1
|
Broocks G, Kniep H, McDonough R, Bechstein M, Heitkamp C, Winkelmeier L, Klapproth S, Faizy TD, Schell M, Schön G, Hanning U, Gellißen S, Kemmling A, Papanagiotou P, Fiehler J, Meyer L. Thrombectomy in ischemic stroke patients with large core but minor ischemic changes on non-enhanced computed tomography. Int J Stroke 2024; 19:764-771. [PMID: 38666480 DOI: 10.1177/17474930241249588] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/12/2024]
Abstract
PURPOSE The Alberta Stroke Program Early CT Score (ASPECTS) is regularly used to guide patient selection for mechanical thrombectomy (MT). Similarly, penumbral imaging based on computed tomography perfusion (CTP) may serve as neuroimaging tool to guide treatment. Yet, patients with a large ischemic core on CTP may show only minor ischemic changes resulting in a high ASPECTS. AIM We hypothesized twofold: (1) the treatment effect of vessel recanalization in patients with core volume > 50 mL but ASPECTS ⩾ 6 is not different compared to high ASPECTS patients with core volume < 50 mL, and (2) recanalization is associated with core overestimation. METHODS We conducted an observational study analyzing ischemic stroke patients consecutively treated with MT after triage by multimodal CT. Functional endpoint was the rate of functional independence at Day 90 defined as modified Rankin Scale (mRS) 0-2. Imaging endpoint was core overestimation, which was considered when CTP-derived core was larger than the final infarct volume assessed on follow-up imaging. Recanalization was evaluated with the extended Thrombolysis in Cerebral Infarction (eTICI) scale. Multivariable logistic regression analysis and propensity score matching (PSM) were used to assess the association of recanalization (eTICI ⩾ 2b) with functional outcome and core overestimation. RESULTS Of 630 patients with ASPECTS ⩾ 6, 91 patients (14.4%) had a large ischemic core. Following 1:1 PSM, the treatment effect of recanalization was not different in patients with large core and ASPECTS ⩾ 6 (+ 25.8%, 95% CI: 16.3-35.4, p < 0.001) compared to patients with ASPECTS ⩾ 6 and core volume < 50 mL (+ 14.9%, 95% CI: 5.7-24.1, p = 0.002). Recanalization (aOR: 3.46, 95% CI: 1.85-6.47, p < 0.001) and higher core volume (aOR: 1.03, 95% CI: 1.02-1.04, p < 0.001) were significantly associated with core overestimation. CONCLUSION In patients with ASPECTS ⩾ 6, core volumes did not significantly modify outcomes following recanalization. Reperfusion and higher core volume were significantly associated with core overestimation which may explain the treatment effect of MT for patients with a large ischemic core but minor ischemic changes on non-enhanced CT. DATA ACCESS STATEMENT The data analyzed in this study will be available and shared on reasonable request from any qualified researcher for the purpose of replicating the results after clearance by the local ethics committee.
Collapse
Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Neuroradiology, HELIOS Medical Center, Campus of MSH Medical School Hamburg, Schwerin, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Heitkamp
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laurens Winkelmeier
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susan Klapproth
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maximilian Schell
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Gellißen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andre Kemmling
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Marburg, Marburg, Germany
| | - Panagiotis Papanagiotou
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte, Bremen, Germany
- Department of Radiology, Areteion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
2
|
Broocks G, McDonough RV, Bechstein M, Klapproth S, Faizy TD, Schön G, Kniep HC, Bester M, Hanning U, Kemmling A, Zeleñák K, Fiehler J, Meyer L. Thrombectomy in Patients With Ischemic Stroke Without Salvageable Tissue on CT Perfusion. Stroke 2024; 55:1317-1325. [PMID: 38572635 DOI: 10.1161/strokeaha.123.044916] [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: 08/21/2023] [Accepted: 02/22/2024] [Indexed: 04/05/2024]
Abstract
BACKGROUND Computed tomography perfusion (CTP) imaging is regularly used to guide patient selection for mechanical thrombectomy (MT). However, the effect of MT in patients without salvageable tissue on CTP has not been investigated. The purpose of this study was to assess the effect of MT in patients with stroke without perfusion mismatch profiles. METHODS This observational study analyzed patients with ischemic stroke consecutively treated between March 1, 2015, and January 31, 2022, triaged by multimodal-computed tomography undergoing MT. CTP lesion-core mismatch profiles were defined using a mismatch volume/ratio of ≥10 mL/1.2, respectively. The primary end point was the rate of functional independence at 90 days, defined as the modified Rankin Scale score of 0 to 2. Recanalization was evaluated with the modified Thrombolysis in Cerebral Infarction scale. The effect of baseline variables on functional outcome was assessed using multivariable logistic regression analysis. Outcomes of patients with and without CTP-mismatch profiles were compared using 1:1 propensity score matching. RESULTS Of 724 patients who met the inclusion criteria of this retrospective observational study, 110 (15%) patients had no CTP mismatch and were analyzed. The median age was 74 (interquartile range, 62-80) years and 53% were women. Successful recanalization (modified Thrombolysis in Cerebral Infarction score, ≥2b) was achieved in 66% (73) and associated with functional independence at 90 days (adjusted odds ratio, 7.33 [95% CI, 1.22-43.70]; P=0.03). A significant interaction was observed between recanalization and age, as well as the extent of infarction, indicating MT to be most effective in patients <70 years and with a baseline Alberta Stroke Program Early Computed Tomography Score range between 3 and 7. These findings remained stable after propensity score matching, analyzing 152 matched pairs with similar rates of functional independence between patients with and without CTP-mismatch profiles (17% versus 23%; P=0.42). CONCLUSIONS In patients without CTP-mismatch profiles defined according to the EXTEND (Extending the Time for Thrombolysis in Emergency Neurological Deficits) criteria, recanalization was associated with improved functional outcomes. This effect was associated with baseline Alberta Stroke Program Early Computed Tomography Score and age, but not with the time from onset to imaging.
