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Luo C, Tao C, Li R, Nguyen TN, Jing X, Yuan S, Wang A, Abdalkader M, Gao F, Chen L, Hao P, Cai M, Liu X, Hu W. Thrombectomy improves functional independence in severe basilar artery occlusion with favorable collateral circulation. Eur J Neurol 2024; 31:e16380. [PMID: 38924331 PMCID: PMC11295163 DOI: 10.1111/ene.16380] [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: 02/28/2024] [Revised: 05/14/2024] [Accepted: 05/23/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND AND PURPOSE This study aimed to investigate the effect of collateral circulation on the outcomes of thrombectomy versus medical management alone in basilar artery occlusion (BAO) patients with varying stroke severities. METHODS Data from the ATTENTION cohort were used to perform a post-hoc analysis comparing the outcomes of thrombectomy with medical management in BAO patients with varying degrees of collateral circulation and stroke severity. Basilar Artery on Computed Tomography Angiography (BATMAN) scores were used to quantify the collateral circulation, and the effect was estimated through a primary outcome of 90-day functional independence (modified Rankin Scale score, mRS ≤2). Favorable versus unfavorable BATMAN scores were analyzed as both continuous and categorical variables, and an adjusted multivariate regression model was applied. RESULTS Among 221 BAO patients, thrombectomy significantly improved functional independence compared to medical management in patients with favorable BATMAN scores (aOR 7.75, 95% CI 2.78-26.1), but not in those with unfavorable BATMAN scores (aOR 1.33, 95% CI 0.28-6.92; pinteraction = 0.028). When treated as a continuous variable, increased BATMAN score was found to be associated with a higher likelihood of functional independence in the thrombectomy group (aOR 1.97, 95% CI 1.44-2.81; pinteraction = 0.053). In severe stroke patients with higher BATMAN scores (National Institutes of Health Stroke Scale (NIHSS) ≥21), we identified a significant interaction for treatment effect with thrombectomy compared to medical management (pinteraction = 0.042). CONCLUSION An increased BATMAN score was significantly associated with a higher probability of functional independence after thrombectomy than after medical management, particularly in patients with severe BAO.
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Affiliation(s)
- Cong Luo
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and MedicineUniversity of Science and Technology of ChinaHefeiChina
| | - Chunrong Tao
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and MedicineUniversity of Science and Technology of ChinaHefeiChina
| | - Rui Li
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and MedicineUniversity of Science and Technology of ChinaHefeiChina
| | - Thanh N. Nguyen
- Department of Radiology, Boston Medical CenterBoston University School of MedicineBostonMassachusettsUSA
- Department of NeurologyBoston University School of MedicineBostonMassachusettsUSA
| | - Xiaozhong Jing
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and MedicineUniversity of Science and Technology of ChinaHefeiChina
| | - Shuya Yuan
- Department of Radiology, The First Affiliated Hospital of USTC, Division of Life Sciences and MedicineUniversity of Science and Technology of ChinaHefeiChina
| | - Anmo Wang
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and MedicineUniversity of Science and Technology of ChinaHefeiChina
| | - Mohamad Abdalkader
- Department of Radiology, Boston Medical CenterBoston University School of MedicineBostonMassachusettsUSA
| | - Feiyang Gao
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and MedicineUniversity of Science and Technology of ChinaHefeiChina
| | - Lang Chen
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and MedicineUniversity of Science and Technology of ChinaHefeiChina
| | - Peng Hao
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and MedicineUniversity of Science and Technology of ChinaHefeiChina
| | - Ming Cai
- Department of NeurologyProvincial Hospital Affiliated to Anhui Medical UniversityHefeiChina
| | - Xinfeng Liu
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and MedicineUniversity of Science and Technology of ChinaHefeiChina
| | - Wei Hu
- Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and MedicineUniversity of Science and Technology of ChinaHefeiChina
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Sui Y, Chen W, Chen C, Chang Y, Bivard A, Wang P, Geng Y, Parsons M, Lin L. CTP-Defined Large Core Is a Better Predictor of Poor Outcome for Endovascular Treatment Than ASPECTS-Defined Large Core. Stroke 2024; 55:1227-1234. [PMID: 38488357 DOI: 10.1161/strokeaha.123.045091] [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: 09/05/2023] [Accepted: 01/31/2024] [Indexed: 04/24/2024]
Abstract
BACKGROUND Recent trials confirmed the effectiveness of endovascular therapy in patients with large ischemic cores. Yet the optimal neuroimaging modalities to define large core remains unclear. We tried to address this question by comparing the functional outcomes in patients receiving thrombectomy selected by either noncontrast computed tomography Alberta Stroke Program Early Computed Tomography Score (ASPECTS) or computed tomography perfusion (CTP). METHODS This study retrospectively selected patients enrolled in the International Stroke Perfusion Registry between August 2011 and April 2022. Patients with acute stroke with large vessel occlusion in anterior circulation treated with endovascular therapy were included. All received both CTP and noncontrast computed tomography. The primary outcome was defined as poor functional outcome represented by a modified Rankin Scale score of 5 to 6 at 3 months. Large cores were defined in terms of either (1) noncontrast computed tomography ASPECTS ≤5 or (2) core volume ≥70 mL on CTP. RESULTS A total of 1115 patients were included in the analysis, of which 90 patients had ASPECTS ≤5 (8.1%) and 97 patients CTP core ≥70 mL (8.7%). A fair agreement between ASPECTS and CTP with a κ value of 0.31 (0.21-0.40) was found. Compared with patients with neither CTP nor ASPECTS large cores, those with only ASPECTS-defined large cores (ie, ASPECTS ≤5; n=56) did not have a higher adjusted odds of poor outcome (29%; odds ratio, 1.84 [0.91-3.73]; P=0.089). However, patients with CTP large core but not ASPECTS-defined large core (n=63) had a higher adjusted odds of poor outcome (60%; odds ratio, 3.91 [2.01-7.60]; P<0.001). In time-stratified subgroup analysis (>6 versus ≤6 hours), ASPECTS showed no discriminative difference between ≤5 and >5 in poor outcome for patients receiving endovascular therapy within 6 hours. CONCLUSIONS CTP core ≥70 mL-defined large cores are more predictive of poor outcome than ASPECTS ≤5-defined core in endovascular therapy patients, particularly within 6 hours after stroke onset.
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Affiliation(s)
- Yi Sui
- Department of Neurology, Shenyang First People's Hospital, Shenyang Medical College Affiliated Brain Hospital, Shenyang Clinical Research Center for Neurological Diseases, China (Y.S.)
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang, China (Y.S.)
| | - Wenhuo Chen
- Zhangzhou Affiliated Hospital of Fujian Medical University, China (W.C.)
| | - Chushuang Chen
- Faculty of Health, University of Newcastle, Australia (C.C., M.P., L.L.)
| | - Yanting Chang
- School of Public Health, China Medical University, Shenyang, China (Y.C.)
| | - Andrew Bivard
- Melbourne Brain Centre, University of Melbourne, Australia (A.B.)
| | - Peng Wang
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China (P.W., Y.G.)
| | - Yu Geng
- Center for Rehabilitation Medicine, Department of Neurology, Zhejiang Provincial People's Hospital (Affiliated People's Hospital, Hangzhou Medical College), Hangzhou, China (P.W., Y.G.)
| | - Mark Parsons
- Faculty of Health, University of Newcastle, Australia (C.C., M.P., L.L.)
- South Western Clinical School, University of New South Wales, Sydney, Australia (M.P., L.L.)
| | - Longting Lin
- Faculty of Health, University of Newcastle, Australia (C.C., M.P., L.L.)
- South Western Clinical School, University of New South Wales, Sydney, Australia (M.P., L.L.)
