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Prolonged hospital length of stay in pediatric trauma: a model for targeted interventions. Pediatr Res 2021; 90:464-471. [PMID: 33184499 DOI: 10.1038/s41390-020-01237-0] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Revised: 09/17/2020] [Accepted: 10/11/2020] [Indexed: 11/08/2022]
Abstract
BACKGROUND In this study, trauma-specific risk factors of prolonged length of stay (LOS) in pediatric trauma were examined. Statistical and machine learning models were used to proffer ways to improve the quality of care of patients at risk of prolonged length of stay and reduce cost. METHODS Data from 27 hospitals were retrieved on 81,929 hospitalizations of pediatric patients with a primary diagnosis of trauma, and for which the LOS was >24 h. Nested mixed effects model was used for simplified statistical inference, while a stochastic gradient boosting model, considering high-order statistical interactions, was built for prediction. RESULTS Over 18.7% of the encounters had LOS >1 week. Burns and corrosion and suspected and confirmed child abuse are the strongest drivers of prolonged LOS. Several other trauma-specific and general pediatric clinical variables were also predictors of prolonged LOS. The stochastic gradient model obtained an area under the receiver operator characteristic curve of 0.912 (0.907, 0.917). CONCLUSIONS The high performance of the machine learning model coupled with statistical inference from the mixed effects model provide an opportunity for targeted interventions to improve quality of care of trauma patients likely to require long length of stay. IMPACT Targeted interventions on high-risk patients would improve the quality of care of pediatric trauma patients and reduce the length of stay. This comprehensive study includes data from multiple hospitals analyzed with advanced statistical and machine learning models. The statistical and machine learning models provide opportunities for targeted interventions and reduction in prolonged length of stay reducing the burden of hospitalization on families.
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Saito T, Itabashi R, Yazawa Y, Uchida K, Yamagami H, Sakai N, Morimoto T, Yoshimura S, Doijiri R, Enomoto Y, Ezura M, Fukawa N, Furui E, Handa A, Haraguchi K, Hatano T, Hayase M, Hiyama N, Iihara K, Ikeda N, Imai K, Ishihara H, Kamiya Y, Kanbayashi C, Kimura K, Kitagawa K, Kiura Y, Kobayashi J, Kojima T, Kondo R, Kuwayama N, Matsumaru Y, Matsumoto K, Matsumoto Y, Minematsu K, Morimoto M, Nii K, Ogasawara K, Ohnishi H, Ohta H, Ohta T, Okada Y, Onda T, Sakaguchi M, Sakamoto S, Sasaki M, Satomi J, Shibata M, Shindo A, Takeuchi M, Tanahashi N, Toma N, Toyoda K, Tsumoto T, Tsuruta W, Uchiyama N, Yagita Y, Yamashita T, Yamamoto D, Yamaura I, Yamazaki T, Yasuda H. Clinical Outcome of Patients With Large Vessel Occlusion and Low National Institutes of Health Stroke Scale Scores. Stroke 2020; 51:1458-1463. [DOI: 10.1161/strokeaha.119.028562] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose—
The treatment and prognosis of acute large vessel occlusion with mild symptoms have not been sufficiently studied. The present study aimed to investigate the clinical or radiological predictors of clinical outcome in patients with stroke with mild symptoms due to acute large vessel occlusion.
Methods—
Of 2420 patients with acute large vessel occlusion in the RESCUE-Japan Registry 2 (Recovery by Endovascular Salvage for Cerebral Ultra-Acute Embolism-Japan Registry 2), a multicenter prospective registry in Japan, patients with modified Rankin Scale scores of 0 to 2 before onset and initial National Institutes of Health Stroke Scale (NIHSS) scores of 0 to 5 were examined in post hoc analysis. We examined the clinical and radiological characteristics associated with a favorable outcome (modified Rankin Scale score, 0–2 at 90 days) using multivariate analysis, as well as the factors associated with a favorable outcome in patients treated with endovascular therapy.
Results—
We analyzed 272 patients (median age, 73 years; median NIHSS score on admission, 3). Eighty-six (31.6%) patients were treated with intravenous recombinant tissue-type plasminogen activator, 54 (19.9%) underwent endovascular therapy, and 208 (76.5%) showed a favorable outcome. In multivariate analysis, age <75 years (odds ratio [OR], 2.42 [95% CI, 1.30–4.50]), initial NIHSS score 0 to 3 (OR, 3.08 [95% CI, 1.59–5.98]), intravenous recombinant tissue-type plasminogen activator (OR, 2. 86 [95% CI, 1.32–6.21]), and blood glucose level ≤140 mg/dL (OR, 2.37 [95% CI, 1.22–4.60]) were independently associated with a favorable outcome. However, endovascular therapy was not associated with a favorable outcome (OR, 1.65 [95% CI, 0.71–3.88]). Among 54 patients treated with endovascular therapy, good reperfusion status was more common in the favorable outcome group (88.6% versus 60.0%;
P
<0.05).
Conclusions—
Younger age, lower initial NIHSS score, intravenous recombinant tissue-type plasminogen activator, and absence of hyperglycemia were independently associated with a favorable outcome in patients with acute large vessel occlusion with low NIHSS scores.
Registration—
URL:
https://www.clinicaltrials.gov
; Unique identifier: NCT02419794.
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Affiliation(s)
- Takuya Saito
- From the Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan (T.S., Y.Y.)
| | - Ryo Itabashi
- Division of Neurology and Gerontology, Department of Internal Medicine, School of Medicine, Iwate Medical University, Yahaba, Japan (R.I.)
| | - Yukako Yazawa
- From the Department of Stroke Neurology, Kohnan Hospital, Sendai, Japan (T.S., Y.Y.)
| | - Kazutaka Uchida
- Department of Neurosurgery (K.U., S.Y.), Hyogo College of Medicine, Nishinomiya, Japan
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Japan (H.Y.)
