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Yedavalli VS, Salim HA, Musmar B, Adeeb N, Essibayi MA, ElNaamani K, Henninger N, Sundararajan SH, Kuhn AL, Khalife J, Ghozy S, Scarcia L, Tan BY, Heit JJ, Regenhardt RW, Cancelliere NM, Bernstock JD, Rouchaud A, Fiehler J, Sheth SA, Puri AS, Dyzmann C, Colasurdo M, Barreau X, Renieri L, Filipe JP, Harker P, Radu RA, Marotta TR, Spears J, Ota T, Mowla A, Jabbour P, Biswas A, Clarençon F, Siegler JE, Nguyen TN, Varela R, Baker A, Altschul D, Gonzalez N, Möhlenbruch MA, Costalat V, Gory B, Stracke P, Aziz-Sultan MA, Hecker C, Shaikh H, Liebeskind DS, Pedicelli A, Alexandre AM, Tancredi I, Faizy TD, Kalsoum E, Lubicz B, Patel AB, Mendes Pereira V, Guenego A, Dmytriw AA. Symptomatic intracerebral hemorrhage in proximal and distal medium middle cerebral artery occlusion patients treated with mechanical thrombectomy. J Neurointerv Surg 2024:jnis-2024-021879. [PMID: 38977305 DOI: 10.1136/jnis-2024-021879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2024] [Accepted: 06/17/2024] [Indexed: 07/10/2024]
Abstract
BACKGROUND Acute ischemic stroke (AIS) caused by distal medium vessel occlusions (DMVOs) represents a significant proportion of overall stroke cases. While intravenous thrombolysis (IVT) has been a primary treatment, advancements in endovascular procedures have led to increased use of mechanical thrombectomy (MT) in DMVO stroke patients. However, symptomatic intracerebral hemorrhage (sICH) remains a critical complication of AIS, particularly after undergoing intervention. This study aims to identify factors associated with sICH in DMVO stroke patients undergoing MT. METHODS This retrospective analysis utilized data from the Multicenter Analysis of Distal Medium Vessel Occlusions: Effect of Mechanical Thrombectomy (MAD-MT) registry, involving 37 centers across North America, Asia, and Europe. Middle cerebral artery (MCA) DMVO stroke patients were included. The primary outcome measured was sICH, as defined per the Heidelberg Bleeding Classification. Univariable and multivariable logistic regression were used to identify factors independently associated with sICH. RESULTS Among 1708 DMVO stroke patients, 148 (8.7%) developed sICH. Factors associated with sICH in DMVO patients treated with MT included older age (adjusted odds ratio (aOR) 1.01, 95% confidence interval (95% CI) 1.00 to 1.03, P=0.048), distal occlusion site (M3, M4) compared with medium occlusions (M2) (aOR 1.71, 95% CI 1.07 to 2.74, P=0.026), prior use of antiplatelet drugs (aOR 2.06, 95% CI 1.41 to 2.99, P<0.001), lower Alberta Stroke Program Early CT Scores (ASPECTS) (aOR 0.75, 95% CI 0.66 to 0.84, P<0.001), higher preoperative blood glucose level (aOR 1.00, 95% CI 1.00 to 1.01, P=0.012), number of passes (aOR 1.27, 95% CI 1.15 to 1.39, P<0.001), and successful recanalization (Thrombolysis In Cerebral Infarction (TICI) 2b-3) (aOR 0.43, 95% CI 0.28 to 0.66, P<0.001). CONCLUSION This study provides novel insight into factors associated with sICH in patients undergoing MT for DMVO, emphasizing the importance of age, distal occlusion site, prior use of antiplatelet drugs, lower ASPECTS, higher preoperative blood glucose level, and procedural factors such as the number of passes and successful recanalization. Pending confirmation, consideration of these factors may improve personalized treatment strategies.
