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Ippen FM, Schregel K, Ungerer M, Feisst M, Ringleb PA, Gumbinger CK. Outcomes in elderly patients undergoing endovascular thrombectomy in association with premorbid Rankin Scale scores. Front Neurol 2024; 15:1418415. [PMID: 39022738 PMCID: PMC11252042 DOI: 10.3389/fneur.2024.1418415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2024] [Accepted: 06/10/2024] [Indexed: 07/20/2024] Open
Abstract
Background Endovascular thrombectomy (EVT) reduces disability in patients with acute ischemic stroke (AIS); however, its efficacy in patients aged >80 years remains unclear. Objectives This study aimed to assess the impact of premorbid modified Rankin Scale (pmRS) scores and age on patients with AIS undergoing EVT and the effect of EVT on functional outcome and mortality. Methods We conducted a retrospective cohort study and screened the Heidelberg Recanalization Registry (HeiReKa) database for patients with AIS between 1999 and 2021. Outcomes were stratified by age (<80, 80-89, and ≥90 years) and pmRS score (0-2 vs. 3-5). Adjusted odds ratios for outcomes and mortality at 3 months after treatment were examined. Results Finally, 2,591 patients were included [including those aged ≥90 years (n = 158)]. Poor functional outcomes were associated with advanced age, vascular risk factors, stroke severity, and vessel status. Conversely, lower prestroke disability and younger age were associated with better outcomes and reduced mortality. A pmRS of 3-5 was associated with an increased risk of mortality and worse functional outcomes regardless of age. Notably, patients aged ≥90 years with a pmRS of 0-2 had significantly better outcomes than those aged <80 years with a pmRS of 3-5. Conclusion Both age and pmRS are important in assessing the benefits of EVT. However, prestroke functional status might be more crucial than biological age in determining outcomes following EVT.
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Affiliation(s)
- Franziska M. Ippen
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Katharina Schregel
- Department of Neuroradiology, Heidelberg University Hospital, Heidelberg, Germany
| | - Matthias Ungerer
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Manuel Feisst
- Institute of Medical Biometry, University of Heidelberg, Heidelberg, Germany
| | - Peter A. Ringleb
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
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2
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Demeestere J, Qureshi MM, Vandewalle L, Wouters A, Strbian D, Nogueira RG, Nagel S, Yamagami H, Puetz V, Abdalkader M, Haussen DC, Mohammaden MH, Möhlenbruch MA, Olivé-Gadea M, Winzer S, Ribo M, Michel P, Marto JP, Tanaka K, Yoshimura S, Martinez-Majander N, Caparros F, Henon H, Tomppo L, Dusart A, Bellante F, Ramos JN, Jesser J, Sheth SA, Ortega-Gutiérrez S, Siegler JE, Nannoni S, Kaesmacher J, Dobrocky T, Salazar-Marioni S, Farooqui M, Virtanen P, Ventura R, Zaidi SF, Castonguay AC, Uchida K, Puri AS, Sakai N, Toyoda K, Farzin B, Masoud HE, Klein P, Bui J, Rizzo F, Kaiser DPO, Desfontaines P, Strambo D, Cordonnier C, Lin E, Ringleb PA, Roy D, Zaidat OO, Fischer U, Raymond J, Lemmens R, Nguyen TN. Outcomes of Bridging Intravenous Thrombolysis Versus Endovascular Therapy Alone in Late-Window Acute Ischemic Stroke. Stroke 2024; 55:1767-1775. [PMID: 38748598 DOI: 10.1161/strokeaha.124.046495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2024] [Accepted: 04/26/2024] [Indexed: 06/26/2024]
Abstract