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Japan (N.S.)
| | - Takeshi Morimoto
- Department of Clinical Epidemiology (T.M.), Hyogo College of Medicine, Nishinomiya, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery (K.U., S.Y.), Hyogo College of Medicine, Nishinomiya, Japan
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Schuler F, Rotkopf LT, Apel D, Fabritius MP, Tiedt S, Wollenweber FA, Kellert L, Dorn F, Liebig T, Thierfelder KM, Kunz WG. Differential Benefit of Collaterals for Stroke Patients Treated with Thrombolysis or Supportive Care : A Propensity Score Matched Analysis. Clin Neuroradiol 2019; 30:525-533. [PMID: 31375893 DOI: 10.1007/s00062-019-00815-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 07/05/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE Leptomeningeal collaterals can slow down infarction growth; however, despite good collaterals in the DAWN and DEFUSE 3 trials, outcomes were devastating if reperfusion was not attempted. The aim of this study was to compare the influence of collaterals on morphological and functional outcome in patients with acute middle cerebral artery (MCA) stroke undergoing intravenous thrombolysis (IVT) vs. supportive care (non-IVT). METHODS Out of 1639 consecutive patients examined with multiparametric computed tomography (CT) for suspected ischemic stroke, all patients with confirmed MCA stroke who did not undergo endovascular thrombectomy were selected. Propensity score matching (PSM) was used to match IVT and non-IVT treated patients for potential confounders including age, sex, National Institutes of Health Stroke Scale (NIHSS) score on admission, Alberta Stroke Program Early CT Score (ASPECTS), and occlusion site. Regression analysis after PSM was performed to identify independent associations. RESULTS After PSM, 90 IVT patients were matched with 90 non-IVT patients. In multivariable regression analysis, a high regional leptomeningeal collateral (rLMC) score was independently associated with lower final infarction volume (FIV) in the IVT group (b = -0.472, p < 0.001) but not in the non-IVT group (b = -0.116, p = 0.327). The trichotomized rLMC scores predicted functional outcome in IVT treated patients (adjusted odds ratio, aOR = 4.57, 95% confidence interval, CI, 1.03-20.32, p = 0.046) but showed no independent association with outcome in the non-IVT group (aOR = 0.69, 95% CI 0.07-6.80, p = 0.753). CONCLUSION Good collaterals favored smaller FIV and good functional outcome in IVT treated patients but not in non-IVT treated patients. Good collateral flow may have limited prognostic value if IVT is not administered to attempt reperfusion.
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Affiliation(s)
- Felix Schuler
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany.
| | - Lukas T Rotkopf
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Daniel Apel
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Matthias P Fabritius
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research, University Hospital, LMU Munich, Munich, Germany
| | - Frank A Wollenweber
- Institute for Stroke and Dementia Research, University Hospital, LMU Munich, Munich, Germany
| | - Lars Kellert
- Department of Neurology, University Hospital, LMU Munich, Munich, Germany
| | - Franziska Dorn
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital, LMU Munich, Munich, Germany
| | - Thomas Liebig
- Institute of Diagnostic and Interventional Neuroradiology, University Hospital, LMU Munich, Munich, Germany
| | - Kolja M Thierfelder
- Institute for Diagnostic and Interventional Radiology, University Medical Center Rostock, Rostock, Germany
| | - Wolfgang G Kunz
- Department of Radiology, University Hospital, LMU Munich, Marchioninistr. 15, 81377, Munich, Germany
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Tian H, Parsons MW, Levi CR, Cheng X, Aviv RI, Spratt NJ, Kleinig TJ, O'Brien B, Butcher KS, Lin L, Zhang J, Dong Q, Chen C, Bivard A. Intravenous Thrombolysis May Not Improve Clinical Outcome of Acute Ischemic Stroke Patients Without a Baseline Vessel Occlusion. Front Neurol 2018; 9:405. [PMID: 29928251 PMCID: PMC5997810 DOI: 10.3389/fneur.2018.00405] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2018] [Accepted: 05/17/2018] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: The benefit of thrombolysis in ischemic stroke patients without a visible vessel occlusion still requires investigation. This study tested the hypothesis that non-lacunar stroke patients with no visible vessel occlusion on baseline imaging would have a favorable outcome regardless of treatment with alteplase. Methods: We utilized a prospectively collected registry of ischemic stroke patients [the International Stroke Perfusion Imaging Registry (INSPIRE)] who had baseline computed tomographic perfusion and computed tomographic angiography. The rates of patients achieving modified Rankin Scale (mRS) 0-1 were compared between alteplase treated and untreated patients using logistic regression to generate odds ratios. Results: Of 1569 patients in the INSPIRE registry, 1,277 were eligible for inclusion. Of these, 306 (24%) had no identifiable occlusion and were eligible for alteplase, with 141 (46%) of these patients receiving thrombolysis. The treated and untreated groups had significantly different median baseline National Institutes of Health Stroke Scale (NIHSS) [alteplase 8, interquartile range (IQR) 5-10, untreated 6, IQR 4-8, P < 0.001] and median volume of baseline perfusion lesion [alteplase 5.6 mL, IQR 1.3-17.7 mL, untreated 2.6 mL, IQR 0-6.7 mL, P < 0.001]. After propensity analysis, alteplase treated patients without a vessel occlusion were less likely to have an excellent outcome (mRS 0-1; 56%) than untreated (78.8%, OR, 0.42, 95% confidence interval, 0.24-0.75, P = 0.003). Conclusions: In this non-randomized comparison, alteplase treatment in patients without an identifiable vessel occlusion did not result in higher rates of favorable outcome compared to untreated. However, treated patients displayed less favorable baseline prognostic factors than the untreated group. Further studies may be required to confirm this data.
