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Peycheva M, Padlina G, Genceviciute K, Krasteva MP, Boronylo A, Goeldlin MB, Müller M, Wenz ES, Müller MD, Hammer H, Bücke P, Bigi S, Simonetti BG, Hoffmann A, Umarova RM, Pilgram-Pastor S, Gralla J, Mordasini P, Antonenko K, Heldner MR. Baseline characteristics and outcome of stroke patients after endovascular therapy according to previous symptomatic vascular disease and sex. Front Neurol 2024; 15:1293905. [PMID: 38694775 PMCID: PMC11061446 DOI: 10.3389/fneur.2024.1293905] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2023] [Accepted: 04/02/2024] [Indexed: 05/04/2024] Open
Abstract
Aim The aim of this study was to investigate baseline characteristics and outcome of patients after endovascular therapy (EVT) for acute large vessel occlusion (LVO) in relation to their history of symptomatic vascular disease and sex. Methods Consecutive EVT-eligible patients with LVO in the anterior circulation admitted to our stroke center between 04/2015 and 04/2020 were included in this observational cohort study. All patients were treated according to a standardized acute ischaemic stroke (AIS) protocol. Baseline characteristics and successful reperfusion, recurrent/progressive in-hospital ischaemic stroke, symptomatic in-hospital intracranial hemorrhage, death at discharge and at 3 months, and functional outcome at 3 months were analyzed according to previous symptomatic vascular disease and sex. Results 995 patients with LVO in the anterior circulation (49.4% women, median age 76 years, median admission NIHSS score 14) were included. Patients with multiple vs. no previous vascular events showed higher mortality at discharge (20% vs. 9.3%, age/sex - adjustedOR = 1.43, p = 0.030) and less independency at 3 months (28.8% vs. 48.8%, age/sex - adjustedOR = 0.72, p = 0.020). All patients and men alone with one or multiple vs. patients and men with no previous vascular events showed more recurrent/progressive in-hospital ischaemic strokes (19.9% vs. 6.4% in all patients, age/sex - adjustedOR = 1.76, p = 0.028) (16.7% vs. 5.8% in men, age-adjustedOR = 2.20, p = 0.035). Men vs. women showed more in-hospital symptomatic intracranial hemorrhage among patients with one or multiple vs. no previous vascular events (23.7% vs. 6.6% in men and 15.4% vs. 5.5% in women, OR = 2.32, p = 0.035/age - adjustedOR = 2.36, p = 0.035). Conclusions Previous vascular events increased the risk of in-hospital complications and poorer outcome in the analyzed patients with EVT-eligible LVO-AIS. Our findings may support risk assessment in these stroke patients and could contribute to the design of future studies.
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Affiliation(s)
- Marieta Peycheva
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
- Department of Neurology and Research Institute, Medical University Plovdiv, Plovdiv, Bulgaria
| | - Giovanna Padlina
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
- Clinica Luganese, Mancucco, Lugano, Switzerland
| | - Kotryna Genceviciute
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Marina P. Krasteva
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
- Department of Neurology, University Hospital Queen Giovanna, Sofia, Bulgaria
| | - Anna Boronylo
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Martina B. Goeldlin
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Madlaine Müller
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Elena S. Wenz
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Mandy D. Müller
- Department of Neurosurgery, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Helly Hammer
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Philipp Bücke
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Sandra Bigi
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
- Division of Paediatric Neurology, Department of Paediatrics, Children's Hospital Lucerne, Lucerne, Switzerland
- Institute of Social and Preventive Medicine (ISPM), University of Bern, Bern, Switzerland
| | - Barbara Goeggel Simonetti
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
- Division of Neuropaediatrics, Istituto Pediatrico della Svizzera Italiana IPSI EOC, Ospedale Regionale di Bellinzona e Valli, Bellinzona, Switzerland
- Faculty of Biomedical Sciences, Università della Svizzera Italiana, Lugano, Switzerland
| | - Angelika Hoffmann
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Roza M. Umarova
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Sara Pilgram-Pastor
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Jan Gralla
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Pasquale Mordasini
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
- Netzwerk Radiologie, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Kateryna Antonenko
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Mirjam R. Heldner
- Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
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Huo X, Sun D, Raynald, Jia B, Tong X, Wang A, Ma N, Gao F, Mo D, Nguyen TN, Miao Z. Sex differences in outcomes of endovascular therapy for acute vertebrobasilar occlusion: data from ANGEL-ACT Registry. J Neurol 2024; 271:1376-1384. [PMID: 37950759 DOI: 10.1007/s00415-023-12078-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2023] [Revised: 10/17/2023] [Accepted: 10/23/2023] [Indexed: 11/13/2023]
Abstract
BACKGROUND Understanding sex disparities in stroke can identify gaps in clinical care. The objective of this study was to investigate whether sex differences could influence clinical outcomes of patients with acute vertebrobasilar artery occlusion (VBAO) who underwent endovascular therapy (EVT). METHODS Patients were selected from the ANGEL-ACT Registry. The primary outcome was favorable functional outcome (90-day modified Rankin Scale [mRS] 0-3). Secondary outcomes included 90-day mRS distribution, excellent outcome (mRS 0-1), functional independence (mRS 0-2), early neurological improvement, recanalization, intracranial hemorrhage, and mortality within 90 days. The above outcomes were compared by two adjustment models, including (1) multivariable logistics analysis adjusting for all baseline and procedural variables with a P < 0.05; (2) adjusting for the propensity score. RESULTS There were 347 acute VBAO patients treated with EVT included, of whom 72 (20.7%) were women and 275 (79.3%) were men. Women were older (72[63-76] vs. 62[53-69], P < 0.001) and had a higher rate of atrial fibrillation (31.9% vs. 8.7%, P < 0.001), lower rates of underlying intracranial atherosclerotic disease (30.6% vs. 51.3%, P = 0.007), and tandem occlusion (8.3% vs. 21.8%, P = 0.009) than men. The rate of favorable outcome (mRS 0-3) was similar between women and men (41.7% vs. 51.3%, adjusted odds ratio 1.56, 95%CI: 0.83-2.95, P = 0.171). There were no sex differences in other clinical outcomes (all P > 0.05). CONCLUSIONS In the ANGEL-ACT registry, the percentage of men with acute VBAO undergoing EVT was approximately fourfold higher than that of women with acute VBAO undergoing EVT. Sex differences did not modify the outcomes of acute VBAO after EVT.
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Affiliation(s)
- Xiaochuan Huo
- Cerebrovascular Disease Department, Neurological Disease Center, Beijing Anzhen Hospital, Capital Medical University, NO. 2 Anzhen Road, Chaoyang District, Beijing, 100029, China.
| | - Dapeng Sun
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Raynald
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Baixue Jia
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Thanh N Nguyen
- Department of Neurology, Radiology, Boston Medical Center, Boston, MA, USA.
| | - Zhongrong Miao
- Interventional Neuroradiology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.
