepted: 05/01/2023] [Indexed: 05/31/2023] Open
Abstract
BACKGROUND AND PURPOSE Recombinant human TNK tissue-type plasminogen activator (rhTNK-tPA) was not inferior to alteplase for ischaemic stroke within 4.5 hours. Our study aimed to investigate the efficacy and safety of rhTNK-tPA in patients who had an ischaemic stroke due to large vessel occlusion (LVO) of anterior circulation beyond 4.5 hours. METHODS AND DESIGN Tenecteplase Reperfusion Therapy in Acute Ischaemic Cerebrovascular Events-III (TRACE III) is a multicentre, prospective, randomised, open-label, blind endpoint, controlled clinical trial. Patients who had an ischaemic stroke due to anterior circulation LVO (internal carotid artery, middle cerebral artery M1 and M2 segments) within 4.5-24 hours from last known well (including wake-up stroke and no witness stroke) and with salvageable tissue (ischaemic core volume <70 mL, mismatch ratio ≥1.8 and mismatch volume ≥15 mL) based on CT perfusion or MRI perfusion-weighted imaging (PWI) were included and randomised to rhTNK-tPA 0.25 mg/kg (single bolus) to a maximum of 25 mg or standard medical therapy. Specially, we will exclude patients who are intended for direct thrombectomy. All will be followed up for 90 days. STUDY OUTCOMES Primary efficacy outcome is modified Rankin Scale (mRS) score ≤1 at 90 days. Secondary efficacy outcomes include ordinal distribution of mRS at 90 days, major neurological improvement defined by a decrease ≥8 points compared with the initial deficit or a score ≤1 on the National Institutes of Health Stroke Scale (NIHSS) at 72 hours, mRS score ≤2 at 90 days, the rate of improvement on Tmax >6 s at 24 hours and NIHSS score change from baseline at 7 days. Safety outcomes are symptomatic intracerebral haemorrhage within 36 hours and mortality at 90 days. DISCUSSION TRACE III will provide evidence for the efficacy and safety of rhTNK-tPA in patients who had an ischaemic strokes due to anterior circulation LVO beyond 4.5 hours. TRIAL REGISTRATION NUMBER NCT05141305.
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Affiliation(s)
- Yunyun Xiong
- Neurology, Beijing Tiantan Hospital, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Bruce C V Campbell
- Department of Medicine and Neurology, The University of Melbourne, Melbourne, Victoria, Australia
| | - Marc Fisher
- Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Lee H Schwamm
- Department of Neurology and Comprehensive Stroke Center, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Mark Parsons
- Department of Neurology, University of New South Wales South Western Sydney Clinical School, Liverpool, New South Wales, Australia
| | - Hao Li
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yuesong Pan
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xia Meng
- China National Clinical Research Center for Neurological Diseases, Beijing, China
| | | | - Yongjun Wang
- Neurology, Beijing Tiantan Hospital, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing, China
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13
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Xu J, Chen XY, Wang HY, Shang YF, Shen PP, Zhang S, Guo SY, Tan MM, Geng Y. Hemodynamic predictors of early neurological deterioration and clinical outcome after endovascular treatment in large artery occlusion. Heliyon 2024; 10:e24746. [PMID: 38318012 PMCID: PMC10838741 DOI: 10.1016/j.heliyon.2024.e24746] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 12/07/2023] [Accepted: 01/12/2024] [Indexed: 02/07/2024] Open
Abstract
Objective Half of the patients with acute large artery occlusion (LAO) have poor outcomes after endovascular treatment (EVT). Early complications such as cerebral edema and symptomatic intracranial hemorrhage (sICH) can lead to early neurological deterioration (END), which correlates with hemodynamics. This study aimed to identify the hemodynamic predictors of END and outcomes in LAO patients after EVT. Methods A total of 76 patients with anterior circulation LAO who underwent EVT and received transcranial Doppler (TCD) monitoring were included. Bilateral middle cerebral artery (MCA) blood flow velocities (BFVs) were measured repeatedly within 1 week. Mean flow velocities (MFV) and MFV index (ipsilateral MFV/contralateral MFV) were calculated. The primary outcome was the incidence of END within 72 h. The secondary outcome was the functional outcome at 90 days-a good outcome was defined as a modified Rankin scale (mRS) score of 0-2, while a poor outcome was defined as an mRS score of 3-6. Results A total of 13 patients (17.1 %) experienced END within 72 h, including 5 (38.5 %) with cerebral edema, 5 (38.5 %) with sICH, and 3 (23.0 %) with infarct progression. Multivariable logistic regression analysis showed that a higher 24 h MFV index was independently associated with END (aOR 10.5; 95 % CI 2.28-48.30, p = 0.003) and a poor 90-day outcome (aOR 5.10; 95 % CI 1.38-18.78, p = 0.014). The area under the receiver operating characteristic (ROC) curve (AUC) of the 24 h MFV index for predicting END was 0.807 (95 % CI 0.700-0.915, p = 0.0005), the sensitivity was 84.6 %, and the specificity was 66.7 %. At the 1-week TCD follow-up, patients who had poor 90-day outcomes showed significantly higher 1-week iMFV [73.5 (58.4-99.0) vs. 57.7 (45.3-76.3), p = 0.004] and MFV index [1.24 (0.98-1.57) vs.1.0 (0.87-1.15) p = 0.007]. A persistent high MFV index (PHMI) was independently associated with a poor outcome (aOR 7.77, 95 % CI 1.81-33.3, p = 0.006). Conclusion TCD monitoring within 24 h after EVT in LAO patients can help predict END, while dynamic follow-up within 1 week is valuable in predicting clinical outcomes.
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Affiliation(s)
- Jie Xu
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, 310053, Zhejiang, China
| | - Xin-Yi Chen
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, 310053, Zhejiang, China
| | - Hui-Yuan Wang
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
- School of Clinical Medicine, Graduate School, Bengbu Medical College, Bengbu, 233030, Anhui, China
| | - Ya-Fei Shang
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
- School of Clinical Medicine, Graduate School, Bengbu Medical College, Bengbu, 233030, Anhui, China
| | - Pan-Pan Shen
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
- The Second Clinical Medical College, Zhejiang Chinese Medical University, Hangzhou, 310053, Zhejiang, China
| | - Sheng Zhang
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
| | - Shun-Yuan Guo
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
| | - Ming-Ming Tan
- Department of Quality Management, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
| | - Yu Geng
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, 310014, Zhejiang, China
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14
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Ostmeier S, Axelrod B, Liu Y, Yu Y, Jiang B, Yuen N, Pulli B, Verhaaren BFJ, Kaka H, Wintermark M, Michel P, Mahammedi A, Federau C, Lansberg MG, Albers GW, Moseley ME, Zaharchuk G, Heit JJ. Random expert sampling for deep learning segmentation of acute ischemic stroke on non-contrast CT. J Neurointerv Surg 2024:jnis-2023-021283. [PMID: 38302420 PMCID: PMC11291713 DOI: 10.1136/jnis-2023-021283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/26/2023] [Accepted: 01/15/2024] [Indexed: 02/03/2024]
Abstract
BACKGROUND Outlining acutely infarcted tissue on non-contrast CT is a challenging task for which human inter-reader agreement is limited. We explored two different methods for training a supervised deep learning algorithm: one that used a segmentation defined by majority vote among experts and another that trained randomly on separate individual expert segmentations. METHODS The data set consisted of 260 non-contrast CT studies in 233 patients with acute ischemic stroke recruited from the multicenter DEFUSE 3 (Endovascular Therapy Following Imaging Evaluation for Ischemic Stroke 3) trial. Additional external validation was performed using 33 patients with matched stroke onset times from the University Hospital Lausanne. A benchmark U-Net was trained on the reference annotations of three experienced neuroradiologists to segment ischemic brain tissue using majority vote and random expert sampling training schemes. The median of volume, overlap, and distance segmentation metrics were determined for agreement in lesion segmentations between (1) three experts, (2) the majority model and each expert, and (3) the random model and each expert. The two sided Wilcoxon signed rank test was used to compare performances (1) to 2) and (1) to (3). We further compared volumes with the 24 hour follow-up diffusion weighted imaging (DWI, final infarct core) and correlations with clinical outcome (modified Rankin Scale (mRS) at 90 days) with the Spearman method. RESULTS The random model outperformed the inter-expert agreement ((1) to (2)) and the majority model ((1) to (3)) (dice 0.51±0.04 vs 0.36±0.05 (P<0.0001) vs 0.45±0.05 (P<0.0001)). The random model predicted volume correlated with clinical outcome (0.19, P<0.05), whereas the median expert volume and majority model volume did not. There was no significant difference when comparing the volume correlations between random model, median expert volume, and majority model to 24 hour follow-up DWI volume (P>0.05, n=51). CONCLUSION The random model for ischemic injury delineation on non-contrast CT surpassed the inter-expert agreement ((1) to (2)) and the performance of the majority model ((1) to (3)). We showed that the random model volumetric measures of the model were consistent with 24 hour follow-up DWI.
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Affiliation(s)
- Sophie Ostmeier
- Department of Radiology, Stanford University, Stanford, California, USA
| | | | - Yongkai Liu
- Department of Radiology, Stanford University, Stanford, California, USA
| | - Yannan Yu
- Department of Radiology, University of California San Francisco, San Francisco, California, USA
| | - Bin Jiang
- Department of Radiology, Stanford University, Stanford, California, USA
| | - Nicole Yuen
- Department of Neurology, Stanford University School of Medicine, Stanford, California, USA
| | - Benjamin Pulli
- Department of Radiology, Stanford University, Stanford, California, USA
| | | | - Hussam Kaka
- Department of Radiology, Stanford University, Stanford, California, USA
| | - Max Wintermark
- Department of Radiology, University of Virginia, Charlottesville, Virginia, USA
| | - Patrik Michel
- Department of Neurology Service, University of Lausanne, Lausanne, Switzerland
| | | | | | - Maarten G Lansberg
- Department of Neurology, Stanford University School of Medicine, Stanford, California, USA
| | - Gregory W Albers
- Department of Neurology, Stanford University School of Medicine, Stanford, California, USA
| | - Michael E Moseley
- Department of Radiology, Stanford University, Stanford, California, USA
| | - Gregory Zaharchuk
- Department of Radiology, Stanford University, Stanford, California, USA
| | - Jeremy J Heit
- Department of Radiology, Neuroadiology and Neurointervention Division, Stanford University School of Medicine, Palo Alto, CA, USA
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15
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Vuorinen P, Setälä P, Ollikainen J, Hoppu S. A hybrid strategy using an ambulance and a helicopter to convey thrombectomy candidates to definite care: a prospective observational study. BMC Emerg Med 2024; 24:17. [PMID: 38273239 PMCID: PMC10809465 DOI: 10.1186/s12873-024-00931-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 01/10/2024] [Indexed: 01/27/2024] Open
Abstract
BACKGROUND Mechanical thrombectomy is the treatment of choice for large vessel occlusion strokes done only in comprehensive stroke centres (CSC). We investigated whether the transportation time of thrombectomy candidates from another hospital district could be reduced by using an ambulance and a helicopter and how this affected their recovery. METHODS We prospectively gathered the time points of thrombectomy candidates referred to the Tampere University Hospital from the hospital district of Southern Ostrobothnia. Primary and secondary transports were included. In Hybrid transport, the helicopter emergency medical services (HEMS) unit flew from an airport near the CSC to meet the patient during transport and continued the transport to definitive care. Ground transport was chosen only when the weather prevented flying, or the HEMS crew was occupied in another emergency. We contacted the patients treated with mechanical thrombectomy 90 days after the intervention and rated their recovery with the modified Rankin Scale (mRS). Favourable recovery was considered mRS 0-2. RESULTS During the study, 72 patients were referred to the CSC, 71% of which were first diagnosed at the PSC. Hybrid transport (n = 34) decreased the median time from the start of transport from the PSC to the computed tomography (CT) at the CSC when compared to Ground (n = 17) transport (84 min, IQR 82-86 min vs. 109 min, IQR 104-116 min, p < 0.001). The transport times straight from the scene to CT at the CSC were equal: median 93 min (IQR 80-102 min) in the Hybrid group (n = 11) and 97 min (IQR 91-108 min) in the Ground group (n = 10, p = 0.28). The percentages of favourable recovery were 74% and 50% in the Hybrid and Ground transport groups (p = 0.38) from the PSC. Compared to Ground transportation from the scene, Hybrid transportation had less effect on the positive recovery percentages of 60% and 50% (p = 1.00), respectively. CONCLUSION Adding a HEMS unit to transporting a thrombectomy candidate from a PSC to CSC decreases the transport time compared to ambulance use only. This study showed minimal difference in the recovery after thrombectomy between Hybrid and Ground transports.
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Affiliation(s)
- Pauli Vuorinen
- Emergency Medical Services, Centre for Prehospital Emergency Care, Pirkanmaa wellbeing services county, Tampere, Finland.
- Faculty of Medicine and Health Technology, University of Tampere, Tampere, Finland.