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Lin CH, Ovbiagele B, Liebeskind DS, Saver JL, Lee M. Brain imaging prior to thrombectomy in the late window of large vessel occlusion ischemic stroke: a systematic review and meta-analysis. Neuroradiology 2024; 66:809-816. [PMID: 38427071 DOI: 10.1007/s00234-024-03324-z] [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: 08/14/2023] [Accepted: 02/24/2024] [Indexed: 03/02/2024]
Abstract
PURPOSE Optimal imaging modalities to select patients for endovascular thrombectomy (EVT) in the late window of acute ischemic stroke due to large vessel occlusions (AIS-LVO) are not known. We conducted a systematic review comparing outcomes of patients selected by non-contrast computed tomography (NCCT)/CT angiography (CTA) vs. those selected by CT perfusion (CTP) or magnetic resonance imaging (MRI) for EVT in these patients. METHODS We searched PUBMED, EMBASE, and the Cochrane Library from January 1, 2000, to July 15, 2023, to identify studies comparing outcomes of patients selected for EVT by NCCT/CTA vs. CTP or MRI in the late time window for AIS-LVO. Primary outcome was independence (mRS 0-2) at 90 days or discharge. Secondary outcomes were symptomatic intracranial hemorrhage (sICH) and mortality. We pooled data across studies based on an inverse variance method. RESULTS Six cohort studies with 4208 patients were included. Pooled results showed no significant difference in the rate of independence at 90 days or discharge (RR 0.96, 95% CI 0.88-1.03) and sICH (RR 1.26, 0.85-1.86) between patients selected by NCCT/CTA vs. CTP or MRI for EVT in the late window of AIS-LVO. However, patients selected by NCCT/CTA vs. CTP or MRI for EVT were associated with a higher risk of mortality (RR 1.21, 1.06-1.39). CONCLUSION For AIS-LVO in the late window, patients selected by NCCT/CTA compared with those selected by CTP or MRI for EVT might have a comparable rate of functional independence and sICH. Baseline NCCT/CTA may triage AIS-LVO in the late window.
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Affiliation(s)
- Chun-Hsien Lin
- Division of Neurology, Department of Internal Medicine, Ditmanson Medical Foundation, Chia-Yi Christian Hospital, Chiayi, Taiwan
| | - Bruce Ovbiagele
- Department of Neurology, University of California, San Francisco, San Francisco, CA, USA
| | - David S Liebeskind
- Comprehensive Stroke Center and Department of Neurology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Jeffrey L Saver
- Comprehensive Stroke Center and Department of Neurology, University of California, Los Angeles, Los Angeles, CA, USA
| | - Meng Lee
- Department of Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital, Chiayi Branch, Puzi, Taiwan.
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Zeng H, Zhu Q. Application of imaging modalities for endovascular thrombectomy of large core infarcts in clinical practice. Front Neurol 2024; 15:1272890. [PMID: 38665995 PMCID: PMC11043533 DOI: 10.3389/fneur.2024.1272890] [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: 08/04/2023] [Accepted: 03/13/2024] [Indexed: 04/28/2024] Open
Abstract
Four randomized controlled trials of large infarct core volume (LICV) included three imaging modalities: non-contrast CT (NCCT)-Alberta Stroke Program Early CT Score (ASPECTS), diffusion-weighted imaging (DWI)-ASPECTS, and NCCT-ASPECTS combined with CTP (CT perfusion). However, there is no clear consensus on the optimal imaging modality for endovascular thrombectomy (EVT) trials of large core infarcts. The variety and complexity of imaging modalities make it difficult to apply them in clinical practice. By familiarizing ourselves with these imaging modalities, we can better apply them in the clinic and correctly screen patients with large core infarcts in the anterior circulation who can benefit from EVT therapy.
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Affiliation(s)
| | - Qingfeng Zhu
- Neurosurgery, Second Hospital of Shanxi Medical University, Taiyuan, China
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Dong Z, Deng S, Zhang J, Chen S, Ye Z, Zhang L, Hu R, Zhong C, Liu X, Qin C. Simplified stroke imaging selection modality for endovascular thrombectomy in the extended time window: systematic review and meta-analysis. J Neurointerv Surg 2023; 16:101-106. [PMID: 36597953 PMCID: PMC10803987 DOI: 10.1136/jnis-2022-019556] [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: 08/20/2022] [Accepted: 11/16/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND The impact of imaging selection modality on clinical outcomes of endovascular thrombectomy (EVT) in the 6-24-hour time window remains undetermined. We compared the clinical outcomes of a simplified stroke imaging selection modality using non-contrast computed tomography (NCCT)±CT angiography (CTA) with using advanced CT perfusion (CTP). METHODS PubMed, Embase, Web of Science, and Cochrane Central Register of Controlled Trials were searched from inception to 1 May 2022 to compare NCCT±CTA and CTP for patient selection for EVT in late-presenting stroke with large vessel occlusions (LVO). The primary outcome was the proportion of patients achieving functional independence (modified Rankin Scale score 0-2) within 180 days. The secondary outcomes included mortality within 90 days, successful recanalization, and any intracranial hemorrhage. RESULTS A total of 3419 patients in six articles were included in this meta-analysis. There was no significant difference between NCCT±CTA (no-CTP) and CTP in functional independence either in overall or subgroup analysis. However, the mortality in the no-CTP group was higher than in the CTP group. Furthermore, within the DAWN/DEFUSE 3-like subgroup, there were no significant differences in mortality, successful recanalization, and any intracranial hemorrhage between the two groups. CONCLUSION There was no significant difference between the simplified NCCT±CTA modality and the advanced CTP modality. The use of NCCT±CTA may represent a reasonable option for selecting patients for EVT in the extended time window, especially in the absence of CTP and acute phase MRI capabilities.
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Affiliation(s)
- Zimei Dong
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
- Department of Neurology, People's Hospital of Chuxiong Yi Autonomous Prefecture, Chuxiong, Yunnan, China
| | - Shan Deng
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
- Department of Neurology, Fourth Affiliated Hospital of Guangxi Medical University, Liuzhou, Guangxi, China
| | - Jian Zhang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Shijian Chen
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Ziming Ye
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Limei Zhang
- Department of Cardiology, People's Hospital of Chuxiong Yi Autonomous Prefecture, Chuxiong, Yunnan, China
| | - Ruiting Hu
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Cai Zhong
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Xiuying Liu
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
| | - Chao Qin
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, Guangxi, China
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Bai X, Zhang Y, Sui Y. Noncontrast versus perfusion CT to select endovascular therapy in an extended time window: Systematic review/meta-analysis. J Neuroimaging 2023; 33:889-897. [PMID: 37676117 DOI: 10.1111/jon.13152] [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: 04/24/2023] [Revised: 08/06/2023] [Accepted: 08/25/2023] [Indexed: 09/08/2023] Open
Abstract
BACKGROUND AND PURPOSE The effect of noncontrast CT (NCCT) on the eligibility for endovascular therapy (EVT) in an extended time window remains to be elucidated. We sought to assess the efficacy and safety of NCCT in comparison with CT perfusion (CTP) in selecting patients with acute ischemic stroke (AIS) for EVT 6-24 hours after onset. METHODS PubMed, Embase, and Cochrane libraries were searched from inception to August 31, 2022, to identify all studies reporting 90-day outcomes of EVT in patients with AIS in an extended time window. A meta-analysis was performed for the pooled risk ratio (RR) with 95% confidence interval (CI) using a random-effects model. The primary outcome used to assess efficacy was good functional independence, defined as a modified Rankin Scale score of 0-2 at 90 days. Secondary outcomes included successful reperfusion, symptomatic intracranial hemorrhage (sICH), and mortality at 90 days. RESULTS We included four nonrandomized studies with a total of 2685 patients. The outcomes of good functional independence at 90 days (RR = 0.98; 95% CI: 0.88-1.07; I2 = 0%; p = .62), successful reperfusion (RR = 0.98; 95% CI: 0.93-1.03; I2 = 50.5%; p = .11), sICH (RR = 1.11; 95% CI: 0.55-2.21; I2 = 49.4%; p = .12), or mortality at 90 days (RR = 1.18; 95% CI: 0.99-1.40; I2 = 0%; p = .42) did not differ significantly between the two groups. CONCLUSIONS These findings suggest that NCCT is as effective as CTP in selecting patients for EVT in an extended time window.
