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Ozdemir G, Eren A, Aygul R, Eren F, Kizildag N, Kocaturk I, Mammadi A, Ersoy AN, Korez MK. Endovascular treatment for M3 occlusions. Interv Neuroradiol 2024; 30:202-209. [PMID: 36124395 PMCID: PMC11095351 DOI: 10.1177/15910199221127357] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2022] [Accepted: 09/02/2022] [Indexed: 11/15/2022] Open
Abstract
INTRODUCTION Endovascular treatment (ET) is a beneficial treatment for M1-2 occlusions of the middle cerebral artery. Mortality and disability rates are high if large vessel occlusions are not treated. While these rates are lower in M3 occlusions, important branch blockages can lead to disability. Endovascular treatment of small vessel occlusions is difficult, and there are no studies on the effectiveness of endovascular treatment for M3 occlusions. Accordingly, in this study, our aim was to assess the feasibility, safety, and preliminary efficacy of endovascular therapy for M3 occlusions. METHODS This study involved a retrospective analysis of a prospectively collected from two centres for acute ischemic stroke of the anterior system between July 2015 and April 2020. Demographic, radiologic, procedural and outcome variables were collected for patients who underwent endovascular therapy for acute ischemic stroke of the anterior system. RESULTS Complete or near complete reperfusion (mTICI 2b-3) of the M3 occlusion was achieved in 15 cases (38.5%). Complete (mTICI 3) reperfusion was achieved in 24 cases (61.5%). Twenty-six patients were treated for primary M3 occlusion, while 13 patients with M3 occlusion were treated as a rescue strategy after successful treatment of a proximal greater vascular occlusion. Complete or near complete reperfusion (mTICI 2b-3) of primary occlusion was achieved in eight cases (30.8%), and complete (mTICI 3) reperfusion was achieved in 18 cases (69.2%). In addition, complete or near complete reperfusion (mTICI 2b-3) of rescue M3 occlusion was achieved in seven cases (%53.8), while complete (mTICI 3) reperfusion was achieved in six cases (46.2%). Only one patient with primary M3 occlusion had ICH due to extravasation. The patient's neurological examination one month later was normal. CONCLUSIONS This retrospective study demonstrates that endovascular treatment of M3 occlusions is safe, effective and reliable.
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Affiliation(s)
- Gokhan Ozdemir
- Department of Neurology, Center of Stroke, Selcuk University Medical Faculty, Konya, Turkey
| | - Alper Eren
- Department of Neurology, Center of Stroke, Ataturk University Medical Faculty, Erzurum, Turkey
| | - Recep Aygul
- Department of Neurology, Center of Stroke, Selcuk University Medical Faculty, Konya, Turkey
| | - Fettah Eren
- Department of Neurology, Center of Stroke, Selcuk University Medical Faculty, Konya, Turkey
| | - Nazım Kizildag
- Erzurum Education and Research Hospital, Erzurum, Turkey
| | - Idris Kocaturk
- Department of Neurology, Binali University Medical Faculty, Erzincan, Turkey
| | - Azer Mammadi
- Department of Neurology, Center of Stroke, Selcuk University Medical Faculty, Konya, Turkey
| | - Ayse Nur Ersoy
- Department of Neurology, Center of Stroke, Selcuk University Medical Faculty, Konya, Turkey
| | - Muslu Kazım Korez
- Department of Biostatistics, Selcuk University Medical Faculty, Konya, Turkey
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Parsons M, Tong Y, Valenti SC, Gorelik V, Bhatnagar S, Boily M, Gorelik N. Reporting of Participant Demographics in Clinical Trials Published in General Radiology Journals. Curr Probl Diagn Radiol 2024; 53:81-91. [PMID: 37741699 DOI: 10.1067/j.cpradiol.2023.08.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2023] [Accepted: 08/23/2023] [Indexed: 09/25/2023]
Abstract
OBJECTIVES The reporting of research participant demographics provides insights into study generalizability. Our study aimed to determine the frequency at which participant age, sex/gender, race/ethnicity, and socioeconomic status (SES) are reported and used for subgroup analyses in radiology randomized controlled trials (RCTs) and their secondary analyses; as well as the study characteristics associated with, and the classification systems used for demographics reporting. METHODS RCTs and their secondary analyses published in 8 leading radiology journals between 2013 and 2021 were included. Associations between study characteristics and demographic reporting were tested with the chi-square goodness of fit test for categorical variables, Wilcoxon-Mann-Whitney test for impact factor, and logistic regression for publication year. RESULTS Among 432 included articles, 89.4% (386) reported age, 90.3% (390) sex/gender, 5.6% (24) race/ethnicity, and 3.0% (13) SES. Among articles that reported these demographics and were not specific to a subgroup, results were analyzed by age in 14.2% (55/386), sex/gender in 19.4% (66/340), race/ethnicity in 13.6% (3/22), and SES in 46.2% (6/13). Journal, impact factor, and last author continent were predictors of race/ethnicity and SES reporting. Funding was associated with race/ethnicity reporting. No study reported sex and gender separately, or documented transgender, nonbinary gender spectrum or intersex participants. A single category for race/ethnicity was used in 37.5% (9/24) of studies, consisting of either "White" or "Caucasian." CONCLUSION The reporting of participant demographics in radiology trials is variable and not always representative of the population diversity. Editorial guidelines on the reporting and analysis of participant demographics could help standardize practices.
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Affiliation(s)
- Marlee Parsons
- Department of Diagnostic Radiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Yi Tong
- Department of Diagnostic Radiology, McGill University Health Center, Montreal, Quebec, Canada
| | | | | | - Sahir Bhatnagar
- Department of Diagnostic Radiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Mathieu Boily
- Department of Diagnostic Radiology, McGill University Health Center, Montreal, Quebec, Canada
| | - Natalia Gorelik
- Department of Diagnostic Radiology, McGill University Health Center, Montreal, Quebec, Canada.
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Samaniego EA, Boltze J, Lyden PD, Hill MD, Campbell BCV, Silva GS, Sheth KN, Fisher M, Hillis AE, Nguyen TN, Carone D, Favilla CG, Deljkich E, Albers GW, Heit JJ, Lansberg MG. Priorities for Advancements in Neuroimaging in the Diagnostic Workup of Acute Stroke. Stroke 2023; 54:3190-3201. [PMID: 37942645 PMCID: PMC10841844 DOI: 10.1161/strokeaha.123.044985] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2023] [Accepted: 10/03/2023] [Indexed: 11/10/2023]
Abstract
STAIR XII (12th Stroke Treatment Academy Industry Roundtable) included a workshop to discuss the priorities for advancements in neuroimaging in the diagnostic workup of acute ischemic stroke. The workshop brought together representatives from academia, industry, and government. The participants identified 10 critical areas of priority for the advancement of acute stroke imaging. These include enhancing imaging capabilities at primary and comprehensive stroke centers, refining the analysis and characterization of clots, establishing imaging criteria that can predict the response to reperfusion, optimizing the Thrombolysis in Cerebral Infarction scale, predicting first-pass reperfusion outcomes, improving imaging techniques post-reperfusion therapy, detecting early ischemia on noncontrast computed tomography, enhancing cone beam computed tomography, advancing mobile stroke units, and leveraging high-resolution vessel wall imaging to gain deeper insights into pathology. Imaging in acute ischemic stroke treatment has advanced significantly, but important challenges remain that need to be addressed. A combined effort from academic investigators, industry, and regulators is needed to improve imaging technologies and, ultimately, patient outcomes.
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Affiliation(s)
- Edgar A. Samaniego
- Department of Neurology, Radiology and Neurosurgery, University of Iowa Carver College of Medicine, Iowa City, Iowa, United States
| | - Johannes Boltze
- School of Life Sciences, The University of Warwick, Coventry, United Kingdom
| | - Patrick D. Lyden
- Zilkha Neurogenetic Institute of the Keck School of Medicine at USC, Los Angeles, California, United States
| | - Michael D. Hill
- Department of Clinical Neuroscience & Hotchkiss Brain Institute, University of Calgary & Foothills Medical Centre, Calgary, Canada
| | - Bruce CV Campbell
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Gisele Sampaio Silva
- Department of Neurology and Neurosurgery, Federal University of São Paulo, São Paulo, Brazil
| | - Kevin N Sheth
- Department of Neurology, Division of Neurocritical Care and Emergency Neurology, Yale School of Medicine, New Haven, United States
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Boston, Massachusetts, United States
| | - Argye E. Hillis
- Department of Neurology, School of Medicine, Johns Hopkins University, Baltimore, Maryland, United Stated
| | - Thanh N. Nguyen
- Department of Neurology, Boston Medical Center, Massachusetts, United States
| | - Davide Carone
- Oxford University Hospitals NHS Foundation Trust, Oxford, United Kingdom
| | - Christopher G. Favilla
- Department of Neurology, University of Pennsylvania Philadelphia, Pennsylvania, Unites States
| | | | - Gregory W. Albers
- Department of Neurology, Stanford University, Stanford, California, United States
| | - Jeremy J. Heit
- Department of Radiology and Neurosurgery, Stanford University, Stanford, California, United States
| | - Maarten G Lansberg
- Department of Neurology, Stanford University, Stanford, California, United States
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Yu S, Wang X, Guo Z, Xu P, Tao C, Li R, Hu W, Xiao G. Basilar artery occlusion location and clinical outcome: data from the ATTENTION multicenter registry. J Neurointerv Surg 2023:jnis-2023-020517. [PMID: 37652692 DOI: 10.1136/jnis-2023-020517] [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: 05/03/2023] [Accepted: 08/18/2023] [Indexed: 09/02/2023]
Abstract
BACKGROUND Acute basilar artery occlusion is a disabling and life-threatening condition. The purpose of this study was to evaluate the impact of occluded vessel location on the prognostic outcomes of patients who underwent endovascular treatment for acute basilar artery occlusion. METHODS Patient data for this study were obtained from the ATTENTION registry. Baseline data of the patients were described and compared across different occlusion locations. Univariable and multivariable regression analyses were performed to assess the effect of occluded vessel location on associated prognostic outcomes. RESULTS A total of 1672 patients were included in the analysis, with 583 having distal occlusion, 540 having middle occlusion, and 549 having proximal occlusion. Unlike distal occlusion, both proximal and middle occlusions were significantly and negatively associated with favorable clinical outcomes (for modified Rankin Scale score 0-3: adjusted odds ratio (aOR) 0.634, 95% confidence interval (95% CI) 0.493 to 0.816, P<0.001 in middle occlusion, and aOR 0.620, 95% CI 0.479 to 0.802, P<0.001 in proximal occlusion). Mortality was higher in patients with proximal and middle occlusions (aOR 1.461, 95% CI 1.123 to 1.902, P=0.005 in middle occlusion, and aOR 1.648, 95% CI 1.265 to 2.147, P<0.001 in proximal occlusion). The occluded vessel location was not associated with symptomatic intracranial hemorrhage. CONCLUSIONS Proximal and middle basilar artery occlusions were predominantly associated with poor clinical outcomes and increased risk of death following endovascular treatment.
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Affiliation(s)
- Shuai Yu
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People's Republic of China
- Department of Neurology, The Affiliated Suzhou Hospital of Nanjing Medical University, Suzhou Municipal Hospital, Suzhou, Jiangsu, People's Republic of China
| | - Xiaocui Wang
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People's Republic of China
| | - Zhiliang Guo
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People's Republic of China
| | - Pengfei Xu
- Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, People's Republic of China
| | - Chunrong Tao
- Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, People's Republic of China
| | - Rui Li
- Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, People's Republic of China
| | - Wei Hu
- Stroke Center and Department of Neurology, The First Affiliated Hospital of USTC, Division of Life Sciences and Medicine, University of Science and Technology of China, Hefei, Anhui, People's Republic of China
| | - Guodong Xiao
- Department of Neurology, The Second Affiliated Hospital of Soochow University, Suzhou, Jiangsu, People's Republic of China
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Abdullahi MZ, Mohammad HM, Lawal S, Ibrahim MZ, Bello N, Aliyu I, Muhammad RM. Evaluation of Pattern of Lesions Depicted on Brain Computed Tomography Scan of Patients Presenting with Stroke in Zaria, Nigeria. JOURNAL OF THE WEST AFRICAN COLLEGE OF SURGEONS 2023; 13:16-21. [PMID: 37538210 PMCID: PMC10395855 DOI: 10.4103/jwas.jwas_256_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2022] [Accepted: 11/18/2022] [Indexed: 08/05/2023]
Abstract
Introduction Stroke is a major public health problem worldwide and it is the third leading cause of death in industrialized countries and ranks among the five most common causes of hospital deaths in adults in Africa. Accurate stroke diagnosis has a high significance for patient's outcome. Computed tomography (CT) brain scan is the imaging of choice for patients presenting to the emergency department with stroke. Aim and Objectives The study aimed at evaluating the pattern of lesion depicted on CT brain of patients presenting with stroke in ABUTH, Zaria. Materials and Methods A prospective review of CT findings in 155 patients who presented in the Radiology Department of Ahmadu Bello University Teaching Hospital (ABUTH) with clinical diagnosis of stroke was undertaken over a period of six months (from October 2017 to April 2018).. Results Of the 155 patients seen within the period under review, 88 (56.8%) were males while 67 (43.2%) were females. Age range was 11-90 years (mean 56, standard deviation (SD) 16, 44(28.4%) of patients were in the age group of 61-70 years. Ninety six patients (61.9%) had ischaemic stroke, 27(17.4%) had hemorrhagic stroke, eight (5.2%) was stroke mimic, six patients (3.9%) mixed lesions (ie both ischaemic and haemorrhagic). Eighteen patients (11.6%) had normal brain CT findings. The region most affected by stroke was the parietal region 52(38%). Conclusion Ischaemic stroke is the most common form of stroke in this study.
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Affiliation(s)
| | - Halima Mono Mohammad
- Department of Radiology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
| | - Suleiman Lawal
- Department of Radiology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
| | | | - Nafisa Bello
- Department of Radiology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
| | - Ibrahim Aliyu
- Department of Radiology, Ahmadu Bello University Teaching Hospital, Zaria, Nigeria
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Ozdemir G, Eren F, Aygul R, Kizildag N, Kocaturk I, Mammadi A, Ersoy AN, Ildiz OF, Gunduz ZB, Korez MK. Endovascular treatment for anterior cerebral artery occlusions. Interv Neuroradiol 2023:15910199231162669. [PMID: 36916134 DOI: 10.1177/15910199231162669] [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: 03/16/2023] Open
Abstract
BACKGROUND We sought to examine the feasibility, safety and preliminary efficacy of anterior cerebral artery (ACA) occlusions in patients undergoing endovascular treatment. METHODS Four hundred five consecutive patients with large-vessel occlusion treated with endovascular treatment were analysed to identify all patients with acute ACA occlusion who underwent endovascular treatment. RESULTS Twenty had ACA occlusion (primary ACA occlusion: 9, rescue ACA occlusion: 11), 395 patients had other occlusions (internal carotid artery and MCA). The median [IQR] mRS score in the third month was significantly higher in the ACA-rescue occlusion group versus the ACA-primary occlusion group. The rate of haematoma in patients with ACA-occlusions was significantly higher compared with the ACA-primary occlusion group. Moreover, the three-month mortality rate was higher in patients with ACA-rescue than the patients with ACA-primary. CONCLUSIONS Although endovascular treatment can be considered in patients with primary ACA occlusions, our data suggest that future clinical trials are needed to determine the efficacy of endovascular treatment for ACA occlusions. Unfavourable outcomes in our study were considered to occur in the rescue ACA occlusions.
