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Arquizan C, Lapergue B, Gory B, Labreuche J, Henon H, Albucher JF, Sibon I, Turc G, Richard S, Nouri N, Cognard C, Marnat G, Naggara O, Di Maria F, Duhamel A, Jovin T, Costalat V. Evaluation of acute mechanical revascularization in minor stroke (NIHSS score ⩽ 5) and large vessel occlusion: The MOSTE multicenter, randomized, clinical trial protocol. Int J Stroke 2023; 18:1255-1259. [PMID: 37350574 DOI: 10.1177/17474930231186039] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/24/2023]
Abstract
RATIONALE Mechanical thrombectomy (MT) has become the standard of care for patients with acute ischemic stroke secondary to large vessel occlusion (LVO) of the anterior circulation. Conversely, its benefit in patients with National Institutes of Health Stroke Scale (NIHSS) score ⩽ 5 is unproven. AIM To demonstrate the superiority of immediate MT plus best medical treatment (BMT) compared to BMT (with secondary MT in case of deterioration) for increasing the rate of modified Rankin Scale (mRS) score ⩽ 1 at 90 days after minor stroke (NIHSS score ⩽ 5) and anterior circulation LVO. SAMPLE SIZE ESTIMATES To detect an absolute increase of 10% (80% power) in the 90-day mRS score = 0-1 rate in the MT + BMT group, by assuming an mRS score = 0-1 rate of 60% in the BMT group and by considering two interim efficacy/futility analyses (after study completion by 274 and 548 patients), 824 patients must be included by 36 centers in France, Spain, and the USA. METHODS AND DESIGN MOSTE is an international, multicenter, prospectively randomized into two parallel (1:1) arms, open-label, with blinded endpoint trial. Eligibility criteria are diagnosis of acute ischemic stroke within 23 h of last-seen-well, NIHSS score ⩽ 5, and LVO in the anterior circulation (intracranial internal carotid artery, M1 or M1-M2 segment of the middle cerebral artery). STUDY OUTCOMES The primary endpoint is the rate of excellent outcome at day 90 (mRS score = 0-1). Secondary endpoints include the rates of 90-day mRS score = 0-2 and score = 0, NIHSS score change, secondary MT, revascularization and infarct volume growth at 24 h, and quality of life and cognitive function at day 90. Safety outcomes (90-day all-cause mortality, procedural complications, symptomatic intracerebral hemorrhage, and rapid NIHSS score worsening) are recorded. DISCUSSION The MOSTE trial will determine MT efficacy and safety in patients with minor stroke and LVO in the anterior circulation. TRIAL REGISTRATION MOSTE Trial. NCT03796468.
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Affiliation(s)
- Caroline Arquizan
- Department of Neurology, Hôpital Gui de Chauliac, Montpellier, France
- INSERM U1266, Paris, France
| | | | - Benjamin Gory
- Department of Neuroradiology, Hôpital Central, Nancy, France
- IADI, INSERM U1254, Nancy, France
| | - Julien Labreuche
- Department of Biostatistics, Lille University Hospital, Lille, France
| | - Hilde Henon
- Department of Neurology, Hôpital Salengro, Lille, France
| | | | - Igor Sibon
- Department of Neurology, Hôpital Pellegrin, Bordeaux, France
| | - Guillaume Turc
- INSERM U1266, Paris, France
- Department of Neurology, Hôpital Sainte-Anne, Paris, France
| | | | | | - Christophe Cognard
- Department of Neuroradiology, Hôpital Pierre-Paul Riquet, Toulouse, France
| | - Gauthier Marnat
- Department of Neuroradiology, Hôpital Pellegrin, Bordeaux, France
| | - Olivier Naggara
- INSERM U1266, Paris, France
- Department of Neuroradiology, Hôpital Sainte-Anne, Paris, France
| | | | - Alain Duhamel
- Department of Biostatistics, Lille University Hospital, Lille, France
| | - Tudor Jovin
- Cooper Neurological Institute, Camden, NJ, USA
| | - Vincent Costalat
- Department of Neuroradiology, Hôpital Gui de Chauliac, Montpellier, France
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Anagnostopoulos IS, Georgakopoulou VE, Trakas I, Papalexis P, Trakas N, Spandidos DA, Fotakopoulos G. Thrombectomy vs. medical management for large vessel occlusion strokes with minimal symptoms. Exp Ther Med 2023; 26:377. [PMID: 37456166 PMCID: PMC10347103 DOI: 10.3892/etm.2023.12076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Accepted: 06/09/2023] [Indexed: 07/18/2023] Open
Abstract
Patients with acute ischemic stroke (AIS) presenting mild symptoms with a low National Institutes of Health Stroke Scale (NIHSS) score ≤8 and also found to have an intracranial large vessel occlusion (LVO) undergo endovascular thrombolysis (ET) or medical management alone. The current study aimed to evaluate the safety and effectiveness of medical management vs. ET therapy among patients with mild AIS symptoms (NIHSS score ≤8) accompanied by LVO. The present meta-analysis included articles involving mild AIS, LVO, thrombectomy/ET and medical management alone published in full-text form (from 1980 to 2022). Collected variables included: First author name, covered study period, publication year, the total number of patients and age, number of males, presence of diabetes mellitus, hypertension, atrial fibrillation, prior ischemic stroke, location, NIHSS of admission, modified Rankin scale, bleeding, morbidity and mortality. After the initial search and applying all exclusion and inclusion criteria, eight articles were left in the final article pool. The total number of patients who underwent ET was 569, compared with 1097 with medical management for LVO strokes with minimal symptoms. The findings of the present meta-analysis study point out that ET management may be associated with a high risk of bleeding and mortality in patients with LVO presenting with mild symptoms (NIHSS score ≤8).
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Affiliation(s)
| | - Vasiliki Epameinondas Georgakopoulou
- Department of Infectious Diseases and COVID-19 Unit, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Ilias Trakas
- Department of Infectious Diseases and COVID-19 Unit, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
| | - Petros Papalexis
- Unit of Endocrinology, First Department of Internal Medicine, Laiko General Hospital, Medical School, National and Kapodistrian University of Athens, 11527 Athens, Greece
- Department of Biomedical Sciences, University of West Attica, 12243 Athens, Greece
| | - Nikolaos Trakas
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Demetrios A. Spandidos
- Laboratory of Clinical Virology, School of Medicine, University of Crete, 71003 Heraklion, Greece
| | - George Fotakopoulos
- Department of Neurosurgery, General University Hospital of Larisa, 41221 Larisa, Greece
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3
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Outcomes after endovascular mechanical thrombectomy for low compared to high National Institutes of Health Stroke Scale (NIHSS): A multicenter study. Clin Neurol Neurosurg 2023; 225:107592. [PMID: 36657358 DOI: 10.1016/j.clineuro.2023.107592] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Revised: 01/02/2023] [Accepted: 01/09/2023] [Indexed: 01/15/2023]
Abstract
OBJECTIVE The role of endovascular mechanical thrombectomy (MT) in patients presenting with "minor" stroke is uncertain. We aimed to compare outcomes after MT for ischemic stroke patients presenting with National Institutes of Health Stroke Scale (NIHSS) 5 and - within the low NIHSS cohort - identify predictors of a favorable outcome, mortality, and symptomatic intracranial hemorrhage (ICH). METHODS We retrospectively analyzed a prospectively maintained, international, multicenter database. RESULTS The study cohort comprised a total of 7568 patients from 29 centers. NIHSS was low (<5) in 604 patients (8%), and > 5 in 6964 (92%). Patients with low NIHSS were younger (67 + 14.8 versus 69.6 + 14.7 years, p < 0.001), more likely to have diabetes (31.5% versus 26.9%, p = 0.016), and less likely to have atrial fibrillation (26.6% versus 37.6%, p < 0.001) compared to those with higher NIHSS. Radiographic outcomes (TICI > 2B 84.6% and 84.3%, p = 0.412) and complication rates (8.1% and 7.2%, p = 0.463) were similar between the low and high NIHSS groups, respectively. Clinical outcomes at every follow up interval, including NIHSS at 24 h and discharge, and mRS at discharge and 90 days, were better in the low NIHSS group, however patients in the low NIHSS group experienced a relative decline in NIHSS from admit to discharge. Mortality was lower in the low NIHSS group (10.4% versus 24.5%, p < 0.001). CONCLUSIONS Relative to patients with high NIHSS, MT is safe and effective for stroke patients with low NIHSS, and it is reasonable to offer it to appropriately selected patients presenting with minor stroke symptoms. Our findings justify efforts towards a randomized trial comparing MT versus medical management for patients with low NIHSS.
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Wu W, Cheng Y, Li Y, Jiang J, Chen F, Cai D, Zhang L. Assessment of Primary Collateral Grades Based on the Integrity of Willis' Circle: Predicting the Prognosis of Acute Intracranial Internal Carotid Artery Occlusion Before Thrombectomy. World Neurosurg 2022; 167:e1138-e1146. [PMID: 36087913 DOI: 10.1016/j.wneu.2022.08.137] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2022] [Revised: 08/28/2022] [Accepted: 08/30/2022] [Indexed: 10/31/2022]
Abstract
OBJECTIVE Endovascular mechanical thrombectomy (EVMT) has shown significant efficacy in improving neurological functions in patients with intracranial internal carotid artery occlusion (IICAO), but its clinical outcomes are variable. We examined the relationship between favorable clinical outcomes after EVMT in IICAO and a set of predictors. METHODS In this retrospective study, 189 patients with IICAO treated by EVMT at 3 centers from November 2015 to December 2020 were included and analyzed. Non-contrast computed tomography and computed tomography angiography were evaluated on admission. The morphology of IICAO was categorized into Ia, Ib, L, or T types, depending on the involvement of the posterior communicating artery origin, proximal anterior cerebral artery, and middle cerebral artery. The Willis' circle was categorized as integrated or compromised Willis' circle. In combination with the involvement of the IICAO and the integrity of Willis' circle, we used the primary collateral grade (PCG) to describe the presence of functional Willisian collaterals. Baseline data including demographics, characteristics, vascular risk factors, and initial National Institutes of Health Stroke Scale scores were collected. Hemorrhagic transformation was evaluated using the 24-hour non-contrast computed tomography after EVMT. Favorable outcomes based on modified Rankin scale, were defined as 0-2 at 90 days. RESULTS A total of 189 patients were included (median age, 69 years; 126 male [66.7%]). 104 patients [55.0%] showed reperfusion after EVMT, but 72 patients [38.1%] achieved favorable outcomes at 90 days. The mortality rate of type Ib was significantly higher than that with type Ia (χ2 = 14.21, P = 0.001). The outcome with different structure of Willis' circle was not statistically different between the 2 groups. A multivariate logistic regression analysis showed that IICAO T-type (odds ratio, 0.028 [95% confidence interval: 0.323-3.829], P = 0.042) and PCG 2 (odds ratio 9.427[95% confidence interval:1.863-47.698], P = 0.007) were predictors of favorable outcomes. CONCLUSIONS Evaluation of PCG by determining the type of IICAO and the integrity of Willis' circle may serve as a valuable indicator for the prognosis and as an essential reference for screening patients before EVMT.
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Affiliation(s)
- Wenjuan Wu
- Department of Radiology, Wuxi Second People's Hospital, Wuxi, China
| | - Yue Cheng
- Department of Radiology, Wuxi Second People's Hospital, Wuxi, China
| | - Yuehua Li
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Jingxuan Jiang
- Department of Radiology, Shanghai Jiao Tong University Affiliated Sixth People's Hospital, Shanghai, China
| | - Fangming Chen
- Department of Radiology, Wuxi Second People's Hospital, Wuxi, China
| | - Dongmei Cai
- Department of Radiology, Wuxi Xishan People's Hospital, Wuxi, China
| | - Lei Zhang
- Department of Radiology, Wuxi Second People's Hospital, Wuxi, China.