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Affiliation(s)
- Vivek S Yedavalli
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medicine, Baltimore, Maryland, USA
| | - Hamza Adel Salim
- Department of Radiology, Division of Neuroradiology, Johns Hopkins Medicine, Baltimore, Maryland, USA
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | - Basel Musmar
- Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Shreveport, Louisiana, USA
| | - Nimer Adeeb
- Department of Neurosurgery and Interventional Neuroradiology, Louisiana State University, Shreveport, Louisiana, USA
| | - Muhammed Amir Essibayi
- Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Kareem ElNaamani
- Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Nils Henninger
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, Massachusetts, USA
| | - Sri Hari Sundararajan
- Department of Endovascular Neurosurgery and Neuroradiology, NJMS, Newark, New Jersey, USA
| | - Anna Luisa Kuhn
- Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Jane Khalife
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, New Jersey, USA
| | - Sherief Ghozy
- Departments of Neurological Surgery & Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Luca Scarcia
- Department of Neuroradiology, Henri Mondor Hospital, Creteil, France
| | - Benjamin Yq Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Jeremy Josef Heit
- Department of Interventional Neuroradiology, Stanford Medical Center, Palo Alto, California, USA
| | - Robert W Regenhardt
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | - Nicole M Cancelliere
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St Michael's Hospital, Toronto, Ontario, Canada
| | - Joshua D Bernstock
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Aymeric Rouchaud
- University Hospital of Limoges, Neuroradiology Department, Dupuytren, Université de Limoges, XLIM CNRS, UMR 7252, Limoges, France
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Sunil A Sheth
- Department of Neurology, UTHealth McGovern Medical School, Houston, Texas, USA
| | - Ajit S Puri
- Division of Neurointerventional Radiology, Department of Radiology, University of Massachusetts Medical School, Worcester, Massachusetts, USA
| | - Christian Dyzmann
- Neuroradiology Department, Sana Kliniken, Lübeck GmbH, Lübeck, Schleswig-Holstein, Germany
| | - Marco Colasurdo
- Department of Interventional Radiology, Oregon Health and Science University, Portland, Oregon, USA
| | - Xavier Barreau
- Interventional Neuroradiology Department, Bordeaux University Hospital, Bordeaux, France
| | - Leonardo Renieri
- Interventistica Neurovascolare, Ospedale Careggi di Firenze, Florence, Italy
| | - João Pedro Filipe
- Department of Diagnostic and Interventional Neuroradiology, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Pablo Harker
- Department of Neurology, University of Cincinnati Medical Center, Cincinnati, Ohio, USA
| | - Răzvan Alexandru Radu
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Thomas R Marotta
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St Michael's Hospital, Toronto, Ontario, Canada
| | - Julian Spears
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St Michael's Hospital, Toronto, Ontario, Canada
| | - Takahiro Ota
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Ashkan Mowla
- Division of Stroke and Endovascular Neurosurgery, Department of Neurological Surgery, Keck School of Medicine University of Southern California (USC), Los Angeles, California, USA
| | - Pascal Jabbour
- Department of Neurosurgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Arundhati Biswas
- Department of Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Frédéric Clarençon
- GRC BioFast, Sorbonne Université, Paris, France
- Department of Neuroradiology, Pitié-Salpêtrière Hospital, Paris, France
| | - James E Siegler
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, New Jersey, USA
| | - Thanh N Nguyen
- Departments of Radiology & Neurology, Boston Medical Center, Boston, Massachusetts, USA
| | - Ricardo Varela
- Department of Neurology, Centro Hospitalar Universitário do Porto, Porto, Portugal
| | - Amanda Baker
- Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - David Altschul
- Department of Neurological Surgery and Montefiore-Einstein Cerebrovascular Research Lab, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Nestor Gonzalez
- Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, California, USA
| | - Markus A Möhlenbruch
- Sektion Vaskuläre und Interventionelle Neuroradiologie, Universitätsklinikum Heidelberg, Heidelberg, Germany
| | - Vincent Costalat
- Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier University Medical Center, Montpellier, France
| | - Benjamin Gory
- Department of Interventional Neuroradiology, Nancy University Hospital, Nancy, France
- INSERM U1254, IADI, Université de Lorraine, Vandœuvre-lès-Nancy, France
| | - Paul Stracke
- Department of Radiology, Interventional Neuroradiology Section, University Medical Center Münster, Münster, Germany
| | - Mohammad Ali Aziz-Sultan
- Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Constantin Hecker
- Departments of Neurology & Neurosurgery, Christian Doppler Clinic, Paracelsus Medical University Salzburg, Salzburg, Austria
| | - Hamza Shaikh
- Cooper Neurological Institute, Cooper University Hospital, Cooper Medical School of Rowen University, Camden, New Jersey, USA
| | - David S Liebeskind
- UCLA Stroke Center and Department of Neurology Department, UCLA, Los Angeles, California, USA
| | - Alessandro Pedicelli
