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Chong JSX, Phillips T, Massarotto A, Ghia D. Outcomes of endovascular thrombectomy for ischaemic stroke among nonagenarians with and without pre-existing dependency. J Stroke Cerebrovasc Dis 2024; 33:107722. [PMID: 38616014 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107722] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2024] [Revised: 04/03/2024] [Accepted: 04/11/2024] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND Our aim was to compare the outcomes of treatment with endovascular thrombectomy for pre-stroke dependent versus pre-stroke independent among the very elderly ≥90 years. METHODS A retrospective cohort study was performed on 106 patients ≥90 years who underwent endovascular thrombectomy for ischaemic stroke in Western Australia between June 2016 and September 2021. Patient, stroke and procedural details along with inpatient progress and outcome at 90 days were recorded. Patients were divided into Group A (pre-stroke modified Rankin Scale 0-2) and Group B (pre-stroke modified Rankin Scale >2). Primary outcome measure was functional status at 90 days post-stroke, with favourable clinical outcome defined as a 90-day mRS category equal to the patients' respective pre-stroke mRS category. Secondary outcome measures include successful reperfusion, symptomatic intracranial haemorrhage, hospital length-of-stay, change in accommodation to an aged care facility, and mortality during admission, at 90 days and one year. RESULTS 61 patients were allocated to Group A and 45 to Group B. There was none with pre-stroke mRS 5. Group B had more pre-existing cognitive impairment, aged care facility residents, higher median age and lower Alberta Stroke Program Early CT Score. For primary outcome measure, 38 % of patients in Group A and 49 % in Group B achieved a favourable clinical outcome. The difference was not significant (p=0.3408). For secondary outcome measures, Group B had a significantly higher 90-day mortality rate at 47 % versus 24 % in Group A (p=0.03). All other secondary outcome measures were similar between the two groups. These include the rate of successful reperfusion and symptomatic intracranial haemorrhage, hospital length-of-stay, new transition into an aged care facility, inpatient mortality rate and 1-year mortality rate. CONCLUSION When treated with endovascular thrombectomy for ischaemic stroke, nonagenarians with pre-existing dependency achieved a rate of favourable functional outcome comparable with their independent peers, although they also had higher 90-day mortality rate.
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Affiliation(s)
| | - Timothy Phillips
- Interventional Neuroradiologist, Neurological Intervention & Imaging Service of WA, Australia.
| | | | - Darshan Ghia
- Fiona Stanley Hospital, and Senior Clinical Lecturer, University of Western Australia, Australia.
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Fujiwara S, Matsuoka Y, Ohara N, Hijikata Y, Imamura H, Yamamoto Y, Ariyoshi K, Kawamoto M, Sakai N, Ohta T. Comorbidity burden and outcomes after mechanical thrombectomy for large vessel occlusion: A retrospective analysis. J Stroke Cerebrovasc Dis 2024; 33:107778. [PMID: 38795797 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107778] [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: 10/03/2023] [Revised: 03/29/2024] [Accepted: 05/16/2024] [Indexed: 05/28/2024] Open
Abstract
OBJECTIVES Patients with acute ischemic stroke (AIS) often have an accumulation of pre-existing comorbidities, but its clinical impact on outcomes after mechanical thrombectomy (MT) remains unknown. Therefore, we examined whether comorbidity burden before AIS onset could predict clinical outcomes after MT. METHODS In this retrospective cohort, we enrolled consecutive patients with community-onset AIS who underwent MT between April 2016 and December 2021. To evaluate each patient's comorbidity burden, we calculated Charlson comorbidity index (CCI), then classified the patients into the High CCI (≥ 3) and the Low CCI (< 3) groups. The primary outcome was a good neurological outcome at 90 days, defined as a modified Rankin scale 0-2 or no worse than the previous daily conditions. All-cause mortality at 90 days and hemorrhagic complications after MT were also compared between the two groups. We estimated the odds ratios and their confidence intervals using a multivariable logistic regression model. RESULTS A total of 388 patients were enrolled, of whom 86 (22.2%) were classified into the High CCI group. Patients in the High CCI group were less likely to achieve a good neurological outcome (adjusted odds ratio of 0.26 [95% confidence interval, 0.12-0.58]). Moreover, symptomatic intracranial hemorrhage was more common in the High CCI (14.0% vs. 4.6%; adjusted odds ratio, 4.10 [95% confidence interval, 1.62-10.3]). CONCLUSIONS Comorbidity burden assessed by CCI was associated with clinical outcomes after MT. CCI has the potential to become a simple and valuable tool for predicting neurological prognosis among patients with AIS and MT.
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Affiliation(s)
- Satoru Fujiwara
- Department of Neurology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yoshinori Matsuoka
- Department of Emergency Medicine, Kobe City Medical Center General Hospital, Kobe, Japan; Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan; Department of Research Support, Center for Clinical Research and Innovation, Kobe City Medical Center General Hospital, Kobe, Japan.
| | - Nobuyuki Ohara
- Department of Neurology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yasukazu Hijikata
- Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Hirotoshi Imamura
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan; Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yosuke Yamamoto
- Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Koichi Ariyoshi
- Department of Emergency Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Michi Kawamoto
- Department of Neurology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Tsuyoshi Ohta
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
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Merlino G, Romoli M, Ornello R, Foschi M, Del Regno C, Toraldo F, Marè A, Cordici F, Trosi A, Longoni M, Kuris F, Tereshko Y, Lorenzut S, Gentile C, Janes F, Bax F, Sponza M, Gavrilovic V, Banerjee S, Sacco S, Gigli GL, D'Anna L, Valente M. Stress hyperglycemia is associated with futile recanalization in patients with anterior large vessel occlusion undergoing mechanical thrombectomy. Eur Stroke J 2024:23969873241247400. [PMID: 38624043 DOI: 10.1177/23969873241247400] [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: 04/17/2024] Open
Abstract
INTRODUCTION Mechanical thrombectomy (MT) is the standard treatment for acute ischemic stroke (AIS) due to anterior large vessel occlusion (LVO). Despite successful recanalization, some patients remain disabled after 3 months. Mechanisms that can cause futile recanalization (FR) are still largely unknown. We investigated if stress hyperglycemia might be associated with FR. PATIENTS AND METHODS This is a retrospective analysis of consecutive patients with successful recanalization treated in four participating centers between January 2021 and December 2022. According to the modified Rankin scale (mRS) status at 3 months, patients were divided into two groups: FR, if mRS score >2, and useful recanalization (UR), if mRS score ⩽2. Stress hyperglycemia was estimated by the glucose-to-glycated hemoglobin ratio (GAR) index. RESULTS A total of 691 subjects were included. At 3 months, 403 patients (58.3%) were included in the FR group, while the remaining 288 patients (41.7%) were included in the UR group. At the multivariate analysis, variables independently associated with FR were the following: age (OR 1.04, 95% CI 1.02-1.06, p < 0.001), GAR index (OR 1.08, 95% CI 1.03-1.14, p = 0.003), NIHSS at admission (OR 1.16, 95% CI 1.11-1.22; p < 0.001), and procedure length (OR 1.01, 95% CI 1.00-1.02; p = 0.009). We observed that the model combining age, GAR index, NIHSS at admission, and procedure length had good predictive accuracy (AUC 0.78, 95% CI 0.74-0.81). CONCLUSIONS Stress hyperglycemia predicts FR in patients with successful recanalization after MT. Further studies should explore if managing stress hyperglycemia may reduce futile recanalization. Additionally, we recommend paying close attention to AIS patients with a GAR index greater than 24.8 who exhibit a high risk of FR.
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Affiliation(s)
- Giovanni Merlino
- Stroke Unit, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
- Department of Medicine (DMED), University of Udine, Udine, Italy
| | - Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, AUSL Romagna, Cesena, Italy
| | - Raffaele Ornello
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Matteo Foschi
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Caterina Del Regno
- Department of Medicine (DMED), University of Udine, Udine, Italy
- Clinical Neurology, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | - Francesco Toraldo
- Department of Medicine (DMED), University of Udine, Udine, Italy
- Clinical Neurology, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | - Alessandro Marè
- Department of Medicine (DMED), University of Udine, Udine, Italy
- Clinical Neurology, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | - Francesco Cordici
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, AUSL Romagna, Cesena, Italy
| | - Alessio Trosi
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Marco Longoni
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, AUSL Romagna, Cesena, Italy
| | - Fedra Kuris
- Department of Medicine (DMED), University of Udine, Udine, Italy
- Clinical Neurology, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | - Yan Tereshko
- Stroke Unit, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
- Department of Medicine (DMED), University of Udine, Udine, Italy
| | - Simone Lorenzut
- Stroke Unit, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | - Carolina Gentile
- Stroke Unit, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | - Francesco Janes
- Stroke Unit, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
- Clinical Neurology, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | - Francesco Bax
- Stroke Unit, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
- Clinical Neurology, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
| | - Massimo Sponza
- Division of Vascular and Interventional Radiology, Udine University Hospital, Udine, Italy
| | - Vladimir Gavrilovic
- Division of Vascular and Interventional Radiology, Udine University Hospital, Udine, Italy
| | - Soma Banerjee
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Gian Luigi Gigli
- Department of Medicine (DMED), University of Udine, Udine, Italy
| | - Lucio D'Anna
- Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, London, UK
| | - Mariarosaria Valente
- Department of Medicine (DMED), University of Udine, Udine, Italy
- Clinical Neurology, Department of Head, Neck and Neurosciences, Udine University Hospital, Udine, Italy
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Liu Q, Fang J, Jiang X, Duan T, Luo Y, Gao L, Dong S, Ma M, Zhou M, He L. Endovascular thrombectomy for acute ischemic stroke in elderly patients with large ischemic cores. Neurol Sci 2024; 45:663-670. [PMID: 37700175 DOI: 10.1007/s10072-023-06995-3] [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: 04/30/2023] [Accepted: 07/28/2023] [Indexed: 09/14/2023]
Abstract
BACKGROUND Understanding the benefits and risks of endovascular therapy (EVT) is crucial for elderly patients with large ischemic cores, as the combination of advanced age and extensive brain infarction may negatively impact clinical outcomes. METHODS The study retrospectively analyzed clinical outcomes for elderly stroke patients (age ≥ 70) with large ischemic cores (Alberta Stroke Program Early CT Score [ASPECTS] < 6 or ischemic cores ≥ 70 ml) in the anterior circulation using data from our prospective database between June 2018 and January 2022. The effectiveness and risks of EVT in those patients were investigated, with the primary outcome being fair outcome (modified Rankin Scale, mRS ≤ 3). RESULTS Among 182 elderly patients with large ischemic core volume (120 in the EVT group and 62 in the non-EVT group), 20.9% (38/182, 22.5% in the EVT group vs. 17.7% in the non-EVT group) achieved a fair outcome. Meanwhile, 49.5% (90/182, 45.8% in the EVT group vs. 56.5% in the non-EVT group) of them died at 3 months. The benefits of EVT numerically exceeded non-EVT treatment for those aged ≤ ~ 85 years or with a mismatch volume ≥ ~ 50 ml. However, after adjustment, EVT was associated with an increased risk of symptomatic intracranial hemorrhage (aOR 4.24, 95%CI 1.262-14.247). CONCLUSIONS This study highlights the clinical challenges faced by elderly patients with large infarctions, resulting in poor outcomes at 3 months. EVT may still provide some benefits in this population, but it also carries an increased risk of intracranial hemorrhage.
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Affiliation(s)
- Qian Liu
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Jinghuan Fang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xin Jiang
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Ting Duan
- Department of Radiology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Yaxi Luo
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Lijie Gao
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Shuju Dong
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Mengmeng Ma
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Muke Zhou
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, 610041, China.
| | - Li He
- Department of Neurology, West China Hospital, Sichuan University, Chengdu, 610041, China.
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Mitsuhashi T, Teranishi K, Tokugawa J, Mitsuhashi T, Hishii M, Oishi H. Prognostic Determinants of Anterior Large Vessel Occlusion in Acute Stroke in Elderly Patients. Geriatrics (Basel) 2024; 9:13. [PMID: 38247988 PMCID: PMC10801592 DOI: 10.3390/geriatrics9010013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/25/2023] [Revised: 01/11/2024] [Accepted: 01/12/2024] [Indexed: 01/23/2024] Open
Abstract
This study investigated prognostic factors in elderly patients (80 years and older) undergoing mechanical thrombectomy (MT) for anterior circulation large vessel occlusion (LVO) in acute stroke treatment. Of 59 cases, 47.5% achieved a favorable outcome (mRS ≤ 3) at three months, with a mortality rate of 20.3%. Factors associated with better outcomes included younger age, lower admission National Institute of Health Stroke Scale (NIHSS) scores, lower N-terminal pro-brain natriuretic peptide (NT-proBNP) and D-dimer levels, the presence of the first pass effect (FPE), and successful recanalization. However, logistic regression showed that only lower admission NIHSS scores were significantly correlated with favorable outcomes. In addition, this study suggests that lower admission NT-proBNP and D-dimer levels could potentially serve as prognostic indicators for elderly LVO patients undergoing MT.
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Affiliation(s)
- Takashi Mitsuhashi
- Department of Neurosurgery, Juntendo University Nerima Hospital, Tokyo 177-8521, Japan
| | - Kohsuke Teranishi
- Department of Neurosurgery and Neuroendovascular Therapy, Juntendo University School of Medicine, Tokyo 113-8421, Japan
| | - Joji Tokugawa
- Department of Neurosurgery, Juntendo University Nerima Hospital, Tokyo 177-8521, Japan
| | - Takumi Mitsuhashi
- Department of Neurosurgery, Juntendo University Nerima Hospital, Tokyo 177-8521, Japan
| | - Makoto Hishii
- Department of Neurosurgery, Juntendo University Nerima Hospital, Tokyo 177-8521, Japan
| | - Hidenori Oishi
- Department of Neurosurgery and Neuroendovascular Therapy, Juntendo University School of Medicine, Tokyo 113-8421, Japan
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Terceño M, Bashir S, Puig J, I-Estadella JD, Murias E, Jiménez JM, Díaz EG, Monso JF, Bravo-Rey I, Romero V, Werner M, López-Rueda A, Román LS, Anadaluz JB, Doncel-Moriano A, Rosati S, Pérez-García C, Remollo S, Caamaño IR, Aixut S, Chaparro OSC, Garcia JMS, Porto-Álvarez J, Mendez-Cendón JC, Rayon-Aledo JC, Aguilar Y, Parrilla G, Castaño M, Serena J, Silva Y. Impact of Balloon Guide Catheters in Elderly Patients Treated with Mechanical Thrombectomy: Insights from the ROSSETTI Registry. AJNR Am J Neuroradiol 2023; 44:1275-1281. [PMID: 37827717 PMCID: PMC10631533 DOI: 10.3174/ajnr.a8003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 08/17/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND AND PURPOSE Several nonrandomized studies have demonstrated the effectiveness of balloon guide catheters in treating patients with anterior circulation large-vessel occlusion. However, their impact on the elderly populations has been underreported. We aimed to analyze the effect of balloon guide catheters in a cohort of elderly patients (80 years of age or older) with anterior circulation large-vessel occlusion. MATERIALS AND METHODS Consecutive patients from June 2019 to June 2022 were collected from the ROSSETTI Registry. Demographic and clinical data, angiographic endovascular technique, and clinical outcome were compared between balloon guide catheter and non-balloon guide catheter groups. We studied the association between balloon guide catheters and the rate of complete recanalization after a single first-pass effect modified TICI 2c-3, as well as their association with functional independence at 3 months. RESULTS A total of 808 patients were included during this period, 465 (57.5%) of whom were treated with balloon guide catheters. Patients treated with balloon guide catheters were older, had more neurologic severity at admission and lower baseline ASPECTS, and were less likely to receive IV fibrinolytics. No differences were observed in terms of the modified first-pass effect between groups (45.8 versus 39.9%, P = .096). In the multivariable regression analysis, balloon guide catheter use was not independently associated with a modified first-pass effect or the final modified TICI 2c-3, or with functional independence at 3 months. CONCLUSIONS In our study, balloon guide catheter use during endovascular treatment of anterior circulation large-vessel occlusion in elderly patients did not predict the first-pass effect, near-complete final recanalization, or functional independence at 3 months. Further studies, including randomized clinical trials, are needed to confirm these results.