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5
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Hu Y, Huang S, Li G, Song M, Zhang Y, Wu D, Chen Y, Zhang M, Luo H. Clinical effect of successful reperfusion in patients presenting with NIHSS < 6 and large vessel occlusion. J Stroke Cerebrovasc Dis 2022; 31:106684. [PMID: 36007262 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106684] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2022] [Revised: 06/13/2022] [Accepted: 07/24/2022] [Indexed: 11/30/2022] Open
Abstract
PURPOSE The purpose of this study was to evaluate the impact of reperfusion in patients with large vessel occlusion (LVO) of the anterior circulation and National Institutes of Health Stroke Scale (NIHSS)< 6. METHODS It was a retrospective cohort study. The reperfusion grade was determined using the modified thrombolysis in cerebral infarction (TICI) score. The modified Rankin Score (mRS) ≤1 were defined as excellent and (mRS) ≤2 as favorable outcome at 3-month. Meanwhile, the all-cause mortality, intracerebral hemorrhage, and complications were recorded. Multivariate logistic regression analyses were performed to evaluate outcomes. RESULTS Seventy-six patients (86.4%) achieved reperfusion (TICI2B/3). Excellent outcome was achieved in 62 (70.5%) and favorable outcome in 69 (78.4%). All-cause death occurred in 2 (2.3%). The rate of excellent outcome in patients with TICI0,1,2A was 41.7%, with TICI2B 69.2%, and with TICI3 78.0% (p < 0.05). In a multivariate logistic regression analysis related to excellent outcome, the OR(95% CI) was 5.68(1.35,23.95) for TICI3; the test for linear trend by entering categorical variables as continuous variables in the adjusted model (p for trend=0.02<0.05), defining TICI0,1,2A as reference. Subgroup analyses showed without intravenous thrombolysis (IVT) (OR, 14.29; 95% CI, 1.76-116.37) and with middle cerebral artery (MCA) occlusion (OR, 7.97; 95% CI,1.26-50.32), the excellent outcome further improved with TICI3. Findings were similar in favorable outcome. CONCLUSIONS Our results indicated that successful reperfusion was intensely connected with better functional outcomes for patients with LVO presenting with NIHSS<6 in the anterior circulation, especially MCA occlusion and pretreatment without IVT.
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Affiliation(s)
- Yang Hu
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, No.74 Linjiang Road, Yuzhong District, Chongqing 400010, China
| | - Shuhan Huang
- Department of Neurology, Army Medical Center of PLA, No.10 Changjiang Branch Road, Yuzhong District, Chongqing 400042, China
| | - Gongbo Li
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, No.74 Linjiang Road, Yuzhong District, Chongqing 400010, China
| | - Min Song
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, No.74 Linjiang Road, Yuzhong District, Chongqing 400010, China
| | - Yuqing Zhang
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, No.74 Linjiang Road, Yuzhong District, Chongqing 400010, China
| | - Dongmei Wu
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, No.74 Linjiang Road, Yuzhong District, Chongqing 400010, China
| | - Yangmei Chen
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, No.74 Linjiang Road, Yuzhong District, Chongqing 400010, China
| | - Meng Zhang
- Department of Neurology, Army Medical Center of PLA, No.10 Changjiang Branch Road, Yuzhong District, Chongqing 400042, China.
| | - Haiyan Luo
- Department of Neurology, The Second Affiliated Hospital of Chongqing Medical University, No.74 Linjiang Road, Yuzhong District, Chongqing 400010, China.
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6
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Quandt F, Flottmann F, Madai VI, Alegiani A, Küpper C, Kellert L, Hilbert A, Frey D, Liebig T, Fiehler J, Goyal M, Saver JL, Gerloff C, Thomalla G, Tiedt S. Machine Learning-Based Identification of Target Groups for Thrombectomy in Acute Stroke. Transl Stroke Res 2022; 14:311-321. [PMID: 35670996 PMCID: PMC10159968 DOI: 10.1007/s12975-022-01040-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Revised: 04/19/2022] [Accepted: 05/22/2022] [Indexed: 11/29/2022]
Abstract
Whether endovascular thrombectomy (EVT) improves functional outcome in patients with large-vessel occlusion (LVO) stroke that do not comply with inclusion criteria of randomized controlled trials (RCTs) but that are considered for EVT in clinical practice is uncertain. We aimed to systematically identify patients with LVO stroke underrepresented in RCTs who might benefit from EVT. Following the premises that (i) patients without reperfusion after EVT represent a non-treated control group and (ii) the level of reperfusion affects outcome in patients with benefit from EVT but not in patients without treatment benefit, we systematically assessed the importance of reperfusion level on functional outcome prediction using machine learning in patients with LVO stroke treated with EVT in clinical practice (N = 5235, German-Stroke-Registry) and in patients treated with EVT or best medical management from RCTs (N = 1488, Virtual-International-Stroke-Trials-Archive). The importance of reperfusion level on outcome prediction in an RCT-like real-world cohort equaled the importance of EVT treatment allocation for outcome prediction in RCT data and was higher compared to an unselected real-world population. The importance of reperfusion level was magnified in patient groups underrepresented in RCTs, including patients with lower NIHSS scores (0-10), M2 occlusions, and lower ASPECTS (0-5 and 6-8). Reperfusion level was equally important in patients with vertebrobasilar as with anterior LVO stroke. The importance of reperfusion level for outcome prediction identifies patient target groups who likely benefit from EVT, including vertebrobasilar stroke patients and among patients underrepresented in RCT patients with low NIHSS scores, low ASPECTS, and M2 occlusions.
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Affiliation(s)
- Fanny Quandt
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Vince I Madai
- Charité Lab for Artificial Intelligence in Medicine-CLAIM, Charité - Universitätsmedizin Berlin, Berlin, Germany.,QUEST Center for Transforming Biomedical Research, Berlin Institute of Health, Charité - Universitätsmedizin Berlin, Berlin, Germany.,School of Computing and Digital Technology, Faculty of Computing, Engineering and the Built Environment, Birmingham City University, Birmingham, UK
| | - Anna Alegiani
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Clemens Küpper
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Lars Kellert
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Adam Hilbert
- Charité Lab for Artificial Intelligence in Medicine-CLAIM, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Dietmar Frey
- Charité Lab for Artificial Intelligence in Medicine-CLAIM, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Thomas Liebig
- Institute of Neuroradiology, University Hospital, LMU Munich, Munich, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Mayank Goyal
- Department of Radiology, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA, USA
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research, University Hospital, LMU Munich, Feodor-Lynen-Straße 17, 81377, Munich, Germany.
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7
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Abbas R, Herial NA, Naamani KE, Sweid A, Weinberg JH, Habashy KJ, Tjoumakaris S, Gooch MR, Rosenwasser RH, Jabbour P. Mechanical Thrombectomy in Patients Presenting with NIHSS Score <6: A Safety and Efficacy Analysis. J Stroke Cerebrovasc Dis 2022; 31:106282. [PMID: 34998043 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106282] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 10/24/2021] [Accepted: 12/19/2021] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Groundbreaking trials have shown the tremendous efficacy of mechanical thrombectomy for large vessel occlusions. Currently, mechanical thrombectomy is limited to patients with NIHSS scores ≥6. We investigated the feasibility and safety of MT in patients presenting with NIHSS scores <6. MATERIALS AND METHODS A retrospective review of patient who presented with acute ischemic stroke due to large vessel occlusion with an NIHSS score <6 between 2015 - 2021. The patients were then divided into two groups: those who received mechanical thrombectomy and those who did not. RESULTS Among 83 patients, 41 received a mechanical thrombectomy while 42 received medical treatment only. The mean age in the mechanical thrombectomy group was 66 years versus 60 years in the medical group (p = 0.06). Risk factors for stroke did not differ significantly between both groups. 14 patients (34.1%) in the mechanical thrombectomy group and 20 (47.6%) in the medical group received tissue plasminogen activator. No significant difference in clinical improvement (NIHSS) at discharge (p=0.85) or the mRS score at 90 days (p = 0.15) was noted. Mechanical thrombectomy was associated with smaller infarct size (p=0.04) and decreased mortality (p=0.03). CONCLUSIONS Mechanical thrombectomy is safe and effective for patients who present with large vessel occlusions and low initial NIHSS scores. Therefore, the decision to offer the patient mechanical thrombectomy or not should not be decided by NIHSS score alone. Rather, the decision should be multifactorial with the aim of maximizing the patients' outcomes.
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Affiliation(s)
- Rawad Abbas
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Nabeel A Herial
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Kareem El Naamani
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Ahmad Sweid
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Joshua H Weinberg
- Department of Neurological Surgery, The Ohio State University Wexner Medical Center, Columbus, OH 43210
| | | | - Stavropoula Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Michael R Gooch
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Robert H Rosenwasser
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA
| | - Pascal Jabbour
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
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8
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Mak A, Matouk C, Avery EW, Behland J, Frey D, Madai VI, Vajkoczy P, Malhotra A, Abou Karam A, Sanelli P, Falcone GJ, Petersen NH, Sansing L, Sheth KN, Payabvash S. Similar admission NIHSS may represent larger tissue-at-risk in patients with right-sided versus left-sided large vessel occlusion. J Neurointerv Surg 2021; 14:985-991. [PMID: 34645705 DOI: 10.1136/neurintsurg-2021-017785] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2021] [Accepted: 09/30/2021] [Indexed: 11/03/2022]
Abstract
BACKGROUND We investigated the effects of the side of large vessel occlusion (LVO) on post-thrombectomy infarct volume and clinical outcome with regard to admission National Institutes of Health Stroke Scale (NIHSS) score. METHODS We retrospectively identified patients with anterior LVO who received endovascular thrombectomy and follow-up MRI. Applying voxel-wise general linear models and multivariate analysis, we assessed the effects of occlusion side, admission NIHSS, and post-thrombectomy reperfusion (modified Thrombolysis in Cerebral Infarction, mTICI) on final infarct distribution and volume as well as discharge modified Rankin Scale (mRS) score. RESULTS We included 469 patients, 254 with left-sided and 215 with right-sided LVO. Admission NIHSS was higher in those with left-sided LVO (median (IQR) 16 (10-22)) than in those with right-sided LVO (14 (8-16), p>0.001). In voxel-wise analysis, worse post-thrombectomy reperfusion, lower admission NIHSS score, and poor discharge outcome were associated with right-hemispheric infarct lesions. In multivariate analysis, right-sided LVO was an independent predictor of larger final infarct volume (p=0.003). There was a significant three-way interaction between admission stroke severity (based on NIHSS), LVO side, and mTICI with regard to final infarct volume (p=0.041). Specifically, in patients with moderate stroke (NIHSS 6-15), incomplete reperfusion (mTICI 0-2b) was associated with larger final infarct volume (p<0.001) and worse discharge outcome (p=0.02) in right-sided compared with left-sided LVO. CONCLUSIONS When adjusted for admission NIHSS, worse post-thrombectomy reperfusion is associated with larger infarct volume and worse discharge outcome in right-sided versus left-sided LVO. This may represent larger tissue-at-risk in patients with right-sided LVO when applying admission NIHSS as a clinical biomarker for penumbra.
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Affiliation(s)
- Adrian Mak
- Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA.,CLAIM - Charité Lab for Artificial Intelligence in Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Charles Matouk
- Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Emily W Avery
- Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jonas Behland
- Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA.,CLAIM - Charité Lab for Artificial Intelligence in Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Dietmar Frey
- CLAIM - Charité Lab for Artificial Intelligence in Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany.,Neurosurgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Vince Istvan Madai
- CLAIM - Charité Lab for Artificial Intelligence in Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany.,School of Computing and Digital Technology, Birmingham City University, Birmingham, UK.,QUEST Center for Transforming Biomedical Research, Berlin Institute of Health, Berlin, Germany
| | - Peter Vajkoczy
- Neurosurgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ajay Malhotra
- Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Anthony Abou Karam
- Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Pina Sanelli
- Radiology, Feinstein Institute for Medical Research, Manhasset, New York, USA
| | - Guido J Falcone
- Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Nils H Petersen
- Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Lauren Sansing
- Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Kevin N Sheth
- Neurology, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Seyedmehdi Payabvash
- Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
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Seners P, Ben Hassen W, Lapergue B, Arquizan C, Heldner MR, Henon H, Perrin C, Strambo D, Cottier JP, Sablot D, Girard Buttaz I, Tamazyan R, Preterre C, Agius P, Laksiri N, Mechtouff L, Béjot Y, Duong DL, Mounier-Vehier F, Mione G, Rosso C, Lucas L, Papassin J, Aignatoaie A, Triquenot A, Carrera E, Niclot P, Obadia A, Lyoubi A, Garnier P, Crainic N, Wolff V, Tracol C, Philippeau F, Lamy C, Soize S, Baron JC, Turc G. Prediction of Early Neurological Deterioration in Individuals With Minor Stroke and Large Vessel Occlusion Intended for Intravenous Thrombolysis Alone. JAMA Neurol 2021; 78:321-328. [PMID: 33427887 DOI: 10.1001/jamaneurol.2020.4557] [Citation(s) in RCA: 60] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Importance The best reperfusion strategy in patients with acute minor stroke and large vessel occlusion (LVO) is unknown. Accurately predicting early neurological deterioration of presumed ischemic origin (ENDi) following intravenous thrombolysis (IVT) in this population may help to select candidates for immediate transfer for additional thrombectomy. Objective To develop and validate an easily applicable predictive score of ENDi following IVT in patients with minor stroke and LVO. Design, Setting, and Participants This multicentric retrospective cohort included 729 consecutive patients with minor stroke (National Institutes of Health Stroke Scale [NIHSS] score of 5 or less) and LVO (basilar artery, internal carotid artery, first [M1] or second [M2] segment of middle cerebral artery) intended for IVT alone in 45 French stroke centers, ie, including those who eventually received rescue thrombectomy because of ENDi. For external validation, another cohort of 347 patients with similar inclusion criteria was collected from 9 additional centers. Data were collected from January 2018 to September 2019. Main Outcomes and Measures ENDi, defined as 4 or more points' deterioration on NIHSS score within the first 24 hours without parenchymal hemorrhage on follow-up imaging or another identified cause. Results Of the 729 patients in the derivation cohort, 335 (46.0%) were male, and the mean (SD) age was 70 (15) years; of the 347 patients in the validation cohort, 190 (54.8%) were male, and the mean (SD) age was 69 (15) years. In the derivation cohort, the median (interquartile range) NIHSS score was 3 (1-4), and the occlusion site was the internal carotid artery in 97 patients (13.3%), M1 in 207 (28.4%), M2 in 395 (54.2%), and basilar artery in 30 (4.1%). ENDi occurred in 88 patients (12.1%; 95% CI, 9.7-14.4) and was strongly associated with poorer 3-month outcomes, even in patients who underwent rescue thrombectomy. In multivariable analysis, a more proximal occlusion site and a longer thrombus were independently associated with ENDi. A 4-point score derived from these variables-1 point for thrombus length and 3 points for occlusion site-showed good discriminative power for ENDi (C statistic = 0.76; 95% CI, 0.70-0.82) and was successfully validated in the validation cohort (ENDi rate, 11.0% [38 of 347]; C statistic = 0.78; 95% CI, 0.70-0.86). In both cohorts, ENDi probability was approximately 3%, 7%, 20%, and 35% for scores of 0, 1, 2 and 3 to 4, respectively. Conclusions and Relevance The substantial ENDi rates observed in these cohorts highlights the current debate regarding whether to directly transfer patients with IVT-treated minor stroke and LVO for additional thrombectomy. Based on the strong associations observed, an easily applicable score for ENDi risk prediction that may assist decision-making was derived and externally validated.