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Affiliation(s)
- Huiqiao Tian
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Mark W Parsons
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Christopher R Levi
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Xin Cheng
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Richard I Aviv
- Division of Neuroradiology, Department of Medical Imaging, University of Toronto and Sunnybrook Health Sciences Centre, Toronto, ON, Canada
| | - Neil J Spratt
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, SA, Australia
| | - Billy O'Brien
- Department of Neurology, Gosford Hospital, Gosford, NSW, Australia
| | - Kenneth S Butcher
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Longting Lin
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Jingfen Zhang
- Department of Neurology, Baotou Central Hospital, Baotou, China
| | - Qiang Dong
- Department of Neurology, Huashan Hospital, Fudan University, Shanghai, China
| | - Chushuang Chen
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
| | - Andrew Bivard
- Department of Neurology, John Hunter Hospital, University of Newcastle, Newcastle, NSW, Australia
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5
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Impact of smoking on stroke outcome after endovascular treatment. PLoS One 2018; 13:e0194652. [PMID: 29718909 PMCID: PMC5931491 DOI: 10.1371/journal.pone.0194652] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2017] [Accepted: 03/07/2018] [Indexed: 12/21/2022] Open
Abstract
Background Recent studies suggest a paradoxical association between smoking status and clinical outcome after intravenous thrombolysis (IVT). Little is known about relationship between smoking and stroke outcome after endovascular treatment (EVT). Methods We analyzed data of all stroke patients treated with EVT at the tertiary stroke centre of Berne between January 2005 and December 2015. Using uni- and multivariate modeling, we assessed whether smoking was independently associated with excellent clinical outcome (modified Rankin Scale (mRS) 0–1) and mortality at 3 months. In addition, we also measured the occurrence of symptomatic intracranial hemorrhage (sICH) and recanalization. Results Of 935 patients, 204 (21.8%) were smokers. They were younger (60.5 vs. 70.1 years of age, p<0.001), more often male (60.8% vs. 52.5%, p = 0.036), had less often from hypertension (56.4% vs. 69.6%, p<0.001) and were less often treated with antithrombotics (35.3% vs. 47.7%, p = 0.004) as compared to nonsmokers. In univariate analyses, smokers had higher rates of excellent clinical outcome (39.1% vs. 23.1%, p<0.001) and arterial recanalization (85.6% vs. 79.4%, p = 0.048), whereas mortality was lower (15.6% vs. 25%, p = 0.006) and frequency of sICH similar (4.4% vs. 4.1%, p = 0.86). After correcting for confounders, smoking still independently predicted excellent clinical outcome (OR 1.758, 95% CI 1.206–2.562; p<0.001). Conclusion Smoking in stroke patients may be a predictor of excellent clinical outcome after EVT. However, these data must not be misinterpreted as beneficial effect of smoking due to the observational study design. In view of deleterious effects of cigarette smoking on cardiovascular health, cessation of smoking should still be strongly recommended for stroke prevention.
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Kunz WG, Fabritius MP, Sommer WH, Höhne C, Scheffler P, Rotkopf LT, Fendler WP, Sabel BO, Meinel FG, Dorn F, Ertl-Wagner B, Reiser MF, Thierfelder KM. Effect of stroke thrombolysis predicted by distal vessel occlusion detection. Neurology 2018; 90:e1742-e1750. [PMID: 29678936 DOI: 10.1212/wnl.0000000000005519] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 02/26/2018] [Indexed: 11/15/2022] Open
Abstract
OBJECTIVE Among ischemic stroke patients with negative CT angiography (CTA), we aimed to determine the predictive value of enhanced distal vessel occlusion detection using CT perfusion postprocessing (waveletCTA) for the treatment effect of IV thrombolysis (IVT). METHODS Patients were selected from 1,851 consecutive patients who had undergone CT perfusion. Inclusion criteria were (1) significant cerebral blood flow (CBF) deficit, (2) no occlusion on CTA, and (3) infarction confirmed on follow-up. Favorable morphologic response was defined as smaller values of final infarction volume divided by initial CBF deficit volume (FIV/CBF). Favorable functional outcome was defined as modified Rankin Scale score of ≤2 after 90 days and decrease in NIH Stroke Scale score of ≥3 from admission to 24 hours (∆NIHSS). RESULTS Among patients with negative CTA (n = 107), 58 (54%) showed a distal occlusion on waveletCTA. There was no difference between patients receiving IVT (n = 57) vs supportive care (n = 50) regarding symptom onset, early ischemic changes, perfusion mismatch, or admission NIHSS score (all p > 0.05). In IVT-treated patients, the presence of an occlusion was an independent predictor of a favorable morphologic response (FIV/CBF: β -1.43; 95% confidence interval [CI] -1.96, -0.83; p = 0.001) and functional outcome (90-day modified Rankin Scale: odds ratio 7.68; 95% CI 4.33-11.51; p = 0.039; ∆NIHSS: odds ratio 5.76; 95% CI 3.98-8.27; p = 0.013), while it did not predict outcome in patients receiving supportive care (all p > 0.05). CONCLUSION In stroke patients with negative CTA, distal vessel occlusions as detected by waveletCTA are an independent predictor of a favorable response to IVT.