- Emergency Medical Services, Tampere University Hospital, FI-33521, Tampere, PO Box 2000, Finland.
| | - Piritta Setälä
- Emergency Medical Services, Centre for Prehospital Emergency Care, Pirkanmaa wellbeing services county, Tampere, Finland
| | - Jyrki Ollikainen
- Department of Neurosciences and Rehabilitation, Tampere University Hospital, Tampere, Finland
| | - Sanna Hoppu
- Emergency Medical Services, Centre for Prehospital Emergency Care, Pirkanmaa wellbeing services county, Tampere, Finland
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16
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Borsos B, Allaart CG, van Halteren A. Predicting stroke outcome: A case for multimodal deep learning methods with tabular and CT Perfusion data. Artif Intell Med 2024; 147:102719. [PMID: 38184355 DOI: 10.1016/j.artmed.2023.102719] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2023] [Revised: 11/12/2023] [Accepted: 11/14/2023] [Indexed: 01/08/2024]
Abstract
MOTIVATION Acute ischemic stroke is one of the leading causes of morbidity and disability worldwide, often followed by a long rehabilitation period. To improve and personalize stroke rehabilitation, it is essential to provide a reliable prognosis to caregivers and patients. Deep learning techniques might improve the predictions by incorporating different data modalities. We present a multimodal approach to predict the functional status of acute ischemic stroke patients after their discharge based on tabular data and CT perfusion imaging. METHODS We conducted experiments on tabular, imaging, and multimodal deep learning architectures to predict dichotomized mRS scores 3 months after the event. The dataset was collected from a Dutch hospital and includes 98 CVA patients with a visible occlusion on their CT perfusion scan. Tabular data is based on the Dutch Acute Stroke Audit data, and imaging data consists of summed-up CT perfusion maps. RESULTS On the tabular data, TabNet outperformed our baselines with an AUC of 0.71, while ResNet-10 on the imaging data performed comparably with an AUC of 0.70. Our implementation of the multimodal DAFT architecture outperforms baselines as well as comparable studies by achieving an 0.75 AUC, and 0.80 F1 score. This was achieved with a final model of less than a hundred thousand optimizable parameters, and a dataset less than half the size of reference papers. CONCLUSION Overall, we demonstrate the feasibility of predicting the functional outcome for ischemic stroke patients and the usability of multimodal deep learning architectures for this purpose.
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Affiliation(s)
- Balázs Borsos
- Vrije Universiteit Amsterdam, De Boelelaan 1105, Amsterdam, 1081 HV, Netherlands; St. Antonius Ziekenhuis, Koekoekslaan 1, Nieuwegein, 3435 CM, Netherlands; Philips Research, Hightech Campus 34, Eindhoven, 5656 AE, Netherlands
| | - Corinne G Allaart
- Vrije Universiteit Amsterdam, De Boelelaan 1105, Amsterdam, 1081 HV, Netherlands; St. Antonius Ziekenhuis, Koekoekslaan 1, Nieuwegein, 3435 CM, Netherlands.
| | - Aart van Halteren
- Vrije Universiteit Amsterdam, De Boelelaan 1105, Amsterdam, 1081 HV, Netherlands; Philips Research, Hightech Campus 34, Eindhoven, 5656 AE, Netherlands
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17
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Rai AT, Link PS, Domico JR. Updated estimates of large and medium vessel strokes, mechanical thrombectomy trends, and future projections indicate a relative flattening of the growth curve but highlight opportunities for expanding endovascular stroke care. J Neurointerv Surg 2023; 15:e349-e355. [PMID: 36564202 PMCID: PMC10803998 DOI: 10.1136/jnis-2022-019777] [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: 10/30/2022] [Accepted: 12/02/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND A study was undertaken to determine the incidence of acute ischemic stroke (AIS) and strokes related to large (LVO) and medium (MVO) vessel occlusions, and to estimate annual mechanical thrombectomy (MT) volume, past trends and future growth. METHODS A population-based analysis was performed to estimate the rate of AIS, LVOs (internal carotid artery terminus, M1 branch of the middle cerebral artery, basilar artery) and MVOs (M2 and M3 branches of the middle cerebral artery, anterior and posterior cerebral arteries). MT estimates were determined from multiple governmental data sources. Annual US numbers were adjusted for population growth. RESULTS The incidence of AIS is estimated at 216 (95% CI 199 to 238)/100 000 persons/year or 718 191 (95% CI 661 483 to 791 121) AIS/year in the USA. A vascular occlusion was observed in 21% of patients with AIS (95% CI 15 to 29). The rate of LVO was 24/100 000 persons/year (95% CI 19 to 31) or 80 075 (95% CI 62 457 to 104 375) LVOs/year, and the rate of MVO was 20/100 000 persons/year or 65 798 (95% CI 45 555 to 95 110) MVOs/year. MT estimates for 2021 are 39 164 procedures with a flattening of the growth curve from 2019 (9%, 2020-2021; 4%, 2019-2020) as opposed to initial steep growth from 2015 to 2018. Current MT procedures represent 5% of all AIS, 27% of all vascular occlusions (LVO+MVO) and 38% of all LVO and M2 occlusions. The current trajectory indicates a future growth of 5-10%/year for the next several years. CONCLUSION A decline in MT growth is observed. The incidence of LVO+MVO is estimated at 44/100 000 persons/year or almost 144 000 large and medium vessel strokes annually. Of these, currently an estimated 27% undergo an MT procedure, indicating an opportunity for growth. Further expansion may require focusing on the elderly, medium vessel strokes and workflow efficiencies from diagnosis to treatment.
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Affiliation(s)
- Ansaar T Rai
- Interventional Neuroradiology, West Virginia University Rockefeller Neuroscience Institute, Morgantown, West Virginia, USA
| | - Paul S Link
- Stryker Neurovascular, Fremont, California, USA
| | - Jennifer R Domico
- Interventional Neuroradiology, West Virginia University Rockefeller Neuroscience Institute, Morgantown, West Virginia, USA
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18
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Matur AV, Candelario-Jalil E, Paul S, Karamyan VT, Lee JD, Pennypacker K, Fraser JF. Translating Animal Models of Ischemic Stroke to the Human Condition. Transl Stroke Res 2023; 14:842-853. [PMID: 36125734 DOI: 10.1007/s12975-022-01082-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 08/30/2022] [Accepted: 09/12/2022] [Indexed: 11/30/2022]
Abstract
Ischemic stroke is a leading cause of death and disability. However, very few neuroprotective agents have shown promise for treatment of ischemic stroke in clinical trials, despite showing efficacy in many successful preclinical studies. This may be attributed, at least in part, to the incongruency between experimental animal stroke models used in preclinical studies and the manifestation of ischemic stroke in humans. Most often the human population selected for clinical trials are more diverse than the experimental model used in a preclinical study. For successful translation, it is critical to develop clinical trial designs that match the experimental animal model used in the preclinical study. This review aims to provide a comprehensive summary of commonly used animal models with clear correlates between rodent models used to study ischemic stroke and the clinical stroke pathologies with which they most closely align. By improving the correlation between preclinical studies and clinical trials, new neuroprotective agents and stroke therapies may be more accurately and efficiently identified.
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Affiliation(s)
- Abhijith V Matur
- Department of Radiology, University of Kentucky, Lexington, KY, USA.
| | - Eduardo Candelario-Jalil
- Department of Neuroscience, McKnight Brain Institute, University of Florida, Gainesville, FL, USA
| | - Surojit Paul
- Department of Neurology and Department of Neurosciences, University of New Mexico Health Sciences Center, Albuquerque, NM, USA
| | - Vardan T Karamyan
- Department of Foundational Medical Studies, Oakland University William Beaumont School of Medicine, Rochester, MI, USA
| | - Jessica D Lee
- Department of Neurology, University of Kentucky, Lexington, KY, USA
| | - Keith Pennypacker
- Department of Neurology, University of Kentucky, Lexington, KY, USA
- Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, KY, USA
| | - Justin F Fraser
- Department of Radiology, University of Kentucky, Lexington, KY, USA
- Department of Neurology, University of Kentucky, Lexington, KY, USA
- Center for Advanced Translational Stroke Science, University of Kentucky, Lexington, KY, USA
- Department of Neuroscience, University of Kentucky, Lexington, KY, USA
- Department of Neurological Surgery, University of Kentucky, Lexington, KY, USA
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19
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Patel K, Hamedani AG, Taneja K, Koneru M, Wolfe J, Sprankle K, Patel P, Mullen MT, Siegler JE. Differential thrombectomy utilization across hospital classifications in the United States. J Stroke Cerebrovasc Dis 2023; 32:107401. [PMID: 37897885 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107401] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2023] [Revised: 09/11/2023] [Accepted: 09/29/2023] [Indexed: 10/30/2023] Open
Abstract
OBJECTIVES To determine hospital-level factors associated with thrombectomy uptake. MATERIALS AND METHODS The Nationwide Emergency Department Sample was retrospectively queried to determine the total number of thrombectomies performed based on different hospital characteristics. Joint point analysis was used to determine which years were associated with significant increases in the number of high-volume thrombectomy centers (ostensibly defined as >50 thrombectomies/year), thrombectomy-capable centers (>15 thrombectomies/year), and total number of thrombectomies performed. Multivariable logistic regression was used to determine hospital factors associated with having an increased odds of performing thrombectomies, and of being classified as a high-volume thrombectomy or a thrombectomy-capable center. RESULTS Between 2007-2020 there was a stepwise increase in the number of thrombectomy-capable and high-volume thrombectomy centers in the United States. In 2020, there were a total of 15,705 thrombectomies performed, with 89 high-volume thrombectomy centers, and 359 thrombectomy-capable centers. The number of thrombectomy-capable centers significantly increased after 2011. After 2013 and 2016 there was a significant change in the growth rate of high-volume thrombectomy centers. There was also a significant increase in the total number of thrombectomies performed after 2016. Hospital characteristics that were associated with an increased likelihood of being classified as thrombectomy-capable or high-volume included trauma level 1 and 2 hospitals. CONCLUSIONS Between 2007 and 2020, there was a marked growth in thrombectomy utilization for acute ischemic stroke. This growth outpaced new diagnoses of ischemic stroke, and was driven largely by certain hospital types, with the greatest rises following seminal publications of positive randomized thrombectomy trials.
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Affiliation(s)
- Karan Patel
- Cooper Medical School of Rowan University, Camden, NJ, USA.
| | - Ali G Hamedani
- Departments of Neurology and Ophthalmology and Center for Clinical Epidemiology and Biostatistics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Kamil Taneja
- Renaissance School of Medicine at Stony Brook University, Stony Brook, NY, USA
| | - Manisha Koneru
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Jared Wolfe
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | | | - Pratit Patel
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
| | - Michael T Mullen
- Department of Neurology, Lewis Katz School of Medicine at Temple University, USA
| | - James E Siegler
- Cooper Medical School of Rowan University, Camden, NJ, USA; Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
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20
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Howell DM, Li T, Quellhorst E, Katz JM, Arora R, Berkowitz J. Reducing Door-In to Door-Out Time for Patients Receiving a Mechanical Thrombectomy Using AutoLaunch Protocol. Open Access Emerg Med 2023; 15:367-371. [PMID: 37868690 PMCID: PMC10590110 DOI: 10.2147/oaem.s427945] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 10/11/2023] [Indexed: 10/24/2023] Open
Abstract
Background Door-in to door-out (DIDO) time for large vessel occlusion (LVO) stroke is an emerging stroke performance measure. Initial presentation at a non-Comprehensive Stroke Center (CSC) requires a transfer process that minimizes delays. Our objective was to assess whether DIDO time for stroke patients was reduced after implementation of an AutoLaunch protocol for interfacility transfers. Methods This was a pre-post analysis of an AutoLaunch protocol for all acute stroke patients transferred to a CSC for mechanical thrombectomy. The distribution of DIDO times between patients transferred via the AutoLaunch and traditional dispatch protocols were compared. Results We evaluated 92 interfacility transfers, with 22 utilizing the AutoLaunch protocol and 70 utilizing traditional dispatch. Among AutoLaunch transfers, the median DIDO time was 85 minutes (IQR: 71, 133), while the median DIDO time among the traditional transfers was 109 minutes (IQR, 84, 144) (p=0.044). Conclusion Implementation of an AutoLaunch protocol for patients with suspected LVO was associated with a reduction in DIDO time to CSCs. Further studies should evaluate patient outcomes based on transfer strategies.
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Affiliation(s)
- Devin M Howell
- Department of Emergency Medicine, Northwell Health, Manhasset, NY, USA
- Center for Emergency Medical Services, Northwell Health, Syosset, NY, USA
| | - Timmy Li
- Department of Emergency Medicine, Northwell Health, Manhasset, NY, USA
| | | | - Jeffrey M Katz
- Department of Neurology, Northwell Health, Manhasset, NY, USA
| | - Rohan Arora
- Department of Neurology, Northwell Health, Manhasset, NY, USA
| | - Jonathan Berkowitz
- Center for Emergency Medical Services, Northwell Health, Syosset, NY, USA
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21
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Ostmeier S, Axelrod B, Verhaaren BFJ, Christensen S, Mahammedi A, Liu Y, Pulli B, Li LJ, Zaharchuk G, Heit JJ. Non-inferiority of deep learning ischemic stroke segmentation on non-contrast CT within 16-hours compared to expert neuroradiologists. Sci Rep 2023; 13:16153. [PMID: 37752162 PMCID: PMC10522706 DOI: 10.1038/s41598-023-42961-x] [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: 04/18/2023] [Accepted: 09/17/2023] [Indexed: 09/28/2023] Open
Abstract
We determined if a convolutional neural network (CNN) deep learning model can accurately segment acute ischemic changes on non-contrast CT compared to neuroradiologists. Non-contrast CT (NCCT) examinations from 232 acute ischemic stroke patients who were enrolled in the DEFUSE 3 trial were included in this study. Three experienced neuroradiologists independently segmented hypodensity that reflected the ischemic core on each scan. The neuroradiologist with the most experience (expert A) served as the ground truth for deep learning model training. Two additional neuroradiologists' (experts B and C) segmentations were used for data testing. The 232 studies were randomly split into training and test sets. The training set was further randomly divided into 5 folds with training and validation sets. A 3-dimensional CNN architecture was trained and optimized to predict the segmentations of expert A from NCCT. The performance of the model was assessed using a set of volume, overlap, and distance metrics using non-inferiority thresholds of 20%, 3 ml, and 3 mm, respectively. The optimized model trained on expert A was compared to test experts B and C. We used a one-sided Wilcoxon signed-rank test to test for the non-inferiority of the model-expert compared to the inter-expert agreement. The final model performance for the ischemic core segmentation task reached a performance of 0.46 ± 0.09 Surface Dice at Tolerance 5mm and 0.47 ± 0.13 Dice when trained on expert A. Compared to the two test neuroradiologists the model-expert agreement was non-inferior to the inter-expert agreement, [Formula: see text]. The before, CNN accurately delineates the hypodense ischemic core on NCCT in acute ischemic stroke patients with an accuracy comparable to neuroradiologists.