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Affiliation(s)
- Pierre Seners
- Neurology Department, GHU Paris psychiatrie et neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université de Paris, FHU Neurovasc, Paris, France
| | - Wagih Ben Hassen
- Radiology Department, GHU Paris psychiatrie et neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université de Paris, FHU Neurovasc, Paris, France
| | | | | | - Mirjam R Heldner
- Neurology Department, Inselspital, University Hospital, University of Bern, Bern, Switzerland
| | - Hilde Henon
- Neurology Department, CHU Lille, Université de Lille, INSERM U1171, Lille, France
| | - Claire Perrin
- Neurology Department, GHU Paris psychiatrie et neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université de Paris, FHU Neurovasc, Paris, France
| | - Davide Strambo
- Stroke Center, Neurology Service, CHU Vaudois, Lausanne University, Lausanne, Switzerland
| | | | - Denis Sablot
- Neurology Department, Perpignan Hospital, Perpignan, France
| | | | - Ruben Tamazyan
- Neurology Department, Saint Joseph Hospital, Paris, France
| | - Cécile Preterre
- Neurology Department, Nantes University Hospital, Nantes, France
| | - Pierre Agius
- Neurology Department, Nantes University Hospital, Nantes, France.,Neurology Department, St Nazaire Hospital, Saint-Nazaire, France
| | - Nadia Laksiri
- Neurology Department, La Timone University Hospital, Marseille, France
| | - Laura Mechtouff
- Department of Stroke Medicine, Hospices Civils de Lyon, Lyon, France
| | - Yannick Béjot
- Neurology Department, Dijon University Hospital, Dijon, France
| | - Duc-Long Duong
- Neurology Department, Versailles University Hospital, Versailles, France
| | | | - Gioia Mione
- Neurology Department, Nancy University Hospital, Nancy, France
| | - Charlotte Rosso
- Sorbonne Université, Institut du Cerveau et de la Moelle épinière, ICM, INSERM U 1127, CNRS UMR 7225, AP-HP, Urgences Cérébro-Vasculaires, ICM Infrastructure Stroke Network, Hôpital Pitié-Salpêtrière, Paris, France
| | - Ludovic Lucas
- Stroke Unit, Bordeaux University Hospital, Bordeaux, France
| | - Jérémie Papassin
- Stroke Unit, Grenoble University Hospital, Grenoble, France.,Neurology Department, Centre Hospitalier Metropole-Savoie, Chambery, France
| | - Andreea Aignatoaie
- Neurology Department, Centre Hospitalier Régional d'Orléans, Orléans, France
| | | | - Emmanuel Carrera
- Neurology Department, Geneve University Hospital, Geneve, Switzerland
| | | | - Alexandre Obadia
- Neurology Department, Fondation Adolphe de Rothschild, Paris, France
| | - Aïcha Lyoubi
- Neurology Department, Delafontaine Hospital, Saint-Denis, France
| | - Pierre Garnier
- Stroke Unit, Saint-Etienne University Hospital, Saint-Etienne, France
| | - Nicolae Crainic
- Neurology Department, Brest University Hospital, Brest, France
| | - Valérie Wolff
- Neurology Department, Strasbourg University Hospital, Strasbourg, France
| | - Clément Tracol
- Neurology Department, Rennes University Hospital, Rennes, France
| | | | - Chantal Lamy
- Neurology Department, Amiens University Hospital, Amiens, France
| | - Sébastien Soize
- Neuroradiology Department, Reims University Hospital, Reims, France
| | - Jean-Claude Baron
- Neurology Department, GHU Paris psychiatrie et neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université de Paris, FHU Neurovasc, Paris, France
| | - Guillaume Turc
- Neurology Department, GHU Paris psychiatrie et neurosciences, Institut de Psychiatrie et Neurosciences de Paris, INSERM U1266, Université de Paris, FHU Neurovasc, Paris, France
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Thrombectomy for Basilar Artery Occlusion with Mild Symptoms. World Neurosurg 2021; 149:e400-e414. [PMID: 33578025 DOI: 10.1016/j.wneu.2021.02.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/19/2020] [Revised: 02/02/2021] [Accepted: 02/03/2021] [Indexed: 10/22/2022]
Abstract
BACKGROUND AND OBJECTIVE To evaluate outcomes of thrombectomy in patients with a basilar artery occlusion (BAO) and mild symptoms, defined by an initial National Institutes of Health Stroke Scale (NIHSS) score ≤6. METHODS We performed a retrospective analysis of a multicenter prospective cohort of consecutive patients with acute ischemic stroke with BAO who underwent thrombectomy. We compared baseline and procedural characteristics, as well as outcomes between patients with BAO with an NIHSS score ≤6 and >6. Multivariate analyses were performed to determine baseline and procedural predictors of good outcome (modified Rankin Scale score 0-2) among patients with an NIHSS score ≤6. RESULTS A total of 269 patients were included: 50 (19%) had an initial NIHSS score ≤6 and 219 (81%) had an NIHSS score >6. Patients with mild strokes (NIHSS score ≤6) had better outcomes (68% of modified Rankin Scale score 0-2 vs. 27% for NIHSS score >6; P < 0.0001), lower mortality (14% vs. 48; P < 0.0001) and fewer parenchymal hematomas at day 1 (0% vs. 10%; P = 0.016). A multivariate analysis identified the following predictors for good outcome among patients with BAO with an NIHSS score ≤6: younger age, fewer passes, a cardioembolic cause, and the absence of need for angioplasty/stenting. CONCLUSIONS Thrombectomy seems to be safer and more effective for mild BAO strokes with NIHSS score ≤6 than for more severe patients. Even although thrombectomy showed high rates of recanalization, a substantial proportion (32%) nevertheless had a poor long-term clinical outcome. The number of passes, patient's age, and stroke cause seem to be predictors of clinical outcome.
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11
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Impact of recanalisation by mechanical thrombectomy in mild acute ischemic stroke with large anterior vessel occlusion. Rev Neurol (Paris) 2021; 177:955-963. [PMID: 33487410 DOI: 10.1016/j.neurol.2020.09.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/06/2020] [Accepted: 09/11/2020] [Indexed: 11/23/2022]
Abstract
BACKGROUND The net clinical benefit of mechanical thrombectomy (MT) in patients presenting acute anterior circulation ischemic stroke with large-vessel occlusion (AIS-LVO) and mild neurological deficit is uncertain. AIMS To investigate efficacy and safety of MT in patients with acute AIS-LVO and mild neurological deficit by evaluating i) the influence of recanalisation on three-month outcome and ii) mortality, symptomatic intracerebral hemorrhage (sICH) and procedural complications. METHODS We included consecutive patients with acute AIS-LVO and National Institute of Stroke Scale (NIHSS) score<8, treated by MT at Lille University Hospital. Recanalisation was graded according to modified thrombolysis in cerebral infarction (mTICI) score, mTICI 2b/2c/3 being considered successful. We recorded procedural complications and classified intra-cerebral hemorrhages (ICH) and sICH according with European Cooperative Acute Stroke Study (ECASS) and ECASS2 criteria. Three-month outcome was evaluated by modified Rankin scale (mRS). Excellent and favourable outcomes were respectively defined as mRS 0-1 and 0-2 (or similar to pre-stroke). RESULTS We included 95 patients. At three months, 56 patients (59. 0%) achieved an excellent outcome and 69 (72, 6%) a favourable outcome, both being more frequent in patients with successful recanalisation than in patients without (excellent outcome 71, 1% versus 10, 5%, P<0.001 and favourable outcome 82.9% versus 31.6%, P<0.001). The difference remained unchanged after adjustment for age and pre-MT infarct volume. Similar results were observed in patients with pre-MT NIHSS ≤5. Death occurred in five patients (5.3%), procedural complications in 12 (12.6%), any ICH in 38 (40.0%), including 3 (3.2%) sICH. CONCLUSIONS Achieving successful recanalisation appears beneficial and safe in acute AIS-LVO patients with NIHSS<8 before MT.
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12
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McCarthy DJ, Tonetti DA, Stone J, Starke RM, Narayanan S, Lang MJ, Jadhav AP, Gross BA. More expansive horizons: a review of endovascular therapy for patients with low NIHSS scores. J Neurointerv Surg 2020; 13:146-151. [PMID: 33028674 DOI: 10.1136/neurintsurg-2020-016583] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2020] [Revised: 09/08/2020] [Accepted: 09/13/2020] [Indexed: 11/03/2022]
Abstract
While the landmark 2015 stroke trials demonstrated that endovascular therapy (EVT) was superior to medical management for the treatment of acute ischemic stroke due to large vessel occlusion, the efficacy of EVT for patients presenting with a low NIHSS score remains undetermined. We conducted a review of the EVT low National Institutes of Health Stroke Scale (NIHSS) stroke literature, identifying 24 quantitative and six qualitative publications. Details of study designs and outcome were extracted and critically discussed.All identified qualitative studies were retrospective. There was significant study design heterogeneity, with 18 unique study designs between the 24 identified quantitative manuscripts. Study investigations included low NIHSS EVT feasibility (n=6), EVT versus best medical management (BMM; n=10), EVT versus intravenous therapy (IVT, n=3), and low NIHSS score versus high NIHSS score (n=3). From single-arm EVT feasibility studies, the reported ranges of modified Thrombolysis in Cerebral Infarction and symptomatic intracranial hemorrhage were 78-97% and 0-10%, respectively. The EVT versus BMM literature had heterogeneous results with 40% reporting benefit with EVT and 60% reporting neutral findings. None of the studies comparing EVT with IVT reported a difference between the two revascularization therapies. The four identified meta-analyses had incongruent inclusion criteria and conflicting results. Two randomized trials are currently investigating EVT in patients with a low NIHSS score. Selected meta-analyses do suggest a potential benefit of EVT over BMM; however, current and future randomized clinical trials will better elucidate the efficacy of EVT in this patient population.