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Affiliation(s)
- Mikel Terceño
- From the Stroke Unit, Department of Neurology (M.T., S.B., J.S., Y.S.), Hospital Universitari Doctor Josep Trueta de, Girona, Girona Biomedical Research Institute, Girona, Spain
| | - Saima Bashir
- From the Stroke Unit, Department of Neurology (M.T., S.B., J.S., Y.S.), Hospital Universitari Doctor Josep Trueta de, Girona, Girona Biomedical Research Institute, Girona, Spain
| | - Josep Puig
- Department of Radiology (J.P.), Hospital Universitari de Girona Doctor Josep Trueta, Girona, Catalunya, Spain
| | - Josep Daunis- I-Estadella
- Department of Computer Science (J.D.-I.-E.), Applied Mathematics and Statistics, University of Girona, Girona, Catalunya, Spain
| | - Eduardo Murias
- Department of Radiology (E.M., J.M.J.), Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Jose María Jiménez
- Department of Radiology (E.M., J.M.J.), Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Eva González Díaz
- Department of Interventional Neuroradiology (E.G.D., J.F.M.), Department of Radiology, Cruces University Hospital, Barakaldo, PaísVasco, Spain
| | - Jon Fondevila Monso
- Department of Interventional Neuroradiology (E.G.D., J.F.M.), Department of Radiology, Cruces University Hospital, Barakaldo, PaísVasco, Spain
| | - Isabel Bravo-Rey
- Diagnostic and Therapeutical Neuroradiology Unit (I.B.-R., V.R.), Reina Sofia University Hospital, Cordoba, Andalucía, Spain
| | - Veredas Romero
- Diagnostic and Therapeutical Neuroradiology Unit (I.B.-R., V.R.), Reina Sofia University Hospital, Cordoba, Andalucía, Spain
| | - Mariano Werner
- Neurointerventional Department CDI (M.W.), Hospital Clinic de Barcelona, Barcelona, Spain
| | - Antonio López-Rueda
- Department of Interventional Neuroradiology (A.L.-R., L.S.R., J.B.A.), Clinic University Hospital, Barcelona, Barcelona, Spain
| | - Luis San Román
- Department of Interventional Neuroradiology (A.L.-R., L.S.R., J.B.A.), Clinic University Hospital, Barcelona, Barcelona, Spain
| | - Jordi Blasco Anadaluz
- Department of Interventional Neuroradiology (A.L.-R., L.S.R., J.B.A.), Clinic University Hospital, Barcelona, Barcelona, Spain
| | | | - Santiago Rosati
- Department of Interventional Neurorradiology (S.R., C.P.-G.), Department of Radiology, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Carlos Pérez-García
- Department of Interventional Neurorradiology (S.R., C.P.-G.), Department of Radiology, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Sebastian Remollo
- Department of Interventional Neuroradiology (S.R., I.R.C.), Hospital universitari Germans Trias i Pujol, Badalona, Spain
| | - Isabel Rodríguez Caamaño
- Department of Interventional Neuroradiology (S.R., I.R.C.), Hospital universitari Germans Trias i Pujol, Badalona, Spain
| | - Sonia Aixut
- Department of Interventional Neuroradiology (S.A., O.S.C.C.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Oscar Sabino Chirife Chaparro
- Department of Interventional Neuroradiology (S.A., O.S.C.C.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Jacobo Porto-Álvarez
- Department of Neuroradiology (J.P.-A.), Complexo Hospitalario Universitario de Santiago de, Compostela, Galicia, Spain
| | - Jose Carlos Mendez-Cendón
- Interventional Neuroradiology Unit (J.C.M.-C.), Department of Radiology, Hospital Ramón y Cajal, Madrid, Spain
| | - Jose Carlos Rayon-Aledo
- Department of Interventional Neuroradiology (J.C.R.-A.), Hospital General Universitario de Alicante, Alicante, Valenciana, Spain
| | - Yeray Aguilar
- Department of Radiology (Y.A.), Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Guillermo Parrilla
- Department of Interventional Neuroradiology (G.P.), Department of Radiology, Hospital Clínico Universitario Virgen de la, Murcia, Spain
| | - Miguel Castaño
- Department of Interventional Neuroradiology (M.S.), Hospital Clínico Universitario de Salamanca, Salamanca, Spain
| | - Joaquín Serena
- From the Stroke Unit, Department of Neurology (M.T., S.B., J.S., Y.S.), Hospital Universitari Doctor Josep Trueta de, Girona, Girona Biomedical Research Institute, Girona, Spain
| | - Yolanda Silva
- From the Stroke Unit, Department of Neurology (M.T., S.B., J.S., Y.S.), Hospital Universitari Doctor Josep Trueta de, Girona, Girona Biomedical Research Institute, Girona, Spain
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Take Y, Osakabe M, Okawara M, Yamaguchi H, Maeda T, Kurita H. Efficacy, safety, and predictors for functional outcomes of mechanical thrombectomy in patients aged over 90 years with acute ischemic stroke and literature review. Clin Neurol Neurosurg 2023; 233:107934. [PMID: 37591040 DOI: 10.1016/j.clineuro.2023.107934] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2023] [Revised: 08/01/2023] [Accepted: 08/06/2023] [Indexed: 08/19/2023]
Abstract
BACKGROUND No evidence supports the efficacy and safety of mechanical thrombectomy (MT) in patients aged ≥ 90 years with acute ischemic stroke (AIS). This study clarifies the efficacy, safety, and predictors of MTs in patients aged ≥ 90 years by investigating our results and reviewing previous studies. METHODS We retrospectively investigated data from 80 consecutive patients who underwent MT at our hospital between 2018 and 2021. We analyzed outcomes using the modified Thrombolysis in the Cerebral Infarction (mTICI) scale and modified Rankin Scale (mRS). Functional outcomes were investigated at 90 days or discharge. RESULTS We obtained functional outcomes mRS ≤ 3 patients in 41.6%. The mortality rate was 16.6%. The rate of successful recanalization was 75%. Comparison mRS ≤ 3 and mRS ≥ 4 at 90 days or discharge showed statistical significance in the National Institute of Health Stroke Scale, the location of occluded vessels, and mTICI ≥ 2b at the first pass. Univariable logistic regression analysis indicated that the Alberta Stroke Program Early Computed Tomography Score was a predictor of mRS ≤ 3. CONCLUSIONS The efficacy is lower than that of patients aged < 90; however, MT is effective even in patients aged ≥ 90 years. The safety of MT in patients aged ≥ 90 years was similar to that in those aged < 90 years. Neuro-interventionalists should consider predictors and take the best strategies to achieve successful recanalization in patients aged ≥ 90 years with AIS.
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Affiliation(s)
- Yushiro Take
- Saitama Medical University International Medical Center, Department of Cerebrovascular Surgery, Hidaka, Saitama 320-1298, Japan; Ohkawara Neurosurgical Hospital, Muroran, Hokkaido 050-0082, Japan.
| | - Manabu Osakabe
- Ohkawara Neurosurgical Hospital, Muroran, Hokkaido 050-0082, Japan
| | - Mai Okawara
- Ohkawara Neurosurgical Hospital, Muroran, Hokkaido 050-0082, Japan
| | | | - Takahiro Maeda
- Ohkawara Neurosurgical Hospital, Muroran, Hokkaido 050-0082, Japan
| | - Hiroki Kurita
- Saitama Medical University International Medical Center, Department of Cerebrovascular Surgery, Hidaka, Saitama 320-1298, Japan
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Dabhi N, Kumar J, Kellogg RT, Park MS. Mechanical thrombectomy for treatment of acute ischemic stroke in frail patients: a systematic review of the literature. J Neurointerv Surg 2023:jnis-2023-020476. [PMID: 37487691 DOI: 10.1136/jnis-2023-020476] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 07/07/2023] [Indexed: 07/26/2023]
Abstract
BACKGROUND The overall safety and efficacy of mechanical thrombectomy (MT) for acute ischemic stroke (AIS) in frail patients is not well delineated. This systematic review aims to summarize and compare outcomes in frail and non-frail patients who underwent MT for AIS. METHODS A systematic review of the literature was performed using PubMed, Ovid Medline, and Web of Science to identify studies with outcomes-related data for frail patients with MT-treated AIS. The recanalization rate, procedural complications, and clinical outcome at 90-day follow-up were collected. RESULTS In the four included studies there were 642 frail patients and 499 non-frail patients. Frail patients had reduced rates of good functional outcomes (29% vs 42%; χ2=22, p<0.01) and increased 90-day mortality (51% vs 25%; χ2=38, p<0.01) compared with non-frail patients. CONCLUSION MT for treatment of AIS in frail patients may be associated with worse rates of morbidity and mortality along with reduced efficacy. Given that no studies to date directly compare conservative measures with endovascular management for AIS in frail patients, more studies are required to further evaluate and identify characteristics that may improve outcomes in these patients.
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Affiliation(s)
- Nisha Dabhi
- Department of Neurosurgery, Univerisity of Virginia, Charlottesville, Virginia, USA
| | - Jeyan Kumar
- Department of Neurosurgery, Univerisity of Virginia, Charlottesville, Virginia, USA
| | - Ryan T Kellogg
- Department of Neurosurgery, Univerisity of Virginia, Charlottesville, Virginia, USA
| | - Min S Park
- Department of Neurosurgery, Univerisity of Virginia, Charlottesville, Virginia, USA
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9
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Merlino G, Pez S, Sartor R, Kuris F, Tereshko Y, Nesi L, Lorenzut S, Janes F, Sponza M, Gavrilovic V, Marotti N, Pellegrin A, Dapoto A, Vit A, Pauro A, Gigli GL, Valente M. Stress hyperglycemia as a modifiable predictor of futile recanalization in patients undergoing mechanical thrombectomy for acute ischemic stroke. Front Neurol 2023; 14:1170215. [PMID: 37273693 PMCID: PMC10235599 DOI: 10.3389/fneur.2023.1170215] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Accepted: 05/03/2023] [Indexed: 06/06/2023] Open
Abstract
Introduction Mechanical thrombectomy (MT) is the first line treatment in acute ischemic stroke (AIS) due to large vessel occlusion (LVO). Approximately half of patients treated with MT does not have a favorable outcome 3 months after stroke. The aim of this study was to identify predictors of futile recanalization (FR) in patients with LVO treated with MT. Methods A retrospective analysis of consecutive patients with acute ischemic stroke due to anterior circulation LVO who underwent MT. Patients with a TICI score of 2b or 3 were included. We distinguished two groups, FR and meaningful recanalization (MR), according to patients' disability three months after stroke (FR: mRS score > 2; MR: mRS score < 2). Results We enrolled 238 patients (FR, n = 129, 54.2%; MR, n = 109, 45.8%). Age (OR 1.05, 95% CI 1.01-1.09, p = 0.012), female sex (OR 2.43, 95% CI 1.12-5.30, p = 0.025), stress hyperglycemia, as measured by the GAR index, (OR 1.17, 95% CI 1.06-1.29, p = 0.002), NIHSS at admission (OR 1.15, 95% CI 1.07-1.25, p = 0.001) and time from symptoms onset to MT (OR 1.01, 95% CI 1.00-1.01, p = 0.020) were independent predictors of FR. The AUC for the model combining age, female sex, GAR index, NIHSS at admission and time from symptoms onset to MT was 0.81 (95% CI 0.76-0.87; p < 0.001). The optimal GAR index cut-off score to predict FR was 17.9. Discussion FR is common after MT. We recognized older age, female sex and baseline NIHSS as non-modifiable predictors of FR. On the other hand, time from symptoms onset to MT and stress hyperglycemia were modifiable pre- and post-MT factors, respectively. Any effort should be encouraged to reduce the impact of these modifiable predictors.
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Affiliation(s)
- Giovanni Merlino
- Stroke Unit, Department of Head-Neck and Neuroscience, Udine University Hospital, Udine, Italy
- Clinical Neurology, Udine University Hospital, Udine, Italy
| | - Sara Pez
- Clinical Neurology, Udine University Hospital, Udine, Italy
| | - Roberto Sartor
- Clinical Neurology, Udine University Hospital, Udine, Italy
| | - Fedra Kuris
- Clinical Neurology, Udine University Hospital, Udine, Italy
| | - Yan Tereshko
- Clinical Neurology, Udine University Hospital, Udine, Italy
| | - Lorenzo Nesi
- Clinical Neurology, Udine University Hospital, Udine, Italy
| | - Simone Lorenzut
- Stroke Unit, Department of Head-Neck and Neuroscience, Udine University Hospital, Udine, Italy
| | - Francesco Janes
- Stroke Unit, Department of Head-Neck and Neuroscience, Udine University Hospital, Udine, Italy
- Clinical Neurology, Udine University Hospital, Udine, Italy
| | - Massimo Sponza
- Division of Vascular and Interventional Radiology, Udine University Hospital, Udine, Italy
| | - Vladimir Gavrilovic
- Division of Vascular and Interventional Radiology, Udine University Hospital, Udine, Italy
| | - Nicola Marotti
- Division of Vascular and Interventional Radiology, Udine University Hospital, Udine, Italy
| | - Andrea Pellegrin
- Division of Vascular and Interventional Radiology, Udine University Hospital, Udine, Italy
| | - Annarita Dapoto
- Division of Vascular and Interventional Radiology, Udine University Hospital, Udine, Italy
| | - Alessandro Vit
- Division of Vascular and Interventional Radiology, Udine University Hospital, Udine, Italy
| | - Alessandro Pauro
- Division of Vascular and Interventional Radiology, Udine University Hospital, Udine, Italy
| | - Gian Luigi Gigli
- Dipartimento di Area Medica (DAME), University of Udine, Udine, Italy
| | - Mariarosaria Valente
- Clinical Neurology, Udine University Hospital, Udine, Italy
- Dipartimento di Area Medica (DAME), University of Udine, Udine, Italy
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10
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Laugesen NG, Brandt AH, Stavngaard T, Højgaard J, Hansen K, Truelsen T. Mechanical thrombectomy in stroke patients of advanced age with score-based prediction of outcome. Interv Neuroradiol 2022:15910199221149073. [PMID: 36579806 DOI: 10.1177/15910199221149073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
BACKGROUND Stroke patients ≥80 years constituted only 15% in randomised trials on mechanical thrombectomy (MT), but is a considerable higher proportion in clinical practice. Association of clinical variables collected before MT with functional outcome has not been independently described in these patients, while being important in the decision of patient eligibility for MT. METHODS We included patients consecutively at a single centre (2017-2021) categorised as octogenarians (age: 80-89 years) or nonagenarians (age: 90-99 years). Functional outcome at 90 days was defined as fair (modified Rankin Scale (mRS) 0-3) or poor (mRS 4-6). Clinical variables collected before MT were analysed for association with shift of mRS in a poor direction. Significant predictors were used to produce a risk score of fair outcome. Significance was set at the p < 0.05 level. RESULTS Nonagenarians (n = 43, 15.5%) compared to octogenarians (n = 235, 84.5%) less likely achieved fair outcome (20.9% vs. 46.0%, p < 0.01) with higher mortality (65.1% vs. 31.9%, p < 0.01). Significant predictors of outcome were: age, adjusted odds ratio (aOR) = 0.91 (95% confidence interval (CI): 0.86-0.97); pre-stroke mRS, aOR = 0.57 (95% CI: 0.44-0.73); National Institute of Health Stroke Scale at admission, aOR = 0.91 (95% CI: 0.87-0.95); Alberta Stroke Program Early Computed Tomography, aOR = 1.23 (95% CI: 1.05-1.45). After bootstrap validation, the area under the curve of the risk score was 0.74 and the optimal cut-off for fair outcome was a score of >7 points. CONCLUSIONS One in two octogenarians achieved fair outcome, however, only one in five nonagenarians had fair outcome. The clinical risk score could be considered as guidance when deciding patient eligibility for MT.