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Affiliation(s)
| | - Brian Axelrod
- Department of Computer Science, Stanford University, Stanford, USA
| | | | | | | | | | | | - Li-Jia Li
- Stanford School of Medicine, Stanford, USA
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22
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Nguyen CP, Lahr MMH, van der Zee DJ, van Voorst H, Ribo M, Roos YBWM, van den Wijngaard I, Buskens E, Uyttenboogaart M. Cost-effectiveness of Direct Transfer to Angiography Suite of Patients With Suspected Large Vessel Occlusion. Neurology 2023; 101:e1036-e1045. [PMID: 37438129 PMCID: PMC10491438 DOI: 10.1212/wnl.0000000000207583] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 05/10/2023] [Indexed: 07/14/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Patients with acute ischemic stroke due to large vessel occlusion (LVO) deemed eligible for endovascular thrombectomy (EVT) are transferred from the emergency room to the angiography suite to undergo the procedure. Recently, the strategy of direct transfer of patients with suspected LVO to the angiography suite (DTAS) has been shown to improve functional outcomes. This study aims to evaluate the cost-effectiveness of the DTAS strategy vs initial transfer of patients with suspected LVO (Rapid Arterial Occlusion Evaluation score >4 and NIH Stroke Scale >10) to the emergency room (ITER). METHODS A decision-analytic Markov model was developed to estimate the cost-effectiveness of the DTAS strategy vs the ITER strategy from a Dutch health care perspective with a 10-year time horizon. The primary outcome was the incremental cost-effectiveness ratio (ICER) using Dutch thresholds of $59,135 (€50,000) and $94,616 (€80,000) per quality-adjusted life year (QALY). Uncertainty of input parameters was assessed using 1-way sensitivity analysis, scenario analysis, and probabilistic sensitivity analysis. RESULTS The DTAS strategy yielded 0.65 additional QALYs at an additional $16,089, resulting in an ICER of $24,925/QALY compared with the ITER strategy. The ICER varied from $27,169 to $38,325/QALY across different scenarios. The probabilistic sensitivity analysis showed that the DTAS strategy had a 91.8% and 97.0% likelihood of being cost-effective at a decision threshold of $59,135/QALY and $94,616/QALY, respectively. DISCUSSION The cost-effectiveness of the DTAS strategy over ITER is robust for patients with suspected LVO. Together with recently published clinical results, this means that implementation of the DTAS strategy may be considered to improve the workflow and outcome of EVT.
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Affiliation(s)
- Chi P Nguyen
- From the Department of Operations (C.P.N., D.-J.v.d.Z., E.B.), Faculty of Economics and Business, University of Groningen; Health Technology Assessment (C.P.N., M.M.H.L., D.-J.v.d.Z., E.B.), Department of Epidemiology, and Departments of Neurology (M.U.), and Radiology, Medical Imaging Center (M.U.), University of Groningen, University Medical Center Groningen, the Netherlands; Department of Pharmaceutical Administration and Economics (C.P.N.), Hanoi University of Pharmacy, Vietnam; Departments of Radiology and Nuclear Medicine (H.v.V.), Biomedical Engineering and Physics (H.v.V.), and Neurology (Y.B.W.M.R.), Amsterdam University Medical Center, the Netherlands; Unitat d'Ictus (M.R.), Servei de Neurologia, Hospital Universitari Vall d'Hebron, Spain; Department of Neurology (I.v.d.W.), Haaglanden Medical Center; and Department of Neurology (I.v.d.W.), Leiden University Medical Center.
| | - Maarten M H Lahr
- From the Department of Operations (C.P.N., D.-J.v.d.Z., E.B.), Faculty of Economics and Business, University of Groningen; Health Technology Assessment (C.P.N., M.M.H.L., D.-J.v.d.Z., E.B.), Department of Epidemiology, and Departments of Neurology (M.U.), and Radiology, Medical Imaging Center (M.U.), University of Groningen, University Medical Center Groningen, the Netherlands; Department of Pharmaceutical Administration and Economics (C.P.N.), Hanoi University of Pharmacy, Vietnam; Departments of Radiology and Nuclear Medicine (H.v.V.), Biomedical Engineering and Physics (H.v.V.), and Neurology (Y.B.W.M.R.), Amsterdam University Medical Center, the Netherlands; Unitat d'Ictus (M.R.), Servei de Neurologia, Hospital Universitari Vall d'Hebron, Spain; Department of Neurology (I.v.d.W.), Haaglanden Medical Center; and Department of Neurology (I.v.d.W.), Leiden University Medical Center
| | - Durk-Jouke van der Zee
- From the Department of Operations (C.P.N., D.-J.v.d.Z., E.B.), Faculty of Economics and Business, University of Groningen; Health Technology Assessment (C.P.N., M.M.H.L., D.-J.v.d.Z., E.B.), Department of Epidemiology, and Departments of Neurology (M.U.), and Radiology, Medical Imaging Center (M.U.), University of Groningen, University Medical Center Groningen, the Netherlands; Department of Pharmaceutical Administration and Economics (C.P.N.), Hanoi University of Pharmacy, Vietnam; Departments of Radiology and Nuclear Medicine (H.v.V.), Biomedical Engineering and Physics (H.v.V.), and Neurology (Y.B.W.M.R.), Amsterdam University Medical Center, the Netherlands; Unitat d'Ictus (M.R.), Servei de Neurologia, Hospital Universitari Vall d'Hebron, Spain; Department of Neurology (I.v.d.W.), Haaglanden Medical Center; and Department of Neurology (I.v.d.W.), Leiden University Medical Center
| | - Henk van Voorst
- From the Department of Operations (C.P.N., D.-J.v.d.Z., E.B.), Faculty of Economics and Business, University of Groningen; Health Technology Assessment (C.P.N., M.M.H.L., D.-J.v.d.Z., E.B.), Department of Epidemiology, and Departments of Neurology (M.U.), and Radiology, Medical Imaging Center (M.U.), University of Groningen, University Medical Center Groningen, the Netherlands; Department of Pharmaceutical Administration and Economics (C.P.N.), Hanoi University of Pharmacy, Vietnam; Departments of Radiology and Nuclear Medicine (H.v.V.), Biomedical Engineering and Physics (H.v.V.), and Neurology (Y.B.W.M.R.), Amsterdam University Medical Center, the Netherlands; Unitat d'Ictus (M.R.), Servei de Neurologia, Hospital Universitari Vall d'Hebron, Spain; Department of Neurology (I.v.d.W.), Haaglanden Medical Center; and Department of Neurology (I.v.d.W.), Leiden University Medical Center
| | - Marc Ribo
- From the Department of Operations (C.P.N., D.-J.v.d.Z., E.B.), Faculty of Economics and Business, University of Groningen; Health Technology Assessment (C.P.N., M.M.H.L., D.-J.v.d.Z., E.B.), Department of Epidemiology, and Departments of Neurology (M.U.), and Radiology, Medical Imaging Center (M.U.), University of Groningen, University Medical Center Groningen, the Netherlands; Department of Pharmaceutical Administration and Economics (C.P.N.), Hanoi University of Pharmacy, Vietnam; Departments of Radiology and Nuclear Medicine (H.v.V.), Biomedical Engineering and Physics (H.v.V.), and Neurology (Y.B.W.M.R.), Amsterdam University Medical Center, the Netherlands; Unitat d'Ictus (M.R.), Servei de Neurologia, Hospital Universitari Vall d'Hebron, Spain; Department of Neurology (I.v.d.W.), Haaglanden Medical Center; and Department of Neurology (I.v.d.W.), Leiden University Medical Center
| | - Yvo B W M Roos
- From the Department of Operations (C.P.N., D.-J.v.d.Z., E.B.), Faculty of Economics and Business, University of Groningen; Health Technology Assessment (C.P.N., M.M.H.L., D.-J.v.d.Z., E.B.), Department of Epidemiology, and Departments of Neurology (M.U.), and Radiology, Medical Imaging Center (M.U.), University of Groningen, University Medical Center Groningen, the Netherlands; Department of Pharmaceutical Administration and Economics (C.P.N.), Hanoi University of Pharmacy, Vietnam; Departments of Radiology and Nuclear Medicine (H.v.V.), Biomedical Engineering and Physics (H.v.V.), and Neurology (Y.B.W.M.R.), Amsterdam University Medical Center, the Netherlands; Unitat d'Ictus (M.R.), Servei de Neurologia, Hospital Universitari Vall d'Hebron, Spain; Department of Neurology (I.v.d.W.), Haaglanden Medical Center; and Department of Neurology (I.v.d.W.), Leiden University Medical Center
| | - Ido van den Wijngaard
- From the Department of Operations (C.P.N., D.-J.v.d.Z., E.B.), Faculty of Economics and Business, University of Groningen; Health Technology Assessment (C.P.N., M.M.H.L., D.-J.v.d.Z., E.B.), Department of Epidemiology, and Departments of Neurology (M.U.), and Radiology, Medical Imaging Center (M.U.), University of Groningen, University Medical Center Groningen, the Netherlands; Department of Pharmaceutical Administration and Economics (C.P.N.), Hanoi University of Pharmacy, Vietnam; Departments of Radiology and Nuclear Medicine (H.v.V.), Biomedical Engineering and Physics (H.v.V.), and Neurology (Y.B.W.M.R.), Amsterdam University Medical Center, the Netherlands; Unitat d'Ictus (M.R.), Servei de Neurologia, Hospital Universitari Vall d'Hebron, Spain; Department of Neurology (I.v.d.W.), Haaglanden Medical Center; and Department of Neurology (I.v.d.W.), Leiden University Medical Center
| | - Erik Buskens
- From the Department of Operations (C.P.N., D.-J.v.d.Z., E.B.), Faculty of Economics and Business, University of Groningen; Health Technology Assessment (C.P.N., M.M.H.L., D.-J.v.d.Z., E.B.), Department of Epidemiology, and Departments of Neurology (M.U.), and Radiology, Medical Imaging Center (M.U.), University of Groningen, University Medical Center Groningen, the Netherlands; Department of Pharmaceutical Administration and Economics (C.P.N.), Hanoi University of Pharmacy, Vietnam; Departments of Radiology and Nuclear Medicine (H.v.V.), Biomedical Engineering and Physics (H.v.V.), and Neurology (Y.B.W.M.R.), Amsterdam University Medical Center, the Netherlands; Unitat d'Ictus (M.R.), Servei de Neurologia, Hospital Universitari Vall d'Hebron, Spain; Department of Neurology (I.v.d.W.), Haaglanden Medical Center; and Department of Neurology (I.v.d.W.), Leiden University Medical Center
| | - Maarten Uyttenboogaart
- From the Department of Operations (C.P.N., D.-J.v.d.Z., E.B.), Faculty of Economics and Business, University of Groningen; Health Technology Assessment (C.P.N., M.M.H.L., D.-J.v.d.Z., E.B.), Department of Epidemiology, and Departments of Neurology (M.U.), and Radiology, Medical Imaging Center (M.U.), University of Groningen, University Medical Center Groningen, the Netherlands; Department of Pharmaceutical Administration and Economics (C.P.N.), Hanoi University of Pharmacy, Vietnam; Departments of Radiology and Nuclear Medicine (H.v.V.), Biomedical Engineering and Physics (H.v.V.), and Neurology (Y.B.W.M.R.), Amsterdam University Medical Center, the Netherlands; Unitat d'Ictus (M.R.), Servei de Neurologia, Hospital Universitari Vall d'Hebron, Spain; Department of Neurology (I.v.d.W.), Haaglanden Medical Center; and Department of Neurology (I.v.d.W.), Leiden University Medical Center
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Hindsholm MF, Damgaard D, Gurol ME, Gaist D, Simonsen CZ. Management and Prognosis of Acute Stroke in Atrial Fibrillation. J Clin Med 2023; 12:5752. [PMID: 37685819 PMCID: PMC10489015 DOI: 10.3390/jcm12175752] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Revised: 08/25/2023] [Accepted: 09/01/2023] [Indexed: 09/10/2023] Open
Abstract
Atrial fibrillation (AF) is an important risk factor for ischemic stroke (IS). Oral anticoagulation (OAC) significantly reduces the risk of IS in AF but also increases the risk of systemic bleeding, including intracerebral hemorrhage (ICH). AF-related strokes are associated with greater disability and mortality compared to non-AF strokes. The management of patients with AF-related strokes is challenging, and it involves weighing individual risks and benefits in the acute treatment and preventive strategies of these patients. This review summarizes the current knowledge of the acute management of ischemic and hemorrhagic stroke in patients with AF, and the prognosis and potential implications for management both in the acute and long-term setting.