BACKGROUND Studies comparing bridging intravenous thrombolysis (IVT) with direct endovascular therapy (EVT) in patients with acute ischemic stroke who present late are limited. We aimed to compare the clinical outcomes and safety of bridging IVT in patients with acute ischemic stroke due to anterior circulation large vessel occlusion who underwent EVT 6 to 24 hours after time last known well. METHODS We enrolled patients with anterior circulation large vessel occlusion stroke and a National Institutes of Health Stroke Scale score of ≥6 from 20 centers across 10 countries in the multicenter retrospective CLEAR study (CT for Late Endovascular Reperfusion) between January 2014 and May 2022. We used inverse probability of treatment weighting modeling adjusted for clinical and imaging confounders to compare functional outcomes, reperfusion success, symptomatic intracranial hemorrhage, and mortality between EVT patients with and without prior IVT. RESULTS Of 5098 patients screened for eligibility, we included 2749 patients, of whom 549 received bridging IVT before EVT. The timing of IVT was not recorded. Witnessed stroke onset and transfer rates were higher in the bridging IVT group (25% versus 12% and 77% versus 55%, respectively, P value for both <0.0001), and time intervals between stroke onset and treatment were shorter (time last known well-start of EVT median 560 minutes [interquartile range, 432-791] versus 724 minutes [interquartile range, 544-912]; P<0.0001). After adjustment for confounders, there was no difference in functional outcome at 3 months (adjusted common odds ratio for modified Rankin Scale shift, 1.03 [95% CI, 0.89-1.19]; P=0.72) or successful reperfusion (adjusted odds ratio, 1.19 [95% CI, 0.81-1.75]; P=0.39). There were no safety concerns associated with bridging IVT versus direct EVT (symptomatic intracranial hemorrhage: adjusted odds ratio, 0.75 [95% CI, 0.38-1.48]; P=0.40; mortality: adjusted odds ratio, 1.14 [95% CI, 0.89-1.46]; P=0.31). Results were unchanged when the analysis was limited to patients who received IVT >6 hours after last known well. CONCLUSIONS In patients with an anterior circulation large vessel occlusion stroke who underwent EVT 6 to 24 hours from last known well, bridging IVT was not associated with a difference in outcomes compared with direct EVT. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT04096248.
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Affiliation(s)
- Jelle Demeestere
- Laboratory for Neurobiology, KU Leuven, Belgium (J.D., L.V., A.W., R.L.)
- Neurology, UZ Leuven, Belgium (J.D., L.V., A.W., R.L.)
| | - Muhammad M Qureshi
- Radiology (M.M.Q., M.A., P.K., J.B., T.N.N.), Boston Medical Center, MA
- Radiation Oncology (M.M.Q.), Boston Medical Center, MA
- Boston University Chobanian & Avedisian School of Medicine, MA (M.M.Q., M.A., P.K., T.N.N.)
| | - Lieselotte Vandewalle
- Laboratory for Neurobiology, KU Leuven, Belgium (J.D., L.V., A.W., R.L.)
- Neurology, UZ Leuven, Belgium (J.D., L.V., A.W., R.L.)
| | - Anke Wouters
- Laboratory for Neurobiology, KU Leuven, Belgium (J.D., L.V., A.W., R.L.)
- Neurology, UZ Leuven, Belgium (J.D., L.V., A.W., R.L.)
| | - Daniel Strbian
- Neurology (D.S., N.M.-M., L.T.), Helsinki University Hospital, Finland
- University of Helsinki, Finland (D.S., N.M.-M., L.T., P.V.)
| | - Raul G Nogueira
- Neurology, Neurosurgery, University of Pittsburgh Medical Center, MA (R.G.N.)
- Neurology, Grady Memorial Hospital, Atlanta, GA (R.G.N., D.C.H., M.H.M.)
| | - Simon Nagel
- Neurology, Klinikum Ludwigshafen, Germany (S.N.)
- Neurology (S.N., P.A.R.), Heidelberg University Hospital, Germany
| | | | - Volker Puetz
- Neurology (V.P., S.W.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
- Dresden Neurovascular Center (V.P., S.W., D.P.O.K.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Mohamad Abdalkader
- Radiology (M.M.Q., M.A., P.K., J.B., T.N.N.), Boston Medical Center, MA
- Boston University Chobanian & Avedisian School of Medicine, MA (M.M.Q., M.A., P.K., T.N.N.)
| | - Diogo C Haussen
- Neurology, Grady Memorial Hospital, Atlanta, GA (R.G.N., D.C.H., M.H.M.)
| | | | | | - Marta Olivé-Gadea
- Neurology, Hospital Vall d'Hebron, Barcelona, Spain (M.O.G., M.R., F.R.)