Collapse
Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
- Department of Neuroradiology, HELIOS Medical Center, Campus of MSH Medical School Hamburg, Schwerin, Germany (G.B.)
| | | | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Susan Klapproth
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Gerhard Schön
- Institute of Medical Biometry and Epidemiology (G.S.) University Medical Center Hamburg-Eppendorf, Germany
| | - Helge C Kniep
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Maxim Bester
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - André Kemmling
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Marburg, Marburg, Germany (A.K.)
| | - Kamil Zeleñák
- Department of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Martin, Slovakia (K.Z.)
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology (G.B., R.V.M., M.B., S.K., T.D.F., H.C.K., M.B., U.H., J.F., L.M.), University Medical Center Hamburg-Eppendorf, Germany
| |
Collapse
|
3
|
Sun D, Guo X, Nguyen TN, Pan Y, Ma G, Tong X, Raynald, Wang M, Ma N, Gao F, Mo D, Huo X, Miao Z. Alberta Stroke Program Early Computed Tomography Score, Infarct Core Volume, and Endovascular Therapy Outcomes in Patients With Large Infarct: A Secondary Analysis of the ANGEL-ASPECT Trial. JAMA Neurol 2024; 81:30-38. [PMID: 38010691 PMCID: PMC10682939 DOI: 10.1001/jamaneurol.2023.4430] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/17/2023] [Accepted: 09/28/2023] [Indexed: 11/29/2023]
Abstract
Importance Endovascular therapy (EVT) demonstrated better outcomes compared with medical management in recent randomized clinical trials (RCTs) of patients with large infarct. Objective To compare outcomes of EVT vs medical management across different strata of the Alberta Stroke Program Early Computed Tomography Score (ASPECTS) and infarct core volume in patients with large infarct. Design, Setting, and Participants This prespecified secondary analysis of subgroups of the Endovascular Therapy in Acute Anterior Circulation Large Vessel Occlusive Patients With a Large Infarct Core (ANGEL-ASPECT) RCT included patients from 46 stroke centers across China between October 2, 2020, and May 18, 2022. Participants were enrolled within 24 hours of symptom onset and had ASPECTS of 3 to 5 or 0 to 2 and infarct core volume of 70 to 100 mL. Patients were divided into 3 groups: ASPECTS of 3 to 5 with infarct core volume less than 70 mL, ASPECTS of 3 to 5 with infarct core volume of 70 mL or greater, and ASPECTS of 0 to 2. Interventions Endovascular therapy or medical management. Main Outcomes and Measures The primary outcome was the ordinal 90-day modified Rankin Scale (mRS) score. Results There were 455 patients in the trial; median age was 68 years (IQR, 60-73 years), and 279 (61.3%) were male. The treatment effect did not vary significantly across the 3 baseline imaging subgroups (P = .95 for interaction). The generalized odds ratio for the shift in the 90-day mRS distribution toward better outcomes with EVT vs medical management was 1.40 (95% CI, 1.06-1.85; P = .01) in patients with ASPECTS of 3 to 5 and infarct core volume less than 70 mL, 1.22 (95% CI, 0.81-1.83; P = .23) in patients with ASPECTS of 3 to 5 and infarct core volume of 70 mL or greater, and 1.59 (95% CI, 0.89-2.86; P = .09) in patients with ASPECTS of 0 to 2. Conclusions and Relevance In this study, no significant interaction was found between baseline imaging status and the benefit of EVT compared with medical management in patients with large infarct core volume. However, estimates within subgroups were underpowered. A pooled analysis of large core trials stratified by ASPECTS and infarct core volume strata is warranted. Trial Registration ClinicalTrials.gov Identifier: NCT04551664.