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Affiliation(s)
- Mette F. Hindsholm
- Department of Neurology, Aarhus University Hospital, 8200 Aarhus, Denmark; (D.D.); (C.Z.S.)
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus, Denmark
| | - Dorte Damgaard
- Department of Neurology, Aarhus University Hospital, 8200 Aarhus, Denmark; (D.D.); (C.Z.S.)
| | - M. Edip Gurol
- Department of Neurology, Massachusetts General Hospital, Boston, MA 02114, USA;
- Harvard Medical School, Boston, MA 02115, USA
| | - David Gaist
- Research Unit for Neurology, Odense University Hospital, University of Southern Denmark, 5000 Odense, Denmark;
| | - Claus Z. Simonsen
- Department of Neurology, Aarhus University Hospital, 8200 Aarhus, Denmark; (D.D.); (C.Z.S.)
- Department of Clinical Medicine, Aarhus University, 8200 Aarhus, Denmark
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Shibata A, Yanagawa T, Sugasawa S, Ikeda S, Ikeda T. Multiple large vessel occlusions resulting in vessel perforation in single pass of mechanical thrombectomy with stent retriever. Radiol Case Rep 2023; 18:3206-3211. [PMID: 37448599 PMCID: PMC10338195 DOI: 10.1016/j.radcr.2023.06.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 06/08/2023] [Indexed: 07/15/2023] Open
Abstract
Mechanical thrombectomy (MT) is a highly effective treatment for acute ischemic stroke, and hemorrhagic complications caused by vessel injury are rare. However, there is no evidence regarding the efficacy of MT for multiple large vessel occlusion or its procedural strategy. Herein, we report a case of MT with a stent retriever for multiple large vessel occlusion in the internal carotid artery and middle cerebral artery M1 distal, which resulted in vessel perforation in a single pass. A 79-year-old woman underwent MT for internal carotid artery occlusion, and multiple large vessel occlusion was observed on digital subtraction angiography. A longer and larger stent retriever was selected for thrombus retrieval in a single pass. Immediately after retrieval, digital subtraction angiography revealed internal carotid artery recanalization. Then, extravasation was observed from the M1 distal occlusion. Treatment was interrupted after hemostasis was confirmed. Nevertheless, rebleeding occurred after 4 hours. Emergency trapping was performed, and vessel perforation of >1 mm was observed. When retrieving a thrombus in a single pass with a stent retriever for multiple large vessel occlusion, vessel perforation may occur if the device is selected according to the diameter of the proximal occluded vessel. Based on the type of device, even a single pass may result in vessel perforation. Although aggressive MT intervention should be performed for multiple large vessel occlusion, a device that is appropriate for the pathological condition must be selected.
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25
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Guterud M, Fagerheim Bugge H, Røislien J, Kramer-Johansen J, Toft M, Ihle-Hansen H, Bache KG, Larsen K, Braarud AC, Sandset EC, Ranhoff Hov M. Prehospital screening of acute stroke with the National Institutes of Health Stroke Scale (ParaNASPP): a stepped-wedge, cluster-randomised controlled trial. Lancet Neurol 2023; 22:800-811. [PMID: 37596006 DOI: 10.1016/s1474-4422(23)00237-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Revised: 06/13/2023] [Accepted: 06/15/2023] [Indexed: 08/20/2023]
Abstract
BACKGROUND Timely treatment of acute stroke depends on early identification and triage. Improved methods for recognition of stroke in the prehospital setting are needed. We aimed to assess whether use of the National Institutes of Health Stroke Scale (NIHSS) by paramedics in the ambulance could improve communication with the hospital, augment triage, and enhance diagnostic accuracy of acute stroke. METHODS The Paramedic Norwegian Acute Stroke Prehospital Project (ParaNASPP) was a stepped-wedge, single-blind, cluster-randomised controlled trial. Patients with suspected acute stroke, who were evaluated by paramedics from five ambulance stations in Oslo, Norway, were eligible for inclusion. The five ambulance stations (defined as clusters) all initially managed patients according to a standard stroke protocol (control group), with randomised sequential crossover of each station to the intervention group. The intervention consisted of supervised training on NIHSS scoring, a mobile application to aid scoring, and standardised communication with stroke physicians. Random allocation was done via a simple lottery draw by administrators at Oslo University Hospital, who were independent of the research team. Allocation concealment was not possible due to the nature of the intervention. The primary outcome was the positive predictive value (PPV) for prehospital identification of patients with a final discharge diagnosis of acute stroke, analysed by intention to treat. Prespecified secondary safety outcomes were median prehospital on-scene time and median door-to-needle time. This trial is registered with ClinicalTrials.gov, NCT04137874, and is completed. FINDINGS Between June 3, 2019, and July 1, 2021, 935 patients were evaluated by paramedics for suspected acute stroke. 134 patients met exclusion criteria or did not consent to participate. The primary analysis included 447 patients in the intervention group and 354 in the control group. There was no difference in PPV for prehospital identification of patients with a final discharge diagnosis of acute stroke between the intervention group (48·1%, 95% CI 43·4-52·8) and control group (45·8%, 40·5-51·1), with an estimated percentage points difference between groups of 2·3 (95% CI -4·6 to 9·3; p=0·51). Median prehospital on-scene time increased by 5 min in the intervention group (29 min [IQR 23-36] vs 24 min [19-31]; p<0·0001), whereas median door-to-needle time was similar between groups (26 min [21-36] vs 27 min [20-36]; p=0·90). No prehospital deaths were reported in either group. INTERPRETATION The intervention did not improve diagnostic accuracy in patients with suspected stroke. A general increase in prehospital time during the pandemic and the identification of smaller strokes that require more deliberation are possible explanations for the increased on-scene time. The ParaNASPP model is to be implemented in Norway from 2023, and will provide real-life data for further research. FUNDING Norwegian Air Ambulance Foundation and Oslo University Hospital.
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Affiliation(s)
- Mona Guterud
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway; Division of Prehospital Services, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Helge Fagerheim Bugge
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway; Department of Neurology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Jo Røislien
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway
| | - Jo Kramer-Johansen
- Norwegian National Advisory Unit on Prehospital Emergency Medicine (NAKOS) and Air Ambulance Department, Division of Prehospital Services, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Mathias Toft
- Department of Neurology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway
| | | | - Kristi G Bache
- Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway; Department of Research and Dissemination, Østfold University College, Halden, Norway
| | - Karianne Larsen
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway
| | | | - Else Charlotte Sandset
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway; Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Maren Ranhoff Hov
- Department of Research, Norwegian Air Ambulance Foundation, Oslo, Norway; Department of Neurology, Oslo University Hospital, Oslo, Norway; Department of Health Science, Oslo Metropolitan University, Oslo, Norway.
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Siegler JE, Dasgupta S, Abdalkader M, Penckofer M, Yaghi S, Nguyen TN. Cerebrovascular Disease in COVID-19. Viruses 2023; 15:1598. [PMID: 37515284 PMCID: PMC10385090 DOI: 10.3390/v15071598] [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: 06/16/2023] [Revised: 07/18/2023] [Accepted: 07/20/2023] [Indexed: 07/30/2023] Open
Abstract
Not in the history of transmissible illnesses has there been an infection as strongly associated with acute cerebrovascular disease as the novel human coronavirus SARS-CoV-2. While the risk of stroke has known associations with other viral infections, such as influenza and human immunodeficiency virus, the risk of ischemic and hemorrhagic stroke related to SARS-CoV-2 is unprecedented. Furthermore, the coronavirus disease 2019 (COVID-19) pandemic has so profoundly impacted psychosocial behaviors and modern medical care that we have witnessed shifts in epidemiology and have adapted our treatment practices to reduce transmission, address delayed diagnoses, and mitigate gaps in healthcare. In this narrative review, we summarize the history and impact of the COVID-19 pandemic on cerebrovascular disease, and lessons learned regarding the management of patients as we endure this period of human history.
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Affiliation(s)
- James E Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ 08103, USA
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - Savanna Dasgupta
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ 08103, USA
| | - Mohamad Abdalkader
- Department of Neurology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA 02118, USA
| | - Mary Penckofer
- Cooper Medical School of Rowan University, Camden, NJ 08103, USA
| | - Shadi Yaghi
- Department of Neurology, Rhode Island Hospital, Brown University, Providence, RI 02912, USA
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA 02118, USA
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Ho-Tin-Noé B, Desilles JP, Mazighi M. Thrombus composition and thrombolysis resistance in stroke. Res Pract Thromb Haemost 2023; 7:100178. [PMID: 37538503 PMCID: PMC10394565 DOI: 10.1016/j.rpth.2023.100178] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2022] [Revised: 04/14/2023] [Accepted: 05/05/2023] [Indexed: 08/05/2023] Open
Abstract
A State of the Art lecture titled "Thrombus Composition and Thrombolysis Resistance in Stroke" was presented at the ISTH Congress in 2022. Intravenous thrombolysis (IVT) remains the only pharmacologic option to re-establish cerebral perfusion at the acute phase of ischemic stroke. IVT is based on the administration of recombinant tissue plasminogen activator with the objective of dissolving fibrin, the major fibrillar protein component of thrombi. Almost 30 years on from its introduction, although the clinical benefits of IVT have been clearly demonstrated, IVT still suffers from a relatively low efficacy, with a rate of successful early recanalization below 50% overall. Analyses of thrombectomy-recovered acute ischemic stroke (AIS) thrombi have shown that apart from occlusion site, thrombus length, and collateral status, AIS thrombus structure and composition are also important modulators of IVT efficacy. In this article, after a brief presentation of IVT principle and current knowledge on IVT resistance, we review recent findings on how compaction and structural alterations of fibrin together with nonfibrin thrombus components such as neutrophil extracellular traps and von Willebrand factor interfere with IVT in AIS. We further discuss how these new insights could soon result in the development of original adjuvant therapies for improved IVT in AIS. Finally, we summarize relevant new data presented during the 2022 ISTH Congress.
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Affiliation(s)
- Benoit Ho-Tin-Noé
- Université Paris Cité, Inserm, Optimisation Thérapeutique en Neuropsychopharmacologie, Paris, France
| | - Jean-Philippe Desilles
- Université Paris Cité, Inserm, Optimisation Thérapeutique en Neuropsychopharmacologie, Paris, France
- Interventional Neuroradiology Department and Biological Resources Center, Rothschild Foundation Hospital, Paris, France
| | - Mikael Mazighi
- Université Paris Cité, Inserm, Optimisation Thérapeutique en Neuropsychopharmacologie, Paris, France
- Interventional Neuroradiology Department and Biological Resources Center, Rothschild Foundation Hospital, Paris, France
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Andralojc LE, Kim DH, Edwards AJ. Diagnostic accuracy of a decision-support software for the detection of intracranial large-vessel occlusion in CT angiography. Clin Radiol 2023; 78:e313-e318. [PMID: 36754714 DOI: 10.1016/j.crad.2022.10.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2022] [Revised: 10/05/2022] [Accepted: 10/15/2022] [Indexed: 01/13/2023]
Abstract
AIM To investigate the real-world clinical performance of the decision-support software "e-CTA" (e-Stroke Suite, Brainomix Limited, Oxford UK) for the detection of acute intracranial large-vessel occlusion (LVO) on computed tomography (CT) angiography at a UK district general hospital. MATERIALS AND METHODS The retrospective study included 300 consecutive CT angiograms of the head and neck performed between 8 March 2021 and 20 May 2021. e-CTA findings were recorded and compared with the radiologist report. Cases in which there was disagreement between e-CTA and the radiologist were reviewed by a sub-specialist vascular radiologist as the reference standard. RESULTS The incidence of intracranial LVO was 7%. e-CTA correctly identified 18 of 21 intracranial proximal LVOs (86%). There were 34 false positives. The sensitivity was 0.86 (95% confidence interval [CI], 0.64-0.97), with specificity of 0.88 (95% CI, 0.83-0.91). The positive predictive value was 0.35 (95% CI, 0.27-0.43). The negative predictive value was 0.99 (95% CI, 0.96-1.00). CONCLUSION Sensitivity, specificity, and negative predictive values were similar to those reported in the literature (Seker et al., Int J Stroke. 2021; 17:77-82); however, the positive predictive value for e-CTA was significantly lower. In practice, this meant that over half of all reported occlusions by the software were false positives. Radiologists should be aware of these metrics in order to assign appropriate weight to software findings when formulating a report. Differences in population demographics, scanners, CT protocols, and incidence are all factors potentially influencing software accuracy. Local validation testing may help provide accuracy metrics more relevant to individual institutions.