| | - Simon Winzer
- Neurology (V.P., S.W.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
- Dresden Neurovascular Center (V.P., S.W., D.P.O.K.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | - Marc Ribo
- Neurology, Hospital Vall d'Hebron, Barcelona, Spain (M.O.G., M.R., F.R.)
| | - Patrik Michel
- Neurology, Lausanne University Hospital and University of Lausanne, Switzerland (P.M., D.S.)
| | - João Pedro Marto
- Neurology (J.P.M., R.V.), Hospital de Egas Moniz, Centro Hospitalar Lisboa Occidental, Lisbon, Portugal
| | - Kanta Tanaka
- Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan (K. Tanaka, K. Toyoda)
| | | | - Nicolas Martinez-Majander
- Neurology (D.S., N.M.-M., L.T.), Helsinki University Hospital, Finland
- University of Helsinki, Finland (D.S., N.M.-M., L.T., P.V.)
| | - Francois Caparros
- Neurology, Centre Hospitalier Universitaire de Lille, France (F.C., H.H., C.C.)
- Neurology, University of Lille, France (F.C., H.H., C.C.)
| | - Hilde Henon
- Neurology, Centre Hospitalier Universitaire de Lille, France (F.C., H.H., C.C.)
- Neurology, University of Lille, France (F.C., H.H., C.C.)
| | - Liisa Tomppo
- Neurology (D.S., N.M.-M., L.T.), Helsinki University Hospital, Finland
- University of Helsinki, Finland (D.S., N.M.-M., L.T., P.V.)
| | - Anne Dusart
- Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium (A.D., F.B.)
| | - Flavio Bellante
- Neurology, Hôpital Civil Marie Curie, Charleroi, Belgium (A.D., F.B.)
| | - João Nuno Ramos
- Radiology (J.N.R.), Hospital de Egas Moniz, Centro Hospitalar Lisboa Occidental, Lisbon, Portugal
| | - Jessica Jesser
- Neuroradiology (M.A.M., J.J.), Heidelberg University Hospital, Germany
| | - Sunil A Sheth
- Neurology, UTHealth McGovern Medical School, Houston, TX (S.A.S., S.S.-M.)
| | | | | | - Stefania Nannoni
- Clinical Neurosciences, University of Cambridge, United Kingdom (S.N.)
| | - Johannes Kaesmacher
- Diagnostic and Interventional Neuroradiology, University Hospital Bern, Switzerland (J.K., T.D.)
| | - Tomas Dobrocky
- Diagnostic and Interventional Neuroradiology, University Hospital Bern, Switzerland (J.K., T.D.)
| | | | | | - Pekka Virtanen
- Radiology (P.V.), Helsinki University Hospital, Finland
- University of Helsinki, Finland (D.S., N.M.-M., L.T., P.V.)
| | - Rita Ventura
- Neurology (J.P.M., R.V.), Hospital de Egas Moniz, Centro Hospitalar Lisboa Occidental, Lisbon, Portugal
| | - Syed F Zaidi
- Neurology, University of Toledo, OH (S.F.Z., A.C.C.)
| | | | - Kazutaka Uchida
- Neurosurgery, Hyogo Medical University, Nishinomiya, Japan (S.Y., K.U.)
| | - Ajit S Puri
- Interventional Neuroradiology, University of Massachusetts Memorial Medical Center, Worcester (A.S.P.)
| | - Nobuyuki Sakai
- Neurovascular Research, Kobe City Medical Center General Hospital, Japan (N.S.)
| | - Kazunori Toyoda
- Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Japan (K. Tanaka, K. Toyoda)
| | - Behzad Farzin
- Interventional Neuroradiology, Centre Hospitalier de l'Universite de Montreal, Canada (B.F., D.R., J.R.)
| | | | - Piers Klein
- Radiology (M.M.Q., M.A., P.K., J.B., T.N.N.), Boston Medical Center, MA
- Boston University Chobanian & Avedisian School of Medicine, MA (M.M.Q., M.A., P.K., T.N.N.)
| | - Jenny Bui
- Radiology (M.M.Q., M.A., P.K., J.B., T.N.N.), Boston Medical Center, MA
| | - Federica Rizzo
- Neurology, Hospital Vall d'Hebron, Barcelona, Spain (M.O.G., M.R., F.R.)
| | - Daniel P O Kaiser
- Dresden Neurovascular Center (V.P., S.W., D.P.O.K.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
- Institute of Neuroradiology (D.P.O.K.), Faculty of Medicine and University Hospital Carl Gustav Carus, Technische Universität Dresden, Germany
| | | | - Davide Strambo
- Neurology, Lausanne University Hospital and University of Lausanne, Switzerland (P.M., D.S.)
| | - Charlotte Cordonnier
- Neurology, Centre Hospitalier Universitaire de Lille, France (F.C., H.H., C.C.)