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Affiliation(s)
- Wolfgang G Kunz
- From the Departments of Radiology (W.G.K., M.P.F., W.H.S., L.T.R., B.O.S., F.G.M., B.E.-W., M.F.R., K.M.T.), Neurology (C.H., P.S.), Nuclear Medicine (W.P.F.), and Neuroradiology (F.D.), University Hospital, LMU Munich; and the Institute of Diagnostic and Interventional Radiology (F.G.M., K.M.T.), University Medical Center Rostock, Germany.
| | - Matthias P Fabritius
- From the Departments of Radiology (W.G.K., M.P.F., W.H.S., L.T.R., B.O.S., F.G.M., B.E.-W., M.F.R., K.M.T.), Neurology (C.H., P.S.), Nuclear Medicine (W.P.F.), and Neuroradiology (F.D.), University Hospital, LMU Munich; and the Institute of Diagnostic and Interventional Radiology (F.G.M., K.M.T.), University Medical Center Rostock, Germany
| | - Wieland H Sommer
- From the Departments of Radiology (W.G.K., M.P.F., W.H.S., L.T.R., B.O.S., F.G.M., B.E.-W., M.F.R., K.M.T.), Neurology (C.H., P.S.), Nuclear Medicine (W.P.F.), and Neuroradiology (F.D.), University Hospital, LMU Munich; and the Institute of Diagnostic and Interventional Radiology (F.G.M., K.M.T.), University Medical Center Rostock, Germany
| | - Christopher Höhne
- From the Departments of Radiology (W.G.K., M.P.F., W.H.S., L.T.R., B.O.S., F.G.M., B.E.-W., M.F.R., K.M.T.), Neurology (C.H., P.S.), Nuclear Medicine (W.P.F.), and Neuroradiology (F.D.), University Hospital, LMU Munich; and the Institute of Diagnostic and Interventional Radiology (F.G.M., K.M.T.), University Medical Center Rostock, Germany
| | - Pierre Scheffler
- From the Departments of Radiology (W.G.K., M.P.F., W.H.S., L.T.R., B.O.S., F.G.M., B.E.-W., M.F.R., K.M.T.), Neurology (C.H., P.S.), Nuclear Medicine (W.P.F.), and Neuroradiology (F.D.), University Hospital, LMU Munich; and the Institute of Diagnostic and Interventional Radiology (F.G.M., K.M.T.), University Medical Center Rostock, Germany
| | - Lukas T Rotkopf
- From the Departments of Radiology (W.G.K., M.P.F., W.H.S., L.T.R., B.O.S., F.G.M., B.E.-W., M.F.R., K.M.T.), Neurology (C.H., P.S.), Nuclear Medicine (W.P.F.), and Neuroradiology (F.D.), University Hospital, LMU Munich; and the Institute of Diagnostic and Interventional Radiology (F.G.M., K.M.T.), University Medical Center Rostock, Germany
| | - Wolfgang P Fendler
- From the Departments of Radiology (W.G.K., M.P.F., W.H.S., L.T.R., B.O.S., F.G.M., B.E.-W., M.F.R., K.M.T.), Neurology (C.H., P.S.), Nuclear Medicine (W.P.F.), and Neuroradiology (F.D.), University Hospital, LMU Munich; and the Institute of Diagnostic and Interventional Radiology (F.G.M., K.M.T.), University Medical Center Rostock, Germany
| | - Bastian O Sabel
- From the Departments of Radiology (W.G.K., M.P.F., W.H.S., L.T.R., B.O.S., F.G.M., B.E.-W., M.F.R., K.M.T.), Neurology (C.H., P.S.), Nuclear Medicine (W.P.F.), and Neuroradiology (F.D.), University Hospital, LMU Munich; and the Institute of Diagnostic and Interventional Radiology (F.G.M., K.M.T.), University Medical Center Rostock, Germany
| | - Felix G Meinel
- From the Departments of Radiology (W.G.K., M.P.F., W.H.S., L.T.R., B.O.S., F.G.M., B.E.-W., M.F.R., K.M.T.), Neurology (C.H., P.S.), Nuclear Medicine (W.P.F.), and Neuroradiology (F.D.), University Hospital, LMU Munich; and the Institute of Diagnostic and Interventional Radiology (F.G.M., K.M.T.), University Medical Center Rostock, Germany
| | - Franziska Dorn
- From the Departments of Radiology (W.G.K., M.P.F., W.H.S., L.T.R., B.O.S., F.G.M., B.E.-W., M.F.R., K.M.T.), Neurology (C.H., P.S.), Nuclear Medicine (W.P.F.), and Neuroradiology (F.D.), University Hospital, LMU Munich; and the Institute of Diagnostic and Interventional Radiology (F.G.M., K.M.T.), University Medical Center Rostock, Germany
| | - Birgit Ertl-Wagner
- From the Departments of Radiology (W.G.K., M.P.F., W.H.S., L.T.R., B.O.S., F.G.M., B.E.-W., M.F.R., K.M.T.), Neurology (C.H., P.S.), Nuclear Medicine (W.P.F.), and Neuroradiology (F.D.), University Hospital, LMU Munich; and the Institute of Diagnostic and Interventional Radiology (F.G.M., K.M.T.), University Medical Center Rostock, Germany
| | - Maximilian F Reiser
- From the Departments of Radiology (W.G.K., M.P.F., W.H.S., L.T.R., B.O.S., F.G.M., B.E.-W., M.F.R., K.M.T.), Neurology (C.H., P.S.), Nuclear Medicine (W.P.F.), and Neuroradiology (F.D.), University Hospital, LMU Munich; and the Institute of Diagnostic and Interventional Radiology (F.G.M., K.M.T.), University Medical Center Rostock, Germany
| | - Kolja M Thierfelder
- From the Departments of Radiology (W.G.K., M.P.F., W.H.S., L.T.R., B.O.S., F.G.M., B.E.-W., M.F.R., K.M.T.), Neurology (C.H., P.S.), Nuclear Medicine (W.P.F.), and Neuroradiology (F.D.), University Hospital, LMU Munich; and the Institute of Diagnostic and Interventional Radiology (F.G.M., K.M.T.), University Medical Center Rostock, Germany
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Bhaskar S, Stanwell P, Cordato D, Attia J, Levi C. Reperfusion therapy in acute ischemic stroke: dawn of a new era? BMC Neurol 2018; 18:8. [PMID: 29338750 PMCID: PMC5771207 DOI: 10.1186/s12883-017-1007-y] [Citation(s) in RCA: 142] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Accepted: 12/14/2017] [Indexed: 12/14/2022] Open
Abstract
Following the success of recent endovascular trials, endovascular therapy has emerged as an exciting addition to the arsenal of clinical management of patients with acute ischemic stroke (AIS). In this paper, we present an extensive overview of intravenous and endovascular reperfusion strategies, recent advances in AIS neurointervention, limitations of various treatment paradigms, and provide insights on imaging-guided reperfusion therapies. A roadmap for imaging guided reperfusion treatment workflow in AIS is also proposed. Both systemic thrombolysis and endovascular treatment have been incorporated into the standard of care in stroke therapy. Further research on advanced imaging-based approaches to select appropriate patients, may widen the time-window for patient selection and would contribute immensely to early thrombolytic strategies, better recanalization rates, and improved clinical outcomes.