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Affiliation(s)
| | - Andreas Hjelm Brandt
- Neurovascular Section, Department of Radiology, 53146Rigshospitalet, Copenhagen, Denmark
| | - Trine Stavngaard
- Neurovascular Section, Department of Radiology, 53146Rigshospitalet, Copenhagen, Denmark
| | - Joan Højgaard
- Stroke Center Rigshospitalet, Department of Neurology, 53146Rigshospitalet, Copenhagen, Denmark
| | - Klaus Hansen
- Stroke Center Rigshospitalet, Department of Neurology, 53146Rigshospitalet, Copenhagen, Denmark
- 53139Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Truelsen
- Stroke Center Rigshospitalet, Department of Neurology, 53146Rigshospitalet, Copenhagen, Denmark
- 53139Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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11
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Dunphy H, Garcia-Esperon C, Beom Hong J, Manoczki C, Wilson D, Lim Alvin Chew B, Beharry J, Bivard A, Hasnain MG, Krauss M, Collecutt W, Miteff F, Spratt N, Parsons MW, Alan Barber P, Ranta A, Fink JN, Wu TY. Endovascular thrombectomy for acute ischaemic stroke improves and maintains function in the very elderly: A multicentre propensity score matched analysis. Eur Stroke J 2022; 8:191-198. [PMID: 37021178 PMCID: PMC10069224 DOI: 10.1177/23969873221145778] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2022] [Accepted: 11/30/2022] [Indexed: 12/31/2022] Open
Abstract
Introduction: The very elderly (⩾80 years) are under-represented in randomised endovascular thrombectomy (EVT) clinical trials for acute ischaemic stroke. Rates of independent outcome in this group are generally lower than the less-old patients but the comparisons may be biased by an imbalance of non-age related baseline characteristics, treatment related metrics and medical risk factors. Patients and methods: We compared outcomes between very elderly (⩾80) and the less-old (<80 years) using retrospective data from consecutive patients receiving EVT from four comprehensive stroke centres in New Zealand and Australia. We used propensity score matching or multivariable logistic regression to account for confounders. Results: We included 600 patients (300 in each age cohort) after propensity score matching from an initial group of 1270 patients. The median baseline National Institutes of Health Stroke Scale was 16 (11–21), with 455 (75.8%) having symptom free pre-stroke independent function, and 268 (44.7%) receiving intravenous thrombolysis. Good functional outcome (90-day modified Rankin Scale 0–2) was achieved in 282 (46.8%), with very elderly patients having less proportion of good outcome compared to the less-old (118 (39.3%) vs 163 (54.3%), p < 0.01). There was no difference between the very elderly and the less-old in the proportion of patients who returned to baseline function at 90 days (56 (18.7%) vs 62 (20.7%), p = 0.54). All-cause 90-day mortality was higher in the very elderly (75 (25%) vs 49 (16.3%), p < 0.01), without a difference in symptomatic haemorrhage (very elderly 11 (3.7%) vs 6 (2.0%), p = 0.33). In the multivariable logistic regression models, the very elderly were significantly associated with reduced odds of good 90-day outcome (OR 0.49, 95% CI 0.34–0.69, p < 0.01) but not with return to baseline function (OR 0.85, 90% CI 0.54–1.29, p = 0.45) after adjusting for confounders. Conclusion: Endovascular thrombectomy can be successfully and safely performed in the very elderly. Despite an increase in all-cause 90-day mortality, selected very elderly patients are as likely as younger patients with similar baseline characteristics to return to baseline function following EVT.
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Affiliation(s)
- Harriette Dunphy
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Carlos Garcia-Esperon
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
- Heart and Stroke Program, Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Jae Beom Hong
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand
| | - Csilla Manoczki
- Department of Neurology, Wellington Hospital, University of Otago, Wellington, New Zealand
| | - Duncan Wilson
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
- New Zealand Brain Research Institute, Christchurch, New Zealand
| | | | - James Beharry
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Andrew Bivard
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Md Golam Hasnain
- Heart and Stroke Program, Hunter Medical Research Institute, Newcastle, NSW, Australia
| | - Martin Krauss
- Department of Radiology, Christchurch Hospital, New Zealand
| | | | - Ferdi Miteff
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
| | - Neil Spratt
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
- Heart and Stroke Program, Hunter Medical Research Institute, Newcastle, NSW, Australia
- The University of Newcastle, School of Biomedical Sciences and Pharmacy, Callaghan, NSW, Australia
| | - Mark W Parsons
- Department of Neurology, John Hunter Hospital, Newcastle, NSW, Australia
- University of New South Wales South Western Sydney Clinical Campus, The Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
| | - Peter Alan Barber
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand
- Centre for Brain Research, University of Auckland, Auckland, New Zealand
| | - Annemarei Ranta
- Department of Neurology, Wellington Hospital, University of Otago, Wellington, New Zealand
- Department of Medicine, University of Otago, Wellington, New Zealand
| | - John N Fink
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
- New Zealand Brain Research Institute, Christchurch, New Zealand
- Department of Medicine, University of Otago, Christchurch, New Zealand
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12
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Inoue M, Ota T, Hara T, Shigeta K, Kamiya Y, Arakawa H, Aoki R, Tsuruta W, Ichijo M, Kaneko J, Shiokawa Y, Hirano T. An Initial High National Institutes of Health Stroke Scale Score and Any Intracranial Hemorrhage Are Independent Factors for a Poor Outcome in Nonagenarians Treated with Thrombectomy for Acute Large Vessel Occlusion: The Tokyo/Tama-REgistry of Acute Endovascular Thrombectomy (TREAT) Study. World Neurosurg 2022; 165:e325-e330. [PMID: 35717017 DOI: 10.1016/j.wneu.2022.06.038] [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: 04/01/2022] [Revised: 06/07/2022] [Accepted: 06/08/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Mechanical thrombectomy (MT) is effective in acute ischemic stroke patients ≥80 years old with large vessel occlusion (LVO). However, data for patients ≥90 years old remain very limited, and factors influencing functional outcomes are unclear. This study aimed to investigate factors influencing functional outcomes in patients ≥90 years old treated with MT for acute LVO. METHODS This retrospective observational study used prospectively collected data from the Tokyo/tama-REgistry of Acute endovascular Thrombectomy (TREAT) study. Inclusion criteria were as follows: 1) patients ≥90 years old treated with MT for LVO and 2) prestroke modified Rankin Scale (mRS) score, 0-3. The functional outcome was defined based on the mRS score at 90 days after the procedure: good functional outcome, mRS score 0-3 and poor functional outcome, mRS score 4-6. RESULTS Data were analyzed for 104 patients ≥90 years old. The good functional outcome was observed in 25 patients (24.0%), and the poor functional outcome was observed in the remaining 79 patients. Significant differences were identified in initial National Institutes of Health Stroke Scale (NIHSS) score, modified Thrombolysis in Cerebral Infarction grade 2b-3, modified Thrombolysis in Cerebral Infarction grade 3, and any intracranial hemorrhage and hemorrhagic infarction in univariate analyses. Multivariable analysis confirmed the initial NIHSS score (odds ratio, 1.08; 95% confidence interval, 1.01-1.17; P = 0.045) and any intracranial hemorrhage (odds ratio, 11.6; 95% confidence interval, 1.43-95.0; P = 0.022) as independent factors for the functional outcome. CONCLUSIONS An initial high NIHSS score and any intracranial hemorrhage are independent factors for the poor functional outcome in acute ischemic stroke patients ≥90 years old treated with MT.
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Affiliation(s)
- Masato Inoue
- Department of Neurosurgery, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan.
| | - Takahiro Ota
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Tetsuo Hara
- Department of Neurosurgery, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan
| | - Keigo Shigeta
- Department of Neurosurgery, National Hospital Organization Disaster Medical Center, Tokyo, Japan
| | - Yuki Kamiya
- Department of Neurology, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Hideki Arakawa
- Department of Neurosurgery, Omori Red Cross Hospital, Tokyo, Japan
| | - Rie Aoki
- Department of Neurosurgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Wataro Tsuruta
- Department of Endovascular Neurosurgery, Toranomon Hospital, Tokyo, Japan
| | - Masahiko Ichijo
- Department of Neurology, Musashino Red Cross Hospital, Tokyo, Japan
| | - Junya Kaneko
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan
| | | | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Tokyo, Japan
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13
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Rotschild O, Honig A, Hallevi H, Horev A, Seyman E, Ben-Assayag E, Jonas-Kimchi T, Sadeh U, Cohen J, Leker RR, Molad J. Endovascular thrombectomy is beneficial for functional nonagenarians - a multicenter cohort analysis. J Stroke Cerebrovasc Dis 2022; 31:106699. [PMID: 36054973 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106699] [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: 06/21/2022] [Revised: 07/19/2022] [Accepted: 08/01/2022] [Indexed: 10/14/2022] Open
Abstract
INTRODUCTION The use of endovascular thrombectomy (EVT) has dramatically increased in recent years. However, most existing studies used an upper age limit of 80 and data regarding the safety and efficacy of EVT among nonagenarians is still lacking. METHODS 767 consecutive patients undergoing EVT for large vessel occlusion (LVO) in three participating centers were recruited into a prospective ongoing database. Demographic, clinical and imaging characteristics were documented. Statistical analysis was done to evaluate EVT outcome among nonagenarians compared to younger patients. RESULTS The current analysis included 41 (5.4%) patients older than 90 years. Compared to younger patients, nonagenarians were more often female (78% versus 50.3%, p ≤ 0.001), had worse baseline mRS scores (2 [0-3] versus 0 [0-2], p < 0.001), higher rates of hypertension and hyperlipidemia and a higher admission NIHSS (20 [14-23] versus 16 [11-20], p < 0.001). No differences were found between groups regarding the involved vessel, stroke etiology, time from symptoms to door or symptoms to EVT, successful recanalization rates and hemorrhagic transformation rates. Nonagenarians had worse mRS at 90 days (5 [3-6] versus 3 [2-5], p = 0.001), similar discharge NIHSS (5 [1-11] versus 4 [1-11], p = 0.78) and higher mortality rates (36.6% versus 15.8%, p < 0.001). All nonagenarians with baseline mRS 4 have died within 90 days. 36.4% of nonagenarian patients with baseline MRS of 3 or less had favorable outcome. DISCUSSION This study demonstrates that nonagenarian stroke patients with baseline mRS of 3 or less benefit from EVT with no significant difference in the rate of favorable outcome compared to octogenarians.
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Affiliation(s)
- Ofer Rotschild
- Department of Stroke & Neurology, Tel-Aviv Sourasky Medical Center, 6 Weizmann Street, Tel-Aviv 64239, Israel
| | - Asaf Honig
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Hen Hallevi
- Department of Stroke & Neurology, Tel-Aviv Sourasky Medical Center, 6 Weizmann Street, Tel-Aviv 64239, Israel; Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Anat Horev
- Department of Neurology, Soroka- University Medical Center, Beer-Sheva, Israel
| | - Estelle Seyman
- Department of Stroke & Neurology, Tel-Aviv Sourasky Medical Center, 6 Weizmann Street, Tel-Aviv 64239, Israel
| | - Einor Ben-Assayag
- Department of Stroke & Neurology, Tel-Aviv Sourasky Medical Center, 6 Weizmann Street, Tel-Aviv 64239, Israel; Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Tali Jonas-Kimchi
- Department of Radiology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Udi Sadeh
- Department of Radiology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Jose Cohen
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ronen R Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Jeremy Molad
- Department of Stroke & Neurology, Tel-Aviv Sourasky Medical Center, 6 Weizmann Street, Tel-Aviv 64239, Israel.
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14
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Kniep H, Bechstein M, Broocks G, Brekenfeld C, Flottmann F, van Horn N, Geest V, Faizy TD, Deb‐Chatterji M, Alegiani A, Thomalla G, Gellißen S, Fiehler J, Hanning U, Meyer L. Early Surrogates of Outcome after Thrombectomy in Posterior Circulation Stroke. Eur J Neurol 2022; 29:3296-3306. [DOI: 10.1111/ene.15519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 07/30/2022] [Accepted: 08/01/2022] [Indexed: 11/26/2022]
Affiliation(s)
- Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Vincent Geest
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Tobias D. Faizy
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | | | - Anna Alegiani
- Department of Neurology, Asklepios Klinik Altona Hamburg Germany
| | - Götz Thomalla
- Department of Neurology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Susanne Gellißen
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg‐Eppendorf Hamburg
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15
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Rahangdale R, Hackett CT, Cerejo R, Fuller NM, Malhotra K, Williamson R, Hentosz T, Tayal AH, Rana SS. Outcomes of endovascular thrombectomy in patients selected by computed tomography perfusion imaging - a matched cohort study comparing nonagenarians to younger patients. J Neurointerv Surg 2022; 14:747-751. [PMID: 34475251 DOI: 10.1136/neurintsurg-2021-017727] [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: 05/01/2021] [Accepted: 07/31/2021] [Indexed: 12/30/2022]
Abstract
BACKGROUND Endovascular thrombectomy (EVT) is efficacious for appropriately selected patients with large vessel occlusions (LVO) up to 24 hours from symptom onset. There is limited information on outcomes of nonagenarians, selected with computed tomography perfusion (CTP) imaging. METHODS We retrospectively analyzed data from a large academic hospital between December 2017 and October 2019. Patients receiving EVT for anterior circulation LVO were stratified into nonagenarian (≥90 years) and younger (<90 years) groups. We performed propensity score matching on 18 covariates. In the matched cohort we compared: primary outcome of inpatient mortality and secondary outcomes of successful reperfusion (TICI ≥2B), symptomatic intracranial hemorrhage (sICH), and functional independence. Subgroup analysis compared CTP predicted core volumes in nonagenarians with outcomes. RESULTS Overall, 214 consecutive patients (26 nonagenarians, 188 younger) underwent EVT. Nonagenarians were aged 92.8±2.9 years and younger patients were 74.5±13.5 years. Mortality rate was significantly greater in nonagenarians compared with younger patients (43.5% vs 10.4%, OR 9.33, 95% CI 2.88 to 47.97, P<0.0001) and a greater proportion of nonagenarians developed sICH (13.0% vs 3.0%, OR 6.00, 95% CI 1.34 to 55.20, P=0.02). There were no significant differences for successful reperfusion (P=1.00) or functional independence (P=0.75). Nonagenarians selected with smaller ischemic core volumes had decreased mortality rates (P=0.045). CONCLUSIONS Nonagenarians were noted to have greater mortality and sICH rates following EVT compared with matched younger patients, which may be ameliorated by selecting patients with smaller CTP core volumes. Nonagenarians undergoing EVT had similar rates of successful reperfusion and functional independence compared with the younger cohort.