- Neurology, University of Lille, France (F.C., H.H., C.C.)
| | - Eugene Lin
- Neuroscience and Stroke Program, Bon Secours Mercy Health St. Vincent Hospital, Toledo, OH (E.L., O.O.Z.)
| | - Peter A Ringleb
- Neurology (S.N., P.A.R.), Heidelberg University Hospital, Germany
| | - Daniel Roy
- Interventional Neuroradiology, Centre Hospitalier de l'Universite de Montreal, Canada (B.F., D.R., J.R.)
| | - Osama O Zaidat
- Neuroscience and Stroke Program, Bon Secours Mercy Health St. Vincent Hospital, Toledo, OH (E.L., O.O.Z.)
| | - Urs Fischer
- Neurology, University Hospital Basel, Switzerland (U.F.)
| | - Jean Raymond
- Interventional Neuroradiology, Centre Hospitalier de l'Universite de Montreal, Canada (B.F., D.R., J.R.)
| | - Robin Lemmens
- Laboratory for Neurobiology, KU Leuven, Belgium (J.D., L.V., A.W., R.L.)
- Neurology, UZ Leuven, Belgium (J.D., L.V., A.W., R.L.)
| | - Thanh N Nguyen
- Radiology (M.M.Q., M.A., P.K., J.B., T.N.N.), Boston Medical Center, MA
- Boston University Chobanian & Avedisian School of Medicine, MA (M.M.Q., M.A., P.K., T.N.N.)
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3
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Le Floch A, Clarençon F, Rouchaud A, Kyheng M, Labreuche J, Sibon I, Boulouis G, Gory B, Richard S, Caroff J, Blanc R, Seners P, Eker OF, Cho TH, Consoli A, Bourcier R, Guillon B, Dargazanli C, Arquizan C, Denier C, Eugene F, Vannier S, Gentric JC, Gauberti M, Naggara O, Rosso C, Turc G, Ozkul-Wermester O, Cognard C, Albucher JF, Timsit S, Bourdain F, Le Bras A, Richter S, Moulin S, Pop R, Heck O, Moreno R, L'Allinec V, Lapergue B, Marnat G. Influence of prior intravenous thrombolysis in patients treated with mechanical thrombectomy for M2 occlusions: insight from the Endovascular Treatment in Ischemic Stroke (ETIS) registry. J Neurointerv Surg 2023; 15:e289-e297. [PMID: 36460462 DOI: 10.1136/jnis-2022-019672] [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: 09/22/2022] [Accepted: 11/16/2022] [Indexed: 12/04/2022]
Abstract
BACKGROUND Intravenous thrombolysis (IVT) for patients treated with mechanical thrombectomy (MT) for proximal occlusions has recently been questioned through randomized trials. However, few patients with M2 occlusions were included. We investigated the influence of prior IVT for patients presenting M2 occlusions treated with MT in comparison with MT alone. METHODS We conducted a retrospective analysis of the Endovascular Treatment in Ischemic Stroke (ETIS) registry, a multicenter observational study. Data from consecutive patients treated with MT for M2 occlusions between January 2015 and January 2022 at 26 comprehensive stroke centers were analyzed. The primary endpoint was 90-day modified Rankin Scale score of 0-2. Outcomes were compared using propensity score approaches. We also performed sensitivity analysis in relevant subgroups of patients. RESULTS Among 1132 patients with M2 occlusions treated with MT, 570 received prior IVT. The two groups were comparable after propensity analysis. The rate of favorable functional outcome was significantly higher in the IVT+MT group compared with the MT alone group (59.8% vs 44.7%; adjusted OR 1.38, 95% CI 1.10 to 1.75, P=0.008). Hemorrhagic and procedural complications were similar in both groups. In sensitivity analysis excluding patients with anticoagulation treatment, favorable recanalization was more frequent in the IVT+MT group (OR 1.37, 95% CI 1.11 to 1.70, P=0.004). CONCLUSIONS In cases of M2 occlusions, prior IVT combined with MT resulted in better functional outcome than MT alone, without increasing the rate of hemorrhagic or procedural complications. These results suggest the benefit of IVT in patients undergoing MT for M2 occlusions.