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Affiliation(s)
- Sonu Bhaskar
- Western Sydney University (WSU), School of Medicine, South West Sydney Clinical School, Sydney, NSW 2170 Australia
- Liverpool Hospital, Department of Neurology & Neurophysiology, Liverpool, 2170 NSW Australia
- The Sydney Partnership for Health, Education, Research & Enterprise (SPHERE), Liverpool, NSW Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW 2170 Australia
- Department of Neurology, John Hunter Hospital, Newcastle, NSW Australia
- Priority Research Centre for Stroke & Brain Injury, Faculty of Health & Medicine, Hunter Medical Research institute (HMRI) and School of Medicine & Public Health, University of Newcastle, Newcastle, NSW Australia
| | - Peter Stanwell
- Priority Research Centre for Stroke & Brain Injury, Faculty of Health & Medicine, Hunter Medical Research institute (HMRI) and School of Medicine & Public Health, University of Newcastle, Newcastle, NSW Australia
| | - Dennis Cordato
- Liverpool Hospital, Department of Neurology & Neurophysiology, Liverpool, 2170 NSW Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW 2170 Australia
- School of Medicine, University of New South Wales (UNSW), Sydney, NSW Australia
| | - John Attia
- Priority Research Centre for Stroke & Brain Injury, Faculty of Health & Medicine, Hunter Medical Research institute (HMRI) and School of Medicine & Public Health, University of Newcastle, Newcastle, NSW Australia
- Centre for Clinical Epidemiology & Biostatistics, Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW Australia
| | - Christopher Levi
- Western Sydney University (WSU), School of Medicine, South West Sydney Clinical School, Sydney, NSW 2170 Australia
- Liverpool Hospital, Department of Neurology & Neurophysiology, Liverpool, 2170 NSW Australia
- The Sydney Partnership for Health, Education, Research & Enterprise (SPHERE), Liverpool, NSW Australia
- Stroke & Neurology Research Group, Ingham Institute for Applied Medical Research, 1 Campbell Street, Liverpool, NSW 2170 Australia
- School of Medicine, University of New South Wales (UNSW), Sydney, NSW Australia
- Department of Neurology, John Hunter Hospital, Newcastle, NSW Australia
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8
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Detection of single-phase CTA occult vessel occlusions in acute ischemic stroke using CT perfusion-based wavelet-transformed angiography. Eur Radiol 2017; 27:2657-2664. [DOI: 10.1007/s00330-016-4613-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2016] [Revised: 08/21/2016] [Accepted: 09/15/2016] [Indexed: 10/20/2022]
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Rotzinger DC, Mosimann PJ, Meuli RA, Maeder P, Michel P. Site and Rate of Occlusive Disease in Cervicocerebral Arteries: A CT Angiography Study of 2209 Patients with Acute Ischemic Stroke. AJNR Am J Neuroradiol 2017; 38:868-874. [PMID: 28302611 DOI: 10.3174/ajnr.a5123] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2016] [Accepted: 12/13/2016] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE CTA can rapidly and accurately detect and localize occlusive disease in patients with ischemic stroke. We have used CTA to assess arterial stenosis and occlusion in an ischemic stroke population arriving at a tertiary stroke center within 24 hours of symptom onset in order to obtain a comprehensive picture of occlusive disease pattern, and to determine the proportion of eligible candidates for endovascular treatment. MATERIALS AND METHODS Data from consecutive patients with acute ischemic stroke admitted to a single center between 2003 and 2012, collected in the Acute Stroke Registry and Analysis of Lausanne data base, were retrospectively analyzed. Patients with a diagnostic CTA within 24 hours of symptom onset were selected. Relevant extra- and intracranial pathology, defined as stenosis of ≥50% and occlusions, were registered and classified into 21 prespecified segments. RESULTS Of the 2209 included patients (42.1% women; median age, 72 years), 1075 (48.7%) had pathology in and 308 (13.9%) had pathology outside the ischemic territory. In the 50,807 arterial segments available for revision, 1851 (3.6%) abnormal segments were in the ischemic (symptomatic) territory and another 408 (0.8%) were outside it (asymptomatic). In the 1211 patients with ischemic stroke imaged within 6 hours of symptom onset, 40.7% had symptomatic large, proximal occlusions potentially amenable to endovascular therapy. CONCLUSIONS CTA in patients with acute ischemic stroke shows large individual variations of occlusion sites and degrees. Approximately half of such patients have no visible occlusive disease, and 40% imaged within 6 hours show large, proximal segment occlusions amenable to endovascular therapy. These findings show the importance of early noninvasive imaging of extra- and intracranial arteries for identifying occlusive disease, planning recanalization strategies, and designing interventional trials.