Collapse
Affiliation(s)
- Dapeng Sun
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Guo
- Cerebrovascular Disease Department, Neurological Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Thanh N. Nguyen
- Department of Neurology, Radiology, Boston Medical Center, Boston, Massachusetts
| | - Yuesong Pan
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gaoting Ma
- Department of Neurology, Beijing Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Raynald
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Mengxing Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Radiology, Boston Medical Center, Boston, Massachusetts
| | - Dapeng Mo
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Radiology, Boston Medical Center, Boston, Massachusetts
| | - Xiaochuan Huo
- Cerebrovascular Disease Department, Neurological Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| |
Collapse
|
4
|
Broocks G, Meyer L, Bechstein M, Elsayed S, Schön G, Kniep H, Kemmling A, Hanning U, Fiehler J, McDonough RV. Penumbra salvage in extensive stroke: exploring limits for reperfusion therapy. J Neurointerv Surg 2023; 15:e419-e425. [PMID: 36878689 DOI: 10.1136/jnis-2022-020025] [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: 12/22/2022] [Accepted: 02/17/2023] [Indexed: 03/08/2023]
Abstract
BACKGROUND The effect of thrombectomy in patients presenting with extensive ischemic stroke at baseline is currently being investigated; it remains uncertain to what extent brain tissue may be saved by reperfusion in such patients. Penumbra salvage volume (PSV) has been described as a tool to measure the volume of rescued penumbra. OBJECTIVE To assess whether the effect of recanalization on PSV is dependent on the extent of early ischemic changes. METHODS Observational study of patients with anterior circulation ischemic stroke triaged by multimodal-CT undergoing thrombectomy. PSV was defined as the difference between baseline penumbra volume and net infarct growth to follow-up. The effect of vessel recanalization on PSV depending on the extent of early ischemic changes (defined using Alberta Stroke Program Early CT Score (ASPECTS) and core volumes based on relative cerebral blood flow) was determined using multivariable linear regression analysis, and the association with functional outcome at day 90 was tested using multivariable logistic regression. RESULTS 384 patients were included, of whom 292 (76%) achieved successful recanalization (modified Thrombolysis in Cerebral Infarction ≥2b). Successful recanalization was independently associated with 59 mL PSV (95% CI 29.8 to 88.8 mL) and was linked to increased penumbra salvage up to an ASPECTS of 3 and core volume up to 110 mL. Recanalization was associated with a higher probability of a modified Rankin Scale score of ≤2 up to a core volume of 100 mL. CONCLUSIONS Recanalization was associated with significant penumbra salvage up to a lower ASPECTS margin of 3 and upper core volume margin of 110 mL. The clinical benefit of recanalization for patients with very large ischemic regions of >100 mL or ASPECTS <3 remains uncertain and requires prospective investigation.
Collapse
Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sarah Elsayed
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rosalie V McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| |
Collapse
|
5
|
Migdady I, Johnson-Black PH, Leslie-Mazwi T, Malhotra R. Current and Emerging Endovascular and Neurocritical Care Management Strategies in Large-Core Ischemic Stroke. J Clin Med 2023; 12:6641. [PMID: 37892779 PMCID: PMC10607145 DOI: 10.3390/jcm12206641] [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: 09/16/2023] [Revised: 10/17/2023] [Accepted: 10/18/2023] [Indexed: 10/29/2023] Open
Abstract
The volume of infarcted tissue in patients with ischemic stroke is consistently associated with increased morbidity and mortality. Initial studies of endovascular thrombectomy for large-vessel occlusion excluded patients with established large-core infarcts, even when large volumes of salvageable brain tissue were present, due to the high risk of hemorrhagic transformation and reperfusion injury. However, recent retrospective and prospective studies have shown improved outcomes with endovascular thrombectomy, and several clinical trials were recently published to evaluate the efficacy of endovascular management of patients presenting with large-core infarcts. With or without thrombectomy, patients with large-core infarcts remain at high risk of in-hospital complications such as hemorrhagic transformation, malignant cerebral edema, seizures, and others. Expert neurocritical care management is necessary to optimize blood pressure control, mitigate secondary brain injury, manage cerebral edema and elevated intracranial pressure, and implement various neuroprotective measures. Herein, we present an overview of the current and emerging evidence pertaining to endovascular treatment for large-core infarcts, recent advances in neurocritical care strategies, and their impact on optimizing patient outcomes.
Collapse
Affiliation(s)
- Ibrahim Migdady
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurological Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Health Policy and Management, Mailman School of Public Health, Columbia University, New York, NY 10032, USA
| | - Phoebe H. Johnson-Black
- Department of Neurosurgery, Division of Neurocritical Care, UCLA David Geffen School of Medicine, Ronald Reagan Medical Center, Los Angeles, CA 90095, USA;
| | | | - Rishi Malhotra
- Division of Critical Care Medicine, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurology, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
- Department of Neurological Surgery, Albert Einstein College of Medicine, Montefiore Medical Center, Bronx, NY 10467, USA
| |
Collapse
|
6
|
Molad J, Honig A. Current advances in endovascular treatment. Curr Opin Neurol 2023; 36:125-130. [PMID: 36762653 DOI: 10.1097/wco.0000000000001142] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
PURPOSE OF REVIEW Endovascular thrombectomy (EVT) is the most beneficial reperfusion therapy for acute ischemic stroke. Currently, much effort is done to promote trials examining EVT efficacy and safety in various conditions not included in the main randomized controlled trials established the superiority of EVT. This review summarizes the current advances of EVT patients' selection and periprocedural management. RECENT FINDINGS Recent evidence points to beneficial effect of EVT among patients with relatively large ischemic core, premorbid independent nonagenarians and basilar artery occlusion, and suggest that intravenous thrombolysis bridging treatment is associated with better reperfusion rates. Ongoing trials currently examine EVT efficacy and safety in distal vessel occlusions and in large vessel occlusion with low NIHSS. Current evidence also support use of general anaesthesia and avoid postprocedural extremely low or high blood pressure as well as haemodynamic instability. SUMMARY The field of EVT is rapidly evolving. The results of recent trials have dramatically increased the indications for EVT, with many ongoing trials examining further indications.