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Affiliation(s)
- L E Andralojc
- The Department of Clinical Imaging, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, TR1 3LJ, UK
| | - D H Kim
- The Department of Clinical Imaging, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, TR1 3LJ, UK.
| | - A J Edwards
- The Department of Clinical Imaging, Royal Cornwall Hospitals NHS Trust, Truro, Cornwall, TR1 3LJ, UK
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Ollikainen J, Jolma P, Pienimäki JP, Vuorinen P, Oksala N, Kimpimäki M, Grönroos M, Haula TM, Janhunen H, Pauniaho SL. Less is more - The Finnish Prehospital Stroke Scale prospective validation. J Stroke Cerebrovasc Dis 2023; 32:106996. [PMID: 36801497 DOI: 10.1016/j.jstrokecerebrovasdis.2023.106996] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2022] [Revised: 01/13/2023] [Accepted: 01/14/2023] [Indexed: 02/18/2023] Open
Abstract
OBJECTIVES The current bifurcation of the acute stroke care pathway requires prehospital separation of strokes caused by large vessel occlusion. The first four binary items of the Finnish Prehospital Stroke Scale (FPSS) identify stroke in general, while the fifth binary item alone identifies stroke due to large vessel occlusion. The straightforward design is both easy for paramedics and statistically beneficial. We implemented FPSS based Western Finland Stroke Triage Plan, including medical districts of a comprehensive stroke center and four primary stroke centers. PATIENTS AND METHODS The prospective study population was consecutive recanalization candidates transported to the comprehensive stroke center within the first six months of implementing the stroke triage plan. Cohort 1 consisted of n=302 thrombolysis- or endovascular treatment candidates transported from the comprehensive stroke center hospital district. Cohort 2 comprised ten endovascular treatment candidates transferred directly to the comprehensive stroke center from the medical districts of four primary stroke centers. RESULTS In Cohort 1, FPSS sensitivity for large vessel occlusion was 0.66, specificity 0.94, positive predictive value 0.70, and negative predictive value 0.93. Of the ten Cohort 2 patients, nine had large vessel occlusion, and one had an intracerebral hemorrhage. CONCLUSIONS FPSS is straightforward enough to be implemented in primary care services to identify candidates for endovascular treatment and thrombolysis. When used by paramedics, it predicted two-thirds of large vessel occlusions with the highest specificity and positive predictive value reported to date.
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Affiliation(s)
- Jyrki Ollikainen
- Department of Neuroscience and Rehabilitation, Tampere University Hospital and University of Tampere, Tampere, Finland.
| | - Pasi Jolma
- Department of Neuroscience and Rehabilitation, Tampere University Hospital and University of Tampere, Tampere, Finland
| | - Juha-Pekka Pienimäki
- Vascular Centre, Tampere University Hospital, Tampere University Hospital, and the University of Tampere, Tampere, Finland
| | - Pauli Vuorinen
- Emergency Care Service, Prehospital Emergency Care Centre, Department of Emergency Care, Anesthesia and Pain Medicine Tampere University Hospital and University of Tampere, Tampere, Finland
| | - Niku Oksala
- Vascular Centre, Tampere University Hospital, Tampere University Hospital, and the University of Tampere, Tampere, Finland; Faculty of Medicine and Health Sciences, University of Tampere, Tampere, Finland
| | | | | | | | | | - Satu-Liisa Pauniaho
- Department of Adolescent Psychiatry, Tampere University Hospital and University of Tampere, Tampere, Finland; Emergency Department, Tampere University Hospital, Tampere, Finland
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Eastin TM, Dye JA, Pillai P, Lopez-Gonzalez MA, Huang L, Zhang JH, Boling WW. Delayed revascularization in acute ischemic stroke patients. Front Pharmacol 2023; 14:1124263. [PMID: 36843940 PMCID: PMC9945110 DOI: 10.3389/fphar.2023.1124263] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2022] [Accepted: 01/30/2023] [Indexed: 02/11/2023] Open
Abstract
Stroke shares a significant burden of global mortality and disability. A significant decline in the quality of life is attributed to the so-called post-stroke cognitive impairment including mild to severe cognitive alterations, dementia, and functional disability. Currently, only two clinical interventions including pharmacological and mechanical thrombolysis are advised for successful revascularization of the occluded vessel. However, their therapeutic effect is limited to the acute phase of stroke onset only. This often results in the exclusion of a significant number of patients who are unable to reach within the therapeutic window. Advances in neuroimaging technologies have allowed better assessment of salvageable penumbra and occluded vessel status. Improvement in diagnostic tools and the advent of intravascular interventional devices such as stent retrievers have expanded the potential revascularization window. Clinical studies have demonstrated positive outcomes of delayed revascularization beyond the recommended therapeutic window. This review will discuss the current understanding of ischemic stroke, the latest revascularization doctrine, and evidence from clinical studies regarding effective delayed revascularization in ischemic stroke.
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Affiliation(s)
- T. Marc Eastin
- Department of Neurological Surgery, Loma Linda University Medical Center, Loma Linda, CA, United States
| | - Justin A. Dye
- Department of Neurological Surgery, Loma Linda University Medical Center, Loma Linda, CA, United States
| | - Promod Pillai
- Department of Neurological Surgery, Loma Linda University Medical Center, Loma Linda, CA, United States
| | - Miguel A. Lopez-Gonzalez
- Department of Neurological Surgery, Loma Linda University Medical Center, Loma Linda, CA, United States
| | - Lei Huang
- Department of Neurological Surgery, Loma Linda University Medical Center, Loma Linda, CA, United States,Department of Pharmacology and Physiology, Loma Linda University, Loma Linda, CA, United States
| | - John H. Zhang
- Department of Neurological Surgery, Loma Linda University Medical Center, Loma Linda, CA, United States,Department of Pharmacology and Physiology, Loma Linda University, Loma Linda, CA, United States,Department of Neurology, Loma Linda University Medical Center, Loma Linda, CA, United States,Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA, United States
| | - Warren W. Boling
- Department of Neurological Surgery, Loma Linda University Medical Center, Loma Linda, CA, United States,*Correspondence: Warren W. Boling,
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Prediction of Poor Outcome after Successful Thrombectomy in Patients with Severe Acute Ischemic Stroke: A Pilot Retrospective Study. Neurol Int 2023; 15:225-237. [PMID: 36810470 PMCID: PMC9944107 DOI: 10.3390/neurolint15010015] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/06/2023] [Revised: 01/16/2023] [Accepted: 01/30/2023] [Indexed: 02/05/2023] Open
Abstract
Several baseline hematologic and metabolic laboratory parameters have been linked to acute ischemic stroke (AIS) clinical outcomes in patients who successfully recanalized. However, no study has directly investigated these relationships within the severe stroke subgroup. The goal of this study is to identify potential predictive clinical, lab, and radiographic biomarkers in patients who present with severe AIS due to large vessel occlusion and have been successfully treated with mechanical thrombectomy. This single-center, retrospective study included patients who experienced AIS secondary to large vessel occlusion with an initial NIHSS score ≥ 21 and were recanalized successfully with mechanical thrombectomy. Retrospectively, demographic, clinical, and radiologic data from electronic medical records were extracted, and laboratory baseline parameters were obtained from emergency department records. The clinical outcome was defined as the modified Rankin Scale (mRS) score at 90 days, which was dichotomized into favorable functional outcome (mRS 0-3) or unfavorable functional outcome (mRS 4-6). Multivariate logistic regression was used to build predictive models. A total of 53 patients were included. There were 26 patients in the favorable outcome group and 27 in the unfavorable outcome group. Age and platelet count (PC) were found to be predictors of unfavorable outcomes in the multivariate logistic regression analysis. The areas under the receiver operating characteristic (ROC) curve of models 1 (age only model), 2 (PC only model), and 3 (age and PC model) were 0.71, 0.68, and 0.79, respectively. This is the first study to reveal that elevated PC is an independent predictor of unfavorable outcomes in this specialized group.
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32
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Muacevic A, Adler JR, Nevin C, Ranasinghe T, Jacob S, Ferari C, Adcock A. Incidence of Atrial Fibrillation in Large Vessel Occlusion and Large Embolic Stroke of Undetermined Source. Cureus 2023; 15:e33700. [PMID: 36793841 PMCID: PMC9925036 DOI: 10.7759/cureus.33700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/12/2023] [Indexed: 01/15/2023] Open
Abstract
INTRODUCTION Large vessel occlusion (LVO) stroke is a common presentation of acute ischemic stroke and is often unknown or cryptogenic in etiology. There is a strong association between atrial fibrillation (AF) and cryptogenic LVO stroke, making it a unique stroke subgroup. Therefore, we propose that any LVO stroke meeting the criteria for an embolic stroke of an undetermined source (ESUS) be classified as large ESUS (LESUS). The purpose of this retrospective cohort study was to report the etiology of anterior LVO strokes that underwent endovascular thrombectomy. METHODS This was a single-center retrospective cohort study characterizing the etiology of acute anterior circulation LVO strokes that received emergent endovascular thrombectomy from 2011 to 2018. Patients with LESUS designation at hospital discharge were changed to cardioembolic etiology if AF was discovered during the two-year follow-up period. Results: Overall, 155 (45%) of 307 patients in the study were found to have AF. New onset AF was discovered in 12 (23%) of 53 LESUS patients after hospitalization. Furthermore, eight (35%) of 23 LESUS patients who received extended cardiac monitoring were found to have AF. CONCLUSION Nearly half the patients with LVO stroke who received endovascular thrombectomy were found to have AF. With the use of extended cardiac monitoring devices after hospitalization, AF is frequently discovered in patients with LESUS and may change the secondary stroke prevention strategy.
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Beaman C, Holodinsky JK, Goyal M, Tateshima S, Hill MD, Saver JL, Kamal N. Modeling optimal patient transport in a stroke network capable of remote telerobotic endovascular therapy. Interv Neuroradiol 2022:15910199221140177. [PMID: 36398447 DOI: 10.1177/15910199221140177] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/17/2024] Open
Abstract
BACKGROUND Telerobotic endovascular therapy (EVT) has the potential to decrease time to treatment and expand existing networks of care to more rural populations. It is currently unclear how its implementation would impact existing stroke networks. METHODS Conditional probability models were generated to predict the probability of excellent outcome for patients with suspected large vessel occlusion (LVO). A baseline stroke network was created for California using existing intravenous thrombolysis (IVT) centers and comprehensive stroke centers (CSCs) capable of IVT and EVT. Optimal transport decisions and catchment areas were generated for the baseline model and three hypothetical scenarios through conversion of IVT centers at various distances from a CSC into centers capable of telerobotic EVT [i.e., hospitals ≥15 and <50 miles from a CSC were converted (Scenario 1), ≥50 and <100 miles (Scenario 2), and ≥100 miles (Scenario 3)]. Procedural times and success rates were varied systematically. RESULTS Telerobotic EVT centers decreased median travel time for LVO patients in all three scenarios. The estimated number of robotically treated LVOs per year in Scenarios 1, 2, and 3 were 2,172, 740, and 212, respectively. Scenario 1 (15-50 miles) was the most sensitive to robotic time delay and success rate, but all three scenarios were more sensitive to decreases in procedural success rate compared to time delay. CONCLUSIONS Telerobotic EVT has the potential to improve care for stroke patients outside of major urban centers. Compared to procedural time delays in robotic EVT, a decrease in procedural success rate would not be well tolerated.
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Affiliation(s)
- Charles Beaman
- Department of Neurology & David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
- Division of Interventional Neuroradiology, Department of Radiological Sciences & David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Jessalyn K Holodinsky
- Department of Clinical Neurosciences, The University of Calgary, Calgary, Alberta, Canada
| | - Mayank Goyal
- Department of Clinical Neurosciences, The University of Calgary, Calgary, Alberta, Canada
| | - Satoshi Tateshima
- Division of Interventional Neuroradiology, Department of Radiological Sciences & David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Michael D Hill
- Department of Clinical Neurosciences, The University of Calgary, Calgary, Alberta, Canada
| | - Jeffrey L Saver
- Department of Neurology & David Geffen School of Medicine, UCLA, Los Angeles, CA, USA
| | - Noreen Kamal
- 3688Department of Industrial Engineering, Dalhousie University, Halifax, Nova Scotia, Canada
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Markers of infection and inflammation are associated with post-thrombectomy mortality in acute stroke. Clin Neurol Neurosurg 2022; 222:107467. [DOI: 10.1016/j.clineuro.2022.107467] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Revised: 09/29/2022] [Accepted: 10/02/2022] [Indexed: 11/20/2022]
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Kobeissi H, Liu M, Ghozy S, Kadirvel R, Kallmes DF. Outcomes of young patients following mechanical thrombectomy for stroke: A systematic review and meta-analysis. Interv Neuroradiol 2022; 30:15910199221121378. [PMID: 35979592 PMCID: PMC10956453 DOI: 10.1177/15910199221121378] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2022] [Accepted: 08/03/2022] [Indexed: 01/26/2023] Open
Abstract
BACKGROUND Young patients experience acute ischemic stroke (AIS) at much lower rates than their older counterparts. We performed a systematic review and meta-analysis to assess the question regarding outcomes and clinical characteristics of young stroke patients who underwent mechanical thrombectomy for AIS. METHODS Following PRISMA guidelines, a systematic review of the literature was conducted using the databases PubMed, MEDLINE, and Embase. The primary outcome of interest was 90-day modified Rankin Scale (mRS) 0-2. Secondary outcome variables included rate of successful reperfusion (TICI 2b/3), symptomatic intracerebral hemorrhage (sICH), and mortality. Using R software version 4.1.2, we calculated pooled event rates and their corresponding 95% confidence intervals (CI) for all outcomes. RESULTS Our analysis included eight studies with a total of 1903 patients. Definitions of young patients included age ranges of 18-49/50 years, 18-54/55 years, and 18-64/65 years. Functional independence was achieved in 62.0% of the patients, with an overall mortality of 9.0%. Moreover, successful reperfusion was achieved in 82.0% of the patients with sICH rates of 5.7%. There was significant heterogeneity among different analyses, which could not be attributed to the differences of the definition of young patients. CONCLUSIONS Following mechanical thrombectomy for AIS, patients aged 18-65 years achieved relatively high rates of functional independence and successful reperfusion and low rates of mortality and sICH.Clinical Perspective In this systematic review and meta-analysis of eight studies, we examined outcomes in young stroke patients, aged 18-65 years old, following mechanical thrombectomy for acute ischemic stroke. We found that young patients achieved high rates of functional independence, high rates of successful reperfusion, and low rates of mortality and symptomatic intracerebral hemorrhage.While there have been several papers examining outcomes following mechanical thrombectomy for acute ischemic stroke in young patients, the results of these studies have yet to be pooled together in a meta-analysis. Our results indicate that young patients have good outcomes following mechanical thrombectomy. Further studies that examine these outcomes are warranted so that a higher-powered analysis can be performed to better informed clinicians regarding outcomes in this patient age-group cohort.
