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Mierzwa AT, Nelson A, Kasab SA, Ortega Gutierrez S, Vivanco-Suarez J, Farooqui M, Jadhav AP, Desai S, Toth G, Alrohimi A, Nguyen TN, Klein P, Abdalkader M, Salahuddin H, Pandey A, Wilseck Z, Koduri S, Vora N, Aladamat N, Gharaibeh K, Afreen E, Al-Hajala H, Shawver J, Zaidi S, Jumaa M. Predictors of outcome and symptomatic intracranial hemorrhage in acute basilar artery occlusions: Analysis of the PC-SEARCH thrombectomy registry. Eur Stroke J 2024:23969873241234713. [PMID: 38403924 DOI: 10.1177/23969873241234713] [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: 02/27/2024] Open
Abstract
INTRODUCTION Recent randomized controlled trials demonstrated superiority of mechanical thrombectomy compared to medical therapy in acute basilar artery occlusions, however, little data is available to guide clinicians in functional prognosis and risk stratification. PATIENTS AND METHODS Data from the retrospectively established PC-SEARCH Thrombectomy registry, which included patients with basilar artery occlusion from eight sites from January 2015 to December 2021, was interrogated. Outcomes were dichotomized into 90-day favorable (mRS ⩽ 3) and unfavorable (mRS > 3). Multivariate logistic regression analysis was performed with respect to the outcome groups and were adjusted for potential confounding baseline characteristics. RESULTS Four-hundred-forty-four patients were included in this analysis. Mean age was 66 [SD 15], with 56% male, and comprised of 76% Caucasian. Patients presented with an initial median NIHSS of 18 and 199 patients (44.8%) achieved favorable 90-day functional outcomes. Independent predictors of favorable outcomes included younger age, pc-ASPECTS > 8 (OR 2.30 p < 0.001), and TICI ⩾ 2b (OR 7.56 p < 0.001). Unfavorable outcomes were associated with increasing number of passes (OR 1.29 p = 0.004) and sICH (OR 4.19 p = 0.015). IA-tPA was an independent risk factor for sICH (OR 7.15 p = 0.002) without improving favorable functional outcomes. CONCLUSION AND DISCUSSION PC-ASPECTS > 8, successful recanalization (TICI ⩾ 2b), first-pass recanalization, and younger age are independent predictors of favorable 90-day functional outcome in thrombectomy treated patients with acute basilar artery occlusion. Conversely, sICH were independent predictors of unfavorable outcomes. IA-tPA and unsuccessful recanalization are independently associated with sICH.
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Affiliation(s)
- Adam T Mierzwa
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
- Promedica Stroke Network, Toledo, OH, USA
| | - Ashley Nelson
- Department of Neurology and Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | - Sami Al Kasab
- Department of Neurology and Neurosurgery, Medical University of South Carolina, Charleston, SC, USA
| | | | | | | | - Ashutosh P Jadhav
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Shashvat Desai
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Gabor Toth
- Cleveland Clinic Foundation, Cleveland, OH, USA
| | | | - Thanh N Nguyen
- Department of Neurology, Radiology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Piers Klein
- Department of Neurology, Radiology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Mohamad Abdalkader
- Department of Neurology, Radiology, Boston Medical Center, Boston University Chobanian & Avedisian School of Medicine, Boston, MA, USA
| | - Hisham Salahuddin
- Department of Neurology, Antelope Valley Hospital, Los Angeles, CA, USA
| | - Aditya Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Zachary Wilseck
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Sravanthi Koduri
- Department of Neurosurgery, University of Michigan, Ann Arbor, MI, USA
| | - Niraj Vora
- Ohio Health Riverside Methodist Hospital, Columbus, OH, USA
| | - Nameer Aladamat
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Khaled Gharaibeh
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | - Ehad Afreen
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
- Promedica Stroke Network, Toledo, OH, USA
| | - Hisham Al-Hajala
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
| | | | - Syed Zaidi
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
- Promedica Stroke Network, Toledo, OH, USA
| | - Mouhammad Jumaa
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, Toledo, OH, USA
- Promedica Stroke Network, Toledo, OH, USA
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Wang K, Jiang Q, Gao M, Wei X, Xu C, Yin C, Liu H, Gu R, Wang H, Li W, Rong L. A clinical prediction model based on interpretable machine learning algorithms for prolonged hospital stay in acute ischemic stroke patients: a real-world study. Front Endocrinol (Lausanne) 2023; 14:1165178. [PMID: 38075055 PMCID: PMC10703471 DOI: 10.3389/fendo.2023.1165178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 04/21/2023] [Indexed: 12/18/2023] Open
Abstract
Objective Acute ischemic stroke (AIS) brings an increasingly heavier economic burden nowadays. Prolonged length of stay (LOS) is a vital factor in healthcare expenditures. The aim of this study was to predict prolonged LOS in AIS patients based on an interpretable machine learning algorithm. Methods We enrolled AIS patients in our hospital from August 2017 to July 2019, and divided them into the "prolonged LOS" group and the "no prolonged LOS" group. Prolonged LOS was defined as hospitalization for more than 7 days. The least absolute shrinkage and selection operator (LASSO) regression was applied to reduce the dimensionality of the data. We compared the predictive capacity of extended LOS in eight different machine learning algorithms. SHapley Additive exPlanations (SHAP) values were used to interpret the outcome, and the most optimal model was assessed by discrimination, calibration, and clinical utility. Results Prolonged LOS developed in 149 (22.0%) of the 677 eligible patients. In eight machine learning algorithms, prolonged LOS was best predicted by the Gaussian naive Bayes (GNB) model, which had a striking area under the curve (AUC) of 0.878 ± 0.007 in the training set and 0.857 ± 0.039 in the validation set. The variables sorted by the gap values showed that the strongest predictors were pneumonia, dysphagia, thrombectomy, and stroke severity. High net benefits were observed at 0%-76% threshold probabilities, while good agreement was found between the observed and predicted probabilities. Conclusions The model using the GNB algorithm proved excellent for predicting prolonged LOS in AIS patients. This simple model of prolonged hospitalization could help adjust policies and better utilize resources.