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Affiliation(s)
- Rahul Rahangdale
- Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA.,Neurology, St John Medical Center, Tulsa, Oklahoma, USA
| | | | - Russell Cerejo
- Cerebrovascular Center, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Nicholas M Fuller
- Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA.,Dartmouth College Geisel School of Medicine, Hanover, New Hampshire, USA
| | - Konark Malhotra
- Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Richard Williamson
- Cerebrovascular Center, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Terry Hentosz
- Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Ashis H Tayal
- Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
| | - Sandeep S Rana
- Neurology, Allegheny Health Network, Pittsburgh, Pennsylvania, USA
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16
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Scopelliti G, Pero G, Macera A, Quilici L, Cervo A, Platania G, Tadeo CS, Prelle AC, Muscia F, Riggio MG, Zilioli A, Agostoni EC, Piano M, Pantoni L. Outcome of a Real-World Cohort of Patients Subjected to Endovascular Treatment for Acute Ischemic Stroke. J Stroke Cerebrovasc Dis 2022; 31:106511. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Revised: 04/04/2022] [Accepted: 04/08/2022] [Indexed: 11/26/2022] Open
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17
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McDonough RV, Ospel JM, Campbell BCV, Hill MD, Saver JL, Dippel DWJ, Demchuk AM, Majoie CBLM, Brown SB, Mitchell PJ, Bracard S, Guillemin F, Jovin TG, Muir KW, White P, Goyal M. Functional Outcomes of Patients ≥85 Years With Acute Ischemic Stroke Following EVT: A HERMES Substudy. Stroke 2022; 53:2220-2226. [PMID: 35703094 DOI: 10.1161/strokeaha.121.037770] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Observational studies have shown endovascular treatment (EVT) for acute ischemic stroke to be effective in the elderly, despite resulting in poorer outcomes and higher rates of mortality compared with younger patients. Randomized data on the effect of advanced age on outcomes following EVT are, however, lacking. Our aim was to assess the EVT effect for ischemic stroke in patients aged ≥85 years and the influence of age on outcome in a large, randomized trial dataset. METHODS Data were from the HERMES (Highly Effective Reperfusion Evaluated in Multiple Endovascular Stroke Trials) collaboration, a meta-analysis of 7 randomized trials published between January 1, 2010, and May 31, 2017, that tested the efficacy of EVT. A possible multiplicative interaction effect of age on the relationship between treatment and outcome was investigated. Ordinal logistic regression tested the association between EVT and 90-day functional outcome (modified Rankin Scale, primary outcome) in patients ≥85 years. Multivariable binary logistic regression was performed to compare primary and secondary outcomes (modified Rankin Scale score of 0-2/5-6) of patients ≥85 years versus those <85 years. RESULTS We included 1764 patients in the analysis, of whom 77 (4.4%) were ≥85 years old. A significant interaction of age and treatment on poor outcome (modified Rankin Scale score of 5-6, P=0.020) and mortality (P=0.031) was observed, with older adults having worse functional outcomes at 90 days compared with younger patients (adjusted common odds ratio, 0.20 [95% CI, 0.13-0.33]). However, a benefit of EVT was observed in the ≥85-year-old patient subgroup (common odds ratio, 4.20 [95% CI, 1.56-11.32]). Age ≥85 years was not significantly associated with differing rates of symptomatic intracerebral hemorrhage or reperfusion (adjusted odds ratio, 1.92 [95% CI, 0.71-5.15] and adjusted odds ratio, 0.91 [95% CI, 0.40-2.06], respectively). CONCLUSIONS Patients ≥85 years old with independent premorbid function more often achieve good functional outcomes and have lower rates of mortality when treated with EVT compared with conservative management, with an observed treatment effect modification of age on outcome. EVT should therefore not be withheld in this subgroup.
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Affiliation(s)
- Rosalie V McDonough
- Department of Diagnostic Imaging (R.V.M., J.M.O.), Foothills Medical Center, University of Calgary, AB, Canada.,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (R.V.M.)
| | - Johanna M Ospel
- Department of Diagnostic Imaging (R.V.M., J.M.O.), Foothills Medical Center, University of Calgary, AB, Canada.,Division of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, University of Basel, Switzerland (J.M.O.)
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre, Australia (B.C.V.C.)
| | - Michael D Hill
- Department of Clinical Neurosciences (M.D.H., A.M.D., M.G.), Foothills Medical Center, University of Calgary, AB, Canada
| | - Jeffrey L Saver
- Department of Neurology, University of California Los Angeles Medical Center (J.L.S.)
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC University Medical Center, Rotterdam, the Netherlands (D.W.J.D.)
| | - Andrew M Demchuk
- Department of Clinical Neurosciences (M.D.H., A.M.D., M.G.), Foothills Medical Center, University of Calgary, AB, Canada
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Centers, location AMC, Amsterdam, the Netherlands (C.B.L.M.M.)
| | - Scott B Brown
- BRIGHT Research Partners, Inc, Mooresville, NC (S.B.B.)
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Australia (P.J.M.)
| | - Serge Bracard
- Department of Diagnostic and Interventional Neuroradiology (S.B.), University of Lorraine and University Hospital of Nancy, France
| | - Francis Guillemin
- Department of Clinical Epidemiology (F.G.), University of Lorraine and University Hospital of Nancy, France
| | - Tudor G Jovin
- Department of Neurology, Stroke Institute, University of Pittsburgh Medical Center Stroke Institute, Presbyterian University Hospital, PA (T.G.J.)
| | - Keith W Muir
- Institute of Neuroscience and Psychology, University of Glasgow, Queen Elizabeth University Hospital, Glasgow, United Kingdom (K.W.M.)
| | - Philip White
- Institute of Neuroscience, Newcastle University, Newcastle upon Tyne, United Kingdom (P.W.)
| | - Mayank Goyal
- Department of Clinical Neurosciences (M.D.H., A.M.D., M.G.), Foothills Medical Center, University of Calgary, AB, Canada
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18
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Adcock AK, Schwamm LH, Smith EE, Fonarow GC, Reeves MJ, Xu H, Matsouaka RA, Xian Y, Saver JL. Trends in Use, Outcomes, and Disparities in Endovascular Thrombectomy in US Patients With Stroke Aged 80 Years and Older Compared With Younger Patients. JAMA Netw Open 2022; 5:e2215869. [PMID: 35671055 PMCID: PMC9175073 DOI: 10.1001/jamanetworkopen.2022.15869] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
IMPORTANCE Patients aged 80 years and older were often excluded or underrepresented in pivotal endovascular thrombectomy (EVT) trials. Accordingly, trends in frequency, outcomes, and disparities of EVT use merit close analysis. OBJECTIVE To delineate temporal trends in EVT use, outcomes, and disparities among patients with acute ischemic stroke aged 80 years and older vs those younger than 80 years. DESIGN, SETTING, AND PARTICIPANTS A US nationwide retrospective cohort study using prospectively collected data was conducted in patients admitted with a primary diagnosis of acute ischemic stroke between April 1, 2012, and June 30, 2019. Data were obtained from hospitals participating in the Get With the Guidelines-Stroke (GWTG-Stroke) program, which is a stroke quality improvement registry, with data collected prospectively, sponsored by the American Heart Association/American Stroke Association. Data analysis was conducted from November 2, 2020, to June 25, 2021. EXPOSURES Potentially eligible for EVT based on arrival within 6 hours and National Institutes of Health Stroke Scale score greater than or equal to 6. MAIN OUTCOMES AND MEASURES Efficacy outcomes included discharge to home, independent ambulation at discharge, and functional independence (modified Rankin Scale score 0-2) at discharge. Safety outcomes included in-hospital mortality, combined in-hospital mortality or discharge to hospice, and symptomatic intracranial hemorrhage. RESULTS Among 302 965 patients with ischemic stroke meeting study criteria as potentially eligible for EVT admitted to 614 GWTG-Stroke hospitals, 14.0% (42 422) received EVT (21 634 women [51.0%]), including 10.7% (12 768 of 119 453) of patients aged 80 years and older (median [IQR] age, 85 [82-89] years) and 16.2% (29 654 of 183 512) of patients younger than 80 years (median [IQR] age, 65 [56-73] years). Among patients aged 80 years and older, EVT rates increased substantially during the study period, from 3.3% in early 2012 to 20.8% in early 2019. By study end, the relative rate of EVT among eligible patients aged 80 years and older compared with those younger than 80 years increased from 0.49 (3.3% vs 6.7%) to 0.76 (20.8% vs 27.3%). Older patients had worse outcomes at discharge compared with younger patients, including discharge to home: 12.5% vs 31.1% (adjusted odds ratio [aOR], 0.43; 95% CI, 0.40-0.46), functional independence (modified Rankin Scale score 0-2): 10.9% vs 26.6% (aOR, 0.45; 95% CI, 0.41-0.49), and inpatient death or discharge to hospice, 34.5% vs 16.1% (aOR, 2.22; 95% CI, 2.09-2.36). Symptomatic intracranial hemorrhage rates did not differ significantly (6.9% vs 6.5%; aOR, 1.04; 95% CI, 0.94-1.14). CONCLUSIONS AND RELEVANCE In this cohort study, use of EVT among individuals aged 80 years and older increased substantially from 2012 to 2019, although the rate remained lower than in younger patients. Although favorable functional outcomes at discharge were lower and combined mortality or discharge to hospice was higher in the older patients, the risk of symptomatic intracranial hemorrhage was not increased.
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Affiliation(s)
- Amelia K. Adcock
- Department of Neurology, West Virginia University School of Medicine, Morgantown
| | - Lee H. Schwamm
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Eric E. Smith
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Gregg C. Fonarow
- Division of Cardiology, University of California, Los Angeles
- Section Editor, Health Care Quality and Guidelines, JAMA Cardiology
| | - Mathew J. Reeves
- Department of Epidemiology, Michigan State University, East Lansing
| | - Haolin Xu
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | | | - Ying Xian
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
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19
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Hahn M, Gröschel S, Tanyildizi Y, Brockmann MA, Gröschel K, Uphaus T. The Bigger the Better? Center Volume Dependent Effects on Procedural and Functional Outcome in Established Endovascular Stroke Centers. Front Neurol 2022; 13:828528. [PMID: 35309589 PMCID: PMC8925986 DOI: 10.3389/fneur.2022.828528] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2021] [Accepted: 01/24/2022] [Indexed: 11/13/2022] Open
Abstract
Background Mechanical thrombectomy (MT) rates for the treatment of acute ischaemic stroke due to large vessel occlusion are steadily increasing, but are delivered in heterogenic settings. We aim to investigate effects of procedural load in centers with established MT-structures by comparing high- vs. low-volume centers with regard to procedural characteristics and functional outcomes. Methods Data from 5,379 patients enrolled in the German Stroke Registry Endovascular Treatment (GSR-ET) between June 2015 and December 2019 were compared between three groups: high volume: ≥180 MTs/year, 2,342 patients; medium volume: 135-179 MTs/year, 2,202 patients; low volume: <135 MTs/year, 835 patients. Univariate analysis and multiple linear and logistic regression analyses were performed to identify differences between high- and low-volume centers. Results We identified high- vs. low-volume centers to be an independent predictor of shorter intra-hospital (admission to groin puncture: 60 vs. 82 min, β = -26.458; p < 0.001) and procedural times (groin puncture to flow restoration: 36 vs. 46.5 min; β = -12.452; p < 0.001) after adjusting for clinically relevant factors. Moreover, high-volume centers predicted a shorter duration of hospital stay (8 vs. 9 days; β = -2.901; p < 0.001) and favorable medical facility at discharge [transfer to neurorehabilitation facility/home vs. hospital/nursing home/in-house fatality, odds ratio (OR) 1.340, p = 0.002]. Differences for functional outcome at 90-day follow-up were observed only on univariate level in the subgroup of primarily to MT center admitted patients (mRS 0-2 38.5 vs. 32.8%, p = 0.028), but did not persist in multivariate analyses. Conclusion Differences in efficiency measured by procedural times call for analysis and optimization of in-house procedural workflows at regularly used but comparatively low procedural volume MT centers.
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Affiliation(s)
- Marianne Hahn
- Department of Neurology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Sonja Gröschel
- Department of Neurology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Yasemin Tanyildizi
- Department of Neuroradiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Marc A. Brockmann
- Department of Neuroradiology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Klaus Gröschel
- Department of Neurology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
| | - Timo Uphaus
- Department of Neurology, University Medical Center of the Johannes Gutenberg University, Mainz, Germany
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20
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Joyce N, Atkinson T, Mc Guire K, Wiggam MI, Gordon PL, Kerr EL, Patterson CE, McILmoyle J, Roberts GE, Flynn PA, Burns P, Rennie IR, Taylor Rowan M, Quinn TJ, Fearon P. Frailty and stroke thrombectomy outcomes-an observational cohort study. Age Ageing 2022; 51:6527375. [PMID: 35150584 DOI: 10.1093/ageing/afab260] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Mechanical thrombectomy (MT) can improve outcomes following ischaemic stroke. Patient selection for MT is predominantly based on physiological and imaging parameters. We assessed whether people living with pre-stroke frailty had differing outcomes following MT. METHODS We included consecutive patients undergoing MT at a UK comprehensive stroke centre. We calculated a cumulative deficits frailty index to identify pre-stroke frailty in those patients presenting directly to the centre. Frailty was defined as an index score ≥ 0.24. We assessed univariable and multivariable association between pre-stroke frailty and stroke outcomes. Our primary outcomes were modified Rankin Scale (mRS) and mortality at 90 days. RESULTS Of 175 patients who underwent MT (2014-2018), we identified frailty in 49 (28%). Frail and non-frail patients had similar rates of thrombolysis administration, successful recanalization and onset to recanalization times. Those with pre-stroke frailty had higher 24 hour National Institutes of Health Stroke Scale (12(IQR: 8-17) versus 3(IQR: 2-13); P = 0.001); were less likely to be independent (mRS 0-2: 18% versus 61%; P < 0.001) and more likely to die (47% versus 14%; P < 0.001) within 90 days. Adjusting for age, baseline NIHSS and thrombolysis, frailty remained a strong, independent predictor of poor clinical outcome at 90 days (Death OR: 3.12 (95% CI: 1.32-7.4); dependency OR: 3.04 (95%CI: 1.10-8.44). Age was no longer a predictor of outcome when adjusted for frailty. CONCLUSION Pre-stroke frailty is prevalent in real-world patients eligible for MT and is an important predictor of poor outcomes. Routine assessment of pre-stroke frailty could help decision-making around patient selection for MT.
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Affiliation(s)
- Nevan Joyce
- Department of Stroke Medicine, Royal Victoria Hospital, Belfast, UK
| | - Timothy Atkinson
- Department of Stroke Medicine, Royal Victoria Hospital, Belfast, UK
| | - Karen Mc Guire
- Department of Stroke Medicine, Royal Victoria Hospital, Belfast, UK
| | - M Ivan Wiggam
- Department of Stroke Medicine, Royal Victoria Hospital, Belfast, UK
| | | | - Enda L Kerr
- Department of Stroke Medicine, Royal Victoria Hospital, Belfast, UK
| | | | - Jim McILmoyle
- Department of Stroke Medicine, Royal Victoria Hospital, Belfast, UK
| | | | - Peter A Flynn
- Department of Neuroradiology, Royal Victoria Hospital, Belfast, UK
| | - Paul Burns
- Department of Neuroradiology, Royal Victoria Hospital, Belfast, UK
| | - Ian R Rennie
- Department of Neuroradiology, Royal Victoria Hospital, Belfast, UK
| | - Martin Taylor Rowan
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Terence J Quinn
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Patricia Fearon
- Department of Stroke Medicine, Royal Victoria Hospital, Belfast, UK
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21
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Luijten SPR, Compagne KCJ, van Es ACGM, Roos YBWEM, Majoie CBLM, van Oostenbrugge RJ, van Zwam WH, Dippel DWJ, Wolters FJ, van der Lugt A, Bos D. Brain atrophy and endovascular treatment effect in acute ischemic stroke: a secondary analysis of the MR CLEAN trial. Int J Stroke 2021; 17:17474930211054964. [PMID: 34711105 PMCID: PMC9483187 DOI: 10.1177/17474930211054964] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2021] [Accepted: 09/29/2021] [Indexed: 11/16/2022]
Abstract
BACKGROUND Brain atrophy is suggested to impair the potential for functional recovery after acute ischemic stroke. We assessed whether the effect of endovascular treatment is modified by brain atrophy in patients with acute ischemic stroke due to large vessel occlusion. METHODS We used data from MR CLEAN, a multicenter trial including patients with acute ischemic stroke due to anterior circulation large vessel occlusion randomized to endovascular treatment plus medical care (intervention) versus medical care alone (control). We segmented total brain volume (TBV) and intracranial volume (ICV) on baseline non-contrast computed tomography (n = 410). Next, we determined the degree of atrophy as the proportion of brain volume in relation to head size (1 - TBV/ICV) × 100%, analyzed as continuous variable and in tertiles. The primary outcome was a shift towards better functional outcome on the modified Rankin Scale expressed as adjusted common odds ratio. Treatment effect modification was tested using an interaction term between brain atrophy (as continuous variable) and treatment allocation. RESULTS We found that brain atrophy significantly modified the effect of endovascular treatment on functional outcome (P for interaction = 0.04). Endovascular treatment led to larger shifts towards better functional outcome in the higher compared to the lower range of atrophy (adjusted common odds ratio, 1.86 [95% CI: 0.97-3.56] in the lowest tertile vs. 1.97 [95% CI: 1.03-3.74] in the middle tertile vs. 3.15 [95% CI: 1.59-6.24] in the highest tertile). CONCLUSION Benefit of endovascular treatment is larger in the higher compared to the lower range of atrophy, demonstrating that advanced atrophy should not be used as an argument to withhold endovascular treatment.