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Affiliation(s)
- D C Rotzinger
- From the Department of Diagnostic and Interventional Radiology (D.C.R., P.J.M., R.A.M., P. Maeder)
| | - P J Mosimann
- From the Department of Diagnostic and Interventional Radiology (D.C.R., P.J.M., R.A.M., P. Maeder)
| | - R A Meuli
- From the Department of Diagnostic and Interventional Radiology (D.C.R., P.J.M., R.A.M., P. Maeder)
| | - P Maeder
- From the Department of Diagnostic and Interventional Radiology (D.C.R., P.J.M., R.A.M., P. Maeder)
| | - P Michel
- Neurology Service (P. Michel), Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
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10
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Mair G, von Kummer R, Adami A, White PM, Adams ME, Yan B, Demchuk AM, Farrall AJ, Sellar RJ, Sakka E, Palmer J, Perry D, Lindley RI, Sandercock PAG, Wardlaw JM. Arterial Obstruction on Computed Tomographic or Magnetic Resonance Angiography and Response to Intravenous Thrombolytics in Ischemic Stroke. Stroke 2016; 48:353-360. [PMID: 28008093 PMCID: PMC5266422 DOI: 10.1161/strokeaha.116.015164] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2016] [Revised: 11/01/2016] [Accepted: 11/11/2016] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Computed tomographic angiography and magnetic resonance angiography are used increasingly to assess arterial patency in patients with ischemic stroke. We determined which baseline angiography features predict response to intravenous thrombolytics in ischemic stroke using randomized controlled trial data. METHODS We analyzed angiograms from the IST-3 (Third International Stroke Trial), an international, multicenter, prospective, randomized controlled trial of intravenous alteplase. Readers, masked to clinical, treatment, and outcome data, assessed prerandomization computed tomographic angiography and magnetic resonance angiography for presence, extent, location, and completeness of obstruction and collaterals. We compared angiography findings to 6-month functional outcome (Oxford Handicap Scale) and tested for interactions with alteplase, using ordinal regression in adjusted analyses. We also meta-analyzed all available angiography data from other randomized controlled trials of intravenous thrombolytics. RESULTS In IST-3, 300 patients had prerandomization angiography (computed tomographic angiography=271 and magnetic resonance angiography=29). On multivariable analysis, more extensive angiographic obstruction and poor collaterals independently predicted poor outcome (P<0.01). We identified no significant interaction between angiography findings and alteplase effect on Oxford Handicap Scale (P≥0.075) in IST-3. In meta-analysis (5 trials of alteplase or desmoteplase, including IST-3, n=591), there was a significantly increased benefit of thrombolytics on outcome (odds ratio>1 indicates benefit) in patients with (odds ratio, 2.07; 95% confidence interval, 1.18-3.64; P=0.011) versus without (odds ratio, 0.88; 95% confidence interval, 0.58-1.35; P=0.566) arterial obstruction (P for interaction 0.017). CONCLUSIONS Intravenous thrombolytics provide benefit to stroke patients with computed tomographic angiography or magnetic resonance angiography evidence of arterial obstruction, but the sample was underpowered to demonstrate significant treatment benefit or harm among patients with apparently patent arteries. CLINICAL TRIAL REGISTRATION URL: http://www.isrctn.com. Unique identifier: ISRCTN25765518.
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Affiliation(s)
- Grant Mair
- From the Division of Neuroimaging Sciences (G.M., A.J.F., R.J.S., E.S., J.P., J.M.W.) and Division of Clinical Neurosciences (D.P., P.A.G.S.), University of Edinburgh, United Kingdom; Department of Neuroradiology, Dresden University Stroke Centre, Germany (R.v.K.); Stroke Center, Sacro Cuore-Don Calabria Hospital, Verona, Italy (A.A.); Stroke Research Group, Newcastle upon Tyne, United Kingdom (P.M.W.); National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.E.A.); Neurovascular Research Group, Royal Melbourne Hospital, Australia (B.Y.); Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (A.M.D.); and Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Australia (R.I.L.)
| | - Rüdiger von Kummer
- From the Division of Neuroimaging Sciences (G.M., A.J.F., R.J.S., E.S., J.P., J.M.W.) and Division of Clinical Neurosciences (D.P., P.A.G.S.), University of Edinburgh, United Kingdom; Department of Neuroradiology, Dresden University Stroke Centre, Germany (R.v.K.); Stroke Center, Sacro Cuore-Don Calabria Hospital, Verona, Italy (A.A.); Stroke Research Group, Newcastle upon Tyne, United Kingdom (P.M.W.); National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.E.A.); Neurovascular Research Group, Royal Melbourne Hospital, Australia (B.Y.); Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (A.M.D.); and Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Australia (R.I.L.)
| | - Alessandro Adami
- From the Division of Neuroimaging Sciences (G.M., A.J.F., R.J.S., E.S., J.P., J.M.W.) and Division of Clinical Neurosciences (D.P., P.A.G.S.), University of Edinburgh, United Kingdom; Department of Neuroradiology, Dresden University Stroke Centre, Germany (R.v.K.); Stroke Center, Sacro Cuore-Don Calabria Hospital, Verona, Italy (A.A.); Stroke Research Group, Newcastle upon Tyne, United Kingdom (P.M.W.); National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.E.A.); Neurovascular Research Group, Royal Melbourne Hospital, Australia (B.Y.); Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (A.M.D.); and Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Australia (R.I.L.)
| | - Philip M White
- From the Division of Neuroimaging Sciences (G.M., A.J.F., R.J.S., E.S., J.P., J.M.W.) and Division of Clinical Neurosciences (D.P., P.A.G.S.), University of Edinburgh, United Kingdom; Department of Neuroradiology, Dresden University Stroke Centre, Germany (R.v.K.); Stroke Center, Sacro Cuore-Don Calabria Hospital, Verona, Italy (A.A.); Stroke Research Group, Newcastle upon Tyne, United Kingdom (P.M.W.); National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.E.A.); Neurovascular Research Group, Royal Melbourne Hospital, Australia (B.Y.); Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (A.M.D.); and Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Australia (R.I.L.)