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Affiliation(s)
- Kai Wang
- Department of Neurology, The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
- Key Laboratory of Neurological Diseases, The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Qianmei Jiang
- Department of General Practice, Xindu District People’s Hospital of Chengdu, Chengdu, Sichuan, China
| | - Murong Gao
- Department of Rehabilitation, Beijing Rehabilitation Hospital Affiliated to Capital Medical University, Beijing, China
| | - Xiu’e Wei
- Department of Neurology, The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
- Key Laboratory of Neurological Diseases, The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Chan Xu
- Department of Dermatology, Xianyang Central Hospital, Xianyang, China
| | - Chengliang Yin
- Faculty of Medicine, Macau University of Science and Technology, Macau, Macao SAR, China
| | - Haiyan Liu
- Department of Neurology, The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
- Key Laboratory of Neurological Diseases, The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
| | - Renjun Gu
- School of Chinese Medicine and School of Integrated Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
| | - Haosheng Wang
- School of Chinese Medicine and School of Integrated Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
- State Key Laboratory of Pharmaceutical Biotechnology, Division of Sports Medicine and Adult Reconstructive Surgery, Department of Orthopedic Surgery, Nanjing Drum Tower Hospital, The Affiliated Hospital of Nanjing University Medical School, Nanjing, Jiangsu, China
| | - Wenle Li
- Key Laboratory of Neurological Diseases, The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
- The State Key Laboratory of Molecular Vaccinology and Molecular Diagnostics and Center for Molecular Imaging and Translational Medicine, School of Public Health, Xiamen University, Xiamen, China
| | - Liangqun Rong
- Department of Neurology, The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
- Key Laboratory of Neurological Diseases, The Second Affiliated Hospital of Xuzhou Medical University, Xuzhou, Jiangsu, China
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Safety outcomes of early initiation of antithrombotic agents within 24 h after intravenous alteplase at 0.6 mg/kg. J Neurol Sci 2023; 445:120546. [PMID: 36657370 DOI: 10.1016/j.jns.2023.120546] [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: 09/03/2022] [Revised: 12/27/2022] [Accepted: 01/04/2023] [Indexed: 01/09/2023]
Abstract
BACKGROUND We examined outcome of acute ischemic stroke (AIS) with administration of antithrombotics within 24 h after intravenous low-dose alteplase. METHODS Consecutive AIS patients who were treated with intravenous alteplase at 0.6 mg/kg from 2005 to 2021 were retrospectively included in our single-center registry. Patients were classified into two groups: those who received antithrombotics within 24 h after intravenous alteplase (early initiation group) and those who did not (control group). Safety outcomes were any intracranial hemorrhage (ICH), symptomatic ICH (sICH) within 36 h after onset, and death within 3 months. sICH was defined as any ICH with a ≥ 4-point increase in the National Institutes of Health Stroke Scale (NIHSS) score or death within 36 h. RESULTS Of 1111 patients (women, 426; median age, 76 [interquartile range, 69-83] years; median NIHSS score, 11 [6-19]; cardioembolism, 580 [52.2%]), early initiation group comprised 58 patients (22; 72 [65-80] years; 7 [4-12]; 11 [19.0%]) and control group comprised 1053 patients (404; 77 [69-84] years; 11 [6-19]; 569 [54.1%]). No significant between-group differences were observed in the incidence of any ICH (17.2% vs. 21.6%; adjusted odds ratio [aOR], 1.18; 95% confidence interval [CI], 0.57-2.44), sICH (0% vs. 0.9%, P = 1.00), or death within 3 months (5.2% vs. 6.7%; aOR, 1.23; 95% CI, 0.36-4.23). CONCLUSIONS Early initiation of antithrombotics after intravenous alteplase at 0.6 mg/kg did not increase the rate of sICH or death within 3 months and may be used with caution in patients with advanced neurological deterioration.
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Winkelmeier L, Heit JJ, Adusumilli G, Geest V, Guenego A, Broocks G, Prüter J, Gloyer NO, Meyer L, Kniep H, Lansberg MG, Albers GW, Wintermark M, Fiehler J, Faizy TD. Poor venous outflow profiles increase the risk of reperfusion hemorrhage after endovascular treatment. J Cereb Blood Flow Metab 2023; 43:72-83. [PMID: 36127828 PMCID: PMC9875351 DOI: 10.1177/0271678x221127089] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
To investigate whether unfavorable cerebral venous outflow (VO) predicts reperfusion hemorrhage after endovascular treatment (EVT), we conducted a retrospective multicenter cohort study of patients with acute ischemic stroke and large vessel occlusion (AIS-LVO). 629 AIS-LVO patients met inclusion criteria. VO profiles were assessed on admission CT angiography using the Cortical Vein Opacification Score (COVES). Unfavorable VO was defined as COVES ≤ 2. Reperfusion hemorrhages on follow-up imaging were subdivided into no hemorrhage (noRH), hemorrhagic infarction (HI) and parenchymal hematoma (PH). Patients with PH and HI less frequently achieved good clinical outcomes defined as 90-day modified Rankin Scale scores of ≤ 2 (PH: 13.6% vs. HI: 24.6% vs. noRH: 44.1%; p < 0.001). The occurrence of HI and PH on follow-up imaging was more likely in patients with unfavorable compared to patients with favorable VO (HI: 25.1% vs. 17.4%, p = 0.023; PH: 18.3% vs. 8.5%; p = <0.001). In multivariable regression analyses, unfavorable VO increased the likelihood of PH (aOR: 1.84; 95% CI: 1.03-3.37, p = 0.044) and HI (aOR: 2.05; 95% CI: 1.25-3.43, p = 0.005), independent of age, sex, admission National Institutes Health Stroke Scale scores and arterial collateral status. We conclude that unfavorable VO was associated with the occurrence of HI and PH, both related to worse clinical outcomes.