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Andrea M Alexandre
- UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Illario Tancredi
- Department of Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Erwah Kalsoum
- Department of Neuroradiology, Henri Mondor Hospital, Creteil, France
| | - Boris Lubicz
- Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Aman B Patel
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
| | - Vitor Mendes Pereira
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St Michael's Hospital, Toronto, Ontario, Canada
| | - Adrien Guenego
- Department of Diagnostic and Interventional Neuroradiology, Erasme University Hospital, Brussels, Belgium
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Harvard University, Boston, Massachusetts, USA
- Neurovascular Centre, Departments of Medical Imaging and Neurosurgery, St Michael's Hospital, Toronto, Ontario, Canada
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Sun D, Li S, Raynald, Huo X, Jia B, Tong X, Wang A, Ma N, Gao F, Mo D, Nguyen TN, Miao Z. Outcomes of antiplatelet therapy before endovascular treatment of acute large vessel occlusion: Data from the ANGEL-ACT registry. J Neuroradiol 2024; 51:101183. [PMID: 38346535 DOI: 10.1016/j.neurad.2024.02.001] [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: 09/06/2023] [Revised: 12/26/2023] [Accepted: 02/09/2024] [Indexed: 02/16/2024]
Abstract
OBJECTIVES To investigate whether single or dual antiplatelet therapy (SAPT or DAPT) within 24 hours before endovascular treatment (EVT) could improve the clinical outcomes of patients with large vessel occlusion (LVO). METHODS Patients from the ANGEL-ACT registry were divided into antiplatelet therapy (APT) and non-APT groups. The APT group was divided into SAPT and DAPT groups. Outcome measurement included 90-day modified Rankin Scale (mRS) distribution, change in the NIHSS at 7 days or discharge, number of passes, modified first pass effect (mFPE), symptomatic intracranial hemorrhage (SICH), and mortality within 90 days. To compare the outcomes, we performed multivariable analyses by adjusting for the propensity score calculated by the logistic regression model. RESULTS Of 1611 patients, 1349 were in the non-APT group, while 262 (16.3 %) were in the APT group (122 [46.6 %] received SAPT, 140 [53.4 %] received DAPT). APT, SAPT or DAPT were not associated with a shift to better outcomes (non-APT vs. APT, 3[0-5] vs. 3[0-5], common odds ratio [OR], 1.04, 95 %confidence interval [CI]:0.82-1.34, P = 0.734). DAPT was associated with mFPE (OR,2.05, 95 %CI:1.39-3.01, P<0.001), more NIHSS reduction at 7 days or discharge (β, -2.13, 95 %CI: -4.02--0.24, P = 0.028), lower number of passes (β, -0.40, 95 %CI: -0.68--0.12, P=0.006), and shorter procedure duration (β, -12.4, 95 %CI: -23.74--1.05, P = 0.032) without increasing odds of successful recanalization, PH within 24 hours and mortality with 90 days . CONCLUSIONS APT before MT for AIS due to LVO does not affect clinical outcome in 90 days despite a tendency to reduce MT procedure time and number of passes. APT before MT in LVO does not increase SICH or mortality rates.
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Affiliation(s)
- Dapeng Sun
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Shuo Li
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Raynald
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaochuan Huo
- Cerebrovascular Disease Department, Neurological Disease Center, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Baixue Jia
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anxin 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
| | - Feng Gao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Thanh N Nguyen
- Department of Neurology, Radiology, Boston Medical Center, Boston, Massachusetts, USA
| | - Zhongrong Miao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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3
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Jia M, Jin F, Li S, Ren C, Ruchi M, Ding Y, Zhao W, Ji X. No-reflow after stroke reperfusion therapy: An emerging phenomenon to be explored. CNS Neurosci Ther 2024; 30:e14631. [PMID: 38358074 PMCID: PMC10867879 DOI: 10.1111/cns.14631] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 01/02/2024] [Accepted: 01/21/2024] [Indexed: 02/16/2024] Open
Abstract
In the field of stroke thrombectomy, ineffective clinical and angiographic reperfusion after successful recanalization has drawn attention. Partial or complete microcirculatory reperfusion failure after the achievement of full patency of a former obstructed large vessel, known as the "no-reflow phenomenon" or "microvascular obstruction," was first reported in the 1960s and was later detected in both experimental models and patients with stroke. The no-reflow phenomenon (NRP) was reported to result from intraluminal occlusions formed by blood components and extraluminal constriction exerted by the surrounding structures of the vessel wall. More recently, an emerging number of clinical studies have estimated the prevalence of the NRP in stroke patients following reperfusion therapy, ranging from 3.3% to 63% depending on its evaluation methods or study population. Studies also demonstrated its detrimental effects on infarction progress and neurological outcomes. In this review, we discuss the research advances, underlying pathogenesis, diagnostic techniques, and management approaches concerning the no-reflow phenomenon in the stroke population to provide a comprehensive understanding of this phenomenon and offer references for future investigations.