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Affiliation(s)
- Xue Bai
- School of Public Health, China Medical University, Shenyang, China
| | - Yao Zhang
- Department of Neurology, Shenyang First People's Hospital, Shenyang Medical College Affiliated Brain Hospital, Shenyang, China
| | - Yi Sui
- School of Public Health, China Medical University, Shenyang, China
- Department of Neurology, Shenyang First People's Hospital, Shenyang Medical College Affiliated Brain Hospital, Shenyang, China
- Department of Neurology, The First Affiliated Hospital of China Medical University, Shenyang, China
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Sequeiros JM, Rodriguez-Calienes A, Chavez-Malpartida SS, Morán-Mariños C, Alvarado-Gamarra G, Malaga M, Quincho-Lopez A, Hernadez-Fernandez W, Pacheco-Barrios K, Ortega-Gutierrez S, Hoit D, Arthur AS, Alexandrov AV, Alva-Diaz C, Elijovich L. Stroke imaging modality for endovascular therapy in the extended window: systematic review and meta-analysis. J Neurointerv Surg 2023; 15:e46-e53. [PMID: 35725306 DOI: 10.1136/neurintsurg-2022-018896] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Accepted: 06/08/2022] [Indexed: 02/06/2023]
Abstract
BACKGROUND In anterior circulation large vessel occlusion (LVO) in the extended time window, the guidelines recommend advanced imaging (ADVI) to select patients for endovascular therapy (EVT). However, questions remain regarding its availability and applicability in the real world. It is unclear whether an approach to the extended window EVT that does not use ADVI would be equivalent. METHODS In April 2022, a literature search was performed to identified randomized controlled trials (RCT) and observational studies describing 90-day outcomes. We performed a meta-analysis of the proportion of aggregate using a random effect to estimate rates of functional independence, defined as modified Rankin Scale (mRS) score ≤2 at 90 days, mean mRS, mortality and symptomatic intracranial hemorrhage (sICH) stratified by imaging modality. RESULTS Four RCTs and 28 observational studies were included. The pooled proportion of functional independence among patients selected by ADVI was 44% (95% CI 39% to 48%; I2=80%) and 48% (95% CI 41% to 55%; I2=75%) with non-contrast CT/CT angiography (NCCT/CTA) (p=0.36). Mean mRS with ADVI was 2.88 (95% CI 2.36 to 3.41; I2=0.0%) and 2.79 (95% CI 2.31 to 3.27; I2=0.0%) with NCCT (p=0.79). Mortality in patients selected by ADVI was 13% (95% CI 10% to 17%; I2=81%) and 16% (95% CI 12% to 22%; I2=69%) with NCCT (p=0.29). sICH with ADVI was 4% (95% CI 3% to 7%; I2=73%) and 6% with NCCT/CTA (95% CI 4% to 8%; I2=6%, p=0.27). CONCLUSIONS Our study suggests that, in anterior circulation LVO, the rates of functional independence may be similar when patients are selected using ADVI or NCCT for EVT in the extended time window. A simplified triage protocol does not seem to increase mortality or sICH. PROTOCOL REGISTRATION NUMBER: (PROSPERO ID: CRD42021236092).
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Affiliation(s)
- Joel M Sequeiros
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Aaron Rodriguez-Calienes
- Grupo de Investigacion Neurociencia, Efectividad Clinica y Salud Publica, Universidad Científica del Sur, Lima, Peru
| | - Sandra S Chavez-Malpartida
- Facultad de Medicina Humana, Universidad Nacional Mayor de San Marcos, Lima, Peru
- Red de Eficacia Clínica y Sanitaria, REDECS, Lima, Peru
- Servicio de Neurologia, Departamento de Medicina y Oficina de Apoyo a la Docencia e Investigacion, Hospital Daniel Alcides Carrion, Callao, Peru
| | - Cristian Morán-Mariños
- Unidad de Investigacion en Bibliometria, Universidad San Ignacio de Loyola, Lima, Peru
- Servicio de Neumologia, Hospital Nacional Dos de Mayo, Lima, Peru
| | - Giancarlo Alvarado-Gamarra
- Red de Eficacia Clínica y Sanitaria, REDECS, Lima, Peru
- Departamento de Pediatria, Hospital Nacional Edgardo Rebagliati Martins, Lima, Peru
- Departamento de Pediatria, Instituto de Investigación Nutricional, Lima, Peru
| | - Marco Malaga
- Red de Eficacia Clínica y Sanitaria, REDECS, Lima, Peru
| | - Alvaro Quincho-Lopez
- Facultad de Medicina Humana, Universidad Nacional Mayor de San Marcos, Lima, Peru
| | - Wendy Hernadez-Fernandez
- Servicio de Neurologia, Departamento de Medicina y Oficina de Apoyo a la Docencia e Investigacion, Hospital Daniel Alcides Carrion, Callao, Peru
| | - Kevin Pacheco-Barrios
- Neuromodulation Center and Center for Clinical Research Learning, Spaulding Rehabilitation Hospital and Massachusetts General Hospital, Boston, Massachusetts, USA
- Vicerrectorado de Investigacion, Unidad de Investigacion para la Generacion y Síntesis de Evidencias en Salud, Universidad San Ignacio de Loyola, Lima, Peru
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Daniel Hoit
- Department of Neurosurgery, University of Tennessee Health Science Center - Semmens Murphy Clinic, Memphis, TN, USA
| | - Adam S Arthur
- Department of Neurosurgery, University of Tennessee Health Science Center - Semmens Murphy Clinic, Memphis, TN, USA
| | - Andrei V Alexandrov
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Carlos Alva-Diaz
- Grupo de Investigacion Neurociencia, Efectividad Clinica y Salud Publica, Universidad Científica del Sur, Lima, Peru
- Servicio de Neurologia, Departamento de Medicina y Oficina de Apoyo a la Docencia e Investigacion, Hospital Daniel Alcides Carrion, Callao, Peru
| | - Lucas Elijovich
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
- Department of Neurosurgery, University of Tennessee Health Science Center - Semmens Murphy Clinic, Memphis, TN, USA
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Ohta T, Satow T, Inoue M, Tanaka K, Koge J, Yoshimoto T, Hamano E, Ikedo T, Sumi M, Shimonaga K, Kushi Y, Mori H, Iihara K, Ihara M, Koga M, Toyoda K, Kataoka H. Impact on Clinical Outcomes of Changes in the Practice of Mechanical Thrombectomy due to the COVID-19 Pandemic. JOURNAL OF NEUROENDOVASCULAR THERAPY 2022; 16:498-502. [PMID: 37502202 PMCID: PMC10370824 DOI: 10.5797/jnet.oa.2022-0018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/13/2022] [Indexed: 07/29/2023]
Abstract
Objective To evaluate whether changes in the practice of mechanical thrombectomy could affect the clinical outcomes during the coronavirus disease (COVID-19) pandemic. Methods Patients who underwent mechanical thrombectomy from April 2019 to March 2021 for anterior circulation proximal large artery occlusion in our institute were divided into two groups of pre- and post-COVID-19, with April 2020 assumed to be the start of the COVID-19 era with the first declaration of a state of emergency. We compared patient characteristics, proportions of patient selection depending on rapid processing of perfusion and diffusion (RAPID) CT perfusion, outcomes including treatment variables such as time and reperfusion status, and patient independence at 3 months. Results Data for 112 patients (median age, 79 years; 44 females) were included in the analysis. A total of 50 patients were assigned to the pre-COVID-19 group (45%). More patients were selected with RAPID CT perfusion in the post-COVID-19 compared with the pre-COVID-19 (69% vs. 16%; P <0.001). Treatment details and clinical outcomes did not differ between the groups, including the door-to-puncture time (median [interquartile range], 66 [54-90] min vs. 74 [61-89] min; P = 0.15), proportions of significant reperfusion (82% vs. 87%; P = 0.60), and modified Rankin scale score of ≤2 at 3 months (46% vs. 45%; P >0.99). Multivariate logistic regression analysis for the clinical outcome of modified Rankin scale score of ≤2 at 3 months was performed and included the following factors: age, sex, the onset-to-door time, significant reperfusion, and pre- and post-COVID-19. The treatment period did not influence the outcomes (post-COVID-19 group, odds ratio, 0.79; 95% confidence interval, 0.34-1.85, P = 0.59). Conclusion In the setting of a limited access to emergency MRI during the COVID-19 pandemic, RAPID CT perfusion was performed significantly more often. Changes in the practice of mechanical thrombectomy with the protected code stroke did not bring the different level of treatment and clinical outcomes as before.
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Affiliation(s)
- Tsuyoshi Ohta
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Tetsu Satow
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Manabu Inoue
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kanta Tanaka
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Junpei Koge
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Takeshi Yoshimoto
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Eika Hamano
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Taichi Ikedo
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Masatake Sumi
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Koji Shimonaga
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Yuji Kushi
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Hisae Mori
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Koji Iihara
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Masafumi Ihara
- Department of Neurology, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Masatoshi Koga
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Hiroharu Kataoka
- Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
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Jadhav AP, Goyal M, Ospel J, Campbell BC, Majoie CBLM, Dippel DW, White P, Bracard S, Guillemin F, Davalos A, Hill MD, Demchuk AM, Brown S, Saver JL, Muir KW, Mitchell P, Desai SM, Jovin TG. Thrombectomy With and Without Computed Tomography Perfusion Imaging in the Early Time Window: A Pooled Analysis of Patient-Level Data. Stroke 2022; 53:1348-1353. [PMID: 34844423 DOI: 10.1161/strokeaha.121.034331] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
BACKGROUND The optimal imaging paradigm for endovascular thrombectomy (EVT) patient selection in early time window (0-6 hours) treated acute ischemic stroke patients remains uncertain. We aimed to compare post-EVT outcomes between patients who underwent prerandomization basic (noncontrast computed tomography [CT], CT angiography only) versus additional advanced imaging (computed tomography perfusion [CTP] imaging) and to determine the association of performance of prerandomization CTP imaging with clinical outcomes. METHODS The HERMES collaboration (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) pooled patient-level data from randomized controlled trials comparing EVT with usual care for acute ischemic stroke due to anterior circulation large vessel occlusion. Good functional outcome, defined as modified Rankin Scale score 0 to 2 at 90 days, was compared between randomized patients with and without CTP baseline imaging. Univariable and multivariable binary logistic regression analysis was performed to determine the association of baseline CTP imaging and good functional outcome. RESULTS We analyzed 1348 patients 610 (45.3%) of whom underwent CTP prerandomization. The benefit of EVT compared with best medical management was maintained irrespective of the baseline imaging paradigm (90-day modified Rankin Scale score 0-2 in EVT versus control patients: with CTP: 46.0% (137/298) versus 28.9% (88/305), without CTP: 44.1% (162/367) versus 27.3% (100/366). Performance of CTP baseline imaging compared with baseline noncontrast CT and CT angiography only yielded similar rates of good outcome (odds ratio, 1.05 [95% CI, 0.82-1.33], adjusted odds ratio, 1.04, [95% CI, 0.80-1.35]). CONCLUSIONS Rates of good functional outcome were similar among patients in whom CTP was or was not performed, and EVT treatment effect in the 0- to 6-hour time window was similar in patients with and without baseline CTP imaging.