Collapse
Affiliation(s)
- Jeremy Molad
- Department of Stroke & Neurology, Tel-Aviv Sourasky Medical Center, Tel-Aviv
| | - Asaf Honig
- Department of Neurology, Soroka Medical Center, Beer-Sheva, Israel
| |
Collapse
|
7
|
Chen M, Leslie-Mazwi TM, Hirsch JA, Albuquerque FC. Large core stroke thrombectomy: paradigm shift or futile exercise? J Neurointerv Surg 2023; 15:413-414. [PMID: 36810356 DOI: 10.1136/jnis-2023-020219] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/14/2023] [Indexed: 02/23/2023]
Affiliation(s)
- Michael Chen
- Neurological Sciences, Rush University Medical Center, Chicago, Illinois, USA
| | | | - Joshua A Hirsch
- NeuroEndovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Felipe C Albuquerque
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| |
Collapse
|
8
|
Jabal MS, Ibrahim MK, Thurnham J, Kallmes KM, Kobeissi H, Ghozy S, Hardy N, Tarchand R, Bilgin C, Heit JJ, Brinjikji W, Kallmes DF. Common Data Elements Analysis of Mechanical Thrombectomy Clinical Trials for Acute Ischemic Stroke with Large Core Infarct. Clin Neuroradiol 2022; 33:307-317. [DOI: 10.1007/s00062-022-01239-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2022] [Accepted: 11/09/2022] [Indexed: 12/23/2022]
|
9
|
Garcia-Esperon C, Bivard A, Johns H, Chen C, Churilov L, Lin L, Butcher K, Kleinig TJ, Choi PMC, Cheng X, Dong Q, Aviv RI, Miteff F, Spratt NJ, Levi CR, Parsons MW. Association of Endovascular Thrombectomy With Functional Outcome in Patients With Acute Stroke With a Large Ischemic Core. Neurology 2022; 99:e1345-e1355. [PMID: 35803723 DOI: 10.1212/wnl.0000000000200908] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2021] [Accepted: 05/16/2022] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Endovascular thrombectomy (EVT) is effective for patients with large vessel occlusion (LVO) stroke with smaller volumes of CT perfusion (CTP)-defined ischemic core. However, the benefit of EVT is unclear in those with a core volume >70 mL. We aimed to compare outcomes of EVT and non-EVT patients with an ischemic core volume ≥70 mL, hypothesizing that there would be a benefit from EVT for fair outcome (3-month modified Rankin scale [mRS] 0-3) after stroke. METHODS A retrospective analysis of patients enrolled into a multicenter (Australia, China, and Canada) registry (2012-2020) who underwent CTP within 24 hours of stroke onset and had a baseline ischemic core volume ≥70 mL was performed. The primary outcome was the estimation of the association of EVT in patients with core volume ≥70 mL and within 70-100 and ≥100 mL subgroups with fair outcome. RESULTS Of the 3,283 patients in the registry, 299 had CTP core volume ≥70 mL and 269 complete data (135 had core volume between 70 and 100 mL and 134 had core volume ≥100 mL). EVT was performed in 121 (45%) patients. EVT-treated patients were younger (median 69 vs 75 years; p = 0.011), had lower prestroke mRS, and smaller median core volumes (92 [79-116.5] mL vs 105.5 [85.75-138] mL, p = 0.004). EVT-treated patients had higher odds of achieving fair outcome in adjusted analysis (30% vs 13.9% in the non-EVT group; adjusted odds ratio [aOR] 2.1, 95% CI 1-4.2, p = 0.038). The benefit was seen predominantly in those with 70-100 mL core volume (71/135 [52.6%] EVT-treated), with 54.3% in the EVT-treated vs 21% in the non-EVT group achieving a fair outcome (aOR 2.5, 95% CI 1-6.2, p = 0.005). Of those with a core volume ≥100 mL, 50 of the 134 (37.3%) underwent EVT. Proportions of fair outcome were very low in both groups (8.1% vs 8.7%; p = 0.908). DISCUSSION We found a positive association of EVT with the 3-month outcome after stroke in patients with a baseline CTP ischemic core volume 70-100 mL but not in those with core volume ≥100 mL. Randomized data to confirm these findings are required. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that EVT is associated with better motor outcomes 3 months after CTP-defined ischemic stroke with a core volume of 70-100 mL.
Collapse
Affiliation(s)
- Carlos Garcia-Esperon
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia.