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Affiliation(s)
- Milan Jia
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Feiyang Jin
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Sijie Li
- Department of Emergency, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Changhong Ren
- Beijing Key Laboratory of Hypoxic Conditioning Translational Medicine, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Mangal Ruchi
- Department of NeurosurgeryWayne State University School of MedicineDetroitMichiganUSA
| | - Yuchuan Ding
- Department of NeurosurgeryWayne State University School of MedicineDetroitMichiganUSA
| | - Wenbo Zhao
- Department of Neurology, Xuanwu HospitalCapital Medical UniversityBeijingChina
| | - Xunming Ji
- Department of Neurosurgery, Xuanwu HospitalCapital Medical UniversityBeijingChina
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4
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Wu H, Qian J, Shen W, Zhu J, Wu Y, Gu J, Zhang Q. Impact of prior antiplatelet therapy on outcomes of acute ischemic stroke undergoing endovascular treatment: A systematic review and meta-analysis. J Clin Neurosci 2024; 119:22-29. [PMID: 37976911 DOI: 10.1016/j.jocn.2023.11.001] [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: 08/08/2023] [Revised: 10/23/2023] [Accepted: 11/01/2023] [Indexed: 11/19/2023]
Abstract
It is unclear how prior antiplatelet (APT) therapy affects outcomes of acute ischemic stroke (AIS) undergoing endovascular treatment. This review pooled data from the literature to compare outcomes of AIS between prior APT users vs non-users. PubMed, Embase, CENTRAL, and Scopus for studies were searched for studies comparing outcomes of AIS between APT users vs non-users up to 30th May 2023. Ten studies were included comparing 2648 APT users with 5076 non-users. Meta-analysis failed to demonstrate any statistically significant difference in symptomatic intracranial hemorrhage (sICH) but there was a tendency of higher mortality rates in prior APT users vs non-users. Although patients with prior APT therapy had significantly higher rates of successful recanalization as compared to patients with no prior APT treatment, meta-analysis showed significantly lower odds of functional independence amongst APT users vs non-users (OR: 0.77 95% CI: 0.68, 0.87 I2 = 22%). However, pooled analysis of adjusted data with fewer studies showed that there was no difference in sICH (OR: 1.04 95% CI: 0.78, 1.39 I2 = 0%), mortality (OR: 0.89 95% CI: 0.47, 1.68 I2 = 68%), successful recanalization (OR: 1.34 95% CI: 0.96, 1.88 I2 = 54%), and functional independence (OR: 0.96 95% CI: 0.81, 1.14 I2 = 0%) between APT users and non-users. Analysis of crude data indicates that prior APT therapy may improve successful recanalization without increasing sICH rates in AIS patients treated with endovascular therapy. However, there was an adverse effect of APT therapy on 3-month functional and survival outcomes. After adjustment of confounders, there was no difference in the odds of sICH, mortality, successful recanalization, and functional independence between APT users vs non-users.
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Affiliation(s)
- Huichao Wu
- Department of Emergency, First People's Hospital of Jiashan County, China
| | - Jiale Qian
- Department of nursing, First People's Hospital of Jiashan County, China
| | - Wei Shen
- Department of Infectious Diseases, First People's Hospital of Jiashan County, China
| | - Jiayi Zhu
- Department of General Medicine, Youchegang Town Health Center, Xiuzhou District, Jiaxing City, China
| | - Yuanling Wu
- Department of Emergency, Jiashan County Hospital of Traditional Chinese Medicine, China
| | - Jingying Gu
- Department of Internal Medicine, Xitang Health Center, Jiashan County, China
| | - Qing Zhang
- Department of Emergency, First People's Hospital of Jiashan County, China.
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5
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Klail T, Sedova P, Vinklarek JF, Kovacova I, Bar M, Cihlar F, Cernik D, Kočí L, Jura R, Herzig R, Husty J, Kocher M, Kovar M, Nevšímalová M, Raupach J, Rocek M, Sanak D, Sevcik P, Skoloudik D, Sramek M, Vanicek J, Vaško P, Vaclavik D, Tomek A, Mikulik R. Safety and Efficacy of Baseline Antiplatelet Treatment in Patients Undergoing Mechanical Thrombectomy for Ischemic Stroke: Antiplatelets Before Mechanical Thrombectomy. J Vasc Interv Radiol 2023; 34:1502-1510.e12. [PMID: 37192724 DOI: 10.1016/j.jvir.2023.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 03/17/2023] [Accepted: 05/08/2023] [Indexed: 05/18/2023] Open
Abstract
PURPOSE To investigate the safety and efficacy of baseline antiplatelet treatment in patients with acute ischemic stroke (AIS) undergoing mechanical thrombectomy (MT). MATERIALS AND METHODS Baseline use of antiplatelet medication before MT for (AIS) may provide benefit on reperfusion and clinical outcome but could also carry an increased risk of intracranial hemorrhage (ICH). All consecutive patients with AIS and treated with MT with and without intravenous thrombolysis (IVT) between January 2012 and December 2019 in all centers performing MT nationwide were reviewed. Data were prospectively collected in national registries (eg, SITS-TBY and RES-Q). Primary outcome was functional independence (modified Rankin Scale 0-2) at 3 months; secondary outcome was ICH. RESULTS Of the 4,351 patients who underwent MT, 1,750 (40%) and 666 (15%) were excluded owing to missing data from the functional independence and ICH outcome cohorts, respectively. In the functional independence cohort (n = 2,601), 771 (30%) patients received antiplatelets before MT. Favorable outcome did not differ in any antiplatelet, aspirin, and clopidogrel groups when compared with that in the no-antiplatelet group: odds ratio (OR), 1.00 (95% CI, 0.84-1.20); OR, 1.05 (95% CI, 0.86-1.27); and OR, 0.88 (95% CI, 0.55-1.41), respectively. In the ICH cohort (n = 3,685), 1095 (30%) patients received antiplatelets before MT. The rates of ICH did not increase in any treatment options (any antiplatelet, aspirin, clopidogrel, and dual antiplatelet groups) when compared with those in the no-antiplatelet group: OR, 1.03 (95% CI, 0.87-1.21); OR, 0.99 (95% CI, 0.83-1.18); OR, 1.10 (95% CI, 0.82-1.47); and OR, 1.43 (95% CI, 0.87-2.33), respectively. CONCLUSIONS Antiplatelet monotherapy before MT did not improve functional independence or increase the risk of ICH.