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Affiliation(s)
- David J McCarthy
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Daniel A Tonetti
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Jeremy Stone
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Robert M Starke
- Department of Neurological Surgery, University of Miami MILLER School of Medicine, Miami Beach, Florida, USA.,Department of Neurosurgery, University of Miami School of Medicine, Miami, Florida, USA
| | - Sandra Narayanan
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Michael J Lang
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ashutosh P Jadhav
- Department of Neurology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Bradley A Gross
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
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13
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Hussein O, Abd Elazim A, Sawalha K, Salam S, Saba K, Hamed M, Peng J, Hinduja A. Role of Non-Perfusion Factors in Mildly Symptomatic Large Vessel Occlusion Stroke. J Stroke Cerebrovasc Dis 2020; 29:105172. [PMID: 32912550 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105172] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2020] [Revised: 06/25/2020] [Accepted: 07/16/2020] [Indexed: 12/23/2022] Open
Abstract
INTRODUCTION Uncertainty regarding reperfusion of mildly-symptomatic (minor) large vessel occlusion (LVO)-strokes exists. Recently, benefits from reperfusion were suggested. However, there is still no strong data to support this. Furthermore, a proportion of those patients don't improve even after non-hemorrhagic reperfusion. Our study evaluated whether or not non-perfusion factors account for such persistent deconditioning. METHODS Patients with identified minor LVO-strokes (NIHSS ≤ 8) from our stroke alert registry between January-2016 and May-2018 were included. Variables/ predictors of outcome were tested using univariate/multivariate logistic and linear regression analyses. Three month-modified ranking scale (mRS) was used to differentiate between favorable (mRS = 0-2) and unfavorable outcomes (mRS = 3-6). RESULTS Eighty-one patients were included. Significant differences between the two outcome groups regarding admission-NIHSS and discharge-NIHSS existed (OR = 0.47, 0.49 / p = 0.0005, <0.0001 respectively).The two groups had matching perfusion measures. In the poor outcome group, discharge-NIHSS was unchanged from the admission-NIHSS while in the good outcome group, discharge-NIHSS significantly improved. CONCLUSION Admission and discharge NIHSS are independent predictors of outcome in patients with minor-LVO strokes. Unchanged discharge-NIHSS predicts worse outcomes while improved discharge-NIHSS predicts good outcomes. Unchanged NIHSS in the poor outcome group was independent of the perfusion parameters. In literature, complement activation and pro-inflammatory responses to ischemia might account for the progression of stroke symptoms in major-strokes. Our study concludes similar phenomena might be present in minor-strokes. Therefore, discharge-NIHSS may be useful as a clinical marker for future therapies.
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Affiliation(s)
- Omar Hussein
- University of New Mexico Health Sciences Center, Department of Neurology, Albuquerque, New Mexico, USA.
| | - Ahmed Abd Elazim
- University of New Mexico Health Sciences Center, Department of Neurology, Albuquerque, New Mexico, USA
| | - Khalid Sawalha
- University of Massachusetts-Baystate Medical Center - Department of Internal-Medicine, 3601 Main St, Springfield, MA 01107, USA
| | - Smeer Salam
- The Ohio State University Wexner Medical Center, Department of Neurology, 410 W 10th Ave, Columbus, USA
| | - Kasser Saba
- Atrium Health, Department of Neurology, Charlotte, North Carolina, USA
| | - Mohammad Hamed
- The Ohio State University Wexner Medical Center, Department of Neurology, 410 W 10th Ave, Columbus, USA
| | - Juan Peng
- The Ohio State University, Department of Biostatistics, 410 W 10th Ave, Columbus, USA
| | - Archana Hinduja
- The Ohio State University Wexner Medical Center, Department of Neurology, 410 W 10th Ave, Columbus, USA
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14
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Mechanical thrombectomy in patients with proximal occlusions and low NIHSS: Results from a large prospective registry. J Stroke Cerebrovasc Dis 2020; 29:105091. [PMID: 32912516 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105091] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2020] [Revised: 05/29/2020] [Accepted: 06/22/2020] [Indexed: 11/23/2022] Open
Abstract
BACKGROUND Mechanical thrombectomy is now standard of care for treatment of acute ischemic stroke secondary to large vessel occlusion in the setting of high NIHSS. We analysed a large nationwide registry focusing on patients with large vessel occlusion and low NIHSS on admission to evaluate the efficacy and safety of thrombectomy in this patient population METHODS: 2826 patients treated with mechanical thrombectomy were included in a multicentre registry from January 1, 2011 to December 31, 2015. We included patients with large vessel occlusion and NIHSS ≤ 6 on admission. Baseline characteristics, imaging, clinical outcome, procedure adverse events and positive and negative outcome predictors were analysed. RESULTS 134 patients were included. 90/134 had an anterior circulation and 44 a posterior circulation stroke. One patient died before treatment. Successful revascularization (mTICI 2b-3) was achieved in 73.7% (98/133) of the patients. Intraprocedural adverse event was observed in 3% (4/133) of cases. Symptomatic intracranial haemorrhage rate was 5.3% (7/133). At three months, 70.9% (95/134) of the patients had mRS score 0-2, 15.7% (21/134) mRS 3-5 and 13.4% (18/134) mRS 6. Age and successful recanalization were significant predictors of a good clinical outcome on both univariate (p= 0.005 and p=0.007) and multivariable (p=0.0018 and p=0.009 [nat log]) analysis. Absence of vessel recanalization and symptomatic intracranial hemorrhage were independent predictors of poor outcome (p=0.021) . CONCLUSIONS Our study suggests that patients with large vessel occlusion and low NIHSS score on admission can benefit from mechanical thrombectomy. Randomized trials are warranted.
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15
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Kaesmacher J, Chaloulos-Iakovidis P, Panos L, Mordasini P, Michel P, Hajdu SD, Ribo M, Requena M, Maegerlein C, Friedrich B, Costalat V, Benali A, Pierot L, Gawlitza M, Schaafsma J, Mendes Pereira V, Gralla J, Fischer U. Mechanical Thrombectomy in Ischemic Stroke Patients With Alberta Stroke Program Early Computed Tomography Score 0-5. Stroke 2020; 50:880-888. [PMID: 30827193 PMCID: PMC6430594 DOI: 10.1161/strokeaha.118.023465] [Citation(s) in RCA: 89] [Impact Index Per Article: 22.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose— If anterior circulation large vessel occlusion acute ischemic stroke patients presenting with ASPECTS 0–5 (Alberta Stroke Program Early CT Score) should be treated with mechanical thrombectomy remains unclear. Purpose of this study was to report on the outcome of patients with ASPECTS 0–5 treated with mechanical thrombectomy and to provide data regarding the effect of successful reperfusion on clinical outcomes and safety measures in these patients. Methods— Multicenter, pooled analysis of 7 institutional prospective registries: Bernese-European Registry for Ischemic Stroke Patients Treated Outside Current Guidelines With Neurothrombectomy Devices Using the SOLITAIRE FR With the Intention for Thrombectomy (Clinical Trial Registration—URL: https://www.clinicaltrials.gov. Unique identifier: NCT03496064). Primary outcome was defined as modified Rankin Scale 0–3 at day 90 (favorable outcome). Secondary outcomes included rates of day 90 modified Rankin Scale 0–2 (functional independence), day 90 mortality and occurrence of symptomatic intracerebral hemorrhage. Multivariable logistic regression analyses were performed to assess the association of successful reperfusion with clinical outcomes. Outputs are displayed as adjusted Odds Ratios (aOR) and 95% CI. Results— Two hundred thirty-seven of 2046 patients included in this registry presented with anterior circulation large vessel occlusion and ASPECTS 0–5. In this subgroup, the overall rates of favorable outcome and mortality at day 90 were 40.1% and 40.9%. Achieving successful reperfusion was independently associated with favorable outcome (aOR, 5.534; 95% CI, 2.363–12.961), functional independence (aOR, 5.583; 95% CI, 1.964–15.873), reduced mortality (aOR, 0.180; 95% CI, 0.083–0.390), and lower rates of symptomatic intracerebral hemorrhage (aOR, 0.235; 95% CI, 0.062–0.887). The mortality-reducing effect remained in patients with ASPECTS 0–4 (aOR, 0.167; 95% CI, 0.056–0.499). Sensitivity analyses did not change the primary results. Conclusions— In patients presenting with ASPECTS 0–5, who were treated with mechanical thrombectomy, successful reperfusion was beneficial without increasing the risk of symptomatic intracerebral hemorrhage. Although the results do not allow for general treatment recommendations, formal testing of mechanical thrombectomy versus best medical treatment in these patients in a randomized controlled trial is warranted.
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Affiliation(s)
- Johannes Kaesmacher
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., P. Mordasini, J.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland.,Department of Neurology (J.K., P.C.-I., L.P., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland.,University Institute of Diagnostic, Interventional and Pediatric Radiology (J.K.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Panagiotis Chaloulos-Iakovidis
- Department of Neurology (J.K., P.C.-I., L.P., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Leonidas Panos
- Department of Neurology (J.K., P.C.-I., L.P., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Pasquale Mordasini
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., P. Mordasini, J.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Patrik Michel
- Department of Neurology (P. Michel) and Department of Radiology (S.D.H.), CHUV Lausanne, Switzerland
| | - Steven D Hajdu
- Department of Neurology (P. Michel) and Department of Radiology (S.D.H.), CHUV Lausanne, Switzerland
| | - Marc Ribo
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain (M. Ribo, M. Requena)
| | - Manuel Requena
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain (M. Ribo, M. Requena)
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Germany (C.M., B.F.)
| | - Benjamin Friedrich
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Germany (C.M., B.F.)
| | - Vincent Costalat
- Department of Neuroradiology, CHU Montpellier, France (V.C., A.B.), Toronto Western Hospital, ON
| | - Amel Benali
- Department of Neuroradiology, CHU Montpellier, France (V.C., A.B.), Toronto Western Hospital, ON
| | - Laurent Pierot
- Department of Neuroradiology, CHU Reims, France (L.P., M.G.), Toronto Western Hospital, ON
| | - Matthias Gawlitza
- Department of Neuroradiology, CHU Reims, France (L.P., M.G.), Toronto Western Hospital, ON
| | | | | | - Jan Gralla
- From the University Institute of Diagnostic and Interventional Neuroradiology (J.K., P. Mordasini, J.G.), University Hospital Bern, Inselspital, University of Bern, Switzerland
| | - Urs Fischer
- Department of Neurology (J.K., P.C.-I., L.P., U.F.), University Hospital Bern, Inselspital, University of Bern, Switzerland
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Williams MM, Leslie-Mazwi T, Hirsch JA, Kittel C, Spiotta A, De Leacy R, Mocco J, Albuquerque FC, Ducruet AF, Goyal N, Arthur AS, Kan P, Mokin M, Dumont TM, Reeves A, Wolfe SQ, Fargen K. Real-world effects of late window neurothrombectomy: procedure rates increase without night-time bias. J Neurointerv Surg 2019; 12:460-464. [PMID: 31723049 DOI: 10.1136/neurintsurg-2019-015223] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2019] [Revised: 09/23/2019] [Accepted: 10/01/2019] [Indexed: 01/13/2023]
Abstract
INTRODUCTION With the expansion of the interventional time window for stroke from emergent large vessel occlusion (ELVO), the rate of mechanical thrombectomy (MT) is expected to rise, potentially causing higher burnout rates and requiring hospitals to develop strategies for adequate coverage of these procedures. METHODS Neurointerventional physicians at 10 participating stroke centers prospectively recorded time requirements for all MT consultations over 30 consecutive 24-hour call periods, including both false positive consultations and MT procedures, during mid to late 2018. Consult start time, procedure start and end time, and data regarding commute to the hospital and delay in scheduled procedures were collected and compared with those from an identical prospective study performed in 2017. RESULTS Data were collected from a total of 300 days of call. A total of 166 procedures were performed (mean 0.55 per day), an increase from 0.32 per day in 2017. Overall mean MT direct time burden during each 24-hour call was 124 min (compared with 85 min in 2017). The percentage of consultations for thrombectomy varied based on time of day, with 87% of consults between the hours of midnight and 04:00 proceeding to thrombectomy compared with 37% between the hours of 16:00 and 20:00. CONCLUSIONS MT procedural volumes have increased from one every 5 days in 2016 to one every 2 days in 2018. The highest percentage of consults leading to thrombectomy occur in the early morning hours after midnight. Compared with similar data from 2016 and 2017, call demands continue to escalate, representing a significant demand on neurointerventional teams.