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van der Meij A, Holswilder G, Bernsen MLE, van Os HJ, Hofmeijer J, Spaander FH, Martens JM, van den Wijngaard IR, Lingsma HF, Konduri PR, Blm Majoie C, Schonewille WJ, Dippel DW, Kruyt ND, Nederkoorn PJ, van Walderveen MA, Wermer MJ. Sex differences in clot, vessel and tissue characteristics in patients with a large vessel occlusion treated with endovascular thrombectomy. Eur Stroke J 2024:23969873241231125. [PMID: 38420950 DOI: 10.1177/23969873241231125] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/02/2024] Open
Abstract
INTRODUCTION To improve our understanding of the relatively poor outcome after endovascular treatment (EVT) in women we assessed possible sex differences in baseline neuroimaging characteristics of acute ischemic stroke patients with large anterior vessel occlusion (LVO). PATIENTS AND METHODS We included all consecutive patients from the MR CLEAN Registry who underwent EVT between 2014 and 2017. On baseline non-contrast CT and CT angiography, we assessed clot location and clot burden score (CBS), vessel characteristics (presence of atherosclerosis, tortuosity, size, and collateral status), and tissue characteristics with the Alberta Stroke Program Early Computed Tomography Score (ASPECTS). Radiological outcome was assessed with the extended thrombolysis in cerebral infarction score (eTICI) and functional outcome with the modified Rankin Scale score (mRS) at 90 days. Sex-differences were assessed with multivariable regression analyses with adjustments for possible confounders. RESULTS 3180 patients were included (median age 72 years, 48% women). Clots in women were less often located in the intracranial internal carotid artery (ICA) (25%vs 28%, odds ratio (OR) 0.85;95% confidence interval: 0.73-1.00). CBS was similar between sexes (median 6, IQR 4-8). Intracranial (aOR 0.73;95% CI:0.62-0.87) and extracranial (aOR 0.64;95% CI:0.43-0.95) atherosclerosis was less prevalent in women. Vessel tortuosity was more frequent in women in the cervical ICA (aOR 1.89;95% CI:1.39-2.57) and women more often had severe elongation of the aortic arch (aOR 1.38;95% CI:1.00-1.91). ICA radius was smaller in women (2.3vs 2.5 mm, mean difference 0.22;95% CI:0.09-0.35) while M1 radius was essentially equal (1.6vs 1.7 mm, mean difference 0.09;95% CI:-0.02-0.21). Women had better collateral status (⩾50% filling in 62%vs 53% in men, aOR 1.48;95% CI:1.29-1.70). Finally, ASPECT scores were equal between women and men (median 9 in both sexes, IQR 8-10vs 9-10). Reperfusion rates were similar between women and men (acOR 0.94;95% CI:0.83-1.07). However, women less often reached functional independence than men (34%vs 46%, aOR 0.68;95% CI:0.53-0.86). DISCUSSION AND CONCLUSION On baseline imaging of this Dutch Registry, men and women with LVO mainly differ in vessel characteristics such as atherosclerotic burden, extracranial vessel tortuosity, and collateral status. These sex differences do not result in different reperfusion rates and are, therefore, not likely to explain the worse functional outcome in women after EVT.
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Affiliation(s)
- Anne van der Meij
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Ghislaine Holswilder
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Marie Louise E Bernsen
- Department of Radiology and Nuclear Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Hendrikus Ja van Os
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Public Health & Primary Care, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeannette Hofmeijer
- Department of Neurology, Rijnstate Hospital, Arnhem, The Netherlands
- Department of Clinical Neurophysiology, University of Twente, Enschede, The Netherlands
| | | | - Jasper M Martens
- Department of Radiology and Nuclear Medicine, Rijnstate Hospital, Arnhem, The Netherlands
| | - Ido R van den Wijngaard
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurology, Haaglanden Medical Center, Den Haag, The Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Praneeta R Konduri
- Department of Biomedical Engineering and Physics, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | - Charles Blm Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Diederik Wj Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Nyika D Kruyt
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
| | - Paul J Nederkoorn
- Department of Neurology, Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, The Netherlands
| | | | - Marieke Jh Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, The Netherlands
- Department of Neurology, University Medical Center Groningen, Groningen, The Netherlands
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Overmars LM, van Solinge WW, Ruijter HMD, van der Worp HB, Van Es B, Hulsbergen-Veelken CAR, Biessels GJ, Exalto LG, Haitjema S. Sexual dimorphism in peripheral blood cell characteristics linked to recanalization success of endovascular thrombectomy in acute ischemic stroke. J Thromb Thrombolysis 2023; 56:614-625. [PMID: 37596427 PMCID: PMC10550865 DOI: 10.1007/s11239-023-02881-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 08/02/2023] [Indexed: 08/20/2023]
Abstract
Endovascular thrombectomy (EVT) success to treat acute ischemic stroke varies with factors like stroke etiology and clot composition, which can differ between sexes. We studied if sex-specific blood cell characteristics (BCCs) are related to recanalization success. We analyzed electronic health records of 333 EVT patients from a single intervention center, and extracted 71 BCCs from the Sapphire flow cytometry analyzer. Through Sparse Partial Least Squares Discriminant Analysis, incorporating cross-validation and stability selection, we identified BCCs associated with successful recanalization (TICI 3) in both sexes. Stroke etiology was considered, while controlling for cardiovascular risk factors. Of the patients, successful recanalization was achieved in 51% of women and 49% of men. 21 of the 71 BCCs showed significant differences between sexes (pFDR-corrected < 0.05). The female-focused recanalization model had lower error rates than both combined [t(192.4) = 5.9, p < 0.001] and male-only models [t(182.6) = - 15.6, p < 0.001]. In women, successful recanalization and cardioembolism were associated with a higher number of reticulocytes, while unsuccessful recanalization and large artery atherosclerosis (LAA) as cause of stroke were associated with a higher mean corpuscular hemoglobin concentration. In men, unsuccessful recanalization and LAA as cause of stroke were associated with a higher coefficient of variance of lymphocyte complexity of the intracellular structure. Sex-specific BCCs related to recanalization success varied and were linked to stroke etiology. This enhanced understanding may facilitate personalized treatment for acute ischemic stroke.
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Affiliation(s)
- L Malin Overmars
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands.
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center, Utrecht University, Utrecht, The Netherlands.
| | - Wouter W van Solinge
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - Hester M den Ruijter
- Laboratory of Experimental Cardiology, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center, Utrecht University, Utrecht, The Netherlands
| | - Bram Van Es
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
| | | | - Geert Jan Biessels
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center, Utrecht University, Utrecht, The Netherlands
| | - Lieza G Exalto
- Department of Neurology and Neurosurgery, UMC Utrecht Brain Center, University Medical Center, Utrecht University, Utrecht, The Netherlands
| | - Saskia Haitjema
- Central Diagnostic Laboratory, University Medical Center Utrecht, Utrecht University, Utrecht, The Netherlands
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Kobeissi H, Ghozy S, Turfe B, Amoukhteh M, Bilgin C, Kadirvel R, Brinjikji W, Rabinstein AA, Kallmes DF. Differences between males and females following endovascular therapy for stroke: A systematic review and meta-analysis. J Stroke Cerebrovasc Dis 2023; 32:107124. [PMID: 37031502 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107124] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 04/02/2023] [Accepted: 04/03/2023] [Indexed: 04/11/2023] Open
Abstract
BACKGROUND Endovascular therapy (EVT) represents the standard of care for eligible patients with acute ischemic stroke (AIS) and large vessel occlusion. To better understand differences in baseline characteristics and outcomes between males and females following EVT, we conducted a systematic review and meta-analysis. METHODS We identified, using the Nested Knowledge AutoLit platform, prospective studies that reported 90-day outcomes in males and females treated with EVT for AIS. The primary outcome of interest was 90-day modified Rankin Scale (mRS) 0-2. Secondary outcome variables included mRS 0-1, symptomatic intracranial hemorrhage (sICH), thrombolysis in cerebral infarction (TICI) score 2b-3, and mortality. Using R software version 4.1.2, we calculated pooled odds ratios (ORs) and their corresponding 95% confidence intervals (CI). RESULTS We included 10 studies with 10,209 patients. There was no difference between males and females in rate of mRS 0-2 (OR= 1.16; 95% CI= 0.87-1.56; P-value= 0.316); however, after removing outliers, males had higher rates of mRS 0-2 (OR= 1.40; 95% CI= 1.19-1.66; P-value< 0.001). Similar results were reported for mRS 0-1 (OR= 1.21; 95% CI= 0.93-1.56; P-value= 0.15), after removing outliers (OR= 1.32; 95% CI= 1.17-1.50; P-value< 0.001). There was no difference between males and females in rate of sICH (OR= 0.89; 95% CI= 0.74-1.08; P-value= 0.246), mortality (OR= 0.88; 95% CI= 0.74-1.05; P-value= 0.15), or TICI 2b-3 (OR= 1.19; 95% CI= 0.85-1.67; P-value= 0.309). CONCLUSIONS Males tend to experience better outcomes following EVT for AIS, even in the setting of similar reperfusion. The mechanisms underlying this phenomenon remain unclear, and further research is warranted. EVT remains a safe and effective option for both males and females with AIS.