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Affiliation(s)
- Tomas Klail
- Faculty of Medicine, Masaryk University, Brno, Czech Republic; University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Bern, Switzerland
| | - Petra Sedova
- Department of Neurology, St Anne's University Hospital, Brno, Czech Republic; International Clinical Research Centre, Stroke Research Program, St Anne's University Hospital, Brno, Czech Republic; Faculty of Medicine, Masaryk University, Brno, Czech Republic; Department of Neurology, Mayo Clinic, Rochester, Minnesota; Department of Internal Medicine and Cardiology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic.
| | - Jan F Vinklarek
- Department of Neurology, St Anne's University Hospital, Brno, Czech Republic; Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Ingrid Kovacova
- International Clinical Research Centre, Stroke Research Program, St Anne's University Hospital, Brno, Czech Republic
| | - Michal Bar
- Department of Neurology, University Hospital, Ostrava, Czech Republic; Faculty of Medicine, Ostrava University, Ostrava, Czech Republic
| | - Filip Cihlar
- Department of Radiology, Masaryk's Hospital, Faculty of Health Studies, J.E. Purkinje University, KZ a.s., Ústí nad Labem, Czech Republic
| | - David Cernik
- Department of Radiology, Masaryk's Hospital, Faculty of Health Studies, J.E. Purkinje University, KZ a.s., Ústí nad Labem, Czech Republic
| | - Lubomir Kočí
- Neurocentre, Regional Hospital Liberec, Liberec, Czech Republic
| | - Rene Jura
- Faculty of Medicine, Masaryk University, Brno, Czech Republic; Department of Neurology, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Roman Herzig
- Department of Neurology, Comprehensive Stroke Centre, Charles University Faculty of Medicine and University Hospital in Hradec Králové, Hradec Králové, Czech Republic
| | - Jakub Husty
- Faculty of Medicine, Masaryk University, Brno, Czech Republic; Department of Radiology and Nuclear Medicine, University Hospital Brno and Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Martin Kocher
- Department of Radiology, Palacky University Medical School and Hospital, Olomouc, Czech Republic
| | - Martin Kovar
- Department of Neurology, Na Homolce Hospital, Prague, Czech Republic
| | - Miroslava Nevšímalová
- Department of Neurology, Hospital Ceske Budejovice, Ceske Budejovice, Czech Republic
| | - Jan Raupach
- Department of Radiology, University Hospital and Faculty of Medicine Hradec Králové, Charles University in Prague, Hradec Králové, Czech Republic
| | - Miloslav Rocek
- Department of Radiology, 2nd Medical School of Charles University and Motol University Hospital, Prague, Czech Republic
| | - Daniel Sanak
- Department of Neurology, Palacky Medical School and University Hospital, Comprehensive Stroke Center, Olomouc, Czech Republic
| | - Petr Sevcik
- Department of Neurology, Faculty of Medicine in Pilsen, Charles University, Pilsen, Czech Republic
| | - David Skoloudik
- Center for Health Research, Medical Faculty, Ostrava University, Ostrava, Czech Republic
| | - Martin Sramek
- Department of Neurosurgery and Neurooncology, 1st Faculty of Medicine, Charles University and Military University Hospital, Prague, Czech Republic; Department of Clinical Neurosciences, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Jiri Vanicek
- Department of Medical Imaging, St Anne's University Hospital, Brno, Czech Republic; Faculty of Medicine, Masaryk University, Brno, Czech Republic
| | - Peter Vaško
- Department of Neurology, Faculty Hospital Kralovske Vinohrady and 3rd Faculty of Medicine, Charles University Prague, Prague, Czech Republic
| | - Daniel Vaclavik
- Neurology, Agel Research and Training Institute, Ostrava Vitkovice Hospital, Ostrava, Czech Republic; Department of Clinical Neurosciences, Faculty of Medicine, University of Ostrava, Ostrava, Czech Republic
| | - Ales Tomek
- Department of Neurology, 2nd Medical School of Charles University and Motol University Hospital, Prague, Czech Republic
| | - Robert Mikulik
- Department of Neurology, St Anne's University Hospital, Brno, Czech Republic; International Clinical Research Centre, Stroke Research Program, St Anne's University Hospital, Brno, Czech Republic; Faculty of Medicine, Masaryk University, Brno, Czech Republic
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Alobaida M, Lip GYH, Lane DA, Sagris D, Hill A, Harrison SL. Endovascular treatment for ischemic stroke patients with and without atrial fibrillation, and the effects of adjunctive pharmacotherapy: a narrative review. Expert Opin Pharmacother 2023; 24:377-388. [PMID: 36541626 DOI: 10.1080/14656566.2022.2161362] [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: 12/24/2022]
Abstract