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Affiliation(s)
- Agathe Le Floch
- Neuroradiology, CHU Bordeaux GH Pellegrin, Bordeaux, Aquitaine, France
| | - Frédéric Clarençon
- Interventional neuroradiology, University Hospital Pitié Salpêtrière, Paris, France
| | - Aymeric Rouchaud
- Interventional neuroradiology, Centre Hospitalier Universitaire de Limoges, Limoges, France
- CNRS, XLIM, UMR 7252, Université de Limoges, Limoges, Nouvelle-Aquitaine, France
| | - Maeva Kyheng
- Biostatistics, CHU Lille, Lille, Hauts-de-France, France
| | | | - Igor Sibon
- Neurology, CHU de Bordeaux, Bordeaux, France
| | | | - Benjamin Gory
- Diagnostic and Interventional Neuroradiology, Centre Hospitalier Universitaire de Nancy, Nancy, France
| | - Sébastien Richard
- Neurology Stroke Unit, University Hospital Centre Nancy, Nancy, France
| | - Jildaz Caroff
- Department of Interventional Neuroradiology - NEURI Brain Vascular Center, Bicêtre Hospital, APHP, Le Kremlin Bicêtre, France
| | - Raphaël Blanc
- Departement of interventional neuroradiology, Fondation Rothschild, Paris, Île-de-France, France
| | - Pierre Seners
- Neurology, Fondation Rothschild, Paris, Île-de-France, France
| | - Omer F Eker
- Neuroradiology, Hospices Civils de Lyon, Bron, France
| | - Tae-Hee Cho
- Neurology, CHU Lyon, Lyon, Auvergne-Rhône-Alpes, France
| | - Arturo Consoli
- Interventional Neuroradiologie, Hopital Foch, Suresnes, Ile-de-France, France
| | | | - Benoit Guillon
- Stroke unit, CHU Nantes, Nantes, Pays de la Loire, France
| | - Cyril Dargazanli
- Department of Neuroradiology, University Hospital Centre Montpellier, Montpellier, Occitanie, France
| | - Caroline Arquizan
- Neurology, CHU Montpellier, Montpellier, Languedoc-Roussillon, France
| | | | | | | | | | | | - Olivier Naggara
- Neuroradiology, GHU Paris Pôle Neuro Sainte-Anne, Paris, Île-de-France, France
| | - Charlotte Rosso
- Neurology, Hôpital Universitaire Pitié Salpêtrière, Paris, Île-de-France, France
| | - Guillaume Turc
- Neurology, GHU Paris Pôle Neuro Sainte-Anne, Paris, Île-de-France, France
| | | | - Christophe Cognard
- Diagnostic and Therapeutic Neuroradiology, CHU Toulouse, Toulouse, Occitanie, France
| | | | | | - Frederic Bourdain
- Neurology, Centre Hospitalier de la Cote Basque, Bayonne, Aquitaine, France
| | - Anthony Le Bras
- Department of Radiology, Centre Hospitalier Bretagne Atlantique, Vannes, Bretagne, France
- Neuroradiology, CHU Rennes Service de radiologie et d'imagerie médicale, Rennes, France
| | | | - Solène Moulin
- Neurology, University Hospital Centre Reims, Reims, Champagne-Ardenne, France
| | - Raoul Pop
- Neuroradiolology, CHU Strasbourg, Strasbourg, Alsace, France
| | - Olivier Heck
- Neurology, CHU Grenoble Alpes, Grenoble, Auvergne-Rhone-Alpes, France
| | - Ricardo Moreno
- Department Of Neuroradiology, CHU Clermont-Ferrand, Clermont-Ferrand, France
| | | | | | - Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, CHU Bordeaux GH Pellegrin, Bordeaux, Aquitaine, France
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Hendrix P, Schirmer CM. Early recanalization with intravenous thrombolysis before mechanical thrombectomy: considerations to explore with tenecteplase. J Neurointerv Surg 2022; 15:513-514. [PMID: 36564199 DOI: 10.1136/jnis-2022-019981] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2022] [Accepted: 12/09/2022] [Indexed: 12/25/2022]
Affiliation(s)
- Philipp Hendrix
- Department of Neurosurgery, Geisinger, Wilkes-Barre & Danville, PA, USA
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Bücke P, Cohen JE, Horvath T, Cimpoca A, Bhogal P, Bäzner H, Henkes H. What You Always Wanted to Know about Endovascular Therapy in Acute Ischemic Stroke but Never Dared to Ask: A Comprehensive Review. Rev Cardiovasc Med 2022; 23:340. [PMID: 39077121 PMCID: PMC11267361 DOI: 10.31083/j.rcm2310340] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Revised: 05/08/2022] [Accepted: 06/08/2022] [Indexed: 07/31/2024] Open
Abstract