| | - Matthew E Adams
- From the Division of Neuroimaging Sciences (G.M., A.J.F., R.J.S., E.S., J.P., J.M.W.) and Division of Clinical Neurosciences (D.P., P.A.G.S.), University of Edinburgh, United Kingdom; Department of Neuroradiology, Dresden University Stroke Centre, Germany (R.v.K.); Stroke Center, Sacro Cuore-Don Calabria Hospital, Verona, Italy (A.A.); Stroke Research Group, Newcastle upon Tyne, United Kingdom (P.M.W.); National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.E.A.); Neurovascular Research Group, Royal Melbourne Hospital, Australia (B.Y.); Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (A.M.D.); and Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Australia (R.I.L.)
| | - Bernard Yan
- From the Division of Neuroimaging Sciences (G.M., A.J.F., R.J.S., E.S., J.P., J.M.W.) and Division of Clinical Neurosciences (D.P., P.A.G.S.), University of Edinburgh, United Kingdom; Department of Neuroradiology, Dresden University Stroke Centre, Germany (R.v.K.); Stroke Center, Sacro Cuore-Don Calabria Hospital, Verona, Italy (A.A.); Stroke Research Group, Newcastle upon Tyne, United Kingdom (P.M.W.); National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.E.A.); Neurovascular Research Group, Royal Melbourne Hospital, Australia (B.Y.); Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (A.M.D.); and Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Australia (R.I.L.)
| | - Andrew M Demchuk
- From the Division of Neuroimaging Sciences (G.M., A.J.F., R.J.S., E.S., J.P., J.M.W.) and Division of Clinical Neurosciences (D.P., P.A.G.S.), University of Edinburgh, United Kingdom; Department of Neuroradiology, Dresden University Stroke Centre, Germany (R.v.K.); Stroke Center, Sacro Cuore-Don Calabria Hospital, Verona, Italy (A.A.); Stroke Research Group, Newcastle upon Tyne, United Kingdom (P.M.W.); National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.E.A.); Neurovascular Research Group, Royal Melbourne Hospital, Australia (B.Y.); Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (A.M.D.); and Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Australia (R.I.L.)
| | - Andrew J Farrall
- From the Division of Neuroimaging Sciences (G.M., A.J.F., R.J.S., E.S., J.P., J.M.W.) and Division of Clinical Neurosciences (D.P., P.A.G.S.), University of Edinburgh, United Kingdom; Department of Neuroradiology, Dresden University Stroke Centre, Germany (R.v.K.); Stroke Center, Sacro Cuore-Don Calabria Hospital, Verona, Italy (A.A.); Stroke Research Group, Newcastle upon Tyne, United Kingdom (P.M.W.); National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.E.A.); Neurovascular Research Group, Royal Melbourne Hospital, Australia (B.Y.); Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (A.M.D.); and Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Australia (R.I.L.)
| | - Robin J Sellar
- From the Division of Neuroimaging Sciences (G.M., A.J.F., R.J.S., E.S., J.P., J.M.W.) and Division of Clinical Neurosciences (D.P., P.A.G.S.), University of Edinburgh, United Kingdom; Department of Neuroradiology, Dresden University Stroke Centre, Germany (R.v.K.); Stroke Center, Sacro Cuore-Don Calabria Hospital, Verona, Italy (A.A.); Stroke Research Group, Newcastle upon Tyne, United Kingdom (P.M.W.); National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.E.A.); Neurovascular Research Group, Royal Melbourne Hospital, Australia (B.Y.); Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (A.M.D.); and Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Australia (R.I.L.)
| | - Eleni Sakka
- From the Division of Neuroimaging Sciences (G.M., A.J.F., R.J.S., E.S., J.P., J.M.W.) and Division of Clinical Neurosciences (D.P., P.A.G.S.), University of Edinburgh, United Kingdom; Department of Neuroradiology, Dresden University Stroke Centre, Germany (R.v.K.); Stroke Center, Sacro Cuore-Don Calabria Hospital, Verona, Italy (A.A.); Stroke Research Group, Newcastle upon Tyne, United Kingdom (P.M.W.); National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.E.A.); Neurovascular Research Group, Royal Melbourne Hospital, Australia (B.Y.); Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (A.M.D.); and Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Australia (R.I.L.)
| | - Jeb Palmer
- From the Division of Neuroimaging Sciences (G.M., A.J.F., R.J.S., E.S., J.P., J.M.W.) and Division of Clinical Neurosciences (D.P., P.A.G.S.), University of Edinburgh, United Kingdom; Department of Neuroradiology, Dresden University Stroke Centre, Germany (R.v.K.); Stroke Center, Sacro Cuore-Don Calabria Hospital, Verona, Italy (A.A.); Stroke Research Group, Newcastle upon Tyne, United Kingdom (P.M.W.); National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.E.A.); Neurovascular Research Group, Royal Melbourne Hospital, Australia (B.Y.); Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (A.M.D.); and Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Australia (R.I.L.)
| | - David Perry
- From the Division of Neuroimaging Sciences (G.M., A.J.F., R.J.S., E.S., J.P., J.M.W.) and Division of Clinical Neurosciences (D.P., P.A.G.S.), University of Edinburgh, United Kingdom; Department of Neuroradiology, Dresden University Stroke Centre, Germany (R.v.K.); Stroke Center, Sacro Cuore-Don Calabria Hospital, Verona, Italy (A.A.); Stroke Research Group, Newcastle upon Tyne, United Kingdom (P.M.W.); National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.E.A.); Neurovascular Research Group, Royal Melbourne Hospital, Australia (B.Y.); Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (A.M.D.); and Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Australia (R.I.L.)
| | - Richard I Lindley
- From the Division of Neuroimaging Sciences (G.M., A.J.F., R.J.S., E.S., J.P., J.M.W.) and Division of Clinical Neurosciences (D.P., P.A.G.S.), University of Edinburgh, United Kingdom; Department of Neuroradiology, Dresden University Stroke Centre, Germany (R.v.K.); Stroke Center, Sacro Cuore-Don Calabria Hospital, Verona, Italy (A.A.); Stroke Research Group, Newcastle upon Tyne, United Kingdom (P.M.W.); National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.E.A.); Neurovascular Research Group, Royal Melbourne Hospital, Australia (B.Y.); Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (A.M.D.); and Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Australia (R.I.L.)
