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Gandhi D, Chen H, Zaidi S, Sahlein DH, Maidan L, Kreitel K, Miller TR, Rahimi S, Al Shekhlee A, Woo HH, Toth G, Schirmer C, Loh Y, Fiorella D. SOFIA Aspiration System as first-line Technique (SOFAST): a prospective, multicenter study to assess the efficacy and safety of the 6 French SOFIA Flow Plus aspiration catheter for endovascular stroke thrombectomy. J Neurointerv Surg 2024:jnis-2024-021811. [PMID: 38937082 DOI: 10.1136/jnis-2024-021811] [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: 04/06/2024] [Accepted: 06/07/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND Mechanical thrombectomy (MT) is the standard of care for acute ischemic stroke (AIS) patients with large vessel occlusion (LVO). The SOFAST study collected clinical evidence on the safety and efficacy of the 6 French SOFIA Flow Plus aspiration catheter (SOFIA 6F) when used as first-line treatment. METHODS This was a prospective, multicenter investigation to assess the safety and efficacy of SOFIA 6F used for first-line aspiration. Anterior circulation LVO stroke patients were enrolled. The primary endpoint was the final modified Thrombolysis in Cerebral Infarction (mTICI)≥2b rate. Secondary endpoints included first-pass and first-line mTICI≥2b rates, times from arteriotomy to clot contact and mTICI≥2b, and 90-day modified Rankin Scale (mRS)≤2. First-line and final mTICI scores were adjudicated by an independent imaging core lab. Safety events were assessed by an independent clinical events adjudicator. RESULTS A total of 108 patients were enrolled across 12 centers from July 2020 to June 2022. Median age was 67 years, median National Institutes of Health Stroke Scale (NIHSS) was 15.5, and 56.5% of patients received intravenous thrombolytics. At the end of the procedure, 97.2%, 85.2%, and 55.6% of patients achieved mTICI≥2b, ≥2c, and 3, respectively. With SOFIA 6F first-line aspiration, 87.0%, 79.6%, and 52.8% achieved mTICI≥2b, ≥2c, and 3, respectively. After the first pass, 75.0%, 70.4%, and 50.9% achieved mTICI≥2b, ≥2c, and 3, respectively. Median times from arteriotomy to clot contact and successful revascularization were 12 and 17 min, respectively. At 90 days, 66.7% of patients achieved mRS≤2. CONCLUSIONS First-line aspiration with SOFIA 6F is safe and effective with high revascularization rates and short procedure times.
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Affiliation(s)
- Dheeraj Gandhi
- Diagnostic Radiology and Nuclear Medicine, Neurology and Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Huanwen Chen
- Diagnostic Radiology and Nuclear Medicine, Neurology and Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
- National Institute of Neurological Disorders and Stroke, National Institutes of Health, Bethesda, Maryland, USA
| | - Syed Zaidi
- Department of Interventional Neurology, Promedica Toledo Hospital, Toledo, Ohio, USA
| | - Daniel H Sahlein
- Neuroendovascular, Goodman Campbell Brain and Spine, Carmel, Indiana, USA
| | - Lucian Maidan
- Department of Neurovascular Medicine, Mercy San Juan Medical Center, Carmichael, California, USA
| | - Kenneth Kreitel
- Department of Neurointerventional Surgery, Ascension Borgess Hospital, Kalamazoo, Michigan, USA
| | - Timothy R Miller
- Diagnostic Radiology and Nuclear Medicine, Neurology and Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland, USA
| | - Scott Rahimi
- Neurosurgery, Augusta University Health System, Augusta, Georgia, USA
| | - Amer Al Shekhlee
- Neuroscience Institutes, SSM Health DePaul Hospital - St Louis, Bridgeton, Missouri, USA
| | - Henry H Woo
- Neurosurgery, Northwell Health, Manhasset, New York, USA
| | - Gabor Toth
- Cerebrovascular Center, Cleveland Clinic Foundation, Cleveland Heights, Ohio, USA
| | - Clemens Schirmer
- Department of Neurosurgery, Geisinger Health System, Danville, Pennsylvania, USA
| | - Yince Loh
- Department of Neurosurgery, Swedish Health Services, Seattle, Washington, USA
| | - David Fiorella
- Neurosurgery, Stony Brook University, Stony Brook, New York, USA
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Jiang X, Hu Y, Wang J, Ma M, Bao J, Fang J, He L. Outcomes and risk factors for infection after endovascular treatment in patients with acute ischemic stroke. CNS Neurosci Ther 2024; 30:e14753. [PMID: 38727582 PMCID: PMC11086021 DOI: 10.1111/cns.14753] [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: 02/17/2024] [Revised: 04/24/2024] [Accepted: 04/25/2024] [Indexed: 05/12/2024] Open
Abstract
AIMS Infection is a common complication following acute ischemic stroke (AIS) and significantly contributes to poor functional outcomes after stroke. This study aimed to investigate the effects of infection after endovascular treatment (post-EVT infection) on clinical outcomes and risk factors in patients with AIS. METHODS We retrospectively analyzed AIS patients treated with endovascular treatment (EVT) between January 2016 and December 2022. A post-EVT infection was defined as any infection diagnosed within 7 days after EVT. The primary outcome was functional independence, defined as a modified Rankin scale (mRS) score of 0-2 at 90 days. A multivariable logistic regression analysis was conducted to determine independent predictors of post-EVT infection and the associations between post-EVT infection and clinical outcomes. RESULTS A total of 675 patients were included in the analysis; 306 (45.3%) of them had post-EVT infections. Patients with post-EVT infection had a lower rate of functional independence than patients without infection (31% vs 65%, p = 0.006). In addition, patients with post-EVT infection achieved less early neurological improvement (ENI) after EVT (25.8% vs 47.4%, p < 0.001). For safety outcomes, the infection group had a higher incidence of any intracranial hemorrhage (23.9% vs 15.7%, p = 0.01) and symptomatic intracranial hemorrhage (10.1% vs 5.1%, p = 0.01). Unsuccessful recanalization (aOR 1.87, 95% CI 1.11-3.13; p = 0.02) and general anesthesia (aOR 2.22, 95% CI 1.25-3.95; p = 0.01) were identified as independent predictors for post-EVT infection in logistic regression analysis. CONCLUSION AIS patients who develop post-EVT infections are more likely to experience poor clinical outcomes. Unsuccessful recanalization and general anesthesia were independent risk factors for the development of post-EVT infection.
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Affiliation(s)
- Xin Jiang
- Department of Neurology, West China HospitalSichuan UniversityChengduChina
| | - Yaowen Hu
- Department of Neurology, West China HospitalSichuan UniversityChengduChina
| | - Jian Wang
- Department of Neurology, West China HospitalSichuan UniversityChengduChina
| | - Mengmeng Ma
- Department of Neurology, West China HospitalSichuan UniversityChengduChina
| | - Jiajia Bao
- Department of Neurology, West China HospitalSichuan UniversityChengduChina
| | - Jinghuan Fang
- Department of Neurology, West China HospitalSichuan UniversityChengduChina
| | - Li He
- Department of Neurology, West China HospitalSichuan UniversityChengduChina
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Stoll G, Schuhmann MK, Kollikowski AM, Pham M. New mechanisms-based therapies in acute ischaemic stroke. Eur Heart J 2024; 45:1190-1192. [PMID: 38195195 DOI: 10.1093/eurheartj/ehad865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2024] Open
Affiliation(s)
- Guido Stoll
- Institute of Experimental Biomedicine I, University Hospital Wuerzburg, Josef-Schneider-Str. 2, 97080 Wuerzburg, Germany
| | | | | | - Mirko Pham
- Department of Neuroradiology, University Hospital Wuerzburg, Wuerzburg, Germany
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Cheng X, Hong L, Lin L, Churilov L, Ling Y, Zhang Y, Yang L, Parsons M, Dong Q. CHinese Acute Tissue-Based Imaging Selection for Lysis In Stroke Tenecteplase II (CHABLIS-T II): rationale and design. Stroke Vasc Neurol 2024:svn-2023-002890. [PMID: 38302191 DOI: 10.1136/svn-2023-002890] [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: 10/06/2023] [Accepted: 12/12/2023] [Indexed: 02/03/2024] Open
Abstract
BACKGROUND AND PURPOSE Tenecteplase (TNK) has demonstrated non-inferiority to alteplase in patients who had an acute ischaemic stroke presenting within 4.5 hours from symptom onset. The trial is aimed to explore the efficacy and safety of TNK in Chinese patients who had an acute ischaemic stroke with large/medium vessel occlusion in an extended time window. METHODS AND DESIGN Chinese Acute Tissue-Based Imaging Selection for Lysis In Stroke Tenecteplase II (CHABLIS-T II) is a multicentre, prospective, block-randomised, open-label, blinded-endpoint, phase IIb study. Eligible patients are 1:1 randomised into two groups: 0.25 mg/kg TNK versus best medical management (excluding TNK). The safety and efficacy of 0.25 mg/kg TNK are assessed through reperfusion status and presence of symptomatic intracranial haemorrhage (sICH). STUDY OUTCOMES The primary outcome is major reperfusion without sICH at 24-48 hours after randomisation. Major reperfusion is defined as restoration of blood flow to greater than 50% of the involved ischaemic territory assessed by catheter angiography or repeated perfusion imaging. Secondary outcomes include post-thrombolytic recanalisation, neurological improvements, change in the National Institutes of Health Stroke Scale score, haemorrhagic transformation at 24-48 hours, systematic bleeding at discharge, modified Rankin Scale (mRS) 0-1, mRS 0-2, mRS 5-6, mRS distribution and Barthel index at 90 days. DISCUSSION CHABLIS-T II will provide important evidence of intravenous thrombolysis with TNK for patients who had an acute stroke in an extended time window.
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Affiliation(s)
- Xin Cheng
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Lan Hong
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Longting Lin
- University of New South Wales South Western Sydney Clinical School, Ingham Institute for Applied Medical Research, Department of Neurology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Leonid Churilov
- Melbourne Medical School, The Royal Melbourne Hospital, University of Melbourne, Melbourne, Victoria, Australia
| | - Yifeng Ling
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Yiran Zhang
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Lumeng Yang
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Mark Parsons
- University of New South Wales South Western Sydney Clinical School, Ingham Institute for Applied Medical Research, Department of Neurology, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Qiang Dong
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
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5
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Marko M, Goyal M, Ospel JM, Singh N, Venema E, Nogueira RG, Demchuk AM, McTaggart RA, Poppe AY, Menon BK, Zerna C, Mulder M, Dippel DW, Lingsma HF, Roozenbeek B, Tymianski M, Hill MD. Predicting outcome in acute stroke with large vessel occlusion-application and validation of MR PREDICTS in the ESCAPE-NA1 population. Interv Neuroradiol 2023:15910199231221491. [PMID: 38115793 DOI: 10.1177/15910199231221491] [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: 12/21/2023] Open
Abstract
BACKGROUND Predicting outcome after endovascular treatment for acute ischemic stroke is challenging. We aim to investigate differences between predicted and observed outcomes in patients with acute ischemic stroke treated with endovascular treatment and to evaluate the performance of a validated outcome prediction score. PATIENTS AND METHODS MR PREDICTS is an outcome prediction tool based on a logistic regression model designed to predict the treatment benefit of endovascular treatment based on the MR CLEAN and HERMES populations. ESCAPE-NA1 is a randomized trial of nerinetide vs. placebo in patients with acute stroke and large vessel occlusion. We applied MR PREDICTS to patients in the control arm of ESCAPE-NA1. Model performance was assessed by calculating its discriminative ability and calibration. RESULTS Overall, 556/1105 patients (50.3%) in the ESCAPE-NA1-trial were randomized to the control arm, 435/556 (78.2%) were treated within 6 h of symptom onset. Good outcome (modified Rankin scale 0-2) at 3 months was achieved in 275/435 patients (63.2%), the predicted probability of good outcome was 52.5%. Baseline characteristics were similar in the study and model derivation cohort except for age (ESCAPE-NA1: mean: 70 y vs. HERMES: 66 y), hypertension (72% vs. 57%), and collaterals (good collaterals, 15% vs. 44%). Compared to HERMES we observed higher rates of successful reperfusion (TICI 2b-3, ESCAPE-NA1: 87% vs. HERMES: 71%) and faster times from symptom onset to reperfusion (median: 201 min vs. 286 min). Model performance was good, indicated by a c-statistic of 0.76 (95%confidence interval: 0.71-0.81). CONCLUSION Outcome-prediction using models created from HERMES data, based on information available in the emergency department underestimated the actual outcome in patients with acute ischemic stroke and large vessel occlusion receiving endovascular treatment despite overall good model performance, which might be explained by differences in quality of and time to reperfusion. These findings underline the importance of timely and successful reperfusion for functional outcomes in acute stroke patients.
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Affiliation(s)
- Martha Marko
- Department of Neurology, Medical University of Vienna, Wien, Austria
| | - Mayank Goyal
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Johanna M Ospel
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Nishita Singh
- Department of Clinical Neurosciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Esmee Venema
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Emergency Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Raul G Nogueira
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, USA
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Ryan A McTaggart
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Alexandre Y Poppe
- Department of Medicine (Neurology), Centre Hospitalier de l'Université de Montréal, QC, Calgary, Canada
| | - Bijoy K Menon
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Charlotte Zerna
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Maxim Mulder
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Diederik Wj Dippel
- Department of Emergency Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Bob Roozenbeek
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | - Michael D Hill
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
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6
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Di Donna A, Muto G, Giordano F, Muto M, Guarnieri G, Servillo G, De Mase A, Spina E, Leone G. Diagnosis and management of tandem occlusion in acute ischemic stroke. Eur J Radiol Open 2023; 11:100513. [PMID: 37609048 PMCID: PMC10440394 DOI: 10.1016/j.ejro.2023.100513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/31/2023] [Accepted: 08/07/2023] [Indexed: 08/24/2023] Open
Abstract
Approximately 20-30% of patients with acute ischemic stroke, caused by large intracranial vessel occlusion, have a tandem lesion, defined as simultaneous presence of high-grade stenosis or occlusion of the cervical internal carotid artery and thromboembolic occlusion of the intracranial terminal internal carotid artery or its branches, usually the middle cerebral artery. Patients with tandem lesions have usually worse outcomes than patients with single intracranial occlusions, and intravenous thrombolysis is less effective in these patients. Although endovascular thrombectomy is currently a cornerstone therapy in the management of acute ischemic stroke due to large vessel occlusion, the optimal management of extracranial carotid lesions in tandem occlusion remains controversial. Acute placement of a stent in the cervical carotid artery lesion is the most used therapeutic strategy compared with stented balloon angioplasty and thrombectomy alone without carotid artery revascularization; however, treatment strategies in these patients are often more complex than with single occlusion, so treatment decisions can change based on clinical and technical considerations. The aim of this review is to analyze the results of different studies and trials, investigating the periprocedural neurointerventional management of patients with tandem lesions and the safety, efficacy of the different technical strategies available as well as their impact on the clinical outcome in these patients, to strengthen current recommendations and thus optimize patient care.
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Affiliation(s)
- Antonio Di Donna
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Gianluca Muto
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Flavio Giordano
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Massimo Muto
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Gianluigi Guarnieri
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Giovanna Servillo
- Unit of Neurorology and Stroke Unit, Department of Emergency and Acceptance, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Antonio De Mase
- Unit of Neurorology and Stroke Unit, Department of Emergency and Acceptance, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Emanuele Spina
- Unit of Neurorology and Stroke Unit, Department of Emergency and Acceptance, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Giuseppe Leone
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
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7
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Yoshie T, Ueda T, Hasegawa Y, Takeuchi M, Morimoto M, Tsuboi Y, Yamamoto R, Kaku S, Ayabe J, Akiyama T, Yamamoto D, Mori K, Kagami H, Ito H, Onodera H, Kaga Y, Ohtsubo H, Tatsuno K, Usuki N, Takaishi S, Yamano Y. Ischemic stroke patients with low DWI ASPECTS scores require puncture to recanalization within 30 min for large vessel occlusion. J Neurol Sci 2023; 454:120852. [PMID: 37924594 DOI: 10.1016/j.jns.2023.120852] [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: 07/13/2023] [Revised: 09/24/2023] [Accepted: 10/22/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND The clinical benefits of faster recanalization in acute large vessel occlusion are well recognized, but the optimal procedure time remains uncertain. The aim of this study was to identify patient characteristics that necessitate puncture-to-recanalization (P-R) time within 30 min to achieve favorable outcome. METHODS We evaluated the patients from a prospective, multicenter, observational registry of acute ischemic stroke patients. The study included patients who underwent endovascular therapy for ICA or MCA M1 occlusion and achieved successful recanalization. Patients were categorized into subgroups based on pre-treatment characteristics and the frequency of favorable outcomes was compared between P-R time < 30 min and ≥ 30 min. Interaction terms were incorporated into the models to assess the correlation between each patient characteristic and P-R time. RESULTS A total of 1053 patients were included in the study. Univariate analysis within each subgroup revealed a significant association between P-R < 30 min and favorable outcomes in patients with DWI ASPECTS ≤6, age > 85 and NIHSS ≥16. In the multivariable analysis, NIHSS, age, time from symptom recognition to puncture, and DWI ASPECTS were significant independent predictors of favorable outcomes. Notably, only DWI ASPECTS exhibited interaction terms with P-R < 30 min. The multivariable analysis indicated that P-R < 30 min was an independent predictor for favorable outcome in DWI ASPECTS ≤6 group, whereas not in DWI ≥7. CONCLUSIONS P-R time < 30 min is predictive of favorable outcomes; however, the effect depends on DWI ASPECTS. Target P-R time < 30 min is appropriate for patients with DWI ASPECTS ≤6.