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Affiliation(s)
| | - Mayank Goyal
- Department of Radiology (M.G., J.O.), University of Calgary, Foothills Hospital, AB, Canada
| | - Johanna Ospel
- Department of Radiology (M.G., J.O.), University of Calgary, Foothills Hospital, AB, Canada
| | - Bruce C Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre (B.C.C.), University of Melbourne, Parkville, VIC, Australia
| | - Charles B L M Majoie
- Department of Radiology & Nuclear Medicine, Amsterdam University Medical Centers, location AMC, the Netherlands (C.B.L.M.M.)
| | - Diederik W Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands (D.W.D.)
| | - Phil White
- Department of Radiology, Royal Melbourne Hospital (P.M.), University of Melbourne, Parkville, VIC, Australia.,Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom (P.W.)
| | | | | | - Antoni Davalos
- Department of Neuroscience, University Autònoma de Barcelona, Spain (A.D.)
| | - Michael D Hill
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine (M.D.H., A.M.D.), University of Calgary, Foothills Hospital, AB, Canada
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, Hotchkiss Brain Institute, Cumming School of Medicine (M.D.H., A.M.D.), University of Calgary, Foothills Hospital, AB, Canada
| | - Scott Brown
- Altair Biostatistics, St Louis Park, MN (S.B.)
| | - Jeffrey L Saver
- David Geffen School of Medicine, University of California, Los Angeles (J.L.S.)
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, United Kingdom (K.W.M.)
| | | | - Shashvat M Desai
- Barrow Neurological Institute, Phoenix, Arizona (A.P.J., S.M.D.)
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10
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Shchehlov D, Konotopchyk S, Pastushyn O. Clinical protocol of the ischemic stroke patients treatment. UKRAINIAN INTERVENTIONAL NEURORADIOLOGY AND SURGERY 2022. [DOI: 10.26683/2786-4855-2021-3(37)-14-56] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Today in Ukraine there is no single standardized protocol for the treatment of patients in the acute period of ischemic stroke using modern methods of diagnosis and treatment, which include thrombolytic therapy and endovascular treatment. This protocol was created and implemented in Scientific-practical Center of endovascular neuroradiology, NAMS of Ukraine and is based on the latest recommendations of AHA/ASA and ESO, as well as registers of patients with ischemic stroke. The main purpose of this publication is the creation and implementation of «instructions» for the diagnosis and selection of objective tactics for treating patients in the acute period of ischemic stroke.
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11
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Thon JM, Jovin TG. Imaging as a Selection Tool for Thrombectomy in Acute Ischemic Stroke: Pathophysiologic Considerations. Neurology 2021; 97:S52-S59. [PMID: 34785604 DOI: 10.1212/wnl.0000000000012793] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Large vessel occlusion (LVO) stroke represents a stroke subset associated with the highest morbidity and mortality. Multiple prospective randomized trials have shown that thrombectomy, alone or in conjunction with IV thrombolysis, is highly effective in reestablishing cerebral perfusion and improving clinical outcomes. In unselected patients and especially in patients with poor collaterals, the benefit of reperfusion therapy is exquisitely time sensitive; the earlier thrombectomy is started, the lower the likelihood of disability or death. Understanding both the pathophysiologic underpinnings and the modifying factors of this strong time-to-treatment effect demonstrated in numerous randomized clinical trials is important for implementation of intrahospital workflow measures to maximize time efficiency of thrombectomy. Reducing delays in reperfusion therapy initiation has become a priority in acute stroke care, and therefore a thorough understanding of the main systems-based factors responsible for these delays is critical. Because the time spent evaluating the patient in the emergency department, which typically includes neuroimaging studies performed in scanners remote from the angiography suite, represents the main source of delays in thrombectomy initiation, the direct to angiography (DTA) model has emerged as a means to substantially reduce treatment times and is being instituted at an increasing number of thrombectomy centers across the world. The aim of this report is to introduce DTA as an emerging stroke care paradigm for patients with suspicion of LVO stroke, review results from studies evaluating its feasibility and impact on outcomes, describe current barriers to its more widespread adoption, and propose potential solutions to overcoming these barriers.
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Affiliation(s)
- Jesse M Thon
- From Cooper Neurological Institute and Cooper Medical School of Rowan University, Camden, NJ
| | - Tudor G Jovin
- From Cooper Neurological Institute and Cooper Medical School of Rowan University, Camden, NJ.
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12
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Requena M, Ren Z, Ribo M. Direct Transfer to Angiosuite in Acute Stroke: Why, When, and How? Neurology 2021; 97:S34-S41. [PMID: 34785602 DOI: 10.1212/wnl.0000000000012799] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2021] [Accepted: 05/05/2021] [Indexed: 02/04/2023] Open
Abstract
Time to reperfusion is one of the strongest predictors of functional outcome in acute stroke due to a large vessel occlusion (LVO). Direct transfer to angiography suite (DTAS) protocols have shown encouraging results in reducing in-hospital delays. DTAS allows bypassing of conventional imaging in the emergency room by ruling out an intracranial hemorrhage or a large established infarct with imaging performed before transfer to the thrombectomy-capable center in the angiography suite using flat-panel CT (FP-CT). The rate of patients with stroke code primarily admitted to a comprehensive stroke center with a large ischemic established lesion is <10% within 6 hours from onset and remains <20% among patients with LVO or transferred from a primary stroke center. At the same time, stroke severity is an acceptable predictor of LVO. Therefore, ideal DTAS candidates are patients admitted in the early window with severe symptoms. The main difference between protocols adopted in different centers is the inclusion of FP-CT angiography to confirm an LVO before femoral puncture. While some centers advocate for FP-CT angiography, others favor additional time saving by directly assessing the presence of LVO with an angiogram. The latter, however, leads to unnecessary arterial punctures in patients with no LVO (3%-22% depending on selection criteria). Independently of these different imaging protocols, DTAS has been shown to be effective and safe in improving in-hospital workflow, achieving a reduction of door-to-puncture time as low as 16 minutes without safety concerns. The impact of DTAS on long-term functional outcomes varies between published studies, and randomized controlled trials are warranted to examine the benefit of DTAS.
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Affiliation(s)
- Manuel Requena
- From the Stroke Unit (M.R., M.R.), Neurology Department, Vall D'Hebron University Hospital, Barcelona, Spain; and Department of Neurosurgery (Z.R.), Cleveland Clinic Florida, Weston
| | - Zeguang Ren
- From the Stroke Unit (M.R., M.R.), Neurology Department, Vall D'Hebron University Hospital, Barcelona, Spain; and Department of Neurosurgery (Z.R.), Cleveland Clinic Florida, Weston
| | - Marc Ribo
- From the Stroke Unit (M.R., M.R.), Neurology Department, Vall D'Hebron University Hospital, Barcelona, Spain; and Department of Neurosurgery (Z.R.), Cleveland Clinic Florida, Weston.