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Affiliation(s)
- Hassan Kobeissi
- Department of Radiology, Mayo Clinic, Rochester, MN, USA; College of Medicine, Central Michigan University, Mt. Pleasant, MI, USA.
| | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Bilal Turfe
- School of Medicine, Ross University, Barbados
| | | | - Cem Bilgin
- Department of Radiology, Mayo Clinic, Rochester, MN, USA
| | - Ramanathan Kadirvel
- Department of Radiology, Mayo Clinic, Rochester, MN, USA; Department of Neurologic Surgery, Mayo Clinic, Rochester, MN, USA
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Sex Differences in Functional Outcomes Following Endovascular Treatment for Acute Ischemic Stroke. Can J Neurol Sci 2023; 50:174-181. [PMID: 35220985 DOI: 10.1017/cjn.2022.22] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND Sex disparities have been reported across many aspects of acute ischemic stroke (AIS) care; however, there is a relative paucity of research examining sex differences in outcomes following endovascular treatment (EVT). Some studies report worse functional independence for females following EVT. Few, if any of these studies account for differences in age, baseline function, and comorbidity burden. This retrospective cohort study aimed to assess for sex differences in functional outcomes following EVT by comparing 90-day modified Rankin Scale (mRS) of males and females while controlling for baseline function and comorbidity burden. METHODS Baseline demographic and clinical data, and stroke severity were compared for 230 consecutive patients undergoing EVT for AIS between October 2014 and July 2019 at a tertiary stroke centre in Toronto, Canada. Effect of sex on likelihood of functional independence post-EVT was assessed using regression analysis with and without correction for age, baseline mRS, and Charlson Comorbidity Index (CCI). RESULTS Females undergoing EVT for AIS were older (75 ± 13 vs. 66 ± 15, p < 0.0001), with worse clinical and functional baselines. Unadjusted, males were more functionally independent (90-day mRS < 3) [OR = 1.831, 95%CI 1.082-3.098]. After controlling for age, baseline mRS and CCI, there was no difference between groups [OR 1.21, 95%CI 0.61-2.37]. CONCLUSIONS This study provides evidence that prior findings of sex disparities in function after EVT may be accounted for by differences in age, baseline clinical status and functional independence between males and females when a comprehensive measure of comorbidity burden is utilized.
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7
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Sun D, Raynald, Huo X, Jia B, Tong X, Ma G, Wang A, Ma N, Gao F, Mo D, Nguyen TN, Miao Z. Sex-Related Differences in Outcomes of Endovascular Treatment for Anterior Circulation Large Vessel Occlusion. Stroke 2023; 54:327-336. [PMID: 36689588 DOI: 10.1161/strokeaha.122.041195] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Accepted: 12/15/2022] [Indexed: 01/24/2023]
Abstract
BACKGROUND Sex disparities in acute large vessel occlusion (LVO) following endovascular treatment (EVT) have been recently reported. However, there is uncertainty about the effect of sex differences on functional outcomes after EVT, particularly in an Asian population. The present study aimed to compare the clinical and safety outcomes between men and women with anterior circulation LVO treated with EVT. METHODS We analyzed data from the ANGEL-ACT (Endovascular Treatment Key Technique and Emergency Work Flow Improvement of Acute Ischemic Stroke: a Prospective Multicenter Registry Study) Registry, which was conducted at 111 hospitals from 26 provinces in China between November 2017 and March 2019. Men and women with anterior circulation LVO treated with EVT were matched using propensity scores. After a 1:1 propensity score matching, we compared the clinical outcomes including 90-day ordinal modified Rankin Scale distribution (primary outcome), procedure duration, successful reperfusion, symptomatic intracranial hemorrhage, and mortality. Furthermore, we explored sex modification on the primary outcome in subgroup analysis. RESULTS Of 1321 patients, 483 (36.6%) were women and 838 (63.4%) were men. The mean age for women and men were 68 and 62 years old, respectively. Among 578 patients identified after matching, there were no sex differences (men versus women) in 90-day ordinal modified Rankin Scale distribution (median [interquartile range], 4 [1-5] versus 3 [1-5], P=0.464), successful reperfusion (86.5% versus 91.0%, P=0.089), symptomatic intracranial hemorrhage (6.5% versus 7.9%, P=0.512), and mortality within 90 days (17.7% versus 17.0%, P=0.826). However, men had a longer median procedure duration than women (86 [52-128] versus 72 [48-110] minutes, β=14.51, [95% CI, 4.19-24.84]; P=0.006). Subgroup analysis showed that in patients with National Institutes of Health Stroke Scale score <15, women tended to have a better outcome than men, whereas there was no gender effect in those with National Institutes of Health Stroke Scale score ≥15 (P for interaction=0.032). CONCLUSIONS Overall, this matched-control study from the ANGEL-ACT study showed similar clinical outcomes between men and women with anterior circulation LVO treated with EVT. However, in the subgroup of patients presenting with lower stroke severity (ie, National Institutes of Health Stroke Scale score <15), women tended to have a better outcome than men highlighting a potential sex disparity for further investigation. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT03370939.
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Affiliation(s)
- Dapeng Sun
- Department of Interventional Neuroradiology (D.S., R., X.H., B.J., X.T., N.M., F.G., D.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Raynald
- Department of Interventional Neuroradiology (D.S., R., X.H., B.J., X.T., N.M., F.G., D.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurosurgery, Beijing Fengtai You anmen Hospital, China (R.)
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology (D.S., R., X.H., B.J., X.T., N.M., F.G., D.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Baixue Jia
- Department of Interventional Neuroradiology (D.S., R., X.H., B.J., X.T., N.M., F.G., D.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Department of Interventional Neuroradiology (D.S., R., X.H., B.J., X.T., N.M., F.G., D.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Gaoting Ma
- Department of Neurology, Beijing Xuanwu Hospital (G.M.), Capital Medical University, Beijing, China
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases (A.X.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Department of Interventional Neuroradiology (D.S., R., X.H., B.J., X.T., N.M., F.G., D.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Department of Interventional Neuroradiology (D.S., R., X.H., B.J., X.T., N.M., F.G., D.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Department of Interventional Neuroradiology (D.S., R., X.H., B.J., X.T., N.M., F.G., D.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Thanh N Nguyen
- Department of Neurology, Radiology, Boston Medical Center, MA (T.N.N.)