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Affiliation(s)
- Tomohide Yoshie
- Department of Strokology and Neuroendovascular Therapy, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan.
| | - Toshihiro Ueda
- Department of Strokology and Neuroendovascular Therapy, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan
| | - Yasuhiro Hasegawa
- Department of Neurology, St. Marianna University School of Medicine, Kawasaki, Japan
| | | | - Masafumi Morimoto
- Department of Neurosurgery, Yokohama Shintoshi Neurosurgical Hospital, Yokohama, Japan
| | - Yoshifumi Tsuboi
- Department of Neurosurgery, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Ryoo Yamamoto
- Department of Neurology, Yokohama Brain and Spine Center, Yokohama, Japan
| | - Shogo Kaku
- Department of Neurosurgery, Neurosurgical East Yokohama Hospital, Yokohama, Japan
| | - Junichi Ayabe
- Department of Neurosurgery, Yokosuka Kyosai Hospital, Yokohama, Japan
| | - Takekazu Akiyama
- Department of Neurosurgery, Akiyama Neurosurgical Hospital, Yokohama, Japan
| | - Daisuke Yamamoto
- Department of Neurosurgery, Kitasato University Hospital, Sagamihara, Japan
| | - Kentaro Mori
- Department of Neurosurgery, Yokohama Sakae Kyosai Hospital, Yokohama, Japan
| | - Hiroshi Kagami
- Department of Neurosurgery, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Hidemichi Ito
- Department of Neurosurgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hidetaka Onodera
- Department of Neurosurgery, St. Marianna University Yokohama Seibu Hospital, Yokohama, Japan
| | - Yasuyuki Kaga
- Department of Neurology, St. Marianna University School of Medicine, Kawasaki, Japan; ESP corporation, Tokyo, Japan
| | - Haruki Ohtsubo
- Department of Strokology and Neuroendovascular Therapy, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan
| | - Kentaro Tatsuno
- Department of Strokology and Neuroendovascular Therapy, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan
| | - Noriko Usuki
- Department of Strokology and Neuroendovascular Therapy, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan
| | - Satoshi Takaishi
- Department of Strokology and Neuroendovascular Therapy, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan
| | - Yoshihisa Yamano
- Department of Neurology, St. Marianna University School of Medicine, Kawasaki, Japan
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8
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Zhao BH, Ruze A, Zhao L, Li QL, Tang J, Xiefukaiti N, Gai MT, Deng AX, Shan XF, Gao XM. The role and mechanisms of microvascular damage in the ischemic myocardium. Cell Mol Life Sci 2023; 80:341. [PMID: 37898977 PMCID: PMC11073328 DOI: 10.1007/s00018-023-04998-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2023] [Revised: 09/08/2023] [Accepted: 10/02/2023] [Indexed: 10/31/2023]
Abstract
Following myocardial ischemic injury, the most effective clinical intervention is timely restoration of blood perfusion to ischemic but viable myocardium to reduce irreversible myocardial necrosis, limit infarct size, and prevent cardiac insufficiency. However, reperfusion itself may exacerbate cell death and myocardial injury, a process commonly referred to as ischemia/reperfusion (I/R) injury, which primarily involves cardiomyocytes and cardiac microvascular endothelial cells (CMECs) and is characterized by myocardial stunning, microvascular damage (MVD), reperfusion arrhythmia, and lethal reperfusion injury. MVD caused by I/R has been a neglected problem compared to myocardial injury. Clinically, the incidence of microvascular angina and/or no-reflow due to ineffective coronary perfusion accounts for 5-50% in patients after acute revascularization. MVD limiting drug diffusion into injured myocardium, is strongly associated with the development of heart failure. CMECs account for > 60% of the cardiac cellular components, and their role in myocardial I/R injury cannot be ignored. There are many studies on microvascular obstruction, but few studies on microvascular leakage, which may be mainly due to the lack of corresponding detection methods. In this review, we summarize the clinical manifestations, related mechanisms of MVD during myocardial I/R, laboratory and clinical examination means, as well as the research progress on potential therapies for MVD in recent years. Better understanding the characteristics and risk factors of MVD in patients after hemodynamic reconstruction is of great significance for managing MVD, preventing heart failure and improving patient prognosis.
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Affiliation(s)
- Bang-Hao Zhao
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asian, Department of Cardiology, the First Affiliated Hospital of Xinjiang Medical University, Clinical Medical Research Institute of Xinjiang Medical University, 137 Liyushan South Road, Urumqi, 830054, China
- Xinjiang Key Laboratory of Medical Animal Model Research, Urumqi, China
| | - Amanguli Ruze
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asian, Department of Cardiology, the First Affiliated Hospital of Xinjiang Medical University, Clinical Medical Research Institute of Xinjiang Medical University, 137 Liyushan South Road, Urumqi, 830054, China
- Xinjiang Key Laboratory of Medical Animal Model Research, Urumqi, China
| | - Ling Zhao
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asian, Department of Cardiology, the First Affiliated Hospital of Xinjiang Medical University, Clinical Medical Research Institute of Xinjiang Medical University, 137 Liyushan South Road, Urumqi, 830054, China
- Xinjiang Key Laboratory of Medical Animal Model Research, Urumqi, China
| | - Qiu-Lin Li
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asian, Department of Cardiology, the First Affiliated Hospital of Xinjiang Medical University, Clinical Medical Research Institute of Xinjiang Medical University, 137 Liyushan South Road, Urumqi, 830054, China
- Xinjiang Key Laboratory of Medical Animal Model Research, Urumqi, China
| | - Jing Tang
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asian, Department of Cardiology, the First Affiliated Hospital of Xinjiang Medical University, Clinical Medical Research Institute of Xinjiang Medical University, 137 Liyushan South Road, Urumqi, 830054, China
- Xinjiang Key Laboratory of Medical Animal Model Research, Urumqi, China
| | - Nilupaer Xiefukaiti
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asian, Department of Cardiology, the First Affiliated Hospital of Xinjiang Medical University, Clinical Medical Research Institute of Xinjiang Medical University, 137 Liyushan South Road, Urumqi, 830054, China
- Xinjiang Key Laboratory of Medical Animal Model Research, Urumqi, China
| | - Min-Tao Gai
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asian, Department of Cardiology, the First Affiliated Hospital of Xinjiang Medical University, Clinical Medical Research Institute of Xinjiang Medical University, 137 Liyushan South Road, Urumqi, 830054, China
- Xinjiang Key Laboratory of Medical Animal Model Research, Urumqi, China
| | - An-Xia Deng
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asian, Department of Cardiology, the First Affiliated Hospital of Xinjiang Medical University, Clinical Medical Research Institute of Xinjiang Medical University, 137 Liyushan South Road, Urumqi, 830054, China
- Xinjiang Key Laboratory of Medical Animal Model Research, Urumqi, China
| | - Xue-Feng Shan
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asian, Department of Cardiology, the First Affiliated Hospital of Xinjiang Medical University, Clinical Medical Research Institute of Xinjiang Medical University, 137 Liyushan South Road, Urumqi, 830054, China
- Xinjiang Key Laboratory of Medical Animal Model Research, Urumqi, China
| | - Xiao-Ming Gao
- State Key Laboratory of Pathogenesis, Prevention and Treatment of High Incidence Diseases in Central Asian, Department of Cardiology, the First Affiliated Hospital of Xinjiang Medical University, Clinical Medical Research Institute of Xinjiang Medical University, 137 Liyushan South Road, Urumqi, 830054, China.
- Xinjiang Key Laboratory of Medical Animal Model Research, Urumqi, China.
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9
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Mierzwa AT, Al Kasab S, Nelson A, Ortega Gutierrez S, Vivanco-Suarez J, Farooqui M, Jadhav AP, Desai S, Toth G, Alrohimi A, Nguyen TN, Klein P, Abdalkader M, Salahuddin H, Pandey A, Koduri S, Vora N, Aladamat N, Gharaibeh K, Afreen E, Zaidi S, Jumaa M. Comparing Functional Outcomes and Safety Profiles of First-Line Aspiration Thrombectomy Versus Stentriever for Acute Basilar Artery Occlusion: Propensity Analysis of the PC-SEARCH Thrombectomy Registry. Stroke 2023; 54:2512-2521. [PMID: 37747965 DOI: 10.1161/strokeaha.123.043579] [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: 04/17/2023] [Accepted: 08/03/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Aspiration catheters (ASPs) and stentriever thrombectomy devices have comparable safety and efficacy in anterior circulation ischemic strokes. However, there is lack of high-quality comparative data in acute basilar artery occlusions. Our objective is to compare the outcomes and safety of ASPs and stentriever devices in acute basilar artery occlusions. METHODS This is an analysis of the retrospectively established PC-SEARCH Thrombectomy (Posterior-Circulation Ischemic Stroke Evaluation: Analyzing Radiographic and Intraprocedural Predictors for Mechanical Thrombectomy) registry. Patients were dichotomized based on their first-line thrombectomy device (ASP and stentriever) and associated with their 90-day functional outcomes, intraprocedural metrics, and safety measures. Propensity analysis based on unequal baseline characteristics was performed. Consecutive patients with acute basilar artery occlusions who received mechanical thrombectomy were included from January 2015 to December 2021. Patients received either first-line contact aspiration or stentriever mechanical thrombectomy. Primary clinical and safety outcomes were 90-day functional independence measured by a modified Rankin Scale score of 0 to 3 and symptomatic intracranial hemorrhage, respectively. Secondary outcomes included puncture-recanalization times, first-pass recanalization rates, crossovers to other thrombectomy device, and neurological/hospital complications. RESULTS Five hundred eighteen patients were included in the registry, and a total of 383 patients were included (mean [SD] age, 65.5 [15] years; 228 [59%] men) in this analysis. Of these, 219 patients were first-line ASP while 164 patients received first-line stentriever devices. Median premorbid modified Rankin Scale was zero and median presenting National Institutes of Health Stroke Scale was 17 (interquartile range, 8-26). The proportion of favorable functional outcome was similar between the 2 techniques before (47.3% versus 42.5%; odds ratio, 1.22 [95% CI, 0.78-1.89]; P=0.38) and after propensity matching (odds ratio, 1.46 [95% CI, 0.85-2.49]; P=0.17). In our propensity-matched cohorts, puncture-recanalization times (18 versus 52 minutes; P<0.01) favored first-line ASP; however, first-pass recanalization rates (43.5% versus 44.5%; P=0.90) were similar between groups. First-line ASP was associated with higher rates of crossover (22% versus 6%; P<0.01), whereas stentriever was associated with higher rates of symptomatic intracranial hemorrhage (9.8% versus 3.4%; P=0.04). CONCLUSIONS First-line ASP and stentriever methods demonstrated similar functional outcome and recanalization rates. Stentriever methods were associated with higher rates of symptomatic intracranial hemorrhage, whereas ASPs were associated with higher rates of crossover to alternative technique in patients with acute basilar occlusions.
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Affiliation(s)
- Adam T Mierzwa
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, OH (A.T.M., N.A., K.G., E.A., S.Z., M.J.)
- Promedica Stroke Network, Toledo, OH (A.T.M., E.A., S.Z., M.J.)
| | - Sami Al Kasab
- Department of Neurology and Neurosurgery, Medical University of South Carolina, Charleston (S.A.K., A.N.)
| | - Ashley Nelson
- Department of Neurology and Neurosurgery, Medical University of South Carolina, Charleston (S.A.K., A.N.)
| | | | | | | | - Ashutosh P Jadhav
- Department of Neurology, University of Pittsburgh Medical Center, PA (A.P.J., S.D.)
| | - Shashvat Desai
- Department of Neurology, University of Pittsburgh Medical Center, PA (A.P.J., S.D.)
| | - Gabor Toth
- Cleveland Clinic Foundation, OH (G.T., A.A.)
| | | | - Thanh N Nguyen
- Department of Neurology, Radiology, Boston University Chobanian and Avedisian School of Medicine, MA (T.N.N., P.K., M.A.)
| | - Piers Klein
- Department of Neurology, Radiology, Boston University Chobanian and Avedisian School of Medicine, MA (T.N.N., P.K., M.A.)
| | - Mohamad Abdalkader
- Department of Neurology, Radiology, Boston University Chobanian and Avedisian School of Medicine, MA (T.N.N., P.K., M.A.)
| | - Hisham Salahuddin
- Department of Neurology, Antelope Valley Hospital, Los Angeles, CA (H.S.)
| | - Aditya Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor (A.P., S.K.)
| | - Sravanthi Koduri
- Department of Neurosurgery, University of Michigan, Ann Arbor (A.P., S.K.)
| | - Niraj Vora
- Ohio Health Riverside Methodist Hospital, Columbus (N.V.)
| | - Nameer Aladamat
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, OH (A.T.M., N.A., K.G., E.A., S.Z., M.J.)
| | - Khaled Gharaibeh
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, OH (A.T.M., N.A., K.G., E.A., S.Z., M.J.)
| | - Ehad Afreen
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, OH (A.T.M., N.A., K.G., E.A., S.Z., M.J.)
- Promedica Stroke Network, Toledo, OH (A.T.M., E.A., S.Z., M.J.)
| | - Syed Zaidi
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, OH (A.T.M., N.A., K.G., E.A., S.Z., M.J.)
- Promedica Stroke Network, Toledo, OH (A.T.M., E.A., S.Z., M.J.)
| | - Mouhammad Jumaa
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, OH (A.T.M., N.A., K.G., E.A., S.Z., M.J.)
- Promedica Stroke Network, Toledo, OH (A.T.M., E.A., S.Z., M.J.)
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10
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Cuoco JA, Entwistle JJ, Siddiq F, Puri AS, Woodward K, Hanel RA, Ansari SA, Frei D, Patel BM. The balloon occlusion sheath for stroke (BOSS) balloon guide catheter for stroke intervention: Safety and technical success. Interv Neuroradiol 2023:15910199231198273. [PMID: 37649344 DOI: 10.1177/15910199231198273] [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: 09/01/2023] Open
Abstract
BACKGROUND We describe the first-in-human experience using the Balloon Occlusion Stroke Sheath (BOSSTM) balloon-guide catheter to perform stroke thrombectomy in 50 consecutive patients enrolled in the Flow Arrest Safety and Technical success with balloon-guide catheters trial. This aspiration system includes a novel 9.4F balloon-guide catheter conduit for the insertion and guidance of catheters with a balloon providing temporary flow arrest. METHODS The Flow Arrest Safety and Technical success with balloon-guide catheter trial is a single-arm, prospective, multi-center, non-randomized, observational registry evaluating the use of the market-released BOSSTM balloon-guide catheter in adult patients diagnosed with an acute ischemic stroke attributable to large vessel occlusion. The purpose of the current trial was to assess the safety and technical success associated with the use of the BOSSTM balloon-guide catheter. RESULTS Fifty patients met inclusion criteria with a mean baseline National Institutes of Health Stroke Scale (NIHSS) of 16. Treatment devices, including aspiration and stent retriever devices, were used in a total of 88 passes. The BOSSTM balloon-guide catheter was compatible with all stroke thrombectomy treatment devices used in 98% (49/50) of procedures. Balloon inflation and flow arrest were achieved in 100% (50/50) and 98% (49/50) of cases, respectively. Balloon deflation and retraction were observed in 100% (50/50) of cases. Successful reperfusion (modified thrombolysis in cerebral infarction score > 2b) was achieved in 100% of cases with single-pass reperfusion achieved in 62% (31/50) of cases. CONCLUSIONS The BOSSTM balloon-guide catheter is a safe and technically effective adjunctive device for mechanical thrombectomy of acute ischemic stroke due to large vessel occlusion.
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Affiliation(s)
- Joshua A Cuoco
- Department of Neurosurgery, Carilion Clinic, Roanoke, VA, USA
| | | | - Farhan Siddiq
- Department of Neurosurgery, University of Missouri, Columbia, MO, USA
| | - Ajit S Puri
- Department of Radiology, New England Center for Stroke Research, University of Massachusetts Chan Medical School, Worcester, MA, USA
| | - Keith Woodward
- Department of Neurointerventional Radiology, Fort Saunders Regional Medical Center, Knoxville, TN, USA
| | - Ricardo A Hanel
- Department of Neurosurgery, Lyerly Neurosurgery, Baptist Neurological Institute, Jacksonville, FL, USA
- Baptist Medical Center Jacksonville, FL, USA
| | - Sameer A Ansari
- Department of Radiology, Neurology, Neurological Surgery, Northwestern University, Feinberg School of Medicine, Chicago, IL, USA
| | - Donald Frei
- Department of Neurointerventional Surgery, Swedish Medical Center, Denver, CO, USA
- Radiology Imaging Associates, RIA Neurovascular Clinic, Englewood, CO, USA
| | - Biraj M Patel
- Department of Neurosurgery, Carilion Clinic, Roanoke, VA, USA
- Department of Radiology, Carilion Clinic, Roanoke, VA, USA
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11
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Lo BM, Carpenter CR, Ducey S, Gottlieb M, Kaji A, Diercks DB, Diercks DB, Wolf SJ, Anderson JD, Byyny R, Carpenter CR, Friedman B, Gemme SR, Gerardo CJ, Godwin SA, Hahn SA, Hatten BW, Haukoos JS, Kaji A, Kwok H, Lo BM, Mace SE, Moran M, Promes SB, Shah KH, Shih RD, Silvers SM, Slivinski A, Smith MD, Thiessen MEW, Tomaszewski CA, Trent S, Valente JH, Wall SP, Westafer LM, Yu Y, Cantrill SV, Finnell JT, Schulz T, Vandertulip K. Clinical Policy: Critical Issues in the Management of Adult Patients Presenting to the Emergency Department With Acute Ischemic Stroke. Ann Emerg Med 2023; 82:e17-e64. [PMID: 37479410 DOI: 10.1016/j.annemergmed.2023.03.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2023]
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12
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TICI-RANKIN mismatch: Poor clinical outcome despite complete endovascular reperfusion in the ETIS Registry. Rev Neurol (Paris) 2023; 179:230-237. [PMID: 36804012 DOI: 10.1016/j.neurol.2022.10.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 09/15/2022] [Accepted: 10/10/2022] [Indexed: 02/17/2023]
Abstract
INTRODUCTION Endovascular treatment (EVT) is a well-established technic for acute ischemic stroke, but despite a high recanalization rate of near 80%, at 3 months roughly 50% of patients have a poor functional outcome with a modified Rankin score (mRS) ≥3. The aim of this study was to determine predictive factors of poor functional outcomes in patients with complete recanalization after EVT, defined as modified thrombolysis in cerebral infarction (mTICI) 3. PATIENTS AND METHODS This retrospective analysis based on the prospective multicenter ETIS registry (endovascular treatment in ischemic stroke) in France included 795 patients from January 2015 and November 2019 with acute ischemic stroke due to anterior circulation occlusion and prestroke mRS 0-1, treated with EVT and who achieved complete recanalization. Univariate and multivariate logistic regression models were used to identify predictive factors of poor functional outcome. RESULTS 365 patients (46%) showed a poor functional outcome (mRS>2). In backward-stepwise logistic regression analysis, poor functional outcome was independently associated with older age (OR per 10-year increase, 1.51; 95%CI, 1.30 to 1.75), higher admission NIHSS (OR per 1 point increase, 1.28; 95%CI, 1.21 to 1.34), absence of prior intravenous thrombolysis (OR, 0.59; 95%CI, 0.39 to 0.90), and an unfavorable 24-hour NIHSS change (24h-baseline) (OR, 0.82; 95%CI, 0.79 to 0.87). We calculated that patients whose 24h NIHSS decreased by less than 5 points are more at risk of a poor outcome, with a sensitivity and a specificity of 65.0%. CONCLUSION Despite complete reperfusion after EVT, half of patients had a poor clinical outcome. These patients, who were mainly older with a high initial NIHSS and an unfavorable post-EVT 24h NIHSS change, could represent a target population for early neurorepair and neurorestorative strategies.