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13
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Nguyen TN, Abdalkader M, Nagel S, Qureshi MM, Ribo M, Caparros F, Haussen DC, Mohammad MH, Sheth SA, Ortega-Gutierrez S, Siegler JE, Zaidi S, Olive-Gadea M, Henon H, Möhlenbruch MA, Castonguay AC, Nannoni S, Kaesmacher J, Puri AS, Seker F, Farooqui M, Salazar-Marioni S, Kuhn AL, Kaliaev A, Farzin B, Boisseau W, Masoud HE, Lopez CY, Rana A, Kareem SA, Sathya A, Klein P, Kassem MW, Ringleb PA, Cordonnier C, Gralla J, Fischer U, Michel P, Jovin TG, Raymond J, Zaidat OO, Nogueira RG. Noncontrast Computed Tomography vs Computed Tomography Perfusion or Magnetic Resonance Imaging Selection in Late Presentation of Stroke With Large-Vessel Occlusion. JAMA Neurol 2021; 79:22-31. [PMID: 34747975 PMCID: PMC8576630 DOI: 10.1001/jamaneurol.2021.4082] [Citation(s) in RCA: 116] [Impact Index Per Article: 38.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Question In patients with proximal anterior circulation occlusion stroke presenting in the extended window, are rates of favorable outcomes at 90 days comparable in the patients selected for thrombectomy with noncontrast computed tomography vs patients selected with computed tomography perfusion or magnetic resonance imaging? Findings In a multicenter cohort of 1604 patients in the extended window with large-vessel occlusion, patients selected by noncontrast computed tomography had comparable clinical and safety outcomes with patients selected by computed tomography perfusion or magnetic resonance imaging. Meaning These findings suggest noncontrast computed tomography alone may be used as an alternative to advanced imaging in selecting patients with late-presenting large-vessel occlusion for mechanical thrombectomy. Importance Advanced imaging for patient selection in mechanical thrombectomy is not widely available. Objective To compare the clinical outcomes of patients selected for mechanical thrombectomy by noncontrast computed tomography (CT) vs those selected by computed tomography perfusion (CTP) or magnetic resonance imaging (MRI) in the extended time window. Design, Setting, and Participants This multinational cohort study included consecutive patients with proximal anterior circulation occlusion stroke presenting within 6 to 24 hours of time last seen well from January 2014 to December 2020. This study was conducted at 15 sites across 5 countries in Europe and North America. The duration of follow-up was 90 days from stroke onset. Exposures Computed tomography with Alberta Stroke Program Early CT Score, CTP, or MRI. Main Outcomes and Measures The primary end point was the distribution of modified Rankin Scale (mRS) scores at 90 days (ordinal shift). Secondary outcomes included the rates of 90-day functional independence (mRS scores of 0-2), symptomatic intracranial hemorrhage, and 90-day mortality. Results Of 2304 patients screened for eligibility, 1604 patients were included, with a median (IQR) age of 70 (59-80) years; 848 (52.9%) were women. A total of 534 patients were selected to undergo mechanical thrombectomy by CT, 752 by CTP, and 318 by MRI. After adjustment of confounders, there was no difference in 90-day ordinal mRS shift between patients selected by CT vs CTP (adjusted odds ratio [aOR], 0.95 [95% CI, 0.77-1.17]; P = .64) or CT vs MRI (aOR, 0.95 [95% CI, 0.8-1.13]; P = .55). The rates of 90-day functional independence (mRS scores 0-2 vs 3-6) were similar between patients selected by CT vs CTP (aOR, 0.90 [95% CI, 0.7-1.16]; P = .42) but lower in patients selected by MRI than CT (aOR, 0.79 [95% CI, 0.64-0.98]; P = .03). Successful reperfusion was more common in the CT and CTP groups compared with the MRI group (474 [88.9%] and 670 [89.5%] vs 250 [78.9%]; P < .001). No significant differences in symptomatic intracranial hemorrhage (CT, 42 [8.1%]; CTP, 43 [5.8%]; MRI, 15 [4.7%]; P = .11) or 90-day mortality (CT, 125 [23.4%]; CTP, 159 [21.1%]; MRI, 62 [19.5%]; P = .38) were observed. Conclusions and Relevance In patients undergoing proximal anterior circulation mechanical thrombectomy in the extended time window, there were no significant differences in the clinical outcomes of patients selected with noncontrast CT compared with those selected with CTP or MRI. These findings have the potential to widen the indication for treating patients in the extended window using a simpler and more widespread noncontrast CT–only paradigm.
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Affiliation(s)
- Thanh N Nguyen
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts.,Department of Radiology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Mohamad Abdalkader
- Department of Radiology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Simon Nagel
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Muhammad M Qureshi
- Department of Radiology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts.,Department of Radiation Oncology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Marc Ribo
- Stroke Unit, Department of Neurology, Hospital Universitario Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Francois Caparros
- University Lille, Inserm, Centre Hospitalier Universitaire de Lille, U1172, LilNCog-Lille Neuroscience & Cognition, Lille, France
| | - Diogo C Haussen
- Department of Neurology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia
| | - Mahmoud H Mohammad
- Department of Neurology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia
| | - Sunil A Sheth
- Department of Neurology, McGovern Medical School at UTHealth, Houston, Texas
| | | | - James E Siegler
- Department of Neurology, Cooper University Hospital, Camden, New Jersey
| | - Syed Zaidi
- Department of Neurology, University of Toledo, Toledo, Ohio
| | - Marta Olive-Gadea
- Stroke Unit, Department of Neurology, Hospital Universitario Vall d'Hebron, Universitat Autonoma de Barcelona, Barcelona, Spain
| | - Hilde Henon
- University Lille, Inserm, Centre Hospitalier Universitaire de Lille, U1172, LilNCog-Lille Neuroscience & Cognition, Lille, France
| | - Markus A Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Stefania Nannoni
- Stroke Center, Neurology Service, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, Bern, Switzerland.,Institute of Diagnostic, Interventional and Pediatric Radiology, University Hospital Bern, Inselspital, Bern, Switzerland
| | - Ajit S Puri
- Neurointerventional Radiology, Department of Radiology, University of Massachusetts, Worcester, Massachusetts
| | - Fatih Seker
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | | | | | - Anna L Kuhn
- Neurointerventional Radiology, Department of Radiology, University of Massachusetts, Worcester, Massachusetts
| | - Artem Kaliaev
- Department of Radiology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Behzad Farzin
- Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
| | - William Boisseau
- Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
| | - Hesham E Masoud
- Department of Neurology, SUNY Upstate Medical University Hospital, Syracuse, New York
| | - Carlos Ynigo Lopez
- Department of Neurology, SUNY Upstate Medical University Hospital, Syracuse, New York
| | - Ameena Rana
- Department of Neurology, Cooper University Hospital, Camden, New Jersey
| | - Samer Abdul Kareem
- Neuroscience and Stroke Program, Bon Secours Mercy Health St Vincent Hospital, Toledo, Ohio
| | - Anvitha Sathya
- Department of Neurology, Boston University School of Medicine, Boston, Massachusetts
| | - Piers Klein
- Department of Radiology, Boston Medical Center, Boston University School of Medicine, Boston, Massachusetts
| | - Mohammad W Kassem
- Neuroscience and Stroke Program, Bon Secours Mercy Health St Vincent Hospital, Toledo, Ohio
| | - Peter A Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Charlotte Cordonnier
- University Lille, Inserm, Centre Hospitalier Universitaire de Lille, U1172, LilNCog-Lille Neuroscience & Cognition, Lille, France
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Bern, University of Bern, Bern, Switzerland.,Department of Neurology, University Hospital Basel, University of Basel, Switzerland
| | - Patrik Michel
- Stroke Center, Neurology Service, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Tudor G Jovin
- Department of Neurology, Cooper University Hospital, Camden, New Jersey
| | - Jean Raymond
- Interventional Neuroradiology, Centre Hospitalier de l'Université de Montréal, Montréal, Quebec, Canada
| | - Osama O Zaidat
- Neuroscience and Stroke Program, Bon Secours Mercy Health St Vincent Hospital, Toledo, Ohio
| | - Raul G Nogueira
- Department of Neurology, Grady Memorial Hospital, Emory University School of Medicine, Atlanta, Georgia
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14
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Bouslama M, Haussen DC, Rodrigues G, Barreira C, Frankel M, Nogueira RG. Novel selection paradigms for endovascular stroke treatment in the extended time window. J Neurol Neurosurg Psychiatry 2021; 92:1152-1157. [PMID: 34117100 DOI: 10.1136/jnnp-2020-325284] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2020] [Accepted: 05/31/2021] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND PURPOSE The optimal selection methodology for stroke thrombectomy beyond 6 hours remains to be established. METHODS Review of a prospectively collected database of thrombectomy patients with anterior circulation strokes, adequate CT perfusion (CTP) maps, National Institute of Health Stroke Scale (NIHSS)≥10 and presenting beyond 6 hours from January 2014 to October 2018. Patients were categorised according to five selection paradigms: DAWN clinical-core mismatch (DAWN-CCM): between age-adjusted NIHSS and CTP core, DEFUSE 3 perfusion imaging mismatch (DEFUSE-3-PIM): between CTP-derived perfusion defect (Tmax >6 s lesion) and ischaemic core volumes and three non-contrast CT Alberta Stroke Program Early CT Score (ASPECTS)-based criteria: age-adjusted clinical-ASPECTS mismatch (aCAM): between age-adjusted NIHSS and ASPECTS, eloquence-adjusted clinical ASPECTS mismatch (eCAM): ASPECTS 6-10 and non-involvement of the right M6 and left M4 areas and standard clinical ASPECTS mismatch (sCAM): ASPECTS 6-10. RESULTS 310 patients underwent analysis. DEFUSE-3-PIM had the highest proportion of qualifying patients followed by sCAM, eCAM, aCAM and DAWN-CCM (93.5%, 92.6%, 90.6%, 90% and 84.5%, respectively). Patients meeting aCAM, eCAM, sCAM and DAWN-CCM criteria had higher rates of 90-day good outcome compared with their non-qualifying counterparts(43.2% vs 12%,p=0.002; 42.4% vs 17.4%, p=0.02; 42.4% vs 11.2%, p=0.009; and 43.7% vs 20.5%, p=0.007, respectively). There was no difference between patients meeting DEFUSE-3-PIM criteria versus not(40.8% vs 31.3%,p=0.45). In multivariate analysis, all selection modalities except for DEFUSE-3-PIM were independently associated with 90-day good outcome. CONCLUSIONS ASPECTS-based selection paradigms for late presenting and wake-up strokes ET have comparable proportions of qualifying patients and similar 90-day functional outcomes as DAWN-CCM and DEFUSE-3-PIM. They also might lead to better outcome discrimination. These could represent a potential alternative for centres where access to advanced imaging is limited.