| | - Andrew Bivard
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia
| | - Hannah Johns
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia
| | - Chushuang Chen
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia
| | - Leonid Churilov
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia
| | - Longting Lin
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia
| | - Kenneth Butcher
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia
| | - Timothy J Kleinig
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia
| | - Philip M C Choi
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia
| | - Xin Cheng
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia
| | - Qiang Dong
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia
| | - Richard I Aviv
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia
| | - Ferdinand Miteff
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia
| | - Neil J Spratt
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia
| | - Christopher R Levi
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia
| | - Mark W Parsons
- From the Department of Neurology (C.G.-E., F.M., N.J.S., C.R.L.), John Hunter Hospital, New Lambton Heights; College of Health, Medicine, and Wellbeing (C.G.-E., F.M., N.J.S., C.R.L., M.W.P.), University of Newcastle; Hunter Medical Research Institute (C.G.-E., C.C., L.L., F.M., N.J.S., C.R.L., M.W.P.), Newcastle; Melbourne Brain Center at the Royal Melbourne Hospital (A.B., H.J., L.C., M.W.P.), University of Melbourne, Parkville; Melbourne Medical School (H.J., L.C.), University of Melbourne, Victoria; Prince of Wales Clinical School (K.B.), University of New South Wales, Sydney; Royal Adelaide Hospital (T.J.K.); Box Hill Hospital (P.M.C.C.), Melbourne; Eastern Health Clinical School (P.M.C.C.), Monash University, Melbourne, Australia; Huashan Hospital (X.C., Q.D.), Fudan University, Shanghai, China; Neuroradiology Section (R.I.A.), Department of Radiology, The Ottawa Hospital and University of Ottawa, Ontario, Canada; and Department of Neurology (L.L., M.W.P.), Liverpool Hospital, Ingham Institute for Applied Medical Research, University of New South Wales South Western Sydney Clinical School, Australia
| | | |
Collapse
|
10
|
Huo X, Ma G, Zhang X, Pan Y, Tong X, Sun D, Liu L, Wang Y, Liebeskind DS, Wang Y, Pereira VM, Ren Z, Miao Z. Endovascular therapy in acute anterior circulation large vessel occlusive patients with a large infarct core (ANGEL-ASPECT): protocol of a multicentre randomised trial. Stroke Vasc Neurol 2022; 8:169-174. [PMID: 36137599 PMCID: PMC10176983 DOI: 10.1136/svn-2022-001865] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2022] [Accepted: 09/07/2022] [Indexed: 11/03/2022] Open
Abstract
BACKGROUND The benefit of stroke thrombectomy for large infarct core still lacks robust randomised controlled studies. AIM To demonstrate the design of a clinical trial on endovascular therapy for acute anterior circulation large vessel occlusion (LVO) patients with large infarct core volume. DESIGN ANGEL-ASPECT is a multicentre, prospective, randomised, open-label, blinded End-point trial to evaluate whether best medical management (BMM) combined with endovascular therapy improves neurological functional outcomes as compared with BMM alone in acute LVO patients with Alberta Stroke Program Early CT Score (ASPECTS) of 3-5 on non-contrast CT or infarct core volume range of 70-100 mL (defined as rCBF <30% on CT perfusion or ADC <620 on MRI) up to 24 hours from symptom onset or last seen well. STUDY OUTCOMES The primary efficacy outcome is 90 (±7) days modified Rankin Scale. Symptomatic intracranial haemorrhage within 48 hours from randomisation is the primary safety outcome. DISCUSSION The ANGEL-ASPECT trial will screen patients with large infarct core (ASPECTS 3-5 or 70-100 mL) through image evaluation criteria within 24 hours and explore the efficacy and safety of endovascular therapy compared with BMM.
Collapse
Affiliation(s)
- Xiaochuan Huo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Beijing, China
| | - Gaoting Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Beijing, China
| | - Xuelei Zhang
- Clinical Research Center, Capital Medical University, Institute of Brain Disorders, Beijing, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Xu Tong
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Beijing, China
| | - Dapeng Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Yilong Wang
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - David S Liebeskind
- Department of Neurology, University of California, Los Angeles, California, USA
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Beijing, China
| | - Vitor Mendes Pereira
- Division of Neurosurgery, Department of Surgery, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Zeguang Ren
- Department of Neurosurgery, The Affiliated Hospital of Guizhou Medical University, Guiyang, Guizhou, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China .,Department of Neurology, Beijing Tiantan Hospital, Beijing, China
| |
Collapse
|
11
|
Fiehler J. Do we need CT perfusion for stroke patients? Define your terms. J Neurointerv Surg 2022; 14:847-848. [PMID: 35961677 DOI: 10.1136/jnis-2022-019481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/02/2022] [Indexed: 11/04/2022]
Affiliation(s)
- Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg Eppendorf, Hamburg, Germany
| |
Collapse
|
12
|
Karamchandani RR, Yang H, Prasad T, Strong D, Rhoten JB, Defilipp G, Clemente J, Stetler WR, Bernard J, Asimos AW. Endovascular Thrombectomy Reduces Risk of Poor Functional Outcomes in Patients Presenting within 0-6 Hours with Large Ischemic Core Volumes on Computed Tomography Perfusion. J Stroke Cerebrovasc Dis 2022; 31:106548. [PMID: 35567936 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106548] [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: 01/18/2022] [Revised: 04/02/2022] [Accepted: 05/01/2022] [Indexed: 12/30/2022] Open
Abstract
INTRODUCTION Patients presenting with large ischemic core volumes (LICVs) on computed tomography perfusion (CTP) are at high risk for poor functional outcomes. We sought to identify predictors of outcome in patients with an internal carotid artery (ICA) or middle cerebral artery (MCA) occlusion and LICV. METHODS A large healthcare system's prospectively collected code stroke registry was utilized for this retrospective analysis of patients presenting within 6 hours with at least 50 ml of CTP reduced relative cerebral blood flow (CBF) < 30%. A multivariable logistic regression model was constructed to identify independent predictors (p < 0.05) of poor discharge outcome (modified Rankin scale score 4-6). RESULTS Over a 38-month period, we identified 104 patients meeting inclusion criteria, with a mean age of 65.4 ± 16.2 years, median presenting National Institutes of Health Stroke Scale score 20 (IQR 16-24), median ischemic core volume (CBF < 30%) 82 ml (IQR 61-118), and median mismatch volume 80 ml (IQR 56-134). Seventy-five patients (72.1%) had a discharge modified Rankin scale score of 4-6. Sixty-six of 104 (63.5%) patients were treated with endovascular thrombectomy (EVT). In the multivariable regression model, EVT (OR 0.303; 95% CI 0.080-0.985; p = 0.049) and lower blood glucose (per 1-point increase, OR 1.014; 95% CI 1.003-1.030; p = 0.030) were independently protective against poor discharge outcome. CONCLUSIONS EVT is independently associated with a reduced risk of poor functional outcome in patients presenting within 6 hours with ICA or MCA occlusions and LICV.