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13
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Ibrahim MK, Shehata MA, Ghozy S, Bilgin C, Jabal MS, Heiferman DM, Kadirvel R, Kallmes DF. Operator assessment versus core laboratory adjudication of recanalization following endovascular treatment of acute ischemic stroke: a systematic review and meta-analysis. J Neurointerv Surg 2023; 15:133-138. [PMID: 36163347 DOI: 10.1136/jnis-2022-019266] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2022] [Accepted: 08/29/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND Successful recanalization after endovascular thrombectomy serves as the primary endpoint in clinical trials and is a crucial predictor of long-term outcomes. Radiographic outcomes for various interventions have been shown to vary based on the type of interpreter, including the site interventionalist compared with an independent reader. OBJECTIVE To compare angiographic outcomes in stroke thrombectomy procedures based on the type of reader. METHODS A systematic literature search was conducted in Medline, EMBASE, Scopus, and Web-of-Science through February 2022. We included primary studies that reported core laboratory-read and operator angiographic outcomes after mechanical thrombectomy for ischemic stroke. Furthermore, study-defined successful recanalization data were collected. RESULTS Eight studies were included with 4797 patients, 51.2% of whom were male. Four thousand, four hundred and thirty-one patients had core readings, and 4211 had operator readings. Study-defined successful recanalization was significantly higher for operator (84%, 3543/4211) examinations than for core laboratory-read (78.4%, 3476/4431) examinations (p<0.001; OR=1.462, 95% CI 1.175 to 1.819). The modified Thrombolysis in Cerebral Infarction (mTICI) scale score of ≥2 b was higher for operator (85%, 3341/3929) examinations than for core laboratory-read (78.6%, 3107/3952) examinations (p<0.001; OR=1.349, 95% CI 1.071 to 1.701). mTICI 3 was significantly higher for operator (54.6%, 1000/1832) examinations than for core laboratory-read (39.9%, 731/1832) examinations (p<0.001; OR=1.823, 95% CI 1.598 to 2.081). CONCLUSION Operator angiographic reads are statistically significantly higher than core laboratory-read readings following stroke thrombectomy, especially for complete recanalization. These differences should be considered when interpreting reports of angiographic outcomes after thrombectomy.
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Affiliation(s)
| | | | - Sherief Ghozy
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | - Cem Bilgin
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
| | | | - Daniel M Heiferman
- Department of Neurological Surgery, Loyola University Medical Center, Maywood, Illinois, USA
| | | | - David F Kallmes
- Department of Radiology, Mayo Clinic, Rochester, Minnesota, USA
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14
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PREDICT-juvenile-stroke: PRospective evaluation of a prediction score determining individual clinical outcome three months after ischemic stroke in young adults - a study protocol. BMC Neurol 2023; 23:2. [PMID: 36597038 PMCID: PMC9811707 DOI: 10.1186/s12883-022-03003-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2022] [Accepted: 12/02/2022] [Indexed: 01/05/2023] Open
Abstract
BACKGROUND Although of high individual and socioeconomic relevance, a reliable prediction model for the prognosis of juvenile stroke (18-55 years) is missing. Therefore, the study presented in this protocol aims to prospectively validate the discriminatory power of a prediction score for the 3 months functional outcome after juvenile stroke or transient ischemic attack (TIA) that has been derived from an independent retrospective study using standard clinical workup data. METHODS PREDICT-Juvenile-Stroke is a multi-centre (n = 4) prospective observational cohort study collecting standard clinical workup data and data on treatment success at 3 months after acute ischemic stroke or TIA that aims to validate a new prediction score for juvenile stroke. The prediction score has been developed upon single center retrospective analysis of 340 juvenile stroke patients. The score determines the patient's individual probability for treatment success defined by a modified Rankin Scale (mRS) 0-2 or return to pre-stroke baseline mRS 3 months after stroke or TIA. This probability will be compared to the observed clinical outcome at 3 months using the area under the receiver operating characteristic curve. The primary endpoint is to validate the clinical potential of the new prediction score for a favourable outcome 3 months after juvenile stroke or TIA. Secondary outcomes are to determine to what extent predictive factors in juvenile stroke or TIA patients differ from those in older patients and to determine the predictive accuracy of the juvenile stroke prediction score on other clinical and paraclinical endpoints. A minimum of 430 juvenile patients (< 55 years) with acute ischemic stroke or TIA, and the same number of older patients will be enrolled for the prospective validation study. DISCUSSION The juvenile stroke prediction score has the potential to enable personalisation of counselling, provision of appropriate information regarding the prognosis and identification of patients who benefit from specific treatments. TRIAL REGISTRATION The study has been registered at https://drks.de on March 31, 2022 ( DRKS00024407 ).
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15
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Castonguay AC, Zoghi Z, Zaidat OO, Burgess RE, Zaidi SF, Mueller-Kronast N, Liebeskind DS, Jumaa MA. Predicting Functional Outcome Using 24-Hour Post-Treatment Characteristics: Application of Machine Learning Algorithms in the STRATIS Registry. Ann Neurol 2023; 93:40-49. [PMID: 36214566 PMCID: PMC10091739 DOI: 10.1002/ana.26528] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2022] [Revised: 09/27/2022] [Accepted: 10/05/2022] [Indexed: 02/05/2023]
Abstract
FOR SOCIAL MEDIA: @AliciaCastongu2, @FazalZaidi9, @oozaidat, @Mouhammad_Jumaa OBJECTIVE: Machine learning (ML) algorithms have emerged as powerful predictive tools in the field stroke. Here, we examine the predictive accuracy of ML models for predicting functional outcomes using 24-hour post-treatment characteristics in the Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke (STRATIS) Registry. METHODS ML models, adaptive boost, random forest (RF), classification and regression trees (CART), C5.0 decision tree (C5.0), support vector machine (SVM), least absolute shrinkage and selection operator (LASSO), and logistic regression (LR), and traditional LR models were used to predict 90-day functional outcome (modified Rankin Scale score 0-2). Twenty-four-hour National Institutes of Health Stroke Scale (NIHSS) was examined as a continuous or dichotomous variable in all models. Model accuracy was assessed using the area under characteristic curve (AUC). RESULTS The 24-hour NIHSS score was a top-predictor of functional outcome in all models. ML models using the continuous 24-hour NIHSS scored showed moderate-to-good predictive performance (range mean AUC: 0.76-0.92); however, RF (AUC: 0.92 ± 0.028) outperformed all ML models, except LASSO (AUC: 0.89 ± 0.023, p = 0.0958). Importantly, RF demonstrated a significantly higher predictive value than LR (AUC: 0.87 ± 0.031, p = 0.048) and traditional LR (AUC: 85 ± 0.06, p = 0.035) when using the 24-hour continuous NIHSS score. Predictive accuracy was similar between the 24-hour NIHSS score dichotomous and continuous ML models. INTERPRETATION In this substudy, we found similar predictive accuracy for functional outcome when using the 24-hour NIHSS score as a continuous or dichotomous variable in ML models. ML models had moderate-to-good predictive accuracy, with RF outperforming LR models. External validation of these ML models is warranted. ANN NEUROL 2023;93:40-49.
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Affiliation(s)
| | - Zeinab Zoghi
- ProMedica Stroke Network, ProMedica Toledo Hospital, Toledo, OH
| | | | | | - Syed F Zaidi
- Department of Neurology, University of Toledo, Toledo, OH.,ProMedica Stroke Network, ProMedica Toledo Hospital, Toledo, OH
| | | | - David S Liebeskind
- Department of Neurology, University of California Los Angeles, Los Angeles, CA
| | - Mouhammad A Jumaa
- Department of Neurology, University of Toledo, Toledo, OH.,ProMedica Stroke Network, ProMedica Toledo Hospital, Toledo, OH
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16
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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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17
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Ma G, Yu Z, Jia B, Xian Y, Ren Z, Mo D, Ma N, Gao F, Tong X, Shi X, Li L, Pan Y, Miao Z. Time to Endovascular Reperfusion and Outcome in Acute Ischemic Stroke : A Nationwide Prospective Registry in China. Clin Neuroradiol 2022; 32:997-1009. [PMID: 35622100 DOI: 10.1007/s00062-022-01178-7] [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: 03/15/2022] [Accepted: 04/25/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE The benefit of endovascular reperfusion therapy for acute ischemic stroke is highly time-dependent but the relation of delays in workflow with outcomes and the key determinants of delays remain uncertain. This study aimed to evaluate the association between faster endovascular therapy and outcomes in a Chinese population with acute ischemic stroke. METHODS Patients treated with endovascular therapy within 7 h due to anterior large vessel occlusion were enrolled in the ANGEL-ACT registry. Time intervals from hospital arrival to arterial puncture (door-to-puncture), hospital arrival to reperfusion (door-to-reperfusion) and puncture-to-reperfusion were recorded. The outcomes included modified Rankin Scale (mRS) scores 0-1, 0-2, mortality at 3 months, substantial reperfusion, and symptomatic intracranial hemorrhage (sICH). RESULTS Of 932 patients receiving endovascular therapy (mean age 65.1 years, 60.1% male), the median door-to-puncture, door-to-reperfusion, and puncture-to-perfusion times were 110min (interquartile range, IQR 72-155min), 200min (IQR, 149-260min), and 76min (IQR, 50-118min). Of the patients 87.4% achieved substantial reperfusion and 9.6% had sICH. The mRS 0-1, 0-2, and mortality at 3 months were 39.8%, 43.2%, and 16.4%. Faster door-to-reperfusion and puncture-to-reperfusion were associated with higher likelihood of mRS 0-1, mRS 0-2, and lower rate of sICH. There was a trend of improved mRS, lower mortality, and fewer ICH with shorter door-to-puncture time; however, most differences were not statistically significant. CONCLUSION Among patients with acute ischemic stroke in routine clinical practice, shorter time to reperfusion was associated with better outcome after endovascular therapy. Standardized workflows and training in endovascular treatment techniques should be promoted nationally to reduce in-hospital delays.
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Affiliation(s)
- Gaoting Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, 100070, Fengtai District, Beijing, China
| | - Zequan Yu
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, 100070, Fengtai District, Beijing, China.,Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Baixue Jia
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, 100070, Fengtai District, Beijing, China
| | - Ying Xian
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Zeguang Ren
- Department of Neurosurgery, University of South Florida, Tampa, FL, USA
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, 100070, Fengtai District, Beijing, China
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, 100070, Fengtai District, Beijing, China
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, 100070, Fengtai District, Beijing, China
| | - Xu Tong
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, 100070, Fengtai District, Beijing, China
| | - Xiangqun Shi
- Department of Neurology, Shunde Hospital, Southern Medical University, Foshan, Guangdong, China
| | - Ling Li
- Department of Neurology, The Affiliated Hospital of Hebei University, Baoding, China
| | - Yuesong Pan
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China. .,China National Clinical Research Center for Neurological Diseases, No.119, South 4th Ring West Road, 100070, Fengtai District, Beijing, China.
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, No.119, South 4th Ring West Road, 100070, Fengtai District, Beijing, China.
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Zheng SF, Zhang YB, Xie BS, Wang HJ, Fan WJ, Chen GR, Dai LS, Yu LH, Yao PS, Kang DZ. Mechanical Thrombectomy with Tandem Double Stent Retriever in Combination with Intermediate Catheter Aspiration for Refractory Severe Hemorrhagic Cerebral Venous Sinus Thrombosis. World Neurosurg 2022; 167:e990-e997. [PMID: 36058490 DOI: 10.1016/j.wneu.2022.08.123] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2022] [Accepted: 08/26/2022] [Indexed: 11/19/2022]
Abstract
OBJECTIVE We aimed to describe the initial experience of mechanical thrombectomy using tandem double stent retrievers combined with intermediate catheter aspiration to treat refractory severe hemorrhagic (SH)-cerebral venous sinus thrombosis (CVST). METHODS All refractory SH-CVST patients treated with mechanical thrombectomy using tandem double stent retriever (SR) combined with intermediate catheter aspiration (MT-TDSA) in our institution were retrospectively reviewed. MT-TDSA is a technique that fully engages the clot with double SRs and retrieves the clot using a double SR in combination with aspiration from an intermediate catheter. Demographics, clinical manifestation, medical history, the location of the occluded venous sinus, intraoperative details, procedure-related complications, and modified Rankin Scale (1, 6, 12 months postoperatively) were collected and analyzed. RESULTS Fourteen patients (median age, 43 years) with refractory SH-CVST were treated with MT-TDSA between January 2016 and January 2020. Ten of 14 (71.4%) had a successful intraoperative recanalization rate (>90%) using MT-TDSA. No procedure-related complications occurred. Eleven patients had good clinical outcomes (modified Rankin Scale score 0-2 at 12 months postoperatively). CONCLUSIONS MT-TDSA for refractory SH-CVST might improve clot-capturing ability and remove blood clots from cerebral venous sinuses effectively and safely, achieving good clinical outcomes.
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Affiliation(s)
- Shu-Fa Zheng
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Yi-Bin Zhang
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Bin-Sen Xie
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Hao-Jie Wang
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Wen-Jian Fan
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Guo-Rong Chen
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Lin-Sun Dai
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Liang-Hong Yu
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Pei-Sen Yao
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - De-Zhi Kang
- Department of Neurosurgery, Neurosurgery Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China; Fujian Provincial Clinical Research Center for Neurological Disease, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China; Department of Neurosurgery, National Regional Medical Center, Binhai Campus of the First Affiliated Hospital, Fujian Medical University, Fuzhou, China; Fujian Provincial Institutes of Brain Disorders and Brain Sciences, The First Affiliated Hospital, Fujian Medical University, Fuzhou, China; Clinical research and translation center, the First Affiliated Hospital, Fujian Medical University, Fuzhou, China.
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19
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Zhang Y, Hong L, Ling Y, Yang L, Li S, Cheng X, Dong Q. Association of time to groin puncture with patient outcome after endovascular therapy stratified by etiology. Front Aging Neurosci 2022; 14:884087. [PMID: 36299609 PMCID: PMC9590449 DOI: 10.3389/fnagi.2022.884087] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/25/2022] [Accepted: 09/05/2022] [Indexed: 11/26/2022] Open
Abstract
Background Randomized clinical trials and large stroke registries have demonstrated a time-dependent benefit of endovascular treatment (EVT) in patients with acute ischemic stroke (AIS) due to large vessel occlusion (LVO). The aim of this study was to investigate whether this could be applied to different stroke subtypes in a real-world single-center cohort. Materials and methods Consecutive ischemic stroke patients with LVOs presenting within 24 h after symptom onset were prospectively registered and retrospectively assessed. Baseline multimodal imaging was conducted before EVT. Independent predictors of functional independence [90-day modified Rankin scale (mRS), 0–2] and any incidence of intracranial hemorrhage (ICH) were explored using a stepwise logistic regression model in the entire cohort and in stroke subtypes. Results From 2015 to 2020, 140 eligible patients received EVT, of whom 59 (42%) were classified as large artery atherosclerosis (LAA)-related. Time from last known normal to groin puncture was identified as an independent predictor for functional independence in patients of cardioembolic (CE) subtype [odds ratio (OR) 0.90 per 10 min; 95% CI 0.82–0.98; P = 0.013] but not in the LAA subtype and the whole cohort. Groin puncture within 6 h after the time of last known normal was associated with a lower risk of any ICH in the whole cohort (OR 0.36, 95% CI 0.17–0.75, P = 0.007). Sensitivity analysis of patients with complete imaging profiles also confirmed the above findings. Besides, compared with patients of the CE subtype, the LAA subtype had a smaller baseline ischemic core volume, a better collateral status, a slower core growth rate, and a numerically smaller final infarct volume. Conclusion Faster groin puncture has a more pronounced effect on the functional outcome in patients of CE subtype than those of LAA subtype. Reducing time to groin puncture is of great importance in improving the prognosis of patients after EVT, especially those of CE subtype, and reducing the incidence of any ICH in all patients.