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Affiliation(s)
- Mehdi Bouslama
- Neurology, Emory University, Atlanta, Georgia, USA.,Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA, USA
| | - Diogo C Haussen
- Neurology, Emory University, Atlanta, Georgia, USA.,Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA, USA
| | - Gabriel Rodrigues
- Neurology, Emory University, Atlanta, Georgia, USA.,Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA, USA
| | - Clara Barreira
- Neurology, Emory University, Atlanta, Georgia, USA.,Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA, USA
| | - Michael Frankel
- Neurology, Emory University, Atlanta, Georgia, USA.,Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA, USA
| | - Raul G Nogueira
- Neurology, Emory University, Atlanta, Georgia, USA .,Marcus Stroke and Neuroscience Center, Grady Memorial Hospital, Atlanta, GA, USA
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15
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Wang T, Chen L, Jin X, Yuan Y, Zhang Q, Shao C, Lu J. CT perfusion based ASPECTS improves the diagnostic performance of early ischemic changes in large vessel occlusion. BMC Med Imaging 2021; 21:67. [PMID: 33845791 PMCID: PMC8040219 DOI: 10.1186/s12880-021-00593-5] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 03/25/2021] [Indexed: 11/23/2022] Open
Abstract
Background ASPECTS scoring method varies, but which one is most suitable for predicting the prognosis still unclear. We aimed to evaluate the diagnostic performance of Automated (Auto)-, noncontrast CT (NCCT)- and CT perfusion (CTP) -ASPECTS for early ischemic changes (EICs) in acute ischemic stroke patients with large vessel occlusion (LVO) and to explore which scoring method is most suitable for predicting the clinical outcome. Methods Eighty-one patients with anterior circulation LVO were retrospectively enrolled and grouped as having a good (0–2) or poor (3–6) clinical outcome using a 90-day modified Rankin Scale score. Clinical characteristics and perfusion parameters were compared between the patients with good and poor outcomes. Differences in scores obtained with the three scoring methods were assessed. Diagnosis performance and receiver operating characteristic (ROC) curves were used to evaluate the value of the three ordinal or dichotomized ASPECTS methods for predicting the clinical outcome. Results Sixty-three patients were finally included, with 36 (57.1%) patients having good clinical outcome. Significant differences were observed in the ordinal or dichotomized Auto-, NCCT- and CTP-ASPECTS between the patients with good and poor clinical outcomes (all p < 0.01). The areas under the curves (AUCs) of the ordinal and dichotomized CTP-ASPECTS were higher than that of the other two methods (all p < 0.01), but the AUCs of the Auto-ASPECTS was similar to that of the NCCT-ASPECTS (p > 0.05). Conclusions The CTP-ASPECTS is superior to the Auto- and NCCT-ASPECTS in detecting EICs in LVO. CTP-ASPECTS with a cutoff value of 6 is a good predictor of the clinical outcome at 90-day follow-up.
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Affiliation(s)
- Tiegong Wang
- Department of Radiology, Changhai Hospital of Shanghai, Navy Medical University (Second Military Medical University), No. 168 Changhai Road, Shanghai, 200433, China
| | - Luguang Chen
- Department of Radiology, Changhai Hospital of Shanghai, Navy Medical University (Second Military Medical University), No. 168 Changhai Road, Shanghai, 200433, China
| | - Xianglan Jin
- Department of Cardiac Surgery, Shanghai Tenth People's Hospital, Tongji University School of Medicine, No. 301 Yanchang Middle Road, Shanghai, 200072, China
| | - Yuan Yuan
- Department of Radiology, Changhai Hospital of Shanghai, Navy Medical University (Second Military Medical University), No. 168 Changhai Road, Shanghai, 200433, China
| | - Qianwen Zhang
- Department of Radiology, Changhai Hospital of Shanghai, Navy Medical University (Second Military Medical University), No. 168 Changhai Road, Shanghai, 200433, China
| | - Chengwei Shao
- Department of Radiology, Changhai Hospital of Shanghai, Navy Medical University (Second Military Medical University), No. 168 Changhai Road, Shanghai, 200433, China.
| | - Jianping Lu
- Department of Radiology, Changhai Hospital of Shanghai, Navy Medical University (Second Military Medical University), No. 168 Changhai Road, Shanghai, 200433, China.
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16
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Bouslama M, Barreira CM, Haussen DC, Rodrigues GM, Pisani L, Frankel MR, Nogueira RG. Endovascular reperfusion outcomes in patients with a stroke and low ASPECTS is highly dependent on baseline infarct volumes. J Neurointerv Surg 2021; 14:117-121. [PMID: 33722970 DOI: 10.1136/neurintsurg-2020-017184] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2020] [Revised: 02/12/2021] [Accepted: 02/13/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND Patients with large vessel occlusion stroke (LVOS) and a low Alberta Stroke Program Early CT Score (ASPECTS) are often not offered endovascular therapy (ET) as they are thought to have a poor prognosis. OBJECTIVE To compare the outcomes of patients with low and high ASPECTS undergoing ET based on baseline infarct volumes. METHODS Review of a prospectively collected endovascular database at a tertiary care center between September 2010 and March 2020. All patients with anterior circulation LVOS and interpretable baseline CT perfusion (CTP) were included. Subjects were divided into groups with low ASPECTS (0-5) and high ASPECTS (6-10) and subsequently into limited and large CTP-core volumes (cerebral blood flow 30% >70 cc). The primary outcome measure was the difference in rates of 90-day good outcome as defined by a modified Rankin Scale (mRS) score of 0 to 2 across groups. RESULTS 1248 patients fit the inclusion criteria. 125 patients had low ASPECTS, of whom 16 (12.8%) had a large core (LC), whereas 1123 patients presented with high ASPECTS, including 29 (2.6%) patients with a LC. In the category with a low ASPECTS, there was a trend towards lower rates of functional independence (90-day modified Rankin Scale (mRS) score 0-2) in the LC group (18.8% vs 38.9%, p=0.12), which became significant after adjusting for potential confounders in multivariable analysis (aOR=0.12, 95% CI 0.016 to 0.912, p=0.04). Likewise, LC was associated with significantly lower rates of functional independence (31% vs 51.9%, p=0.03; aOR=0.293, 95% CI 0.095 to 0.909, p=0.04) among patients with high ASPECTS. CONCLUSIONS Outcomes may vary significantly in the same ASPECTS category depending on infarct volume. Patients with ASPECTS ≤5 but baseline infarct volumes ≤70 cc may achieve independence in nearly 40% of the cases and thus should not be excluded from treatment.