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Affiliation(s)
- Sven PR Luijten
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Kars CJ Compagne
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Adriaan CGM van Es
- Department of Radiology, Leiden University Medical Center, Leiden, The Netherlands
| | - Yvo BWEM Roos
- Department of Neurology, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Charles BLM Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, Amsterdam, The Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, Cardiovascular Research Institute Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Diederik WJ Dippel
- Department of Neurology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Frank J Wolters
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Daniel Bos
- Department of Radiology and Nuclear Medicine, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Epidemiology, Erasmus Medical Center, Rotterdam, The Netherlands
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22
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Millán M, Ramos-Pachón A, Dorado L, Bustamante A, Hernández-Pérez M, Rodríguez-Esparragoza L, Gomis M, Remollo S, Castaño C, Werner M, Wenger D, Rubio S, Domínguez-Lizarbe M, Terceño M, Paipa AJ, Rodríguez-Vázquez A, Boned S, Camps-Renom P, Cánovas D, Giralt E, López-Cancio E, Dávalos A, Ros-Roig J, Pérez de la Ossa N. Predictors of Functional Outcome After Thrombectomy in Patients With Prestroke Disability in Clinical Practice. Stroke 2021; 53:845-854. [PMID: 34702065 DOI: 10.1161/strokeaha.121.034960] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND AND PURPOSE Mechanical thrombectomy (MT) in ischemic stroke patients with poor prestroke conditions remains controversial. We aimed to analyze the frequency of previously disabled patients treated with MT in clinical practice, the safety and clinical response to MT of patients with preexisting disability, and the disabled patient characteristics associated with a better response to MT. METHODS We studied all consecutive patients with anterior circulation occlusion treated with MT from January 2017 to December 2019 included in the Codi Ictus Catalunya registry-a government-mandated, prospective, hospital-based data set. Prestroke disability was defined as modified Rankin Scale score 2 or 3. Functional outcome at 90 days was centrally assessed by a blinded evaluator of the Catalan Stroke Program. Favorable outcome (to return at least to prestroke modified Rankin Scale at 90 days) and safety and secondary outcomes were compared with patients without previous disability. Logistic regression analysis was used to assess the association between prestroke disability and outcomes and to identify a disabled patient profile with favorable outcome after MT. RESULTS Of 2487 patients included in the study, 409 (17.1%) had prestroke disability (313 modified Rankin Scale score 2 and 96 modified Rankin Scale score 3). After adjustment for covariates, prestroke disability was not associated with a lower chance of achieving favorable outcome at 90 days (24% versus 30%; odds ratio, 0.79 [0.57-1.08]), whereas it was independently associated with a higher risk of symptomatic intracranial hemorrhage (5% versus 3%; odds ratio, 2.04 [1.11-3.72]) and long-term mortality (31% versus 18%; odds ratio, 1.74 [1.27-2.39]) compared with patients without disability. Prestroke disabled patients without diabetes, Alberta Stroke Program Early CT Score >8 and National Institutes of Health Stroke Scale score <17 showed similar safety and outcome results after MT as patients without prestroke disability. CONCLUSIONS Despite a higher mortality and risk of symptomatic intracranial hemorrhage, prestroke-disabled patients return as often as independent patients to their prestroke level of function, especially those nondiabetic patients with favorable early ischemic signs profile. These data support a potential benefit of MT in patients with previous mild or moderate disability after large anterior vessel occlusion stroke.
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Affiliation(s)
- Mònica Millán
- Stroke Unit and Interventional Neuroradiology Section, Department of Neurosciences, Hospital Germans Trias, Universitat Autònoma de Barcelona, Badalona, Spain (M.M., A.R.-P., L.D., A.B., M.H.-P., L.R.-E., M.G., S.R., C.C., M.W., D.W., S.R., M.D.-L., A.D., N.P.d.l.O.)
| | - Anna Ramos-Pachón
- Stroke Unit and Interventional Neuroradiology Section, Department of Neurosciences, Hospital Germans Trias, Universitat Autònoma de Barcelona, Badalona, Spain (M.M., A.R.-P., L.D., A.B., M.H.-P., L.R.-E., M.G., S.R., C.C., M.W., D.W., S.R., M.D.-L., A.D., N.P.d.l.O.)
| | - Laura Dorado
- Stroke Unit and Interventional Neuroradiology Section, Department of Neurosciences, Hospital Germans Trias, Universitat Autònoma de Barcelona, Badalona, Spain (M.M., A.R.-P., L.D., A.B., M.H.-P., L.R.-E., M.G., S.R., C.C., M.W., D.W., S.R., M.D.-L., A.D., N.P.d.l.O.)
| | - Alejandro Bustamante
- Stroke Unit and Interventional Neuroradiology Section, Department of Neurosciences, Hospital Germans Trias, Universitat Autònoma de Barcelona, Badalona, Spain (M.M., A.R.-P., L.D., A.B., M.H.-P., L.R.-E., M.G., S.R., C.C., M.W., D.W., S.R., M.D.-L., A.D., N.P.d.l.O.)
| | - María Hernández-Pérez
- Stroke Unit and Interventional Neuroradiology Section, Department of Neurosciences, Hospital Germans Trias, Universitat Autònoma de Barcelona, Badalona, Spain (M.M., A.R.-P., L.D., A.B., M.H.-P., L.R.-E., M.G., S.R., C.C., M.W., D.W., S.R., M.D.-L., A.D., N.P.d.l.O.)
| | - Luís Rodríguez-Esparragoza
- Stroke Unit and Interventional Neuroradiology Section, Department of Neurosciences, Hospital Germans Trias, Universitat Autònoma de Barcelona, Badalona, Spain (M.M., A.R.-P., L.D., A.B., M.H.-P., L.R.-E., M.G., S.R., C.C., M.W., D.W., S.R., M.D.-L., A.D., N.P.d.l.O.)
| | - Meritxell Gomis
- Stroke Unit and Interventional Neuroradiology Section, Department of Neurosciences, Hospital Germans Trias, Universitat Autònoma de Barcelona, Badalona, Spain (M.M., A.R.-P., L.D., A.B., M.H.-P., L.R.-E., M.G., S.R., C.C., M.W., D.W., S.R., M.D.-L., A.D., N.P.d.l.O.)
| | - Sebastia Remollo
- Stroke Unit and Interventional Neuroradiology Section, Department of Neurosciences, Hospital Germans Trias, Universitat Autònoma de Barcelona, Badalona, Spain (M.M., A.R.-P., L.D., A.B., M.H.-P., L.R.-E., M.G., S.R., C.C., M.W., D.W., S.R., M.D.-L., A.D., N.P.d.l.O.)
| | - Carlos Castaño
- Stroke Unit and Interventional Neuroradiology Section, Department of Neurosciences, Hospital Germans Trias, Universitat Autònoma de Barcelona, Badalona, Spain (M.M., A.R.-P., L.D., A.B., M.H.-P., L.R.-E., M.G., S.R., C.C., M.W., D.W., S.R., M.D.-L., A.D., N.P.d.l.O.)
| | - Mariano Werner
- Stroke Unit and Interventional Neuroradiology Section, Department of Neurosciences, Hospital Germans Trias, Universitat Autònoma de Barcelona, Badalona, Spain (M.M., A.R.-P., L.D., A.B., M.H.-P., L.R.-E., M.G., S.R., C.C., M.W., D.W., S.R., M.D.-L., A.D., N.P.d.l.O.)
| | - Denisse Wenger
- Stroke Unit and Interventional Neuroradiology Section, Department of Neurosciences, Hospital Germans Trias, Universitat Autònoma de Barcelona, Badalona, Spain (M.M., A.R.-P., L.D., A.B., M.H.-P., L.R.-E., M.G., S.R., C.C., M.W., D.W., S.R., M.D.-L., A.D., N.P.d.l.O.)
| | - Sara Rubio
- Stroke Unit and Interventional Neuroradiology Section, Department of Neurosciences, Hospital Germans Trias, Universitat Autònoma de Barcelona, Badalona, Spain (M.M., A.R.-P., L.D., A.B., M.H.-P., L.R.-E., M.G., S.R., C.C., M.W., D.W., S.R., M.D.-L., A.D., N.P.d.l.O.)
| | - Manuel Domínguez-Lizarbe
- Stroke Unit and Interventional Neuroradiology Section, Department of Neurosciences, Hospital Germans Trias, Universitat Autònoma de Barcelona, Badalona, Spain (M.M., A.R.-P., L.D., A.B., M.H.-P., L.R.-E., M.G., S.R., C.C., M.W., D.W., S.R., M.D.-L., A.D., N.P.d.l.O.)
| | - Mikel Terceño
- Stroke Unit, Neurology Service, Hospital Dr. Josep Trueta, Girona, Spain (M.T.)
| | - Andrés Julián Paipa
- Stroke Unit, Neurology Department, Hospital de Bellvitge, L'Hospitalet de Llobregat Barcelona, Spain (A.J.P.)
| | | | - Sandra Boned
- Stroke Unit, Neurology Department, Hospital Vall d'Hebron, Barcelona, Spain (S.B.)
| | - Pol Camps-Renom
- Stroke Unit, Neurology Department, Hospital de la Santa Creu i Sant Pau, Barcelona, Spain (P.C.-R.)
| | - David Cánovas
- Stroke Unit, Neurology Department, Hospital Parc Taulí, Sabadell, Spain (D.C.)
| | - Eva Giralt
- Stroke Unit, Neurology Department, Hospital del Mar, Barcelona, Spain (E.G.)
| | - Elena López-Cancio
- Stroke Unit, Neurology Department, Hospital Universitario Central de Asturias, Spain (E.L.-C.)
| | - Antoni Dávalos
- Stroke Unit and Interventional Neuroradiology Section, Department of Neurosciences, Hospital Germans Trias, Universitat Autònoma de Barcelona, Badalona, Spain (M.M., A.R.-P., L.D., A.B., M.H.-P., L.R.-E., M.G., S.R., C.C., M.W., D.W., S.R., M.D.-L., A.D., N.P.d.l.O.)
| | - Josep Ros-Roig
- Catalan Stroke Programme, Catalan Public Health Department (J.R.-R., N.P.d.l.O.)
| | - Natalia Pérez de la Ossa
- Stroke Unit and Interventional Neuroradiology Section, Department of Neurosciences, Hospital Germans Trias, Universitat Autònoma de Barcelona, Badalona, Spain (M.M., A.R.-P., L.D., A.B., M.H.-P., L.R.-E., M.G., S.R., C.C., M.W., D.W., S.R., M.D.-L., A.D., N.P.d.l.O.).,Catalan Stroke Programme, Catalan Public Health Department (J.R.-R., N.P.d.l.O.)
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Pinho J, Küppers C, Nikoubashman O, Wiesmann M, Schulz JB, Reich A, Werner CJ. Frailty is an outcome predictor in patients with acute ischemic stroke receiving endovascular treatment. Age Ageing 2021; 50:1785-1791. [PMID: 34087930 DOI: 10.1093/ageing/afab092] [Citation(s) in RCA: 22] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 03/14/2021] [Indexed: 11/13/2022] Open
Abstract
INTRODUCTION Frailty is a disorder of multiple physiological systems impairing the capacity of the organism to cope with insult or stress. It is associated with poor outcomes after acute illness. Our aim was to study the impact of frailty on the functional outcome of patients with acute ischemic stroke (AIS) submitted to endovascular stroke treatment (EST). METHODS We performed a retrospective study of patients with AIS of the anterior circulation submitted to EST between 2012 and 2017, based on a prospectively collected local registry of consecutive patients. The Hospital Frailty Risk Score (HFRS) at discharge was calculated for each patient. We compared groups of patients with and without favourable 3-month outcome after index AIS (modified Rankin Scale 0-2 and 3-6, respectively). A multivariable logistic regression model was used to identify variables independently associated with favourable 3-month outcome. Diagnostic test statistics were used to compare HFRS with other prognostic scores for AIS. RESULTS We included 489 patients with median age 75.6 years (interquartile range [IQR] = 65.3-82.3) and median NIHSS 15 (IQR = 11-19). About 29.7% presented a high frailty risk (HFRS >15 points). Patients with favourable 3-month outcome presented lower HFRS and lower prevalence of high frailty risk. High frailty risk was independently associated with decreased likelihood of favourable 3-month outcome (adjusted odds ratio = 0.48, 95% confidence interval = 0.26-0.89). Diagnostic performances of HFRS and other prognostic scores (THRIVE and PRE scores, SPAN-100 index) for outcome at 3-months were similar. DISCUSSION Frailty is an independent predictor of outcome in AIS patients submitted to EST.
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Affiliation(s)
- João Pinho
- Department of Neurology, Medical Faculty, RWTH Aachen University, Aachen D-52074, Germany
| | - Charlotte Küppers
- Department of Neurology, Medical Faculty, RWTH Aachen University, Aachen D-52074, Germany
| | - Omid Nikoubashman
- Department of Neuroradiology, Medical Faculty, RWTH Aachen University, Aachen D-52074, Germany
| | - Martin Wiesmann
- Department of Neuroradiology, Medical Faculty, RWTH Aachen University, Aachen D-52074, Germany
| | - Jörg B Schulz
- Department of Neurology, Medical Faculty, RWTH Aachen University, Aachen D-52074, Germany
- JARA-BRAIN Institute Molecular Neuroscience and Neuroimaging, Forschungszentrum Jülich GmbH and RWTH Aachen University, Aachen D-52074, Germany
| | - Arno Reich
- Department of Neurology, Medical Faculty, RWTH Aachen University, Aachen D-52074, Germany
| | - Cornelius J Werner
- Department of Neurology, Medical Faculty, RWTH Aachen University, Aachen D-52074, Germany
- Department of Neurology, Medical Faculty, Section Interdisciplinary Geriatrics, RWTH Aachen University, Aachen D-52074, Germany
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24
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Meyer L, Bechstein M, Bester M, Hanning U, Brekenfeld C, Flottmann F, Kniep H, van Horn N, Deb-Chatterji M, Thomalla G, Sporns P, Yeo LLL, Tan BYQ, Gopinathan A, Kastrup A, Politi M, Papanagiotou P, Kemmling A, Fiehler J, Broocks G. Thrombectomy in Extensive Stroke May Not Be Beneficial and Is Associated With Increased Risk for Hemorrhage. Stroke 2021; 52:3109-3117. [PMID: 34470489 DOI: 10.1161/strokeaha.120.033101] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose This study evaluates the benefit of endovascular treatment (EVT) for patients with extensive baseline stroke compared with best medical treatment. Methods This retrospective, multicenter study compares EVT and best medical treatment for computed tomography (CT)–based selection of patients with extensive baseline infarcts (Alberta Stroke Program Early CT Score ≤5) attributed to anterior circulation stroke. Patients were selected from the German Stroke Registry and 3 tertiary stroke centers. Primary functional end points were rates of good (modified Rankin Scale score of ≤3) and very poor outcome (modified Rankin Scale score of ≥5) at 90 days. Secondary safety end point was the occurrence of symptomatic intracerebral hemorrhage. Angiographic outcome was evaluated with the modified Thrombolysis in Cerebral Infarction Scale. Results After 1:1 pair matching, a total of 248 patients were compared by treatment arm. Good functional outcome was observed in 27.4% in the EVT group, and in 25% in the best medical treatment group (P=0.665). Advanced age (adjusted odds ratio, 1.08 [95% CI, 1.05–1.10], P<0.001) and symptomatic intracerebral hemorrhage (adjusted odds ratio, 6.35 [95% CI, 2.08–19.35], P<0.001) were independently associated with very poor outcome. Mortality (43.5% versus 28.9%, P=0.025) and symptomatic intracerebral hemorrhage (16.1% versus 5.6%, P=0.008) were significantly higher in the EVT group. The lowest rates of good functional outcome (≈15%) were observed in groups of failed and partial recanalization (modified Thrombolysis in Cerebral Infarction Scale score of 0/1–2a), whereas patients with complete recanalization (modified Thrombolysis in Cerebral Infarction Scale score of 3) with recanalization attempts ≤2 benefitted the most (modified Rankin Scale score of ≤3:42.3%, P=0.074) compared with best medical treatment. Conclusions In daily clinical practice, EVT for CT–based selected patients with low Alberta Stroke Program Early CT Score anterior circulation stroke may not be beneficial and is associated with increased risk for hemorrhage and mortality, especially in the elderly. However, first- or second-pass complete recanalization seems to reveal a clinical benefit of EVT highlighting the vulnerability of the low Alberta Stroke Program Early CT Score subgroup. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT03356392.