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Affiliation(s)
- Yiran Zhang
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Lan Hong
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Yifeng Ling
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Lumeng Yang
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Siyuan Li
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
| | - Xin Cheng
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
- *Correspondence: Xin Cheng,
| | - Qiang Dong
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, Fudan University, Shanghai, China
- State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
- Qiang Dong,
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20
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Zhang LN, Chen QY, Wang M, Wang Y, Lei D, Chen SL. Analysis of the Therapeutic Effect of Multimode Mechanical Thrombectomy in the Treatment of Acute Ischemic Stroke. World Neurosurg 2022; 165:e488-e493. [PMID: 35750143 DOI: 10.1016/j.wneu.2022.06.085] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Revised: 06/15/2022] [Accepted: 06/16/2022] [Indexed: 12/14/2022]
Abstract
OBJECTIVE We sought to observe the effectiveness and safety of multimode mechanical thrombectomy in the treatment of acute ischemic stroke. METHODS The data from patients with acute intracranial artery occlusion treated with multimode mechanical thrombectomy between November 2018 and December 2019 were collected, and the clinical features, imaging data, treatment, and clinical follow-up results 90 days after the operation were analyzed. Postoperative recanalization and the 90-day modified Rankin Scale score were used as clinically effective endpoints. The incidence of symptomatic intracranial hemorrhage within 72 hours and postoperative 90-day mortality were used to evaluate safety. RESULTS A total of 70 patients were enrolled, including 18 cases with bridging treatment, 11 cases with stent implantation, and 10 cases with balloon dilatation. During the 90 days of follow-up after surgery, 35.7% of (25/70) patients had a good prognosis (modified Rankin Scale score of 0-2). The incidence of postoperative symptomatic intracranial hemorrhage was 11.4% (8/70), and postoperative mortality was 34.3% (24/70). The onset-to-puncture time in the good-prognosis group and the poor-prognosis group was 270 (225-345) versus 330 (270-420) minutes, respectively, and the onset-to-recanalization time in the 2 groups was 350 (295-405) versus 410 (340-470) minutes, respectively. Successful recanalization in the good-prognosis group and the poor-prognosis group was 96.0% versus 57.8%, respectively, and the incidence of symptomatic intracranial hemorrhage in the 2 groups was 0% versus 17.8%, respectively. The difference between the 2 groups was statistically significant (P < 0.05). CONCLUSIONS Multimode mechanical thrombectomy is a safe and effective therapy for the intracranial occlusion of large vessels in patients with acute ischemic stroke.
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Affiliation(s)
- Li-Na Zhang
- Department of Neurology, ChongQing University Three Gorges Hospital, Chongqing, China
| | - Qi-Yan Chen
- Department of Neurology, ChongQing University Three Gorges Hospital, Chongqing, China
| | - Min Wang
- Department of Neurology, ChongQing University Three Gorges Hospital, Chongqing, China
| | - Yong Wang
- Department of Neurology, ChongQing University Three Gorges Hospital, Chongqing, China
| | - Da Lei
- Department of Neurology, ChongQing University Three Gorges Hospital, Chongqing, China
| | - Sheng-Li Chen
- Department of Neurology, ChongQing University Three Gorges Hospital, Chongqing, China.
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21
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González Diaz E, Rodríguez-Paz C, Fernandez-Prieto A, Martínez-Galdámez M, Martínez-Moreno R, Ortega Quintanilla J, Tomasello A, Zamarro J, Liebeskind D, Zaidat OO, Mueller-Kronast NH. Economic impact of the first pass effect in mechanical thrombectomy for acute ischaemic stroke treatment in Spain: a cost-effectiveness analysis from the national health system perspective. BMJ Open 2022; 12:e054816. [PMID: 36258310 PMCID: PMC9438077 DOI: 10.1136/bmjopen-2021-054816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVE The mechanical thrombectomy (MT) benefit is related to the degree of reperfusion achieved. First pass effect (FPE) is defined as complete/near revascularisation of the large-vessel occlusion (modified Thrombolysis in Cerebral Infarction (mTICI) 2c-3) after a single device pass. This study assessed the health benefit and economic impact of achieving FPE for acute ischaemic stroke (AIS) patients from the Spanish National Health System (NHS) perspective. DESIGN A lifetime Markov model was used to estimate incremental costs and health outcomes (measured in quality-adjusted life-years (QALYs)) of patients that achieve FPE. A subanalysis of the Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischaemic Stroke (STRATIS) registry was performed to obtain clinical outcomes. The base case included all patients that achieved at least a final mTICI ≥2 b, while the alternative scenario included all patients regardless of their final mTICI (0-3). Treatment costs were updated to reflect current practice based on expert panel consensus, while other acute and long-term costs were obtained from a previous cost-effectiveness analysis of MT performed in Spain. Sensitivity analyses were performed to assess the model's robustness. SETTING Spanish healthcare perspective. PARTICIPANTS AIS patients in Spain. INTERVENTIONS FPE following MT. OUTCOME MEASURES The model estimated QALYs, lifetime costs and net monetary benefit for the FPE and non-FPE group, depending on the inclusion of reperfusion groups and formal care costs. RESULTS STRATIS subanalysis estimated significantly better clinical outcomes at 90 days for the FPE group in all scenarios. In the base case, the model estimated lifetime cost saving per patient of €16 583 and an incremental QALY gain of 1.2 years of perfect health for the FPE group. Cost savings and QALY gains were greater in the alternative scenario (-€44 289; 1.75). In all scenarios, cost savings were driven by the long-term cost reduction. CONCLUSION Achieving FPE after MT can lead to better health outcomes per AIS patient and important cost savings for the Spanish NHS.
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Affiliation(s)
- Eva González Diaz
- Neurointerventional Radiology, Radiology Department, Cruces University Hospital, Barakaldo, Spain
| | - Carlos Rodríguez-Paz
- Neuroradiology Unit, Department of Radiology, Hospital Álvaro Cunqueiro, Vigo, Spain
| | - Andres Fernandez-Prieto
- Neurointerventional Radiology, Radiology Department, Hospital Universitario La Paz, Madrid, Spain
| | | | | | | | - Alejandro Tomasello
- Interventional Neuroradiology Section, Department of Radiology, Vall d'Hebron University Hospital, Barcelona, Spain
- Vall d'Hebron Research Institute (VHIR), Vall d'Hebron University Hospital, Barcelona, Spain
| | - Joaquín Zamarro
- Interventional Neuroradiology, Hospital Clinico Universitario Virgen de la Arrixaca, Murcia, Spain
| | - David Liebeskind
- Neurovascular Imaging Core and UCLA Stroke Center, Department of Neurology, University of California, Los Angeles, California, USA
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22
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Stoll G, Schuhmann MK, Nieswandt B, Kollikowski AM, Pham M. An intravascular perspective on hyper-acute neutrophil, T-cell and platelet responses: Similarities between human and experimental stroke. J Cereb Blood Flow Metab 2022; 42:1561-1567. [PMID: 35676801 PMCID: PMC9441733 DOI: 10.1177/0271678x221105764] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
In stroke patients, local sampling of pial blood within the occluded vasculature before recanalization by mechanical thrombectomy emerged as powerful tool enabling insights into ultra-early stroke pathophysiology. Thereby, a strong intravascular inflammatory response hallmarked by hyper-acute neutrophil recruitment, altered lymphocyte composition and platelet activation could be observed. These human findings mirror experimental stroke. Here, neutrophil and T-cell activation are driven by platelets involving engagement of platelet glycoprotein receptor (GP)Ib, GPVI and CD84 as well as α-granule release orchestrating infarct progression. Thus, targeting of early intravascular inflammation may evolve as a new therapeutic strategy to augment the effects of recanalization.
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Affiliation(s)
- Guido Stoll
- Department of Neurology, University of Würzburg, Würzburg, Germany
| | | | - Bernhard Nieswandt
- Institute for Experimental Biomedicine and Rudolf-Virchow-Center, University of Würzburg, Würzburg, Germany
| | | | - Mirko Pham
- Department of Neuroradiology, University of Würzburg, Würzburg, Germany
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23
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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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Abstract
Our Japanese colleagues deserve much praise for finishing the first randomized clinical trial of thrombectomy in Alberta Stroke Program Early CT Score 3 to 5 patients showing an impressive therapy effect of thrombectomy. The predominant use of magnetic resonance imaging for patient selection, the low rate of alteplase therapy and its low dose limit direct comparisons with patients treated outside of Japan. Another limitation is the lack of benefit when using the traditional metric–modified Rankin Scale score 0–2. We consider the results of RESCUE-Japan LIMIT encouraging and a clear motivation to continue and complete other studies.
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Affiliation(s)
- Diogo C. Haussen
- Emory University School of Medicine/Grady Memorial Hospital, Atlanta, GA. (D.C.H.)
| | - Jens Fiehler
- Department of Neuroradiology, University Center Hamburg-Eppendorf, Germany (J.F.)
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25
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Haarmann A, Zimmermann L, Bieber M, Silwedel C, Stoll G, Schuhmann MK. Regulation and Release of Vasoactive Endoglin by Brain Endothelium in Response to Hypoxia/Reoxygenation in Stroke. Int J Mol Sci 2022; 23:ijms23137085. [PMID: 35806090 PMCID: PMC9267030 DOI: 10.3390/ijms23137085] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2022] [Revised: 06/21/2022] [Accepted: 06/23/2022] [Indexed: 02/01/2023] Open
Abstract
In large vessel occlusion stroke, recanalization to restore cerebral perfusion is essential but not necessarily sufficient for a favorable outcome. Paradoxically, in some patients, reperfusion carries the risk of increased tissue damage and cerebral hemorrhage. Experimental and clinical data suggest that endothelial cells, representing the interface for detrimental platelet and leukocyte responses, likely play a crucial role in the phenomenon referred to as ischemia/reperfusion (I/R)-injury, but the mechanisms are unknown. We aimed to determine the role of endoglin in cerebral I/R-injury; endoglin is a membrane-bound protein abundantly expressed by endothelial cells that has previously been shown to be involved in the maintenance of vascular homeostasis. We investigated the expression of membranous endoglin (using Western blotting and RT-PCR) and the generation of soluble endoglin (using an enzyme-linked immunosorbent assay of cell culture supernatants) after hypoxia and subsequent reoxygenation in human non-immortalized brain endothelial cells. To validate these in vitro data, we additionally examined endoglin expression in an intraluminal monofilament model of permanent and transient middle cerebral artery occlusion in mice. Subsequently, the effects of recombinant human soluble endoglin were assessed by label-free impedance-based measurement of endothelial monolayer integrity (using the xCELLigence DP system) and immunocytochemistry. Endoglin expression is highly inducible by hypoxia in human brain endothelial monolayers in vitro, and subsequent reoxygenation induced its shedding. These findings were corroborated in mice during MCAO; an upregulation of endoglin was displayed in the infarcted hemispheres under occlusion, whereas endoglin expression was significantly diminished after transient MCAO, which is indicative of shedding. Of note is the finding that soluble endoglin induced an inflammatory phenotype in endothelial monolayers. The treatment of HBMEC with endoglin resulted in a decrease in transendothelial resistance and the downregulation of VE-cadherin. Our data establish a novel mechanism in which hypoxia triggers the initial endothelial upregulation of endoglin and subsequent reoxygenation triggers its release as a vasoactive mediator that, when rinsed into adjacent vascular beds after recanalization, can contribute to cerebral reperfusion injury.
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Affiliation(s)
- Axel Haarmann
- Department of Neurology, University of Würzburg, 97080 Würzburg, Germany; (L.Z.); (M.B.); (G.S.)
- Correspondence: (A.H.); (M.K.S.)
| | - Lena Zimmermann
- Department of Neurology, University of Würzburg, 97080 Würzburg, Germany; (L.Z.); (M.B.); (G.S.)
| | - Michael Bieber
- Department of Neurology, University of Würzburg, 97080 Würzburg, Germany; (L.Z.); (M.B.); (G.S.)
| | - Christine Silwedel
- University Children’s Hospital, University of Würzburg, 97080 Würzburg, Germany;
| | - Guido Stoll
- Department of Neurology, University of Würzburg, 97080 Würzburg, Germany; (L.Z.); (M.B.); (G.S.)
| | - Michael K. Schuhmann
- Department of Neurology, University of Würzburg, 97080 Würzburg, Germany; (L.Z.); (M.B.); (G.S.)
- Correspondence: (A.H.); (M.K.S.)
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26
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Lylyk P, Cirio J, Toranzo C, Aiello E, Valencia J, Paredes-Fernández D. Mechanical thrombectomy for acute ischemic stroke due to large vessel occlusion in Argentina: An economic analysis. J Stroke Cerebrovasc Dis 2022; 31:106595. [PMID: 35716524 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106595] [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: 02/03/2022] [Revised: 05/11/2022] [Accepted: 06/06/2022] [Indexed: 11/17/2022] Open
Abstract
OBJECTIVES Mechanical thrombectomy (MT) after intravenous thrombolysis (IV-tPA) is an effective and cost-saving treatment for stroke due to large vessel occlusion. However, rates of MT use are low in Argentina. This study was designed to estimate the economic value and the budget impact of incorporating MT after thrombolysis, simulating scenarios from Argentinian compulsory social health insurance (Obras Sociales) and private insurances (Empresas de Medicina Prepaga). MATERIALS AND METHODS We adapted a previously published cost-utility and budget-impact (CUA and BIA) model to the Argentinian setting. The CUA was carried out for a lifetime horizon with efficacy inputs from the SWIFT PRIME clinical trial. For seven possible health states, we identified local costs (Argentinian Pesos AR$), utility (QALY), and transition/distribution probabilities (5% discounted rate) and performed deterministic and probabilistic sensitivity analyses. The BIA was based on a six-step approach and a static model for a five-year horizon, and two scenarios (staggered growth and no growth). RESULTS Despite higher incremental procedure costs, IV-tPA and MT was dominant over IV-tPA alone (AR$1,049,062 overall savings). Cost-effectiveness remained in the deterministic sensitivity analysis (100% probability of cost-effectiveness). Increased MT procedure volume resulted in savings in years three (0.96%), four (2.6%), and five (4.4%). By year five, 1,280 patients were treated with MT (versus 480) with overall savings of 1.8% (AR$817,244,417). CONCLUSIONS MT after IV-tPA is cost-effective in Argentina. Savings offset the incremental hospitalization and long-term costs from the third year onwards. With increased, access the superior efficacy of MT mitigates future disability and comorbidity, reducing overall expenses.
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Affiliation(s)
- Pedro Lylyk
- Instituto Médico ENERI - Equipo de Neurocirugía Endovascular y Radiología Intervencionista, Buenos Aires, Argentina; Stroke Unit, Clínica La Sagrada Familia, Buenos Aires, Argentina
| | - Juan Cirio
- Instituto Médico ENERI - Equipo de Neurocirugía Endovascular y Radiología Intervencionista, Buenos Aires, Argentina; Stroke Unit, Clínica La Sagrada Familia, Buenos Aires, Argentina
| | - Carlos Toranzo
- Instituto Médico ENERI - Equipo de Neurocirugía Endovascular y Radiología Intervencionista, Buenos Aires, Argentina; Stroke Unit, Clínica La Sagrada Familia, Buenos Aires, Argentina
| | | | - Juan Valencia
- Health Economics, Policy and Reimbursement, Medtronic Latin-America, USA
| | - Daniela Paredes-Fernández
- Health Economics, Policy and Reimbursement, Medtronic South Latin-America, 532 Rosario Norte Street, Las Condes, Chile.
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Safety and effectiveness of mechanical thrombectomy for acute ischemic stroke using single plane angiography. J Stroke Cerebrovasc Dis 2022; 31:106553. [PMID: 35689934 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106553] [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: 02/23/2022] [Revised: 05/02/2022] [Accepted: 05/08/2022] [Indexed: 11/22/2022] Open
Abstract
OBJECTIVES Nearly all data on mechanical thrombectomy for acute ischemic stroke is based on procedures performed on biplane angiography systems. However, thrombectomy may be performed on single-plane systems in situations of triage or limited resources. We present the first US study comparing the safety and effectiveness of mechanical thrombectomy performed on single-plane vs. biplane systems. METHODS AND METHODS A retrospective review of a prospectively maintained database identified all patients treated with thrombectomy between July 2020 and July 2021 by a high-volume practice. Patients were dichotomized into those treated on single plane and biplane systems. Demographic, procedural, clinical and follow-up characteristics were compared. RESULTS Of the 246 patients treated with mechanical thrombectomy, 70 (33%) and 141 (66%) patients were treated on SP and BP systems, respectively. No significant differences were detected in follow-up 'good functional outcome' (mRS ≤ 2; SP 51% vs BP 43%, p = 0.14), successful recanalization (SP 87% vs BP 88%, p = 0.72), intra-procedural vascular injury (SP 3% vs BP 2%, p = 0.96), or time from groin puncture to reperfusion (SP 24 min vs BP 26 min, p = 0.58). Additionally, no significant differences were detected in peri-procedural complications, fluoroscopy times or total radiation. Patients treated on single plane systems required significantly more contrast. CONCLUSIONS Mechanical thrombectomy for acute ischemic stroke performed on single plane angiography systems is as safe and efficacious as when performed on biplane systems. Our results may have implications for increasing stroke care access, both domestically in underserved/rural areas and internationally when considering requirements for stroke care in lower-income countries.