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Affiliation(s)
- Michelle Marie Williams
- Neurological Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Thabele Leslie-Mazwi
- Interventional Neuroradiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Joshua A Hirsch
- Interventional Neuroradiology, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Carol Kittel
- Neurological Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Alejandro Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Reade De Leacy
- Neurosurgery, Mount Sinai Hospital, New York City, New York, USA
| | - J Mocco
- Neurosurgery, Mount Sinai Hospital, New York City, New York, USA
| | | | - Andrew F Ducruet
- Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | - Nitin Goyal
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
| | - Adam S Arthur
- UT Dept Neurosurgery/Semmes-Murphey Clinic, Memphis, Tennessee, USA
| | - Peter Kan
- Neurosurgery, Baylor College of Medicine, Houston, Texas, USA
| | - Maxim Mokin
- Neurosurgery, University of South Florida, Tampa, Florida, USA
| | - Travis M Dumont
- Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
| | - Alan Reeves
- Neuroendovascular Division, Department of Radiology, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Stacey Q Wolfe
- Neurological Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Kyle Fargen
- Neurological Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
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17
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Sarraj A, Hassan A, Savitz SI, Grotta JC, Cai C, Parsha KN, Farrell CM, Imam B, Sitton CW, Reddy ST, Kamal H, Goyal N, Elijovich L, Reishus K, Krishnan R, Sangha N, Wu A, Costa R, Malik R, Mir O, Hasan R, Snodgrass LM, Requena M, Graybeal D, Abraham M, Chen M, McCullough LD, Ribo M. Endovascular Thrombectomy for Mild Strokes: How Low Should We Go? Stroke 2019; 49:2398-2405. [PMID: 30355094 DOI: 10.1161/strokeaha.118.022114] [Citation(s) in RCA: 95] [Impact Index Per Article: 19.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Background and Purpose- Endovascular thrombectomy (EVT) is effective for acute ischemic stroke with large vessel occlusion and National Institutes of Health Stroke Scale (NIHSS) ≥6. However, EVT benefit for mild deficits large vessel occlusions (NIHSS, <6) is uncertain. We evaluated EVT efficacy and safety in mild strokes with large vessel occlusion. Methods- A retrospective cohort of patients with anterior circulation large vessel occlusion and NIHSS <6 presenting within 24 hours from last seen normal were pooled. Patients were divided into 2 groups: EVT or medical management. Ninety-day mRS of 0 to 1 was the primary outcome, mRS of 0 to 2 was the secondary. Symptomatic intracerebral hemorrhage was the safety outcome. Clinical outcomes were compared through a multivariable logistic regression after adjusting for age, presentation NIHSS, time last seen normal to presentation, center, IV alteplase, Alberta Stroke Program early computed tomographic score, and thrombus location. We then performed propensity score matching as a sensitivity analysis. Results were also stratified by thrombus location. Results- Two hundred fourteen patients (EVT, 124; medical management, 90) were included from 8 US and Spain centers between January 2012 and March 2017. The groups were similar in age, Alberta Stroke Program early computed tomographic score, IV alteplase rate and time last seen normal to presentation. There was no difference in mRS of 0 to 1 between EVT and medical management (55.7% versus 54.4%, respectively; adjusted odds ratio, 1.3; 95% CI, 0.64-2.64; P=0.47). Similar results were seen for mRS of 0 to 2 (63.3% EVT versus 67.8% medical management; adjusted odds ratio, 0.9; 95% CI, 0.43-1.88; P=0.77). In a propensity matching analysis, there was no treatment effect in 62 matched pairs (53.5% EVT, 48.4% medical management; odds ratio, 1.17; 95% CI, 0.54-2.52; P=0.69). There was no statistically significant difference when stratified by any thrombus location; M1 approached significance ( P=0.07). Symptomatic intracerebral hemorrhage rates were higher with thrombectomy (5.8% EVT versus 0% medical management; P=0.02). Conclusions- Our retrospective multicenter cohort study showed no improvement in excellent and independent functional outcomes in mild strokes (NIHSS, <6) receiving thrombectomy irrespective of thrombus location, with increased symptomatic intracerebral hemorrhage rates, consistent with the guidelines recommending the treatment for NIHSS ≥6. There was a signal toward benefit with EVT only in M1 occlusions; however, this needs to be further evaluated in future randomized control trials.
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Affiliation(s)
- Amrou Sarraj
- From the Department of Neurology (A.S., S.I.S., J.C.G., K.N.P., C.M.F., B.I., S.T.R., H.K., K.R., L.D.M.), University of Texas Health Science Center at Houston
| | - Ameer Hassan
- Department of Interventional Neurology, University of Texas-Rio Grande Valley, Harlingen (A.H.)
| | - Sean I Savitz
- From the Department of Neurology (A.S., S.I.S., J.C.G., K.N.P., C.M.F., B.I., S.T.R., H.K., K.R., L.D.M.), University of Texas Health Science Center at Houston
| | - James C Grotta
- From the Department of Neurology (A.S., S.I.S., J.C.G., K.N.P., C.M.F., B.I., S.T.R., H.K., K.R., L.D.M.), University of Texas Health Science Center at Houston
| | - Chunyan Cai
- Department of Internal Medicine (C.C.), University of Texas Health Science Center at Houston
| | - Kaushik N Parsha
- From the Department of Neurology (A.S., S.I.S., J.C.G., K.N.P., C.M.F., B.I., S.T.R., H.K., K.R., L.D.M.), University of Texas Health Science Center at Houston
| | - Christine M Farrell
- From the Department of Neurology (A.S., S.I.S., J.C.G., K.N.P., C.M.F., B.I., S.T.R., H.K., K.R., L.D.M.), University of Texas Health Science Center at Houston
| | - Bita Imam
- From the Department of Neurology (A.S., S.I.S., J.C.G., K.N.P., C.M.F., B.I., S.T.R., H.K., K.R., L.D.M.), University of Texas Health Science Center at Houston
| | - Clark W Sitton
- Department of Diagnostic and Interventional Imaging (C.W.S.), University of Texas Health Science Center at Houston
| | - Sujan T Reddy
- From the Department of Neurology (A.S., S.I.S., J.C.G., K.N.P., C.M.F., B.I., S.T.R., H.K., K.R., L.D.M.), University of Texas Health Science Center at Houston
| | - Haris Kamal
- From the Department of Neurology (A.S., S.I.S., J.C.G., K.N.P., C.M.F., B.I., S.T.R., H.K., K.R., L.D.M.), University of Texas Health Science Center at Houston
| | - Nitin Goyal
- Department of Neurology and Neurosurgery (L.E., N.G.), University of Tennessee Health Sciences Center, Memphis
| | - Lucas Elijovich
- Department of Neurology and Neurosurgery (L.E., N.G.), University of Tennessee Health Sciences Center, Memphis
| | - Katelin Reishus
- From the Department of Neurology (A.S., S.I.S., J.C.G., K.N.P., C.M.F., B.I., S.T.R., H.K., K.R., L.D.M.), University of Texas Health Science Center at Houston
| | - Rashi Krishnan
- Department of Neurology (R.K.), University of Tennessee Health Sciences Center, Memphis
| | - Navdeep Sangha
- Department of Neurology, Kaiser Permanente Los Angeles, CA (N.S., A.W.)
| | - Abel Wu
- Department of Neurology, Kaiser Permanente Los Angeles, CA (N.S., A.W.)
| | - Renata Costa
- Department of Neurology, Rush University Medical Center, Chicago, IL (M.C., R.C., R.M.)
| | - Ruqayyah Malik
- Department of Neurology, Rush University Medical Center, Chicago, IL (M.C., R.C., R.M.)
| | - Osman Mir
- Department of Neurology, Baylor University Medical Center, Texas A&M University, Dallas (O.M., R.H., D.G.)
| | - Rashedul Hasan
- Department of Neurology, Baylor University Medical Center, Texas A&M University, Dallas (O.M., R.H., D.G.)
| | - Lindsay M Snodgrass
- Department of Neuroscience, Baylor University Medical Center, Dallas, TX (L.M.S.)
| | - Manuel Requena
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain (M. Ribo, M. Requena)
| | - Dion Graybeal
- Department of Neurology, Baylor University Medical Center, Texas A&M University, Dallas (O.M., R.H., D.G.)
| | - Michael Abraham
- Department of Neurology and Radiology, Kansas University Hospital, MO (M.A.)
| | - Michael Chen
- Department of Neurology, Rush University Medical Center, Chicago, IL (M.C., R.C., R.M.)
| | - Louise D McCullough
- From the Department of Neurology (A.S., S.I.S., J.C.G., K.N.P., C.M.F., B.I., S.T.R., H.K., K.R., L.D.M.), University of Texas Health Science Center at Houston
| | - Marc Ribo
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain (M. Ribo, M. Requena)
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18
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Shang XJ, Shi ZH, He CF, Zhang S, Bai YJ, Guo YT, Sun B, Li S, Wang HM, Zhou ZM, Zi WJ, Liu XF. Efficacy and safety of endovascular thrombectomy in mild ischemic stroke: results from a retrospective study and meta-analysis of previous trials. BMC Neurol 2019; 19:150. [PMID: 31277603 PMCID: PMC6610891 DOI: 10.1186/s12883-019-1372-9] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 06/19/2019] [Indexed: 12/02/2022] Open
Abstract
Background Mechanical thrombectomy has been proven as a standard care for moderate to severe ischemic stroke with anterior large vessel occlusion (LVO); however, whether it is equally effective in mild ischemic stroke (MIS) is controversial. Methods In this retrospective study, a total of 177 Chinese patients presenting with MIS (NIHSS ≤8) and LVO between January 2014 and September 2017 from seven comprehensive stroke centers were identified. Odds of good outcome with endovascular thrombectomy versus medical treatment were obtained by logistic regression analysis and propensity-score matching method, and a meta-analysis pooled results from six studies (n = 733). Results Good outcome (mRS: 0–1) was 58.2% (46/79) in the thrombectomy and 46.9% (46/98) in the medical group, which showed no statistical significance before adjustment (P = 0.13; OR = 1.57, 95% CI: 0.86 to 2.86). The adjusted ORs of thrombectomy versus medical group were 3.23 (95% CI, 1.35 to 7.73; P = 0.008) by multivariable logistic analysis, 2.78 (1.12 to 6.89; P = 0.02) by propensity score matching analysis, and 3.20 (1.22 to 8.37; P = 0.01) by propensity score matching analysis with additional adjustments, respectively. Thrombectomy treatment did not result in excessive mortality or symptomatic intracranial hemorrhage after adjustments. The meta-analysis did not confirm the associations between good outcome and endovascular treatment. Conclusions The current study indicates that endovascular thrombectomy is associated with good functional outcome in MIS patients with LVO, and without additional risk of symptomatic intracranial hemorrhage and mortality. Although the meta-analysis failed to demonstrate its superiority compared to medical treatment, randomized clinical trials are needed. Electronic supplementary material The online version of this article (10.1186/s12883-019-1372-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Xian-Jin Shang
- Department of Neurology, Jinling Hospital, Jinling Clinical College of Nanjing Medical University, Nanjing, 210002, Jiangsu, China.,Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, 241001, Anhui, China
| | - Zhong-Hua Shi
- Department of Neurosurgery, The 101st Hospital of the People's Liberation Army, Wuxi, 214000, Jiangsu, China
| | - Cai-Feng He
- Department of Dermatology, Yijishan Hospital of Wannan Medical College, Wuhu, 241001, Anhui, China
| | - Shuai Zhang
- Department of Neurology, Jinling Hospital, Jinling Clinical College of Nanjing Medical University, Nanjing, 210002, Jiangsu, China.,Department of Neurology, The affiliated Hospital of Yangzhou University, Yangzhou, 225001, Jiangsu, China
| | - Yong-Jie Bai
- Department of Neurology, Jinling Hospital, Jinling Clinical College of Nanjing Medical University, Nanjing, 210002, Jiangsu, China.,Department of Neurology, First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, 471003, China
| | - Yong-Tao Guo
- Department of Neurology, Jinling Hospital, Jinling Clinical College of Nanjing Medical University, Nanjing, 210002, Jiangsu, China.,Department of Neurology, The Affiliated Huai'an NO.1 People's Hospital, Nanjing Medical University, Huai'an, 223300, Jiangsu, China
| | - Bo Sun
- Department of Neurology, Jinling Hospital, Jinling Clinical College of Nanjing Medical University, Nanjing, 210002, Jiangsu, China.,Department of Neurology, The Affiliated Huai'an NO.1 People's Hospital, Nanjing Medical University, Huai'an, 223300, Jiangsu, China
| | - Shun Li
- Department of Neurology, Jinling Hospital, Jinling Clinical College of Nanjing Medical University, Nanjing, 210002, Jiangsu, China.,Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, 210002, Jiangsu, China
| | - Huai-Ming Wang
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China
| | - Zhi-Ming Zhou
- Department of Neurology, Yijishan Hospital of Wannan Medical College, Wuhu, 241001, Anhui, China
| | - Wen-Jie Zi
- Department of Neurology, Jinling Hospital, Jinling Clinical College of Nanjing Medical University, Nanjing, 210002, Jiangsu, China. .,Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, 210002, Jiangsu, China.
| | - Xin-Feng Liu
- Department of Neurology, Jinling Hospital, Jinling Clinical College of Nanjing Medical University, Nanjing, 210002, Jiangsu, China. .,Department of Neurology, Jinling Hospital, Southern Medical University, Nanjing, 210002, Jiangsu, China. .,Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, 210002, Jiangsu, China.