In 2015, mechanical thrombectomy (MT) in combination with intravenous thrombolysis was demonstrated to be superior to best medical treatment alone in patients with anterior circulation stroke. This finding resulted in an unprecedented boost in endovascular stroke therapy, and MT became widely available. MT was initially approved for patients presenting with large vessel occlusion in the anterior circulation (intracranial internal carotid artery or proximal middle cerebral artery) within a 6-hour time window. Eventually, it was shown to be beneficial in a broader group of patients, including those without known symptom-onset, wake-up stroke, or patients with posterior circulation stroke. Technical developments and the implementation of novel thrombectomy devices further facilitated endovascular recanalization for acute ischemic stroke. However, some aspects remain controversial. Is MT suitable for medium or very distal vessel occlusions? Should emergency stenting be performed for symptomatic stenosis or recurrent occlusion? How should patients with large vessel occlusion without disabling symptoms be treated? Do certain patients benefit from MT without intravenous thrombolysis? In the era of personalized decision-making, some of these questions require an individualized approach based on comorbidities, imaging criteria, and the severity or duration of symptoms. Despite its successful development in the past decade, endovascular stroke therapy will remain a challenging and fascinating field in the years to come. This review aims to provide an overview of patient selection, and the indications for and execution of MT in patients with acute ischemic stroke.
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Affiliation(s)
- Philipp Bücke
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, 3012 Bern, Switzerland
| | - Jose E. Cohen
- Department of Neurosurgery, Hadassah Medical Center, Hebrew University Jerusalem, 91905 Jerusalem, Israel
| | - Thomas Horvath
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, 3012 Bern, Switzerland
| | - Alexandru Cimpoca
- Neuroradiologische Klinik, Klinikum Stuttgart, 70174 Stuttgart, Germany
| | - Pervinder Bhogal
- Interventional Neuroradiology Department, The Royal London Hospital, E1 1FR London, UK
| | - Hansjörg Bäzner
- Neurologische Klinik, Klinikum Stuttgart, 70174 Stuttgart, Germany
| | - Hans Henkes
- Neuroradiologische Klinik, Klinikum Stuttgart, 70174 Stuttgart, Germany
- Medical Faculty, Universität Duisburg-Essen, 45141 Essen, Germany
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6
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Turc G, Tsivgoulis G, Audebert HJ, Boogaarts H, Bhogal P, De Marchis GM, Fonseca AC, Khatri P, Mazighi M, Pérez de la Ossa N, Schellinger PD, Strbian D, Toni D, White P, Whiteley W, Zini A, van Zwam W, Fiehler J. European Stroke Organisation - European Society for Minimally Invasive Neurological Therapy expedited recommendation on indication for intravenous thrombolysis before mechanical thrombectomy in patients with acute ischaemic stroke and anterior circulation large vessel occlusion. Eur Stroke J 2022; 7:I-XXVI. [PMID: 35300256 PMCID: PMC8921785 DOI: 10.1177/23969873221076968] [Citation(s) in RCA: 54] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 01/13/2022] [Indexed: 11/15/2022] Open
Abstract
Six randomized controlled clinical trials have assessed whether mechanical thrombectomy (MT) alone is non-inferior to intravenous thrombolysis (IVT) plus MT within 4.5 hours of symptom onset in patients with anterior circulation large vessel occlusion (LVO) ischaemic stroke and no contraindication to IVT. An expedited recommendation process was initiated by the European Stroke Organisation (ESO) and conducted with the European Society of Minimally Invasive Neurological Therapy (ESMINT) according to ESO standard operating procedure based on the GRADE system. We identified two relevant Population, Intervention, Comparator, Outcome (PICO) questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence and wrote evidence-based recommendations. Expert opinion was provided if insufficient evidence was available to provide recommendations based on the GRADE approach. For stroke patients with anterior circulation LVO directly admitted to a MT-capable centre ('mothership') within 4.5 hours of symptom onset and eligible for both treatments, we recommend IVT plus MT over MT alone (moderate evidence, strong recommendation). MT should not prevent the initiation of IVT, nor should IVT delay MT. In stroke patients with anterior circulation LVO admitted to a centre without MT facilities and eligible for IVT ≤4.5 hrs and MT, we recommend IVT followed by rapid transfer to a MT capable-centre ('drip-and-ship') in preference to omitting IVT (low evidence, strong recommendation). Expert consensus statements on ischaemic stroke on awakening from sleep are also provided. Patients with anterior circulation LVO stroke should receive IVT in addition to MT if they have no contraindications to either treatment.