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Uniken Venema SM, Dankbaar JW, Wolff L, van Es ACGM, Sprengers M, van der Lugt A, Dippel DWJ, van der Worp HB. Collateral status and recanalization after endovascular treatment for acute ischemic stroke. J Neurointerv Surg 2022; 15:531-538. [PMID: 35584911 DOI: 10.1136/neurintsurg-2021-018545] [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: 12/14/2021] [Accepted: 05/02/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Successful recanalization and good collateral status are associated with good clinical outcomes after endovascular treatment (EVT) for acute ischemic stroke, but the relationships among them are unclear. OBJECTIVE To assess if collateral status is associated with recanalization after EVT and if collateral status modifies the association between successful recanalization and functional outcome. METHODS We retrospectively analyzed data from the MR CLEAN Registry, a multicenter prospective cohort study of patients with a proximal anterior occlusion who underwent EVT in the Netherlands. We determined collateral status with a previously validated four-point visual grading scale and defined successful recanalization as an extended Thrombolysis in Cerebral Infarction score ≥2B. Functional outcome was determined using the modified Rankin Scale score at 90 days. We assessed, with multivariable logistic regression models, the associations between (1) collateral status and successful recanalization, (2) successful recanalization and functional outcome, (3) collateral status and functional outcome. An interaction of collateral status and successful recanalization was assessed. Subgroup analyses were performed for patients treated with intravenous thrombolysis. RESULTS We included 2717 patients, of whom 1898 (70%) had successful recanalization. There was no relationship between collateral status and successful recanalization (adjusted common OR (95% CI) of grades 1, 2, and 3 vs 0: 1.19 (0.82 to 1.72), 1.20 (0.83 to 1.75), and 1.10 (0.74 to 1.63), respectively). Successful recanalization (acOR (95% CI): 2.15 (1.84 to 2.52)) and better collateral grades (acOR (95% CI) of grades 1, 2, and 3 vs 0: 2.12 (1.47 to 3.05), 3.46 (2.43 to 4.92), and 4.16 (2.89 to 5.99), respectively) were both associated with a shift towards better functional outcome, without an interaction between collateral status and successful recanalization. Results were similar for the subgroup of thrombolysed patients. CONCLUSIONS Collateral status is not associated with the probability of successful recanalization after EVT and does not modify the association between successful recanalization and functional outcome.
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Affiliation(s)
- Simone M Uniken Venema
- Department of Neurology and Neurosurgery, Brain Center, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - Jan Willem Dankbaar
- Department of Radiology, University Medical Center Utrecht Imaging Division, Utrecht, The Netherlands
| | - Lennard Wolff
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Adriaan C G M van Es
- Department of Radiology, Leiden Universitair Medisch Centrum, Leiden, Zuid-Holland, The Netherlands
| | - Marieke Sprengers
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Locatie AMC, Amsterdam, North Holland, The Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus Medical Center, Rotterdam, Zuid-Holland, The Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Centre Utrecht, Utrecht, The Netherlands
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Amini M, van Leeuwen N, Eijkenaar F, van de Graaf R, Samuels N, van Oostenbrugge R, van den Wijngaard IR, van Doormaal PJ, Roos YBWEM, Majoie C, Roozenbeek B, Dippel D, Burke J, Lingsma HF, Dippel DWJ, van der Lugt A, Majoie CBLM, Roos YBWEM, van Oostenbrugge RJ, van Zwam WH, Boiten J, Vos JA, Brouwer J, den Hartog SJ, Hinsenveld WH, Kappelhof M, Compagne KCJ, Goldhoorn RJB, Mulder MJHL, Jansen IGH, Dippel DWJ, Roozenbeek B, van der Lugt A, van Es ACGM, Majoie CBLM, Roos YBWEM, Emmer BJ, Coutinho JM, Schonewille WJ, Vos JA, Wermer MJH, van Walderveen MAA, Staals J, van Oostenbrugge RJ, van Zwam WH, Hofmeijer J, Martens JM, Lycklama à Nijeholt GJ, Boiten J, de Bruijn SF, van Dijk LC, van der Worp HB, Lo RH, van Dijk EJ, Boogaarts HD, de Vries J, de Kort PLM, van Tuijl J, Peluso JJP, Fransen P, van den Berg JSP, van Hasselt BAAM, Aerden LAM, Dallinga RJ, Uyttenboogaart M, Eschgi O, Bokkers RPH, Schreuder THCML, Heijboer RJJ, Keizer K, Yo LSF, den Hertog HM, Sturm EJC, Brouwers P, Majoie CBLM, van Zwam WH, van der Lugt A, Lycklama à Nijeholt GJ, van Walderveen MAA, Sprengers MES, Jenniskens SFM, van den Berg R, Yoo AJ, Beenen LFM, Postma AA, Roosendaal SD, van der Kallen BFW, van den Wijngaard IR, van Es ACGM, Emmer BJ, Martens JM, Yo LSF, Vos JA, Bot J, van Doormaal PJ, Meijer A, Ghariq E, Bokkers RPH, van Proosdij MP, Krietemeijer GM, Peluso JP, Boogaarts HD, Lo R, Gerrits D, Dinkelaar W, Appelman APA, Hammer B, Pegge S, van der Hoorn A, Vinke S, Dippel DWJ, van der Lugt A, Majoie CBLM, Roos YBWEM, van Oostenbrugge RJ, van Zwam WH, Lycklama à Nijeholt GJ, Boiten J, Vos JA, Schonewille WJ, Hofmeijer J, Martens JM, van der Worp HB, Lo RH, van Oostenbrugge RJ, Hofmeijer J, Flach HZ, Lingsma HF, el Ghannouti N, Sterrenberg M, Puppels C, Pellikaan W, Sprengers R, Elfrink M, Simons M, Vossers M, de Meris J, Vermeulen T, Geerlings A, van Vemde G, Simons T, van Rijswijk C, Messchendorp G, Nicolaij N, Bongenaar H, Bodde K, Kleijn S, Lodico J, Droste H, Wollaert M, Verheesen S, Jeurrissen D, Bos E, Drabbe Y, Sandiman M, Elfrink M, Aaldering N, Zweedijk B, Khalilzada M, Vervoort J, Droste H, Nicolaij N, Simons M, Ponjee E, Romviel S, Kanselaar K, Bos E, Barning D, Venema E, Chalos V, Geuskens RR, van Straaten T, Ergezen S, Harmsma RRM, Muijres D, de Jong A, Berkhemer OA, Boers AMM, Huguet J, Groot PFC, Mens MA, van Kranendonk KR, Treurniet KM, Jansen IGH, Tolhuisen ML, Alves H, Weterings AJ, Kirkels ELF, Voogd EJHF, Schupp LM, Collette S, Groot AED, LeCouffe NE, Konduri PR, Prasetya H, Arrarte-Terreros N, Ramos LA. Estimation of treatment effects in observational stroke care data: comparison of statistical approaches. BMC Med Res Methodol 2022; 22:103. [PMID: 35399057 PMCID: PMC8996562 DOI: 10.1186/s12874-022-01590-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 03/22/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Introduction
Various statistical approaches can be used to deal with unmeasured confounding when estimating treatment effects in observational studies, each with its own pros and cons. This study aimed to compare treatment effects as estimated by different statistical approaches for two interventions in observational stroke care data.
Patients and methods
We used prospectively collected data from the MR CLEAN registry including all patients (n = 3279) with ischemic stroke who underwent endovascular treatment (EVT) from 2014 to 2017 in 17 Dutch hospitals. Treatment effects of two interventions – i.e., receiving an intravenous thrombolytic (IVT) and undergoing general anesthesia (GA) before EVT – on good functional outcome (modified Rankin Scale ≤2) were estimated. We used three statistical regression-based approaches that vary in assumptions regarding the source of unmeasured confounding: individual-level (two subtypes), ecological, and instrumental variable analyses. In the latter, the preference for using the interventions in each hospital was used as an instrument.
Results
Use of IVT (range 66–87%) and GA (range 0–93%) varied substantially between hospitals. For IVT, the individual-level (OR ~ 1.33) resulted in significant positive effect estimates whereas in instrumental variable analysis no significant treatment effect was found (OR 1.11; 95% CI 0.58–1.56). The ecological analysis indicated no statistically significant different likelihood (β = − 0.002%; P = 0.99) of good functional outcome at hospitals using IVT 1% more frequently. For GA, we found non-significant opposite directions of points estimates the treatment effect in the individual-level (ORs ~ 0.60) versus the instrumental variable approach (OR = 1.04). The ecological analysis also resulted in a non-significant negative association (0.03% lower probability).
Discussion and conclusion
Both magnitude and direction of the estimated treatment effects for both interventions depend strongly on the statistical approach and thus on the source of (unmeasured) confounding. These issues should be understood concerning the specific characteristics of data, before applying an approach and interpreting the results. Instrumental variable analysis might be considered when unobserved confounding and practice variation is expected in observational multicenter studies.
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30
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Compagne KCJ, Kappelhof M, Hinsenveld WH, Brouwer J, Goldhoorn RJB, Uyttenboogaart M, Bokkers RPH, Schonewille WJ, Martens JM, Hofmeijer J, van der Worp HB, Lo RTH, Keizer K, Yo LSF, Lycklama À Nijeholt GJ, den Hertog HM, Sturm EJC, Brouwers PJAM, van Walderveen MAA, Wermer MJH, de Bruijn SF, van Dijk LC, Boogaarts HD, van Dijk EJ, van Tuijl JH, Peluso JPP, de Kort PLM, van Hasselt BAAM, Fransen PS, Schreuder THCML, Heijboer RJJ, Jenniskens SFM, Sprengers MES, Ghariq E, van den Wijngaard IR, Roosendaal SD, Meijer AFJA, Beenen LFM, Postma AA, van den Berg R, Yoo AJ, van Doormaal PJ, van Proosdij MP, Krietemeijer MGM, Gerrits DG, Hammer S, Vos JA, Boiten J, Coutinho JM, Emmer BJ, van Es ACGM, Roozenbeek B, Roos YBWEM, van Zwam WH, van Oostenbrugge RJ, Majoie CBLM, Dippel DWJ, van der Lugt A. Improvements in Endovascular Treatment for Acute Ischemic Stroke: A Longitudinal Study in the MR CLEAN Registry. Stroke 2022; 53:1863-1872. [PMID: 35135323 PMCID: PMC9126265 DOI: 10.1161/strokeaha.121.034919] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
We evaluated data from all patients in the Netherlands who underwent endovascular treatment for acute ischemic stroke in the past 3.5 years, to identify nationwide trends in time to treatment and procedural success, and assess their effect on clinical outcomes.
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Affiliation(s)
- Kars C J Compagne
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, the Netherlands. (K.C.J.C., P.J.v.D.).,Department of Neurology, Erasmus MC, University Medical Center' Rotterdam' the Netherlands. (K.C.J.C., B.R., D.W.J.D.)
| | - Manon Kappelhof
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam' the Netherlands. (M.K., M.E.S.S., S.D.R., L.F.M.B., R.v.d.B., B.J.E., C.B.L.M.M.)
| | - Wouter H Hinsenveld
- Department of Radiology and Nuclear Medicine, School for Cardiovascular Diseases (CARIM), School for Mental Health and Sciences, Maastricht University Medical Center' the Netherlands. (A.A.P., W.H.v.Z.)
| | - Josje Brouwer
- Department of Neurology, Amsterdam UMC, University of Amsterdam' the Netherlands. (J.B., J.M.C., Y.B.W.E.M.R.)
| | - Robert-Jan B Goldhoorn
- Department of Neurology, School for Cardiovascular Diseases (CARIM), School for Mental Health and Sciences, Maastricht University Medical Center' the Netherlands. (W.H.H., R.-J.B.G., R.J.v.O.)
| | | | - Reinoud P H Bokkers
- Department of Radiology, University Medical Center Groningen' the Netherlands. (R.P.H.B.)
| | | | - Jasper M Martens
- Department of Radiology, Rijnstate Hospital' Arnhem' the Netherlands. (J.M.M.)
| | - Jeannette Hofmeijer
- Department of Neurology, Rijnstate Hospital' Arnhem' the Netherlands. (J.H.)
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht' the Netherlands. (H.B.v.d.W.)
| | - Rob T H Lo
- Department of Radiology, University Medical Center Utrecht' the Netherlands. (R.T.H.L.O.)
| | - Koos Keizer
- Department of Neurology, Catharina Hospital' Eindhoven' the Netherlands. (K.K.)
| | - Lonneke S F Yo
- Department of Radiology, Catharina Hospital' Eindhoven' the Netherlands. (L.S.F.Y., M.G.M.K.)
| | | | - Heleen M den Hertog
- Department of Neurology, Isala Klinieken' the Netherlands. (H.M.d.H., P.S.F.)
| | - Emiel J C Sturm
- Department of Radiology, Medical Spectrum Twente' the Netherlands. (E.J.C.S., D.G.G.)
| | - Paul J A M Brouwers
- Department of Neurology, Medical Spectrum Twente' the Netherlands. (P.J.A.M.B.)
| | | | - Marieke J H Wermer
- Department of Neurology, Leiden University Medical Center' the Netherlands. (M.J.H.W.)
| | | | - Lukas C van Dijk
- Department of Radiology, HAGA Hospital' the Netherlands. (L.C.v.D.)
| | - Hieronymus D Boogaarts
- Department of Neurosurgery, Radboud University Medical Center' the Netherlands. (H.D.B.)
| | - Ewout J van Dijk
- Department of Neurology, Radboud University Medical Center' the Netherlands. (E.J.v.D.)
| | | | - Jo P P Peluso
- Department of Radiology, Sint Elisabeth Hospital' the Netherlands. (J.P.P.)
| | - Paul L M de Kort
- Department of Neurology, Sint Elisabeth Hospital' the Netherlands. (P.L.M.d.K.)
| | | | - Puck S Fransen
- Department of Neurology, Isala Klinieken' the Netherlands. (H.M.d.H., P.S.F.)
| | | | | | - Sjoerd F M Jenniskens
- Department of Radiology, Radboud University Medical Center' the Netherlands. (S.F.M.J., A.F.J.A.M.)
| | - Marieke E S Sprengers
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam' the Netherlands. (M.K., M.E.S.S., S.D.R., L.F.M.B., R.v.d.B., B.J.E., C.B.L.M.M.)
| | - Elias Ghariq
- Department of Radiology, Haaglanden Medical Center' the Netherlands. (G.J.L.à.N., E.G.)
| | | | - Stefan D Roosendaal
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam' the Netherlands. (M.K., M.E.S.S., S.D.R., L.F.M.B., R.v.d.B., B.J.E., C.B.L.M.M.)
| | - Anton F J A Meijer
- Department of Radiology, Radboud University Medical Center' the Netherlands. (S.F.M.J., A.F.J.A.M.)
| | - Ludo F M Beenen
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam' the Netherlands. (M.K., M.E.S.S., S.D.R., L.F.M.B., R.v.d.B., B.J.E., C.B.L.M.M.)
| | - Alida A Postma
- Department of Radiology and Nuclear Medicine, School for Cardiovascular Diseases (CARIM), School for Mental Health and Sciences, Maastricht University Medical Center' the Netherlands. (A.A.P., W.H.v.Z.)
| | - René van den Berg
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam' the Netherlands. (M.K., M.E.S.S., S.D.R., L.F.M.B., R.v.d.B., B.J.E., C.B.L.M.M.)
| | - Albert J Yoo
- Department of Radiology, Texas Stroke Institute' Plano' TX (A.J.Y.)
| | - Pieter Jan van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, the Netherlands. (K.C.J.C., P.J.v.D.)
| | - Marc P van Proosdij
- Department of Radiology, Noordwest Ziekenhuisgroep' the Netherlands (M.P.v.P.)
| | - Menno G M Krietemeijer
- Department of Radiology, Catharina Hospital' Eindhoven' the Netherlands. (L.S.F.Y., M.G.M.K.)
| | - Dick G Gerrits
- Department of Radiology, Medical Spectrum Twente' the Netherlands. (E.J.C.S., D.G.G.)
| | | | - Jan Albert Vos
- Department of Radiology, Sint Antonius Hospital' the Netherlands. (J.A.V.)
| | - Jelis Boiten
- Department of Neurology, Haaglanden Medical Center' the Netherlands. (I.R.v.d.W., J.B.)
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC, University of Amsterdam' the Netherlands. (J.B., J.M.C., Y.B.W.E.M.R.)
| | - Bart J Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam' the Netherlands. (M.K., M.E.S.S., S.D.R., L.F.M.B., R.v.d.B., B.J.E., C.B.L.M.M.)
| | - Ad C G M van Es
- Department of Radiology, Leiden University Medical Center' the Netherlands. (M.A.A.v.W., A.C.G.M.v.E.)
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC, University Medical Center' Rotterdam' the Netherlands. (K.C.J.C., B.R., D.W.J.D.)
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam UMC, University of Amsterdam' the Netherlands. (J.B., J.M.C., Y.B.W.E.M.R.)
| | - Wim H van Zwam
- Department of Neurology, School for Cardiovascular Diseases (CARIM), School for Mental Health and Sciences, Maastricht University Medical Center' the Netherlands. (W.H.H., R.-J.B.G., R.J.v.O.)
| | - Robert J van Oostenbrugge
- Department of Neurology, School for Cardiovascular Diseases (CARIM), School for Mental Health and Sciences, Maastricht University Medical Center' the Netherlands. (W.H.H., R.-J.B.G., R.J.v.O.)
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC, University of Amsterdam' the Netherlands. (M.K., M.E.S.S., S.D.R., L.F.M.B., R.v.d.B., B.J.E., C.B.L.M.M.)
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC, University Medical Center' Rotterdam' the Netherlands. (K.C.J.C., B.R., D.W.J.D.)