| | - Peter A G Sandercock
- From the Division of Neuroimaging Sciences (G.M., A.J.F., R.J.S., E.S., J.P., J.M.W.) and Division of Clinical Neurosciences (D.P., P.A.G.S.), University of Edinburgh, United Kingdom; Department of Neuroradiology, Dresden University Stroke Centre, Germany (R.v.K.); Stroke Center, Sacro Cuore-Don Calabria Hospital, Verona, Italy (A.A.); Stroke Research Group, Newcastle upon Tyne, United Kingdom (P.M.W.); National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.E.A.); Neurovascular Research Group, Royal Melbourne Hospital, Australia (B.Y.); Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (A.M.D.); and Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Australia (R.I.L.)
| | - Joanna M Wardlaw
- From the Division of Neuroimaging Sciences (G.M., A.J.F., R.J.S., E.S., J.P., J.M.W.) and Division of Clinical Neurosciences (D.P., P.A.G.S.), University of Edinburgh, United Kingdom; Department of Neuroradiology, Dresden University Stroke Centre, Germany (R.v.K.); Stroke Center, Sacro Cuore-Don Calabria Hospital, Verona, Italy (A.A.); Stroke Research Group, Newcastle upon Tyne, United Kingdom (P.M.W.); National Hospital for Neurology and Neurosurgery, London, United Kingdom (M.E.A.); Neurovascular Research Group, Royal Melbourne Hospital, Australia (B.Y.); Calgary Stroke Program, Hotchkiss Brain Institute, University of Calgary, Canada (A.M.D.); and Westmead Hospital Clinical School and The George Institute for Global Health, University of Sydney, Australia (R.I.L.).
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11
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Ajili N, Decroix JP, Preda C, Labreuche J, Lopez D, Bejot Y, Michel P, Sévin-Allouet M, Sibon I, Vergnet S, Wang A, Sanda N, Mazighi M, Bourdain F, Lapergue B. Impact of thrombolysis in acute ischaemic stroke without occlusion: an observational comparative study. Eur J Neurol 2016; 23:1380-6. [PMID: 27222165 DOI: 10.1111/ene.13042] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 04/04/2016] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE The impact of intravenous recombinant tissue plasminogen activator (IV-rtPA) in patients with acute ischaemic stroke (AIS) but no arterial occlusion is currently a matter of debate. This study aimed to assess functional outcome of such patients with respect to IV-rtPA use. METHODS A retrospective case-control analysis was performed comparing the outcome of AIS patients without arterial occlusion with or without IV-rtPA use. Patients were selected from prospective consecutive observational registries of five European university hospitals. The primary study outcome was excellent outcome at 3 months after stroke, as defined by a modified Rankin Scale (mRS) 0-1. RESULTS A total of 488 patients without arterial occlusion documented by angiography were included in the present study; 300 received IV-rtPA and 188 did not. No between-group difference was found for excellent outcome before and after adjustment for baseline characteristics (adjusted odds ratio for no IV-rtPA use 0.79, 95% confidence interval 0.51-1.24, P = 0.31). Similar results were found for favourable outcome (defined as a 90-day mRS of 0-2) whereas a higher rate of early neurological improvement was found in IV-rtPA-treated patients (adjusted odds ratio 1.99; 95% confidence interval 1.29-3.07, P = 0.002). Sensitivity analyses yielded similar results. CONCLUSIONS Our study suggests that AIS patients without visible arterial occlusion treated with IV-rtPA may have no better outcome at 3 months than those untreated. However, only a randomized controlled trial would provide a definitive answer about the impact of rtPA in acute stroke patients without occlusion. Until then, these patients should be treated by rtPA as recommended.
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Affiliation(s)
- N Ajili
- Division of Neurology, Stroke Centre, Foch Hospital, University Versailles Saint-Quentin en Yvelines, Suresnes, France
| | - J P Decroix
- Division of Neurology, Stroke Centre, Foch Hospital, University Versailles Saint-Quentin en Yvelines, Suresnes, France
| | - C Preda
- Laboratoire de Mathématiques Paul Painlevé, UMR CNRS 8524, Lille, France
| | - J Labreuche
- Department of Biostatistics, Lille University Medical Centre, Lille, France
| | - D Lopez
- Division of Neurology, Stroke Centre, Foch Hospital, University Versailles Saint-Quentin en Yvelines, Suresnes, France
| | - Y Bejot
- Department of Neurology, University Hospital and Medical School of Dijon, Dijon, France
| | - P Michel
- Neurology Service, Centre Hospitalier Universitaire Vaudois and University of Lausanne, Lausanne, Switzerland
| | - M Sévin-Allouet
- Department of Neurology, Nantes University Hospital, Nantes, France
| | - I Sibon
- Université Bordeaux 2, CHU Bordeaux, Pole de Neurosciences Cliniques, Unité neuro-vasculaire, Bordeaux, France
| | - S Vergnet
- Université Bordeaux 2, CHU Bordeaux, Pole de Neurosciences Cliniques, Unité neuro-vasculaire, Bordeaux, France
| | - A Wang
- Division of Neurology, Stroke Centre, Foch Hospital, University Versailles Saint-Quentin en Yvelines, Suresnes, France
| | - N Sanda
- Division of Neurology, Stroke Centre, Foch Hospital, University Versailles Saint-Quentin en Yvelines, Suresnes, France
| | - M Mazighi
- Department of Neurology and Stroke Centre, Lariboisière Hospital, Paris, France
| | - F Bourdain
- Division of Neurology, Stroke Centre, Foch Hospital, University Versailles Saint-Quentin en Yvelines, Suresnes, France
| | - B Lapergue
- Division of Neurology, Stroke Centre, Foch Hospital, University Versailles Saint-Quentin en Yvelines, Suresnes, France
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