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Affiliation(s)
- Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Université de Paris, Paris, France
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Heinrich J. Audebert
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin, Center for Stroke Research Berlin, Berlin, Germany
| | - Hieronymus Boogaarts
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pervinder Bhogal
- Department of Interventional Neuroradiology, Royal London hospital, Barts NHS Trust, London, UK
| | - Gian Marco De Marchis
- Neurology and Stroke Center, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Ana Catarina Fonseca
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria-CHLN, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati, Cincinnati, OH, USA
| | - Mikaël Mazighi
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France
- Stroke Unit, Lariboisière Hospital, AP-HP-Nord, FHU NeuroVasc, Université de Paris, Paris, France
| | | | - Peter D. Schellinger
- Departments of Neurology and Neurogeriatrics, Johannes Wesling Medical Center Minden, University hospitals of the Ruhr-University of Bochum, Bochum, Germany
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Danilo Toni
- Hospital Policlinico Umberto I, Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Philip White
- Translational and Clinical Research Institute, Newcastle University, UK & Newcastle upon Tyne Hospitals NHS Foundation Trust, United Kingdom
| | - William Whiteley
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Wim van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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7
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Turc G, Tsivgoulis G, Audebert HJ, Boogaarts H, Bhogal P, De Marchis GM, Fonseca AC, Khatri P, Mazighi M, Pérez de la Ossa N, Schellinger PD, Strbian D, Toni D, White P, Whiteley W, Zini A, van Zwam W, Fiehler J. European Stroke Organisation (ESO)-European Society for Minimally Invasive Neurological Therapy (ESMINT) expedited recommendation on indication for intravenous thrombolysis before mechanical thrombectomy in patients with acute ischemic stroke and anterior circulation large vessel occlusion. J Neurointerv Surg 2022; 14:209. [PMID: 35115395 DOI: 10.1136/neurintsurg-2021-018589] [Citation(s) in RCA: 61] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Accepted: 01/09/2022] [Indexed: 12/30/2022]
Abstract
Six randomized controlled clinical trials have assessed whether mechanical thrombectomy (MT) alone is non-inferior to intravenous thrombolysis (IVT) plus MT within 4.5 hours of symptom onset in patients with anterior circulation large vessel occlusion (LVO) ischemic stroke and no contraindication to IVT. An expedited recommendation process was initiated by the European Stroke Organisation (ESO) and conducted with the European Society of Minimally Invasive Neurological Therapy (ESMINT) according to ESO standard operating procedure based on the GRADE system. We identified two relevant Population, Intervention, Comparator, Outcome (PICO) questions, performed systematic reviews and meta-analyses of the literature, assessed the quality of the available evidence, and wrote evidence-based recommendations. Expert opinion was provided if insufficient evidence was available to provide recommendations based on the GRADE approach.For stroke patients with anterior circulation LVO directly admitted to a MT-capable center ('mothership') within 4.5 hours of symptom onset and eligible for both treatments, we recommend IVT plus MT over MT alone (moderate evidence, strong recommendation). MT should not prevent the initiation of IVT, nor should IVT delay MT. In stroke patients with anterior circulation LVO admitted to a center without MT facilities and eligible for IVT ≤4.5 hours and MT, we recommend IVT followed by rapid transfer to a MT capable-center ('drip-and-ship') in preference to omitting IVT (low evidence, strong recommendation). Expert consensus statements on ischemic stroke on awakening from sleep are also provided. Patients with anterior circulation LVO stroke should receive IVT in addition to MT if they have no contraindications to either treatment.