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Sacks D, Dhand S, Hegg R, Hirsch K, McCollom V, Sarin S, Vadlamudi V, Wasser T, Zylak C. Outcomes of Stroke Thrombectomy Performed by Interventional Radiologists vs Neurointerventional Physicians. J Vasc Interv Radiol 2022; 33:619-626.e1. [PMID: 35150837 DOI: 10.1016/j.jvir.2021.11.018] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 11/04/2021] [Accepted: 11/25/2021] [Indexed: 11/27/2022] Open
Abstract
PURPOSE To test the hypothesis that interventional radiologists (IR) have outcomes for endovascular stroke thrombectomy (EVT) similar to Neurointerventional (NI) physicians and could be used to improve availability of thrombectomy. MATERIALS AND METHODS Eight hospitals providing EVT performed by IR and NI in the same institution submitted sequential retrospective data limited to the era of modern devices. Good clinical outcome (90 day modified Rankin score 0-2) and successful revascularization (modified Thrombolysis in Cerebral Infarction score > 2b) were compared between specialties, adjusted for treating hospital, patient age, stroke severity, Alberta Stroke Program Early CT Score (ASPECTS), time from symptom onset to door, and clot location. Propensity score matching was used to compare outcomes. A total of 1009 patients were entered (622 treated by IR and 387 treated by NI). RESULTS Median stroke onset to puncture was 245 vs 253 minutes (p=.49), technically successful revascularization was 81.8% vs 82.4% (p=.81), and good clinical outcome was 45.5% vs 50.1% (p=.16), respectively. After adjusting, physician specialty was not a significant predictor of good clinical outcome (odds ratio 1.028 [95% CI 0.760-1.390]; p=.86). After matching, mRS 0-2 was 47.7% for IR and 51.1% for NI (p=0.366). CONCLUSION There was no significant difference in successful revascularization and good clinical outcomes between IR and NI physicians. Outcomes by IR were similar to NI outcomes from previously published trials and registries. This may be useful to address coverage and access to stroke interventions.
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Affiliation(s)
| | | | - Ryan Hegg
- Research Medical Center, Kansas City, MO
| | | | | | - Shawn Sarin
- George Washington University Hospital, Washington, DC
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Preclinical modeling of mechanical thrombectomy. J Biomech 2021; 130:110894. [PMID: 34915309 DOI: 10.1016/j.jbiomech.2021.110894] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2021] [Revised: 11/16/2021] [Accepted: 11/18/2021] [Indexed: 11/21/2022]
Abstract
Mechanical thrombectomy to treat large vessel occlusions (LVO) causing a stroke is one of the most effective treatments in medicine, with a number needed to treat to improve clinical outcomes as low as 2.6. As the name implies, it is a mechanical solution to a blocked artery and modeling these mechanics preclinically for device design, regulatory clearance and high-fidelity physician training made clinical applications possible. In vitro simulation of LVO is extensively used to characterize device performance in representative vascular anatomies with physiologically accurate hemodynamics. Embolus analogues, validated against clots extracted from patients, provide a realistic simulated use experience. In vitro experimentation produces quantitative results such as particle analysis of distal emboli generated during the procedure, as well as pressure and flow throughout the experiment. Animal modeling, used mostly for regulatory review, allows estimation of device safety. Other than one recent development, nearly all animal modeling does not incorporate the desired target organ, the brain, but rather is performed in the extracranial circulation. Computational modeling of the procedure remains at the earliest stages but represents an enormous opportunity to rapidly characterize and iterate new thrombectomy concepts as well as optimize procedure workflow. No preclinical model is a perfect surrogate; however, models available can answer important questions during device development and have to date been successful in delivering efficacious and safe devices producing excellent clinical outcomes. This review reflects on the developments of preclinical modeling of mechanical thrombectomy with particular focus on clinical translation, as well as articulate existing gaps requiring additional research.
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Vogt ML, Kollikowski AM, Weidner F, Strinitz M, Feick J, Essig F, Neugebauer H, Haeusler KG, Pham M, Maerz A. Safety and Effectiveness of the New Generation APERIO® Hybrid Stent-retriever Device in Large Vessel Occlusion Stroke. Clin Neuroradiol 2021; 32:141-151. [PMID: 34936016 PMCID: PMC8894307 DOI: 10.1007/s00062-021-01122-1] [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: 05/22/2021] [Accepted: 11/05/2021] [Indexed: 11/28/2022]
Abstract
Background It is unknown whether technological advancement of stent-retriever devices influences typical observational indicators of safety or effectiveness. Methods Observational retrospective study of APERIO® (AP) vs. new generation APERIO® Hybrid (APH) (Acandis®, Pforzheim, Germany) stent-retriever device (01/2019–09/2020) for mechanical thrombectomy (MT) in large vessel occlusion (LVO) stroke. Primary effectiveness endpoint was successful recanalization eTICI (expanded Thrombolysis In Cerebral Ischemia) ≥ 2b67, primary safety endpoint was occurrence of hemorrhagic complications after MT. Secondary outcome measures were time from groin puncture to first pass and successful reperfusion, and the total number of passes needed to achieve the final recanalization result. Results A total of 298 patients with LVO stroke who were treated by MT matched the inclusion criteria: 148 patients (49.7%) treated with AP vs. 150 patients (50.3%) treated with new generation APH. Successful recanalization was not statistically different between both groups: 75.7% for AP vs. 79.3% for APH; p = 0.450. Postinterventional hemorrhagic complications and particularly subarachnoid hemorrhage as the entity possibly associated with stent-retriever device type was significantly less frequent in the group treated with the APH: 29.7% for AP and 16.0% for APH; p = 0.005; however, rates of symptomatic hemorrhage with clinical deterioration and in domo mortality were not statistically different. Neither the median number of stent-retriever passages needed to achieve final recanalization, time from groin puncture to first pass, time from groin puncture to final recanalization nor the number of cases in which successful recanalization could only be achieved by using a different stent-retriever as bail-out device differed between both groups. Conclusion In the specific example of the APERIO® stent-retriever device, we observed that further technological developments of the new generation device were not associated with disadvantages with respect to typical observational indicators of safety or effectiveness.
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Affiliation(s)
- Marius L Vogt
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Würzburg, Würzburg, Germany.
| | - Alexander M Kollikowski
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Würzburg, Würzburg, Germany
| | - Franziska Weidner
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Würzburg, Würzburg, Germany
| | - Marc Strinitz
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Würzburg, Würzburg, Germany
| | - Jörn Feick
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Würzburg, Würzburg, Germany
| | - Fabian Essig
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | - Hermann Neugebauer
- Department of Neurology, University Hospital Würzburg, Würzburg, Germany
| | | | - Mirko Pham
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Würzburg, Würzburg, Germany
| | - Alexander Maerz
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Würzburg, Würzburg, Germany
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Jadhav AP, Desai SM, Zaidat OO, Nogueira RG, Jovin TG, Haussen DC, Mueller-Kronast N, Liebeskind DS. First Pass Effect With Neurothrombectomy for Acute Ischemic Stroke: Analysis of the Systematic Evaluation of Patients Treated With Stroke Devices for Acute Ischemic Stroke Registry. Stroke 2021; 53:e30-e32. [PMID: 34784741 DOI: 10.1161/strokeaha.121.035457] [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] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Achieving complete revascularization after a single pass of a mechanical thrombectomy device (first pass effect [FPE]) is associated with good clinical outcomes in patients with acute ischemic stroke due to large vessel occlusion. We assessed patient characteristics, outcomes, and predictors of FPE among a large real-world cohort of patients (Systematic Evaluation of Patients Treated with Stroke Devices for Acute Ischemic Stroke registry). METHODS Demographics, clinical outcomes, and procedural characteristics were analyzed among patients in whom FPE (modified Thrombolysis in Cerebral Infarction 2c/3 after first pass) was achieved versus those requiring multiple passes (MP). Modified FPE and modified MP included patients achieving modified Thrombolysis in Cerebral Infarction 2B-3. Primary outcomes included 90-day modified Rankin Scale (mRS) score and mortality. RESULTS Among 984 Systematic Evaluation of Patients Treated with Stroke Devices for Acute Ischemic Stroke patients, 930 had complete 90-day follow-up. FPE was achieved in 40.5% (377/930) of patients and MP in 20.0% (186/930). Baseline characteristics were similar across all groups. The FPE group had fewer internal carotid artery occlusions compared with MP (P=0.029). The FPE group had faster puncture to recanalization time (P≤0.001), higher rates of 90-day mRS score of 0 to 1 (52.6% versus 38.6%, P=0.003), mRS score of 0 to 2 (65.4% versus 52.0%, P=0.003), and lower 90-day mortality compared with the MP group (12.0% versus 18.7%, P=0.038). Similarly, compared with modified MP patients, the modified FPE group had fewer internal carotid artery occlusions (P=0.004), faster puncture to recanalization time (P≤0.001), and higher rates of 90-day mRS score of 0 to 1 (P=0.002) and mRS score of 0 to 2 (P=0.003). CONCLUSIONS Our findings demonstrate that FPE and modified FPE are associated with superior clinical outcomes.
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Affiliation(s)
- Ashutosh P Jadhav
- Department of Neurology and Neurosurgery, Barrow Neurological Institute, Phoenix, AZ (A.P.J.)
| | | | - Osama O Zaidat
- Mercy Health-St. Vincent Mercy Medical Center, Toledo, OH (O.O.Z)
| | - Raul G Nogueira
- Department of Neurology, Emory University Grady Memorial Hospital, Atlanta, GA (R.G.N., D.H.)
| | - Tudor G Jovin
- Department of Neurology, Cooper University, Camden, NJ (T.G.J)
| | - Diogo C Haussen
- Department of Neurology, Emory University Grady Memorial Hospital, Atlanta, GA (R.G.N., D.H.)
| | - Nils Mueller-Kronast
- Advanced Neuroscience Network/Tenet South Florida, Boynton Beach, FL (N.H.M.-K.)
| | - David S Liebeskind
- Neurovascular Imaging Research Core and Stroke Center, Department of Neurology, UCLA, Los Angeles, CA (D.S.L.)
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Ajiboye N, Yoo AJ. Biomarkers of Technical Success After Embolectomy for Acute Stroke. Neurology 2021; 97:S91-S104. [PMID: 34785608 DOI: 10.1212/wnl.0000000000012800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2020] [Accepted: 09/25/2020] [Indexed: 11/15/2022] Open
Abstract
PURPOSE OF THE REVIEW Stent retrievers and large-bore aspiration catheters have doubled substantial reperfusion rates compared to first-generation devices. This has been accompanied by a 3-fold reduction in procedural time to revascularization. To measure future thrombectomy improvements, new benchmarks for technical efficacy are needed. This review summarizes the recent literature concerning biomarkers of procedural success and harm and highlights future directions. RECENT FINDINGS Expanded Treatment in Cerebral Ischemia (eTICI), which incorporates scores for greater levels of reperfusion, improves outcome prediction. Core laboratory-adjudicated studies show that outcomes following eTICI 2c (90%-99% reperfusion) are superior to eTICI 2b50 and nearly equivalent to eTICI 3. Moreover, eTICI 2c improves scale reliability. Studies also confirm the importance of rapid revascularization, whether measured as first pass effect or procedural duration under 30 minutes. Distal embolization is a complication that impedes the extent and speed of revascularization, but few studies have reported its per-pass occurrence. Distal embolization and emboli to new territory should be measured after each thrombectomy maneuver. Collaterals have been shown to be an important modifier of thrombectomy benefit. A drawback of the currently accepted collateral grading scale is that it does not discriminate among the broad spectrum of partial collateralization. Important questions that require investigation include reasons for failed revascularization, the utility of a global Treatment in Cerebral Ischemia scale, and the optimal grading system for vertebrobasilar occlusions. SUMMARY Emerging data support a lead technical efficacy endpoint that combines the extent and speed of reperfusion. Efforts are needed to better characterize angiographic measures of treatment harm and of collateralization.
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Affiliation(s)
| | - Albert J Yoo
- From the Texas Stroke Institute, Dallas-Fort Worth.
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36
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Rodrigues G, Barreira CM, Bouslama M, Haussen DC, Al-Bayati A, Pisani L, Liberato B, Bhatt N, Frankel MR, Nogueira RG. Automated Large Artery Occlusion Detection in Stroke: A Single-Center Validation Study of an Artificial Intelligence Algorithm. Cerebrovasc Dis 2021; 51:259-264. [PMID: 34710872 DOI: 10.1159/000519125] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 08/16/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Expediting notification of lesions in acute ischemic stroke (AIS) is critical. Limited availability of experts to assess such lesions and delays in large vessel occlusion (LVO) recognition can negatively affect outcomes. Artificial intelligence (AI) may aid LVO recognition and treatment. This study aims to evaluate the performance of an AI-based algorithm for LVO detection in AIS. METHODS Retrospective analysis of a database of AIS patients admitted in a single center between 2014 and 2019. Vascular neurologists graded computed tomography angiographies (CTAs) for presence and site of LVO. Studies were analyzed by the Viz-LVO Algorithm® version 1.4 - neural network programmed to detect occlusions from the internal carotid artery terminus (ICA-T) to the Sylvian fissure. Comparisons between human versus AI-based readings were done by test characteristic analysis and Cohen's kappa. Primary analysis included ICA-T and/or middle cerebral artery (MCA)-M1 LVOs versus non-LVOs/more distal occlusions. Secondary analysis included MCA-M2 occlusions. RESULTS 610 CTAs were analyzed. The AI algorithm rejected 2.5% of the CTAs due to poor quality, which were excluded from the analysis. Viz-LVO identified ICA-T and MCA-M1 LVOs with a sensitivity of 87.6%, specificity of 88.5%, and accuracy of 87.9% (AUC 0.88, 95% CI: 0.85-0.92, p < 0.001). Cohen's kappa was 0.74. In the secondary analysis, the algorithm yielded a sensitivity of 80.3%, specificity of 88.5%, and accuracy of 82.7%. The mean run time of the algorithm was 2.78 ± 0.5 min. CONCLUSION Automated AI reading allows for fast and accurate identification of LVO strokes with timely notification to emergency teams, enabling quick decision-making for reperfusion therapies or transfer to specialized centers if needed.
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Affiliation(s)
- Gabriel Rodrigues
- Emory University, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia,
| | - Clara M Barreira
- Emory University, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia
| | - Mehdi Bouslama
- Emory University, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia
| | - Diogo C Haussen
- Emory University, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia
| | - Alhamza Al-Bayati
- Emory University, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia
| | - Leonardo Pisani
- Emory University, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia
| | - Bernardo Liberato
- Emory University, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia
| | - Nirav Bhatt
- Emory University, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia
| | - Michael R Frankel
- Emory University, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia
| | - Raul G Nogueira
- Emory University, Marcus Stroke & Neuroscience Center, Grady Memorial Hospital, Atlanta, Georgia
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Luo G, Gao F, Zhang X, Jia B, Huo X, Liu R, Chi MS, Ma G, Peng G, Zhang J, Qi Z, Guo X, Han B, Tong X, Wang B, Song L, Liu L, He Z, Mo D, Ma N, Sun X, Yang M, Miao Z. Intracranial Stenting as Rescue Therapy After Failure of Mechanical Thrombectomy for Basilar Artery Occlusion: Data From the ANGEL-ACT Registry. Front Neurol 2021; 12:739213. [PMID: 34659098 PMCID: PMC8514631 DOI: 10.3389/fneur.2021.739213] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2021] [Accepted: 09/03/2021] [Indexed: 11/20/2022] Open
Abstract
Background and Purpose: Studies on rescue therapy for acute posterior circulation stroke due to basilar artery occlusion (BAO) are limited in the modern era of mechanical thrombectomy (MT). The aim of this study was to evaluate the safety and efficacy of rescue stenting (RS) following MT failure in patients with BAO. Methods: Data were collected from the Endovascular Treatment Key Technique and Emergency Work Flow Improvement of Acute Ischemic Stroke (ANGEL-ACT) prospective registry in China. Patients who underwent MT for BAO with failure of recanalization were enrolled in this study. The patients were divided into the RS and non-RS groups. Clinical and laboratory findings, procedural details, and clinical outcomes were compared between the two groups. Results: Overall, 93 patients with acute BAO were analyzed. The RS group included 81 (87.1%) patients, and the non-RS group included 12 patients. A modified treatment in cerebral infarction (mTICI) score of 2b/3 was achieved in 75 (92.6%) patients in the RS group. Compared with the non-RS group, the RS group had a significantly higher rate of successful recanalization and favorable clinical outcomes (modified Rankin Scale score at 90 days post-procedure, 0–3: 16.7 vs. 51.9%, respectively; P = 0.023) without an increase in the rate of symptomatic intracranial hemorrhage and a significantly lower mortality rate (58.3 vs. 18.5%, respectively; P = 0.006). Furthermore, the use of a glycoprotein IIb/IIIa inhibitor improved the rate of recanalization of the target artery without increasing the rate of symptomatic intracranial hemorrhage. Conclusions: Permanent stenting appears to be a feasible rescue modality when MT fails and might provide functional benefits in patients with acute ischemic stroke due to BAO.