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Affiliation(s)
- Laurens Winkelmeier
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Gautam Adusumilli
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Vincent Geest
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Adrien Guenego
- Department of Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Gabriel Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julia Prüter
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nils-Ole Gloyer
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maarten G Lansberg
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Gregory W Albers
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Max Wintermark
- Department of Neuroradiology, MD Andersen Cancer Center, Houston, TX, USA
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Bai X, Qiu J, Wang Y. Endovascular thrombectomy with or without intravenous alteplase in acute stroke: a systematic review and meta-analysis of randomized clinical trials. J Neurol 2023; 270:223-232. [PMID: 36197568 DOI: 10.1007/s00415-022-11413-3] [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: 07/23/2022] [Revised: 09/28/2022] [Accepted: 09/29/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND AND PURPOSE This study investigated clinical outcomes after direct endovascular thrombectomy (EVT) compared to bridging therapy (EVT with prior intravenous alteplase) in acute stroke within 4.5 h after onset. METHODS PubMed and Embase were searched for eligible randomized controlled trials. The primary outcome was the rates of neurological functional independence defined as modified Rankin scale score 0-2 at 90 days, whose non-inferiority margin was set at - 15%, - 10%, - 6.5%, - 5%, and - 1.3% for its risk difference (RD). RESULTS We included six studies enrolling 2334 participants. The crude cumulative rates of functional independence were 49.0% with direct EVT vs 50.9% with bridging therapy, without significant difference (Odd ratio [OR] = 0.93, 95% confidence interval [CI] 0.79-1.09) between two groups, where the pooled RD was - 2% (95% CI - 6 to 2%) whose lower 95% CI bound fell within non-inferiority margins of - 15%, - 10%, -6.5%, but not - 5% and - 1.3%. Between the two groups, no significant difference was found in excellent function rate (30.2% vs 30.6%, OR = 0.99, 95% CI 0.82-1.18) with RD of 0% (95% CI - 3 to 4%), mortality rate (16.0% vs 15.0%, OR = 1.08, 95% CI 0.86-1.35) with RD of 1% (95% CI - 2 to 4%), and symptomatic intracranial hemorrhage rate (4.3% vs 5.0%, OR = 0.86, 95% CI 0.58-1.27) with RD of 0% (95% CI - 2 to 1%). CONCLUSIONS No statistical difference was found in functional and safety outcomes between direct EVT and bridging therapy groups in acute stroke within 4.5 h after symptom onset. EVT alone was non-inferior to bridging therapy for several, but not the more stringent, non-inferiority margins.
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Affiliation(s)
- Xuan Bai
- Department of Neurology, People's Hospital of Liaoning Province, 33 Wenyi Road, Shenhe District, Shenyang, 110016, People's Republic of China
| | - Jianting Qiu
- Department of Neurology, People's Hospital of Liaoning Province, 33 Wenyi Road, Shenhe District, Shenyang, 110016, People's Republic of China
| | - Yujie Wang
- Department of Neurology, People's Hospital of Liaoning Province, 33 Wenyi Road, Shenhe District, Shenyang, 110016, People's Republic of China.
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Qureshi AI, Akinci Y, Huang W, Ishfaq MF, Hassan AE, Siddiq F, Gomez CR. Cost-effectiveness analysis of endovascular treatment with or without intravenous thrombolysis in acute ischemic stroke. J Neurosurg 2023; 138:223-232. [PMID: 35901768 DOI: 10.3171/2022.4.jns22514] [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: 03/03/2022] [Accepted: 04/25/2022] [Indexed: 01/06/2023]
Abstract
OBJECTIVE Intravenous (IV) recombinant tissue plasminogen activator (r-tPA) may not provide additional benefit in terms of functional outcomes in patients with acute ischemic stroke (AIS) who undergo endovascular treatment (EVT). In this context, the cost-effectiveness of EVT alone compared with its application following IV r-tPA has not been evaluated. METHODS The authors determined the average rates of death or disability in each of the two treatment groups from four randomized clinical trials that enrolled patients with AIS within 4.5 hours of symptom onset and randomly assigned patients to EVT alone and IV r-tPA and EVT. By using three sources derived from previous studies, the authors determined the cost of IV r-tPA, cost of staff time for administration, cost of the EVT, cost of hospital stay, costs of supported discharge and community care, and cost of posthospitalization care and disability. They then assessed the cost-effectiveness of EVT alone using a decision tree for the 1st year after AIS and a Markov model with a 10-year horizon, including probabilistic assessment by Monte Carlo simulations. RESULTS The 1-year cost was higher with IV r-tPA and EVT compared with EVT alone (incremental cost ranging between $3554 and $13,788 per patient). The mean incremental cost-effectiveness ratios (ICERs) were -$1589, -$78,327, and -$15,471 per quality-adjusted life-year gained for cost sources 1, 2, and 3, respectively, for EVT alone compared with IV r-tPA and EVT at 10 years. The ceiling ICER (willingness to pay) for a probability of 100% that EVT alone was more cost-effective ranged between $25,000 and $100,000 in the three models. CONCLUSIONS EVT alone appears to be more cost-effective compared with EVT and IV r-tPA for the treatment of AIS patients presenting within 4.5 hours of symptom onset.