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Affiliation(s)
- Gokhan Ozdemir
- Department of Neurology, Center of Stroke, Selcuk University Medical Faculty, Konya, Turkey
| | - Fettah Eren
- Department of Neurology, Center of Stroke, Selcuk University Medical Faculty, Konya, Turkey
| | - Recep Aygul
- Department of Neurology, Center of Stroke, Selcuk University Medical Faculty, Konya, Turkey
| | - Nazım Kizildag
- Department of Neurology, Stroke Center, Ataturk University, Erzurum, Turkey
| | - Idris Kocaturk
- Department of Neurology, Binali University Medical Faculty, Erzincan, Turkey
| | - Azer Mammadi
- Department of Neurology, Center of Stroke, Selcuk University Medical Faculty, Konya, Turkey
| | - Ayse Nur Ersoy
- Department of Neurology, Center of Stroke, Selcuk University Medical Faculty, Konya, Turkey
| | - Omer Faruk Ildiz
- Department of Neurology, Center of Stroke, Selcuk University Medical Faculty, Konya, Turkey
| | | | - Muslu Kazım Korez
- Department of Biostatistics, 485663Selcuk University Medical Faculty, Konya, Turkey
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Yogendrakumar V, Beharry J, Churilov L, Alidin K, Ugalde M, Pesavento L, Weir L, Mitchell PJ, Kleinig TJ, Yassi N, Thijs V, Wu TY, Shah DG, Dewey HM, Wijeratne T, Yan B, Desmond PM, Sharma G, Parsons MW, Donnan GA, Davis SM, Campbell BCV, Bush S, Scroop R, Simpson M, Brooks M, Asadi H, Ang T, Miteff F, Levi C, Rodrigues E, Zhao H, Alemseged F, Ng F, Salvaris P, Garcia‐Esperon C, Bailey P, Rice H, de Villiers L, Choi P, Brown H, Redmond K, Leggett D, Fink J, Collecutt W, Kraemer T, Cordato D, Muller C, Coulthard A, Mitchell K, Clouston J, Mahady K, Field D, O’Brien B, Clissold B, Clissold A, Cloud G, Bolitho L, Bonavia L, Bhattacharya A, Wright A, Mamun A, O’Rourke F, Worthington J, Wong A, Ma H, Phan T, Chong W, Chandra R, Slater L, Krause M, Harrington T, Faulder K, Steinfort B, Bladin C. Tenecteplase Improves Reperfusion across Time in Large Vessel Stroke. Ann Neurol 2023; 93:489-499. [PMID: 36394101 DOI: 10.1002/ana.26547] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 09/17/2022] [Accepted: 11/08/2022] [Indexed: 11/18/2022]
Abstract
OBJECTIVE Tenecteplase improves reperfusion compared to alteplase in patients with large vessel occlusions. To determine whether this improvement varies across the spectrum of thrombolytic agent to reperfusion assessment times, we performed a comparative analysis of tenecteplase and alteplase reperfusion rates. METHODS Patients with large vessel occlusion and treatment with thrombolysis were pooled from the Melbourne Stroke Registry, and the EXTEND-IA and EXTEND-IA TNK trials. The primary outcome, thrombolytic-induced reperfusion, was defined as the absence of retrievable thrombus or >50% reperfusion at imaging reassessment. We compared the treatment effect of tenecteplase and alteplase, accounting for thrombolytic to assessment exposure times, via Poisson modeling. We compared 90-day outcomes of patients who achieved reperfusion with a thrombolytic to patients who achieved reperfusion via endovascular therapy using ordinal logistic regression. RESULTS Among 893 patients included in the primary analysis, thrombolytic-induced reperfusion was observed in 184 (21%) patients. Tenecteplase was associated with higher rates of reperfusion (adjusted incidence rate ratio [aIRR] = 1.50, 95% confidence interval [CI] = 1.09-2.07, p = 0.01). Findings were consistent in patient subgroups with first segment (aIRR = 1.41, 95% CI = 0.93-2.14) and second segment (aIRR = 2.07, 95% CI = 0.98-4.37) middle cerebral artery occlusions. Increased thrombolytic to reperfusion assessment times were associated with reperfusion (tenecteplase: adjusted risk ratio [aRR] = 1.08 per 15 minutes, 95% CI = 1.04-1.13 vs alteplase: aRR = 1.06 per 15 minutes, 95% CI = 1.00-1.13). No significant treatment-by-time interaction was observed (p = 0.87). Reperfusion via thrombolysis was associated with improved 90-day modified Rankin Scale scores (adjusted common odds ratio = 2.15, 95% CI = 1.54-3.01) compared to patients who achieved reperfusion following endovascular therapy. INTERPRETATION Tenecteplase, compared to alteplase, increases prethrombectomy reperfusion, regardless of the time from administration to reperfusion assessment. Prethrombectomy reperfusion is associated with better clinical outcomes. ANN NEUROL 2023;93:489-499.
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Affiliation(s)
- Vignan Yogendrakumar
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - James Beharry
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia.,Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia
| | - Leonid Churilov
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Khairunnisa Alidin
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Melissa Ugalde
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Lauren Pesavento
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Louise Weir
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, South Australia, Australia
| | - Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia.,Population Health and Immunity Division, Walter and Eliza Hall Institute of Medical Research, Parkville, Victoria, Australia
| | - Vincent Thijs
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Victoria, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Victoria, Australia
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Darshan G Shah
- Department of Neurology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Helen M Dewey
- Eastern Health and Eastern Health Clinical School, Department of Neurosciences, Monash University, Clayton, Victoria, Australia
| | - Tissa Wijeratne
- Melbourne Medical School, Department of Medicine and Neurology, University of Melbourne and Western Health, Sunshine Hospital, St Albans, Victoria, Australia
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia.,Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Patricia M Desmond
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Gagan Sharma
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Mark W Parsons
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia.,Department of Neurology, Liverpool Hospital, University of New South Wales, Sydney, New South Wales, Australia
| | - Geoffrey A Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
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Collateral Status and Outcomes after Thrombectomy. Transl Stroke Res 2023; 14:22-37. [PMID: 35687300 DOI: 10.1007/s12975-022-01046-z] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Revised: 05/29/2022] [Accepted: 05/31/2022] [Indexed: 01/31/2023]
Abstract
Endovascular treatment (EVT) using novel mechanical thrombectomy devices has been the gold standard for patients with acute ischemic stroke caused by large vessel occlusion. Selection criteria of randomized control trials commonly include baseline infarct volume with or without penumbra evaluation. Although the collateral status has been studied and is known to modify imaging results and clinical course, it has not been commonly used for trials. Many post hoc studies, however, revealed that collateral status can help predict infarct growth, recanalization success, decreased hemorrhagic transformation after EVT, and extension of the therapeutic time window for revascularization. Here, we systematically review the recent literature and summarized the outcomes of EVT according to the collateral status of patients with acute ischemic stroke caused by large vessel occlusion. The studies reviewed indicate that pretreatment collateral circulation is associated with both clinical and imaging outcomes after EVT in patients with acute ischemic stroke due to large vessel occlusion although most patients were already selected by other imaging or clinical criteria. However, treatment decisions using information on patients' collateral status have not progressed in clinical practice. Further randomized trials are needed to evaluate the risks and benefits of EVT in consideration of collateral status.
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9
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Wagner L, Mohrbach D, Ebinger M, Endres M, Nolte CH, Harmel P, Audebert HJ, Rohmann JL, Siegerink B. Impact of time between thrombolysis and endovascular thrombectomy on outcomes in patients with acute ischaemic stroke. Front Neurol 2022; 13:1018630. [PMID: 36408513 PMCID: PMC9667508 DOI: 10.3389/fneur.2022.1018630] [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: 08/13/2022] [Accepted: 10/03/2022] [Indexed: 01/25/2023] Open
Abstract
BACKGROUND Benefits of endovascular thrombectomy (ET) after intravenous thrombolysis (IVT) for patients with acute ischaemic stroke (AIS) have been demonstrated, but analyses of the relationship between IVT-ET time delay and functional outcomes among patients receiving both treatments are lacking. METHODS We used data from the "Berlin-Specific Acute Treatment in Ischaemic and haemorrhAgic stroke with Long-term outcome" (B-SPATIAL) registry. Between January 1st, 2016 and December 31st, 2019, we included patients who received both IVT and ET. The primary outcome was the 3-month ordinal modified Rankin scale (mRS) score. The IVT-ET time delay was analyzed in categories and continuously. We used adjusted ordinal logistic regression to estimate common odds ratios (cOR) and 95% confidence intervals (CI). Secondary analyses involved flexible modeling of IVT-ET delay and dichotomous outcomes. RESULTS Of 11,049 patients, 714 who received IVT followed by ET were included. Compared with having an IVT-ET window >120 min (reference), for an IVT-ET window < 30 min, we obtained adjusted cORs for mRS of 0.41 (95% CI: 0.22 to 0.78); and 0.52 (95% CI: 0.33 to 0.82) for 30 to 120 min. Secondary analyses also found protective effects of shorter time delays against "poor" functional outcomes at 3 months. CONCLUSIONS In patients with AIS, shorter IVT-ET intervals were associated with better 3-month functional outcomes. While the time-to-IVT and time-to-ET include the time until medical attention is received, the IVT-ET time delays fall entirely within the domain of medical management and thus might be easier to optimize.
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Affiliation(s)
- Lora Wagner
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Desiree Mohrbach
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany,Klinik für Neurologie mit Experimenteller Neurologie, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Martin Ebinger
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany,Klinik für Neurologie, Medical Park Berlin Humboldtmühle, Berlin, Germany
| | - Matthias Endres
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany,Klinik für Neurologie mit Experimenteller Neurologie, Charité—Universitätsmedizin Berlin, Berlin, Germany,Berlin Institute of Health (BIH), Charité—Universitätsmedizin Berlin, Berlin, Germany,German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany,German Centre for Cardiovascular Research (DZHK), Partner Site Berlin, Berlin, Germany
| | - Christian H. Nolte
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany,Klinik für Neurologie mit Experimenteller Neurologie, Charité—Universitätsmedizin Berlin, Berlin, Germany,Berlin Institute of Health (BIH), Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Peter Harmel
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany,Klinik für Neurologie mit Experimenteller Neurologie, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Heinrich J. Audebert
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany,Klinik für Neurologie mit Experimenteller Neurologie, Charité—Universitätsmedizin Berlin, Berlin, Germany
| | - Jessica L. Rohmann
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany,Institute of Public Health, Charité—Universitätsmedizin Berlin, Berlin, Germany,*Correspondence: Jessica L. Rohmann
| | - Bob Siegerink
- Center for Stroke Research Berlin, Charité—Universitätsmedizin Berlin, Berlin, Germany,Department of Clinical Epidemiology, Leiden University Medical Center, Leiden University, Leiden, Netherlands
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10
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Dzialowski I, Puetz V, Parsons M, Bivard A, von Kummer R. Computed Tomography-Based Evaluation of Cerebrovascular Disease. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00047-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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11
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Quantitative analysis of thrombus migration before mechanical thrombectomy: Determinants and relationship with procedural and clinical outcomes. J Neuroradiol 2021; 49:385-391. [PMID: 34808221 DOI: 10.1016/j.neurad.2021.11.005] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Revised: 11/11/2021] [Accepted: 11/13/2021] [Indexed: 10/19/2022]
Abstract
BACKGROUND AND PURPOSE In patients with acute ischemic stroke (AIS) and a large vessel occlusion (LVO), thrombus migration (T-Mig) is a common phenomenon before mechanical thrombectomy (MT), revealed by pre-treatment imaging. Previous works have used qualitative scales to define T-Mig. The aim of this study was to evaluate the determinants and impact of quantitatively assessed T-Mig on procedural characteristics and clinical outcome. METHODS Consecutive patients with AIS due to LVO treated by MT at a reference academic hospital were analysed. Distance between vessel origin and beginning of the thrombus on MRI (3D-time-of-flight and/or contrast-enhanced magnetic-resonance-angiography) and digital-substracted-angiography (DSA) were measured in millimeters using a curve tool. Thrombus migration was defined quantitatively as ∆TD calculated as the difference between pre-MT-DSA and MRI thrombus location. ∆TD was rated as significant if above 5mm. RESULTS A total of 267 patients were included (mean age 70±12 years; 46% females) were analyzed. Amongst them, 65 (24.3%) experienced any degree of T-Mig. T-Mig was found to be associated with iv-tPA administration prior to thrombectomy (β-estimate 2.52; 95% CI [1.25-3.79]; p<0.001), fewer device passes during thrombectomy (1.22±1.31 vs 1.66±0.99; p<0.05), and shorter pre-treatment thrombi (β-estimate -0.1millimeter; 95% CI [-0.27-0.07]; p<0.05). There was no association between T-Mig and a favourable outcome (defined by a 0-to-2 modified-Rankin-Scale at 3months, adjusted OR: 2.16 [0.93 - 5.02]; p=0.06) CONCLUSION: Thrombus migration happens in almost a fourth of our study sample, and its quantitative extent was associated with iv-tPA administration prior to MT, but not with clinical outcome.