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19
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Ren Z, Mokin M, Bauer CT, Miao Z, Burgin WS, Wang Y. Indications for Mechanical Thrombectomy—Too Wide or Too Narrow? World Neurosurg 2019; 127:492-499. [DOI: 10.1016/j.wneu.2019.04.116] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2019] [Revised: 04/10/2019] [Accepted: 04/11/2019] [Indexed: 10/27/2022]
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20
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Bhogal P, AlMatter M, Hellstern V, Pérez MA, Ganslandt O, Bäzner H, Henkes H. Mechanical thrombectomy for recurrent large vessel occlusion. J Clin Neurosci 2019; 66:107-112. [PMID: 31113697 DOI: 10.1016/j.jocn.2019.05.010] [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] [Received: 07/08/2018] [Revised: 04/13/2019] [Accepted: 05/07/2019] [Indexed: 11/16/2022]
Abstract
Although mechanical thrombectomy (MT) has been shown in numerous trials to be a successful treatment option for patients with large vessel occlusion (LVO), there is limited information on the safety and effectiveness of the technique in cases of recurrent LVO. To this end, we performed a retrospective review of our prospectively maintained database to identify all patients that had undergone more than one MT procedure January 2008 and January 2018. The data collected on these patients included baseline demographics and any history of diabetes mellitus, hypercholesterolaemia, hypertension, atrial fibrillation or smoking. We also recorded when the symptoms had started, the patient's NIHSS and ASPECT scores, the number of passes taken, the patient's final TICI score, any complications which arose and the patient's mRS at 90 days. Our dataset encompassed 25 patients (of which 17 (68%) were female) who had undergone a total number of 52 MT's. Average age at 1st presentation was 70 ± 12.8 years. The median time between one stroke and the next was 71 days (range 1-1059, IQR 183 days). The majority of the strokes were deemed cardioembolic (86.5%) in origin. There was no significant difference in the procedure times, number of passes or TICI scores. There was a significant difference in the mRS after the 1st and 2nd events (p = 0.014) but no significant difference if the 2nd event occurred contralateral to the 1st event (p = 0.66) (n = 22). It is therefore concluded that recurrent thrombectomy can be safely performed with no significant difference in the technical aspects of the procedure.
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Affiliation(s)
- P Bhogal
- The Royal London Hospital, Whitechapel Road, London, UK.
| | - M AlMatter
- Neurological Clinic, Neurocenter, Klinikum Stuttgart, Germany
| | - V Hellstern
- Neurological Clinic, Neurocenter, Klinikum Stuttgart, Germany
| | - M Aguilar Pérez
- Neurological Clinic, Neurocenter, Klinikum Stuttgart, Germany
| | - O Ganslandt
- Neurosurgical Clinic, Neurocenter, Klinikum Stuttgart, Germany
| | - H Bäzner
- Neurological Clinic, Neurocenter, Klinikum Stuttgart, Germany
| | - H Henkes
- Neurological Clinic, Neurocenter, Klinikum Stuttgart, Germany; Medical Faculty, University Duisburg-Essen, Germany
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21
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Kaesmacher J, Chaloulos-Iakovidis P, Panos L, Mordasini P, Heldner MR, Kurmann CC, Michel P, Hajdu SD, Ribo M, Requena M, Maegerlein C, Friedrich B, Costalat V, Benali A, Pierot L, Gawlitza M, Schaafsma J, Pereira VM, Gralla J, Fischer U. Clinical effect of successful reperfusion in patients presenting with NIHSS < 8: data from the BEYOND-SWIFT registry. J Neurol 2019; 266:598-608. [PMID: 30617997 PMCID: PMC6394689 DOI: 10.1007/s00415-018-09172-1] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Revised: 12/22/2018] [Accepted: 12/25/2018] [Indexed: 01/01/2023]
Abstract
BACKGROUND AND PURPOSE If patients presenting with large vessel occlusions (LVO) and mild symptoms should be treated with endvoascular treatment (EVT) remains unclear. Aims of this study were (1) assessing the safety and technical efficacy of EVT in patients with NIHSS < 8 as opposed to a comparison group of patients presenting with NIHSS ≥ 8 and (2) evaluation of the clinical effect of reperfusion in patients with NIHSS < 8. METHODS Patients included into the retrospective multicenter BEYOND-SWIFT registry (NCT03496064) were analyzed. Clinical effect of achieving successful reperfusion (defined as modified Thrombolysis in Cerebral Infarction grade 2b/3) in patients presenting with NIHSS < 8 (N = 193) was evaluated using multivariable logistic regression analyses (displayed as adjusted Odds Ratios, aOR and 95% confidence intervals, 95%-CI). Primary outcome was excellent functional outcome (modified Rankin Scale, mRS 0-1) at day 90. Safety and efficacy of mechanical thrombectomy in patients with NIHSS < 8 was compared to patients presenting with NIHSS ≥ 8 (N = 1423). RESULTS Among patients with NIHSS < 8 (N = 193, 77/193, 39.9% receiving pre-interventional IV-tPA), successful reperfusion was significantly related to mRS 0-1 (aOR 3.217, 95%-CI 1.174-8.816) and reduced the chances of non-hemorrhagic neurological worsening (aOR 0.194, 95%-CI 0.050-0.756) after adjusting for prespecified confounders. In interaction analyses, the relative merits of achieving successful reperfusion were mostly comparable between patients presenting with NIHSS < 8 and NIHSS ≥ 8 as evidenced by non-significantly different aOR. Interventional safety and efficacy metrics were similar between patients with NIHSS < 8 and NIHSS ≥ 8. CONCLUSIONS Achieving successful reperfusion is beneficial in patients with persisting LVO presenting with NIHSS < 8 and reduces the risk of non-hemorrhagic neurological worsening.
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Affiliation(s)
- Johannes Kaesmacher
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland
| | - Panagiotis Chaloulos-Iakovidis
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland
| | - Leonidas Panos
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland
| | - Pasquale Mordasini
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Mirjam R Heldner
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland
| | - Christoph C Kurmann
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland
| | - Patrik Michel
- Department of Neurology, CHUV Lausanne, Lausanne, Switzerland
| | - Steven D Hajdu
- Department of Radiology, CHUV Lausanne, Lausanne, Switzerland
| | - Marc Ribo
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Manuel Requena
- Department of Neurology, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Benjamin Friedrich
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University Munich, Munich, Germany
| | - Vincent Costalat
- Department of Neuroradiology, CHU Montpellier, Montpellier, France
| | - Amel Benali
- Department of Neuroradiology, CHU Montpellier, Montpellier, France
| | | | | | - Joanna Schaafsma
- Department of Neurology, Toronto Western Hospital, Toronto, ON, Canada
| | - Vitor Mendes Pereira
- Joint Department of Medical Imaging, Toronto Western Hospital, Toronto, ON, Canada
| | - Jan Gralla
- University Institute of Diagnostic and Interventional Neuroradiology, University Hospital Bern, Inselspital, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Bern, Inselspital, University of Bern, Freiburgstrasse 8, 3010, Bern, Switzerland.
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22
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Koge J. [Reperfusion therapy in patients with minor or mild ischemic stroke]. Rinsho Shinkeigaku 2019; 59:84-92. [PMID: 30700691 DOI: 10.5692/clinicalneurol.cn-001255] [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: 11/05/2022]
Abstract
A significant number of patients with minor or mild stroke symptoms on initial presentation subsequently develop neurological deterioration and poor clinical outcomes at hospital discharge. The presence of an underlying large vessel occlusion is a strong predictor of both clinical worsening and poor outcome. Although patients with a low baseline National Institutes of Health Stroke Scale (NIHSS) could have been included in some randomized controlled trials, the benefits of the mechanical thrombectomy for patients with a low NIHSS score are unknown. The causes of neurological deterioration in patients with underlying large vessel occlusion are heterogeneous, but include collateral failure, and no straightforward mechanisms are found in the majority of cases. Patients with internal carotid artery occlusion, but with a patent middle cerebral artery (MCA), can occasionally have good collateral circulation and develop only minor or mild stroke. These patients exhibit collateral MCA flow via the circle of Willis despite ipsilateral internal carotid artery occlusion. However, thrombus migration may cause occlusion of collateral MCA flow, leading to dramatic neurological deterioration. Careful observation and detailed assessment are required for the management of these patients. Recent studies have examined the efficacy and optimal timing of thrombolysis or mechanical thrombectomy for patients with minor or mild stroke. Herein, we review the mechanisms of neurological deterioration, and the efficacy of reperfusion therapy, for patients with minor or mild stroke.
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Affiliation(s)
- Junpei Koge
- Division of Neurology, Saiseikai Fukuoka General Hospital
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23
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Safety and Outcome of Endovascular Treatment for Minor Ischemic Stroke: Results From the Multicenter Clinical Registry of Endovascular Treatment of Acute Ischemic Stroke in the Netherlands. J Stroke Cerebrovasc Dis 2018; 28:542-549. [PMID: 30527790 DOI: 10.1016/j.jstrokecerebrovasdis.2018.10.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2018] [Accepted: 10/23/2018] [Indexed: 11/20/2022] Open
Abstract
GOAL Insufficient data is available about safety and efficacy of endovascular treatment (EVT) in patients with minor stroke symptoms because these patients were excluded from most randomized trials. We aimed to compare characteristics, functional outcome, and complications in patients with minor ischemic stroke National Institutes of Health Stroke Scale score ≤5 (NIHSS score ≤5) and moderate to severe ischemic stroke (NIHSS score ≥6) due to intracranial proximal artery occlusion of the anterior circulation who underwent EVT. MATERIALS AND METHODS We report patients with an anterior circulation occlusion who were included between March 2014 and June 2016 in the multicenter randomized clinical trial of EVT of acute ischemic stroke in the Netherlands Registry, a prospective, multicenter, observational study for stroke centers that perform EVT in the Netherlands. Minor ischemic stroke was defined as baseline NIHSS score of 5 or less. Primary outcome is the modified Rankin Scale (mRS) score at 90 days. Secondary outcomes include symptomatic intracranial hemorrhage (sICH) and mortality. FINDINGS Seventy-one (5.5%) patients had a NIHSS score of 5 or less. Functional independence (mRS 0-2 at 90 days) was reached in 75% of these patients, compared to 40% of patients with NIHSS score of 6 or more. sICH occurred in 4% of patients, of which 1% occurred peri-interventionally. Death occurred in 6% of patients. CONCLUSIONS Patients with minor ischemic stroke with an intracranial proximal arterial occlusion of the anterior circulation who underwent EVT have a high chance of favorable outcome and appear to have low occurrence of treatment-related sICH. Therefore, our results encourage the use of EVT for minor ischemic stroke in the absence of effect estimates from controlled studies.
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24
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Abstract
Background and Purpose—
We aimed to describe the safety and efficacy of immediate mechanical thrombectomy (MT) in patients with large vessel occlusions and low National Institutes of Health Stroke Scale (NIHSS) versus best medical management.
Methods—
Patients from prospectively collected databases of 6 international comprehensive stroke centers with large vessel occlusions (distal intracranial internal carotid, middle cerebral artery-M1 and M2 segments, or basilar artery with or without tandem occlusions) and NIHSS 0 to 5 were identified and divided into 2 groups for analysis: immediate MT or initial best medical management which included rescue MT after neurological deterioration (best medical management-MT). Uni- and multivariate analyses and patient-level matching for age, baseline NIHSS, and occlusion site were performed to compare baseline and outcome variables across the 2 groups. The primary outcome was defined as good outcome (modified Rankin Scale score, 0–2) at day 90. Safety outcome was symptomatic intracranial hemorrhage as defined by the ECASS (European Cooperative Acute Stroke Study) II and mortality at day 90.
Results—
Compared with best medical management-MT (n=220), patients with immediate MT (n=80) were younger (65.3±13.5 versus 69.5±14.1;
P
=0.021), had more often atrial fibrillation (44.8% versus 28.2%;
P
=0.012), higher baseline NIHSS (4, 0–5 versus 3, 0–5;
P
=0.005), higher Alberta Stroke Program Early CT Score (10, 7–10 versus 10, 5–10;
P
=0.023), more middle cerebral artery-M1, and less middle cerebral artery-M2 (41.3% versus 21.9% and 28.8% versus 49.3%;
P
=0.016) occlusions. The adjusted odds ratio for good outcome was 3.1 (95% CI, 1.4–6.9) favoring immediate MT. In the matched analysis, there was a 14.4% absolute difference in good outcome (84.4% versus 70.1%;
P
=0.03) at day 90 favoring immediate MT. There were no safety concerns.