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Affiliation(s)
- Hassan Kobeissi
- College of Medicine, Central Michigan University, Mt. Pleasant, MI, USA
| | - Michael Liu
- Department of Neurology, Mayo Clinic, Rochester, MN, USA
| | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
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Mohamed GA, Marmarchi F, Fonkeu Y, Alshaer Q, Rangaraju S, Carr M, Jones A, Peczka M, Contreras I, Bahdsalvi L, Brasher C, Nahab F. Cincinnati Prehospital Stroke Scale Implementation of an Urban County Severity-Based Stroke Triage Protocol: Impact and Outcomes on a Comprehensive Stroke Center. J Stroke Cerebrovasc Dis 2022; 31:106575. [PMID: 35661542 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106575] [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: 04/10/2022] [Accepted: 05/15/2022] [Indexed: 11/27/2022] Open
Abstract
BACKGROUND AND PURPOSE Screening scales are recommended to assist field-based triage of acute stroke patients to designated stroke centers. Cincinnati prehospital stroke scale (CPSS) is a commonly used prehospital stroke screening tool and has been validated to identify large vessel occlusion (LVO). This study addresses the impact of county-based CPSS implementation to triage suspected LVO patients to a comprehensive stroke center (CSC). MATERIALS AND METHODS Dekalb County in Atlanta, Georgia, implemented CPSS-based protocol with score of 3 and last seen normal time < 24 h mandating transfer to the nearest CSC if the added bypass time was <15 min. Frequency of stroke codes, LVO, IV-tPA use, and thrombectomy treatment were compared six months before and after protocol change (November 1, 2020). RESULTS During the study period, 907 stroke patients presented to the CSC by EMS, including 289 (32%) with CPSS score 3. There was an increase in monthly ischemic stroke volume (pre-16 ± 2 vs.19 ± 3 p = 0.03), LVO (pre-4.3 ± 1.7 vs. post-7.0 ± 2.4; p = 0.03), EVT (pre-15% vs. post-30%; p = 0.001), without significant increase in stroke mimic volume or delay in mean time from last seen normal to IV-tPA (pre-165 ± 66, post-158 ± 49 min; p = 0.35). CPSS score 3 was associated with increased likelihood of LVO diagnosis (OR 8.5, 95% CI 5.0-14.4; p = 0.001) and decreased the likelihood of stroke mimics (OR 0.66, 95% CI 0.50-0.88; p = 0.004). CONCLUSION CPSS is a quick, easy to implement, and reliable prehospital severity scale for EMS to triage LVO to CSC without delaying IV-tPA treatment or significantly increasing stroke mimics.
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Affiliation(s)
- Ghada A Mohamed
- Department of Neurology, Emory School of Medicine, Atlanta, GA, USA
| | - Fahad Marmarchi
- Department of Neurology, Emory School of Medicine, Atlanta, GA, USA
| | - Yombe Fonkeu
- Department of Neurology, Emory School of Medicine, Atlanta, GA, USA
| | - Qasem Alshaer
- Department of Neurology, Emory School of Medicine, Atlanta, GA, USA
| | | | - Michael Carr
- Department of Emergency Medicine, Emory School of Medicine, American Medical Response (AMR) DeKalb County, Atlanta, GA, USA
| | - Andrew Jones
- Department of Emergency Medicine, Emory School of Medicine, Atlanta, GA, USA
| | | | | | - Lori Bahdsalvi
- Department of Neurology, Emory University School of Medicine, USA
| | - Cynthia Brasher
- Department of Neurology, Emory University School of Medicine, USA
| | - Fadi Nahab
- Department of Neurology, Emory University School of Medicine, USA.
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Fibrinolysis without intracranial hemorrhage. Blood 2022; 140:300-302. [PMID: 35900787 DOI: 10.1182/blood.2022016925] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2022] [Accepted: 05/13/2022] [Indexed: 11/20/2022] Open
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Tosello R, Riera R, Tosello G, Clezar CN, Amorim JE, Vasconcelos V, Joao BB, Flumignan RL. Type of anaesthesia for acute ischaemic stroke endovascular treatment. Cochrane Database Syst Rev 2022; 7:CD013690. [PMID: 35857365 PMCID: PMC9298671 DOI: 10.1002/14651858.cd013690.pub2] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND The use of mechanical thrombectomy to restore intracranial blood flow after proximal large artery occlusion by a thrombus has increased over time and led to better outcomes than intravenous thrombolytic therapy alone. Currently, the type of anaesthetic technique during mechanical thrombectomy is under debate as having a relevant impact on neurological outcomes. OBJECTIVES To assess the effects of different types of anaesthesia for endovascular interventions in people with acute ischaemic stroke. SEARCH METHODS We searched the Cochrane Stroke Group Specialised Register of Trials on 5 July 2022, and CENTRAL, MEDLINE, and seven other databases on 21 March 2022. We performed searches of reference lists of included trials, grey literature sources, and other systematic reviews. SELECTION CRITERIA: We included all randomised controlled trials with a parallel design that compared general anaesthesia versus local anaesthesia, conscious sedation anaesthesia, or monitored care anaesthesia for mechanical thrombectomy in acute ischaemic stroke. We also included studies reported as full-text, those published as abstract only, and unpublished data. We excluded quasi-randomised trials, studies without a comparator group, and studies with a retrospective design. DATA COLLECTION AND ANALYSIS Two review authors independently applied the inclusion criteria, extracted data, and assessed the risk of bias and the certainty of the evidence using the GRADE approach. The outcomes were assessed at different time periods, ranging from the onset of the stroke symptoms to 90 days after the start of the intervention. The main outcomes were functional outcome, neurological impairment, stroke-related mortality, all intracranial haemorrhage, target artery revascularisation status, time to revascularisation, adverse events, and quality of life. All included studies reported data for early (up to 30 days) and long-term (above 30 days) time points. MAIN RESULTS We included seven trials with 982 participants, which investigated the type of anaesthesia for endovascular treatment in large vessel occlusion in the intracranial circulation. The outcomes were assessed at different time periods, ranging from the onset of stroke symptoms to 90 days after the procedure. Therefore, all included studies reported data for early (up to 30 days) and long-term (above 30 up to 90 days) time points. General anaesthesia versus non-general anaesthesia(early) We are uncertain about the effect of general anaesthesia on functional outcomes compared to non-general anaesthesia (mean difference (MD) 0, 95% confidence interval (CI) -0.31 to 0.31; P = 1.0; 1 study, 90 participants; very low-certainty evidence) and in time to revascularisation from groin puncture until the arterial reperfusion (MD 2.91 minutes, 95% CI -5.11 to 10.92; P = 0.48; I² = 48%; 5 studies, 498 participants; very low-certainty evidence). General anaesthesia may lead to no difference in neurological impairment up to 48 hours after the procedure (MD -0.29, 95% CI -1.18 to 0.59; P = 0.52; I² = 0%; 7 studies, 982 participants; low-certainty evidence), and in stroke-related mortality (risk ratio (RR) 0.98, 95% CI 0.52 to 1.84; P = 0.94; I² = 0%; 3 studies, 330 participants; low-certainty evidence), all intracranial haemorrhages (RR 0.92, 95% CI 0.65 to 1.29; P = 0.63; I² = 0%; 5 studies, 693 participants; low-certainty evidence) compared to non-general anaesthesia. General anaesthesia may improve adverse events (haemodynamic instability) compared to non-general anaesthesia (RR 0.21, 95% CI 0.05 to 0.79; P = 0.02; I² = 71%; 2 studies, 229 participants; low-certainty evidence). General anaesthesia improves target artery revascularisation compared to non-general anaesthesia (RR 1.10, 95% CI 1.02 to 1.18; P = 0.02; I² = 29%; 7 studies, 982 participants; moderate-certainty evidence). There were no available data for quality of life. General anaesthesia versus non-general anaesthesia (long-term) There is no difference in general anaesthesia compared to non-general anaesthesia for dichotomous and continuous functional outcomes (dichotomous: RR 1.21, 95% CI 0.93 to 1.58; P = 0.16; I² = 29%; 4 studies, 625 participants; low-certainty evidence; continuous: MD -0.14, 95% CI -0.34 to 0.06; P = 0.17; I² = 0%; 7 studies, 978 participants; low-certainty evidence). General anaesthesia showed no changes in stroke-related mortality compared to non-general anaesthesia (RR 0.88, 95% CI 0.64 to 1.22; P = 0.44; I² = 12%; 6 studies, 843 participants; low-certainty evidence). There were no available data for neurological impairment, all intracranial haemorrhages, target artery revascularisation status, time to revascularisation from groin puncture until the arterial reperfusion, adverse events (haemodynamic instability), or quality of life. Ongoing studies We identified eight ongoing studies. Five studies compared general anaesthesia versus conscious sedation anaesthesia, one study compared general anaesthesia versus conscious sedation anaesthesia plus local anaesthesia, and two studies compared general anaesthesia versus local anaesthesia. Of these studies, seven plan to report data on functional outcomes using the modified Rankin Scale, five studies on neurological impairment, six studies on stroke-related mortality, two studies on all intracranial haemorrhage, five studies on target artery revascularisation status, four studies on time to revascularisation, and four studies on adverse events. One ongoing study plans to report data on quality of life. One study did not plan to report any outcome of interest for this review. AUTHORS' CONCLUSIONS In early outcomes, general anaesthesia improves target artery revascularisation compared to non-general anaesthesia with moderate-certainty evidence. General anaesthesia may improve adverse events (haemodynamic instability) compared to non-general anaesthesia with low-certainty evidence. We found no evidence of a difference in neurological impairment, stroke-related mortality, all intracranial haemorrhage and haemodynamic instability adverse events between groups with low-certainty evidence. We are uncertain whether general anaesthesia improves functional outcomes and time to revascularisation because the certainty of the evidence is very low. However, regarding long-term outcomes, general anaesthesia makes no difference to functional outcomes compared to non-general anaesthesia with low-certainty evidence. General anaesthesia did not change stroke-related mortality when compared to non-general anaesthesia with low-certainty evidence. There were no reported data for other outcomes. In view of the limited evidence of effect, more randomised controlled trials with a large number of participants and good protocol design with a low risk of bias should be performed to reduce our uncertainty and to aid decision-making in the choice of anaesthesia.
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Affiliation(s)
- Renato Tosello
- Department of Neurointerventional Radiology, Hospital Beneficencia Portuguesa de Sao Paulo, Sao Paulo, Brazil
| | - Rachel Riera
- Centre of Health Technology Assessment, Universidade Federal de São Paulo, São Paulo, Brazil
- Núcleo de Ensino e Pesquisa em Saúde Baseada em Evidências e Avaliação Tecnológica em Saúde (NEP-Sbeats), Universidade Federal de São Paulo, São Paulo, Brazil
| | | | - Caroline Nb Clezar
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Jorge E Amorim
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Vladimir Vasconcelos
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Benedito B Joao
- Division of Anesthesia, Pain, and Intensive Medicine, Department of Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
| | - Ronald Lg Flumignan
- Department of Surgery, Division of Vascular and Endovascular Surgery, Universidade Federal de São Paulo, São Paulo, Brazil
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Matuja SS, Ahmed RA, Munseri P, Khanbhai K, Tessua K, Lyimo F, Rodriguez GJ, Gupta V, Maud A, Chaudhury MR, Manji M, Sheriff F. Ischemic Stroke at a Tertiary Academic Hospital in Tanzania: A Prospective Cohort Study With a Focus on Presumed Large Vessel Occlusion. Front Neurol 2022; 13:882928. [PMID: 35911912 PMCID: PMC9330741 DOI: 10.3389/fneur.2022.882928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2022] [Accepted: 06/17/2022] [Indexed: 11/13/2022] Open
Abstract
Background Large vessel ischemic strokes account for more than one-third of all strokes associated with substantial morbidity and mortality without early intervention. The incidence of large vessel occlusion (LVO) is not known in sub-Saharan Africa (SSA). Definitive vessel imaging is not routinely available in resource-limited settings. Aims We aimed to investigate the burden and outcomes of presumed LVO among patients with ischemic stroke admitted to a large tertiary academic hospital in Tanzania. Methods This cohort study recruited all consenting first-ever ischemic stroke participants admitted at a tertiary hospital in Tanzania. Demographic data were recorded, and participants were followed up to 1 year using the modified Rankin Scale (mRS). A diagnosis of presumed LVO was made by a diagnostic neuroradiologist and interventional neurologist based on contiguous ischemic changes in a pattern consistent with proximal LVO on a non-contrast computed tomography head. We examined factors associated with presumed LVO using logistic regression analysis. Inter-observer Kappa was calculated. Results We enrolled 158 first-ever ischemic strokes over 8 months with a mean age of 59.7 years. Presumed LVO accounted for 39.2% [95% confidence interval (CI) 31.6–47.3%] and an overall meantime from the onset of stroke symptoms to hospital arrival was 1.74 days. Participants with presumed LVO were more likely to involve the middle cerebral artery (MCA) territory (70.9%), p < 0.0001. Independent factors on multivariate analysis associated with presumed LVO were hypertension [adjusted odds ratio (aOR) 5.74 (95% CI: 1.74–18.9)] and increased waist-hip ratio [aOR 7.20 (95% CI: 1.83–28.2)]. One-year mortality in presumed LVO was 80% when compared with 73.1% in participants without presumed LVO. The Cohen's Kappa inter-observer reliability between the diagnostic neuroradiologist and interventional neurologist was 0.847. Conclusion There is a high burden of presumed LVO associated with high rates of 1-year morbidity and mortality at a tertiary academic hospital in Tanzania. Efforts are needed to confirm these findings with definitive vessel imaging, promoting cost-effective preventive strategies to reduce the burden of non-communicable diseases (NCDs), and a call for adopting endovascular therapies to reduce morbidity and mortality.