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12
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Nene RV, Wali AR, Santiago-Dieppa DR, Srinivas S, Guluma KZ. A Case for Thrombectomy: Acute Onset Hemiparesis from a Large Vessel Occlusion. J Emerg Med 2021; 61:587-589. [PMID: 34774413 DOI: 10.1016/j.jemermed.2021.09.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2021] [Revised: 07/27/2021] [Accepted: 09/11/2021] [Indexed: 11/26/2022]
Affiliation(s)
- Rahul V Nene
- Department of Emergency Medicine, University of California, San Diego, San Diego, California
| | - Arvin R Wali
- Department of Neurological Surgery, University of California, San Diego, San Diego, California
| | - David R Santiago-Dieppa
- Department of Neurological Surgery, University of California, San Diego, San Diego, California
| | - Shanmukha Srinivas
- Department of Neurological Surgery, University of California, San Diego, San Diego, California
| | - Kama Z Guluma
- Department of Emergency Medicine, University of California, San Diego, San Diego, California
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13
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Belachew NF, Dobrocky T, Meinel TR, Hakim A, Vynckier J, Arnold M, Seiffge DJ, Wiest R, Piechowiak EI, Fischer U, Gralla J, Mordasini P, Kaesmacher J. Risks of Undersizing Stent Retriever Length Relative to Thrombus Length in Patients with Acute Ischemic Stroke. AJNR Am J Neuroradiol 2021; 42:2181-2187. [PMID: 34649917 DOI: 10.3174/ajnr.a7313] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2021] [Accepted: 07/30/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE Results regarding the association of thrombus length, stent retriever length, and recanalization success in patients with acute ischemic stroke are inconsistent. We hypothesized that the ratio of thrombus length to stent retriever length may be of particular relevance. MATERIALS AND METHODS Patients with acute ischemic stroke undergoing stent retriever thrombectomy at our institution between January 2010 and December 2018 were reviewed retrospectively. Thrombus length was assessed by measuring the susceptibility vessel sign on SWI using a 1.5T or 3T MR imaging scanner. Multivariable logistic regression models were used to determine the association between thrombus length, stent retriever length, and thrombus length/stent retriever length ratio with first-pass recanalization, overall recanalization, and embolization in new territories. Results are shown as adjusted ORs with 95% CIs. Additional mediation analyses were performed to test for indirect effects on first-pass recanalization and overall recanalization success. RESULTS The main analysis included 418 patients (mean age, 74.9 years). Increasing stent retriever length was associated with first-pass recanalization. Decreasing thrombus length and lower thrombus length/stent retriever length ratios were associated with first-pass recanalization and overall recanalization. Thrombus length and stent retriever length showed no association with first-pass recanalization or overall recanalization once thrombus length/stent retriever length ratio was factored in, while thrombus length/stent retriever length ratio remained a significant factor in both models (adjusted OR, 0.316 [95% CI, 0.112-0.892]; P = .030 and adjusted OR, = 0.366 [95% CI, 0.194-0.689]; P = .002). Mediation analyses showed that decreasing thrombus length and increasing stent retriever length had a significant indirect effect on first-pass recanalization mediated through thrombus length/stent retriever length ratio. The only parameter associated with embolization in new territories was an increasing thrombus length/stent retriever length ratio (adjusted OR, 5.079 [95% CI, 1.332-19.362]; P = .017). CONCLUSIONS Information about thrombus and stent length is more valuable when combined. High thrombus length/stent retriever length ratios, which may raise the risk of unsuccessful recanalization and embolization in new territories, should be avoided by adapting stent retriever selection to thrombus length whenever possible.
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Affiliation(s)
- N F Belachew
- From the Departments of Diagnostic and Interventional Neuroradiology (N.F.B., T.D., A.H., R.W., E.I.P., J.G., P.M., J.K.)
| | - T Dobrocky
- From the Departments of Diagnostic and Interventional Neuroradiology (N.F.B., T.D., A.H., R.W., E.I.P., J.G., P.M., J.K.)
| | - T R Meinel
- Department of Neurology (T.R.M., J.V., M.A., D.J.S., U.F.)
| | - A Hakim
- From the Departments of Diagnostic and Interventional Neuroradiology (N.F.B., T.D., A.H., R.W., E.I.P., J.G., P.M., J.K.)
| | - J Vynckier
- Department of Neurology (T.R.M., J.V., M.A., D.J.S., U.F.)
| | - M Arnold
- Department of Neurology (T.R.M., J.V., M.A., D.J.S., U.F.)
| | - D J Seiffge
- Department of Neurology (T.R.M., J.V., M.A., D.J.S., U.F.)
| | - R Wiest
- From the Departments of Diagnostic and Interventional Neuroradiology (N.F.B., T.D., A.H., R.W., E.I.P., J.G., P.M., J.K.)
| | - E I Piechowiak
- From the Departments of Diagnostic and Interventional Neuroradiology (N.F.B., T.D., A.H., R.W., E.I.P., J.G., P.M., J.K.)
| | - U Fischer
- Department of Neurology (T.R.M., J.V., M.A., D.J.S., U.F.)
| | - J Gralla
- From the Departments of Diagnostic and Interventional Neuroradiology (N.F.B., T.D., A.H., R.W., E.I.P., J.G., P.M., J.K.)
| | - P Mordasini
- From the Departments of Diagnostic and Interventional Neuroradiology (N.F.B., T.D., A.H., R.W., E.I.P., J.G., P.M., J.K.)
| | - J Kaesmacher
- From the Departments of Diagnostic and Interventional Neuroradiology (N.F.B., T.D., A.H., R.W., E.I.P., J.G., P.M., J.K.).,Diagnostic, Interventional and Pediatric Radiology (J.K.), Inselspital, Bern University Hospital, and University of Bern, Bern, Switzerland
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14
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Waqas M, Kuo CC, Dossani RH, Monteiro A, Baig AA, Alkhaldi M, Cappuzzo JM, Levy EI, Siddiqui AH. Mechanical thrombectomy versus intravenous thrombolysis for distal large-vessel occlusion: a systematic review and meta-analysis of observational studies. Neurosurg Focus 2021; 51:E5. [PMID: 34198258 DOI: 10.3171/2021.4.focus21139] [Citation(s) in RCA: 18] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/07/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE While several studies have compared the feasibility and safety of mechanical thrombectomy (MT) for distal large-vessel occlusion (LVO) strokes in patients, few studies have compared MT with intravenous thrombolysis (IVT) alone. The purpose of this systematic review was to compare the effectiveness and safety between MT and standard medical management with IVT alone for patients with distal LVOs. METHODS PubMed, Google Scholar, Embase, Scopus, Web of Science, Ovid Medline, and Cochrane Library were searched in order to identify studies that directly compared MT with IVT for distal LVOs (anterior cerebral artery A2, middle cerebral artery M3-4, and posterior cerebral artery P2-4). Primary outcomes of interest included a modified Rankin Scale (mRS) score of 0 to 2 at 90 days posttreatment, occurrence of symptomatic intracerebral hemorrhage (sICH), and all-cause mortality at 90 days posttreatment. RESULTS Four studies representing a total of 381 patients were included in this meta-analysis. The pooled results indicated that the proportion of patients with an mRS score of 0 to 2 at 90 days (OR 1.16, 95% CI 0.23-5.93; p = 0.861), the occurrence of sICH (OR 2.45, 95% CI 0.75-8.03; p = 0.140), and the mortality rate at 90 days (OR 1.73, 95% CI 0.66-4.55; p = 0.263) did not differ between patients who underwent MT and those who received IVT alone. CONCLUSIONS The meta-analysis did not demonstrate a significant difference between MT and standard medical management with regard to favorable outcome, occurrence of sICH, or 90-day mortality. Prospective clinical trials are needed to further compare the efficacy of MT with IVT alone for distal vessel occlusion.
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Affiliation(s)
- Muhammad Waqas
- Departments of1Neurosurgery and.,2Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo
| | | | - Rimal H Dossani
- Departments of1Neurosurgery and.,2Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo
| | - Andre Monteiro
- Departments of1Neurosurgery and.,2Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo
| | - Ammad A Baig
- Departments of1Neurosurgery and.,2Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo
| | - Modhi Alkhaldi
- 4Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Justin M Cappuzzo
- Departments of1Neurosurgery and.,2Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo
| | - Elad I Levy
- Departments of1Neurosurgery and.,2Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo.,5Canon Stroke and Vascular Research Center, University at Buffalo.,6Jacobs Institute, Buffalo, New York; and.,7Radiology
| | - Adnan H Siddiqui
- Departments of1Neurosurgery and.,2Department of Neurosurgery, Gates Vascular Institute at Kaleida Health, Buffalo.,5Canon Stroke and Vascular Research Center, University at Buffalo.,6Jacobs Institute, Buffalo, New York; and.,7Radiology
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15
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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.
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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
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16
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Arrarte Terreros N, Bruggeman AAE, Swijnenburg ISJ, van Meenen LCC, Groot AE, Coutinho JM, Roos YBWEM, Emmer BJ, Beenen LFM, van Bavel E, Marquering HA, Majoie CBLM. Early recanalization in large-vessel occlusion stroke patients transferred for endovascular treatment. J Neurointerv Surg 2021; 14:neurintsurg-2021-017441. [PMID: 33986112 PMCID: PMC9016237 DOI: 10.1136/neurintsurg-2021-017441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2021] [Revised: 04/24/2021] [Accepted: 04/29/2021] [Indexed: 11/25/2022]
Abstract
Background We performed an exploratory analysis to identify patient and thrombus characteristics associated with early recanalization in large-vessel occlusion (LVO) stroke patients transferred for endovascular treatment (EVT) from a primary (PSC) to a comprehensive stroke center (CSC). Methods We included patients with an LVO stroke of the anterior circulation who were transferred to our hospital for EVT and underwent repeated imaging between January 2016 and June 2019. We compared patient characteristics, workflow time metrics, functional outcome (modified Rankin Scale at 90 days), and baseline thrombus imaging characteristics, which included: occlusion location, thrombus length, attenuation, perviousness, distance from terminus of intracranial carotid artery to the thrombus (DT), and clot burden score (CBS), between early-recanalized LVO (ER-LVO), and non-early-recanalized LVO (NER-LVO) patients. Results One hundred and forty-nine patients were included in the analysis. Early recanalization occurred in 32% of patients. ER-LVO patients less often had a medical history of hypertension (31% vs 49%, P=0.04), and more often had clinical improvement between PSC and CSC (ΔNIHSS −5 vs 3, P<0.01), compared with NER-LVO patients. Thrombolysis administration was similar in both groups (88% vs 78%, P=0.18). ER-LVO patients had no ICA occlusions (0% vs 27%, P<0.01), more often an M2 occlusion (35% vs 17%, P=0.01), longer DT (27 mm vs 12 mm, P<0.01), shorter thrombi (17 mm vs 27 mm, P<0.01), and higher CBS (8 vs 6, P<0.01) at baseline imaging. ER-LVO patients had lower mRS scores (1 vs 3, P=0.02). Conclusions Early recanalization is associated with clinical improvement between PSC and CSC admission, more distal occlusions and shorter thrombi at baseline imaging, and better functional outcome.
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Affiliation(s)
- Nerea Arrarte Terreros
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location AMC, Amsterdam, the Netherlands .,Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Agnetha A E Bruggeman
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Isabella S J Swijnenburg
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location AMC, Amsterdam, the Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Laura C C van Meenen
- Department of Neurology, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Adrien E Groot
- Department of Neurology, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Bart J Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Ludo F M Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Ed van Bavel
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Henk A Marquering
- Department of Biomedical Engineering and Physics, Amsterdam UMC, location AMC, Amsterdam, the Netherlands.,Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, location AMC, Amsterdam, the Netherlands
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17
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Hefferman GM, Baird GL, Swenson DW, Ward RC, Jayaraman MV, Cutting S, Jindal G. Effects of multiphase versus single-phase CT angiography for the detection of distal cerebral vessel occlusion. Emerg Radiol 2021; 28:891-898. [PMID: 33866443 DOI: 10.1007/s10140-021-01933-2] [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: 01/30/2021] [Accepted: 04/08/2021] [Indexed: 10/21/2022]
Abstract
PURPOSE The goal of this study was to determine whether the benefits of multiphase CTA (mCTA) over single-phase CTA (sCTA) for the detection of proximal cerebrovascular occlusions similarly extend to the distal cerebral vasculature. METHODS Four attending radiologists, two neuroradiologists and two emergency radiologists, contributed as readers to this retrospective study. For each reader, two sessions were conducted, one using sCTA and one using mCTA. During each session, the reader interpreted the studies of 104 patients who underwent imaging for suspicion of acute ischemic stroke, resulting in a total of 832 interpretations. Changes in diagnostic accuracy, time to render final decision, and reported levels of reader confidence were quantitatively assessed. Further analysis comparing the effects for neuroradiologists versus emergency radiologists was additionally conducted. RESULTS Using mCTA resulted in a significant 5.0% absolute increase in sensitivity (91.6% vs. 96.6%, p = .004) and an insignificant increase in specificity (99.5% vs. 99.7%, p = .39). A significant reduction in reading time (66.7 s vs. 59.6 s, p = .001) and an increase in diagnostic confidence (2.26 vs. 2.58, p < .001) were observed. Using sCTA, higher sensitivity was achieved by neuroradiologists than emergency radiologists (96.0% vs. 86.9%, p = .002); using mCTA resulted in an absolute increase in sensitivity of 0.9% (97.4%, p = .44) for neuroradiologists and 9.6% (96.5%, p < .001) for emergency radiologists, eliminating significant differences between the groups (p = 0.57). CONCLUSION The use of mCTA results in increased sensitivity and negative predictive value, decreased reading time, increased diagnostic confidence, and the elimination of differences in accuracy between neuroradiologists and emergency radiologists.
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Affiliation(s)
- Gerald M Hefferman
- Department of Diagnostic Imaging, Rhode Island Hospital and the Warren Alpert Medical School of Brown University, Providence, RI, USA. .,Department of Radiology, Brigham and Women's Hospital and Harvard Medical School, 75 Francis Street, Boston, MA, 02115, USA.
| | - Grayson L Baird
- Department of Diagnostic Imaging, Rhode Island Hospital and the Warren Alpert Medical School of Brown University, Providence, RI, USA.,The Lifespan Biostatistics Core, Rhode Island Hospital and the Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - David W Swenson
- Department of Diagnostic Imaging, Rhode Island Hospital and the Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Robert C Ward
- Department of Diagnostic Imaging, Rhode Island Hospital and the Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Mahesh V Jayaraman
- Department of Diagnostic Imaging, Rhode Island Hospital and the Warren Alpert Medical School of Brown University, Providence, RI, USA.,Department of Neurology, Rhode Island Hospital and the Warren Alpert Medical School of Brown University, Providence, RI, USA.,Department of Neurosurgery, Rhode Island Hospital and the Warren Alpert Medical School of Brown University, Providence, RI, USA.,The Norman Prince Neuroscience Institute, Rhode Island Hospital and the Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Shawna Cutting
- Department of Neurology, Rhode Island Hospital and the Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Gaurav Jindal
- Department of Diagnostic Imaging, Rhode Island Hospital and the Warren Alpert Medical School of Brown University, Providence, RI, USA
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18
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Goyal M, Ospel JM, Kappelhof M, Ganesh A. Challenges of Outcome Prediction for Acute Stroke Treatment Decisions. Stroke 2021; 52:1921-1928. [PMID: 33765866 DOI: 10.1161/strokeaha.120.033785] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Physicians often base their decisions to offer acute stroke therapies to patients around the question of whether the patient will benefit from treatment. This has led to a plethora of attempts at accurate outcome prediction for acute ischemic stroke treatment, which have evolved in complexity over the years. In theory, physicians could eventually use such models to make a prediction about the treatment outcome for a given patient by plugging in a combination of demographic, clinical, laboratory, and imaging variables. In this article, we highlight the importance of considering the limits and nuances of outcome prediction models and their applicability in the clinical setting. From the clinical perspective of decision-making about acute treatment, we argue that it is important to consider 4 main questions about a given prediction model: (1) what outcome is being predicted, (2) what patients contributed to the model, (3) what variables are in the model (considering their quantifiability, knowability at the time of decision-making, and modifiability), and (4) what is the intended purpose of the model? We discuss relevant aspects of these questions, accompanied by clinically relevant examples. By acknowledging the limits of outcome prediction for acute stroke therapies, we can incorporate them into our decision-making more meaningfully, critically examining their contents, outcomes, and intentions before heeding their predictions. By rigorously identifying and optimizing modifiable variables in such models, we can be empowered rather than paralyzed by them.