| | - Zhongrong Miao
- Department of Interventional Neuroradiology (D.S., R., X.H., B.J., X.T., N.M., F.G., D.M., Z.M.), Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Casetta I, Fainardi E, Pracucci G, Saia V, Sallustio F, da Ros V, Nappini S, Nencini P, Bigliardi G, Vinci S, Grillo F, Bracco S, Tassi R, Bergui M, Cerrato P, Saletti A, De Vito A, Gasparotti R, Magoni M, Simonetti L, Zini A, Ruggiero M, Longoni M, Castellan L, Malfatto L, Castellini P, Cosottini M, Comai A, Franchini E, Lozupone E, Della Marca G, Puglielli E, Casalena A, Baracchini C, Savio D, Duc E, Ricciardi G, Cappellari M, Chiumarulo L, Petruzzellis M, Cavallini A, Cavasin N, Critelli A, Burdi N, Boero G, Giorgianni A, Versino M, Biraschi F, Nicolini E, Comelli S, Melis M, Padolecchia R, Tassinari T, Paolo Nuzzi N, Marcheselli S, Sacco S, Invernizzi P, Gallesio I, Ferrandi D, Fancello M, Valeria Saddi M, Russo M, Pischedda A, Baule A, Mannino M, Florio F, Inchingolo V, Elena Flacco M, Romano D, Silvagni U, Inzitari D, Mangiafico S, Toni D. Sex differences in outcome after thrombectomy for acute ischemic stroke. A propensity score-matched study. Eur Stroke J 2022; 7:151-157. [PMID: 35647312 PMCID: PMC9134778 DOI: 10.1177/23969873221091648] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/14/2022] [Accepted: 03/14/2022] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND AND PURPOSE We sought to investigate whether there are gender differences in clinical outcome after stroke due to large vessel occlusion (LVO) after mechanical thrombectomy (EVT) in a large population of real-world patients. METHODS From the Italian Registry of Endovascular Thrombectomy, we extracted clinical and outcome data of patients treated for stroke due to large vessel occlusion. We compared clinical and safety outcomes in men and women who underwent EVT alone or in combination with intravenous thrombolysis (IVT) in the total population and in a Propensity Score matched set. RESULTS Among 3422 patients included in the study, 1801 (52.6%) were women. Despite older age at onset (mean 72.4 vs 68.7; p < 0.001), and higher rate of atrial fibrillation (41.7% vs 28.6%; p < 0.001), women had higher probability of 3-month functional independence (adjusted odds ratio-adjOR 1.19; 95% CI 1.02-1.38), of complete recanalization (adjOR 1.25; 95% CI 1.09-1.44) and lower probability of death (adjOR 0.75; 95% CI 0.62-0.90). After propensity-score matching, a well-balanced cohort comprising 1150 men and 1150 women was analyzed, confirming the same results regarding functional outcome (3-month functional independence: OR 1.25; 95% CI 1.04-1.51), and complete recanalization (OR 1.29; 95% CI 1.09-1.53). CONCLUSIONS Subject to the limitations of a non-randomized comparison, women with stroke due to LVO treated with mechanical thrombectomy had a better chance to achieve complete recanalization, and 3-month functional independence than men. The results could be driven by women who underwent combined treatment.
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Affiliation(s)
- Ilaria Casetta
- Clinical Neurology, University of
Ferrara, Ferrara, Italy
| | | | | | - Valentina Saia
- Hospital Santa Corona Pietra Ligure,
Pietra Ligure, Italy
| | | | | | | | | | | | | | | | | | | | | | | | - Andrea Saletti
- Azienda Ospedaliero Universitaria di
Ferrara, Ferrara, Italy
| | | | | | - Mauro Magoni
- Azienda Socio Sanitaria Territoriale
degli Spedali Civili di Brescia, Brescia, Italy
| | | | - Andrea Zini
- IRCCS Istituto Delle Scienze
Neurologiche di Bologna, Bologna, Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Enrica Duc
- Ospedale San Giovanni Bosco, Torino,
Italy
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Francesco Florio
- Fondazione di Religione e di Culto
Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | - Vincenzo Inchingolo
- Fondazione di Religione e di Culto
Casa Sollievo della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | | | | | | | | | | | - Danilo Toni
- University of Rome La Sapienza, RM,
Roma, Italy
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9
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Lagebrant C, Ramgren B, Hassani Espili A, Marañon A, Kremer C. Sex Differences in Collateral Circulation and Outcome After Mechanical Thrombectomy in Acute Ischemic Stroke. Front Neurol 2022; 13:878759. [PMID: 35665053 PMCID: PMC9160377 DOI: 10.3389/fneur.2022.878759] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2022] [Accepted: 04/19/2022] [Indexed: 11/23/2022] Open
Abstract
Background Collateral circulation is known to lead to smaller infarct volume and better functional outcome after mechanical thrombectomy (MT), but studies examining sex differences in collateral circulation are scarce. The aim of this study was to investigate if collateral circulation has a different impact on outcome in women and men. Methods A single-center retrospective study of 487 patients (230 men and 257 women) treated with MT for acute ischemic stroke in the anterior cerebral circulation. Collateral circulation was assessed on computed tomography angiography images. The outcome was evaluated at 90 days according to the modified Rankin Scale (mRS). Results Women were older, median age 76 years (IQR 68-83) vs. 71 years (IQR 63–78). Stroke severity and time to recanalization were comparable. More women had moderate or good collaterals in 58.4 vs. 47.0% for men (p = 0.01). Among patients with moderate and good collaterals significantly more men (61%) were functionally independent (mRS 0–2) than women (41.5%) (p = < 0.01). This difference remained significant after correcting for age by linear weighting, 60.4 vs. 46.8% (p = 0.03). Conclusion Women had better collateral flow but showed worse functional outcomes, while good collateral flow led to better outcomes in men, even after correcting for age. Further clinical studies on peri- and post-interventional care, factors affecting recovery after hospital discharge as well as basic research on the neurovascular unit are needed to find modifiable targets to improve clinical outcomes for women.
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Affiliation(s)
| | - Birgitta Ramgren
- Department of Diagnostic Radiology, Neuroradiology, Department of Clinical Sciences, Lund University, Lund, Sweden
| | | | | | - Christine Kremer
- Neurology Department, Department of Clinical Sciences, Skåne University Hospital Malmö, Lund University, Lund, Sweden
- *Correspondence: Christine Kremer
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10
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Xu L, Li B, Zhang X, Bai X, Dmytriw AA, Wang T, Wang X, Yang K, Min X, Jiao L. Sex differences in outcomes after mechanical thrombectomy for acute ischemic stroke in the 'real world': protocol for a systematic review and meta-analysis study. BMJ Open 2022; 12:e056025. [PMID: 35428633 PMCID: PMC9014052 DOI: 10.1136/bmjopen-2021-056025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Mechanical thrombectomy (MT) had been regarded as the first-line therapy for acute ischaemic stroke patients. The sex differences in post-MT treatment outcomes were analysed by randomised controlled trial (RCT) studies with inconsistent conclusions. We suggest the results from the real-world data may differ from RCT containing studies. Therefore, the sex difference in non-clinical trial populations needs to be clarified. METHODS AND ANALYSIS In order to obtain relative studies comprehensively, we will search the main document databases, consisting of Web of Science, Medline in Ovid, Embase in Ovid and Cochrane Library, and trials registers, including Clinical Trails register. The clinical outcomes of real-world studies published between January 2015 and March 2022 will be included. The assessment methods of bias risk will be performed according to study type. The inclusion of studies, evaluation of risk and publication bias, data extraction will be implemented by two reviewers, respectively. The primary outcomes include successful recanalisation and 90-day favourable outcome. Secondary outcomes include vascular complication, hospital-related complications, death during hospital stay and follow-up, and intracerebral haemorrhage. The risk bias of observational studies will be evaluated by Newcastle-Ottawa Scale. I2 statistic will be used to perform the assessment of study heterogeneity. ETHICS AND DISSEMINATION With no need of ethics approval in this review, results in this review ground on public data. The results of the study will be eventually presented at international conferences or in a related journal. PROSPERO REGISTRATION NUMBER CRD42021242597.