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Affiliation(s)
- Sarah Shali Matuja
- Department of Internal Medicine, Catholic University of Health and Allied Sciences, Mwanza, Tanzania
- *Correspondence: Sarah Shali Matuja
| | - Rashid Ali Ahmed
- Department of Neurology, Massachusetts General Hospital and Harvard Medical School, Boston, MA, United States
| | - Patricia Munseri
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Khuzeima Khanbhai
- Department of Cardiology, Jakaya Kikwete Cardiac Institute, Dar es Salaam, Tanzania
| | - Kezia Tessua
- Department of Internal Medicine, Ocean Road Cancer Institute, Dar es Salaam, Tanzania
| | - Frederick Lyimo
- Department of Radiology, Muhimbili National Hospital, Dar es Salaam, Tanzania
| | - Gustavo J. Rodriguez
- Department of Neurology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine El Paso, El Paso, TX, United States
| | - Vikas Gupta
- Department of Neurology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine El Paso, El Paso, TX, United States
| | - Alberto Maud
- Department of Neurology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine El Paso, El Paso, TX, United States
| | - Mohammad Rauf Chaudhury
- Department of Neurology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine El Paso, El Paso, TX, United States
| | - Mohamed Manji
- Department of Internal Medicine, Muhimbili University of Health and Allied Sciences, Dar es Salaam, Tanzania
| | - Faheem Sheriff
- Department of Neurology, Texas Tech University Health Sciences Center, Paul L Foster School of Medicine El Paso, El Paso, TX, United States
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Alsrouji OK, Chebl AB. Acute Neurointervention for Ischemic Stroke. Interv Cardiol Clin 2022; 11:339-347. [PMID: 35710287 DOI: 10.1016/j.iccl.2022.03.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Acute ischemic stroke (AIS) is one of the major causes of death worldwide and a leading cause of disability. Until recently treatment of AIS was supportive, and in a minority of patients intravenous thrombolysis was available but with marginal clinical benefit. With the advent of stent retrievers, distal aspiration catheters as well as improved patient selection neurologic outcomes have greatly improved. However, the care of patients with AIS is still challenging and requires the early recognition of stroke symptoms, extensive diagnostic testing, early intervention, and advanced nursing and critical care.
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Affiliation(s)
- Owais Khadem Alsrouji
- Department of Neurosurgery, Henry Ford Hospital, K11, 2799 West Grand Boulevard, Detroit, MI 48202, USA
| | - Alex Bou Chebl
- Division of Vascular Neurology, Department of Neurology, Harris Comprehensive Stroke Center, Henry Ford Health System, Clara Ford Pavillion, Room 453, 2799 W Grand Boulevard, Detroit, MI 48202, USA.
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Avery EW, Behland J, Mak A, Haider SP, Zeevi T, Sanelli PC, Filippi CG, Malhotra A, Matouk CC, Griessenauer CJ, Zand R, Hendrix P, Abedi V, Falcone GJ, Petersen N, Sansing LH, Sheth KN, Payabvash S. CT angiographic radiomics signature for risk stratification in anterior large vessel occlusion stroke. Neuroimage Clin 2022; 34:103034. [PMID: 35550243 PMCID: PMC9108990 DOI: 10.1016/j.nicl.2022.103034] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2021] [Revised: 03/27/2022] [Accepted: 05/03/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND AND PURPOSE As "time is brain" in acute stroke triage, the need for automated prognostication tools continues to increase, particularly in rapidly expanding tele-stroke settings. We aimed to create an automated prognostication tool for anterior circulation large vessel occlusion (LVO) stroke based on admission CTA radiomics. METHODS We automatically extracted 1116 radiomics features from the anterior circulation territory on admission CTAs of 829 acute LVO stroke patients who underwent mechanical thrombectomy in two academic centers. We trained, optimized, validated, and compared different machine-learning models to predict favorable outcome (modified Rankin Scale ≤ 2) at discharge and 3-month follow-up using four different input sets: "Radiomics", "Radiomics + Treatment" (radiomics, post-thrombectomy reperfusion grade, and intravenous thrombolysis), "Clinical + Treatment" (baseline clinical variables and treatment), and "Combined" (radiomics, treatment, and baseline clinical variables). RESULTS For discharge outcome prediction, models were optimized/trained on n = 494 and tested on an independent cohort of n = 100 patients from Yale. Receiver operating characteristic analysis of the independent cohort showed no significant difference between best-performing Combined input models (area under the curve, AUC = 0.77) versus Radiomics + Treatment (AUC = 0.78, p = 0.78), Radiomics (AUC = 0.78, p = 0.55), or Clinical + Treatment (AUC = 0.77, p = 0.87) models. For 3-month outcome prediction, models were optimized/trained on n = 373 and tested on an independent cohort from Yale (n = 72), and an external cohort from Geisinger Medical Center (n = 232). In the independent cohort, there was no significant difference between Combined input models (AUC = 0.76) versus Radiomics + Treatment (AUC = 0.72, p = 0.39), Radiomics (AUC = 0.72, p = 0.39), or Clinical + Treatment (AUC = 76, p = 0.90) models; however, in the external cohort, the Combined model (AUC = 0.74) outperformed Radiomics + Treatment (AUC = 0.66, p < 0.001) and Radiomics (AUC = 0.68, p = 0.005) models for 3-month prediction. CONCLUSION Machine-learning signatures of admission CTA radiomics can provide prognostic information in acute LVO stroke candidates for mechanical thrombectomy. Such objective and time-sensitive risk stratification can guide treatment decisions and facilitate tele-stroke assessment of patients. Particularly in the absence of reliable clinical information at the time of admission, models solely using radiomics features can provide a useful prognostication tool.
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Affiliation(s)
- Emily W Avery
- Section of Neuroradiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States
| | - Jonas Behland
- Section of Neuroradiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States; CLAIM - Charité Lab for Artificial Intelligence in Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Adrian Mak
- Section of Neuroradiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States; CLAIM - Charité Lab for Artificial Intelligence in Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Stefan P Haider
- Section of Neuroradiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States; Department of Otorhinolaryngology, University Hospital of Ludwig Maximilians Universität München, Munich, Germany
| | - Tal Zeevi
- Section of Neuroradiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States
| | - Pina C Sanelli
- Section of Neuroradiology, Department of Radiology, Northwell Health, Manhasset, NY, United States
| | - Christopher G Filippi
- Section of Neuroradiology, Department of Radiology, Tufts School of Medicine, Boston, MA, United States
| | - Ajay Malhotra
- Section of Neuroradiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States
| | - Charles C Matouk
- Division of Neurovascular Surgery, Department of Neurosurgery, Yale University School of Medicine, New Haven, CT, United States
| | - Christoph J Griessenauer
- Department of Neurosurgery, Geisinger Medical Center, Danville, PA, United States; Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria; Department of Neurosurgery, Paracelsus Medical University, Salzburg, Austria
| | - Ramin Zand
- Department of Neurology, Geisinger, Danville, PA, United States
| | - Philipp Hendrix
- Department of Neurosurgery, Geisinger Medical Center, Danville, PA, United States; Department of Neurosurgery, Saarland University Medical Center, Homburg, Germany
| | - Vida Abedi
- Department of Molecular and Functional Genomics, Geisinger, Danville, PA, United States; Biocomplexity Institute, Virginia Tech, Blacksburg, VA, USA
| | - Guido J Falcone
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
| | - Nils Petersen
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
| | - Lauren H Sansing
- Division of Stroke and Vascular Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
| | - Kevin N Sheth
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT, United States
| | - Seyedmehdi Payabvash
- Section of Neuroradiology, Department of Radiology and Biomedical Imaging, Yale School of Medicine, New Haven, CT, United States.
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Enriquez BA, Tennøe B, Nome T, Gjertsen Ø, Nedregaard B, Sletteberg R, Skattør T, Sökjer M, Johansen H, Skagen KR, Skjelland M, Aamodt AH, Lund CG. Mekanisk trombektomi ved akutt hjerneinfarkt. TIDSSKRIFT FOR DEN NORSKE LEGEFORENING 2022; 142:21-0577. [PMID: 35510464 DOI: 10.4045/tidsskr.21.0577] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/23/2022] Open
Abstract
Mechanical thrombectomy is now the standard treatment for acute ischaemic stroke with occlusion of a carotid or intercranial artery. With occlusions of this type, thrombolytic treatment often has limited effect. The therapeutic outcome with the use of thrombectomy is time-dependent, and a personalised approach to indication is always necessary. To achieve the best possible results, the main prerequisites are good clinical procedures, an optimal patient pathway, high neuroradiological competence and coordinated, interdisciplinary teams.
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Affiliation(s)
| | - Bjørn Tennøe
- Nevroradiologisk enhet, Oslo universitetssykehus, Rikshospitalet
| | - Terje Nome
- Nevroradiologisk enhet, Oslo universitetssykehus, Rikshospitalet
| | - Øyvind Gjertsen
- Nevroradiologisk enhet, Oslo universitetssykehus, Rikshospitalet
| | - Bård Nedregaard
- Nevroradiologisk enhet, Oslo universitetssykehus, Rikshospitalet
| | - Ruth Sletteberg
- Nevroradiologisk enhet, Oslo universitetssykehus, Rikshospitalet
| | - Thor Skattør
- Nevroradiologisk enhet, Oslo universitetssykehus, Rikshospitalet
| | - Martin Sökjer
- Nevroradiologisk enhet, Oslo universitetssykehus, Rikshospitalet
| | | | | | - Mona Skjelland
- Nevrologisk avdeling, Oslo universitetssykehus, og, Institutt for klinisk medisin, Universitetet i Oslo
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Simonetto M, Wechsler PM, Merkler AE. Stroke Treatment in the Era of COVID-19: a Review. Curr Treat Options Neurol 2022; 24:155-171. [PMID: 35497091 PMCID: PMC9035774 DOI: 10.1007/s11940-022-00713-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/06/2022] [Indexed: 12/15/2022]
Abstract
Purpose of Review To describe a comprehensive review of the epidemiology, pathophysiology, and treatment of stroke in the era of COVID-19. Recent Findings COVID-19 is associated with myriad neurological disorders, including cerebrovascular disease. While ischemic stroke is the most common, COVID-19 is associated with an increased risk of intracranial hemorrhage, arterial dissection, posterior reversible encephalopathy syndrome, and cerebral venous sinus thrombosis. In this review, we discuss the epidemiology, pathophysiology, and treatment of stroke due to COVID-19. In addition, we describe how COVID-19 has changed the landscape of stroke systems of care and the effect this has had on patients with cerebrovascular disease. Summary While COVID-19 is associated with a heightened risk of stroke, the pandemic has led to advances in stroke systems of care that may reduce the long-term burden of stroke.
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Affiliation(s)
- Marialaura Simonetto
- Department of Neurology, Weill Cornell Medicine, New York Presbyterian Hospital, Room F610, 525 East 68th Street, New York, NY 10065 USA
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY USA
| | - Paul M. Wechsler
- Department of Neurology, Weill Cornell Medicine, New York Presbyterian Hospital, Room F610, 525 East 68th Street, New York, NY 10065 USA
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY USA
| | - Alexander E. Merkler
- Department of Neurology, Weill Cornell Medicine, New York Presbyterian Hospital, Room F610, 525 East 68th Street, New York, NY 10065 USA
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute, Weill Cornell Medicine, New York, NY USA
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Weyland CS, Papanagiotou P, Schmitt N, Joly O, Bellot P, Mokli Y, Ringleb PA, Kastrup A, Möhlenbruch MA, Bendszus M, Nagel S, Herweh C. Hyperdense Artery Sign in Patients With Acute Ischemic Stroke-Automated Detection With Artificial Intelligence-Driven Software. Front Neurol 2022; 13:807145. [PMID: 35449516 PMCID: PMC9016329 DOI: 10.3389/fneur.2022.807145] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2021] [Accepted: 02/28/2022] [Indexed: 01/22/2023] Open
Abstract
Background Hyperdense artery sign (HAS) on non-contrast CT (NCCT) can indicate a large vessel occlusion (LVO) in patients with acute ischemic stroke. HAS detection belongs to routine reporting in patients with acute stroke and can help to identify patients in whom LVO is not initially suspected. We sought to evaluate automated HAS detection by commercial software and compared its performance to that of trained physicians against a reference standard. Methods Non-contrast CT scans from 154 patients with and without LVO proven by CT angiography (CTA) were independently rated for HAS by two blinded neuroradiologists and an AI-driven algorithm (Brainomix®). Sensitivity and specificity were analyzed for the clinicians and the software. As a secondary analysis, the clot length was automatically calculated by the software and compared with the length manually outlined on CTA images as the reference standard. Results Among 154 patients, 84 (54.5%) had CTA-proven LVO. HAS on the correct side was detected with a sensitivity and specificity of 0.77 (CI:0.66–0.85) and 0.87 (0.77–0.94), 0.8 (0.69–0.88) and 0.97 (0.89–0.99), and 0.93 (0.84–0.97) and 0.71 (0.59–0.81) by the software and readers 1 and 2, respectively. The automated estimation of the thrombus length was in moderate agreement with the CTA-based reference standard [intraclass correlation coefficient (ICC) 0.73]. Conclusion Automated detection of HAS and estimation of thrombus length on NCCT by the tested software is feasible with a sensitivity and specificity comparable to that of trained neuroradiologists.