INTRODUCTION Endovascular thrombectomy (EVT) is associated with good clinical outcomes in patients with ischemic stroke, but the impact of EVT on clinical outcomes in patients with ischemic stroke with and without atrial fibrillation (AF), and the effect of adjunctive pharmacological therapies with EVT, remains unclear. AREAS COVERED The goal of this narrative review is to provide an overview of studies which have examined: 1) associations between EVT and outcomes for patients following ischemic stroke, 2) associations between EVT and outcomes for patients following ischemic stroke with and without AF , including function, reperfusion, hemorrhage, and mortality, 3) the effect of adjunctive pharmacological therapies peri- and post-thrombectomy, and 4) integration of prehospital care on endovascular treatment outcomes. EXPERT OPINION There is little evidence from randomized controlled trials on the effect of AF on stroke outcomes following EVT and the safety and efficacy of AF treatment in the peri-EVT such as tirofiban or Intravenous thrombolysis with Non-vitamin K Antagonist Oral Anticoagulant. The available evidence from observational studies on AF and EVT outcomes is inconsistent, but factors such as procedural EVT devices, the center volume, clinician experience, stroke recognition, and inclusion criteria of studies have all been associated with poorer clinical outcomes. Enhancing the clinical network among prehospital and hospitals will facilitate direct transfer to EVT centers, reducing stroke onset to EVT time and optimizing stroke outcomes.
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Affiliation(s)
- Muath Alobaida
- Liverpool Centre for Cardiovascular Science, University of Liverpool, Liverpool, UK.,Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Department of Basic Science, Prince Sultan Bin Abdulaziz College for Emergency Medical Services, King Saud University, Riyadh, Saudi Arabia
| | - Gregory Y H Lip
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Deirdre A Lane
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, UK.,Department of Clinical Medicine, Aalborg University, Aalborg, Denmark
| | - Dimitrios Sagris
- Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, UK.,Department of Medicine and Research Laboratory, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - Andrew Hill
- Department of Medicine, Whiston Hospital, St Helens and Knowsley Teaching Hospitals NHS Trust, UK
| | - Stephanie L Harrison
- Department of Cardiovascular and Metabolic Medicine, Institute of Life Course and Medical Sciences, University of Liverpool, Liverpool, UK.,Liverpool Centre for Cardiovascular Science, University of Liverpool & Liverpool Heart and Chest Hospital, Liverpool, UK
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Sun J, Lam C, Christie L, Blair C, Li X, Werdiger F, Yang Q, Bivard A, Lin L, Parsons M. Risk factors of hemorrhagic transformation in acute ischaemic stroke: A systematic review and meta-analysis. Front Neurol 2023; 14:1079205. [PMID: 36891475 PMCID: PMC9986457 DOI: 10.3389/fneur.2023.1079205] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 01/31/2023] [Indexed: 02/22/2023] Open
Abstract
Background Hemorrhagic transformation (HT) following reperfusion therapies for acute ischaemic stroke often predicts a poor prognosis. This systematic review and meta-analysis aims to identify risk factors for HT, and how these vary with hyperacute treatment [intravenous thrombolysis (IVT) and endovascular thrombectomy (EVT)]. Methods Electronic databases PubMed and EMBASE were used to search relevant studies. Pooled odds ratio (OR) with 95% confidence interval (CI) were estimated. Results A total of 120 studies were included. Atrial fibrillation and NIHSS score were common predictors for any intracerebral hemorrhage (ICH) after reperfusion therapies (both IVT and EVT), while a hyperdense artery sign (OR = 2.605, 95% CI 1.212-5.599, I 2 = 0.0%) and number of thrombectomy passes (OR = 1.151, 95% CI 1.041-1.272, I 2 = 54.3%) were predictors of any ICH after IVT and EVT, respectively. Common predictors for symptomatic ICH (sICH) after reperfusion therapies were age and serum glucose level. Atrial fibrillation (OR = 3.867, 95% CI 1.970-7.591, I 2 = 29.1%), NIHSS score (OR = 1.082, 95% CI 1.060-1.105, I 2 = 54.5%) and onset-to-treatment time (OR = 1.003, 95% CI 1.001-1.005, I 2 = 0.0%) were predictors of sICH after IVT. Alberta Stroke Program Early CT score (ASPECTS) (OR = 0.686, 95% CI 0.565-0.833, I 2 =77.6%) and number of thrombectomy passes (OR = 1.374, 95% CI 1.012-1.866, I 2 = 86.4%) were predictors of sICH after EVT. Conclusion Several predictors of ICH were identified, which varied by treatment type. Studies based on larger and multi-center data sets should be prioritized to confirm the results. Systematic review registration https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=268927, identifier: CRD42021268927.