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Affiliation(s)
- Gang Luo
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Feng Gao
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xuelei Zhang
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Beijing Institute of Brain Disorders, Capital Medical University, Beijing, China
| | - Baixue Jia
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiaochuan Huo
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Raynald Liu
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Man Sum Chi
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Department of Medicine and Geriatrics, Tuen Mun Hospital, Tuen Mun, Hong Kong, SAR China
| | - Gaoting Ma
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Guangge Peng
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Jingyu Zhang
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhongqi Qi
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xu Guo
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Department of Neurology, Shanxi Provincial People's Hospital, Taiyuan, China
| | - Bin Han
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China.,Department of Interventional Neurology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Bo Wang
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ligang Song
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Lian Liu
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zijun He
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Dapeng Mo
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ning Ma
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xuan Sun
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Ming Yang
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Zhongrong Miao
- Interventional Neuroradiology Center, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
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Hong L, Lin L, Li G, Yang J, Geng Y, Lou M, Parsons M, Cheng X, Dong Q. Identification of embolic stroke in patients with large vessel occlusion: The Chinese embolic stroke score, CHESS. CNS Neurosci Ther 2021; 28:531-539. [PMID: 34559949 PMCID: PMC8928917 DOI: 10.1111/cns.13729] [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: 05/11/2021] [Revised: 08/17/2021] [Accepted: 08/29/2021] [Indexed: 11/28/2022] Open
Abstract
Aims The aim of the study was to develop a simple and objective score using clinical variables and quantified perfusion measures to identify embolic stroke with large vessel occlusions. Methods Eligible patients from five centers participating in the International Stroke Perfusion Imaging Registry were included in this study. Patients were split into a derivation cohort (n = 213) and a validation cohort (n = 116). A score was developed according to the coefficients of independent predictors of embolic stroke from stepwise logistic regression model in the derivation cohort. The performance of the score was validated by assessing its discrimination and calibration. Results The independent predictors of embolic stroke made up the Chinese Embolic Stroke Score (CHESS). There were: history of atrial fibrillation (3 points), non‐hypertension history (2 points), and delay time>6 s volume/delay time>3 s volume on perfusion imaging ≥0.23 (2 points). The AUC of CHESS in the derivation cohort and validation cohort were 0.87 and 0.79, respectively. Patients with a CHESS of 0 could be identified as low‐risk of embolic stroke, with a CHESS of 2–4 could be identified as medium‐risk and with a CHESS of 5–7 could be regarded as high‐risk. The observed rate of embolic stroke of each risk group was well‐calibrated with the predicted rate. Conclusion CHESS could reliably and independently identify embolic stroke as the cause of large vessel occlusion.
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Affiliation(s)
- Lan Hong
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Longting Lin
- South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia
| | - Gang Li
- Department of Neurology, Shanghai East Hospital, Tongji University, Shanghai, China
| | - Jianhong Yang
- Department of Neurology, Ningbo First Hospital, Ningbo, China
| | - Yu Geng
- Department of Neurology, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, Hangzhou, China
| | - Min Lou
- Department of Neurology, the Second Affiliated Hospital of Zhejiang University, Hangzhou, China
| | - Mark Parsons
- South Western Sydney Clinical School, University of New South Wales, Liverpool, Australia
| | - Xin Cheng
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
| | - Qiang Dong
- Department of Neurology, National Center for Neurological Disorders, National Clinical Research Centre for Aging and Medicine, Huashan Hospital, State Key Laboratory of Medical Neurobiology, Fudan University, Shanghai, China
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Acute Recanalization of Large Vessel Occlusion in the Anterior Circulation Stroke: Is Mechanical Thrombectomy Alone Better in Patients over 80 Years of Age? Findings from a Retrospective Observational Study. J Clin Med 2021; 10:jcm10184266. [PMID: 34575377 PMCID: PMC8468316 DOI: 10.3390/jcm10184266] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Revised: 09/02/2021] [Accepted: 09/14/2021] [Indexed: 12/23/2022] Open
Abstract
Real-world data report worse 3-month clinical outcomes in elderly patients with acute ischemic stroke (AIS) treated with mechanical thrombectomy (MT). The aim was to identify factors influencing clinical outcome in elderly patients with anterior circulation AIS treated with MT (±intravenous thrombolysis (IVT)). In a retrospective, monocentric study, analysis of prospectively collected data of 138 patients (≥80 years) was performed. IVT was an independent negative predictor (OR 0.356; 95% CI: 0.134–0.942) and female sex an independent positive predictor (OR 4.179, 95% CI: 1.300–13.438) of 3-month good clinical outcome (modified Rankin scale 0–2). Female sex was also an independent negative predictor of 3-month mortality (OR 0.244, 95% CI: 0.100–0.599). Other independent negative predictors of 3-month good clinical outcome were older age, lower pre-stroke self-sufficiency, more severe neurological deficit and longer procedural intervals. Mortality was also independently predicted by longer procedural interval and by the occurrence of symptomatic intracerebral hemorrhage (p < 0.05 in all cases). Our results demonstrated, that in patients aged ≥80 years with anterior circulation AIS undergoing MT (±IVT), IVT reduced the chance of 3-month good clinical outcome and female sex was associated with a greater likelihood of 3-month good clinical outcome and lower probability of 3-month mortality.
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40
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Seo KD, Kang MJ, Lee JK, Suh SH, Lee KY. Mechanical thrombectomy reduces the gap in treatment outcomes of ischemic stroke between hospital levels of care: analysis of a Korean nationwide data. ANNALS OF TRANSLATIONAL MEDICINE 2021; 9:1227. [PMID: 34532364 PMCID: PMC8421926 DOI: 10.21037/atm-21-2342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/07/2021] [Accepted: 06/25/2021] [Indexed: 11/06/2022]
Abstract
Background Mechanical thrombectomy (MT) of ischemic stroke was demonstrated to be effective in clinical trials and was reported to have favorable outcomes in real clinical settings since 2015. We aimed to determine the national trends of MT and compare the outcomes between the different levels of treating hospital. Methods We obtained data from the nationwide database from 2008 to 2017. Patients with ischemic stroke who received MT were identified using the International Classification of Disease Codes. Good outcome was defined as discharge to home, and a poor outcome was defined as cerebral hemorrhage, physical disability, or death. The study period was divided into three (off-label MT, transitional, MT period). Hospital groups where MT was performed were divided into tertiary and non-tertiary hospitals. Results In MT period, 47.0% of the MT procedures were performed in non-tertiary hospitals compared with 36.1% in off-label MT period. Comparison of the 3-month mortality between patients who were treated in tertiary vs. non-tertiary hospitals revealed significant lower mortality in tertiary hospital through all period. The incidence of cerebral hemorrhage and physical disability did not differ between hospital groups. However, the percentage of patients discharged home was 41.4% for tertiary hospitals and 42.4% for non-tertiary hospitals, which was not statistically different in MT period (P=0.4671). Conclusions Analysis of the nationwide data confirmed that the extent of increase in MT was higher in non-tertiary hospitals than tertiary hospitals. In addition, no significant difference was revealed in the number of favorable clinical outcome between the hospital groups during MT period.
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Affiliation(s)
- Kwon-Duk Seo
- Department of Neurology, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Min Jin Kang
- Institute of Health Insurance and Clinical Research, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Jae Kwang Lee
- Institute of Health Insurance and Clinical Research, National Health Insurance Service Ilsan Hospital, Goyang, Korea
| | - Sang Hyun Suh
- Department of Radiology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung-Yul Lee
- Department of Neurology, Gangnam Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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Jahan R, Liebeskind DS, Zaidat OO, Mueller-Kronast NH, Froehler MT, Saver JL. Stent Retriever Thrombectomy for Anterior vs. Posterior Circulation Ischemic Stroke: Analysis of the STRATIS Registry. Front Neurol 2021; 12:706130. [PMID: 34504469 PMCID: PMC8421856 DOI: 10.3389/fneur.2021.706130] [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: 05/06/2021] [Accepted: 07/26/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: The benefits of mechanical thrombectomy (MT) in vertebrobasilar artery occlusions have not been well-studied. We compared clinical, procedural, and safety outcomes of MT for posterior circulation (PC) vs. anterior circulation (AC) occlusions among patients in the STRATIS registry. Methods: Data from STRATIS including patient demographics, procedural characteristics, and outcomes including symptomatic intracranial hemorrhage (sICH) at 24 h, serious adverse events (SAE), substantial reperfusion [modified thrombolysis in cerebral infarction (mTICI) 2b/3], 90-day functional independence [modified Rankin Scale (mRS) 0–2], and 90-day mortality were analyzed. Univariate logistic regression was used to calculate predictors of good clinical outcome. Results: Of 984 STRATIS patients, 43 (4.4%) patients with PC occlusions [mean age 63.0 ± 13.6, 25.6% (11/43) female] and 932 (94.7%) with AC occlusions [mean age 68.5 ± 14.8, 46.9% (437/932) female] were included for analysis. Median National Institutes of Health Stroke Scale (NIHSS) scores at baseline were 17.0 (13.0, 12.0) for the AC group and 12.0 (11.0, 24.0) for the PC group. Time from onset to procedure end was longer for the PC group [median (IQR): 322.0 min (255.0–421.0) vs. 271.0 min (207.0–360.0); p = 0.007]. PC and AC groups had similar rates of substantial reperfusion [89.2% (33/37) vs. 87.7% (684/780)], procedure-related SAE [0.0% (0/43) vs. 1.7% (16/932)], sICH [0.0% (0/38) vs. 1.5% (12/795)], 90-day functional independence [66.7% (26/39) vs. 55.9% (480/858)] and mortality [12.8% (5/39) vs. 15.8% (136/861)]. National Institutes of Health Stroke Scale score and patient sex were significant univariate predictors of good clinical outcome (p < 0.05). Conclusions: Despite longer reperfusion times, MT in PC stroke has similar rates of 90-day functional independence with no significant difference in procedure-related SAE, sICH, or mortality, supporting the use of MT in PC acute ischemic stroke (AIS). Clinical Trial Registration:https://www.clinicaltrials.gov, Identifier: NCT02239640.
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Affiliation(s)
- Reza Jahan
- Division of Interventional Neuroradiology, Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - David S Liebeskind
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Osama O Zaidat
- Department of Neurology, Mercy Health St. Vincent Hospital, Toledo, OH, United States
| | | | - Michael T Froehler
- Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Jeffrey L Saver
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
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To support safe provision of mechanical thrombectomy services for patients with acute ischaemic stroke: 2021 consensus guidance from BASP, BSNR, ICSWP, NACCS, and UKNG. Clin Radiol 2021; 76:862.e1-862.e17. [PMID: 34482987 DOI: 10.1016/j.crad.2021.08.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/05/2021] [Indexed: 01/01/2023]
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Zhang Y, Hua W, Li Z, Peng Y, Han Z, Li T, Yin C, Wang S, Nan G, Zhao Z, Yang H, Zhou B, Li T, Cai Y, Zhang J, Li G, Peng X, Guan S, Zhou J, Ye M, Wang L, Zhang L, Hong B, Zhang Y, Wan J, Wang Y, Zhu Q, Liu J, Yang P. Efficacy and Safety of a Novel Thrombectomy Device in Patients With Acute Ischemic Stroke: A Randomized Controlled Trial. Front Neurol 2021; 12:686253. [PMID: 34456847 PMCID: PMC8397519 DOI: 10.3389/fneur.2021.686253] [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: 03/26/2021] [Accepted: 06/28/2021] [Indexed: 01/01/2023] Open
Abstract
Purpose: The Tonbridge stent is a novel retriever with several design improvements which aim to achieve promising flow reperfusion in the treatment of acute ischemic stroke (AIS). We conducted a randomized controlled, multicenter, non-inferiority trial to compare the safety and efficacy of the Tonbridge stent with the Solitaire FR. Methods: AIS patients aged 18-85 years with large vessel occlusion in anterior circulation who could undergo puncture within 6 h of symptom onset were included. Randomization was performed on a 1:1 ratio to thrombectomy with either the Tonbridge stent or the Solitaire FR. The primary efficacy endpoint was successful reperfusion using a modified thrombolysis in cerebral infarction score (mTICI) of 2b/3. Safety outcomes were symptomatic intracranial hemorrhage (sICH) within 24 ± 6 h and all-cause mortality within 90 days. A clinically relevant non-inferiority margin of 12% was chosen as the acceptable difference between groups. Secondary endpoints included time from groin puncture to reperfusion, National Institutes of Health Stroke Scale (NIHSS) score at 24 h and at 7 days, and a modified Rankin Scale (mRS) score of 0-2 at 90 days. Results: A total of 220 patients were enrolled; 104 patients underwent thrombectomy with the Tonbridge stent and 104 were treated with the Solitaire FR. In all test group patients, the Tonbridge was used as a single retriever without rescuing by other thrombectomy devices. Angioplasty with balloon and/or stent was performed in 26 patients in the Tonbridge group and 16 patients in the Solitaire group (p = 0.084). Before angioplasty, 86.5% of those in the Tonbridge group and 81.7% of those in the Solitaire group reached successful reperfusion (p = 0.343). Finally, more patients in the Tonbridge group achieved successful reperfusion (92.3 vs. 84.6%, 95% CI of difference value 0.9-16.7%, p < 0.0001). There were no significant differences on sICH within 24 ± 6 h between the two groups. All-cause mortality within 90 days was 13.5% in the Tonbridge group and 16.3% in the Solitaire group (p = 0.559). We noted no significant differences between groups on the NIHSS at either 24 h or 7 days and the mRS of 0-2 at 90 days. Conclusion: The trial indicated that the Tonbridge stent was non-inferior to the Solitaire FR within 6 h of symptom onset in cases of large vessel occlusion stroke. Clinical Trial Registration:ClinicalTrials.gov, number: NCT03210623.
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Affiliation(s)
- Yongxin Zhang
- Department of Stroke Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Weilong Hua
- Department of Stroke Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Zifu Li
- Department of Stroke Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Ya Peng
- Department of Neurosurgery, The First People's Hospital of Changzhou, Changzhou, China
| | - Zhian Han
- Zhongshan City People's Hospital, Zhongshan, China
| | - Tong Li
- Department of Neurology, The Second Nanning People's Hospital, Nanning, China
| | - Congguo Yin
- Department of Neurology, Affiliated Hangzhou First People's Hospital, Zhejiang University School of Medical, Hangzhou, China
| | - Shoucun Wang
- Department of Neurology, The First Hospital of Jilin University, Jilin, China
| | - Guangxian Nan
- Department of Neurology, China-Japan Union Hospital of Jilin University, Jilin, China
| | - Zhenwei Zhao
- Department of Neurosurgery, Tangdu Hospital the Fourth Military Medical University, Xi'an, China
| | - Hua Yang
- Department of Neurosurgery, The Affiliated Hospital of Guizhou Medical University, Guizhou, China
| | - Bin Zhou
- The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, China
| | - Tianxiao Li
- Henan Provincial People's Hospital, Zhengzhou, China
| | - Yiling Cai
- PLA Strategic Support Force Characteristic Medical Center, Beijing, China
| | - Jianmin Zhang
- Department of Neurosurgery, The Second Affiliated Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Guifu Li
- Guangdong Provincial Hospital of Traditional Chinese Medicine, Guangzhou, China
| | - Xiaoxiang Peng
- Department of Neurology, The Third People's Hospital of Hubei Province, Wuhan, China
| | - Sheng Guan
- The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Junshan Zhou
- Nanjing First Hospital, Nanjing Medical University, Nanjing, China
| | - Ming Ye
- The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, China
| | - Liqin Wang
- The Fifth Affiliated Hospital of Sun Yat-Sen University, Zhuhai, China
| | - Lei Zhang
- Department of Stroke Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Bo Hong
- Department of Stroke Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Yongwei Zhang
- Department of Stroke Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Jieqing Wan
- Renji Hospital Affiliated to Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Yang Wang
- Medical Research & Biometrics Center, National Center for Cardiovascular Disease, China
| | - Qing Zhu
- Zhuhai Ton-Bridge Medical Tech. Co., Ltd., Zhuhai, China
| | - Jianmin Liu
- Department of Stroke Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
| | - Pengfei Yang
- Department of Stroke Center, Changhai Hospital, Naval Military Medical University, Shanghai, China
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Singh N, Ospel J, Mayank A, Marko M, Zaidat OO, Mueller-Kronast NH, Liebeskind DS, Goyal M. Nonstenotic Carotid Plaques in Ischemic Stroke: Analysis of the STRATIS Registry. AJNR Am J Neuroradiol 2021; 42:1645-1652. [PMID: 34326103 DOI: 10.3174/ajnr.a7218] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2021] [Accepted: 04/27/2021] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND PURPOSE Few studies assess nonstenotic carotid plaques on CTA, and the causative role of these plaques in stroke is not entirely clear. We used CTA to determine the prevalence of nonstenotic carotid plaques (<50%), plaque features, and their association with ipsilateral strokes in patients with cardioembolic and cryptogenic strokes. MATERIALS AND METHODS Data were from the Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke (STRATIS) registry, a prospective, nonrandomized registry of patients undergoing thrombectomy with the Solitaire device. The prevalence of nonstenotic carotid plaques ipsilateral and contralateral to the stroke was compared in patients with cryptogenic and cardioembolic strokes. Plaque features were further compared within both subgroups between patients with and without ipsilateral stroke. Adjusted associations among nonstenotic carotid plaque, plaque characteristics, and ipsilateral stroke in both subgroups were determined with logistic regression. RESULTS Of the 946 patients in the data base, 226 patients with cardioembolic stroke (median age, 72 years) and 141 patients with cryptogenic stroke (median age, 69 years) were included in the analysis. The prevalence of nonstenotic carotid plaque in the cardioembolic and cryptogenic subgroups was 33/226 (14.6%) and 32/141 (22.7%), respectively. Bilateral nonstenotic carotid plaques were seen in 10/226 (4.4%) patients with cardioembolic and 13/141 (9.2%) with cryptogenic strokes. Nonstenotic carotid plaques were significantly associated with ipsilateral strokes in the cardioembolic stroke (adjusted OR = 1.91; 95% CI, 1.15-3.18) and the cryptogenic stroke (adjusted OR = 1.69; 95% CI, 1.05-2.73) groups. Plaque irregularity, hypodensity, and per-millimeter increase in plaque thickness were significantly associated with ipsilateral stroke in the cryptogenic subgroup. CONCLUSIONS Nonstenotic carotid plaques were significantly associated with ipsilateral stroke in cardioembolic and cryptogenic stroke groups, and there was an association of plaque irregularity and hypodense plaque with ipsilateral stroke in the cryptogenic group, suggesting these plaques could be a potential cause of stroke in these patient subgroups.