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Affiliation(s)
- Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology (L.M., M. Bechstein, M. Bester, U.H., C.B., F.F., H.K., N.v.H., P.S., J.F., G.B.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology (L.M., M. Bechstein, M. Bester, U.H., C.B., F.F., H.K., N.v.H., P.S., J.F., G.B.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maxim Bester
- Department of Diagnostic and Interventional Neuroradiology (L.M., M. Bechstein, M. Bester, U.H., C.B., F.F., H.K., N.v.H., P.S., J.F., G.B.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology (L.M., M. Bechstein, M. Bester, U.H., C.B., F.F., H.K., N.v.H., P.S., J.F., G.B.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology (L.M., M. Bechstein, M. Bester, U.H., C.B., F.F., H.K., N.v.H., P.S., J.F., G.B.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology (L.M., M. Bechstein, M. Bester, U.H., C.B., F.F., H.K., N.v.H., P.S., J.F., G.B.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology (L.M., M. Bechstein, M. Bester, U.H., C.B., F.F., H.K., N.v.H., P.S., J.F., G.B.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology (L.M., M. Bechstein, M. Bester, U.H., C.B., F.F., H.K., N.v.H., P.S., J.F., G.B.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology (M.D.-C., G.T.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology (M.D.-C., G.T.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Sporns
- Department of Diagnostic and Interventional Neuroradiology (L.M., M. Bechstein, M. Bester, U.H., C.B., F.F., H.K., N.v.H., P.S., J.F., G.B.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Department of Diagnostic and Interventional Neuroradiology, University Hospital Basel, Switzerland (P.S.)
| | - Leonard Leong-Litt Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore (L.L.-L.Y., B.Y.-Q.T.).,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore (L.L.-L.Y., B.Y.-Q.T., A.G.)
| | - Benjamin Yong-Qiang Tan
- Division of Neurology, Department of Medicine, National University Health System, Singapore, Singapore (L.L.-L.Y., B.Y.-Q.T.).,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore (L.L.-L.Y., B.Y.-Q.T., A.G.)
| | - Anil Gopinathan
- Division of Interventional Radiology, Department of Diagnostic Imaging, National University Hospital, Singapore, Singapore (A.G.).,Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore (L.L.-L.Y., B.Y.-Q.T., A.G.)
| | - Andreas Kastrup
- Department of Neurology, Hospital Bremen-Mitte, Bremen, Germany (A. Kastrup)
| | - Maria Politi
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte, Germany (M.P., P.P.)
| | - Panagiotis Papanagiotou
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte, Germany (M.P., P.P.).,Areteion University Hospital, National and Kapodistrian University of Athens, Greece (P.P.)
| | - André Kemmling
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany (A. Kemmling).,Department of Diagnostic and Interventional Neuroradiology, University Medical Center Marburg, Marburg University, Germany (A. Kemmling)
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology (L.M., M. Bechstein, M. Bester, U.H., C.B., F.F., H.K., N.v.H., P.S., J.F., G.B.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology (L.M., M. Bechstein, M. Bester, U.H., C.B., F.F., H.K., N.v.H., P.S., J.F., G.B.), University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Salhadar N, Dibas M, Sarraj A, Tekle W, Hassan AE. The outcomes of mechanical thrombectomy in nonagenarians and octogenarians in a majority hispanic population. Clin Neurol Neurosurg 2021; 208:106872. [PMID: 34391086 DOI: 10.1016/j.clineuro.2021.106872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2021] [Revised: 07/26/2021] [Accepted: 08/02/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND/OBJECTIVE Elderly patients (≥ 80 years) were underrepresented in randomized trials that proved the efficacy and safety of mechanical thrombectomy (MT) in acute ischemic strokes (AIS) due to large vessel occlusion (LVO). Additionally, the impact of race and socioeconomics on AIS outcomes is well-reported. We sought to compare the MT clinical outcomes between octogenarians and nonagenarians, the majority of whom are Hispanic, in underserved border communities. METHODS This is a retrospective cohort study that was conducted in a comprehensive stroke center between 2012 and 2020. The baseline characteristics and outcomes were compared between the two groups. The primary measured outcome included a favorable outcome on the modified Rankin Scale (mRS) after three months (mRS ≤ 2). Secondary outcomes included mortality, symptomatic intracerebral hemorrhage (sICH), and an improvement in NIH Stroke Scale (NIHSS) score (≤4). RESULTS Of 215 included patients, 184 (85.6%) were octogenarians and 31 (14.4%) were nonagenarians. There were no significant differences between octogenarians and nonagenarians in terms of rates of favorable outcomes after three months (30.4% vs. 19.4%, p = 0.247), clinical improvement in discharge NIHSS (16.3% vs. 19.4%, p = 0.753), mortality (24.5% vs. 29.0%; p = 0.710) and sICH (6.5% vs. 3.2%, p = 0.780). Furthermore, Hispanic and non-Hispanic patients had similar outcomes. CONCLUSION There were no significant differences in the outcomes of MT between octogenarians and nonagenarians and between Hispanic and non-Hispanic patients. The similar clinical outcomes between both age groups in our study and the lower rates of sICH support the use of this treatment among people who are aged 80 or older.
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Affiliation(s)
- Nura Salhadar
- University of Texas Rio Grande Valley, Brownsville, TX, USA
| | - Mahmoud Dibas
- Sulaiman Al Rajhi University, College of Medicine, Qassim, Saudi Arabia.
| | - Amrou Sarraj
- Department of Neurology, University of Texas at Houston Stroke Center, USA
| | - Wondwossen Tekle
- Department of Neurology, University of Texas Rio Grande Valley, Valley Baptist Medical Center - Harlingen, TX, USA
| | - Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley, Valley Baptist Medical Center - Harlingen, TX, USA
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26
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Outcome Following Mechanical Thrombectomy for Anterior Circulation Large Vessel Occlusion Stroke in the Elderly. Clin Neuroradiol 2021; 32:369-374. [PMID: 34313798 DOI: 10.1007/s00062-021-01063-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2021] [Accepted: 06/28/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Pooled data of randomized controlled trials investigating mechanical thrombectomy (MT) to treat anterior circulation large vessel occlusion have demonstrated safety and effectiveness across all age groups, including ≥ 80 years of age; however, only a few nonagenarians were in the ≥ 80 years subgroup. Therefore, the benefit of MT in nonagenarians is mostly unknown. METHODS Two comprehensive stroke centers retrospectively reviewed all acute ischemic stroke patients who underwent MT for anterior circulation large vessel occlusion (LVO) stroke between February 2016 and August 2020. Revascularization TICI2b/3, symptomatic intracranial hemorrhage (ICH), and functional outcome using modified Rankin scale (mRS) were assessed for cases aged < 80 years, 80-89 years, and 90-99 years. Favorable functional outcome was defined as mRS 0-2 or reaching the prestroke mRS and moderate as mRS 0-3. RESULTS The final data set comprised a total of 736 cases. Of these, 466 aged < 80 years, 219 aged 80-89 years, and 51 aged 90-99 years. In nonagenarians, TICI 2b/3 revascularization was observed in 84.3% while symptomatic ICH was observed in 4%. These rates were similar to 80-89 years and < 80 years age groups. Favorable and moderate functional outcome as well as death rates differed significantly between nonagenarians and < 80 years (19.6%, 29.4%, 51.0% vs 47.9%, 60.7%, 18.7%, respectively, p < 0.001), but were similar between nonagenarians and octogenarians (29.7%, 38.8%, 38.8%, p = 0.112-0.211). CONCLUSION A moderate outcome among nonagenarians was observed in about 30%, while mortality rates were about 50%. Withholding mechanical thrombectomy does not appear justifiable, although the absolute treatment effect among nonagenarians remains unknown.
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27
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Al-Mufti F, Schirmer CM, Starke RM, Chaudhary N, De Leacy R, Tjoumakaris SI, Haranhalli N, Abecassis IJ, Amuluru K, Bulsara KR, Hetts SW. Thrombectomy in special populations: report of the Society of NeuroInterventional Surgery Standards and Guidelines Committee. J Neurointerv Surg 2021; 14:1033-1041. [PMID: 34244337 DOI: 10.1136/neurintsurg-2021-017888] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2021] [Accepted: 06/22/2021] [Indexed: 12/20/2022]
Abstract
BACKGROUND The purpose of this guideline is to summarize the data available for performing mechanical thrombectomy (MT) for emergent large vessel occlusion (ELVO) stroke in special populations not typically included in large randomized controlled clinical trials, including children, the elderly, pregnant women, patients who have recently undergone surgery, and patients with thrombocytopenia, collagen vascular disorders, and endocarditis. METHODS We performed a literature review for studies examining the indications, efficacy, and outcomes for patients undergoing MT for ischemic stroke aged <18 years and >80 years, pregnant patients, patients who have recently undergone surgery, and those with thrombocytopenia, collagen vascular diseases, or endocarditis. We graded the quality of the evidence. RESULTS MT can be effective for the treatment of ELVO in ischemic stroke for patients over age 80 years and under age 18 years, thrombocytopenic patients, pregnant patients, and patients with endocarditis. While outcomes are worse compared to younger patients and those with normal platelet counts (respectively), there is still a benefit in the elderly (in both mRS and mortality). Data are very limited for patients with collagen vascular diseases; although diagnostic cerebral angiography carries increased risks, MT may be appropriate in carefully selected patients in whom untreated ELVO would likely result in disabling or fatal outcome.
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Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurology and Neurosurgery, Westchester Medical Center, Valhalla, New York, USA
| | - Clemens M Schirmer
- Department of Neurosurgery, Geisinger Health System, Wilkes-Barre, Pennsylvania, USA
| | - Robert M Starke
- Department of Neurosurgery & Radiology, University of Miami Miller School of Medicine, Miami, Florida, USA
| | - Neeraj Chaudhary
- Department of Radiology, University of Michigan Health System, Ann Arbor, Michigan, USA
| | - Reade De Leacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Stavropoula I Tjoumakaris
- Department of Neurological Surgery, Thomas Jefferson University Hospital, Philadelphia, Pennsylvania, USA
| | - Neil Haranhalli
- Department of Neurosurgery, Montefiore Hospital and Medical Center, Bronx, New York, USA
| | - Isaac Josh Abecassis
- Department of Neurological Surgery, University of Miami School of Medicine, Miami, Florida, USA.,Department of Neurological Surgery, University of Washington, Seattle, Washington, USA
| | - Krishna Amuluru
- Department of Interventional Neuroradiology, Goodman Campbell Brain and Spine, Carmel, Indiana, USA
| | - Ketan R Bulsara
- Division of Neurosurgery, University of Connecticut, Farmington, Connecticut, USA
| | - Steven W Hetts
- Department of Radiology, UCSF, San Francisco, California, USA
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Jian Y, Zhao L, Jia B, Tong X, Li T, Wu Y, Wang X, Gao Z, Gong Y, Zhang X, Wang H, Zhang R, Zhang L, Miao Z, Zhang G. Direct versus Bridging Mechanical Thrombectomy in Elderly Patients with Acute Large Vessel Occlusion: A Multicenter Cohort Study. Clin Interv Aging 2021; 16:1265-1274. [PMID: 34262266 PMCID: PMC8275117 DOI: 10.2147/cia.s313171] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2021] [Accepted: 06/01/2021] [Indexed: 12/22/2022] Open
Abstract
Purpose Elderly people represent a growing stroke population with different pathophysiological states than younger. Whether intravenous thrombolysis (IVT) before mechanical thrombectomy (MT) is beneficial for elderly patients remains unclear. This study compared the efficacy and safety between elderly patients treated with MT alone and those treated with both IVT and MT. Patients and Methods Patients aged ≥65 years who were eligible for IVT within 4.5 h from symptom onset were selected from the ANGEL-ACT (Endovascular Treatment Key Technique and Emergency Work Flow Improvement of Acute Ischemic Stroke) registry, a prospective registry program for patients with endovascular treatment from 111 Chinese stroke centers. The primary efficacy outcome was the 90-day modified Rankin Scale score. We compared efficacy and safety outcomes using ordinal or binary logistic regression or a generalized linear model. Results In total, 482 elderly patients were included: 187 (38.8%) received IVT and MT (bridging MT) and 295 (61.2%) received MT alone (direct MT). There was no significant difference in the 90-day modified Rankin Scale score between the two groups (median: 4 vs 4 points, respectively; adjusted β=−0.048, P=0.822). The direct MT group had a shorter onset-to-puncture time (225 vs 255 min, respectively; adjusted β=−55.074, P=0.002) and a lower rate of parenchymal hemorrhage type 2 within 24 h (2.80% vs 6.63%, respectively; adjusted odds ratio [OR]=0.287, 95% confidence interval [CI]=0.096–0.856, P=0.025). In addition, the direct MT group showed a trend toward a lower incidence of sICH (5.67% vs 10.06%, adjusted OR=0.453, P=0.061), procedure-related complications (7.12% vs 12.30%, adjusted OR=0.499, P=0.052) and distal or new territorial embolization (4.07% vs 6.95%, adjusted OR=0.450, P=0.093). Conclusion Direct MT had similar efficacy to bridging MT in terms of the 90-day functional outcome in elderly patients, whereas bridging MT had a longer onset-to-puncture time and increased risk of hemorrhagic transformation and procedure-related complications.
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Affiliation(s)
- Yating Jian
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, People's Republic of China
| | - Lili Zhao
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, People's Republic of China
| | - Baixue Jia
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Xu Tong
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Tao Li
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, People's Republic of China
| | - Yulun Wu
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, People's Republic of China
| | - Xiaoya Wang
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, People's Republic of China
| | - Zhen Gao
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, People's Republic of China
| | - Yu Gong
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, People's Republic of China
| | - Xuelei Zhang
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Huqing Wang
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, People's Republic of China
| | - Ru Zhang
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, People's Republic of China
| | - Lei Zhang
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, People's Republic of China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, People's Republic of China
| | - Guilian Zhang
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, 710004, Shaanxi, People's Republic of China
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[Border areas of thrombectomy]. DER NERVENARZT 2021; 92:762-772. [PMID: 34100125 PMCID: PMC8342321 DOI: 10.1007/s00115-021-01138-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Accepted: 04/29/2021] [Indexed: 11/05/2022]
Abstract
Die mechanische Thrombektomie (MT) hat sich als Standardverfahren für die Behandlung akuter ischämischer Schlaganfälle aufgrund eines Verschlusses einer großen, proximalen Hirnarterie der vorderen Zirkulation etabliert. Dennoch sind nach aktuellen Guidelines noch große Patientenkollektive von dieser hocheffektiven Behandlungsmethode ausgeschlossen. Diese Arbeit gibt daher einen Überblick über mögliche Erweiterungen der Behandlungsindikationen für die MT, wie z. B. Patienten im erweiterten Zeitfenster, mit distalen Verschlüssen, mit großem Infarktkern oder auch für sehr alte (> 90 Jahre) und junge (0–17 Jahre) Patienten. Zusätzlich besprechen wir neue Entwicklungen in der interventionellen Behandlung von Schlaganfällen, wie z. B. neue Triage-Konzepte oder die Fragestellung, ob die zusätzliche intravenöse Thrombolyse bei MT-Patienten notwendig ist. Abschließend geben wir für die besprochenen Behandlungsindikationen unsere Einschätzungen basierend auf der aktuellen Literatur und unserer klinischen Erfahrung.