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Affiliation(s)
- Lixin Xu
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, People's Republic of China
- China International Neuroscience Institute (China-INI), Beijing, People's Republic of China
| | - Binglong Li
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, People's Republic of China
- Department of Emergency, The Third Hospital of Jinan, Jinan, Shandong, People's Republic of China
| | - Xiao Zhang
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, People's Republic of China
| | - Xuesong Bai
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, People's Republic of China
| | - Adam Andrew Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Boston, Massachusetts, USA
| | - Tao Wang
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, People's Republic of China
| | - Xue Wang
- Medical Library, Xuanwu Hospital Capital Medical University, Beijing, People's Republic of China
| | - Kun Yang
- Department of Evidence-based Medicine, Xuanwu Hospital Capital Medical University, Beijing, People's Republic of China
| | - Xiaoli Min
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, People's Republic of China
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital of Kunming Medical University, Kunming, Yunnan, People's Republic of China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital Capital Medical University, Beijing, People's Republic of China
- Department of Interventional Neuroradiology, Xuanwu Hospital Capital Medical University, Beijing, People's Republic of China
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11
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Bala F, Casetta I, Nannoni S, Herlihy D, Goyal M, Fainardi E, Michel P, Thornton J, Power S, Saia V, Hegarty A, Pracucci G, Demchuk A, Mangiafico S, Boyle K, Hill MD, Toni D, Murphy S, Ademola A, Kim BJ, Menon BK, Almekhlafi MA. Sex-Related Differences in Outcomes After Endovascular Treatment of Patients With Late-Window Stroke. Stroke 2022; 53:311-318. [PMID: 34983244 DOI: 10.1161/strokeaha.121.037127] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Sex-related differences exist in many aspects of acute stroke and were mainly investigated in the early time window with conflicting results. However, data regarding sex disparities in late presenters are scarce. Therefore, we sought to investigate differences in outcomes between women and men treated with endovascular treatment in the late time window. METHODS Analyses were based on the SOLSTICE Consortium (Selection of Late-Window Stroke for Thrombectomy by Imaging Collateral Extent), which was an individual-patient level analysis of seven trials and registries. Baseline characteristics, 90-day functional independence (modified Rankin Scale score ≤2), mortality, and symptomatic intracranial hemorrhage were compared between women and men. Effect of sex on the association of age and successful reperfusion (final Thrombolysis in Cerebral Infarction 2b-3) with outcomes was assessed using multivariable logistic regression adjusted for age, National Institutes of Health Stroke Scale score, Alberta Stroke Program Early CT Score, time from onset to puncture, occlusion location, intravenous thrombolysis, and successful reperfusion, with interaction terms. RESULTS Among 608 patients treated with endovascular treatment, 50.5% were women. Women were older than men (median age of 72 versus 68 years, P=0.02) and had a lower prevalence of tandem occlusions (14.0% versus 22.9%, P=0.005). Workflow times were similar between sexes. Adjusted outcomes did not differ between women and men. Functional independence at 90 days was achieved by 127 out of 292 women (43.5%) and 135 out of 291 men (46.4%). Mortality at 90 days (54 [18.5%] versus 48 [16.5%]) and symptomatic intracranial hemorrhage (37 [13.3%] versus 33 [11.6%]) were similar between women and men. There was no sex-by-age interaction on functional outcomes. However, men had higher likelihood of mortality (Pinteraction=0.003) and symptomatic intracranial hemorrhage (Pinteraction=0.017) with advancing age. Sex did not influence the relation between successful reperfusion and outcomes. CONCLUSIONS In this multicenter analysis of late patients treated with endovascular treatment, sex was not associated with functional outcome. However, sex influenced the association between age and safety outcomes, with men experiencing worse outcomes with advancing age.
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Affiliation(s)
- Fouzi Bala
- Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, University of Calgary, Alberta, Canada. (F.B., M.G., A.D., M.D.H., B.K.M., M.A.A.)
| | - Ilaria Casetta
- Clinica Neurologica, University of Ferrara, Italy (I.C.)
| | - Stefania Nannoni
- Stroke Center, Neurology Service, Lausanne University Hospital and University of Lausanne, Switzerland (S.N., P.M.)
| | - Darragh Herlihy
- Neuroradiology Department, Beaumont Hospital, Dublin, Ireland. (D.H., J.T., S.P., A.H.)
| | - Mayank Goyal
- Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, University of Calgary, Alberta, Canada. (F.B., M.G., A.D., M.D.H., B.K.M., M.A.A.)
| | - Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Italy (E.F.)
| | - Patrik Michel
- Stroke Center, Neurology Service, Lausanne University Hospital and University of Lausanne, Switzerland (S.N., P.M.)
| | - John Thornton
- Neuroradiology Department, Beaumont Hospital, Dublin, Ireland. (D.H., J.T., S.P., A.H.).,Royal College of Surgeons in Ireland, Dublin, Ireland (J.T.)
| | - Sarah Power
- Neuroradiology Department, Beaumont Hospital, Dublin, Ireland. (D.H., J.T., S.P., A.H.)
| | - Valentina Saia
- Stroke Unit, Santa Corona Hospital, Pietra Ligure (SV), Italy (V.S.)
| | - Aidan Hegarty
- Neuroradiology Department, Beaumont Hospital, Dublin, Ireland. (D.H., J.T., S.P., A.H.)
| | | | - Andrew Demchuk
- Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, University of Calgary, Alberta, Canada. (F.B., M.G., A.D., M.D.H., B.K.M., M.A.A.)
| | | | - Karl Boyle
- Department of Geriatric and Stroke Medicine, Beaumont Hospital, Dublin, Ireland. (K.B.)
| | - Michael D Hill
- Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, University of Calgary, Alberta, Canada. (F.B., M.G., A.D., M.D.H., B.K.M., M.A.A.).,Department of Community Health Sciences, University of Calgary, Alberta, Canada. (M.D.H., A.A., B.K.M., M.A.A.)
| | - Danilo Toni
- Emergency Department, Stroke Unit, Sapienza University Hospital, Rome, Italy (D.T.)
| | - Sean Murphy
- Department of Geriatric and Stroke Medicine, The Mater Misericordiae University Hospital; School of Medicine, Royal College of Surgeons in Ireland; School of Medicine, University College Dublin, Ireland (S.M.)
| | - Ayoola Ademola
- Department of Community Health Sciences, University of Calgary, Alberta, Canada. (M.D.H., A.A., B.K.M., M.A.A.)
| | - Beom Joon Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Gyeonggi-do, Republic of Korea (B.J.K.)
| | - Bijoy K Menon
- Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, University of Calgary, Alberta, Canada. (F.B., M.G., A.D., M.D.H., B.K.M., M.A.A.).,Department of Community Health Sciences, University of Calgary, Alberta, Canada. (M.D.H., A.A., B.K.M., M.A.A.)
| | - Mohammed A Almekhlafi
- Calgary Stroke Program, Department of Clinical Neurosciences and Radiology, University of Calgary, Alberta, Canada. (F.B., M.G., A.D., M.D.H., B.K.M., M.A.A.).,Department of Community Health Sciences, University of Calgary, Alberta, Canada. (M.D.H., A.A., B.K.M., M.A.A.)