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Affiliation(s)
| | - Panagiotis Papanagiotou
- Department of Neuroradiology, Klinikum Bremen-Mitte, Bremen, Germany.,Department of Radiology, Areteion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Niclas Schmitt
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | | | | | - Yahia Mokli
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | | | - A Kastrup
- Neurology, Klinikum Bremen-Mitte, Bremen, Germany
| | | | - Martin Bendszus
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Simon Nagel
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
| | - Christian Herweh
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
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Sacks D, Dhand S, Hegg R, Hirsch K, McCollom V, Sarin S, Vadlamudi V, Wasser T, Zylak C. Outcomes of Stroke Thrombectomy Performed by Interventional Radiologists vs Neurointerventional Physicians. J Vasc Interv Radiol 2022; 33:619-626.e1. [PMID: 35150837 DOI: 10.1016/j.jvir.2021.11.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/04/2021] [Accepted: 11/25/2021] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To test the hypothesis that interventional radiologists (IR) have outcomes for endovascular stroke thrombectomy (EVT) similar to Neurointerventional (NI) physicians and could be used to improve availability of thrombectomy. MATERIALS AND METHODS Eight hospitals providing EVT performed by IR and NI in the same institution submitted sequential retrospective data limited to the era of modern devices. Good clinical outcome (90 day modified Rankin score 0-2) and successful revascularization (modified Thrombolysis in Cerebral Infarction score > 2b) were compared between specialties, adjusted for treating hospital, patient age, stroke severity, Alberta Stroke Program Early CT Score (ASPECTS), time from symptom onset to door, and clot location. Propensity score matching was used to compare outcomes. A total of 1009 patients were entered (622 treated by IR and 387 treated by NI). RESULTS Median stroke onset to puncture was 245 vs 253 minutes (p=.49), technically successful revascularization was 81.8% vs 82.4% (p=.81), and good clinical outcome was 45.5% vs 50.1% (p=.16), respectively. After adjusting, physician specialty was not a significant predictor of good clinical outcome (odds ratio 1.028 [95% CI 0.760-1.390]; p=.86). After matching, mRS 0-2 was 47.7% for IR and 51.1% for NI (p=0.366). CONCLUSION There was no significant difference in successful revascularization and good clinical outcomes between IR and NI physicians. Outcomes by IR were similar to NI outcomes from previously published trials and registries. This may be useful to address coverage and access to stroke interventions.
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Affiliation(s)
| | | | - Ryan Hegg
- Research Medical Center, Kansas City, MO
| | | | | | - Shawn Sarin
- George Washington University Hospital, Washington, DC
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Optimization of Large Vessel Occlusion Detection in Acute Ischemic Stroke Using Machine Learning Methods. Life (Basel) 2022; 12:life12020230. [PMID: 35207517 PMCID: PMC8877679 DOI: 10.3390/life12020230] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Revised: 01/27/2022] [Accepted: 01/31/2022] [Indexed: 12/18/2022] Open
Abstract
The early detection of large-vessel occlusion (LVO) strokes is increasingly important as these patients are potential candidates for endovascular therapy, the availability of which is limited. Prehospital LVO detection scales mainly contain symptom variables only; however, recent studies revealed that other types of variables could be useful as well. Our aim was to comprehensively assess the predictive ability of several clinical variables for LVO prediction and to develop an optimal combination of them using machine learning tools. We have retrospectively analysed data from a prospectively collected multi-centre stroke registry. Data on 41 variables were collected and divided into four groups (baseline vital parameters/demographic data, medical history, laboratory values, and symptoms). Following the univariate analysis, the LASSO method was used for feature selection to select an optimal combination of variables, and various machine learning methods (random forest (RF), logistic regression (LR), elastic net method (ENM), and simple neural network (SNN)) were applied to optimize the performance of the model. A total of 526 patients were included. Several neurological symptoms were more common and more severe in the group of LVO patients. Atrial fibrillation (AF) was more common, and serum white blood cell (WBC) counts were higher in the LVO group, while systolic blood pressure (SBP) was lower among LVO patients. Using the LASSO method, nine variables were selected for modelling (six symptom variables, AF, chronic heart failure, and WBC count). When applying machine learning methods and 10-fold cross validation using the selected variables, all models proved to have an AUC between 0.736 (RF) and 0.775 (LR), similar to the performance of National Institutes of Health Stroke Scale (AUC: 0.790). Our study highlights that, although certain neurological symptoms have the best ability to predict an LVO, other variables (such as AF and CHF in medical history and white blood cell counts) should also be included in multivariate models to optimize their efficiency.
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Aroor SR, Asif KS, Potter-Vig J, Sharma A, Menon BK, Inoa V, Zevallos CB, Romano JG, Ortega-Gutierrez S, Goldstein LB, Yavagal DR. Mechanical Thrombectomy Access for All? Challenges in Increasing Endovascular Treatment for Acute Ischemic Stroke in the United States. J Stroke 2022; 24:41-48. [PMID: 35135058 PMCID: PMC8829477 DOI: 10.5853/jos.2021.03909] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2021] [Accepted: 01/11/2022] [Indexed: 11/11/2022] Open
Abstract
Mechanical thrombectomy (MT) is the most effective treatment for selected patients with an acute ischemic stroke due to emergent large vessel occlusions (LVOs). There is an urgent need to identify and address challenges in access to MT to maximize the numbers of patients who can benefit from this treatment. Barriers in access to MT include delays in evaluation and accurate diagnosis of LVO leading to inappropriate triage, logistical delays related to availability of facilities and trained interventionalists, and financial hurdles that affect treatment reimbursement. Collection of regional data related to these barriers is critical to better understand current access gaps and a measurable access score to thrombectomy could be useful to plan local public health intervention.
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Affiliation(s)
- Sushanth Rao Aroor
- Department of Neurology, Rutgers New Jersey Medical School, Newark, NJ, USA
| | - Kaiz S. Asif
- Department of Neurosurgery, University of Illinois and AMITA Health, Chicago, IL, USA
| | | | - Arun Sharma
- University of Miami, Herbert Business School, Miami, FL, USA
| | - Bijoy K. Menon
- Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Violiza Inoa
- Semmes Murphey Clinic, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Cynthia B. Zevallos
- Department of Neurology, University of Iowa Hospital and Clinics, Iowa City, IA, USA
| | - Jose G. Romano
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | | | - Larry B. Goldstein
- Department of Neurology, University of Kentucky College of Medicine, Lexington, KY, USA
| | - Dileep R. Yavagal
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
- Department of Neurosurgery, University of Miami Miller School of Medicine, Miami, FL, USA
- Correspondence: Dileep R. Yavagal Departments of Neurology and Neurosurgery, University of Miami Miller School of Medicine, 1600 NW 10th Ave 1140, Miami, FL 33136, USA Tel: +1-305-355-1103 E-mail:
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Rodríguez-Baz Í, Rodríguez-Pérez MC, Medina Rodríguez A, Hernández Cabezudo I, Sosa Cabrera Y. Associated factors with functional prognosis of patients with acute ischemic stroke undergoing thrombectomy. Med Clin (Barc) 2022; 159:313-320. [PMID: 35042605 DOI: 10.1016/j.medcli.2021.11.010] [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: 10/05/2021] [Revised: 11/12/2021] [Accepted: 11/21/2021] [Indexed: 10/19/2022]
Abstract
INTRODUCTION Mechanical thrombectomy (MT) has meant a change in natural history of acute ischemic stroke. Our aim is to assess the possible association between different factors and prognosis in patients treated with MT in a third degree Spanish hospital. METHODS Cross-sectional study including 198 patients underwent MT because of acute ischemic stroke between 2012 and 2020. Sociodemographic, vascular risk factors (VRF) and clinical-radiologic factors were recorded. Functional outcome was evaluated based on modified Rankin Scale (mRS) at 90 days, being mRS≤2 favorable and mRS≥3 unfavorable outcome. RESULTS Mean age 67.7±13.5 years, 50.5% women. Arterial hypertension was the most prevalent VRF (65.7%). National Institute of Health Stroke Scale (NIHSS) median value at admission was 17.0 (8.0; 22.0). 40.9% of cases also received fibrinolytic treatment. Conscious sedation was performed in 66.7% patients. Median passes of MT were 2, and median duration 41min. Successful recanalization was achieved in 79.9% and mRS≤2 at 90 days was registered at 59.5% cases. Age, type 2 diabetes (T2D), number of MT passes and procedure duration were associated with mRS≥3. Successful recanalization was associated with mRS≤2. Regression model confirmed these associations in age (OR: 1.56CI%: 1.11; 2.20); T2D (OR: 3.51CI%: 1.38; 8.97) and successful recanalization (OR: 0.07CI%: 0.02; 0.28). CONCLUSION Age, T2D and failed recanalization increase risk for unfavorable outcome at 90 days in patients with AIS treated with MT. Procedure time duration should be considered as a possible determinant factor in functional outcome.
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Affiliation(s)
- Íñigo Rodríguez-Baz
- Servicio de Neurología, Hospital Universitario Nuestra Señora de la Candelaria, Santa Cruz de Tenerife, España.
| | | | - Antonio Medina Rodríguez
- Unidad de Ictus, Servicio de Neurología, Hospital Universitario Nuestra Señora de la Candelaria, Santa Cruz de Tenerife, España
| | - Ignacio Hernández Cabezudo
- Servicio de Radiología, Hospital Universitario Nuestra Señora de la Candelaria, Santa Cruz de Tenerife, España
| | - Yolanda Sosa Cabrera
- Servicio de Neurología, Hospital Universitario Nuestra Señora de la Candelaria, Santa Cruz de Tenerife, España
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Wei J, Wang Y, Yang S, Hao Z, Pan X, Ma A. Plasma chromogranin A levels are associated with acute ischemic stroke with anterior circulation large vessel occlusion. Nutr Metab Cardiovasc Dis 2022; 32:195-202. [PMID: 34893409 DOI: 10.1016/j.numecd.2021.09.030] [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: 02/08/2021] [Revised: 08/17/2021] [Accepted: 09/21/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND AND AIMS To investigate the relationship between chromogranin A (CgA) levels and acute ischemic stroke (AIS), especially anterior circulation large vessel occlusion (LVO). METHODS AND RESULTS 587 subjects were included in this study, including 205 AIS patients with anterior circulation LVO and 205 nonocclusive patients, as well as 177 healthy controls. On admission, plasma CgA levels were measured and neurological deficits were assessed by the NIH Stroke Scale. Outcomes were assessed by the modified Rankin Scale at 3 months. The predictive properties of CgA were evaluated by receiver operating characteristic (ROC) curve analysis. Binary logistic analysis assessed the association of CgA levels and AIS or anterior circulation LVO. AIS patients had lower CgA levels than health controls (p < 0.001). Anterior circulation LVO patients had lower CgA levels than nonocclusive patients (p < 0.001). The area under the ROC curve of plasma CgA levels in predicting anterior circulation LVO from AIS was 0.744 and the optimal cutoff value was 15.49 ng/mL with a Youden value of 0.332. Logistic analysis showed that CgA ≤15.49 ng/mL remained an independent risk factor for anterior circulation LVO after adjusting for related factors (OR = 6.519, 95% CI: 3.790-11.214, p < 0.001). CgA was an independent protective factor for mild stroke and good prognosis (p = 0.009, p = 0.005); however, the association disappeared after adjusting for occlusion (p = 0.768, p = 0.335). CONCLUSION CgA levels were lower in AIS patients, especially in anterior circulation LVO patients. Lower CgA levels are potential biomarker for anterior circulation LVO, and they may indicate good prognosis at 3 months in AIS.
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Affiliation(s)
- Jin Wei
- Department of Neurology, The Affiliated Hospital of Qingdao University, 59 Haier Road, Qingdao, 266100, Shandong, China
| | - Yuan Wang
- Department of Neurology, The Affiliated Hospital of Qingdao University, 59 Haier Road, Qingdao, 266100, Shandong, China
| | - Shaonan Yang
- Department of Neurology, The Affiliated Hospital of Qingdao University, 59 Haier Road, Qingdao, 266100, Shandong, China
| | - Zhongnan Hao
- Department of Neurology, The Affiliated Hospital of Qingdao University, 59 Haier Road, Qingdao, 266100, Shandong, China
| | - Xudong Pan
- Department of Neurology, The Affiliated Hospital of Qingdao University, 59 Haier Road, Qingdao, 266100, Shandong, China.
| | - Aijun Ma
- Department of Neurology, The Affiliated Hospital of Qingdao University, 59 Haier Road, Qingdao, 266100, Shandong, China.
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