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Affiliation(s)
- Adnan I Qureshi
- 1Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri
| | - Yasemin Akinci
- 1Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri
| | - Wei Huang
- 1Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri
| | - Muhammad F Ishfaq
- 1Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri
| | - Ameer E Hassan
- 2Department of Neuroscience, Valley Baptist Medical Center, Harlingen, Texas.,3Department of Neurology, University of Texas Rio Grande Valley School of Medicine, Harlingen, Texas; and
| | - Farhan Siddiq
- 4Division of Neurosurgery, University of Missouri, Columbia, Missouri
| | - Camilo R Gomez
- 1Zeenat Qureshi Stroke Institute and Department of Neurology, University of Missouri, Columbia, Missouri
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Broocks G, Heit JJ, Kuraitis GM, Meyer L, van Horn N, Bechstein M, Thaler C, Christensen S, Mlynash M, Lansberg MG, Kemmling A, Schön G, Albers G, Fiehler J, Wintermark M, Faizy TD. Benefit of Intravenous Alteplase Before Thrombectomy Depends on ASPECTS. Ann Neurol 2022; 92:588-595. [PMID: 35801346 DOI: 10.1002/ana.26451] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2021] [Revised: 07/05/2022] [Accepted: 07/05/2022] [Indexed: 11/09/2022]
Abstract
PURPOSE Baseline variables could be used to guide the administration of additional intravenous alteplase (IVT) before mechanical thrombectomy (MT). The aim of this study was to determine how baseline imaging and demographic parameters modify the effect of IVT on clinical outcomes in patients with ischemic stroke due to large vessel occlusion. METHODS Multicenter retrospective cohort study of ischemic stroke patients triaged by multimodal-CT undergoing MT treatment after direct admission to an MT-eligible center. Inverse-probability weighting analysis (IPW) was used to assess the treatment effect of IVT adjusted for baseline variables. Multivariable logistic regression analysis with IPW-weighting and interaction terms for IVT was performed to predict functional independence (mRS 0-2 at 90-days). RESULTS 720 patients were included, of which 366 (51%) received IVT. In IPW, the treatment effect of IVT on outcome (mRS 0-2) distinctively varied according to the ASPECTS subgroup (ASPECTS 9-10: +15%, ASPECTS 6-8: +7%, ASPECTS <6: -11%). In multivariable logistic regression analysis, IVT was independently associated with functional independence (aOR: 1.57, 95%CI: 1.16-2.14, p=0.003) and the interaction term was significant for ASPECTS and IVT revealing that IVT was only significantly associated with better outcomes in patients with higher ASPECTS. No other significant baseline variable interaction terms were identified. INTERPRETATION ASPECTS was the only baseline variable that showed a significant interaction with IVT for outcome prediction. The application of IVT in patients with an ASPECTS of <6 might have detrimental effects on outcome and may only be considered carefully. This article is protected by copyright. All rights reserved.
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Affiliation(s)
- Gabriel Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, CA
| | | | - Lukas Meyer
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf
| | - Noel van Horn
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf
| | - Matthias Bechstein
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf
| | - Christian Thaler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf
| | - Soren Christensen
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA
| | - Michael Mlynash
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA
| | - Maarten G Lansberg
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA
| | - Andre Kemmling
- Department of Neuroradiology, University Marburg.,Department of Neuroradiology, University Schleswig Holstein, Campus Lübeck
| | - Gerhard Schön
- Institute of Epidemiology and Medical Biometry, University Medical Center Hamburg-Eppendorf
| | - Gregory Albers
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf
| | - Max Wintermark
- Department of Radiology, Stanford University School of Medicine, CA
| | - Tobias D Faizy
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf
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8
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Faizy TD, Mlynash M, Marks MP, Christensen S, Kabiri R, Kuraitis GM, Broocks G, Winkelmeier L, Geest V, Nawabi J, Lansberg MG, Albers GW, Fiehler J, Wintermark M, Heit JJ. Intravenous tPA (Tissue-Type Plasminogen Activator) Correlates With Favorable Venous Outflow Profiles in Acute Ischemic Stroke. Stroke 2022; 53:3145-3152. [PMID: 35735008 DOI: 10.1161/strokeaha.122.038560] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND Intravenous tPA (tissue-type plasminogen activator) is often administered before endovascular thrombectomy (EVT). Recent studies have questioned whether tPA is necessary given the high rates of arterial recanalization achieved by EVT, but whether tPA impacts venous outflow (VO) is unknown. We investigated whether tPA improves VO profiles on baseline computed tomography (CT) angiography (CTA) images before EVT. METHODS Retrospective multicenter cohort study of patients with acute ischemic stroke due to large vessel occlusion undergoing EVT triage. Included patients underwent CT, CTA, and CT perfusion before EVT. VO profiles were determined by opacification of the vein of Labbé, sphenoparietal sinus, and superficial middle cerebral vein on CTA as 0, not visible; 1, moderate opacification; and 2, full. Pial arterial collaterals were graded on CTA, and tissue-level collaterals were assessed on CT perfusion using the hypoperfusion intensity ratio. Clinical and demographic data were determined from the electronic medical record. Using multivariable regression analysis, we determined the correlation between tPA administration and favorable VO profiles. RESULTS Seven hundred seventeen patients met inclusion criteria. Three hundred sixty-five patients received tPA (tPA+), while 352 patients were not treated with tPA (tPA-). Fewer tPA+ patients had atrial fibrillation (n=128 [35%] versus n=156 [44%]; P=0.012) and anticoagulants/antiplatelet treatment before acute ischemic stroke due to large vessel occlusion onset (n=130 [36%] versus n=178 [52%]; P<0.001) compared with tPA- patients. One hundred eighty-five patients (51%) in the tPA+ and 100 patients (28%) in the tPA- group exhibited favorable VO (P<0.001). Multivariable regression analysis showed that tPA administration was a strong independent predictor of favorable VO profiles (OR, 2.6 [95% CI, 1.7-4.0]; P<0.001) after control for favorable pial arterial CTA collaterals, favorable tissue-level collaterals on CT perfusion, age, presentation National Institutes of Health Stroke Scale, antiplatelet/anticoagulant treatment, history of atrial fibrillation and time from symptom onset to imaging. CONCLUSIONS In patients with acute ischemic stroke due to large vessel occlusion undergoing thrombectomy triage, tPA administration was strongly associated with the presence of favorable VO profiles.
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Affiliation(s)
- Tobias D Faizy
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (T.D.F., R.K., G.B., L.W., V.G., J.F.)
| | - Michael Mlynash
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (M.M., S.C., M.G.L., G.W.A.)
| | - Michael P Marks
- Department of Radiology, Stanford University School of Medicine, CA (M.P.M., G.M.K., J.J.H.)
| | - Soren Christensen
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (M.M., S.C., M.G.L., G.W.A.)
| | - Reza Kabiri
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (T.D.F., R.K., G.B., L.W., V.G., J.F.)
| | - Gabriella M Kuraitis
- Department of Radiology, Stanford University School of Medicine, CA (M.P.M., G.M.K., J.J.H.)
| | - Gabriel Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (T.D.F., R.K., G.B., L.W., V.G., J.F.)
| | - Laurens Winkelmeier
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (T.D.F., R.K., G.B., L.W., V.G., J.F.)
| | - Vincent Geest
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (T.D.F., R.K., G.B., L.W., V.G., J.F.)
| | - Jawed Nawabi
- Department of Radiology, University Medical Center Charité Berlin (J.N.)
| | - Maarten G Lansberg
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (M.M., S.C., M.G.L., G.W.A.)
| | - Gregory W Albers
- Department of Neurology and Neurological Sciences, Stanford University School of Medicine, CA (M.M., S.C., M.G.L., G.W.A.)