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Affiliation(s)
- Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Canada (M.G., A.G.).,Department of Radiology (M.G.), University of Calgary, Canada.,Hotchkiss Brain Institute (M.G.), University of Calgary, Canada
| | - Johanna Maria Ospel
- Department of Neuroradiology, University Hospital Basel, Switzerland (J.M.O.)
| | - Manon Kappelhof
- Department of Radiology, Amsterdam UMC, University of Amsterdam, the Netherlands (M.K.)
| | - Aravind Ganesh
- Department of Clinical Neurosciences, University of Calgary Cumming School of Medicine, Canada (M.G., A.G.)
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19
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Zapata-Arriaza E, de Albóniga-Chindurza A, Ortega-Quintanilla J, Escudero-Martínez I, Moniche F, Medina-Rodríguez M, Pardo-Galiana B, Rodríguez JAC, Hernández LL, Ainz L, Pérez-Sánchez S, Domínguez-Mayoral A, Barragán A, Cayuela A, Montaner J, García AG. Clinical Outcomes of Mechanical Thrombectomy in Stroke Tandem Lesions According to Intracranial Occlusion Location. J Stroke 2021; 23:124-127. [PMID: 33600709 PMCID: PMC7900399 DOI: 10.5853/jos.2020.02747] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/07/2020] [Accepted: 11/16/2020] [Indexed: 11/30/2022] Open
Affiliation(s)
- Elena Zapata-Arriaza
- Interventional Neurorradiology Department, Stroke Research Program, Institute of Biomedicine of Seville (IBiS)/Virgen del Rocio University Hospital, Seville, Spain
| | - Asier de Albóniga-Chindurza
- Interventional Neurorradiology Department, Stroke Research Program, Institute of Biomedicine of Seville (IBiS)/Virgen del Rocio University Hospital, Seville, Spain
| | - Joaquin Ortega-Quintanilla
- Interventional Neurorradiology Department, Stroke Research Program, Institute of Biomedicine of Seville (IBiS)/Virgen del Rocio University Hospital, Seville, Spain
| | - Irene Escudero-Martínez
- Neurology Department, Institute of Biomedicine of Seville (IBiS)/Virgen del Rocio University Hospital, Seville, Spain
| | - Francisco Moniche
- Neurology Department, Institute of Biomedicine of Seville (IBiS)/Virgen del Rocio University Hospital, Seville, Spain
| | - Manuel Medina-Rodríguez
- Neurology Department, Institute of Biomedicine of Seville (IBiS)/Virgen del Rocio University Hospital, Seville, Spain
| | - Blanca Pardo-Galiana
- Neurology Department, Institute of Biomedicine of Seville (IBiS)/Virgen del Rocio University Hospital, Seville, Spain
| | | | - Lucía Lebrato Hernández
- Neurology Department, Institute of Biomedicine of Seville (IBiS)/Virgen del Rocio University Hospital, Seville, Spain
| | - Leire Ainz
- Neurology Department, Institute of Biomedicine of Seville (IBiS)/Virgen del Rocio University Hospital, Seville, Spain
| | | | | | - Ana Barragán
- Department of Neurology, Virgen Macarena University Hospital, Seville, Spain
| | - Aurelio Cayuela
- Clinical Management of Public Health, Prevention and Health Promotion Unit, Southern Health Management Area of Seville, Hospital de Valme, Seville, Spain
| | - Joan Montaner
- Department of Neurology, Virgen Macarena University Hospital, Seville, Spain
| | - Alejandro González García
- Interventional Neurorradiology Department, Stroke Research Program, Institute of Biomedicine of Seville (IBiS)/Virgen del Rocio University Hospital, Seville, Spain
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20
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Recanalization Therapy for Acute Ischemic Stroke with Large Vessel Occlusion: Where We Are and What Comes Next? Transl Stroke Res 2021; 12:369-381. [PMID: 33409732 PMCID: PMC8055567 DOI: 10.1007/s12975-020-00879-w] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2020] [Revised: 11/15/2020] [Accepted: 11/18/2020] [Indexed: 12/18/2022]
Abstract
In the past 5 years, the success of multiple randomized controlled trials of recanalization therapy with endovascular thrombectomy has transformed the treatment of acute ischemic stroke with large vessel occlusion. The evidence from these trials has now established endovascular thrombectomy as standard of care. This review will discuss the chronological evolution of large vessel occlusion treatment from early medical therapy with tissue plasminogen activator to the latest mechanical thrombectomy. Additionally, it will highlight the potential areas in endovascular thrombectomy for acute ischemic stroke open to exploration and further progress in the next decade.
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21
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Collateral Status in Ischemic Stroke: A Comparison of Computed Tomography Angiography, Computed Tomography Perfusion, and Digital Subtraction Angiography. J Comput Assist Tomogr 2020; 44:984-992. [PMID: 33196604 PMCID: PMC7668337 DOI: 10.1097/rct.0000000000001090] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Supplemental digital content is available in the text. Objective To compare assessment of collaterals by single-phase computed tomography (CT) angiography (CTA) and CT perfusion-derived 3-phase CTA, multiphase CTA and temporal maximum-intensity projection (tMIP) images to digital subtraction angiography (DSA), and relate collateral assessments to clinical outcome in patients with acute ischemic stroke. Methods Consecutive acute ischemic stroke patients who underwent CT perfusion, CTA, and DSA before thrombectomy with occlusion of the internal carotid artery, the M1 or the M2 segments were included. Two observers assessed all CT images and one separate observer assessed DSA (reference standard) with static and dynamic (modified American Society of Interventional and Therapeutic Neuroradiology) collateral grading methods. Interobserver agreement and concordance were quantified with Cohen-weighted κ and concordance correlation coefficient, respectively. Imaging assessments were related to clinical outcome (modified Rankin Scale, ≤ 2). Results Interobserver agreement (n = 101) was 0.46 (tMIP), 0.58 (3-phase CTA), 0.67 (multiphase CTA), and 0.69 (single-phase CTA) for static assessments and 0.52 (3-phase CTA) and 0.54 (multiphase CTA) for dynamic assessments. Concordance correlation coefficient (n = 80) was 0.08 (3-phase CTA), 0.09 (single-phase CTA), and 0.23 (multiphase CTA) for static assessments and 0.10 (3-phase CTA) and 0.27 (multiphase CTA) for dynamic assessments. Higher static collateral scores on multiphase CTA (odds ratio [OR], 1.7; 95% confidence interval [CI], 1.1–2.7) and tMIP images (OR, 2.0; 95% CI, 1.1–3.4) were associated with modified Rankin Scale of 2 or less as were higher modified American Society of Interventional and Therapeutic Neuroradiology scores on 3-phase CTA (OR, 1.5; 95% CI, 1.1–2.2) and multiphase CTA (OR, 1.7; 95% CI, 1.1–2.6). Conclusions Concordance between assessments on CT and DSA was poor. Collateral status evaluated on 3-phase CTA and multiphase CTA, but not on DSA, was associated with clinical outcome.
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22
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Jovin TG, Desai SM, Aghaebrahim A, Ducruet AF, Giurgiutiu DV, Gross BA, Hammer M, Jankowitz BT, Jumaa MA, Kenmuir C, Linares G, Reddy V, Rocha M, Starr M, Totoraitis V, Wechsler L, Zaidi S, Jadhav AP. Neurothrombectomy for Acute Ischemic Stroke Across Clinical Trial Design and Technique: A Single Center Pooled Analysis. Front Neurol 2020; 11:1047. [PMID: 33071935 PMCID: PMC7543690 DOI: 10.3389/fneur.2020.01047] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2020] [Accepted: 08/10/2020] [Indexed: 01/01/2023] Open
Abstract
Introduction: The practice of endovascular therapy has evolved dramatically over the last 10 years with randomized clinical trials investigating the benefit of thrombectomy in select patient populations based on time of presentation, imaging criteria, and procedural technique. We sought to understand the benefit of thrombectomy in patients treated within the context of a clinical trial at a single academic center. Methods: Patient-level data recorded in case forms and core-lab adjudicated data were analyzed from patients enrolled in RCTs investigating the benefit of endovascular thrombectomy over medical management (IMSIII, MR RESCUE, ESCAPE, SWIFT PRIME, and DAWN) between 2007 and 2017 at a single academic referral center. Results: A total of 134 patients (intervention group, n = 81; medical group, n = 53) were identified across five clinical trials (IMSIII, n = 46; MR RESCUE, n = 4; ESCAPE, n = 24; SWIFT PRIME, n = 14; DAWN, n = 46). There were no significant differences between the treatment arm and control arm in terms of age, gender, baseline NIHSS, ASPECTS, and site of occlusion. Rates of good outcome were superior in the intervention group with early neurological recovery (NIHSS of 0–1 or increase NIHSS of 8 points at 24 h) at a higher rate of 49% vs. 17% (p = <0.001) and higher rates of functional independence (90 day mRS 0–2 of 53% vs. 26%, p = 0.002). In multivariate logistic regression analysis, lower NIHSS and younger age were predictors of good outcome. There were comparable rates of good outcome irrespective of clinical trial, imaging selection criteria (CTP vs. MRI), early vs. late time window (0–6 h vs. 6–24 h) and procedural technique (Merci vs. Solitaire/Trevo device). There were no differences in rates of sICH, PH-2 or mortality in the intervention group vs. medical group. Conclusions: At a large academic center, the benefit of endovascular therapy over medical therapy is observed irrespective of clinical trial design, patient selection or procedural technique.
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Affiliation(s)
- Tudor G Jovin
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Shashvat M Desai
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Amin Aghaebrahim
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Andrew F Ducruet
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Dan-Victor Giurgiutiu
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Bradley A Gross
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Maxim Hammer
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Brian T Jankowitz
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Mouhammad A Jumaa
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Cynthia Kenmuir
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Guillermo Linares
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Vivek Reddy
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Marcelo Rocha
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Matthew Starr
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Viktoria Totoraitis
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Lawrence Wechsler
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Syed Zaidi
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
| | - Ashutosh P Jadhav
- Department of Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, United States.,Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
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23
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Wang M, Rajan SS, Jacob AP, Singh N, Parker SA, Bowry R, Grotta JC, Yamal JM. Retrospective collection of 90-day modified Rankin Scale is accurate. Clin Trials 2020; 17:637-643. [PMID: 32755236 DOI: 10.1177/1740774520942466] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The 90-day modified Rankin Scale is a widely used outcome after stroke but is sometimes hard to ascertain due to loss to follow-up. Missing outcomes can result in biased and/or inefficient estimates in clinical trials. The aim of this study is to assess the validity of acquiring the 90-day modified Rankin Scale at a later point of time when the patient has been lost at 90 days to impute the missing value. METHODS Participants who had prospectively completed a 90-day modified Rankin Scale questionnaire on their own in the Benefits of Stroke Treatment Using a Mobile Stroke Unit study were randomly interviewed to recall the 90-day modified Rankin Scale at 6, 9, or 12 months after hospital discharge over the phone. Concordance between the two scores was assessed using kappa and weighted kappa statistics. Logistic regression was used to identify factors associated with inconsistent reporting of the 90-day modified Rankin Scale. RESULTS Substantial agreement was observed between in-the-moment and retrospective 90-day modified Rankin Scale recalled at 6, 9, or 12 months (weighted kappa = 0.93, 95% confidence interval: 0.89-0.98; weighted kappa = 0.93, 95% confidence interval: 0.85-1.00 and weighted kappa = 0.89, 95% confidence interval: 0.82-0.95, respectively). CONCLUSION Retrospective recall of 90-day modified Rankin Scale at a later time point is a valid means to impute missing data in stroke clinical trials.
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Affiliation(s)
- Mengxi Wang
- Department of Biostatistics and Data Science, School of Public Health at The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Suja S Rajan
- Department of Management, Policy and Community Health, School of Public Health at the University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Asha P Jacob
- Department of Biostatistics and Data Science, School of Public Health at The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Noopur Singh
- Department of Biostatistics and Data Science, School of Public Health at The University of Texas Health Science Center at Houston, Houston, TX, USA
| | - Stephanie A Parker
- Mobile Stroke Unit and Stroke Research, Clinical Innovation and Research Institute at the Memorial Hermann Hospital, Houston, TX, USA
| | - Ritvij Bowry
- Department of Neurology, McGovern Medical School at the University of Texas Health Science Center at Houston, Houston, TX, USA
| | - James C Grotta
- Mobile Stroke Unit and Stroke Research, Clinical Innovation and Research Institute at the Memorial Hermann Hospital, Houston, TX, USA
| | - Jose-Miguel Yamal
- Department of Biostatistics and Data Science, School of Public Health at The University of Texas Health Science Center at Houston, Houston, TX, USA
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24
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Huang SJ, Diao SS, Lu Y, Li T, Zhang LL, Ding YP, Fang Q, Cai XY, Xu Z, Kong Y. Value of thrombus imaging in predicting the outcomes of patients with large-vessel occlusive strokes after endovascular therapy. Neurol Sci 2020; 41:1451-1458. [PMID: 32086687 DOI: 10.1007/s10072-020-04296-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Accepted: 11/22/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND Acute ischemic stroke leads to serious long-term disability and high mortality, especially in patients with large-vessel occlusive strokes. Nowadays, endovascular therapy is considered as an alternative treatment for these patients. Several studies have used thrombus characteristics based on non-contrast computed tomography (NCCT) and computed tomography angiography (CTA) to predict prognosis in ischemic stroke. We conducted a systematic review to identify potential imaging predictive factors for successful recanalization and improved clinical outcome after endovascular therapy in patients with large-vessel occlusion (LVO) in anterior arterial circulation. METHODS The PubMed databases were searched for related studies reported between September 18, 2009, and September 18, 2019. RESULTS We selected 11 studies on revascularization and 12 studies on clinical outcome. Patients with thrombus of higher Hounsfield unit (HU), shorter length, higher clot burden score, and increased thrombus permeability may achieve higher recanalization and improved clinical outcome, but the matter is still under debate. CONCLUSION Imaging of thrombus can be used as an aseessment tool to predict the outcomes and it needs further studies in the future.
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Affiliation(s)
- Shuang-Jiao Huang
- Department of neurology, The First Affiliated Hospital of Soochow University, No.899, Pinghai Road, Suzhou, 215000, Jiangsu, China
| | - Shan-Shan Diao
- Department of neurology, The First Affiliated Hospital of Soochow University, No.899, Pinghai Road, Suzhou, 215000, Jiangsu, China
| | - Yue Lu
- Department of neurology, The First Affiliated Hospital of Soochow University, No.899, Pinghai Road, Suzhou, 215000, Jiangsu, China
| | - Tan Li
- Department of neurology, The First Affiliated Hospital of Soochow University, No.899, Pinghai Road, Suzhou, 215000, Jiangsu, China
| | - Lu-Lu Zhang
- Department of neurology, The First Affiliated Hospital of Soochow University, No.899, Pinghai Road, Suzhou, 215000, Jiangsu, China
| | - Yi-Ping Ding
- Department of neurology, The First Affiliated Hospital of Soochow University, No.899, Pinghai Road, Suzhou, 215000, Jiangsu, China
| | - Qi Fang
- Department of neurology, The First Affiliated Hospital of Soochow University, No.899, Pinghai Road, Suzhou, 215000, Jiangsu, China
| | - Xiu-Ying Cai
- Department of neurology, The First Affiliated Hospital of Soochow University, No.899, Pinghai Road, Suzhou, 215000, Jiangsu, China.
| | - Zhuan Xu
- Department of neurology, The First Affiliated Hospital of Soochow University, No.899, Pinghai Road, Suzhou, 215000, Jiangsu, China.
| | - Yan Kong
- Department of neurology, The First Affiliated Hospital of Soochow University, No.899, Pinghai Road, Suzhou, 215000, Jiangsu, China.