Collapse
Affiliation(s)
- Rahul R Karamchandani
- Department of Neurology, Neurosciences Institute, Atrium Health, 1000 Blythe Blvd, Charlotte, NC 28203, United States, 734.883.7844.
| | - Hongmei Yang
- Information and Analytics Services, Atrium Health, Charlotte, NC, USA, 301.910.5966.
| | - Tanushree Prasad
- Information and Analytics Services, Atrium Health, Charlotte, NC, USA, 603.320.7556.
| | - Dale Strong
- Information and Analytics Services, Atrium Health, Charlotte, NC, USA, 410.940.9178.
| | - Jeremy B Rhoten
- Neurosciences Institute, Atrium Health, Charlotte, NC, USA, 304.654.8820.
| | - Gary Defilipp
- Charlotte Radiology, Neurosciences Institute, Atrium Health, Charlotte, NC, USA, 704.458.9612.
| | - Jonathan Clemente
- Charlotte Radiology, Neurosciences Institute, Atrium Health, Charlotte, NC, USA, 704.604.4283.
| | - William R Stetler
- Carolina Neurosurgery and Spine Associates, Neurosciences Institute, Atrium Health, Charlotte, NC, USA, 205.542.1402.
| | - Joe Bernard
- Carolina Neurosurgery and Spine Associates, Neurosciences Institute, Atrium Health, Charlotte, NC, USA, 704.618.4236.
| | - Andrew W Asimos
- Department of Emergency Medicine, Neurosciences Institute, Atrium Health, Charlotte, NC, USA, 704.804.9861.
| |
Collapse
|
13
|
Broocks G, Haupt W, McDonough R, Elsayed S, Flottmann F, Bechstein M, Schön G, Kniep H, Kemmling A, Zeleňák K, Fiehler J, Hanning U, Meyer L. Impact of relative cerebral blood volume reduction on early neurological improvement in extensive ischemic stroke. Eur J Neurol 2022; 29:3264-3272. [PMID: 35808904 DOI: 10.1111/ene.15491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2022] [Accepted: 06/29/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE The benefit of endovascular treatment (EVT) for patients with low ASPECTS is yet ambiguous and currently investigated in randomized trials. As a tool for estimation of infarct extent and progression, CT-perfusion might predict early neurological improvement (ENI) after EVT. OBJECTIVE We hypothesized that the degree of relative cerebral blood volume (rCBV) reduction is directly associated with ENI in low ASPECTS patients undergoing EVT. METHODS Ischemic stroke patients with ASPECTS≤5 who received multimodal-CT and underwent thrombectomy were analyzed. The rCBV reduction was defined as the ratio of CBV measured in the ischemic lesion and contralateral CBV. Complete reperfusion was defined as eTICI 2c-3. Clinical endpoint was early neurological improvement (ENI) at 24-hours defined continuously (NIHSS change from baseline to 24-hours) and binarized (NIHSS at 24-hours≤8). RESULTS 102 patients were included. Lower rCBV reduction and complete EVT were independently associated with ENI (-11.4 NIHSS points, p=0.04; -7.3 points, p<0.0001, respectively). The effect of complete EVT on ENI was directly linked to the degree of rCBV reduction: the probability for binary ENI was +34.6%, p=0.004 in patients with low rCBV reduction versus +8.2%, p=0.28 in patients with high rCBV reduction. CONCLUSION In ischemic stroke with low ASPECTS, ENI was directly linked to the degree of rCBV reduction as a potential indicator of ischemia depth in extensive baseline infarction. Lower rCBV reduction was associated with higher probability of ENI after complete reperfusion suggesting a less pronounced lesion progression despite its large extent and hence, a higher susceptibility to EVT.
Collapse
Affiliation(s)
- Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Wolfgang Haupt
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Rosalie McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Sarah Elsayed
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Gerhard Schön
- Department of Neuroradiology, University Medical Center Marburg, Marburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Andre Kemmling
- Department of Neuroradiology, University Medical Center Marburg, Marburg, Germany
| | - Kamil Zeleňák
- Department of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Martin, Slovakia
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg
| |
Collapse
|
14
|
Yang H, Lin D, Lin X, Wu Y, Yi T, Chen W. Outcomes and CT Perfusion Thresholds of Mechanical Thrombectomy for Patients With Large Ischemic Core Lesions. Front Neurol 2022; 13:856403. [PMID: 35720105 DOI: 10.3389/fneur.2022.856403] [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: 01/17/2022] [Accepted: 05/02/2022] [Indexed: 11/13/2022] Open
Abstract
Objective To explore the clinical prognosis and factors after mechanical thrombectomy (MT) in patients with large cerebral infarction assessed by computed tomographic perfusion (CTP)and the optimal threshold of cerebral blood flow (CBF) for estimating ischemic core. Methods We analyzed data from the anterior circulation database of our hospital (August 2018-June 2021). Multivariate logistic regression analyses identified the predictors of clinical outcomes for patients with large baseline infarcts (>50 ml) assessed by the MIStar software. The receiver operating characteristic (ROC) analysis was used to explore the cutoff value of factors. Results The present study included one hundred thirty-seven patients with large baseline infarcts. Moreover, 23 (16.8%) patients achieved functionally independent outcomes, and 50 (36.5%) patients died at 90 days. A total of 20 (14.7%) patients had symptomatic intracranial hemorrhage (sICH). The multivariable analysis showed that higher age and larger core volume were independent of poor outcomes. The cutoff value of core volume was 90 ml, and the age was 76 years. Hypertension and rt-PA treatment were independent factors of sICH. Higher age and larger ischemic volume were independent risk factors of mortality. Conclusions Mechanical thrombectomy can be applied in patients with large ischemic core volumes. Patients older than 76 years with large cores (>90 ml) are unlikely to benefit from MT. These findings may be helpful in selecting patients with large baseline infarcts to be treated by MT. The threshold of CBF < 30% is the independent factor, and this is worth evaluating in future studies to find the optimal threshold of CBF.