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Affiliation(s)
- Jiacheng Sun
- Sydney Brain Centre, The Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Christina Lam
- Melbourne Brain Centre at Royal Melbourne Hospital, Melbourne, VIC, Australia.,Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Lauren Christie
- Sydney Brain Centre, The Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia.,Allied Health Research Unit, St Vincent's Health Network Sydney, Sydney, NSW, Australia.,Faculty of Health Sciences, Australian Catholic University, North Sydney, NSW, Australia
| | - Christopher Blair
- Sydney Brain Centre, The Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia.,Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, NSW, Australia
| | - Xingjuan Li
- Queensland Department of Agriculture and Fisheries, Brisbane, QLD, Australia
| | - Freda Werdiger
- Melbourne Brain Centre at Royal Melbourne Hospital, Melbourne, VIC, Australia.,Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Qing Yang
- Apollo Medical Imaging Technology Pty Ltd., Melbourne, VIC, Australia
| | - Andrew Bivard
- Melbourne Brain Centre at Royal Melbourne Hospital, Melbourne, VIC, Australia.,Department of Medicine, University of Melbourne, Melbourne, VIC, Australia
| | - Longting Lin
- Sydney Brain Centre, The Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia
| | - Mark Parsons
- Sydney Brain Centre, The Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia.,South Western Sydney Clinical School, University of New South Wales, Sydney, NSW, Australia.,Department of Neurology and Neurophysiology, Liverpool Hospital, Sydney, NSW, Australia
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Wu J, Fang C, Wei L, Liu Y, Xu H, Wang X, Yuan L, Wu X, Xu Y, Zhang A. Spotlight on clinical strategies of Chronic Internal Carotid Artery Occlusion: Endovascular interventions and external-intracarotid bypasses compared to conservative treatment. Front Surg 2022; 9:971066. [PMID: 36425889 PMCID: PMC9679017 DOI: 10.3389/fsurg.2022.971066] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Accepted: 10/18/2022] [Indexed: 10/11/2023] Open
Abstract
Chronic internal carotid artery occlusion (CICAO) has high prevalence and incidence rates, and patients with CICAO can be completely asymptomatic, experience a devastating stroke or die. It is important to note that CICAO causes cerebrovascular accidents. Currently, the external carotid-internal carotid (EC-IC) bypass technique is used to treat CICAO. However, many clinical studies showed that EC-IC bypass was not beneficial for many patients with CICAO. Meanwhile, endovascular intervention treatment options for CICAO are evolving, and an increasing number of patients are undergoing endovascular intervention therapy. Accordingly, a review comparing both techniques is warranted. For this review, we searched PubMed and collected relevant case study reports comparing endovascular interventional therapy and internal and external cervical bypass surgeries to provide strategies for clinical treatment.