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25
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Puig J, Shankar J, Liebeskind D, Terceño M, Nael K, Demchuk AM, Menon B, Dowlatshahi D, Leiva-Salinas C, Wintermark M, Thomalla G, Silva Y, Serena J, Pedraza S, Essig M. From "Time is Brain" to "Imaging is Brain": A Paradigm Shift in the Management of Acute Ischemic Stroke. J Neuroimaging 2020; 30:562-571. [PMID: 32037629 DOI: 10.1111/jon.12693] [Citation(s) in RCA: 44] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 01/21/2020] [Accepted: 01/22/2020] [Indexed: 11/30/2022] Open
Abstract
Arterial recanalization to restore the blood supply and limit the brain damage is the primary goal in the management of acute ischemic stroke (AIS). Since the publication of pivotal randomized clinical trials in 2015, endovascular thrombectomy has become part of the standard of care in selected cases of AIS from large-vessel occlusions up to 6 hours after the onset of symptoms. However, the association between endovascular reperfusion and improved functional outcome is not strictly time dependent. Rather than on rigid time windows, candidates should be selected based on vascular and physiologic information. This approach places imaging data at the center of treatment decisions. Advances in imaging-based management of AIS provide crucial information about vessel occlusion, infarct core, ischemic penumbra, and degree of collaterals. This information is invaluable in identifying patients who are likely to benefit from reperfusion therapies and excluding those who are unlikely to benefit or are at risk of adverse effects. The approach to reperfusion therapies continues to evolve, and imaging is acquiring a greater role in the diagnostic work-up and treatment decisions as shown in recent clinical trials with extended time window. The 2018 American Heart Association/American Stroke Association guidelines reflect a paradigm shift in the management of AIS from "Time is Brain" to "Imaging is Brain." This review discusses the essential role of multimodal imaging developing from recent trials on therapy for AIS.
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Affiliation(s)
- Josep Puig
- Department of Radiology, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Radiology, Hospital Universitari Dr Josep Trueta - IDIBGI, Girona, Spain
| | - Jai Shankar
- Department of Radiology, University of Manitoba, Winnipeg, Manitoba, Canada
| | - David Liebeskind
- Department of Neurology, Neurovascular Imaging Research Core and UCLA Stroke Center, University of California, Los Angeles, CA
| | - Mikel Terceño
- Department of Neurology, Hospital Universitari de Girona Dr Josep Trueta - IDIBGI, Girona, Spain
| | - Kambiz Nael
- Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, CA
| | - Andrew M Demchuk
- Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Bijoy Menon
- Department of Clinical Neurosciences and Radiology, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Dar Dowlatshahi
- Department of Medicine (Neurology), Ottawa Hospital Research Institute, University of Ottawa, Ottawa, Ontario, Canada
| | | | - Max Wintermark
- Department of Radiology, Neuroradiology Section, Stanford University School of Medicine, Stanford, CA
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Yolanda Silva
- Department of Neurology, Hospital Universitari de Girona Dr Josep Trueta - IDIBGI, Girona, Spain
| | - Joaquin Serena
- Department of Neurology, Hospital Universitari de Girona Dr Josep Trueta - IDIBGI, Girona, Spain
| | - Salvador Pedraza
- Department of Radiology, Hospital Universitari Dr Josep Trueta - IDIBGI, Girona, Spain
| | - Marco Essig
- Department of Radiology, University of Manitoba, Winnipeg, Manitoba, Canada
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26
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Venema E, Lingsma HF, Chalos V, Mulder MJHL, Lahr MMH, van der Lugt A, van Es ACGM, Steyerberg EW, Hunink MGM, Dippel DWJ, Roozenbeek B. Personalized Prehospital Triage in Acute Ischemic Stroke. Stroke 2019; 50:313-320. [PMID: 30661502 PMCID: PMC6358183 DOI: 10.1161/strokeaha.118.022562] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose— Direct transportation to a center with facilities for endovascular treatment might be beneficial for patients with acute ischemic stroke, but it can also cause harm by delay of intravenous treatment. Our aim was to determine the optimal prehospital transportation strategy for individual patients and to assess which factors influence this decision. Methods— We constructed a decision tree model to compare outcome of ischemic stroke patients after transportation to a primary stroke center versus a more distant intervention center. The optimal strategy was estimated based on individual patient characteristics, geographic location, and workflow times. In the base case scenario, the primary stroke center was located at 20 minutes and the intervention center at 45 minutes. Additional sensitivity analyses included an urban scenario (10 versus 20 minutes) and a rural scenario (30 versus 90 minutes). Results— Direct transportation to the intervention center led to better outcomes in the base case scenario when the likelihood of a large vessel occlusion as a cause of the ischemic stroke was >33%. With a high likelihood of large vessel occlusion (66%, comparable with a Rapid Arterial Occlusion Evaluation score of 5 or above), the benefit of direct transportation to the intervention center was 0.10 quality-adjusted life years (=36 days in full health). In the urban scenario, direct transportation to an intervention center was beneficial when the risk of large vessel occlusion was 24% or higher. In the rural scenario, this threshold was 49%. Other factors influencing the decision included door-to-needle times, door-to-groin times, and the door-in-door-out time. Conclusions— The preferred prehospital transportation strategy for suspected stroke patients depends mainly on the likelihood of large vessel occlusion, driving times, and in-hospital workflow times. We constructed a robust model that combines these characteristics and can be used to personalize prehospital triage, especially in more remote areas.
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Affiliation(s)
- Esmee Venema
- From the Department of Public Health (E.V., H.F.L., V.C., E.W.S.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Neurology (E.V., V.C., M.J.H.L.M., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Hester F Lingsma
- From the Department of Public Health (E.V., H.F.L., V.C., E.W.S.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Vicky Chalos
- From the Department of Public Health (E.V., H.F.L., V.C., E.W.S.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Neurology (E.V., V.C., M.J.H.L.M., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine (V.C., M.J.H.L.M., A.v.d.L., A.C.G.M.v.E., M.G.M.H., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Maxim J H L Mulder
- Department of Neurology (E.V., V.C., M.J.H.L.M., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine (V.C., M.J.H.L.M., A.v.d.L., A.C.G.M.v.E., M.G.M.H., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Maarten M H Lahr
- Department of Epidemiology, University Medical Center Groningen, the Netherlands (M.M.H.L.)
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine (V.C., M.J.H.L.M., A.v.d.L., A.C.G.M.v.E., M.G.M.H., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Adriaan C G M van Es
- Department of Radiology and Nuclear Medicine (V.C., M.J.H.L.M., A.v.d.L., A.C.G.M.v.E., M.G.M.H., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Ewout W Steyerberg
- From the Department of Public Health (E.V., H.F.L., V.C., E.W.S.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Biomedical Data Sciences, Leiden University Medical Center, the Netherlands (E.W.S.)
| | - M G Myriam Hunink
- Department of Radiology and Nuclear Medicine (V.C., M.J.H.L.M., A.v.d.L., A.C.G.M.v.E., M.G.M.H., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Epidemiology (M.G.M.H.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Centre for Health Decision Science, Harvard T.H. Chan School of Public Health, Boston, MA (M.G.M.H.)
| | - Diederik W J Dippel
- Department of Neurology (E.V., V.C., M.J.H.L.M., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Bob Roozenbeek
- Department of Neurology (E.V., V.C., M.J.H.L.M., D.W.J.D., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands.,Department of Radiology and Nuclear Medicine (V.C., M.J.H.L.M., A.v.d.L., A.C.G.M.v.E., M.G.M.H., B.R.), Erasmus MC University Medical Center, Rotterdam, the Netherlands
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Vagal A, Aviv R, Sucharew H, Reddy M, Hou Q, Michel P, Jovin T, Tomsick T, Wintermark M, Khatri P. Collateral Clock Is More Important Than Time Clock for Tissue Fate. Stroke 2019; 49:2102-2107. [PMID: 30354992 DOI: 10.1161/strokeaha.118.021484] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background and Purpose- Although perfusion abnormality is an increasingly important therapeutic target, the natural history of tissue at risk without reperfusion treatment is understudied. Our objective was to determine how time affects penumbral salvage and infarct growth in untreated acute ischemic stroke patients and whether collateral status affects this relationship. Methods- We used a prospectively collected, multicenter acute stroke registry to assess acute stroke patients who were not treated with intravenous thrombolysis or endovascular treatment. We analyzed baseline computed tomography angiogram and computed tomography perfusion within 24 hours of stroke onset along with follow-up imaging and assessed time from stroke onset to baseline imaging, ASPECTS (Alberta Stroke Program Early CT Score), vessel occlusion, collaterals, ischemic core, and penumbra. Penumbral salvage and infarct growth were calculated. Correlations between time and penumbral salvage and infarct growth were evaluated with Spearman correlation. Penumbral salvage and infarct growth were compared between subjects with good versus poor collateral status using the Wilcoxon rank-sum test. Clinical and imaging factors affecting penumbral salvage and infarct growth were evaluated by linear regression. Results- Among 94 untreated stroke patients eligible for this analysis, the mean age was 65 years, median National Institutes of Health Stroke Scale score was 13, and median (range) time from stroke onset to baseline imaging was 2.9 (0.4-23) hours. There was no correlation between time and salvaged penumbra ( r=0.06; P=0.56) or infarct growth ( r=-0.05; P=0.61). Infarct growth was higher among those with poor collaterals versus those with good collaterals (median, 52.3 versus 0.9 cm3; P<0.01). Penumbral salvage was lower among those with poor collaterals compared with those with good collaterals (poor, 0 [0-0]; good, 5.9 cm3 [0-29.4]; P<0.01). Multivariable linear regression demonstrated that collaterals, but not time, were significantly associated with infarct growth and penumbral salvage. Conclusions- In this natural history study, penumbral salvage and infarct growth were less time dependent and more a measure of collateral flow.
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Affiliation(s)
| | - Richard Aviv
- University of Cincinnati Medical Center, OH; Department of Radiology, Sunnybrook Research Institute, Toronto, ON (R.A.)
| | - Heidi Sucharew
- Department of Biostatistics, Cincinnati Children's Hospital Medical Center, OH (H.S.)
| | | | - Qinghua Hou
- Department of Neurology, Sun Yat-sen University, Guangdong, China (Q.H.)
| | - Patrik Michel
- Department of Neurology, Centre Hospitalier Universitaire Vaudois, Lausanne, AS (P.M.)
| | - Tudor Jovin
- Department of Neurology, University of Pittsburgh, PA (T.J.)
| | | | - Max Wintermark
- Department of Neuroradiology, Stanford University, CA (M.W.)
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Yu W, Jiang WJ. A Simple Imaging Guide for Endovascular Thrombectomy in Acute Ischemic Stroke: From Time Window to Perfusion Mismatch and Beyond. Front Neurol 2019; 10:502. [PMID: 31178813 PMCID: PMC6543836 DOI: 10.3389/fneur.2019.00502] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2018] [Accepted: 04/25/2019] [Indexed: 01/01/2023] Open
Affiliation(s)
- Wengui Yu
- Department of Neurology, University of California Irvine, Irvine, CA, United States
| | - Wei-Jian Jiang
- New Era Stroke Care and Research Institute, The Rocket Force General Hospital, Beijing, China
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Anadani M, Almallouhi E, Wahlquist AE, Debenham E, Holmstedt CA. The Accuracy of Large Vessel Occlusion Recognition Scales in Telestroke Setting. Telemed J E Health 2019; 25:1071-1076. [PMID: 30758256 DOI: 10.1089/tmj.2018.0232] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Introduction: A significant proportion of acute ischemic stroke (AIS) patients who are evaluated through telestroke consultation are transferred to thrombectomy-capable stroke centers (TSCs) for concern of large vessel occlusion (LVO). Patient triage selection is commonly based on the clinical suspicion of LVO, which lacks specificity and could result in unnecessary transfers. In this study, we aimed to assess the accuracy of the most commonly used LVO recognition scales in telestroke setting. Methods: AIS patients transferred to TSCs for suspicion of an LVO were included in this retrospective study. Patients were evaluated by a stroke neurologist through a telestroke consult before transfer. The National Institute of Health Stroke Scale (NIHSS) score documented by the stroke neurologist was retrieved from medical records and used to calculate five other LVO recognition scales (Rapid Arterial Occlusion Evaluation Scale [RACE], Field Assessment Stroke Triage for Emergency Destination [FAST-ED], Cincinnati Prehospital Stroke Severity Scale [CPSSS], 3-item stroke scale [3I-SS], and Prehospital Acute Stroke Severity Scale [PASS]). We calculated the sensitivity, specificity, accuracy, positive and negative predictive values, false positive rate (FPR), and false negative rate (FNR) of each score using published cutoffs and then examined all possible cutoff values for each of these scales in addition to the NIHSS. Results: A total of 439 patients were included in the final analysis. A total of 48.5% of patients had an LVO confirmed on computed tomography angiogram. RACE score had the highest accuracy (78%). Overall, the five derived LVO recognition scores have at least 10% FNR. When examining all possible cutoff values, the NIHSS (cutoff of 6) had a 3% FNR but 73% FPR (false transfer). Conclusion: The use of the NIHSS and other LVO recognition scores over telestroke may result in unnecessary transfers. Better diagnostic tools that could maximize sensitivity with acceptable specificity are urgently needed.
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Affiliation(s)
- Mohammad Anadani
- Department of Neurology and Medical University of South Carolina, Charleston, South Carolina
| | - Eyad Almallouhi
- Department of Neurology and Medical University of South Carolina, Charleston, South Carolina
| | - Amy E Wahlquist
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, South Carolina
| | - Ellen Debenham
- Department of Neurology and Medical University of South Carolina, Charleston, South Carolina
| | - Christine A Holmstedt
- Department of Neurology and Medical University of South Carolina, Charleston, South Carolina
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Sairanen T, Ritvonen J. Should we thrombolyse prior to endovascular treatment in acute stroke? Clin Neurol Neurosurg 2019; 177:117-122. [DOI: 10.1016/j.clineuro.2018.10.012] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2018] [Revised: 07/24/2018] [Accepted: 10/20/2018] [Indexed: 01/19/2023]
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31
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Leiva-Salinas C, Jiang B, Wintermark M. Computed Tomography, Computed Tomography Angiography, and Perfusion Computed Tomography Evaluation of Acute Ischemic Stroke. Neuroimaging Clin N Am 2018; 28:565-572. [DOI: 10.1016/j.nic.2018.06.002] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Affiliation(s)
- Carlos Leiva-Salinas
- Division of Neuroradiology, Department of Radiology, University of Missouri, One Hospital Drive, Columbia, MO 65212, USA
| | - Bin Jiang
- Division of Neuroradiology, Department of Radiology, Stanford University, 300 Pasteur Drive, Stanford, CA 94305, USA
| | - Max Wintermark
- Division of Neuroradiology, Department of Radiology, Stanford University, 300 Pasteur Drive, Stanford, CA 94305, USA.