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (T.D.F., R.K., G.B., L.W., V.G., J.F.)
| | - Max Wintermark
- Department of Neuroradiology, MD Anderson, Houston, TX (M.W.)
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, CA (M.P.M., G.M.K., J.J.H.)
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9
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Broocks G, Meyer L, Ruppert C, Haupt W, Faizy TD, Van Horn N, Bechstein M, Kniep H, Elsayed S, Kemmling A, Barow E, Fiehler J, Hanning U. Effect of Intravenous Alteplase on Functional Outcome and Secondary Injury Volumes in Stroke Patients with Complete Endovascular Recanalization. J Clin Med 2022; 11:jcm11061565. [PMID: 35329891 PMCID: PMC8949925 DOI: 10.3390/jcm11061565] [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: 02/11/2022] [Revised: 03/04/2022] [Accepted: 03/08/2022] [Indexed: 11/22/2022] Open
Abstract
Intravenous thrombolytic therapy with alteplase (IVT) is a standard of care in ischemic stroke, while recent trials investigating direct endovascular thrombectomy (EVT) approaches showed conflicting results. Yet, the effect of IVT on secondary injury volumes in patients with complete recanalization has not been analyzed. We hypothesized that IVT is associated with worse functional outcome and aggravated secondary injury volumes when administered to patients who subsequently attained complete reperfusion after EVT. Anterior circulation ischemic stroke patients with complete reperfusion after thrombectomy defined as thrombolysis in cerebral infarctions (TICI) scale 3 after thrombectomy admitted between January 2013–January 2021 were analyzed. Primary endpoints were the proportion of patients with functional independence defined as modified Rankin Scale (mRS) score 0–2 at day 90, and secondary injury volumes: Edema volume in follow-up imaging measured using quantitative net water uptake (NWU), and the rate of symptomatic intracerebral hemorrhage (sICH). A total of 219 patients were included and 128 (58%) patients received bridging IVT before thrombectomy. The proportion of patients with functional independence was 28% for patients with bridging IVT, and 34% for patients with direct thrombectomy (p = 0.35). The rate of sICH was significantly higher after bridging IVT (20% versus 7.7%, p = 0.01). Multivariable logistic and linear regression analysis confirmed the independent association of bridging IVT with sICH (aOR: 2.78, 95% CI: 1.02–7.56, p = 0.046), and edema volume (aOR: 8.70, 95% CI: 2.57–14.85, p = 0.006). Bridging IVT was associated with increased edema volume and risk for sICH as secondary injury volumes. The results of this study encourage direct EVT approaches, particularly in patients with higher likelihood of successful EVT.
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Affiliation(s)
- Gabriel Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
- Correspondence:
| | - Lukas Meyer
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Celine Ruppert
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Wolfgang Haupt
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Tobias D. Faizy
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Noel Van Horn
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Matthias Bechstein
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Helge Kniep
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Sarah Elsayed
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Andre Kemmling
- Department of Neuroradiology, Philipps-University Marburg, 35037 Marburg, Germany;
- Department of Neuroradiology, University Medical Center Schleswig-Holstein, Campus Lübeck, 23538 Lübeck, Germany
| | - Ewgenia Barow
- Department of Neurology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany;
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
| | - Uta Hanning
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany; (L.M.); (C.R.); (W.H.); (T.D.F.); (N.V.H.); (M.B.); (H.K.); (S.E.); (J.F.); (U.H.)
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10
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Jia ZY, Zhang YX, Cao YZ, Zhao LB, Shi HB, Zhang L, Li ZF, Shen HJ, Lou M, Zhang YW, Yin GC, Ye XF, Yang PF, Liu S, Liu JM, Direct-Mt Investigators T. Effect of baseline infarct size on endovascular thrombectomy with or without intravenous alteplase in stroke patients: a subgroup analysis of a randomized trial (DIRECT-MT). Eur J Neurol 2022; 29:1643-1651. [PMID: 35143095 DOI: 10.1111/ene.15276] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Accepted: 02/03/2022] [Indexed: 11/28/2022]
Abstract
BACKGROUND DIRECT-MT showed that endovascular thrombectomy was non-inferior to thrombectomy preceded by intravenous alteplase with regard to functional outcome in patients with acute ischemic stroke. In this post-hoc analysis, we examined whether infarct size modified the effect of alteplase. METHODS All patients with baseline Alberta Stroke Program Early Computed Tomography Score (ASPECTS) grade were included. The primary outcome was the 90-day modified Rankin Scale (mRS) score. Multivariable ordinal logistic regression analysis was used to calculate the adjusted common odds ratio (OR) for better functional outcome based on the mRS for thrombectomy alone versus combination therapy. An interaction term was entered to test for an interaction with baseline ASPECTS subgroups: 0-4 versus 5-7 versus 8-10. RESULTS Of 649 patients, 323 (49.8%) were in the thrombectomy-alone group and 326 (50.2%) in the combination-therapy group. There was no significant treatment-by-trichotomized ASPECTS interaction with alteplase prior to endovascular treatment for the primary endpoint of ordinal mRS (p-value interaction term relative to ASPECTS 8-10: ASPECTS 0-4, p=0.386; ASPECTS 5-7, p=0.936). Adjusted common OR for improvement in the 90-day mRS with thrombectomy alone compared with combination therapy were 1.99 (95% confidence intervals, 0.72-5.46) for ASPECTS 0-4, 1.07 (0.62-1.86) for ASPECTS 5-7, and 1.03 (0.74-1.45) for ASPECTS 8-10. There was no significant difference in the safety outcomes between the two groups. CONCLUSIONS Baseline infarct size may not modify the effect of alteplase prior to endovascular thrombectomy with regard to favorable functional outcomes and adverse events.