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Yeo LLL, Chen VHE, Leow AST, Meyer L, Fiehler J, Tu TM, Tham CH, Sia CH, Jamous A, Behme D, Kastrup A, Papanagiotou P, Styczen H, Forsting M, Lee TH, Chu CL, Fischer S, Maus V, Abdullayev N, Kabbasch C, Mönch S, Maegerlein C, Arnberg F, Andersson T, Holmin S, Teoh HL, Paliwal P, Ahmad A, Gopinathan A, Yang C, Seet RCS, Chan BPL, Sharma VK, Tan BYQ. Outcomes in young adults with acute ischemic stroke undergoing endovascular thrombectomy: A real-world multicenter experience. Eur J Neurol 2021; 28:2736-2744. [PMID: 33960072 DOI: 10.1111/ene.14899] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2021] [Revised: 04/22/2021] [Accepted: 04/24/2021] [Indexed: 11/29/2022]
Abstract
Endovascular thrombectomy (EVT) is the standard of care for anterior circulation acute ischemic stroke (AIS) with large vessel occlusion (LVO). Young patients with AIS-LVO have distinctly different underlying stroke mechanisms and etiologies. Much is unknown about the safety and efficacy of EVT in this population of young AIS-LVO patients. All consecutive AIS-LVO patients aged 50 years and below were included in this multicenter cohort study. The primary outcome measured was functional recovery at 90 days, with modified Rankin Scale of 0-2 deemed as good functional outcome. A total of 275 AIS-LVO patients that underwent EVT from 10 tertiary centers in Germany, Sweden, Singapore, and Taiwan were included. Successful reperfusion was achieved in 85.1% (234/275). Good functional outcomes were achieved in 66.0% (182/275). Arterial dissection was the most prevalent stroke etiology (42/195, 21.5%). National Institutes of Health Stroke Scale (NIHSS) score at presentation was inversely related to good functional outcomes (aOR: 0.92, 95% CI: 0.88-0.96 per point increase, p < 0.001). Successful reperfusion (aOR: 3.22, 95% CI: 1.44-7.21, p = 0.005), higher ASPECTS (aOR: 1.21, 95% CI: 1.01-1.44, p = 0.036), and bridging intravenous thrombolysis (aOR: 2.37, 95% CI: 1.29-4.34, p = 0.005) independently predicted good functional outcomes. Successful reperfusion was inversely associated with in-hospital mortality (aOR: 0.14, 95% CI: 0.03-0.57, p = 0.006). History of hypertension strongly predicted in-hospital mortality (aOR: 4.59, 95% CI: 1.10-19.13, p = 0.036). While differences in functional outcomes exist across varying stroke aetiologies, high rates of successful reperfusion and good outcomes are generally achieved in young AIS-LVO patients undergoing EVT.
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Affiliation(s)
- Leonard Leong-Litt Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Vanessa Hui En Chen
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
| | - Aloysius Sheng-Ting Leow
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tian-Ming Tu
- Department of Neurology, National Neuroscience Institute, Singapore City, Singapore
| | - Carol Huilian Tham
- Department of Neurology, National Neuroscience Institute, Singapore City, Singapore
| | - Ching-Hui Sia
- Department of Cardiology, National University Heart Center, Singapore City, Singapore
| | - Ala Jamous
- Institute of Neuroradiology, University Medical Center Goettingen, Goettingen, Germany
| | - Daniel Behme
- Institute of Neuroradiology, University Medical Center Goettingen, Goettingen, Germany
| | - Andreas Kastrup
- Department of Neurology, Klinikum Bremen-Mitte, Bremen, Germany
| | - Panagiotis Papanagiotou
- Department of Neuroradiology, Hospital Bremen-Mitte, Bremen, Germany.,Areteion Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | - Hanna Styczen
- Institute of Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Michael Forsting
- Institute of Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Tsong-Hai Lee
- Stroke Section, Department of Neurology, College of Medicine, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Chan-Lin Chu
- Stroke Section, Department of Neurology, College of Medicine, Linkou Chang Gung Memorial Hospital, Chang Gung University, Taoyuan, Taiwan
| | - Sebastian Fischer
- Department of Radiology, Neuroradiology and Nuclear Medicine, University Medical Center Bochum-Langendreer, Bochum, Germany
| | - Volker Maus
- Department of Radiology, Neuroradiology and Nuclear Medicine, University Medical Center Bochum-Langendreer, Bochum, Germany
| | - Nuran Abdullayev
- Institute of Radiology and Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Christoph Kabbasch
- Institute of Radiology and Neuroradiology, University Hospital Cologne, Cologne, Germany
| | - Sebastian Mönch
- Department of Diagnostic and Interventional Neuroradiology, Technical University Munich, Munich, Germany
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Technical University Munich, Munich, Germany
| | - Fabian Arnberg
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Tommy Andersson
- Department of Neuroradiology, Karolinska University Hospital, Stockholm, Sweden.,Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium
| | - Staffan Holmin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Hock-Luen Teoh
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
| | - Prakash Paliwal
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
| | - Aftab Ahmad
- Division of Neurology, Ng Teng Fong Hospital, Singapore City, Singapore
| | - Anil Gopinathan
- Division of Interventional Radiology, Department of Diagnostic Imaging, National University Health System, Singapore City, Singapore
| | - Cunli Yang
- Division of Interventional Radiology, Department of Diagnostic Imaging, National University Health System, Singapore City, Singapore
| | - Raymond Chee-Seong Seet
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
| | - Bernard Poon-Lap Chan
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore
| | - Vijay K Sharma
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
| | - Benjamin Yong-Qiang Tan
- Division of Neurology, Department of Medicine, National University Health System, Singapore City, Singapore.,Yong Loo Lin School of Medicine, National University of Singapore, Singapore City, Singapore
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31
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Analysis of Frailty in Geriatric Patients as a Prognostic Factor in Endovascular Treated Patients with Large Vessel Occlusion Strokes. J Clin Med 2021; 10:jcm10102171. [PMID: 34069797 PMCID: PMC8157268 DOI: 10.3390/jcm10102171] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 05/12/2021] [Accepted: 05/14/2021] [Indexed: 12/21/2022] Open
Abstract
Frailty is associated with an increased risk of adverse health-care outcomes in elderly patients. The Hospital Frailty Risk Score (HFRS) has been developed and proven to be capable of identifying patients which are at high risk of adverse outcomes. We aimed to investigate whether frail patients also face adverse outcomes after experiencing an endovascular treated large vessel occlusion stroke (LVOS). In this retrospective observational cohort study, we analyzed patients ≥ 65 years that were admitted during 2015-2019 with LVOS and endovascular treatment. Primary outcomes were mortality and the modified Rankin Scale (mRS) after three months. Regression models were used to determine the impact of frailty. A total of 318 patients were included in the cohort. The median HFRS was 1.6 (IQR 4.8). A total of 238 (75.1%) patients fulfilled the criteria for a low-frailty risk with a HFRS < 5.72 (22.7%) for moderate-frailty risk with an HFRS from 5-15 and 7 (2.2%) patients for a high-frailty risk. Multivariate regression analyses revealed that the HFRS was associated with an increased mortality after 90 days (CI (95%) 1.001 to 1.236; OR 1.112) and a worse mRS (CI (95%) 1.004 to 1.270; OR 1.129). We identified frailty as an impact factor on functional outcome and mortality in patients undergoing thrombectomy in LVOS.
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32
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Kawaji H, Tomoto K, Arakawa T, Hayashi M, Ishii T, Homma K, Matsui S, Hiramatsu H, Ohashi T, Kurozumi K, Namba H. Feasibility of Mechanical Thrombectomy for Acute Ischemic Stroke Patients Aged 90 Years or Older Compared to Younger Patients. Neurol Med Chir (Tokyo) 2021; 61:397-403. [PMID: 33994450 PMCID: PMC8280327 DOI: 10.2176/nmc.oa.2020-0412] [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] [Indexed: 11/20/2022] Open
Abstract
Mechanical thrombectomy (MT) is a proven treatment for acute ischemic stroke (AIS). However, the efficacy of this treatment is uncertain for very elderly patients. This study aimed to investigate the safety and effectiveness of MT in 90 years or older patients compared with younger patients. We retrospectively reviewed AIS patients treated with MT between October 2018 and June 2020 in our institution. Patients were divided into two groups: aged ≥90 and <90 years. We compared the following factors: functional outcome at discharge, in-hospital death, successful recanalization, and complications. Multivariate logistic regression analysis for the good functional outcome was performed. In consideration of pre-stroke basic activities of very elderly patients, we defined the good functional outcome as modified Rankin Scale (mRS) 0–3. In all, 66 patients were included, and 19 patients (28%) were ≥90 years old. Pre-stoke mRS was higher in ≥90-year-old patients (p = 0.01). In ≥90-year-old patients, we achieved successful recanalization in 17 patients (90%), and only one patient experienced hemorrhagic complication related with the procedure. The good functional outcome (mRS: 0–3) at discharge were six patients (32%) in ≥90 years old versus 19 patients (40%) in <90 years old (p = 0.6). Three patients died in hospital in each group (16% versus 6%) (p = 0.3). Only the stroke severity was negatively related with the good functional outcome in a multivariate analysis. In conclusion, for ≥90-year-old patients compared with younger patients, MT is an equally feasible therapy. Patients should not be excluded from MT based on age alone.
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Affiliation(s)
- Hiroshi Kawaji
- Department of Stroke Center, Seirei Hamamatsu General Hospital.,Department of Neurosurgery, Hamamatsu University School of Medicine
| | - Kyoichi Tomoto
- Department of Stroke Center, Seirei Hamamatsu General Hospital
| | - Tomoya Arakawa
- Department of Stroke Center, Seirei Hamamatsu General Hospital
| | | | - Tatsuhito Ishii
- Department of Stroke Center, Seirei Hamamatsu General Hospital
| | - Kazunari Homma
- Department of Stroke Center, Seirei Hamamatsu General Hospital
| | - Shusuke Matsui
- Department of Neurosurgery, Hamamatsu University School of Medicine
| | - Hisaya Hiramatsu
- Department of Neurosurgery, Hamamatsu University School of Medicine
| | | | | | - Hiroki Namba
- Department of Neurosurgery, Hamamatsu University School of Medicine
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33
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Li H, Ye SS, Wu YL, Huang SM, Li YX, Lu K, Huang JB, Chen L, Li HZ, Wu WJ, Wu ZL, Wu JZ, Zhong WT, Xian WC, Liao F, Tung TH, Wu QL, Chen H, Yuan L, Yang Z, Huang LA. Predicting mortality in acute ischaemic stroke treated with mechanical thrombectomy: analysis of a multicentre prospective registry. BMJ Open 2021; 11:e043415. [PMID: 33795300 PMCID: PMC8021751 DOI: 10.1136/bmjopen-2020-043415] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
OBJECTIVES We aimed to determine predictors of mortality within 90 days and develop a simple score for patients with mechanical thrombectomy (MT). DESIGN Analysis of a multicentre prospective registry. SETTING In six participating centres, patients who had an acute ischaemic stroke (AIS) treated by MT between March 2017 and May 2018 were documented prospectively. PARTICIPANTS 224 patients with AIS were treated by MT. RESULTS Of 224 patients, 49 (21.9%) patients died, and 87 (38.8%) were independent. Variables associated with 90-day mortality were age, previous stroke, admission National Institutes of Health Stroke Scale (NIHSS), fasting blood glucose and occlusion site. Logistic regression identified four variables independently associated with 90-day mortality: age ≥80 years (OR 3.26, 95% CI 1.45 to 7.33), previous stroke (OR 2.33, 95% CI 1.04 to 5.21), admission NIHSS ≥18 (OR 2.37, 95% CI 1.13 to 4.99) and internal carotid artery or basilar artery occlusion (OR 2.92, 95% CI 1.34 to 6.40). Using these data, we developed predicting 90-day mortality of AIS with MT (PRACTICE) score ranging from 0 to 6 points. The receiver operator curve analysis found that PRACTICE score (area under the curve (AUC)=0.744, 95% CI 0.669 to 0.820) was numerically better than iScore (AUC=0.661, 95% CI 0.577 to 0.745) and Predicting Early Mortality of Ischemic Stroke score (AUC=0.638, 95% CI 0.551 to 0.725) for predicting 90-day mortality. CONCLUSIONS We developed a simple score to estimate the 90-day mortality of patients who had an AIS treated with MT. But the score needs to be prospectively validated. TRIAL REGISTRATION NUMBER Chinese Clinical Trial Registry (ChiCTR-OOC-17013052).
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Affiliation(s)
- Hao Li
- Department of Neurology, Maoming People’s Hospital, Maoming, China
| | - Shi-sheng Ye
- Department of Neurology, Maoming People’s Hospital, Maoming, China
| | - Yuan-Ling Wu
- Department of Neurology, Longgang District People’s Hospital of Shenzhen, Shenzhen, China
| | - Sheng-Ming Huang
- Department of Neurology, Jinan University First Affiliated Hospital, Guangzhou, China
| | - Yong-Xin Li
- Department of Neurology, Shunde Hospital of Southern Medical University, Foshan, China
| | - Kui Lu
- Department of Neurology, Zhongshan City People’s Hospital, Zhongshan, China
| | - Jing-Bo Huang
- Department of Neurology, Maoming People’s Hospital, Maoming, China
| | - Lve Chen
- Department of Neurology, Shunde Hospital of Southern Medical University, Foshan, China
| | - Hong-Zhuang Li
- Department of Neurology, Shunde Hospital of Southern Medical University, Foshan, China
| | - Wen-Jun Wu
- Department of Neurology, Zhongshan City People’s Hospital, Zhongshan, China
| | - Zhi-Lin Wu
- Department of Integrated Intervention, Yunfu People’s Hospital, Yunfu, China
| | - Jian-Zhou Wu
- Department of Integrated Intervention, Yunfu People’s Hospital, Yunfu, China
| | - Wang-Tao Zhong
- Department of Neurology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Wen-Chuan Xian
- Department of Neurology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Feng Liao
- Department of Neurology, Affiliated Hospital of Guangdong Medical University, Zhanjiang, China
| | - Tao-Hsin Tung
- Department of Enze Medical Research Center, Affiliated Taizhou Hospital of Wenzhou Medical College, Taizhou, China
| | - Qiao-Ling Wu
- Department of Neurology, Maoming People’s Hospital, Maoming, China
| | - Hai Chen
- Department of Neurology, Maoming People’s Hospital, Maoming, China
| | - Li Yuan
- Department of Neurology, Maoming People’s Hospital, Maoming, China
| | - Zhi Yang
- Department of Neurology, Maoming People’s Hospital, Maoming, China
| | - Li-An Huang
- Department of Neurology, Jinan University First Affiliated Hospital, Guangzhou, China
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34
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Sporns PB, Fiehler J, Ospel J, Safouris A, Hanning U, Fischer U, Goyal M, McTaggart R, Brehm A, Psychogios M. Expanding indications for endovascular thrombectomy-how to leave no patient behind. Ther Adv Neurol Disord 2021; 14:1756286421998905. [PMID: 33796144 PMCID: PMC7970189 DOI: 10.1177/1756286421998905] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2020] [Accepted: 01/18/2021] [Indexed: 01/01/2023] Open
Abstract
Endovascular thrombectomy (EVT) has become standard of care for large vessel
occlusion strokes but current guidelines exclude a large proportion of patients
from this highly effective treatment. This review therefore focuses on expanding
indications for EVT in several borderline indications such as patients in the
extended time window, patients with extensive signs of infarction on admission
imaging, elderly patients and patients with pre-existing deficits. It also
discusses the current knowledge on intravenous thrombolysis as an adjunct to EVT
and EVT as primary therapy for distal vessel occlusions, for tandem occlusions,
for basilar artery occlusions and in pediatric patients. We provide clear
recommendations based on current guidelines and further literature.