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12
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Cui Y, Wang L. A Clinical Observation of Intravenous Thrombolysis in Acute Ischemic Stroke with Minor Trauma. Neuropsychiatr Dis Treat 2021; 17:1983-1987. [PMID: 34168456 PMCID: PMC8216721 DOI: 10.2147/ndt.s290443] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/05/2020] [Accepted: 04/02/2021] [Indexed: 11/24/2022] Open
Abstract
OBJECTIVE This study aimed to observe the curative effect of intravenous thrombolysis with alteplase in patients with acute ischemic stroke and minor trauma. METHODS The data of 25 patients with minor trauma who were treated in our department from January to December 2018 were analyzed retrospectively (observation group), and during the same period, 25 thrombolytic patients were enrolled as the control group. Brain computed tomography (CT) was performed before and at three days after thrombolysis. NIHSS scores were recorded before thrombolysis and at one, three, and seven days after thrombolysis. Additionally, bleeding rate after thrombolysis and 90-day mRS scores were recorded. RESULTS The differences in 1-day, 3-day, and 7-day NIHSS scores and 90-day mRS scores between the two groups were not statistically significant (P>0.05). The bleeding rate was higher in the observation group than in the control group, and this was statistically significant (P<0.05). CONCLUSION Intravenous thrombolysis with alteplase has a good curative effect in acute ischemic stroke patients with minor trauma. The bleeding rate was significantly higher than in the control group, but there was no significant difference in the long-term curative effect.
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Affiliation(s)
- Yansen Cui
- Department of Emergency, Linyi People's Hospital, Linyi, 276001, People's Republic of China
| | - Liquan Wang
- Department of Emergency, Linyi People's Hospital, Linyi, 276001, People's Republic of China
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13
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Deb-Chatterji M, Schlemm E, Flottmann F, Meyer L, Alegiani A, Brekenfeld C, Fiehler J, Gerloff C, Thomalla G. Sex Differences in Outcome After Thrombectomy for Acute Ischemic Stroke are Explained by Confounding Factors. Clin Neuroradiol 2020; 31:1101-1109. [PMID: 33346850 PMCID: PMC8648700 DOI: 10.1007/s00062-020-00983-2] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2020] [Accepted: 11/21/2020] [Indexed: 12/12/2022]
Abstract
PURPOSE The aim of this study was to analyze sex differences in outcome after thrombectomy for acute ischemic stroke in clinical practice in a large prospective multicenter registry. METHODS Data of consecutive stroke patients treated with thrombectomy (June 2015-April 2018) derived from an industry-independent registry (German Stroke Registry-Endovascular Treatment) were prospectively analyzed. Multivariable binary logistic regression analyses were applied to determine whether sex is a predictor of functional independence outcome (defined as a modified Rankin scale [mRS] 0-2) 90 days after stroke. RESULTS In total, 2316 patients were included in the analysis, 1170 (50.5%) were female and 1146 (49.5%) were male. Women were older (median age 78 vs. 72 years; p < 0.001) and more frequently had a prestroke functional impairment defined by mRS >1 (24.8% vs. 14.1%; p < 0.001). In unadjusted analyses, independent outcome at 90 days was less frequent in women (33.2%) than men (40.6%; p < 0.001). Likewise, mortality was higher in women than in men (30.7% vs. 26.4%; p = 0.024). In adjusted regression analyses, however, sex was not associated with outcome. Lower age, a lower baseline National Institutes of Health Stroke Scale score, a higher Alberta Stroke Program Early CT score, prestroke functional independence, successful reperfusion, and concomitant intravenous thrombolysis therapy predicted independent outcome. CONCLUSION Women showed a worse functional outcome after thrombectomy for acute ischemic stroke in clinical practice; however, after adjustment for crucial confounders sex was not a predictor of outcome. The difference in outcome thus appears to result from differences in confounding factors such as age and prestroke functional status.
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Affiliation(s)
- Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Eckhard Schlemm
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Interventional Neuroradiology and Diagnostics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Interventional Neuroradiology and Diagnostics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Alegiani
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Interventional Neuroradiology and Diagnostics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Interventional Neuroradiology and Diagnostics, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Gerloff
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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14
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Effect of Sex on Clinical Outcome and Imaging after Endovascular Treatment of Large-Vessel Ischemic Stroke. J Stroke Cerebrovasc Dis 2020; 30:105468. [PMID: 33227604 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105468] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Revised: 10/21/2020] [Accepted: 11/06/2020] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND AND PURPOSE It is unclear if sex differences explain some of the variability in the outcomes of stroke patients who undergo endovascular treatment (EVT). In this study we assess the effect of sex on radiological and functional outcomes in EVT-treated acute stroke patients and determine if differences in baseline perfusion status between men and women might account for differences in outcomes. METHODS We included patients from the CRISP (Computed tomographic perfusion to Predict Response to Recanalization in ischemic stroke) study, a prospective cohort study of acute stroke patients who underwent EVT up to 18 hours after last seen well. We designed ordinal regression and univariable and multivariable regression models to examine the association between sex and infarct growth, final infarct volume and 90-day mRS score. RESULTS We included 198 patients. At baseline, women had smaller perfusion lesions, more often had a target mismatch perfusion profile, and had better collateral perfusion. Women experienced less ischemic core growth (median 15 mL vs. 29 mL, p < 0.01) and had smaller final infarct volumes (median 26 mL vs. 50 mL, p < 0.01). Female sex was associated with a favorable shift on the modified Rankin Scale (adjusted cOR 1.79 [1.04 - 3.08; p = 0.04]) and lower odds of severe disability or death (adjusted OR 0.29 [0.10 - 0.81]; p = 0.02). CONCLUSIONS The results suggest that women have better collaterals and, therefore, more often exhibit a favorable imaging profile on baseline imaging, experience less lesion growth, and have better clinical outcomes following endovascular therapy.
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15
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Ciardi C, Cirio JJ, Scrivano EV, Bleise CD, Lylyk I, Lylyk P. Sex-Related Differences after Endovascular Treatment of Acute Ischemic Stroke in the 'Real World'. J Stroke Cerebrovasc Dis 2020; 29:105240. [PMID: 33066881 DOI: 10.1016/j.jstrokecerebrovasdis.2020.105240] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2020] [Revised: 08/04/2020] [Accepted: 08/06/2020] [Indexed: 12/17/2022] Open
Abstract
BACKGROUND Gender differences are often reported in the field of ischemic stroke, although most of such discrepancies were observed in randomized trials involving highly selected populations. We therefore explored gender differences regarding 90-day outcomes in large vessel occlusion (LVO) strokes receiving endovascular treatment in a real world setting. METHODS This prospective registry included anterior and/or posterior circulation LVO strokes admitted between January 2014 and December 2019 who received mechanical thrombectomy up to 24 hours from symptoms onset or last known to be well. We explored sex-related differences in rates of functional independence (modified Rankin Scale, mRS, ≤2) at 90 days. Secondary outcomes included "National Institutes of Health Stroke Scale" (NIHSS) at 24 hours, successful reperfusion defined as modified Thrombolysis in Cerebral Infarction (mTICI) scale 2b/3, death, and symptomatic intracranial hemorrhage (sICH). RESULTS A total of 288 LVO stroke patients comprised the study population, involving 148 (51.4%) women. Females were older (71.4±15.7 vs. 66.1±14.0 years, p=0.003) and had lower rates of coronary artery disease (15% vs. 24%, p=0.05). The median time from symptoms onset to hospital arrival was 315 min (IQR 139.5-495.0) in females and 255.0 (IQR 117.0-405.0) in males (p=0.052). Rates of mRS ≤2 at 90 days were comparable (females 46% vs. males 49%, p=0.50). Successful reperfusion was achieved in 82% of females and 89% of males (p=0.10). Rates of sICH (females 10% vs. males 13%, p=0.47) and death (females 18% vs. males 21%, p=0.50) at 90 days were similar. NIHSS at 24 hours was the strongest predictor of functional independence at 90 days (area under ROC curve 0.92 (95%CI 0.87; 0.95)]. CONCLUSIONS Our prospective registry involving a real world setting suggests that females are equally likely to achieve good outcomes after endovascular treatment despite being older and having delayed hospital arrival compared to males. In addition, we found that NIHSS at 24 hours was the strongest predictor of functional independence at 90 days, sICH, and death.