Conclusions—
Our retrospective, pilot analysis suggests that immediate thrombectomy in large vessel occlusions patients with low NIHSS on presentation may be safe and has the potential to result in improved outcomes. Randomized clinical trials are warranted to establish the optimal management for this patient population.
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25
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Di Maria F, Mazighi M, Kyheng M, Labreuche J, Rodesch G, Consoli A, Coskun O, Gory B, Lapergue B. Intravenous Thrombolysis Prior to Mechanical Thrombectomy in Acute Ischemic Stroke: Silver Bullet or Useless Bystander? J Stroke 2018; 20:385-393. [PMID: 30309233 PMCID: PMC6186914 DOI: 10.5853/jos.2018.01543] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2018] [Accepted: 09/10/2018] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND AND PURPOSE Recent single-center series and meta-analyses suggest that mechanical thrombectomy (MT) without prior intravenous thrombolysis (IVT) might be equally effective to bridging therapy. We analyzed, within the Endovascular Treatment in Ischemic Stroke (ETIS) prospective observational registry, the angiographic and clinical outcomes after IVT+MT versus MT alone. METHODS From December 2012 to December 2016, a total of 1,507 consecutive patients with a proximal arterial occlusion of the anterior circulation were treated by MT. Of these, 975 (64.7%) received prior IVT. Immediate angiographic and clinical outcomes at 90 days (modified Rankin Scale [mRS]) were compared between the two groups while checking for propensity score, matched-propensity score and by inverse probability of treatment weighting (IPTW) propensity score method. RESULTS Favorable outcome (mRS 0 to 2) was more frequently achieved after IVT+MT (n=523, 53.6%) than after MT alone (n=222, 41.8%) with an unadjusted odds ratio (OR) for bridging therapy of 1.61 (95% confidence interval [CI], 1. 29 to 2.01). This difference remained not significant in matched-propensity score cohort (OR, 1.21; 95% CI, 0.90 to 1.63) although it remained according to adjusted propensity score (OR, 1.31; 95% CI, 1.02 to 1.68) and IPTW (OR, 1.37; 95% CI, 1.09 to 1.73) analyses. A significant difference was found in terms of excellent outcome (mRS 0 to 1) (adjusted OR, 1.63; 95% CI, 1.25 to 2.11) and successful reperfusion (adjusted OR, 1.58; 95% CI, 1.33 to 2.15). No differences in intracerebral hemorrhage or in allcause mortality within 90 days were found between groups. CONCLUSION s IVT prior to MT is associated with increased excellent outcome and successful reperfusion rates. These findings support the use of bridging therapy.
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Affiliation(s)
- Federico Di Maria
- Department of Diagnostic and Therapeutic Neuroradiology, Foch Hospital, Suresnes, France
| | - Mikael Mazighi
- Department of Interventional Neuroradiology, Fondation Ophtalmologique A. De Rothschild, DHU Neurovasc, Paris 7 Denis Diderot University, Paris, France.,University of Lille, CHU Lille, Lille, France
| | | | | | - Georges Rodesch
- Department of Diagnostic and Therapeutic Neuroradiology, Foch Hospital, Suresnes, France
| | - Arturo Consoli
- Department of Diagnostic and Therapeutic Neuroradiology, Foch Hospital, Suresnes, France
| | - Oguzhan Coskun
- Department of Diagnostic and Therapeutic Neuroradiology, Foch Hospital, Suresnes, France
| | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Nancy, Nancy, France.,University of Lorraine, Nancy, France
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Xiong YJ, Gong JM, Zhang YC, Zhao XL, Xu SB, Pan DJ, Qu WS, Tian DS. Endovascular thrombectomy versus medical treatment for large vessel occlusion stroke with mild symptoms: A meta-analysis. PLoS One 2018; 13:e0203066. [PMID: 30138460 PMCID: PMC6107239 DOI: 10.1371/journal.pone.0203066] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Accepted: 08/14/2018] [Indexed: 01/01/2023] Open
Abstract
It remains controversial as to whether mechanical thrombectomy (MT) is safer and more beneficial in patients with large vessel occlusion stroke (LVOS) presenting with a National Institutes of Health Stroke Scale score ≤ 8. We therefore conducted a meta-analysis of the published data.We searched PubMed and Embase and pooled relevant data in the meta-analyses using fixed effects models. Only studies that directly compared best medical therapy alone (BMT) with MT were included. We used odds ratios to analyze the associations between MT and 90-day functional outcome (evaluated using the modified Rankin Scale (mRS)), mortality, and rates of symptomatic intracerebral hemorrhage (sICH) in patients with LVOS and minor symptoms. Five studies including a total of 581 patients met our inclusion criteria. A significant difference was found that the patients treated with MT were associated with improved 90-day mRS score (OR, 1.68; 95% CI, 1.08-2.61) compared with BMT group. There was no difference in 90-day mortality between the two groups. However, sICH occurred more frequently in the MT group than the BMT group (OR, 3.89; 95% CI, 1.83-8.27). Patients with LVOS with minor or mild symptoms who underwent primary thrombectomy had a significantly improved 90-day mRS score compared to those who received BMT alone. Meanwhile, the risk of sICH was higher in the MT group than that in BMT group. Future randomized clinical controlled trials evaluating the role of endovascular reperfusion for LVOS with minimal symptoms are warranted.
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Affiliation(s)
- Yong-Jie Xiong
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P.R. China
| | - Jia-Ming Gong
- Department of Neurology, Central Hospital of Ankang City, Shanxi, P.R. China
| | - Yi-Chi Zhang
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P.R. China
| | - Xin-ling Zhao
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P.R. China
| | - Sha-Bei Xu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P.R. China
| | - Deng-Ji Pan
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P.R. China
| | - Wen-Sheng Qu
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P.R. China
| | - Dai-Shi Tian
- Department of Neurology, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, P.R. China
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Farah J, Rouchaud A, Henry T, Regen C, Mihalea C, Moret J, Spelle L. Dose reference levels and clinical determinants in stroke neuroradiology interventions. Eur Radiol 2018; 29:645-653. [DOI: 10.1007/s00330-018-5593-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/13/2018] [Revised: 05/22/2018] [Accepted: 06/05/2018] [Indexed: 12/17/2022]
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Kastrup A, Brunner F, Hildebrandt H, Roth C, Winterhalter M, Giessing C, Papanagiotou P. Endovascular Therapy versus Thrombolysis in Patients with Mild Strokes and Large Vessel Occlusions within the Anterior Circulation. INTERVENTIONAL NEUROLOGY 2018; 7:431-438. [PMID: 30410521 DOI: 10.1159/000489708] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/27/2017] [Accepted: 04/28/2018] [Indexed: 11/19/2022]
Abstract
Background In patients with large vessel occlusions, endovascular treatment (ET) has been shown to be superior to intravenous thrombolysis (IVT) in recent trials. However, it is currently unclear if patients with mild strokes also benefit from ET. Methods We compared the discharge rates of good outcome (modified Rankin scale [mRS] ≤2), very good outcome (mRS 0-1), symptomatic intracranial hemorrhages (SICH), and infarct sizes in patients with mild strokes (admission National Institutes of Health Stroke Scale ≤10) and distal intracranial carotid artery, M1, and M2 occlusions during two time periods. Results From 1/2008 to 10/2012 160 patients (mean age: 72 ± 12 years) were treated with IVT, and from 11/2012 to 11/2016 145 patients (mean age: 71 ± 13 years,) received ET with or without IVT. The clinical results were comparable between both treatment groups (59% after ET vs. 56% after IVT, p = 0.5 for an mRS 0-2) and (38% after ET vs. 32% after IVT, p = 0.3 for an mRS 0-1). In the subgroup of patients with an mRS ≤6, the early outcome did not differ significantly between ET and IVT either. The rates of SICH as well as the infarct sizes were not significantly different after ET compared with IVT. Conclusion Compared with IVT, the routine use of ET did not significantly improve the early clinical or radiological outcome in patients with mild strokes and anterior circulation large vessel occlusions. Further randomized trials are urgently needed to determine the role of ET in this cohort.
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Affiliation(s)
- Andreas Kastrup
- Department of Neurology, Klinikum Bremen-Mitte, Bremen, Germany.,Department of Neurology, University of Göttingen, Göttingen, Germany
| | | | | | - Christian Roth
- Department of Neuroradiology, Klinikum Bremen-Mitte, Bremen, Germany
| | | | - Carsten Giessing
- Department of Psychology, Carl von Ossietzky University Oldenburg, Oldenburg, Germany
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29
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Kallmes DF, Siddiqui AH, Ansari SA, Liebeskind DS, Zaidat OO. Aspiring to an improved aspiration literature. J Neurointerv Surg 2018; 10:923-924. [PMID: 29875275 DOI: 10.1136/neurintsurg-2018-014046] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/14/2018] [Indexed: 11/04/2022]
Affiliation(s)
- David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Adnan H Siddiqui
- Departments of Neurosurgery and Radiology, Jacobs School of Medicine and Biomedical Sciences at the University at Buffalo, Buffalo, New York, USA
| | - Sameer A Ansari
- Departments of Radiology, Neurology, and Neurological Surgery, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - David S Liebeskind
- Department of Neurology, University of California, Los Angeles, Los Angeles, California, USA
| | - Osama O Zaidat
- Department of Neurology, St Vincent Mercy Medical Center, Toledo, Ohio, USA
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30
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Rizvi A, Seyedsaadat SM, Murad MH, Brinjikji W, Fitzgerald ST, Kadirvel R, Rabinstein AA, Kallmes DF. Redefining 'success': a systematic review and meta-analysis comparing outcomes between incomplete and complete revascularization. J Neurointerv Surg 2018; 11:9-13. [PMID: 29802163 DOI: 10.1136/neurintsurg-2018-013950] [Citation(s) in RCA: 54] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Revised: 04/18/2018] [Accepted: 04/26/2018] [Indexed: 01/19/2023]
Abstract
BACKGROUND Conventionally, 'successful' endovascular thrombectomy (EVT) had been defined as achieving revascularization of thrombolysis in cerebral infarction (TICI)-2B or greater, rather than as 'complete' (TICI-3) versus 'incomplete' (TICI-2B) revascularization. PURPOSE We performed a systematic review and meta-analysis of studies comparing clinical outcomes between patients with TICI-2B and TICI-3 revascularization. METHODS Multiple databases were searched for relevant publications between January 2003 and March 2018. Studies comparing outcomes between the TICI-2B and the TICI-3 group of acute ischemic stroke (AIS) patients treated with EVT were included. Random effects meta-analysis was performed to evaluate outcomes among TICI-2B and TICI-3 groups. The following outcomes were assessed: good neurologic outcome (modified Rankin Scale (mRS)≤2 at day 90), mortality, and intracerebral hemorrhage (ICH). RESULTS Twenty-one studies comprising 2747 patients were identified. Patients with TICI-2B revascularization had mRS≤2 at day 90 rates of 46% (391/847) compared with 66% (522/791) for TICI-3 patients (OR 0.46, 95% CI 0.37 to 0.57). Mortality rates were significantly higher in the TICI-2B group (78/570, 14%) than in the TICI-3 group (55/709, 8%) (OR 2.00, 95% CI 1.38 to 2.91). The ICH rates were also significantly higher in the TICI-2B group as compared with the TICI-3 group (31% [134/439] vs. 22% [108/490]; OR 2.20, 95% CI 1.47 to 3.30). CONCLUSIONS Differences in all major outcome measures were markedly better in patients with complete versus incomplete but still 'successful' revascularization using prior thresholds, with ORs in the order of those seen in recent definitive trials comparing EVT to an intravenous tissue plasminogen activator.
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Affiliation(s)
- Asim Rizvi
- Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | | | - Waleed Brinjikji
- Radiology, Mayo Clinic, Rochester, Minnesota, USA.,Joint Department of Medical Imaging, Toronto Western Hospital, Toronto, Ontario, Canada
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31
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Bhogal P, Andersson T, Maus V, Mpotsaris A, Yeo L. Mechanical Thrombectomy-A Brief Review of a Revolutionary new Treatment for Thromboembolic Stroke. Clin Neuroradiol 2018; 28:313-326. [PMID: 29744519 DOI: 10.1007/s00062-018-0692-2] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2018] [Accepted: 04/17/2018] [Indexed: 01/19/2023]
Abstract
The recent success of endovascular stroke treatment has heralded a new era in the management of acute ischemic stroke (AIS) with significantly improved outcome for patients. A large number of patients may be amenable to this new treatment and as the evidence expands the number of patients eligible for mechanical thrombectomy continues to increase. Recent evidence suggests that the time window for treatment can be extended up to 24 h after symptom onset for patients with anterior circulation strokes; however, many clinicians and medical professionals may not be aware of these recent changes and it is important that they are kept up-to-date with this rapidly evolving treatment. This review provides an overview of the recent successful trials and highlights important steps that should be instituted in order to achieve rapid reperfusion and optimize the outcome for ischemic stroke patients. It also looks at the remaining controversies facing the field of thrombectomy. A short summary of each of these contentious areas is provided and the current state of the art.