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32
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Menon BK, Al-Ajlan FS, Najm M, Puig J, Castellanos M, Dowlatshahi D, Calleja A, Sohn SI, Ahn SH, Poppe A, Mikulik R, Asdaghi N, Field TS, Jin A, Asil T, Boulanger JM, Smith EE, Coutts SB, Barber PA, Bal S, Subramanian S, Mishra S, Trivedi A, Dey S, Eesa M, Sajobi T, Goyal M, Hill MD, Demchuk AM. Association of Clinical, Imaging, and Thrombus Characteristics With Recanalization of Visible Intracranial Occlusion in Patients With Acute Ischemic Stroke. JAMA 2018; 320:1017-1026. [PMID: 30208455 PMCID: PMC6143104 DOI: 10.1001/jama.2018.12498] [Citation(s) in RCA: 176] [Impact Index Per Article: 29.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022]
Abstract
IMPORTANCE Recanalization of intracranial thrombus is associated with improved clinical outcome in patients with acute ischemic stroke. The association of intravenous alteplase treatment and thrombus characteristics with recanalization over time is important for stroke triage and future trial design. OBJECTIVE To examine recanalization over time across a range of intracranial thrombus occlusion sites and clinical and imaging characteristics in patients with ischemic stroke treated with intravenous alteplase or not treated with alteplase. DESIGN, SETTING, AND PARTICIPANTS Multicenter prospective cohort study of 575 patients from 12 centers (in Canada, Spain, South Korea, the Czech Republic, and Turkey) with acute ischemic stroke and intracranial arterial occlusion demonstrated on computed tomographic angiography (CTA). EXPOSURES Demographics, clinical characteristics, time from alteplase to recanalization, and intracranial thrombus characteristics (location and permeability) defined on CTA. MAIN OUTCOMES AND MEASURES Recanalization on repeat CTA or on first angiographic acquisition of affected intracranial circulation obtained within 6 hours of baseline CTA, defined using the revised arterial occlusion scale (rAOL) (scores from 0 [primary occlusive lesion remains the same] to 3 [complete revascularization of primary occlusion]). RESULTS Among 575 patients (median age, 72 years [IQR, 63-80]; 51.5% men; median time from patient last known well to baseline CTA of 114 minutes [IQR, 74-180]), 275 patients (47.8%) received intravenous alteplase only, 195 (33.9%) received intravenous alteplase plus endovascular thrombectomy, 48 (8.3%) received endovascular thrombectomy alone, and 57 (9.9%) received conservative treatment. Median time from baseline CTA to recanalization assessment was 158 minutes (IQR, 79-268); median time from intravenous alteplase start to recanalization assessment was 132.5 minutes (IQR, 62-238). Successful recanalization occurred at an unadjusted rate of 27.3% (157/575) overall, including in 30.4% (143/470) of patients who received intravenous alteplase and 13.3% (14/105) who did not (difference, 17.1% [95% CI, 10.2%-25.8%]). Among patients receiving alteplase, the following factors were associated with recanalization: time from treatment start to recanalization assessment (OR, 1.28 for every 30-minute increase in time [95% CI, 1.18-1.38]), more distal thrombus location, eg, distal M1 middle cerebral artery (39/84 [46.4%]) vs internal carotid artery (10/92 [10.9%]) (OR, 5.61 [95% CI, 2.38-13.26]), and higher residual flow (thrombus permeability) grade, eg, hairline streak (30/45 [66.7%]) vs none (91/377 [24.1%]) (OR, 7.03 [95% CI, 3.32-14.87]). CONCLUSIONS AND RELEVANCE In patients with acute ischemic stroke, more distal thrombus location, greater thrombus permeability, and longer time to recanalization assessment were associated with recanalization of arterial occlusion after administration of intravenous alteplase; among patients who did not receive alteplase, rates of arterial recanalization were low. These findings may help inform treatment and triage decisions in patients with acute ischemic stroke.
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Affiliation(s)
| | - Fahad S. Al-Ajlan
- King Faisal Specialist Hospital and Research Center, Riyadh, Saudi Arabia
| | | | - Josep Puig
- IDI-IDIBGI, Dr Josep Trueta University Hospital, Girona, Spain
| | - Mar Castellanos
- IDI-IDIBGI, Dr Josep Trueta University Hospital, Girona, Spain
| | | | - Ana Calleja
- Universidad de Valladolid, Valladolid, Spain
| | | | - Seong H. Ahn
- Keimyung University, Daegu, Republic of Korea
- Gwangju Institute of Science and Technology, Gwangju, Republic of Korea
| | - Alex Poppe
- University of Montreal, Montreal, Québec, Canada
| | - Robert Mikulik
- International Clinical Research Center, Department of Neurology, St Ann's University Hospital, Masaryk University, Brno, Czech Republic
| | | | - Thalia S. Field
- University of British Columbia, Vancouver, British Columbia, Canada
| | - Albert Jin
- Queen's University Kingston, Ontario, Canada
| | - Talip Asil
- Bezmialem Vakif Univesitesi Noroloji, Istanbul, Turkey
| | | | | | | | | | | | | | - Sachin Mishra
- Gold Coast University Hospital, Gold Coast, Australia
| | | | | | - Muneer Eesa
- University of Calgary, Calgary, Alberta, Canada
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Ganesh A, Goyal M. Thrombectomy for Acute Ischemic Stroke: Recent Insights and Future Directions. Curr Neurol Neurosci Rep 2018; 18:59. [PMID: 30033493 DOI: 10.1007/s11910-018-0869-8] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
PURPOSE OF REVIEW Mechanical thrombectomy has become the standard of care for acute ischemic stroke with proximal large vessel occlusions (LVO). This article reviews recent research relating to thrombectomy. RECENT FINDINGS Thrombectomy for anterior circulation stroke with proximal LVO was first shown to be highly efficacious within 6 h of stroke onset, but "late-window" trials have further demonstrated efficacy until 24-h postonset in select patients with salvageable tissue. However, the concept of "time is brain" remains critical. Thrombectomy trials have further stimulated worldwide efforts to develop systems of care for rapid treatment of eligible patients. Thrombectomy is cost-effective and likely to have long-term efficacy for both disability and mortality outcomes. Thrombectomy is a highly efficacious acute stroke therapy. Enduring uncertainties include efficacy in patients with premorbid disability, posterior circulation, or more distal occlusions; use of bridging thrombolysis; and optimal techniques to achieve consistent revascularization and address tandem occlusions or stenoses.
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Affiliation(s)
- Aravind Ganesh
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Mayank Goyal
- Calgary Stroke Program, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada. .,Department of Radiology, University of Calgary, Calgary, Canada. .,Seaman Family MR Research Centre, Foothills Medical Centre, University of Calgary, 1403 29th St NW, Calgary, AB, T2N 2T9, Canada.
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Grossberg JA, Rebello LC, Haussen DC, Bouslama M, Bowen M, Barreira CM, Belagaje SR, Frankel MR, Nogueira RG. Beyond Large Vessel Occlusion Strokes: Distal Occlusion Thrombectomy. Stroke 2018; 49:1662-1668. [PMID: 29915125 DOI: 10.1161/strokeaha.118.020567] [Citation(s) in RCA: 122] [Impact Index Per Article: 20.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/13/2017] [Revised: 03/29/2018] [Accepted: 04/16/2018] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND PURPOSE Endovascular therapy is the standard of care for the treatment of proximal large vessel occlusion strokes. Its safety and efficacy in the treatment of distal intracranial occlusions has not been well studied. METHODS The data that support the findings of this study are available from the corresponding author on reasonable request. Retrospective review of a prospectively collected endovascular database (2010-2015, n=949) for all patients with distal intracranial occlusions treated endovascularly. Distal occlusions were defined as any segment of the anterior cerebral artery (ACA), posterior cerebral artery, or occlusion at or distal to the middle cerebral artery (MCA)-M3 opercular segment. RESULTS Distal occlusions were treated in 69 patients. The mean age was 66.7±15.8 and 57% were male. Patients (29 [42%]) received intravenous tPA (tissue-type plasminogen activator). The median preprocedure National Institutes of Health Stroke Scale score was 18 (interquartile range, 13-23). The distal occlusion was the primary treatment location in 45 patients, in 23 patients the distal occlusion was treated as a rescue strategy after successful treatment of a proximal large vessel occlusion strokes, and 1 patient had both primary and rescue treatment. The locations of the primary cases were MCA-M3 (n=21), ACA alone (n=8), ACA with a concomitant MCA-M1 or MCA-M2 (n=10), ACA with a concomitant MCA-M3 (n=3), and posterior cerebral artery (n=3). The locations of the rescue cases were MCA-M3 (n=11), ACA (n=7), posterior cerebral artery (n=4), and both MCA-M3 and ACA (n=1). There was a single patient with primary ACA and MCA-M2 occlusions treated, who then had a rescue MCA-M3 thrombectomy addressed after initial reperfusion. The most common treatment modalities used were stent-retrievers (n=37, 54%), intra-arterial tPA (n=36, 52%), and thromboaspiration (n=31, 45%). Near complete or complete reperfusion of the distal territory (modified Treatment In Cerebral Ischemia [mTICI] 2b-3) was achieved in 57 cases (83%). Three parenchymal hematomas (4%) occurred in the territory of the treated distal occlusion with 2 of these patients also receiving intravenous tPA. At 90 days, 21 patients (30%) had a modified Rankin Scale score of 0 to 2 and 14 (20%) had died. CONCLUSIONS Distal intracranial occlusions can be treated safely and successfully with endovascular therapy. These results need to be corroborated by larger prospective controlled studies.
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Affiliation(s)
- Jonathan A Grossberg
- From the Emory University School of Medicine / Marcus Stroke and Neuroscience Center, Departments of Neurology and Neurosurgery, Grady Memorial Hospital, Atlanta, GA
| | - Leticia C Rebello
- From the Emory University School of Medicine / Marcus Stroke and Neuroscience Center, Departments of Neurology and Neurosurgery, Grady Memorial Hospital, Atlanta, GA
| | - Diogo C Haussen
- From the Emory University School of Medicine / Marcus Stroke and Neuroscience Center, Departments of Neurology and Neurosurgery, Grady Memorial Hospital, Atlanta, GA
| | - Mehdi Bouslama
- From the Emory University School of Medicine / Marcus Stroke and Neuroscience Center, Departments of Neurology and Neurosurgery, Grady Memorial Hospital, Atlanta, GA
| | - Meredith Bowen
- From the Emory University School of Medicine / Marcus Stroke and Neuroscience Center, Departments of Neurology and Neurosurgery, Grady Memorial Hospital, Atlanta, GA
| | - Clara M Barreira
- From the Emory University School of Medicine / Marcus Stroke and Neuroscience Center, Departments of Neurology and Neurosurgery, Grady Memorial Hospital, Atlanta, GA
| | - Samir R Belagaje
- From the Emory University School of Medicine / Marcus Stroke and Neuroscience Center, Departments of Neurology and Neurosurgery, Grady Memorial Hospital, Atlanta, GA
| | - Michael R Frankel
- From the Emory University School of Medicine / Marcus Stroke and Neuroscience Center, Departments of Neurology and Neurosurgery, Grady Memorial Hospital, Atlanta, GA
| | - Raul G Nogueira
- From the Emory University School of Medicine / Marcus Stroke and Neuroscience Center, Departments of Neurology and Neurosurgery, Grady Memorial Hospital, Atlanta, GA.
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Eskey CJ, Meyers PM, Nguyen TN, Ansari SA, Jayaraman M, McDougall CG, DeMarco JK, Gray WA, Hess DC, Higashida RT, Pandey DK, Peña C, Schumacher HC. Indications for the Performance of Intracranial Endovascular Neurointerventional Procedures: A Scientific Statement From the American Heart Association. Circulation 2018; 137:e661-e689. [PMID: 29674324 DOI: 10.1161/cir.0000000000000567] [Citation(s) in RCA: 71] [Impact Index Per Article: 11.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Intracranial endovascular interventions provide effective and minimally invasive treatment of a broad spectrum of diseases. This area of expertise has continued to gain both wider application and greater depth as new and better techniques are developed and as landmark clinical studies are performed to guide their use. Some of the greatest advances since the last American Heart Association scientific statement on this topic have been made in the treatment of ischemic stroke from large intracranial vessel occlusion, with more effective devices and large randomized clinical trials showing striking therapeutic benefit. The treatment of cerebral aneurysms has also seen substantial evolution, increasing the number of aneurysms that can be treated successfully with minimally invasive therapy. Endovascular therapies for such other diseases as arteriovenous malformations, dural arteriovenous fistulas, idiopathic intracranial hypertension, venous thrombosis, and neoplasms continue to improve. The purpose of the present document is to review current information on the efficacy and safety of procedures used for intracranial endovascular interventional treatment of cerebrovascular diseases and to summarize key aspects of best practice.
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Bhaskar S, Stanwell P, Cordato D, Attia J, Levi C. Reperfusion therapy in acute ischemic stroke: dawn of a new era? BMC Neurol 2018; 18:8. [PMID: 29338750 PMCID: PMC5771207 DOI: 10.1186/s12883-017-1007-y] [Citation(s) in RCA: 139] [Impact Index Per Article: 23.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 12/14/2017] [Indexed: 12/14/2022] Open
Abstract
Following the success of recent endovascular trials, endovascular therapy has emerged as an exciting addition to the arsenal of clinical management of patients with acute ischemic stroke (AIS). In this paper, we present an extensive overview of intravenous and endovascular reperfusion strategies, recent advances in AIS neurointervention, limitations of various treatment paradigms, and provide insights on imaging-guided reperfusion therapies. A roadmap for imaging guided reperfusion treatment workflow in AIS is also proposed. Both systemic thrombolysis and endovascular treatment have been incorporated into the standard of care in stroke therapy. Further research on advanced imaging-based approaches to select appropriate patients, may widen the time-window for patient selection and would contribute immensely to early thrombolytic strategies, better recanalization rates, and improved clinical outcomes.