Collapse
Affiliation(s)
- Hongchao Yang
- Department of Neurosurgery, Beijing Chaoyang Hospital, Capital Medical University, Beijing, China
| | - Dinglai Lin
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Xiaohui Lin
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Yanmin Wu
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Tingyu Yi
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Fujian, China
| | - Wenhuo Chen
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Fujian, China
| |
Collapse
|
15
|
Fiehler J, Nawka MT, Meyer L. Persistent challenges in endovascular treatment decision-making for acute ischaemic stroke. Curr Opin Neurol 2022; 35:18-23. [PMID: 34812746 DOI: 10.1097/wco.0000000000001006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Although endovascular treatment (EVT) is the gold standard for treating acute stroke patients with large vessel occlusion (LVO), multiple challenges in decision-making for specific conditions persist. Recent evidence on a selection of patient subgroups will be discussed in this narrative review. RECENT FINDINGS Two randomized controlled trials (RCTs) have been published in EVT of basilar artery occlusion (BAO). Large single arm studies showed promising results in Patients with low Alberta stroke program early CT score (ASPECTS) and more distal vessel occlusions. Recent data confirm patients with low National Institutes of Health Stroke Scale (NIHSS) despite LVO to represent a heterogeneous and challenging patient group. SUMMARY The current evidence does not justify withholding EVT from BAO patients as none of the RCTs showed any signal of superiority of BMT alone vs. EVT. Patients with low ASPECTS, more distal vessel occlusions and patients with low NIHSS scores should be included into RCTs if possible. Without participation in a RCT, patients should be selected for EVT based on age, severity and type of neurological impairment, time since symptom onset, location of the ischaemic lesion and perhaps also results of advanced imaging.
Collapse
Affiliation(s)
- Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | | |
Collapse
|
16
|
Ren Z, Huo X, Ma G, Tong X, Kumar J, Pressman E, Chen W, Yuan G, Wang AYC, Wei M, Zhang J, Nan G, Zhu Q, Liu Y, Zhang L, Song W, Zhou Z, Wang G, Li T, Luo J, Wang E, Ling W, Ju D, Song C, Liu SD, Gui L, Li T, Liu Y, Zhao J, Guo Z, Zheng H, Sun Y, Xu N, Wang YJ, Miao Z. Selection criteria for large core trials: rationale for the ANGEL-ASPECT study design. J Neurointerv Surg 2021; 14:107-110. [PMID: 34326195 PMCID: PMC8785010 DOI: 10.1136/neurintsurg-2021-017798] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2021] [Indexed: 02/05/2023]
Affiliation(s)
- Zeguang Ren
- Department of Neurosurgery, Cleveland Clinic Martin Health, Port St Lucie, Florida, USA
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Gaoting Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Xu Tong
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | - Jay Kumar
- Department of Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Elliot Pressman
- Department of Neurosurgery and Brain Repair, University of South Florida, Tampa, Florida, USA
| | - Wenhuo Chen
- Department of Neurology, Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, Fujian, China
| | - Guangxiong Yuan
- Department of Emergency, Xiangtan Central Hospital, Xiangtan, Hunan, China
| | - Alvin Yi-Chou Wang
- Department of Neurosurgery, Guangdong Provincial Hospital of Traditional Chinese Medicine, Guangzhou, Guangdong, China
| | - Ming Wei
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Jiangang Zhang
- Department of Neurology, Anyang People's Hospital, Anyang, Henan, China
| | - Guangxian Nan
- Department of Neurology, China-Japan Union Hospital of Jilin University, Changchun, Jilin, China
| | - Qiyi Zhu
- Department of Neurology, Linyi People's Hospital, Linyi, Shandong, China
| | - Yajie Liu
- Department of Neurosurgery, Shenzhen Hospital of Southern Medical University, Shenzhen, Guangdong, China
| | - Liyong Zhang
- Department of Neurosurgery, Liaocheng People's Hospital, Liaocheng, Shandong, China
| | - Weigen Song
- Department of Neurology, Yancheng Third People's Hospital, Yancheng, Jiangsu, China
| | - Zhiming Zhou
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - Guoqing Wang
- Department of Neurology, Bin zhou People's Hospital, Binzhou, Shandong, China
| | - Tianxiao Li
- Department of Cerebrovascular Disease, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Jun Luo
- Department of Neurology, Sichuan Mianyang 404 Hospital, Mianyang, Sichuan, China
| | - En Wang
- Department of Neurology, Taizhou Hospital of Zhejiang Province, Linhai, Zhejiang, China
| | - Wentong Ling
- Department of Neurology, ZhongShan City People's Hospital, Zhongshan, China
| | - Dongsheng Ju
- Department of Neurology, Songyuan Jilin oil Field Hospital, Songyuan, Jilin, China
| | - Cunfeng Song
- Department of Interventional Neuroradiology, Liaocheng 3rd People's Hospital, Liaocheng, Shandong, China
| | - Shu-Dong Liu
- Department of Neurology, Yongchuan Hospital of Chongqing Medical University, Chongqing, China
| | - Liqiang Gui
- Emergency and Critical Stroke Ambulance Center, Langfang Changzheng Hospital, Langfang, Hebei, China