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Affiliation(s)
- Celina Ciardi
- Department of Vascular Neurology, Stroke Unit. Instituto Medico ENERI, Clinica La Sagrada Familia, Buenos Aires, Argentina.
| | - Juan J Cirio
- Department of Vascular Neurology, Stroke Unit. Instituto Medico ENERI, Clinica La Sagrada Familia, Buenos Aires, Argentina
| | - Esteban V Scrivano
- Department of Interventional Neuroradiology. Instituto Medico ENERI, Clinica La Sagrada Familia, Buenos Aires, Argentina
| | - Carlos D Bleise
- Department of Interventional Neuroradiology. Instituto Medico ENERI, Clinica La Sagrada Familia, Buenos Aires, Argentina
| | - Ivan Lylyk
- Department of Interventional Neuroradiology. Instituto Medico ENERI, Clinica La Sagrada Familia, Buenos Aires, Argentina
| | - Pedro Lylyk
- Department of Interventional Neuroradiology. Instituto Medico ENERI, Clinica La Sagrada Familia, Buenos Aires, Argentina
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16
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Pérez-Sánchez S, Barragán-Prieto A, Ortega-Quintanilla J, Domínguez-Mayoral A, Gamero-García MÁ, Zapata-Arriaza E, Torres-Chacón RD, de Albóniga-Chindurza A, Zapata-Hidalgo M, Moniche F, Escudero-Martínez I, Baena P, Cabezas JA, Oropesa-Ruiz JM, Sanz-Fernández G, González A, Montaner J. Sex Differences by Hospital-Level in Performance and Outcomes of Endovascular Treatment for Acute Ischemic Stroke. J Stroke 2020; 22:258-261. [PMID: 32635690 PMCID: PMC7341017 DOI: 10.5853/jos.2019.03223] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2019] [Accepted: 02/14/2020] [Indexed: 12/04/2022] Open
Affiliation(s)
- Soledad Pérez-Sánchez
- Department of Neurology, University Hospital Virgen Macarena, Sevilla, Spain.,Neurovascular Research Laboratory, Institute of Biomedicine of Seville-IbiS, Sevilla, Spain
| | - Ana Barragán-Prieto
- Department of Neurology, University Hospital Virgen Macarena, Sevilla, Spain.,Neurovascular Research Laboratory, Institute of Biomedicine of Seville-IbiS, Sevilla, Spain
| | - Joaquín Ortega-Quintanilla
- Neurovascular Research Laboratory, Institute of Biomedicine of Seville-IbiS, Sevilla, Spain.,Department of Radiology, Interventional Neuroradiology, University Hospital Virgen del Rocío, Sevilla, Spain
| | - Ana Domínguez-Mayoral
- Department of Neurology, University Hospital Virgen Macarena, Sevilla, Spain.,Neurovascular Research Laboratory, Institute of Biomedicine of Seville-IbiS, Sevilla, Spain
| | - Miguel Ángel Gamero-García
- Department of Neurology, University Hospital Virgen Macarena, Sevilla, Spain.,Neurovascular Research Laboratory, Institute of Biomedicine of Seville-IbiS, Sevilla, Spain
| | - Elena Zapata-Arriaza
- Neurovascular Research Laboratory, Institute of Biomedicine of Seville-IbiS, Sevilla, Spain.,Department of Radiology, Interventional Neuroradiology, University Hospital Virgen del Rocío, Sevilla, Spain
| | - Reyes de Torres-Chacón
- Department of Neurology, University Hospital Virgen Macarena, Sevilla, Spain.,Neurovascular Research Laboratory, Institute of Biomedicine of Seville-IbiS, Sevilla, Spain
| | - Asier de Albóniga-Chindurza
- Neurovascular Research Laboratory, Institute of Biomedicine of Seville-IbiS, Sevilla, Spain.,Department of Radiology, Interventional Neuroradiology, University Hospital Virgen del Rocío, Sevilla, Spain
| | | | - Francisco Moniche
- Neurovascular Research Laboratory, Institute of Biomedicine of Seville-IbiS, Sevilla, Spain.,Department of Neurology, University Hospital Virgen del Rocío, Sevilla, Spain
| | - Irene Escudero-Martínez
- Neurovascular Research Laboratory, Institute of Biomedicine of Seville-IbiS, Sevilla, Spain.,Department of Neurology, University Hospital Virgen del Rocío, Sevilla, Spain
| | - Pablo Baena
- Neurovascular Research Laboratory, Institute of Biomedicine of Seville-IbiS, Sevilla, Spain.,Department of Neurology, University Hospital Virgen del Rocío, Sevilla, Spain
| | - Juan Antonio Cabezas
- Neurovascular Research Laboratory, Institute of Biomedicine of Seville-IbiS, Sevilla, Spain.,Department of Neurology, University Hospital Virgen del Rocío, Sevilla, Spain
| | | | - Gema Sanz-Fernández
- Department of Neurology, University Hospital Juan Ramón Jiménez, Huelva, Spain
| | - Alejandro González
- Neurovascular Research Laboratory, Institute of Biomedicine of Seville-IbiS, Sevilla, Spain.,Department of Radiology, Interventional Neuroradiology, University Hospital Virgen del Rocío, Sevilla, Spain
| | - Joan Montaner
- Department of Neurology, University Hospital Virgen Macarena, Sevilla, Spain.,Neurovascular Research Laboratory, Institute of Biomedicine of Seville-IbiS, Sevilla, Spain
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17
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Chalos V, de Ridder IR, Lingsma HF, Brown S, van Oostenbrugge RJ, Goyal M, Campbell BCV, Muir KW, Guillemin F, Bracard S, White P, Dávalos A, Jovin TG, Hill MD, Mitchell PJ, Demchuk AM, Saver JL, van Zwam WH, Dippel DWJ. Does Sex Modify the Effect of Endovascular Treatment for Ischemic Stroke? Stroke 2019; 50:2413-2419. [PMID: 31412753 PMCID: PMC6727933 DOI: 10.1161/strokeaha.118.023743] [Citation(s) in RCA: 51] [Impact Index Per Article: 10.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Supplemental Digital Content is available in the text. Previous studies have reported less favorable outcome and less effect of endovascular treatment (EVT) after ischemic stroke in women than in men. Our aim was to study the influence of sex on outcome and on the effect of EVT for ischemic stroke in recent randomized trials on EVT.
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Affiliation(s)
- Vicky Chalos
- From the Department of Neurology, Erasmus MC University Medical Center the Netherlands (V.C., D.W.J.D.).,Department of Public Health, Erasmus MC University Medical Center the Netherlands (V.C., H.F.L.).,Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center the Netherlands (V.C.)
| | - Inger R de Ridder
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, the Netherlands (I.R.d.R., R.J.v.O.)