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Affiliation(s)
- Sonu Bhaskar
- Western Sydney University (WSU), School of Medicine, South West Sydney Clinical School, Sydney, NSW 2170 Australia
- Liverpool Hospital, Department of Neurology & Neurophysiology, Liverpool, 2170 NSW Australia
- The Sydney Partnership for Health, Education, Research & Enterprise (SPHERE), Liverpool, NSW Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW 2170 Australia
- Department of Neurology, John Hunter Hospital, Newcastle, NSW Australia
- Priority Research Centre for Stroke & Brain Injury, Faculty of Health & Medicine, Hunter Medical Research institute (HMRI) and School of Medicine & Public Health, University of Newcastle, Newcastle, NSW Australia
| | - Peter Stanwell
- Priority Research Centre for Stroke & Brain Injury, Faculty of Health & Medicine, Hunter Medical Research institute (HMRI) and School of Medicine & Public Health, University of Newcastle, Newcastle, NSW Australia
| | - Dennis Cordato
- Liverpool Hospital, Department of Neurology & Neurophysiology, Liverpool, 2170 NSW Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW 2170 Australia
- School of Medicine, University of New South Wales (UNSW), Sydney, NSW Australia
| | - John Attia
- Priority Research Centre for Stroke & Brain Injury, Faculty of Health & Medicine, Hunter Medical Research institute (HMRI) and School of Medicine & Public Health, University of Newcastle, Newcastle, NSW Australia
- Centre for Clinical Epidemiology & Biostatistics, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW Australia
| | - Christopher Levi
- Western Sydney University (WSU), School of Medicine, South West Sydney Clinical School, Sydney, NSW 2170 Australia
- Liverpool Hospital, Department of Neurology & Neurophysiology, Liverpool, 2170 NSW Australia
- The Sydney Partnership for Health, Education, Research & Enterprise (SPHERE), Liverpool, NSW Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW 2170 Australia
- School of Medicine, University of New South Wales (UNSW), Sydney, NSW Australia
- Department of Neurology, John Hunter Hospital, Newcastle, NSW Australia
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Qureshi AI, Saleem MA, Aytac E. Comparison of Endovascular Treatment with Intravenous Thrombolysis for Isolated M2 Segment of Middle Cerebral Artery Occlusion in Acute Ischemic Stroke. JOURNAL OF VASCULAR AND INTERVENTIONAL NEUROLOGY 2017; 9:8-14. [PMID: 29163743 PMCID: PMC5683020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Abstract
BACKGROUND The benefit of endovascular treatment for distal large artery ischemic occlusions such as M2 segment of middle cerebral artery is not clear. METHODS We retrospectively analyzed data from 51 subjects who had an isolated M2 segment occlusion on baseline computed tomographic (CT) angiogram who were randomized to either intravenous (IV) recombinant tissue plasminogen activator (rt-PA) followed by endovascular treatment or IV rt-PA alone in a multicenter trial. We determined the effect of endovascular treatment on occurrence of excellent [mRS (modified Rankin scale) scores of 0-1] functional outcomes at three months and any death within 3 and 12 months. We also performed proportional odds logistic regression analysis to compare the distribution of mRS scores between the two groups. Each of the analyses was adjusted for age, baseline Alberta stroke program early CT score strata, and baseline National Institutes of Health Stroke scale score strata. RESULTS At three months, the rate of excellent functional outcome (38.2% versus 17.6%, unadjusted odds ratio 2.9; 95% confidence interval ; 0.7-12.1; p = 0.15) was non-significantly higher among subjects with M2 segment occlusion who were randomized to endovascular treatment. In multivariate analysis, the odds of excellent functional outcome at three months were non-significantly higher among subjects who were randomized to endovascular treatment at three months (OR 2.7; 95% CI; 0.6-13.6; p = 0.22). There was a trend toward lower disability grades in subject randomized to endovascular treatment when distribution of the mRS score at three months were compared (common OR 2.6; p = 0.084), adjusting for potential confounders. The rates of any death within 3 (adjusted OR 0.1; 95% CI; 0.1-0.8; p = 0.031) and within 12 months (adjusted OR 0.1; 95% CI; 0.1-0.7; p = 0.022) were significantly lower among those who were randomized to endovascular treatment. CONCLUSION In this post-hoc analysis, acute ischemic stroke subjects who had isolated M2 segment occlusion randomized to endovascular treatment appeared to have lower mortality and a trend toward lower grades of disability.
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Affiliation(s)
| | | | - Emrah Aytac
- Zeenat Qureshi Stroke Institute, St. Cloud, MN, USA
- Ankara Numune Training and Research Hospital, Neurology Clinic, Ankara, Turkey
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Madhuripan N, Atar OD, Zheng R, Tenenbaum M. Computed Tomography Angiography in Head and Neck Emergencies. Semin Ultrasound CT MR 2017; 38:345-356. [DOI: 10.1053/j.sult.2017.02.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Pikija S, Magdic J, Killer-Oberpfalzer M, Florea C, Hauer L, Novak HF, McCoy MR, Sellner J. Proximal flow to middle cerebral artery is associated with higher thrombus density in terminal internal carotid artery occlusion. Ann Clin Transl Neurol 2017; 4:517-521. [PMID: 28695152 PMCID: PMC5497529 DOI: 10.1002/acn3.429] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2017] [Revised: 04/20/2017] [Accepted: 05/15/2017] [Indexed: 12/04/2022] Open
Abstract
Proximal collaterals may determine the composition of occluding thrombi in acute ischemic stroke (AIS) in addition to source, hematocrit, time, and medication. Here, we performed a retrospective study of 39 consecutive patients with radiological evidence of I‐, L‐, and T‐type terminal internal carotid artery occlusion. Middle cerebral artery (MCA) thrombus density was assessed on noncontrast enhanced CT and proximal collaterals on CT angiography. In patients with presence of proximal collaterals to the MCA we detected more hyperdense clots (P = 0.003) and a higher frequency of leptomeningeal collaterals (P = 0.008). We expand the spectrum of factors that potentially determine clot perviousness and evolution of ischemic stroke.
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Affiliation(s)
- Slaven Pikija
- Department of Neurology Christian Doppler Medical Center Paracelsus Medical University Salzburg Austria
| | - Jozef Magdic
- Department of Neurology University Medical Center Maribor Maribor Slovenia
| | - Monika Killer-Oberpfalzer
- Department of Neurology/Research Institute for Neurointervention Christian Doppler Medical Center Paracelsus Medical University Salzburg Austria
| | - Cristina Florea
- Department of Neurology Christian Doppler Medical Center Paracelsus Medical University Salzburg Austria
| | - Larissa Hauer
- Department of Psychiatry and Psychotherapy Christian Doppler Medical Center Paracelsus Medical University Salzburg Austria
| | - Helmut F Novak
- Department of Neurology Christian Doppler Medical Center Paracelsus Medical University Salzburg Austria
| | - Mark R McCoy
- Division of Neuroradiology Christian Doppler Medical Center Paracelsus Medical University Salzburg Austria
| | - Johann Sellner
- Department of Neurology Christian Doppler Medical Center Paracelsus Medical University Salzburg Austria.,Department of Neurology Klinikum rechts der Isar Technische Universität München München Germany
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Evans MRB, White P, Cowley P, Werring DJ. Revolution in acute ischaemic stroke care: a practical guide to mechanical thrombectomy. Pract Neurol 2017. [PMID: 28647705 PMCID: PMC5537551 DOI: 10.1136/practneurol-2017-001685] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
Abstract
Rapid, safe and effective arterial recanalisation to restore blood flow and improve functional outcome remains the primary goal of hyperacute ischaemic stroke management. The benefit of intravenous thrombolysis with recombinant tissue-type plasminogen activator for patients with severe stroke due to large artery occlusion is limited; early recanalisation is generally less than 30% for carotid, proximal middle cerebral artery or basilar artery occlusion. Since November 2014, nine positive randomised controlled trials of mechanical thrombectomy for large vessel occlusion in the anterior circulation have led to a revolution in the care of patients with acute ischaemic stroke. Its efficacy is unmatched by any previous therapy in stroke medicine, with a number needed to treat of less than 3 for improved functional outcome. With effectiveness shown beyond any reasonable doubt, the key challenge now is how to implement accessible, safe and effective mechanical thrombectomy services. This review aims to provide neurologists and other stroke physicians with a summary of the evidence base, a discussion of practical aspects of delivering the treatment and future challenges. We aim to give guidance on some of the areas not clearly described in the clinical trials (based on evidence where available, but if not, on our own experience and practice) and highlight areas of uncertainty requiring further research.
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Affiliation(s)
- Matthew R B Evans
- Stroke Research Centre, Department of Brain repair and Rehabilitation, University College London Institute of Neurology, London, UK
| | - Phil White
- Stroke Research Centre, Institute of Neuroscience and Newcastle University Institute for Ageing, Newcastle Upon Tyne, UK
| | - Peter Cowley
- Stroke Research Centre, Department of Brain repair and Rehabilitation, University College London Institute of Neurology, London, UK.,Neuroradiological Academic Unit, University College London Institute of Neurology, London, UK
| | - David J Werring
- Stroke Research Centre, Department of Brain repair and Rehabilitation, University College London Institute of Neurology, London, UK
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Affiliation(s)
- Joseph P Broderick
- From the Departments of Neurology and Rehabilitation Medicine (J.P.B.) and Emergency Medicine (O.A.), University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati, OH; and Division of Biostatistics, Medical University of South Carolina, Charleston (J.E.).
| | - Opeolu Adeoye
- From the Departments of Neurology and Rehabilitation Medicine (J.P.B.) and Emergency Medicine (O.A.), University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati, OH; and Division of Biostatistics, Medical University of South Carolina, Charleston (J.E.)
| | - Jordan Elm
- From the Departments of Neurology and Rehabilitation Medicine (J.P.B.) and Emergency Medicine (O.A.), University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati, OH; and Division of Biostatistics, Medical University of South Carolina, Charleston (J.E.)
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Fan L, Yeatts SD, Foster LD, Khatri P, Tomsick T, Broderick JP, Palesch YY. Endovascular Therapy Demonstrates Benefit over Intravenous Recombinant Tissue Plasminogen Activator Based on Repeatedly Measured National Institutes of Health Stroke Scale. INTERVENTIONAL NEUROLOGY 2017; 6:25-30. [PMID: 28611830 DOI: 10.1159/000452137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND AND PURPOSE The Interventional Management of Stroke (IMS) III trial was a randomized controlled trial designed to compare the effect of endovascular therapy after intravenous recombinant tissue plasminogen activator (i.v. rt-PA) as compared to i.v. rt-PA alone. The primary outcome was modified Rankin Scale at 90 days. Secondary outcomes included National Institutes of Health Stroke Scale (NIHSS), which was assessed repeatedly through 90 days. The objective of this analysis is to evaluate the treatment effect of endovascular therapy over time on NIHSS. METHODS 656 subjects were enrolled in the IMS III trial, including 434 subjects randomized to endovascular therapy and 222 to i.v. rt-PA only. NIHSS scores evaluated at 40 min, 24 h, Day 5, and Day 90 were included in the analysis. A covariance structure model was used to investigate the treatment effect on NIHSS over time, adjusting for relevant covariates including baseline stroke severity. Model assumptions were valid. RESULTS Based on the covariance structure model, after adjusting for relevant baseline covariates, a significant time-by-treatment interaction effect (p = 0.0137) was observed. Only NIHSS at Day 90 showed a significant treatment effect (p = 0.0473), with subjects in the endovascular arm having a lower NIHSS (less neurologic deficit) compared to the i.v. rt-PA arm. CONCLUSIONS The IMS III trial demonstrated an endovascular treatment effect based on the secondary outcome of NIHSS. However, the magnitude of this treatment effect varied by the time of assessment. It was only at Day 90 that the endovascular arm had a significantly lower NIHSS compared to that in the i.v. rt-PA arm.
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Affiliation(s)
- Liqiong Fan
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, and Departments of, OH, USA
| | - Sharon D Yeatts
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, and Departments of, OH, USA
| | - Lydia D Foster
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, and Departments of, OH, USA
| | | | - Thomas Tomsick
- Radiology, University of Cincinnati, Cincinnati, OH, USA
| | | | - Yuko Y Palesch
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, and Departments of, OH, USA
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Abstract
Acute ischemic stroke (AIS) is the leading cause of disability worldwide and among the leading causes of mortality. Although intravenous tissue plasminogen activator (IV-rtPA) was approved nearly 2 decades ago for treatment of AIS, only a minority of patients receive it due to a narrow time window for administration and several contraindications to its use. Endovascular approaches to recanalization in AIS developed in the 1980s, and recently, 5 major randomized trials showed an overwhelming superior benefit of combining endovascular mechanical thrombectomy with IV-rtPA over IV-rtPA alone. In this paper, we discuss the evolution of catheter-based treatment from first-generation thrombectomy devices to the game-changing stent retrievers, results from recent trials, and the evolving stroke systems of care to provide timely access to acute stroke intervention to patients in the United States.
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Sillanpää N, Protto S, Saarinen JT, Pienimäki JP, Seppänen J, Numminen H, Rusanen H. Internal Carotid Artery and the Proximal M1 Segment Are Optimal Targets for Mechanical Thrombectomy. INTERVENTIONAL NEUROLOGY 2017; 6:207-218. [PMID: 29118798 DOI: 10.1159/000475606] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Background and Purpose Mechanical thrombectomy (MT) is an established treatment of acute anterior circulation stroke caused by large vessel occlusion (LVO). We compared the clinical outcome (3-month modified Rankin Scale, mRS) in hyperacute (<3h from the onset of symptoms) ischemic stroke between an MT and an intravenous thrombolysis (IVT) cohort in proximal (ICA and the proximal M1 segment of the middle cerebral artery) and distal (the distal M1 and the M2 segment) LVOs. Methods We prospectively reviewed 67 patients who underwent MT with newer-generation stent retrievers. The IVT cohort consisted of 98 patients who received IVT without MT. We recorded baseline clinical, procedural and imaging variables, technical outcome, 24-h imaging outcome, and the clinical outcome. Differences between the groups were studied with theoretically appropriate statistical tests and binary logistic regression analysis. Results The proportion of patients who had a proximal LVO and experienced good (mRS ≤2) or excellent (mRS ≤1) clinical outcome was significantly larger in the MT group (62 vs. 7%, p < 0.001; 47 vs. 3%, p < 0.001, respectively). In a regression model including relevant confounding variables, good clinical outcome was seen significantly more often among patients with proximal occlusions (OR = 6.0, CI 95% 1.9-18.3, p = 0.002). In a similar model, no statistically significant differences were observed in patients with more distal occlusions. Conclusions MT is superior to IVT in achieving good clinical outcome in hyperacute anterior circulation stroke in the most proximal occlusions (ICA and proximal M1 segment). In the distal M1 and M2 segments neither of these therapies clearly outperforms the other.