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Affiliation(s)
- N Singh
- From the Departments of Clinical Neurosciences (N.S., A.M., M.G.)
| | - J Ospel
- Department of Radiology (J.O.), University Hospital of Basel, Basel, Switzerland
| | - A Mayank
- From the Departments of Clinical Neurosciences (N.S., A.M., M.G.)
| | - M Marko
- Department of Neurology (M.M.), Medical University of Vienna, Vienna, Austria
| | - O O Zaidat
- Neuroscience Institute (O.O.Z.), Mercy Health St. Vincent Medical Center, Toledo, Ohio
| | - N H Mueller-Kronast
- Department of Neurology (N.H.M.-K.), Delray Medical Center, Delray Beach, Florida
| | - D S Liebeskind
- UCLA Comprehensive Stroke Center (D.S.L.), Los Angeles, California
| | - M Goyal
- From the Departments of Clinical Neurosciences (N.S., A.M., M.G.) .,Diagnostic Imaging (M.G.), Foothills Medical Center, University of Calgary, Calgary, Alberta, Canada
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Jumaa MA, Castonguay AC, Salahuddin H, Jadhav AP, Limaye K, Farooqui M, Zaidi SF, Mueller-Kronast N, Liebeskind DS, Zaidat OO, Ortega-Gutierrez S. Middle Cerebral Artery M2 Thrombectomy in the STRATIS Registry. Stroke 2021; 52:3490-3496. [PMID: 34311566 DOI: 10.1161/strokeaha.120.033951] [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: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The safety and benefit of mechanical thrombectomy in the treatment of acute ischemic stroke patients with M2 segment middle cerebral artery occlusions remain uncertain. Here, we compare clinical and angiographic outcomes in M2 versus M1 occlusions in the STRATIS (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) Registry. METHODS The STRATIS Registry was a prospective, multicenter, nonrandomized, observational study of acute ischemic stroke large vessel occlusion patients treated with the Solitaire stent-retriever as the first-choice therapy within 8 hours from symptoms onset. Primary outcome was defined as functional disability at 3 months measured by dichotomized modified Rankin Scale. Secondary outcomes included reperfusion rates and rates of symptomatic intracranial hemorrhage. RESULTS A total of 984 patients were included, of which 538 (54.7%) had M1 and 170 (17.3%) had M2 occlusions. Baseline demographics were well balanced within the groups, with the exception of mean baseline National Institutes of Health Stroke Scale score which was significantly higher in the M1 population (17.3±5.5 versus 15.7±5.0, P≤0.001). No difference was seen in mean puncture to revascularization times between the cohorts (46.0±27.8 versus 45.1±29.5 minutes, P=0.75). Rates of successful reperfusion (modified Thrombolysis in Cerebral Infarction≥2b) were similar between the groups (91% versus 95%, P=0.09). M2 patients had significantly increased rates of symptomatic ICH at 24 hours (4% versus 1%, P=0.01). Rates of good functional outcome (modified Rankin Scale score of 0-2; 58% versus 59%, P=0.83) and mortality (15% versus 14%, P=0.75) were similar between the 2 groups. There was no difference in the association of outcome and onset to groin puncture or onset to successful reperfusion in M1 and M2 occlusions. CONCLUSIONS In the STRATIS Registry, M2 occlusions achieved similar rates of successful reperfusion, good functional outcome, and mortality, although increased rates of symptomatic ICH were demonstrated when compared with M1 occlusions. The time dependence of benefit was also similar between the 2 groups. Further studies are needed to understand the benefit of mechanical thrombectomy for M2 occlusions. REGISTRATION URL: https://www.clinicaltrials.gov; Unique identifier: NCT02239640.
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Affiliation(s)
- Mouhammad A Jumaa
- Department of Neurology, University of Toledo, OH (M.A.J., A.C.C., H.S., S.F.Z.).,ProMedica Toledo Hospital, OH (M.A.J., S.F.Z.)
| | - Alicia C Castonguay
- Department of Neurology, University of Toledo, OH (M.A.J., A.C.C., H.S., S.F.Z.)
| | - Hisham Salahuddin
- Department of Neurology, University of Toledo, OH (M.A.J., A.C.C., H.S., S.F.Z.)
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ (A.P.J.)
| | | | | | - Syed F Zaidi
- Department of Neurology, University of Toledo, OH (M.A.J., A.C.C., H.S., S.F.Z.).,ProMedica Toledo Hospital, OH (M.A.J., S.F.Z.)
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Fornazari VR, Castro-Afonso LHD, Nakiri GS, Abud TG, Monsignore LM, Dias FA, Pontes-Neto OM, Abud DG. Analysis of 565 thrombectomies for anterior circulation stroke: A Brazilian registry. Interv Neuroradiol 2021; 28:283-290. [PMID: 34139892 DOI: 10.1177/15910199211026995] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
INTRODUCTION The benefits of mechanical thrombectomy in the treatment of patients with acute stroke due to large vessel occlusions (LVOs) have been extensively demonstrated by randomized trials and registries in developed countries. However, data on thrombectomy outside controlled trials are scarce in developing countries. The aim of this study was to assess the safety and efficacy, and to investigate the predictors for good and poor outcomes of thrombectomy for treatment of AIS due to anterior circulation LVOs in Brazil. MATERIALS AND METHODS This was a single center registry of thrombectomy in the treatment of stroke caused by anterior circulation LVOs. Between 2011 and 2019, a total of 565 patients were included. RESULTS the mean baseline NIHSS score on admission was 17.2. The average baseline ASPECTS was 8, and 91.0% of patients scored ≥6. Half of the patients received intravenous thrombolysis. The mean time from symptom onset to arterial puncture was 296.4 minutes. The mean procedure time was 61.4 minutes. The rates of the main outcomes were recanalization (TICI 2b-3) 85.6%, symptomatic intracranial hemorrhage (sICH) 8,1%, good clinical outcome (mRS=0-2) 43,5%, and mortality 22.1% at three months. CONCLUSIONS This study demonstrates the efficacy and safety of mechanical thrombectomy for treatment of patients with AIS of the anterior circulation in real-life conditions under limited facilities and resources. The results of the present study were relatively similar to those of large trials and population registers of developed countries.
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Affiliation(s)
- Vitor Rodrigues Fornazari
- Division of Interventional Neuroradiology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | - Luís Henrique de Castro-Afonso
- Division of Interventional Neuroradiology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | - Guilherme Seizem Nakiri
- Division of Interventional Neuroradiology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | | | - Lucas Moretti Monsignore
- Division of Interventional Neuroradiology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | - Francisco Antunes Dias
- Division of Neurology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
| | | | - Daniel Giansante Abud
- Division of Interventional Neuroradiology, Medical School of Ribeirão Preto, University of São Paulo, Ribeirão Preto, Brazil
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Todo K, Yoshimura S, Uchida K, Yamagami H, Sakai N, Kishima H, Mochizuki H, Ezura M, Okada Y, Kitagawa K, Kimura K, Sasaki M, Tanahashi N, Toyoda K, Furui E, Matsumaru Y, Minematsu K, Kitano T, Okazaki S, Sasaki T, Sakaguchi M, Takagaki M, Nishida T, Nakamura H, Morimoto T. Time-outcome relationship in acute large-vessel occlusion exists across all ages: subanalysis of RESCUE-Japan Registry 2. Sci Rep 2021; 11:12782. [PMID: 34140563 PMCID: PMC8211644 DOI: 10.1038/s41598-021-92100-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 06/04/2021] [Indexed: 11/11/2022] Open
Abstract
Early reperfusion after endovascular thrombectomy is associated with an improved outcome in ischemic stroke patients; however, the time dependency in elderly patients remains unclear. We investigated the time–outcome relationships in different age subgroups. Of 2420 patients enrolled in the RESCUE-Japan Registry 2 study, a study based on a prospective registry of stroke patients with acute cerebral large-vessel occlusion at 46 centers, we analyzed the data of 1010 patients with successful reperfusion after endovascular therapy (mTICI of 2b or 3). In 3 age subgroups (< 70, 70 to < 80, and ≥ 80 years), the mRS scores at 90 days were analyzed according to 4 categories of onset-to-reperfusion time (< 180, 180 to < 240, 240 to < 300, and ≥ 300 min). In each age subgroup, the distributions of mRS scores were better with shorter onset-to-reperfusion times. The adjusted common odds ratios for better outcomes per 1-category delay in onset-to-reperfusion time were 0.66 (95% CI 0.55–0.80) in ages < 70 years, 0.66 (95% CI 0.56–0.79) in ages 70 to < 80 years, and 0.83 (95% CI 0.70–0.98) in ages ≥ 80 years. Early reperfusion was associated with better outcomes across all age subgroups. Achieving early successful reperfusion is important even in elderly patients.
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Affiliation(s)
- Kenichi Todo
- Stroke Center, Osaka University Hospital, Suita, Osaka, Japan.
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Kazutaka Uchida
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan.,Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Hyogo, Japan
| | | | | | - Masayuki Ezura
- Department of Neurosurgery, National Hospital Organization Sendai Medical Center, Sendai, Miyagi, Japan
| | - Yasushi Okada
- Cerebrovascular Center, National Hospital Organization Kyushu Medical Center, Fukuoka, Japan
| | - Kazuo Kitagawa
- Department of Neurology, Tokyo Women's Medical University, Tokyo, Japan
| | - Kazumi Kimura
- Department of Neurological Science, Graduate School of Medicine, Nippon Medical School, Tokyo, Japan
| | - Makoto Sasaki
- Institute for Biomedical Sciences, Iwate Medical University, Morioka, Iwate, Japan
| | - Norio Tanahashi
- Department of Neurology, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Kazunori Toyoda
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Eisuke Furui
- Department of Stroke Neurology, Saiseikai Toyama Hospital, Toyama, Japan
| | - Yuji Matsumaru
- Division for Stroke Prevention and Treatment, Department of Neurosurgery, University of Tsukuba, Tsukuba, Ibaraki, Japan
| | - Kazuo Minematsu
- Department of Cerebrovascular Medicine, National Cerebral and Cardiovascular Center, Suita, Osaka, Japan
| | - Takaya Kitano
- Stroke Center, Osaka University Hospital, Suita, Osaka, Japan
| | - Shuhei Okazaki
- Stroke Center, Osaka University Hospital, Suita, Osaka, Japan
| | - Tsutomu Sasaki
- Stroke Center, Osaka University Hospital, Suita, Osaka, Japan
| | | | | | - Takeo Nishida
- Stroke Center, Osaka University Hospital, Suita, Osaka, Japan
| | - Hajime Nakamura
- Stroke Center, Osaka University Hospital, Suita, Osaka, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
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Rogers JR, Lee J, Zhou Z, Cheung YK, Hripcsak G, Weng C. Contemporary use of real-world data for clinical trial conduct in the United States: a scoping review. J Am Med Inform Assoc 2021; 28:144-154. [PMID: 33164065 DOI: 10.1093/jamia/ocaa224] [Citation(s) in RCA: 24] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2020] [Revised: 08/11/2020] [Accepted: 09/02/2020] [Indexed: 12/28/2022] Open
Abstract
OBJECTIVE Real-world data (RWD), defined as routinely collected healthcare data, can be a potential catalyst for addressing challenges faced in clinical trials. We performed a scoping review of database-specific RWD applications within clinical trial contexts, synthesizing prominent uses and themes. MATERIALS AND METHODS Querying 3 biomedical literature databases, research articles using electronic health records, administrative claims databases, or clinical registries either within a clinical trial or in tandem with methodology related to clinical trials were included. Articles were required to use at least 1 US RWD source. All abstract screening, full-text screening, and data extraction was performed by 1 reviewer. Two reviewers independently verified all decisions. RESULTS Of 2020 screened articles, 89 qualified: 59 articles used electronic health records, 29 used administrative claims, and 26 used registries. Our synthesis was driven by the general life cycle of a clinical trial, culminating into 3 major themes: trial process tasks (51 articles); dissemination strategies (6); and generalizability assessments (34). Despite a diverse set of diseases studied, <10% of trials using RWD for trial process tasks evaluated medications or procedures (5/51). All articles highlighted data-related challenges, such as missing values. DISCUSSION Database-specific RWD have been occasionally leveraged for various clinical trial tasks. We observed underuse of RWD within conducted medication or procedure trials, though it is subject to the confounder of implicit report of RWD use. CONCLUSION Enhanced incorporation of RWD should be further explored for medication or procedure trials, including better understanding of how to handle related data quality issues to facilitate RWD use.
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Affiliation(s)
- James R Rogers
- Department of Biomedical Informatics, Columbia University, New York, New York, USA
| | - Junghwan Lee
- Department of Biomedical Informatics, Columbia University, New York, New York, USA
| | - Ziheng Zhou
- Institute of Human Nutrition, Columbia University, New York, New York, USA
| | - Ying Kuen Cheung
- Department of Biostatistics, Columbia University, New York, New York, USA, and
| | - George Hripcsak
- Department of Biomedical Informatics, Columbia University, New York, New York, USA.,Medical Informatics Services, New York-Presbyterian Hospital, New York, New York, USA
| | - Chunhua Weng
- Department of Biomedical Informatics, Columbia University, New York, New York, USA
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Zaidat OO, Liebeskind DS, Jadhav AP, Ortega-Gutierrez S, Nguyen TN, Haussen DC, Yavagal DR, Froehler MT, Jahan R, Nogueira RG, Yao TL, Alenzi BA, Bushnaq S, Mueller-Kronast NH. Impact of Age and Alberta Stroke Program Early Computed Tomography Score 0 to 5 on Mechanical Thrombectomy Outcomes: Analysis From the STRATIS Registry. Stroke 2021; 52:2220-2228. [PMID: 34078106 PMCID: PMC8240495 DOI: 10.1161/strokeaha.120.032430] [Citation(s) in RCA: 27] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
Abstract
Supplemental Digital Content is available in the text. Background and Purpose: This study investigates clinical outcomes after mechanical thrombectomy in adult patients with baseline Alberta Stroke Program Early CT Score (ASPECTS) of 0 to 5. Methods: We included data from the STRATIS Registry (Systematic Evaluation of Patients Treated With Neurothrombectomy Devices for Acute Ischemic Stroke) from patients who underwent mechanical thrombectomy within 8 hours of symptom onset and had available ASPECTS data adjudicated by an independent core laboratory. Angiographic and clinical outcomes were collected, including successful reperfusion (modified Thrombolysis in Cerebral Infarction ≥2b), functional independence (modified Rankin Scale score 0–2), 90-day mortality, and symptomatic intracranial hemorrhage at 24 hours. Outcomes were stratified by ASPECTS scores and age. Results: Of the 984 patients enrolled, 763 had available ASPECTS data. Of these patients, 57 had ASPECTS of 0 to 5 with a median age of 63 years (interquartile range, 28–100), whereas 706 patients had ASPECTS of 6 to 10 with a median age of 70 years of age (interquartile range, 19–100). Ten patients had ASPECTS of 0 to 3 and 47 patients had ASPECTS of 4 to 5 at baseline. Successful reperfusion was achieved in 85.5% (47/55) in the ASPECTS of 0 to 5 group. Functional independence was achieved in 28.8% (15/52) in the ASPECTS of 0 to 5 versus 59.7% (388/650) in the 6 to 10 group (P<0.001). Mortality rates were 30.8% (16/52) in the ASPECTS of 0 to 5 and 13.4% (87/650) in the 6 to 10 group (P<0.001). sICH rates were 7.0% (4/57) in the ASPECTS of 0 to 5 and 0.9% (6/682) in the 6 to 10 group (P<0.001). No patients aged >75 years with ASPECTS of 0 to 5 (0/12) achieved functional independence versus 44.8% (13/29) of those age ≤65 (P=0.005). Conclusions: Patients <65 years of age with large core infarction (ASPECTS 0–5) have better rates of functional independence and lower rates of mortality compared with patients >75 years of age. Registration: URL: https://www.clinicaltrials.gov; Unique identifier: NCT02239640.
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Affiliation(s)
- Osama O Zaidat
- Neuroscience Institute, St Vincent Mercy Hospital, Toledo, OH (O.O.Z., S.B.)
| | - David S Liebeskind
- Neurovascular Imaging Research Core and Stroke Center, Department of Neurology (D.S.L.), University of California Los Angeles
| | - Ashutosh P Jadhav
- Department of Neurology, University of Pittsburgh Medical Center, PA (A.P.J.)
| | - Santiago Ortega-Gutierrez
- Departments of Neurology, Neurosurgery and Radiology, University of Iowa Health Care, Carver College of Medicine (S.O.-G.)
| | - Thanh N Nguyen
- Division of Interventional Neuroradiology and Interventional Neurology, Boston Medical Center, MA (T.N.N.)
| | - Diogo C Haussen
- Department of Neurology, Emory University, Atlanta, GA (D.C.H., R.G.N.)
| | - Dileep R Yavagal
- Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine, FL (D.R.Y.)
| | - Michael T Froehler
- Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN (M.T.F.)
| | - Reza Jahan
- Department of Radiology (R.J.), University of California Los Angeles
| | - Raul G Nogueira
- Department of Neurology, Emory University, Atlanta, GA (D.C.H., R.G.N.)
| | - Tom L Yao
- Norton Neuroscience Institute, Norton Healthcare, Louisville, KY (T.L.Y.)
| | - Bader A Alenzi
- Department of Internal Medicine, The Ohio State University Wexner Medical Center, Columbus (B.A.A.)
| | - Saif Bushnaq
- Neuroscience Institute, St Vincent Mercy Hospital, Toledo, OH (O.O.Z., S.B.)
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50
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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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