| | - Tong Li
- Department of Neurosurgery, Nanning Second Peoples Hospital, Nanning, Guangxi, China
| | - Yan Liu
- Department of Neurology, Jingjiang People's Hospital, Jingjiang, Jiangsu, China
| | - Junfeng Zhao
- Department of Neurology, SiPing Central People's Hospital, Siping, Jilin, China
| | - Zaiyu Guo
- Department of Neurology, Tianjin teda Hospital, Tianjin, China
| | - Hongbo Zheng
- Department of Neurology, Sichuan University West China Hospital, Chengdu, Sichuan, China
| | - Yaxuan Sun
- Department of Neurology, Shanxi Provincial Peoples Hospital, Taiyuan, Shanxi, China
| | - Na Xu
- Department of Neurology, Xiamen Medical College Affiliated Second Hospital, Xiamen, Fujian, China
| | - Yong Jun Wang
- Department of Neurology, Beijing Tiantan Hospital, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Beijing, China
| | | |
Collapse
|
17
|
Magoufis G, Safouris A, Raphaeli G, Kargiotis O, Psychogios K, Krogias C, Palaiodimou L, Spiliopoulos S, Polizogopoulou E, Mantatzis M, Finitsis S, Karapanayiotides T, Ellul J, Bakola E, Brountzos E, Mitsias P, Giannopoulos S, Tsivgoulis G. Acute reperfusion therapies for acute ischemic stroke patients with unknown time of symptom onset or in extended time windows: an individualized approach. Ther Adv Neurol Disord 2021; 14:17562864211021182. [PMID: 34122624 PMCID: PMC8175833 DOI: 10.1177/17562864211021182] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 05/10/2021] [Indexed: 02/05/2023] Open
Abstract
Recent randomized controlled clinical trials (RCTs) have revolutionized acute ischemic stroke care by extending the use of intravenous thrombolysis and endovascular reperfusion therapies in time windows that have been originally considered futile or even unsafe. Both systemic and endovascular reperfusion therapies have been shown to improve outcome in patients with wake-up strokes or symptom onset beyond 4.5 h for intravenous thrombolysis and beyond 6 h for endovascular treatment; however, they require advanced neuroimaging to select stroke patients safely. Experts have proposed simpler imaging algorithms but high-quality data on safety and efficacy are currently missing. RCTs used diverse imaging and clinical inclusion criteria for patient selection during the dawn of this novel stroke treatment paradigm. After taking into consideration the dismal prognosis of nonrecanalized ischemic stroke patients and the substantial clinical benefit of reperfusion therapies in selected late presenters, we propose rescue reperfusion therapies for acute ischemic stroke patients not fulfilling all clinical and imaging inclusion criteria as an option in a subgroup of patients with clinical and radiological profiles suggesting low risk for complications, notably hemorrhagic transformation as well as local or remote parenchymal hemorrhage. Incorporating new data to treatment algorithms may seem perplexing to stroke physicians, since treatment and imaging capabilities of each stroke center may dictate diverse treatment pathways. This narrative review will summarize current data that will assist clinicians in the selection of those late presenters that will most likely benefit from acute reperfusion therapies. Different treatment algorithms are provided according to available neuroimaging and endovascular treatment capabilities.
Collapse
Affiliation(s)
- Georgios Magoufis
- Interventional Neuroradiology Unit, Metropolitan Hospital, Piraeus, Greece
| | - Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
- Interventional Neuroradiology Unit, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Guy Raphaeli
- Interventional Neuroradiology Unit, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
| | | | - Klearchos Psychogios
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Lina Palaiodimou
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional Radiology Unit, “ATTIKON” University General Hospital, Athens, Greece
| | - Eftihia Polizogopoulou
- Emergency Medicine Clinic, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Michael Mantatzis
- Department of Radiology, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Stephanos Finitsis
- Department of Interventional Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodore Karapanayiotides
- Second Department of Neurology, Aristotle University of Thessaloniki, School of Medicine, Faculty of Health Sciences, AHEPA University Hospital, Thessaloniki, Greece
| | - John Ellul
- Department of Neurology, University Hospital of Patras, School of Medicine, University of Patras, Patras, Greece
| | - Eleni Bakola
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Elias Brountzos
- Second Department of Radiology, Interventional Radiology Unit, “ATTIKON” University General Hospital, Athens, Greece
| | - Panayiotis Mitsias
- Department of Neurology Medical School, University of Crete, Heraklion, Crete, Greece
| | - Sotirios Giannopoulos
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian, University of Athens, School of Medicine, “Attikon” University Hospital, Iras 39, Gerakas Attikis, Athens, 15344, Greece
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA
| |
Collapse
|