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Affiliation(s)
- Mehdi Bouslama
- Department of Neurology, Emory University, Atlanta, Georgia, USA
| | - Clara M Barreira
- Department of Neurology, Neurosurgery and Radiology, Emory University, Atlanta, Georgia, USA
| | - Diogo C Haussen
- Department of Neurology, Neurosurgery and Radiology, Emory University, Atlanta, Georgia, USA
| | | | - Leonardo Pisani
- Department of Radiology, Georgetown University Medical Center, Washington, District of Columbia, USA
| | | | - Raul G Nogueira
- Department of Neurology and Interventional Neuroradiology, Emory University, Atlanta, Georgia, USA
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Cappellari M, Saia V, Pracucci G, Sallustio F, Gandini R, Nappini S, Nencini P, Vallone S, Zini A, Bigliardi G, Granata F, Grillo F, Cioni S, Tassi R, Bergui M, Cerrato P, Saletti A, De Vito A, Gasparotti R, Magoni M, Taglialatela F, Ruggiero M, Longoni M, Castellan L, Malfatto L, Menozzi R, Castellini P, Cosottini M, Mancuso M, Comai A, Franchini E, Lozupone E, Della Marca G, Ciceri EFM, Bonetti B, Zampieri P, Inzitari D, Mangiafico S, Toni D. Functional and radiological outcomes after bridging therapy versus direct thrombectomy in stroke patients with unknown onset: Bridging therapy versus direct thrombectomy in unknown onset stroke patients with 10-point ASPECTS. Eur J Neurol 2020; 28:209-219. [PMID: 32924246 DOI: 10.1111/ene.14529] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2020] [Revised: 09/03/2020] [Accepted: 09/05/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND AND PURPOSE The aim was to assess functional and radiological outcomes after bridging therapy (intravenous thrombolysis plus mechanical thrombectomy) versus direct mechanical thrombectomy (MT) in unknown onset stroke patients. METHODS A cohort study was conducted on prospectively collected data from unknown onset stroke patients who received endovascular procedures at ≤6 h from symptom recognition or awakening time. RESULTS Of the 349 patients with a 10-point Alberta Stroke Program Early Computed Tomography Score (ASPECTS), 248 received bridging and 101 received direct MT. Of the 134 patients with 6-9-point ASPECTS, 123 received bridging and 111 received direct MT. Each patient treated with bridging was propensity score matched with a patient treated with direct MT for age, sex, study period, pre-stroke disability, stroke severity, type of stroke onset, symptom recognition to groin time (or awakening to groin time), ASPECTS and procedure time. In the two matched groups with 10-point ASPECTS (n = 73 vs. n = 73), bridging was associated with higher rates of excellent outcome (46.6% vs. 28.8%; odds ratio 2.302, 95% confidence interval 1.010-5.244) and successful recanalization (83.6% vs. 63%; odds ratio 3.028, 95% confidence interval 1.369-6.693) compared with direct MT; no significant association was found between bridging and direct MT with regard to rate of symptomatic intracerebral hemorrhage (0% vs. 1.4%). In the two matched groups with 6-9-point ASPECTS (n = 45 vs. n = 45), no significant associations were found between bridging and direct MT with regard to rates of excellent functional outcome (44.4% vs. 31.1%), successful recanalization (73.3% vs. 76.5%) and symptomatic intracerebral hemorrhage (0% vs. 0%). CONCLUSIONS Bridging at ≤ 6 h of symptom recognition or awakening time was associated with better functional and radiological outcomes in unknown onset stroke patients with 10-point ASPECTS.
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Affiliation(s)
- M Cappellari
- Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - V Saia
- Santa Corona Hospital, Pietra Ligure, Italy
| | | | | | - R Gandini
- Policlinico Tor Vergata, Roma, Italy
| | - S Nappini
- Careggi University Hospital, Firenze, Italy
| | - P Nencini
- Careggi University Hospital, Firenze, Italy
| | - S Vallone
- Ospedale Civile S. Agostino-Estense-University Hospital, Modena, Italy
| | - A Zini
- IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
| | - G Bigliardi
- Ospedale Civile S. Agostino-Estense-University Hospital, Modena, Italy
| | - F Granata
- Policlinico G. Martino, Messina, Italy
| | - F Grillo
- Policlinico G. Martino, Messina, Italy
| | - S Cioni
- Ospedale S. Maria delle Scotte-University Hospital, Siena, Italy
| | - R Tassi
- Ospedale S. Maria delle Scotte-University Hospital, Siena, Italy
| | - M Bergui
- Città della Salute e della Scienza-Molinette, Torino, Italy
| | - P Cerrato
- Città della Salute e della Scienza-Molinette, Torino, Italy
| | - A Saletti
- Arcispedale S. Anna-University Hospital, Ferrara, Italy
| | - A De Vito
- Arcispedale S. Anna-University Hospital, Ferrara, Italy
| | | | | | - F Taglialatela
- IRCCS Istituto delle Scienze Neurologiche, Bologna, Italy
| | | | | | | | | | - R Menozzi
- Ospedale Universitario, Parma, Italy
| | | | | | | | - A Comai
- Ospedale Provinciale, Bolzano, Italy
| | | | | | | | - E F M Ciceri
- Fondazione IRCSS-Istituto Neurologico Carlo Besta, Milano, Italy
| | - B Bonetti
- Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - P Zampieri
- Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | | | | | - D Toni
- Sapienza University Hospital, Roma, Italy
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18
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Lopez-Rivera V, Abdelkhaleq R, Yamal JM, Singh N, Savitz SI, Czap AL, Alderazi Y, Chen PR, Grotta JC, Blackburn S, Spiegel G, Dannenbaum MJ, Wu TC, Yoo AJ, McCullough LD, Sheth SA. Impact of Initial Imaging Protocol on Likelihood of Endovascular Stroke Therapy. Stroke 2020; 51:3055-3063. [DOI: 10.1161/strokeaha.120.030122] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose:
Noncontrast head CT and CT perfusion (CTP) are both used to screen for endovascular stroke therapy (EST), but the impact of imaging strategy on likelihood of EST is undetermined. Here, we examine the influence of CTP utilization on likelihood of EST in patients with large vessel occlusion (LVO).
Methods:
We identified patients with acute ischemic stroke at 4 comprehensive stroke centers. All 4 hospitals had 24/7 CTP and EST capability and were covered by a single physician group (Neurology, NeuroIntervention, NeuroICU). All centers performed noncontrast head CT and CT angiography in the initial evaluation. One center also performed CTP routinely with high CTP utilization (CTP-H), and the others performed CTP optionally with lower utilization (CTP-L). Primary outcome was likelihood of EST. Multivariable logistic regression was used to determine whether facility type (CTP-H versus CTP-L) was associated with EST adjusting for age, prestroke mRS, National Institutes of Health Stroke Scale, Alberta Stroke Program Early CT Score, LVO location, time window, and intravenous tPA (tissue-type plasminogen activator).
Results:
Among 3107 patients with acute ischemic stroke, 715 had LVO, of which 403 (56%) presented to CTP-H and 312 (44%) presented to CTP-L. CTP utilization among LVO patients was greater at CTP-H centers (72% versus 18%, CTP-H versus CTP-L,
P
<0.01). In univariable analysis, EST rates for patients with LVO were similar between CTP-H versus CTP-L (46% versus 49%). In multivariable analysis, patients with LVO were less likely to undergo EST at CTP-H (odds ratio, 0.59 [0.41–0.85]). This finding was maintained in multiple patient subsets including late time window, anterior circulation LVO, and direct presentation patients. Ninety-day functional independence (odds ratio, 1.04 [0.70–1.54]) was not different, nor were rates of post-EST PH-2 hemorrhage (1% versus 1%).
Conclusions:
We identified an increased likelihood for undergoing EST in centers with lower CTP utilization, which was not associated with worse clinical outcomes or increased hemorrhage. These findings suggest under-treatment bias with routine CTP.
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Affiliation(s)
- Victor Lopez-Rivera
- Department of Neurology (V.L.-R., R.A., S.I.S., A.L.C., Y.A., G.S., T.-C.W., L.D.M., S.A.S.)
| | - Rania Abdelkhaleq
- Department of Neurology (V.L.-R., R.A., S.I.S., A.L.C., Y.A., G.S., T.-C.W., L.D.M., S.A.S.)
| | - Jose-Miguel Yamal
- School of Public Health (J.-M.Y., N.S.), UTHealth, Houston, TX
- Institute for Stroke and Cerebrovascular Disease (J.-M.Y., S.I.S., A.L.C., Y.A., P.R.C., J.C.G., S.B., S.A.S.), UTHealth, Houston, TX
| | - Noopur Singh
- School of Public Health (J.-M.Y., N.S.), UTHealth, Houston, TX
| | - Sean I. Savitz
- Department of Neurology (V.L.-R., R.A., S.I.S., A.L.C., Y.A., G.S., T.-C.W., L.D.M., S.A.S.)
- Institute for Stroke and Cerebrovascular Disease (J.-M.Y., S.I.S., A.L.C., Y.A., P.R.C., J.C.G., S.B., S.A.S.), UTHealth, Houston, TX
| | - Alexandra L. Czap
- Department of Neurology (V.L.-R., R.A., S.I.S., A.L.C., Y.A., G.S., T.-C.W., L.D.M., S.A.S.)