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Affiliation(s)
- Niko Sillanpää
- Medical Imaging Center, Tampere University Hospital, Tampere, Finland
| | - Sara Protto
- Medical Imaging Center, Tampere University Hospital, Tampere, Finland
| | | | | | - Janne Seppänen
- Medical Imaging Center, Tampere University Hospital, Tampere, Finland
| | - Heikki Numminen
- Department of Neurology, Tampere University Hospital, Tampere, Finland
| | - Harri Rusanen
- Department of Neurology, Oulu University Hospital, Oulu, Finland
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Simpson KN, Simpson AN, Mauldin PD, Palesch YY, Yeatts SD, Kleindorfer D, Tomsick TA, Foster LD, Demchuk AM, Khatri P, Hill MD, Jauch EC, Jovin TG, Yan B, von Kummer R, Molina CA, Goyal M, Schonewille WJ, Mazighi M, Engelter ST, Anderson C, Spilker J, Carrozzella J, Ryckborst KJ, Janis LS, Broderick JP. Observed Cost and Variations in Short Term Cost-Effectiveness of Therapy for Ischemic Stroke in Interventional Management of Stroke (IMS) III. J Am Heart Assoc 2017; 6:e004513. [PMID: 28483774 PMCID: PMC5524059 DOI: 10.1161/jaha.116.004513] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Accepted: 03/22/2017] [Indexed: 12/03/2022]
Abstract
BACKGROUND Examination of linked data on patient outcomes and cost of care may help identify areas where stroke care can be improved. We report on the association between variations in stroke severity, patient outcomes, cost, and treatment patterns observed over the acute hospital stay and through the 12-month follow-up for subjects receiving endovascular therapy compared to intravenous tissue plasminogen activator alone in the IMS (Interventional Management of Stroke) III Trial. METHODS AND RESULTS Prospective data collected for a prespecified economic analysis of the trial were used. Data included hospital billing records for the initial stroke admission and subsequent detailed resource use after the acute hospitalization collected at 3, 6, 9, and 12 months. Cost of follow-up care varied 6-fold for patients in the lowest (0-1) and highest (20+) National Institutes of Health Stroke Scale category at 5 days, and by modified Rankin Scale at 3 months. The kind of resources used postdischarge also varied between treatment groups. Incremental short-term cost-effectiveness ratios varied greatly when treatments were compared for patient subgroups. Patient subgroups predefined by stroke severity had incremental cost-effectiveness ratios of $97 303/quality-adjusted life year (severe stroke) and $3 187 805/quality-adjusted life year (moderately severe stroke). CONCLUSIONS Detailed economic and resource utilization data from IMS III provide powerful evidence for the large effect that patient outcome has on the economic value of medical and endovascular reperfusion therapies. These data can be used to inform process improvements for stroke care and to estimate the cost-effectiveness of endovascular therapy in the US health system for stroke intervention trials. CLINICAL TRIAL REGISTRATION URL: http://www.clinicaltrials.gov. Registration number: NCT00359424.
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Affiliation(s)
- Kit N Simpson
- Department of Healthcare Leadership and Management, Medical University of South Carolina, Charleston, SC
| | - Annie N Simpson
- Department of Healthcare Leadership and Management, Medical University of South Carolina, Charleston, SC
| | - Patrick D Mauldin
- Department of General Internal Medicine and Geriatrics, Medical University of South Carolina, Charleston, SC
| | - Yuko Y Palesch
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Sharon D Yeatts
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Dawn Kleindorfer
- Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Gardner Neuroscience Institute University of Cincinnati Academic Health Center, Cincinnati, OH
| | - Thomas A Tomsick
- Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Gardner Neuroscience Institute University of Cincinnati Academic Health Center, Cincinnati, OH
| | - Lydia D Foster
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC
| | - Andrew M Demchuk
- Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology, Seaman Family MR Research Centre, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Pooja Khatri
- Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Gardner Neuroscience Institute University of Cincinnati Academic Health Center, Cincinnati, OH
| | - Michael D Hill
- Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology, Seaman Family MR Research Centre, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Edward C Jauch
- Division of Emergency Medicine, Medical University of South Carolina, Charleston, SC
| | - Tudor G Jovin
- Stroke Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Bernard Yan
- Melbourne Brain Centre, Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Rüdiger von Kummer
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital Dresden, Dresden, Germany
| | - Carlos A Molina
- Neurovascular Unit, Department of Neurology, Hospital Universitari Vall d'Hebron, Barcelona, Spain
| | - Mayank Goyal
- Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology, Seaman Family MR Research Centre, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Wouter J Schonewille
- Department of Neurology, University Medical Center Utrecht and the Rudolph Magnus Institute of Neurosciences, Utrecht, The Netherlands
- St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Mikael Mazighi
- Department of Neurology and Stroke Center, Lariboisière Hospital, DHU NeuroVasc, Paris, France
| | - Stefan T Engelter
- Neurorehabilitation Unit, Department of Neurology, Basel University Hospital, University of Basel, Basel, Switzerland
- University Center for Medicine of Aging, Felix Platter Hospital, Basel, Switzerland
| | - Craig Anderson
- George Institute for Global Health, Royal Prince Alfred Hospital, University of Sydney, Sydney, Australia
| | - Judith Spilker
- Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Gardner Neuroscience Institute University of Cincinnati Academic Health Center, Cincinnati, OH
| | - Janice Carrozzella
- Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Gardner Neuroscience Institute University of Cincinnati Academic Health Center, Cincinnati, OH
| | - Karla J Ryckborst
- Calgary Stroke Program, Departments of Clinical Neurosciences and Radiology, Seaman Family MR Research Centre, Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - L Scott Janis
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, MD
| | - Joseph P Broderick
- Departments of Neurology and Rehabilitation Medicine and Radiology, University of Cincinnati Gardner Neuroscience Institute University of Cincinnati Academic Health Center, Cincinnati, OH
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Venema E, Mulder MJHL, Roozenbeek B, Broderick JP, Yeatts SD, Khatri P, Berkhemer OA, Emmer BJ, Roos YBWEM, Majoie CBLM, van Oostenbrugge RJ, van Zwam WH, van der Lugt A, Steyerberg EW, Dippel DWJ, Lingsma HF. Selection of patients for intra-arterial treatment for acute ischaemic stroke: development and validation of a clinical decision tool in two randomised trials. BMJ 2017; 357:j1710. [PMID: 28468840 PMCID: PMC5418887 DOI: 10.1136/bmj.j1710] [Citation(s) in RCA: 84] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
Objective To improve the selection of patients with acute ischaemic stroke for intra-arterial treatment using a clinical decision tool to predict individual treatment benefit.Design Multivariable regression modelling with data from two randomised controlled clinical trials.Setting 16 hospitals in the Netherlands (derivation cohort) and 58 hospitals in the United States, Canada, Australia, and Europe (validation cohort).Participants 500 patients from the Multicenter Randomised Clinical Trial of Endovascular Treatment for Acute Ischaemic Stroke in the Netherlands trial (derivation cohort) and 260 patients with intracranial occlusion from the Interventional Management of Stroke III trial (validation cohort).Main outcome measures The primary outcome was the modified Rankin Scale (mRS) score at 90 days after stroke. We constructed an ordinal logistic regression model to predict outcome and treatment benefit, defined as the difference between the predicted probability of good functional outcome (mRS score 0-2) with and without intra-arterial treatment.Results 11 baseline clinical and radiological characteristics were included in the model. The externally validated C statistic was 0.69 (95% confidence interval 0.64 to 0.73) for the ordinal model and 0.73 (0.67 to 0.79) for the prediction of good functional outcome, indicating moderate discriminative ability. The mean predicted treatment benefit varied between patients in the combined derivation and validation cohort from -2.3% to 24.3%. There was benefit of intra-arterial treatment predicted for some individual patients from groups in which no treatment effect was found in previous subgroup analyses, such as those with no or poor collaterals.Conclusion The proposed clinical decision tool combines multiple baseline clinical and radiological characteristics and shows large variations in treatment benefit between patients. The tool is clinically useful as it aids in distinguishing between individual patients who may experience benefit from intra-arterial treatment for acute ischaemic stroke and those who will not.Trial registration clinicaltrials.gov NCT00359424 (IMS III) and isrctn.com ISRCTN10888758 (MR CLEAN).
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Affiliation(s)
- Esmee Venema
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, Netherlands
- Department of Neurology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Maxim J H L Mulder
- Department of Neurology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
- Department of Radiology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Joseph P Broderick
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, Cincinnati, OH, USA
| | - Sharon D Yeatts
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Pooja Khatri
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, Cincinnati, OH, USA
| | - Olvert A Berkhemer
- Department of Radiology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
- Department of Radiology, Academic Medical Centre, Amsterdam, Netherlands
- Department of Radiology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Bart J Emmer
- Department of Radiology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Academic Medical Centre, Amsterdam, Netherlands
| | | | | | - Wim H van Zwam
- Department of Radiology, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Aad van der Lugt
- Department of Radiology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, Netherlands
- Department of Medical Statistics and Bioinformatics, Leiden University Medical Centre, Leiden, Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Centre Rotterdam, Rotterdam, Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Centre Rotterdam, PO Box 2040, 3000 CA Rotterdam, Netherlands
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Mulder MJHL, Venema E, Roozenbeek B, Broderick JP, Yeatts SD, Khatri P, Berkhemer OA, Roos YBWEM, Majoie CBLM, van Oostenbrugge RJ, van Zwam WH, van der Lugt A, Steyerberg EW, Dippel DWJ, Lingsma HF. Towards personalised intra-arterial treatment of patients with acute ischaemic stroke: a study protocol for development and validation of a clinical decision aid. BMJ Open 2017; 7:e013699. [PMID: 28336740 PMCID: PMC5372176 DOI: 10.1136/bmjopen-2016-013699] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
INTRODUCTION Overall, intra-arterial treatment (IAT) proved to be beneficial in patients with acute ischaemic stroke due to a proximal occlusion in the anterior circulation. However, heterogeneity in treatment benefit may be relevant for personalised clinical decision-making. Our aim is to improve selection of patients for IAT by predicting individual treatment benefit or harm. METHODS AND ANALYSIS We will use data collected in the Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands (MR CLEAN) trial to analyse the effect of baseline characteristics on outcome and treatment effect. A multivariable proportional odds model with interaction terms will be developed to predict the outcome for each individual patient, both with and without IAT. Model performance will be expressed as discrimination and calibration, after bootstrap resampling and shrinkage of regression coefficients, to correct for optimism. External validation will be conducted on data of patients in the Interventional Management of Stroke III trial (IMS III). Primary outcome will be the modified Rankin Scale (mRS) at 90 days after stroke. ETHICS AND DISSEMINATION The proposed study will provide an internationally applicable clinical decision aid for IAT. Findings will be disseminated widely through peer-reviewed publications, conference presentations and in an online web application tool. Formal ethical approval was not required as primary data were already collected. TRIAL REGISTRATION NUMBERS ISRCTN10888758; Post-results and NCT00359424; Post-resultsc.
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Affiliation(s)
| | - Esmee Venema
- Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Bob Roozenbeek
- Erasmus University Medical Center, Rotterdam, The Netherlands
| | | | - Sharon D Yeatts
- Medical University of South Carolina, Charleston, South Carolina, USA
| | | | - Olvert A Berkhemer
- Erasmus University Medical Center, Rotterdam, The Netherlands
- Academic Medical Center, Amsterdam, The Netherlands
- Maastricht University Medical Center, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | | | | | - Robert J van Oostenbrugge
- Maastricht University Medical Center, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | - Wim H van Zwam
- Maastricht University Medical Center, Cardiovascular Research Institute Maastricht (CARIM), Maastricht, The Netherlands
| | | | - Ewout W Steyerberg
- Erasmus University Medical Center, Rotterdam, The Netherlands
- Leiden University Medical Center, Leiden, The Netherlands
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Boyle K, Joundi RA, Aviv RI. An historical and contemporary review of endovascular therapy for acute ischemic stroke. ACTA ACUST UNITED AC 2017. [DOI: 10.1186/s40809-016-0025-2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023]
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Abstract
Although stroke declined from the third to fifth most common cause of death in the United States, the annual incidence and overall prevalence continue to increase. Since the available US Food and Drug Administration-approved treatment options are time dependent, improving early stroke care may have more of a public health impact than any other phase of care. Timely and efficient stroke treatment should be a priority for emergency department and prehospital providers. This article discusses currently available and emerging treatment options in acute ischemic stroke focusing on the preservation of salvageable brain tissue, minimizing complications, and secondary prevention.
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Affiliation(s)
- Matthew S Siket
- Department of Emergency Medicine, The Warren Alpert Medical School of Brown University, 55 Claverick Street, 2nd Floor, Providence, RI 02903, USA.
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50
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Muir KW, Ford GA, Messow CM, Ford I, Murray A, Clifton A, Brown MM, Madigan J, Lenthall R, Robertson F, Dixit A, Cloud GC, Wardlaw J, Freeman J, White P. Endovascular therapy for acute ischaemic stroke: the Pragmatic Ischaemic Stroke Thrombectomy Evaluation (PISTE) randomised, controlled trial. J Neurol Neurosurg Psychiatry 2017; 88:38-44. [PMID: 27756804 PMCID: PMC5256149 DOI: 10.1136/jnnp-2016-314117] [Citation(s) in RCA: 243] [Impact Index Per Article: 34.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/31/2016] [Revised: 09/08/2016] [Accepted: 09/24/2016] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The Pragmatic Ischaemic Thrombectomy Evaluation (PISTE) trial was a multicentre, randomised, controlled clinical trial comparing intravenous thrombolysis (IVT) alone with IVT and adjunctive intra-arterial mechanical thrombectomy (MT) in patients who had acute ischaemic stroke with large artery occlusive anterior circulation stroke confirmed on CT angiography (CTA). DESIGN Eligible patients had IVT started within 4.5 hours of stroke symptom onset. Those randomised to additional MT underwent thrombectomy using any Conformité Européene (CE)-marked device, with target interval times for IVT start to arterial puncture of <90 min. The primary outcome was the proportion of patients achieving independence defined by a modified Rankin Scale (mRS) score of 0-2 at day 90. RESULTS Ten UK centres enrolled 65 patients between April 2013 and April 2015. Median National Institutes of Health Stroke Scale score was 16 (IQR 13-21). Median stroke onset to IVT start was 120 min. In the intention-to-treat analysis, there was no significant difference in disability-free survival at day 90 with MT (absolute difference 11%, adjusted OR 2.12, 95% CI 0.65 to 6.94, p=0.20). Secondary analyses showed significantly greater likelihood of full neurological recovery (mRS 0-1) at day 90 (OR 7.6, 95% CI 1.6 to 37.2, p=0.010). In the per-protocol population (n=58), the primary and most secondary clinical outcomes significantly favoured MT (absolute difference in mRS 0-2 of 22% and adjusted OR 4.9, 95% CI 1.2 to 19.7, p=0.021). CONCLUSIONS The trial did not find a significant difference between treatment groups for the primary end point. However, the effect size was consistent with published data and across primary and secondary end points. Proceeding as fast as possible to MT after CTA confirmation of large artery occlusion on a background of intravenous alteplase is safe, improves excellent clinical outcomes and, in the per-protocol population, improves disability-free survival. TRIAL REGISTRATION NUMBER NCT01745692; Results.
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Affiliation(s)
- Keith W Muir
- Institute of Neuroscience & Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK
| | - Gary A Ford
- Division of Medical Sciences, Oxford University Hospitals NHS Trust, Oxford University, Oxford, UK
| | | | - Ian Ford
- Robertson Centre for Biostatistics, University of Glasgow, Glasgow, UK
| | - Alicia Murray
- Institute of Neuroscience & Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, UK
| | | | - Martin M Brown
- Stroke Research Centre, UCL Institute of Neurology, University College London, London, UK
| | | | - Rob Lenthall
- Department of Neuroradiology, Queen's Medical Centre, Nottingham, UK
| | - Fergus Robertson
- Stroke Research Centre, UCL Institute of Neurology, University College London, London, UK
| | - Anand Dixit
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
| | | | - Joanna Wardlaw
- Brain Research Imaging Centre, Centre for Clinical Brain Sciences, University of Edinburgh, Edinburgh, UK
| | | | - Philip White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, UK
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