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center the Netherlands (V.C., H.F.L.)
| | - Scott Brown
- Altair Biostatistics, St. Louis Park, MN (S.B.).,Department of Diagnostic and Interventional Neuroradiology (S.B.)
| | - Robert J van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, the Netherlands (I.R.d.R., R.J.v.O.)
| | - Mayank Goyal
- Departments of Clinical Neuroscience and Radiology, Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Canada (M.G., M.D.H., A.M.D.)
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Australia (B.C.V.C.)
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, United Kingdom (K.W.M.)
| | - Francis Guillemin
- Department of Clinical Epidemiology, Inserm, University of Lorraine and University Hospital of Nancy, France (F.G.)
| | - Serge Bracard
- Altair Biostatistics, St. Louis Park, MN (S.B.).,Department of Diagnostic and Interventional Neuroradiology (S.B.)
| | - Philip White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom (P.W.)
| | - Antoni Dávalos
- Department of Neuroscience, Hospital Germans Trias y Pujol, Barcelona, Spain (A.D.)
| | - Tudor G Jovin
- Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center Stroke Institute, Presbyterian University Hospital, PA (T.G.J.)
| | - Michael D Hill
- Departments of Clinical Neuroscience and Radiology, Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Canada (M.G., M.D.H., A.M.D.)
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Australia (P.J.M.)
| | - Andrew M Demchuk
- Departments of Clinical Neuroscience and Radiology, Hotchkiss Brain Institute, Cummings School of Medicine, University of Calgary, Canada (M.G., M.D.H., A.M.D.)
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of Los Angeles, CA (J.L.S.)
| | - Wim H van Zwam
- Department of Radiology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, the Netherlands (W.H.v.Z.)
| | - Diederik W J Dippel
- From the Department of Neurology, Erasmus MC University Medical Center the Netherlands (V.C., D.W.J.D.)
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18
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Dula AN, Luby M, King BT, Sheth SA, Magadán A, Davis LA, Gealogo GA, Merino JG, Hsia AW, Latour LL, Warach SJ. Neuroimaging evolution of ischemia in men and women: an observational study. Ann Clin Transl Neurol 2019; 6:575-585. [PMID: 30911580 PMCID: PMC6414486 DOI: 10.1002/acn3.733] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2018] [Revised: 01/11/2019] [Accepted: 01/14/2019] [Indexed: 12/25/2022] Open
Abstract
Objective We present an exploratory study for identification of sex differences in imaging biomarkers that could further refine selection of patients for acute reperfusion therapy and trials based on sex and imaging targets. Methods The Lesion Evolution in Stroke and Ischemia On Neuroimaging (LESION) study included consecutive acute stroke patients who underwent MRI within 24 h of time from last known well and prior to therapy. Those demonstrating a potential therapeutic target on imaging were identified by presence of: (1) arterial occlusion on angiography, (2) focal ischemic region on perfusion maps, or (3) a mismatch of perfusion versus diffusion imaging lesion size. The prevalence of imaging targets within clinically relevant time intervals was calculated for each patient and examined. The relationship of time from stroke onset to probability of detection of imaging targets was evaluated. Results Of 7007 patients screened, of which 86.7% were scanned with MRI, 1092 patients (477/615 men/women) were included in LESION. The probability of imaging target detection was significantly different between men and women, with women more likely to present with all assessed imaging targets, odds ratios between 1.36 and 1.59, P < 0.02, adjusted for NIHSS, age, and time from last known well to MRI scan. This trend held for the entire 24‐h studied. Interpretation Women present more often with treatable ischemic stroke than men. The greater probability of potentially viable and/or treatable imaging targets in women at all time points suggests that tissue injury is slower to evolve in women.
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Affiliation(s)
- Adrienne N Dula
- Department of Neurology Dell Medical School at The University of Texas Austin Texas
| | - Marie Luby
- Department of Neurology Dell Medical School at The University of Texas Austin Texas.,National Institute of Neurological Disorders and Stroke National Institutes of Health Baltimore Maryland
| | - Ben T King
- Department of Neurology Dell Medical School at The University of Texas Austin Texas
| | - Sunil A Sheth
- Department of Neurology McGovern Medical School at The University of Texas Health Science Center Houston Texas
| | - Alejandro Magadán
- Department of Neurology and Neurotherapeutics The University of Texas Southwestern Medical School Dallas Texas
| | - Lisa A Davis
- Department of Neurology Dell Medical School at The University of Texas Austin Texas
| | - Gretchel A Gealogo
- Department of Nursing The University of Texas Health Science Center San Antonio Texas
| | - José G Merino
- Department of Neurology University of Maryland School of Medicine Baltimore Maryland
| | - Amie W Hsia
- Department of Neurology Georgetown University Medical Center Washington District of Columbia
| | - Lawrence L Latour
- National Institute of Neurological Disorders and Stroke National Institutes of Health Baltimore Maryland
| | - Steven J Warach
- Department of Neurology Dell Medical School at The University of Texas Austin Texas
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19
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Liu J, Shi Q, Sun Y, He J, Yang B, Zhang C, Guo R. Efficacy of Tirofiban Administered at Different Time Points after Intravenous Thrombolytic Therapy with Alteplase in Patients with Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2019; 28:1126-1132. [PMID: 30655038 DOI: 10.1016/j.jstrokecerebrovasdis.2018.12.044] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2018] [Revised: 12/26/2018] [Accepted: 12/30/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE To evaluate the efficacy of tirofiban administered at different time points within 24 hours of intravenous thrombolysis with alteplase in acute ischemic stroke. METHODS Patients who underwent intravenous thrombolysis with alteplase and fulfilled other inclusion criteria were randomly divided into 4 groups according to the time points of tirofiban administration: Group A (2 h), Group B (2-12 h), Group C (12-24 h), and Group D (control). The changes in National Institutes of Health Stroke Scale score, modified Rankin Scale score, and adverse events were analyzed. RESULTS At 7 ± 1 day, the efficacy in Group A was better than that in Group C (P = .006) and Group D (P = .001), but there was no significant difference in the efficacy between Groups A and B (P = .268). Similarly, at 14 ± 2 d, the efficacy in Group A was better than that in Group C (P = .026) and Group D (P = .001), but there was no significant difference in the efficacy between Groups A and B (P = .394). As evaluated by the modified Rankin Scale, the prognosis in Groups A, B, and C was better than that in Group D (P = .042, .008, .027, respectively), which was unrelated to the time points of tirofiban administration. There was no significant difference in the incidence of adverse events among the four groups. CONCLUSIONS Tirofiban combined with alteplase is effective and safe, and particularly beneficial when administered at 2 hour and 2-12 hours after intravenous thrombolysis with alteplase in acute ischemic stroke.
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Affiliation(s)
- Jin Liu
- Department of Neurology, Affiliated Hospital of North China University of Science and Technology, Tangshan 063000, China.
| | - Qiuyan Shi
- Department of Neurology, Affiliated Hospital of North China University of Science and Technology, Tangshan 063000, China.
| | - Yuan Sun
- Department of Neurology, Affiliated Hospital of North China University of Science and Technology, Tangshan 063000, China.
| | - Jingyuan He
- Department of Neurology, Affiliated Hospital of North China University of Science and Technology, Tangshan 063000, China.
| | - Bin Yang
- Department of Neurology, Affiliated Hospital of North China University of Science and Technology, Tangshan 063000, China.
| | - Chunyang Zhang
- Department of Neurology, Affiliated Hospital of North China University of Science and Technology, Tangshan 063000, China.
| | - Rui Guo
- Department of Neurology, Affiliated Hospital of North China University of Science and Technology, Tangshan 063000, China.
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