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Affiliation(s)
- Junnan Wu
- Department of Emergency, Dongyang Hospital Affiliated to Wenzhou Medical University, Jinhua, China
| | - Chaoyou Fang
- Department of Neurosurgery, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Lingying Wei
- Department of Emergency, Dongyang Hospital Affiliated to Wenzhou Medical University, Jinhua, China
| | - Yibo Liu
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Shanghai, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Houshi Xu
- Department of Neurosurgery, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaoyu Wang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Shanghai, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
| | - Ling Yuan
- Department of Neurosurgery, Shanghai General Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaoya Wu
- Department of Emergency, Dongyang Hospital Affiliated to Wenzhou Medical University, Jinhua, China
| | - Yuanzhi Xu
- Department of Neurosurgery, Huashan Hospital, School of Medicine, Fudan University, Shanghai, China
| | - Anke Zhang
- Department of Neurosurgery, The Second Affiliated Hospital, School of Medicine, Zhejiang University, Shanghai, China
- Clinical Research Center for Neurological Diseases of Zhejiang Province, Hangzhou, China
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Pre-admission antithrombotic use is associated with 3-month mRS score after thrombectomy for acute ischemic stroke. J Thromb Thrombolysis 2022; 54:350-359. [PMID: 35864280 PMCID: PMC9302951 DOI: 10.1007/s11239-022-02680-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 06/28/2022] [Indexed: 10/24/2022]
Abstract
In patients who undergo thrombectomy for acute ischemic stroke, the relationship between pre-admission antithrombotic (anticoagulation or antiplatelet) use and both radiographic and functional outcome is not well understood. We sought to explore the relationship between pre-admission antithrombotic use in patients who underwent thrombectomy for acute ischemic stroke at two medical centers in New York City between December 2018 and November 2020. Analyses were performed using analysis of variance and Pearson's chi-squared tests. Of 234 patients in the analysis cohort, 65 (28%) were on anticoagulation, 64 (27%) were on antiplatelet, and 105 (45%) with no antithrombotic use pre-admission. 3-month Modified Rankin Scale (mRS) score of 3-6 was associated with pre-admission antithrombotic use (71% anticoagulation vs. 77% antiplatelet vs. 56% no antithrombotic, p = 0.04). There was no relationship between pre-admission antithrombotic use and Thrombolysis in Cerebral Iinfarction (TICI) score, post-procedure Alberta Stroke Program Early CT Score (ASPECTS) score, rate of hemorrhagic conversion, length of hospital admission, discharge NIH Stroke Scale (NIHSS), discharge mRS score, or mortality. When initial NIHSS score, post-procedure ASPECTS score, and age at admission were included in multivariate analysis, pre-admission antithrombotic use was still significantly associated with a 3-month mRS score of 3-6 (OR 2.36, 95% CI 1.03-5.54, p = 0.04). In this cohort of patients with acute ischemic stroke who underwent thrombectomy, pre-admission antithrombotic use was associated with 3-month mRS score, but no other measures of radiographic or functional outcome. Further research is needed on the relationship between use of specific anticoagulation or antiplatelet agents and outcome after acute ischemic stroke, but moreover, improve stroke prevention.
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Guo Y, Zhao K, Guo X, Yang M. Antiplatelet therapy and outcomes following endovascular therapy for acute ischemic stroke: A systemic review and meta-analysis. J Clin Neurosci 2021; 90:332-344. [PMID: 34275572 DOI: 10.1016/j.jocn.2021.06.013] [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: 03/13/2021] [Revised: 05/31/2021] [Accepted: 06/12/2021] [Indexed: 10/21/2022]
Abstract
OBJECTIVE The outcomes of antiplatelet therapy (APT) in patients with acute ischemic stroke (AIS) receiving endovascular therapy (EVT) remains controversial. Thus, we sought to make a systematic review and meta-analysis of recent clinical trials to confirm the safety and efficacy of APT. METHODS All of clinical trails were systematically retrieved from PubMed, Embase and Cochrane. The endpoints or main outcome measures included symptomatic intracranial hemorrhage (sICH), 3-month mortality, successful recanalisation (SR) and 3-month functional independence (FI). Odd ratios (ORs) with their 95% confidence intervals (CIs) were calculated to synthesize effect size by using random-effects models. Sensitivity analysis was performed via calculation of rest data owiting one by one. RESULTS 23 articles were included after screening. APT as an adjunct to EVT was associated with a higher likelihood of pooled successful recanalisation (OR 1.46, 95% CI 1.07-2.00) and 3-month FI (OR 1.24, 95% CI 1.01-1.51), no associated with sICH and 3-month mortality. However, Sensitivity analysis indicated that the association between APT and SR and 3-month FI were unstable. For patients with prior use of APT or receiving intravenous thrombolysis before EVT, no associated were found between APT and all of endpoints above. CONCLUSION Although adjuvant APT appears to increase the number of SR and 3-month FI, the results were unstable. Randomised controlled trials are needed to confirm the efficacy.
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Affiliation(s)
- Yu Guo
- Graduate School, Qinghai University, Xining, Qinghai 810016, China
| | - Kai Zhao
- Graduate School, Qinghai University, Xining, Qinghai 810016, China
| | - Xinmei Guo
- Biomedical Engineering Research Center, Kunming Medical University, Kunming, Yunnan 650504, China
| | - Mingfei Yang
- Department of Neurosurgery, Qinghai Provincial People's Hospital, Xining, Qinghai 810007, China.
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