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Affiliation(s)
- Pervinder Bhogal
- St. Bartholomew's and the Royal London Hospital, Whitechapel Road, E1 1BB, London, UK.
| | - Tommy Andersson
- Departments of Neuroradiology and Clinical Neuroscience, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden.,Department of Medical Imaging, AZ Groeninge, 8500, Kortrijk, Belgium
| | - Volker Maus
- Department of Neuroradiology, University Hospital of Göttingen, Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | | | - Leonard Yeo
- Departments of Neuroradiology and Clinical Neuroscience, Karolinska University Hospital and Karolinska Institutet, Stockholm, Sweden.,Department of Medicine (Neurology), National University Health system and Yong Loo Lin school of medicine, National University of Singapore, Singapore, Singapore
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32
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Shang X, Lin M, Zhang S, Li S, Guo Y, Wang W, Zhang M, Wan Y, Zhou Z, Zi W, Liu X. Clinical Outcomes of Endovascular Treatment within 24 Hours in Patients with Mild Ischemic Stroke and Perfusion Imaging Selection. AJNR Am J Neuroradiol 2018; 39:1083-1087. [PMID: 29724764 DOI: 10.3174/ajnr.a5644] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2018] [Accepted: 02/26/2018] [Indexed: 12/28/2022]
Abstract
BACKGROUND AND PURPOSE Endovascular thrombectomy has been accepted as the standard of care for patients with acute ischemic stroke. Our aim was to investigate the clinical outcomes of patients with mild ischemic stroke with acute proximal large-vessel occlusion after endovascular treatment within 24 hours of symptom onset. MATERIALS AND METHODS Between January 2014 and August 2017, ninety-three Chinese patients with mild ischemic stroke (NIHSS scores, 0-8) and large-vessel occlusion with endovascular treatment were retrospectively enrolled from 7 comprehensive stroke centers. They were divided into 2 groups: ≤6 hours and 6-24 hours from symptom onset to groin puncture. We analyzed their modified Rankin Scale scores at 90 days, symptomatic intracranial hemorrhage at 48 hours, and mortality during 90 days. Multivariable linear regression analysis was used to identify predictors for NIHSS shift after discharge. RESULTS Twenty-nine patients received endovascular treatment within 6-24 hours after symptom onset and had an imaging mismatch based on perfusion CT or diffusion-weighted MR imaging. There were no substantial differences between the 2 groups in 90-day functional independence (P = .54) and the risks of the combination of symptomatic intracranial hemorrhage and death (P = .72). Two significant indicators of NIHSS shift were 48-hour symptomatic intracranial hemorrhage (unstandardized β = 7.28; 95% CI, 3.48-11.1; P < .001) and baseline systolic blood pressure (unstandardized β = 0.08; 95% CI, 0.03-0.14; P = .005). CONCLUSIONS Patients with mild ischemic stroke and large-vessel occlusion in the anterior circulation, an imaging mismatch, and endovascular treatment within 6-24 hours of initial symptoms showed no heterogeneity in the efficacy and safety outcome compared with those treated ≤6 hours from symptom onset.
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Affiliation(s)
- X Shang
- From the Department of Neurology (X.S., S.Z., Y.G., X.L.), Jinling Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China.,Department of Neurology (X.S., Z.Z.), Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - M Lin
- Department of Neurology (M.L.), Fuzhou General Hospital of Nanjing Military Region, Fuzhou, Fujian, China
| | - S Zhang
- From the Department of Neurology (X.S., S.Z., Y.G., X.L.), Jinling Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China.,Department of Neurology (S.Z.), Affiliated Hospital of Yangzhou University, Yangzhou University, Yangzhou, Jiangsu, China
| | - S Li
- Department of Neurology (S.L., W.Z., X.L.), Jinling Hospital, Southern Medical University, Nanjing, Jiangsu, China
| | - Y Guo
- From the Department of Neurology (X.S., S.Z., Y.G., X.L.), Jinling Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China.,Department of Neurology (Y.G.), Huai'an First People's Hospital, Nanjing Medical University, Huai'an, Jiangsu, China
| | - W Wang
- Department of Radiology (W.W.), First People's Hospital of Yangzhou, Yangzhou University, Yangzhou, Jiangsu, China
| | - M Zhang
- Department of Neurology (M.Z.), Research Institute of Surgery, Daping Hospital, Third Military Medical University, Chongqing, China
| | - Y Wan
- Department of Neurology (Y.W.), Hubei Zhongshan Hospital, Wuhan, Hubei, China
| | - Z Zhou
- Department of Neurology (X.S., Z.Z.), Yijishan Hospital of Wannan Medical College, Wuhu, Anhui, China
| | - W Zi
- Department of Neurology (S.L., W.Z., X.L.), Jinling Hospital, Southern Medical University, Nanjing, Jiangsu, China
| | - X Liu
- From the Department of Neurology (X.S., S.Z., Y.G., X.L.), Jinling Clinical College of Nanjing Medical University, Nanjing, Jiangsu, China .,Department of Neurology (S.L., W.Z., X.L.), Jinling Hospital, Southern Medical University, Nanjing, Jiangsu, China
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Dargazanli C, Arquizan C, Gory B, Consoli A, Labreuche J, Redjem H, Eker O, Decroix JP, Corlobé A, Mourand I, Gaillard N, Ayrignac X, Charif M, Duhamel A, Labeyrie PE, Riquelme C, Ciccio G, Smajda S, Desilles JP, Gascou G, Lefèvre PH, Mantilla-García D, Cagnazzo F, Coskun O, Mazighi M, Riva R, Bourdain F, Labauge P, Rodesch G, Obadia M, Bonafé A, Turjman F, Costalat V, Piotin M, Blanc R, Lapergue B, Wang A, Evrard S, Tchikviladzé M, Gonzalez-Valcarcel J, Di Maria F, Pico F, Rakotoharinandrasana H, Tassan P, Poll R, Corabianu O, de Broucker T, Smadja D, Alamowitch S, Ille O, Manchon E, Garcia PY. Mechanical Thrombectomy for Minor and Mild Stroke Patients Harboring Large Vessel Occlusion in the Anterior Circulation. Stroke 2017; 48:3274-3281. [DOI: 10.1161/strokeaha.117.018113] [Citation(s) in RCA: 66] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2017] [Revised: 08/16/2017] [Accepted: 09/18/2017] [Indexed: 11/16/2022]
Affiliation(s)
- Cyril Dargazanli
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Caroline Arquizan
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Benjamin Gory
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Arturo Consoli
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Julien Labreuche
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Hocine Redjem
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Omer Eker
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Jean-Pierre Decroix
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Astrid Corlobé
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Isabelle Mourand
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Nicolas Gaillard
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Xavier Ayrignac
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Mahmoud Charif
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Alain Duhamel
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Paul-Emile Labeyrie
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Carlos Riquelme
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Gabriele Ciccio
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Stanislas Smajda
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Jean-Philippe Desilles
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Grégory Gascou
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Pierre-Henri Lefèvre
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Daniel Mantilla-García
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Federico Cagnazzo
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Oguzhan Coskun
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Mikael Mazighi
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Roberto Riva
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Frédéric Bourdain
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Pierre Labauge
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Georges Rodesch
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Michael Obadia
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Alain Bonafé
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Francis Turjman
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Vincent Costalat
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Michel Piotin
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Raphaël Blanc
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
| | - Bertrand Lapergue
- From the Department of Neuroradiology, Gui de Chauliac Hospital, Montpellier, France (C.D., O.E., C.R., G.G., P.-H.L., D.M.-G., F.C., A.B., V.C.); Department of Neurology, Gui de Chauliac Hospital, Montpellier, France (C.A., A.C., I.M., N.G., X.A., M.C., P.L.); Department of Interventional Neuroradiology, Pierre Wertheimer Hospital, Lyon-Bron, France (B.G., P.-E.L., R.R., F.T.); Department of Interventional Neuroradiology (A.C., O.C., G.R.) and Department of Neurology (J.-P.D., F.B., B.L.), Foch
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Zi W, Wang H, Yang D, Hao Y, Zhang M, Geng Y, Lin M, Wan Y, Shi Z, Zhou Z, Wang W, Xu H, Tian X, Lv P, Wang S, Liu W, Wang Z, Liu X, Guo F, Zheng D, Li H, Tu M, Jin P, Xiao G, Liu Y, Xu G, Xiong Y, Liu X. Clinical Effectiveness and Safety Outcomes of Endovascular Treatment for Acute Anterior Circulation Ischemic Stroke in China. Cerebrovasc Dis 2017; 44:248-258. [PMID: 28848210 DOI: 10.1159/000478667] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/11/2017] [Accepted: 06/07/2017] [Indexed: 12/29/2022] Open
Abstract
BACKGROUNDS AND PURPOSE This study was aimed at investigating the outcomes and predictors for the poor functional outcome after endovascular treatment (EVT) in a large, mostly Asian population. METHODS Between January 2014 and June 2016, acute stroke patients with anterior circulation occlusion and EVT were retrospectively enrolled from 21 stroke centers in China. The main outcomes were modified Rankin Scale (0-2 as functional independence, 3-6 as poor) at 90 days, symptomatic intracranial hemorrhage (sICH) at 72 h, and death at 90 days. Logistic regression was used to identify predictors for poor functional outcome at 90 days. RESULTS Of the 698 patients, 304 (43.6%) patients had functional independence at 90 days. The sICH rate was 15.5% (108/698) and mortality rate at 90 days was 25.4% (177/698). Age (OR 1.04, 95% CI 1.02-1.07), National Institutes of Health Stroke Scale score at admission (11-20 vs. ≤10, OR 2.38, 95% CI 1.23-4.59; ≥21 vs. ≤10, OR 3.66, 95% CI 1.72-7.80), baseline glucose level (OR 1.09, 95% CI 1.01-1.18), onset to groin puncture >6 h (OR 1.88, 95% CI 1.06-3.31), sICH (OR 15.49, 95% CI 5.16-46.43), and pneumonia (OR 3.15, 95% CI 1.86-5.32) were independent predictors of poor functional outcomes, while good recanalization (OR 0.26, 95% CI 0.13-0.54), preoperative Alberta Stroke Program Early CT Score 8-10 (OR 0.48, 95% CI 0.28-0.83), and good collateral flow (OR 0.50, 95% CI 0.32-0.79) were protective factors. CONCLUSIONS This study provides evidence in real world to support the performance of EVT in acute anterior circulation stroke patients in Chinese population. Patients with small infarct core, successful recanalization, good collateral status, and short treatment delay without sICH or pneumonia may benefit from EVT.
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Affiliation(s)
- Wenjie Zi
- Department of Neurology, Jinling Hospital, Medical School of Nanjing University, Nanjing, China
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Alqahtani SA, Stemer AB, McCullough MF, Bell RS, Mai J, Liu AH, Armonda RA. Endovascular Management of Stroke Patients with Large Vessel Occlusion and Minor Stroke Symptoms. Cureus 2017; 9:e1355. [PMID: 28721323 PMCID: PMC5510978 DOI: 10.7759/cureus.1355] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
Endovascular mechanical thrombectomy for stroke patients with large vessel occlusion (LVO) in the anterior circulation has become the standard of care based on several major randomized clinical trials. The successful result reported by these trials constitutes what may be the largest achievement in the history of neurological sciences. However, most of these mechanical thrombectomy trials (except for the multicenter randomized clinical trial of endovascular treatment for acute ischemic stroke in the Netherlands, i.e., MR CLEAN and Extending the Time for Thrombolysis in Emergency Neurological Deficits–Intra-Arterial, i.e., EXTEND-IA) excluded stroke patients with minor to mild stroke symptoms with National Institutes of Health Stroke Scale (NIHSS) scores of six to eight or lower. The median NIHSS score for patients who underwent acute endovascular thrombectomy was approximately 15 to 17 in all trials. To date, the evidence is lacking to support the mechanical thrombectomy in patients with acute stroke and LVO with minor to mild severity on NIHSS score. The purpose of this review was to assess the current data, safety and clinical outcomes in stroke patients with minor to mild symptoms who were treated with endovascular thrombectomy.
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Affiliation(s)
| | | | | | - Randy S Bell
- Department of Neurosurgery, Walter Reed Army Medical Center, Washington D.C
| | - Jeffrey Mai
- Neurosurgery, Medstar Georgetown University Hospital
| | - Ai-Hsi Liu
- Neurointerventional Radiology, Medstar Washington Hospital Center
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