- Institute for Stroke and Cerebrovascular Disease (J.-M.Y., S.I.S., A.L.C., Y.A., P.R.C., J.C.G., S.B., S.A.S.), UTHealth, Houston, TX
| | - Yazan Alderazi
- Institute for Stroke and Cerebrovascular Disease (J.-M.Y., S.I.S., A.L.C., Y.A., P.R.C., J.C.G., S.B., S.A.S.), UTHealth, Houston, TX
| | - Peng R. Chen
- Department of Neurosurgery of McGovern Medical School (P.R.C., S.B., M.J.D.), UTHealth, Houston, TX
- Institute for Stroke and Cerebrovascular Disease (J.-M.Y., S.I.S., A.L.C., Y.A., P.R.C., J.C.G., S.B., S.A.S.), UTHealth, Houston, TX
| | - James C. Grotta
- Institute for Stroke and Cerebrovascular Disease (J.-M.Y., S.I.S., A.L.C., Y.A., P.R.C., J.C.G., S.B., S.A.S.), UTHealth, Houston, TX
- Clinical Innovation and Research Institute, Memorial Hermann Hospital, Texas Medical Center, Houston (J.C.G.)
| | - Spiros Blackburn
- Department of Neurosurgery of McGovern Medical School (P.R.C., S.B., M.J.D.), UTHealth, Houston, TX
- Institute for Stroke and Cerebrovascular Disease (J.-M.Y., S.I.S., A.L.C., Y.A., P.R.C., J.C.G., S.B., S.A.S.), UTHealth, Houston, TX
| | - Gary Spiegel
- Department of Neurology (V.L.-R., R.A., S.I.S., A.L.C., Y.A., G.S., T.-C.W., L.D.M., S.A.S.)
| | - Mark J. Dannenbaum
- Department of Neurosurgery of McGovern Medical School (P.R.C., S.B., M.J.D.), UTHealth, Houston, TX
| | - Tzu-Ching Wu
- Department of Neurology (V.L.-R., R.A., S.I.S., A.L.C., Y.A., G.S., T.-C.W., L.D.M., S.A.S.)
| | | | - Louise D. McCullough
- Department of Neurology (V.L.-R., R.A., S.I.S., A.L.C., Y.A., G.S., T.-C.W., L.D.M., S.A.S.)
| | - Sunil A. Sheth
- Department of Neurology (V.L.-R., R.A., S.I.S., A.L.C., Y.A., G.S., T.-C.W., L.D.M., S.A.S.)
- Institute for Stroke and Cerebrovascular Disease (J.-M.Y., S.I.S., A.L.C., Y.A., P.R.C., J.C.G., S.B., S.A.S.), UTHealth, Houston, TX
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19
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Nguyen TN, Abdalkader M, Jovin TG, Nogueira RG, Jadhav AP, Haussen DC, Hassan AE, Novakovic R, Sheth SA, Ortega-Gutierrez S, Panagos PD, Cordina SM, Linfante I, Mansour OY, Malik AM, Narayanan S, Masoud HE, Chou SHY, Khatri R, Janardhan V, Yavagal DR, Zaidat OO, Greer DM, Liebeskind DS. Mechanical Thrombectomy in the Era of the COVID-19 Pandemic: Emergency Preparedness for Neuroscience Teams: A Guidance Statement From the Society of Vascular and Interventional Neurology. Stroke 2020; 51:1896-1901. [PMID: 32347790 PMCID: PMC7202095 DOI: 10.1161/strokeaha.120.030100] [Citation(s) in RCA: 82] [Impact Index Per Article: 20.5] [Reference Citation Analysis] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Affiliation(s)
- Thanh N. Nguyen
- From the Departments of Neurology (T.N.N., D.M.G.)
- Radiology (T.N.N., M.A.)
- Neurosurgery (T.N.N.), Boston Medical Center, Boston University School of Medicine, MA
| | | | - Tudor G. Jovin
- Department of Neurology, Cooper University Health Care, Camden, NJ (T.G.J.)
| | - Raul G. Nogueira
- Department of Neurology, Grady Memorial Hospital/Emory University, Atlanta, GA (R.G.N., D.C.H.)
| | - Ashutosh P. Jadhav
- Department of Neurology (A.P.J., S.N., S.H.-Y.C.)
- Department of Neurosurgery (S.H.-Y.C., A.P.J.), University of Pittsburgh Medical Center, PA
| | - Diogo C. Haussen
- Department of Neurology, Grady Memorial Hospital/Emory University, Atlanta, GA (R.G.N., D.C.H.)
| | - Ameer E. Hassan
- Department of Neuroscience, Valley Baptist Medical Center/University of Texas Rio Grande Valley (A.E.H.)
| | - Roberta Novakovic
- Department of Neurology, UT Southwestern Medical Center, Dallas, TX (R.N.)
| | - Sunil A. Sheth
- Department of Neurology, UT Health McGovern Medical School, Houston, TX (S.A.S.)
| | - Santiago Ortega-Gutierrez
- Departments of Neurology, Neurosurgery, and Radiology, University of Iowa Hospitals and Clinics (S.O.-G.)
| | - Peter D. Panagos
- Department of Emergency Medicine, Washington University School of Medicine, St. Louis, MO (P.D.P.)
| | - Steve M. Cordina
- Departments of Neurology, Neurosurgery, and Radiology, University of Southern Alabama, Mobile, (S.M.C.)
| | - Italo Linfante
- Departments of Interventional Neuroradiology and Endovascular Neurosurgery, Miami Cardiac and Vascular Institute, FL (I.L.)
| | - Ossama Yassin Mansour
- Departments of Neurology and Neuroradiology, Alexandria University Hospital, Egypt (O.Y.M.)
| | - Amer M. Malik
- Department of Neurology, University of Miami, FL (A.M.M., D.R.Y.)
| | | | - Hesham E. Masoud
- Departments of Neurology, Neurosurgery, and Radiology, SUNY Upstate Medical University Hospital, NY (H.E.M.)
| | - Sherry Hsiang-Yi Chou
- Department of Neurology (A.P.J., S.N., S.H.-Y.C.)
- Department of Critical Care Medicine (S.H.-Y.C.)
- Department of Neurosurgery (S.H.-Y.C., A.P.J.), University of Pittsburgh Medical Center, PA
| | - Rakesh Khatri
- Department of Neurointerventional Surgery, Texas Tech University, Lubbock (R.K.)
| | | | | | - Osama O. Zaidat
- Neuroscience Institute, Bon Secours Mercy Health System, St. Vincent Hospital, Toledo, OH (O.O.Z.)
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20
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Endovascular Thrombectomy for Low ASPECTS Large Vessel Occlusion Ischemic Stroke: A Systematic Review and Meta-Analysis. Can J Neurol Sci 2020; 47:612-619. [DOI: 10.1017/cjn.2020.71] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
ABSTRACT:Background:The current American Heart Association guidelines for acute ischemic stroke reserve Grade 1A recommendation for the use of endovascular thrombectomy (EVT) for patients with an Alberta Stroke Program Early Computed Tomography Score (ASPECTS) of ≥6.Objective:We aim to determine the safety and efficacy of EVT for large vessel occlusion ischemic stroke patients with low ASPECTS (5 or less).Methods:Medline, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov were searched for studies appraising the outcomes of EVT for low ASPECTS ischemic stroke. A meta-analysis of proportions compared the clinical outcomes of patients undergoing EVT and those receiving best medical therapy only.Results:Nine studies (1,196 patients) were included. There was a trend (p = 0.11) toward a higher rate of symptomatic intracranial hemorrhage (sICH) in the EVT group (9.2%; 95% CI 6.1–13.6; I2 53.37%) compared to the medical group (5.5%; 95% CI 3.7–8.1; I2 0%). There was no difference (p = 0.41) in the pooled 90-day mortality of EVT patients (30.7%; 95% CI 21.7–41.5; I2 84.23%) and medical patients (36.6%; 95% CI 26.4–48.1; I2 76.2%). EVT patients had better (p = 0.001) 90-day outcomes, with 27.7% (95% CI 21.8–34.5; I2 62.08%) of patients attaining a modified Rankin Scale of 0–2 compared to only 3.7% (95% CI 2.3–5.9; I2 87.21%) in the medical group.Conclusions:This meta-analysis demonstrates a trend in higher sICH among low ASPECTS patients undergoing EVT. Despite this, a significant proportion of this subset of patients still achieved good functional outcomes at 90 days. Randomized trials are necessary to substantiate this result as significant bias is inherent in the observational studies included in this review.
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