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Affiliation(s)
- Zhen Yu Jia
- Department of Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Yong Xin Zhang
- Department of Neurosurgery, Naval Medical University Changhai hospital, Shanghai, China
| | - Yue Zhou Cao
- Department of Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Lin Bo Zhao
- Department of Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Hai Bin Shi
- Department of Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Lei Zhang
- Department of Neurosurgery, Naval Medical University Changhai hospital, Shanghai, China
| | - Zi Fu Li
- Department of Neurosurgery, Naval Medical University Changhai hospital, Shanghai, China
| | - Hong Jian Shen
- Department of Neurosurgery, Naval Medical University Changhai hospital, Shanghai, China
| | - Min Lou
- Department of Neurology, Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Yong Wei Zhang
- Department of Neurology, Naval Medical University Changhai Hospital, Shanghai, China
| | - Guo Cong Yin
- Department of Neurology, Hangzhou First People's Hospital of Zhejiang University, Hangzhou, China
| | - Xiao Fei Ye
- Department of Statistics, Naval Medical University, Shanghai, China
| | - Peng Fei Yang
- Department of Neurosurgery, Naval Medical University Changhai hospital, Shanghai, China
| | - Sheng Liu
- Department of Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Jian Min Liu
- Department of Neurosurgery, Naval Medical University Changhai hospital, Shanghai, China
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11
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Dicpinigaitis AJ, Gandhi CD, Shah SP, Galea VP, Cooper JB, Feldstein E, Shapiro SD, Kamal H, Kurian C, Kaur G, Tyagi R, Biswas A, Rosenberg J, Bauerschmidt A, Bowers CA, Mayer SA, Al-Mufti F. Endovascular thrombectomy with and without preceding intravenous thrombolysis for treatment of large vessel anterior circulation stroke: A cross-sectional analysis of 50,000 patients. J Neurol Sci 2022; 434:120168. [DOI: 10.1016/j.jns.2022.120168] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2021] [Revised: 12/28/2021] [Accepted: 01/19/2022] [Indexed: 10/19/2022]
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12
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Weyland CS, Vey JA, Mokli Y, Feisst M, Kieser M, Herweh C, Schönenberge S, Möhlenbruch MA, Bendszus M, Ringleb PA, Nagel S. Full Reperfusion Without Functional Independence After Mechanical Thrombectomy in the Anterior Circulation : Performance of Prediction Models Before Versus After Treatment Initiation. Clin Neuroradiol 2022; 32:987-995. [PMID: 35532751 PMCID: PMC9744692 DOI: 10.1007/s00062-022-01166-x] [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: 01/12/2022] [Accepted: 03/25/2022] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND PURPOSE Prediction of futile recanalization (FR), i.e. failure of long-term functional independence despite full reperfusion in mechanical thrombectomy (MT), is instrumental in patients undergoing endovascular therapy. METHODS Retrospective single-center analysis of patients treated for anterior circulation LVO ensuing successful MT (mTICI 2c-3) between January 2014 and April 2019. FR was defined as modified Rankin Scale (mRS) 90 days after stroke onset > 2 or mRS > pre-stroke mRS. Multivariable analysis was performed with variables available before treatment initiation regarding their association with FR. Performance of the regression model was then compared with a model including parameters available after MT. RESULTS Successful MT was experienced by 549/1146 patients in total. FR occurred in 262/549 (47.7%) patients. Independent predictors of FR were male sex, odds ratio (OR) with 95% confidence interval (CI) 1.98 (1.31-3.05, p 0.001), age (OR 1.05, CI 1.03-1.07, p < 0.001), NIHSS on admission (OR 1.10, CI 1.06-1.13, p < 0.001), pre-stroke mRS (OR 1.22, CI 1.03-1.46, p 0.025), neutrophile-lymphocyte ratio (OR 1.03, CI 1.00-1.06, p 0.022), baseline ASPECTS (OR 0.77, CI 0.68-0.88, p < 0.001), and absence of bridging i.v. lysis (OR 1.62, 1.09-2.42, p 0.016). The prediction model's Area Under the Curve was 0.78 (CI 0.74-0.82) and increased with parameters available after MT to 0.86 (CI 0.83-0.89) with failure of early neurological improvement being the most important predictor of FR (OR 15.0, CI 7.2-33.8). CONCLUSION A variety of preinterventional factors may predict FR with substantial certainty, but the prediction model can still be improved by considering parameters only available after MT, in particular early neurological improvement.
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Affiliation(s)
- Charlotte S. Weyland
- grid.5253.10000 0001 0328 4908Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Johannes A. Vey
- grid.5253.10000 0001 0328 4908Institute of Medical Biometry, Heidelberg University Hospital, Heidelberg, Germany
| | - Yahia Mokli
- grid.5253.10000 0001 0328 4908Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany ,grid.411067.50000 0000 8584 9230Department of Psychiatry and Psychotherapy, Giessen and Marburg University Hospital, Marburg, Germany
| | - Manuel Feisst
- grid.5253.10000 0001 0328 4908Institute of Medical Biometry, Heidelberg University Hospital, Heidelberg, Germany
| | - Meinhard Kieser
- grid.5253.10000 0001 0328 4908Institute of Medical Biometry, Heidelberg University Hospital, Heidelberg, Germany
| | - Christian Herweh
- grid.5253.10000 0001 0328 4908Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Silvia Schönenberge
- grid.5253.10000 0001 0328 4908Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Markus A. Möhlenbruch
- grid.5253.10000 0001 0328 4908Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Martin Bendszus
- grid.5253.10000 0001 0328 4908Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Peter A. Ringleb
- grid.5253.10000 0001 0328 4908Department of Neurology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120 Heidelberg, Germany
| | - Simon Nagel
- grid.5253.10000 0001 0328 4908Institute of Medical Biometry, Heidelberg University Hospital, Heidelberg, Germany
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13
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Gauberti M, Martinez de Lizarrondo S, Vivien D. Thrombolytic strategies for ischemic stroke in the thrombectomy era. J Thromb Haemost 2021; 19:1618-1628. [PMID: 33834615 DOI: 10.1111/jth.15336] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 03/29/2021] [Accepted: 03/31/2021] [Indexed: 02/03/2023]
Abstract
Twenty-five years ago, intravenous thrombolysis has revolutionized the care of patients with acute ischemic stroke. Since 2015, randomized clinical trials have demonstrated that mechanical thrombectomy improves functional outcome in stroke patients over intravenous thrombolysis alone. More recently, three randomized clinical trials have suggested that mechanical thrombectomy alone is noninferior to a combined strategy with both intravenous thrombolysis and mechanical thrombectomy. In the present review, we will present the last clinical and preclinical studies on the use of thrombolysis in stroke patients in the modern thrombectomy era. At the cost of a potential increased risk of hemorrhagic transformation, thrombolysis may promote arterial recanalization before thrombectomy, improve the rate of successful recanalization after thrombectomy, and restore microcirculation patency downstream of the main thrombus. Besides, new thrombolytic strategies targeting tissue-type plasminogen activator resistant thrombi are being developed, which could strengthen the beneficial effects of thrombolysis without carrying additional pro-hemorrhagic effects. For instance, tenecteplase has shown improved rate of recanalization compared with tissue-type plasminogen activator (alteplase). Beyond fibrinolysis, DNA- and von Willebrand factor-targeted thrombolytic strategies have shown promising results in experimental models of ischemic stroke. New combined strategies, improved thrombolytics, and dedicated clinical trials in selected patients are eagerly awaited to further improve functional outcome in stroke.