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Affiliation(s)
- Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Université de Paris, INSERM U1266, FHU NeuroVasc, Paris, France
| | - Georgios Tsivgoulis
- Second Department of Neurology, Attikon University Hospital, School of Medicine, National and Kapodistrian University of Athens, Athens, Greece.,Department of Neurology, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Heinrich J Audebert
- Klinik und Hochschulambulanz für Neurologie, Campus Benjamin Franklin, Charité Universitätsmedizin Berlin & Center for Stroke Research Berlin, Berlin, Germany
| | - Hieronymus Boogaarts
- Department of Neurosurgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Pervinder Bhogal
- Department of Interventional Neuroradiology, Royal London Hospital, Barts NHS Trust, London, UK
| | - Gian Marco De Marchis
- Neurology and Stroke Center, University Hospital of Basel, University of Basel, Basel, Switzerland
| | - Ana Catarina Fonseca
- Department of Neurosciences and Mental Health (Neurology), Hospital Santa Maria-CHLN, Faculdade de Medicina, Universidade de Lisboa, Lisboa, Portugal
| | - Pooja Khatri
- Department of Neurology, University of Cincinnati, Cincinnati, Ohio, USA
| | - Mikaël Mazighi
- Department of Interventional Neuroradiology, Rothschild Foundation Hospital, Paris, France.,Stroke Unit, Lariboisière Hospital AP-HP-Nord, FHU NeuroVasc, Université de Paris, Paris, France
| | | | - Peter D Schellinger
- Departments of Neurology and Neurogeriatrics, Johannes Wesling Medical Center Minden, University hospitals of the Ruhr-University of Bochum, Bochum, Germany
| | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Danilo Toni
- Hospital Policlinico Umberto I, Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Philip White
- Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne Hospitals NHS Foundation Trust, Newcastle upon Tyne, UK
| | - William Whiteley
- Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | - Andrea Zini
- IRCCS Istituto delle Scienze Neurologiche di Bologna, Department of Neurology and Stroke Center, Maggiore Hospital, Bologna, Italy
| | - Wim van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center and Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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8
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Podlasek A, Dhillon PS, Butt W, Grunwald IQ, England TJ. To bridge or not to bridge: summary of the new evidence in endovascular stroke treatment. Stroke Vasc Neurol 2022; 7:179-181. [PMID: 35105731 PMCID: PMC9240584 DOI: 10.1136/svn-2021-001465] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 01/20/2022] [Indexed: 11/04/2022] Open
Affiliation(s)
- Anna Podlasek
- Tayside Innovation MedTech Ecosystem (TIME), University of Dundee, Dundee, UK .,NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK
| | - Permesh Singh Dhillon
- NIHR Nottingham Biomedical Research Centre, University of Nottingham, Nottingham, UK.,Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Waleed Butt
- Interventional Neuroradiology, Nottingham University Hospitals NHS Trust, Nottingham, UK.,Interventional Neuroradiology, University Hospitals Birmingham NHS Trust, Birmingham, UK
| | - Iris Q Grunwald
- Tayside Innovation MedTech Ecosystem (TIME), University of Dundee, Dundee, UK
| | - Timothy J England
- Stroke, Division of Mental Health and Clinical Neurosciences, School of Medicine, University of Nottingham, Nottingham, UK.,Stroke, University Hospitals of Derby and Burton NHS Foundation Trust, Derby, UK
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