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Affiliation(s)
- Peter B Sporns
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Petersgraben 4, Basel, 4031, Switzerland
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johanna Ospel
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | | | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Mayank Goyal
- Department of Radiology, University of Calgary, Calgary, AB, Canada
| | - Ryan McTaggart
- Department of Interventional Radiology, Warren Alpert Medical School of Brown University, Providence, RI, USA
| | - Alex Brehm
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Marios Psychogios
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, Basel, Switzerland
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35
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Predictors of Outcome After Mechanical Thrombectomy in Stroke Patients Aged ≥85 Years. Can J Neurol Sci 2021; 49:49-54. [PMID: 33685540 DOI: 10.1017/cjn.2021.37] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
BACKGROUND The effectiveness of mechanical thrombectomy (MT) in elderly stroke patients remains debated. We aimed to describe outcomes and their predictors in a cohort of patients aged ≥ 85 years treated with MT. METHODS Data from consecutive patients aged ≥ 85 years undergoing MT at two stroke centers between January 2016 and November 2019 were reviewed. Admission National Institutes of Health Stroke Scale (NIHSS), pre-stroke, and 3-month modified Rankin scale (mRS) were collected. Successful recanalization was defined as modified thrombolysis in cerebral ischemia score ≥ 2b. Good outcome was defined as mRS 0-3 or equal to pre-stroke mRS at 3 months. RESULTS Of 151 included patients, successful recanalization was achieved in 74.2%. At 3 months, 44.7% of patients had a good outcome and 39% had died. Any intracranial hemorrhage (ICH) and symptomatic ICH occurred in 20.3% and 3.6%, respectively. Logistic regression analysis identified lower pre-stroke mRS score (adjusted odds ratio [aOR], 0.52; 95% CI, 0.36-0.76), lower admission NIHSS score (aOR, 0.90; 95% CI, 0.83-0.97), successful recanalization (aOR, 3.65; 95% CI, 1.32-10.09), and absence of ICH on follow-up imaging (aOR, 0.42; 95% CI, 0.08-0.75), to be independent predictors of good outcome. Patients with successful recanalization had a higher proportion of good outcome (45.3% vs 34.3%, p = 0.013) and lower mortality at 3 months (35.8% vs 48.6%, p = 0.006) compared to patients with unsuccessful recanalization. CONCLUSIONS Among patients aged ≥ 85 years, successful recanalization with MT is relatively common and associated with better 3-month outcome and lower mortality than failed recanalization. Attempting to achieve recanalization in elderly patients using MT appears reasonable.
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36
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Bai X, Zhang X, Zhang Y, Yang W, Wang T, Feng Y, Wang Y, Yang K, Wang X, Ma Y, Jiao L. Mechanical Thrombectomy in Nonagenarians: a Systematic Review and Meta-analysis. Transl Stroke Res 2021; 12:394-405. [PMID: 33532934 DOI: 10.1007/s12975-021-00894-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 01/18/2021] [Accepted: 01/20/2021] [Indexed: 12/26/2022]
Abstract
This systematic review and meta-analysis aimed to summarize the current literature on mechanical thrombectomy (MT) in nonagenarians and to provide updated clinical evidence of its feasibility, effectiveness, and safety in nonagenarians. PubMed, EMBASE, the Cochrane Library, and Web of Science were searched for relevant randomized controlled trials and observational studies that reported the clinical outcomes of nonagenarians with acute ischemic stroke after undergoing mechanical thrombectomy. Risk of bias was assessed using different scales. I2 statistic was used to evaluate the heterogeneity of the results, while meta-regression and sensitivity analyses were performed to investigate the source of heterogeneity. Thirteen studies and 657 patients were included. The estimated rate of successful revascularization was 80.82% (95% confidence interval [CI]: 77.48-83.97%), and the rate of favorable outcome (modified Rankin score [mRS] 0-2) was 21.60% (95% CI: 13.81-30.41%). The rate of good outcome (mRS score 0-3) was 23.08% (95% CI: 18.88-27.55%). The estimated risk of death during hospitalization was 20.55% (95% CI: 15.93-25.55%), while the mortality rate at 3 months was 44.38% (95% CI: 33.66-55.36%). The rate of intracranial hemorrhage (ICH) occurrence was 12.84% (95% CI: 5.27-22.68%), while the rate of symptomatic intracranial hemorrhage (sICH) was 3.52% (95% CI: 1.67-5.85%). The rate of hospital-related complications was 26.93% (95% CI: 10.53-47.03%). MT in nonagenarians demonstrated a high rate of successful revascularization. Conversely, the rate of futile revascularization is high with a low functional independence proportion. Therefore, MT should not be indiscriminately advocated in nonagenarians. Satisfactory results require careful selection of patients. Further high-quality studies are needed to clarify the selection algorithm.
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Affiliation(s)
- Xuesong Bai
- China International Neuroscience Institute (China-INI), Beijing, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Xiao Zhang
- China International Neuroscience Institute (China-INI), Beijing, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Yanhong Zhang
- Medical Administration Division, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Wuyang Yang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, USA
| | - Tao Wang
- China International Neuroscience Institute (China-INI), Beijing, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Yao Feng
- China International Neuroscience Institute (China-INI), Beijing, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China
| | - Yan Wang
- China Medical University, No.77 Puhe Road, Shenyang North New Area, Shenyang, Liaoning, China
| | - Kun Yang
- Department of Evidence-Based Medicine, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, China
| | - Xue Wang
- Medical Library, Xuanwu Hospital, Capital Medical University, No. 45 Changchun Street, Beijing, China
| | - Yan Ma
- China International Neuroscience Institute (China-INI), Beijing, China. .,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China.
| | - Liqun Jiao
- China International Neuroscience Institute (China-INI), Beijing, China. .,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, 100053, China. .,Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Beijing, China.
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37
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Sojka M, Szmygin M, Pyra K, Tarkowski P, Luchowski P, Wojczal J, Drelich-Zbroja A, Jargiełło T. Predictors of outcome after mechanical thrombectomy for acute ischemic stroke in patients aged ≥90 years. Clin Neurol Neurosurg 2020; 200:106354. [PMID: 33172718 DOI: 10.1016/j.clineuro.2020.106354] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/24/2020] [Revised: 10/19/2020] [Accepted: 10/29/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Mechanical thrombectomy (MT) has established its role as a first-line treatment of acute ischemic stroke due to large vessel occlusions (LVO). However, patients older than 85 or even 80 years of age are commonly excluded from large randomized controlled stroke studies as this group was found to be associated with significantly poorer clinical outcome and increased mortality compared to younger patients. The aim of this study was to evaluate clinical and procedural factors associated with clinical outcome and mortality among nonagenarians with acute ischemic stroke treated with mechanical thrombectomy. MATERIALS AND METHODS This retrospective, single-center study was conducted on 38 patients with LVO treated with MT. Clinical features including baseline results, radiological imaging, procedural details and outcome results were documented and evaluated. Recanalization was assessed according to the TICI score. The clinical condition was evaluated on admission (NIHSS) and after 3 months (mRS). RESULTS The rate of successful recanalization (TICI ≥2b) was 84.2 % (32/38). Symptomatic intracranial hemorrhage (sICH) was observed in 3 (7.9 %) patients. After 90 days, the mortality rate was 47.4 %. Favorable clinical outcome (mRs 0-2) was regained in 28.9 % of the patients (11/38). Poor clinical outcome (mRs<2) was observed in 9 patients (23.7 %). CONCLUSION Very elderly patients with LVO should not be excluded from MT even if prognosis for good clinical outcome in this age group remains low and the procedure is more challenging. Long-term outcome is predicted by stroke severity (baseline NIHSS and occluded vessel) and hospital arrival time.
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Affiliation(s)
- Michał Sojka
- Medical University of Lublin, Department of Interventional Radiology and Neuroradiology, Poland
| | - Maciej Szmygin
- Medical University of Lublin, Department of Interventional Radiology and Neuroradiology, Poland.
| | - Krzysztof Pyra
- Medical University of Lublin, Department of Interventional Radiology and Neuroradiology, Poland
| | - Piotr Tarkowski
- Medical University of Lublin, Department of Radiology and Nuclear Medicine, Poland
| | - Piotr Luchowski
- Medical University of Lublin, Department of Neurology, Poland
| | - Joanna Wojczal
- Medical University of Lublin, Department of Neurology, Poland
| | - Anna Drelich-Zbroja
- Medical University of Lublin, Department of Interventional Radiology and Neuroradiology, Poland
| | - Tomasz Jargiełło
- Medical University of Lublin, Department of Interventional Radiology and Neuroradiology, Poland
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38
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Meyer L, Broocks G, Bechstein M, Flottmann F, Leischner H, Brekenfeld C, Schön G, Deb-Chatterji M, Alegiani A, Thomalla G, Fiehler J, Kniep H, Hanning U. Early clinical surrogates for outcome prediction after stroke thrombectomy in daily clinical practice. J Neurol Neurosurg Psychiatry 2020; 91:1055-1059. [PMID: 32934109 DOI: 10.1136/jnnp-2020-323742] [Citation(s) in RCA: 28] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Revised: 06/30/2020] [Accepted: 07/01/2020] [Indexed: 11/04/2022]
Abstract
BACKGROUND AND PURPOSE To investigate early clinical surrogates for long-term independency of patients treated with thrombectomy for large vessel occlusion stroke in daily clinical routine. METHODS All patients with anterior circulation stroke enrolled in the German Stroke Registry-Endovascular Treatment from 07/2015 to 04/2018 were analysed. National Institute of Health Stroke Scale (NIHSS) on admission, NIHSS percentage change, NIHSS delta and NIHSS at 24 hours as well as existing binary definitions of early neurological improvement (ENI; improvement of 8 (major ENI)/10 (dramatic ENI) NIHSS points or reaching 0/1 were compared for predicting functional outcome at 90 days using the modified Rankin Scale (mRS). Excellent and favourable outcome were defined as 0-1 and 0-2, respectively. RESULTS Among 2262 endovasculary treated patients with acute ischaemic anterior circulation stroke, NIHSS at 24 hours had the highest discriminative ability to predict excellent (receiver operator characteristics (ROC)NIHSS 24 hours area under the curve (AUC) 0.86 (0.84-0.88)) and favourable long-term functional outcome (ROCNIHSS 24 hours AUC 0.86 (0.85-0.88)) in comparison to NIHSS percentage change (ROC% change AUC mRS ≤1: 0.81 (0.78-0.83) mRS ≤2: 0.81 (0.79-0.83)), NIHSS delta change (ROCΔ change AUC mRS ≤1: 0.74 (0.72-0.77), mRS ≤2: 0.77 (0.74-0.79)) and NIHSS admission (ROCAdm AUC mRS ≤1: 0.70 (0.68-0.73), mRS ≤2: 0.67 (0.68-0.71)). Advanced age was the only independent predictor (adjusted OR 1.05, 95% CI 1.03 to 1.07, p<0.001) for turning the outcome prognosis from favourable (mRS ≤2) to poor (mRS ≥4) at 90 days. CONCLUSION The NIHSS at 24 hours postintervention with a threshold of ≤8 points serves best as a surrogate for long-term functional outcome after thrombectomy for anterior circulation stroke in daily clinical practice. Only advanced age significantly decreases its predictive value.
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Affiliation(s)
- Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hannes Leischner
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerhard Schön
- Department of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Alegiani
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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39
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Specificities of acute phase stroke management in the elderly. Rev Neurol (Paris) 2020; 176:684-691. [PMID: 32980154 DOI: 10.1016/j.neurol.2020.07.006] [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: 10/25/2019] [Revised: 06/22/2020] [Accepted: 07/06/2020] [Indexed: 11/21/2022]
Abstract
Health professionals are currently facing the challenge of managing an increasing number of old patients presenting with acute stroke, due to rapid aging of the population. Compared to their younger counterparts, elderly patients differ in many ways in the setting of acute stroke. Apart from a striking high stroke incidence, which increases exponentially as age increases, cardioembolism also becomes, as patients age, the main cause of ischemic stroke. Delirium, which can challenge the diagnosis, is frequent at the acute phase of stroke, and may be related to an underlying dementia, which is almost exclusively observed in the elderly during stroke. At all levels, management of elderly stroke patients is suboptimal, especially when they are cognitively impaired, with insufficiencies including admission to stroke units, applying standards of care and investigation, reperfusion therapy for ischemic stroke, and finally transfer to rehabilitation centers. A paradigm shift must take place to limit age-related discrimination for acute-phase management of stroke.
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Meyer L, Alexandrou M, Flottmann F, Deb-Chatterji M, Abdullayev N, Maus V, Politi M, Bernkopf K, Roth C, Kastrup A, Hanning U, Brekenfeld C, Thomalla G, Gerloff C, Mpotsaris A, Papanagiotou P, Fiehler J, Leischner H. Endovascular Treatment of Very Elderly Patients Aged ≥90 With Acute Ischemic Stroke. J Am Heart Assoc 2020; 9:e014447. [PMID: 32089059 PMCID: PMC7335589 DOI: 10.1161/jaha.119.014447] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Background Patients aged ≥90 were excluded or under‐represented in past thrombectomy trials; thus, uncertainty remains whether treatment benefits can be expected regardless of age. This study investigates outcome and safety of thrombectomy in nonagenarians to improve decision making in a real‐world setting. Methods and Results All currently available data of patients aged ≥90 enrolled in the GSR‐ET (German Stroke Registry–Endovascular Treatment) were combined with a smaller cohort from 3 tertiary stroke centers. Baseline characteristics, procedural (Thrombolysis in Cerebral Infarction scale) and functional outcomes (modified Rankin Scale; mRS), as well as complications (symptomatic intracranial hemorrhage, serious adverse events; SAEs) were analyzed. Good functional outcome was defined as mRS ≤3 at 90‐days. 203 patients with anterior circulation stroke and prestroke mRS ≤3 were included. The rate of successful recanalization (Thrombolysis in Cerebral Infarction scale ≥2b) was 75.9% (154/203). Good functional outcome (mRS ≤3) was observed in 21.6% (41 of 193) at 90‐days. In‐hospital mortality was 27.1% (55 of 203) and increased significantly at 90 days to 48.9% (93 of 190; P<0.001). Symptomatic intracranial hemorrhage occurred in 3% (6 of 203) of patients. Logistic regression analysis identified Alberta Stroke Program Early CT Score (adjusted odds ratio, 1.93; 95% CI, 1.01–3.70; P=0.046) and initial National Institute of Health Stroke Scale (adjusted odds ratio, 0.85; 95% CI, 0.76–0.97; P=0.014) as independent predictors for good outcome. Patients with successful recanalization had a significant (P=0.001) shift of mRS distribution with higher rates of good functional outcomes (23.8% [34 of 143] versus 14.9% [7 of 47]) and lower mortality at 90‐days (46.8% [67 of 143] versus 55.3% [26 of 47]). Conclusions Despite high mortality and less frequent favorable outcome, our data suggest that thrombectomy is still effective and safe for nonagenarians. Decision making for thrombectomy in patients aged ≥90 should be based on a case‐by‐case basis with regard to initial National Institute of Health Stroke Scale and Alberta Stroke Program Early CT Score.
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Affiliation(s)
- Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Maria Alexandrou
- Department of Diagnostic and Interventional Neuroradiology Hospital Bremen-Mitte Bremen Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Milani Deb-Chatterji
- Department of Neurology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Nuran Abdullayev
- Department of Diagnostic and Interventional Radiology University Hospital of Cologne Germany
| | - Volker Maus
- Department of Radiology, Neuroradiology and Nuclear Medicine Ruhr University Bochum Knappschaftskrankenhaus Bochum Bochum Germany
| | - Maria Politi
- Department of Diagnostic and Interventional Neuroradiology Hospital Bremen-Mitte Bremen Germany
| | - Kathleen Bernkopf
- Clinic and Policlinic for Neurology Hospital of the Technical University Munich Munich Germany
| | - Christian Roth
- Department of Diagnostic and Interventional Neuroradiology Hospital Bremen-Mitte Bremen Germany
| | - Andreas Kastrup
- Department of Neurology Hospital Bremen-Mitte Bremen Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Götz Thomalla
- Department of Neurology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Christian Gerloff
- Department of Neurology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Anastasios Mpotsaris
- Department of Diagnostic and Interventional Neuroradiology University Hospital of Aachen Germany
| | - Panagiotis Papanagiotou
- Department of Diagnostic and Interventional Neuroradiology Hospital Bremen-Mitte Bremen Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg-Eppendorf Hamburg Germany
| | - Hannes Leischner
- Department of Diagnostic and Interventional Neuroradiology University Medical Center Hamburg-Eppendorf Hamburg Germany
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