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Affiliation(s)
- Maxime Gauberti
- Normandie Univ, UNICAEN, INSERM, PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Cyceron, Caen, France
- CHU Caen, Department of Neuroradiology, CHU de Caen Côte de Nacre, Caen, France
| | - Sara Martinez de Lizarrondo
- Normandie Univ, UNICAEN, INSERM, PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Cyceron, Caen, France
| | - Denis Vivien
- Normandie Univ, UNICAEN, INSERM, PhIND "Physiopathology and Imaging of Neurological Disorders", Institut Blood and Brain @ Caen-Normandie, Cyceron, Caen, France
- CHU Caen, Clinical Research Department, CHU de Caen Côte de Nacre, Caen, France
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14
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Li S, Liu DD, Lu G, Liu Y, Zhou JS, Deng QW, Yan FL. Endovascular Treatment With and Without Intravenous Thrombolysis in Large Vessel Occlusions Stroke: A Systematic Review and Meta-Analysis. Front Neurol 2021; 12:697478. [PMID: 34526956 PMCID: PMC8437100 DOI: 10.3389/fneur.2021.697478] [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: 04/19/2021] [Accepted: 07/07/2021] [Indexed: 11/29/2022] Open
Abstract
Background: Previous studies have shown conflicting results about the benefits of pretreatment with intravenous thrombolysis before endovascular treatment (EVT) in patients with acute ischemic stroke (AIS) with large vessel occlusions (LVOs). This study aimed to investigate the clinical efficacy and safety of EVT alone vs. bridging therapy (BT) in patients with AIS with LVOs. Methods: A systematic review with meta-analysis of all available studies comparing clinical outcomes between BT and EVT alone was conducted by searching the National Center for Biotechnology Information/National Library of Medicine PubMed and Web of Science databases for relevant literature from database inception to October 20, 2020. Results: A total of 93 studies enrolling 45,190 patients were included in the present analysis. In both unadjusted and adjusted analyses, BT was associated with a higher likelihood of 90-day good outcome (crude odds ratio [cOR] 1.361, 95% confidence interval [CI] 1.234-1.502 and adjusted OR [aOR] 1.369, 95% CI 1.217-1.540) and successful reperfusion (cOR 1.271, 95% CI 1.149-1.406 and aOR 1.267, 95% CI 1.095-1.465) and lower odds of 90-day mortality (cOR 0.619, 95% CI 0.560-0.684 and aOR 0.718, 95% CI 0.594-0.868) than EVT alone. The two groups did not differ in the occurrence of symptomatic intracranial hemorrhage (sICH) (cOR 1.062, 95% CI 0.915-1.232 and aOR 1.20, 95% CI 0.95-1.47), 24-h early recovery (cOR 1.306, 95% CI 0.906-1.881 and aOR 1.46, 95% CI 0.46-2.19), and number of thrombectomy device passes ≤ 2 (aOR 1.466, 95% CI 0.983-2.185) after sensitivity analyses and adjustment for publication bias. Conclusions: BT provides more benefits than EVT alone in terms of clinical functional outcomes without compromising safety in AIS patients with LVOs.
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Affiliation(s)
- Shuo Li
- Department of Neurology, Affiliated ZhongDa Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Dan-Dan Liu
- Department of Neurology, Affiliated ZhongDa Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Guo Lu
- Department of Neurology, Dezhou People's Hospital, Dezhou, China
| | - Yun Liu
- Department of Neurology, Affiliated ZhongDa Hospital, School of Medicine, Southeast University, Nanjing, China
| | - Jun-Shan Zhou
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- Jun-Shan Zhou
| | - Qi-Wen Deng
- Department of Neurology, Nanjing First Hospital, Nanjing Medical University, Nanjing, China
- Qi-Wen Deng
| | - Fu-Ling Yan
- Department of Neurology, Affiliated ZhongDa Hospital, School of Medicine, Southeast University, Nanjing, China
- Key Laboratory of Developmental Genes and Human Disease, Southeast University, Nanjing, China
- *Correspondence: Fu-Ling Yan
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15
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Akbik F, Alawieh A, Cawley CM, Howard BM, Tong FC, Nahab F, Saad H, Dimisko L, Mustroph C, Samuels OB, Pradilla G, Maier I, Goyal N, Starke RM, Rai A, Fargen KM, Psychogios MN, Jabbour P, De Leacy R, Giles J, Dumont TM, Kan P, Arthur AS, Crosa RJ, Gory B, Spiotta AM, Grossberg JA. Differential effect of mechanical thrombectomy and intravenous thrombolysis in atrial fibrillation associated stroke. J Neurointerv Surg 2020; 13:883-888. [PMID: 33318066 DOI: 10.1136/neurintsurg-2020-016720] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2020] [Revised: 09/17/2020] [Accepted: 10/19/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND Atrial fibrillation (AF) associated ischemic stroke has worse functional outcomes, less effective recanalization, and increased rates of hemorrhagic complications after intravenous thrombolysis (IVT). Limited data exist about the effect of AF on procedural and clinical outcomes after mechanical thrombectomy (MT). OBJECTIVE To determine whether recanalization efficacy, procedural speed, and clinical outcomes differ in AF associated stroke treated with MT. METHODS We performed a retrospective cohort study of the Stroke Thrombectomy and Aneurysm Registry (STAR) from January 2015 to December 2018 and identified 4169 patients who underwent MT for an anterior circulation stroke, 1517 (36.4 %) of whom had comorbid AF. Prospectively defined baseline characteristics, procedural outcomes, and clinical outcomes were reported and compared. RESULTS AF predicted faster procedural times, fewer passes, and higher rates of first pass success on multivariate analysis (p<0.01). AF had no effect on intracranial hemorrhage (aOR 0.69, 95% CI 0.43 to 1.12) or 90-day functional outcomes (aOR 1.17, 95% CI 0.91 to 1.50) after MT, although patients with AF were less likely to receive IVT (46% vs 54%, p<0.0001). CONCLUSIONS In patients treated with MT, comorbid AF is associated with faster procedural time, fewer passes, and increased rates of first pass success without increased risk of intracranial hemorrhage or worse functional outcomes. These results are in contrast to the increased hemorrhage rates and worse functional outcomes observed in AF associated stroke treated with supportive care and or IVT. These data suggest that MT negates the AF penalty in ischemic stroke.
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Affiliation(s)
- Feras Akbik
- Department of Neurology, Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Ali Alawieh
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - C Michael Cawley
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Brian M Howard
- Department of Neurosurgery, Emory University School of Medicine, Atlanta, Georgia, USA.,Department of Radiology and Imaging Sciences, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Frank C Tong
- Department of Radiology, Emory University, Altanta, Georgia, USA
| | - Fadi Nahab
- Department of Neurology, Emory University School of Medicine, Atlanta, Georgia, USA
| | - Hassan Saad
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | | | | | - Owen B Samuels
- Department of Neurology, Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Gustavo Pradilla
- Department of Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Ilko Maier
- Department of Neurology, University Medicine Goettingen, Goettingen, NS, Germany
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami Miller School of Medicine, Miami Beach, Florida, USA
| | - Ansaar Rai
- Radiology, West Virginia University Hospitals, Morgantown, West Virginia, USA
| | - Kyle M Fargen
- Neurosurgery, Wake Forest University, Winston-Salem, North Carolina, USA
| | - Marios N Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Reade De Leacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - James Giles
- Department of Neurology, Washington University in St Louis School of Medicine, St Louis, Missouri, USA
| | - Travis M Dumont
- Department of Surgery, Division of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
| | - Peter Kan
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Adam S Arthur
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA.,Department of Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Roberto Javier Crosa
- Department of Endovascular Neurosurgery, Médica Uruguaya, Montevideo, Montevideo, Uruguay
| | - Benjamin Gory
- Department of Diagnostic and Interventional Neuroradiology, CHRU Nancy, Nancy, Lorraine, France
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Jonathan A Grossberg
- Department of Neurosurgery and Radiology, Emory University School of Medicine, Atlanta, Georgia, USA
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16
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Ye Y, Zhang FT, Wang XY, Tong HX, Zhu YT. Antithrombotic Agents for tPA-Induced Cerebral Hemorrhage: A Systematic Review and Meta-Analysis of Preclinical Studies. J Am Heart Assoc 2020; 9:e017876. [PMID: 33283576 PMCID: PMC7955384 DOI: 10.1161/jaha.120.017876] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/06/2023]
Abstract
Background tPA (tissue‐type plasminogen activator) remains the only approved drug for acute ischemic stroke, with a potentially serious adverse effect: hemorrhagic transformation. The effects of antithrombotic agents on tPA‐induced hemorrhagic transformation after ischemic stroke are not clearly defined. We performed a systematic review and meta‐analysis in preclinical studies aiming to evaluate the efficacy of antithrombotic agents on tPA‐induced hemorrhagic transformation after ischemic stroke. Methods and Results We conducted a systematic review and meta‐analysis of studies testing antithrombotic agents in animal models of tPA‐induced hemorrhagic transformation. The pooled effects were calculated using random‐effects models, and heterogeneity was explored through meta‐regression and subgroup analyses. Publication bias was assessed using trim and fill method and the Egger test. The efficacy of 18 distinct interventions was described in 22 publications. The pooled data showed a significant improvement in cerebral hemorrhage, infarct size, and neurobehavioral outcome in treated compared with control animals (standardized mean difference, 0.45 [95% CI, 0.11–0.78]; standardized mean difference, 1.18 [95% CI, 0.73–1.64]; and standardized mean difference, 0.91 [95% CI, 0.49–1.32], respectively). Subgroup analysis indicated that quality score, random allocation, control of temperature, anesthetic used, stroke model used, route of drug delivery, time of drug administration, and time of assessment were significant factors that influenced the effects of interventions. Conclusions Administration with antiplatelet agents revealed statistically significant improvement in all the outcomes. Anticoagulant agents showed significant effects in infarct size and neurobehavioral score, but fibrinolytic agents did not show any significant improvement in all the outcomes. The conclusions should be interpreted cautiously given the heterogeneity and publication bias identified in this analysis.
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Affiliation(s)
- Yang Ye
- Department of Integration of Chinese and Western Medicine School of Basic Medical Sciences Peking University Beijing China.,Tasly Microcirculation Research Center Peking University Health Science Center Beijing China
| | - Fu-Tao Zhang
- University of Chinese Academy of Sciences Beijing China.,Northeast Institute of Geography and Agroecology Chinese Academy of Sciences Harbin China.,National Engineering Laboratory for Improving Quality of Arable Land Institute of Agricultural Resources and Regional Planning Chinese Academy of Agricultural Sciences Beijing China
| | - Xiao-Yi Wang
- Department of Integration of Chinese and Western Medicine School of Basic Medical Sciences Peking University Beijing China.,Tasly Microcirculation Research Center Peking University Health Science Center Beijing China
| | - Hong-Xuan Tong
- Institute of Basic Theory for Chinese Medicine China Academy of Chinese Medical Sciences Beijing China
| | - Yu-Tian Zhu
- Department of Urology Peking University Third Hospital Beijing China
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