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Pensato U, Demchuk A, Ospel JM. Reader Response: Factors Associated With Fast Early Infarct Growth in Patients With Acute Ischemic Stroke With a Large Vessel Occlusion. Neurology 2024; 103:e209439. [PMID: 39052962 DOI: 10.1212/wnl.0000000000209439] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2024] Open
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Nogueira RG, Doheim MF, Jadhav AP, Aghaebrahim A, Frankel MR, Jankowitz BT, Budzik RF, Bonafe A, Bhuva P, Yavagal DR, Hanel RA, Hassan AE, Ribo M, Cognard C, Sila CA, Jenkins P, Smith WS, Saver JL, Liebeskind DS, Jovin TG, Haussen DC. Mode of Onset Modifies the Effect of Time to Endovascular Reperfusion on Clinical Outcomes after Acute Ischemic Stroke: An Analysis of the DAWN Trial. Ann Neurol 2024; 96:356-364. [PMID: 38877793 DOI: 10.1002/ana.26968] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Revised: 05/01/2024] [Accepted: 05/06/2024] [Indexed: 06/16/2024]
Abstract
OBJECTIVE We aimed to assess the impact of time to endovascular thrombectomy (EVT) on clinical outcomes in the DAWN trial, while also exploring the potential effect modification of mode of stroke onset on this relationship. METHODS The association between every 1-h treatment delay with 90-day functional independence (modified Rankin Scale [mRS] score 0-2), symptomatic intracranial hemorrhage, and 90-day mortality was explored in the overall population and in three modes of onset subgroups (wake-up vs. witnessed vs. unwitnessed). RESULTS Out of the 205 patients, 98 (47.8%) and 107 (52.2%) presented in the 6 to 12 hours and 12 to 24 hours time window, respectively. Considering all three modes of onset together, there was no statistically significant association between time last seen well to randomization with either functional independence or mortality at 90 days in either the endovascular thrombectomy (mRS 0-2 1-hour delay OR 1.07; 95% CI 0.93-1.24; mRS 6 OR 0.84; 95% CI 0.65-1.03) or medical management (mRS 0-2 1-hour delay OR 0.98; 95% CI 0.80-1.14; mRS 6 1-hour delay OR 0.94; 95% CI 0.79-1.09) groups. Moreover, there was no significant interaction between treatment effect and time (p = 0.439 and p = 0.421 for mRS 0-2 and 6, respectively). However, within the thrombectomy group, the models that tested the association between time last seen well to successful reperfusion (modified Treatment in Cerebral Infarction ≥2b) and 90-day functional independence showed a significant interaction with mode of presentation (p = 0.013). This appeared to be driven by a nominally positive slope for both witnessed and unwitnessed strokes versus a significantly (p = 0.018) negative slope in wake-up patients. There was no association between treatment times and symptomatic intracranial hemorrhage. INTERPRETATION Mode of onset modifies the effect of time to reperfusion on thrombectomy outcomes, and should be considered when exploring different treatment paradigms in the extended window. ANN NEUROL 2024;96:356-364.
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Affiliation(s)
- Raul G Nogueira
- Department of Neurology and Neurosurgery, University of Pittsburgh Medical Center, UPMC Stroke Institute, Pittsburgh, PA, USA
| | - Mohamed F Doheim
- Department of Neurology and Neurosurgery, University of Pittsburgh Medical Center, UPMC Stroke Institute, Pittsburgh, PA, USA
| | - Ashutosh P Jadhav
- Department of Neurosurgery, Barrow Neurological Institute, Phoenix, AZ, USA
| | | | - Michael R Frankel
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
| | | | | | - Alain Bonafe
- Department of Neuroradiology, Hôpital Gui-de-Chauliac, Montpellier, France
| | - Parita Bhuva
- Division of Neurointervention, Texas Stroke Institute, Dallas-Fort Worth, Fort Worth, TX, USA
| | - Dileep R Yavagal
- Department of Neurology and Neurosurgery, University of Miami Miller School of Medicine-Jackson Memorial Hospital, Miami, FL, USA
| | | | - Ameer E Hassan
- Department of Neurology, University of Texas Rio Grande Valley, Valley Baptist Hospital, Harlingen, TX, USA
| | - Marc Ribo
- Stroke Unit, Hospital Vall d'Hebrón, Barcelona, Spain
| | - Christophe Cognard
- Department of Diagnostic and Therapeutic Neuroradiology, University Hospital of Toulouse, Toulouse, France
| | - Cathy A Sila
- Department of Neurology, University Hospitals of Cleveland, Cleveland, OH, USA
| | | | - Wade S Smith
- Department of Neurology, University of California, San Francisco, CA, USA
| | - Jeffrey L Saver
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - David S Liebeskind
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Tudor G Jovin
- Department of Neurology, Cooper University Hospital, Neurological Institute, Camden, NJ, USA
| | - Diogo C Haussen
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, GA, USA
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Winkelmeier L, Heit JJ, Broocks G, Prüter J, Heitkamp C, Schell M, Albers GW, Lansberg MG, Wintermark M, Kemmling A, Stracke CP, Guenego A, Paech D, Fiehler J, Faizy TD. Association between occlusion location, net water uptake and ischemic lesion growth in large vessel anterior circulation strokes. J Cereb Blood Flow Metab 2024; 44:1352-1361. [PMID: 38329032 DOI: 10.1177/0271678x241232193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/09/2024]
Abstract
Ischemic lesion net water uptake (NWU) represents a quantitative imaging biomarker for cerebral edema in acute ischemic stroke. Data on NWU for distinct occlusion locations remain scarce, but might help to improve the prognostic value of NWU. In this retrospective multicenter cohort study, we compared NWU between patients with proximal large vessel occlusion (pLVO; ICA or proximal M1) and distal large vessel occlusion (dLVO; distal M1 or M2). NWU was quantified by densitometric measurements of the early ischemic region. Arterial collateral status was assessed using the Maas scale. Regression analysis was used to investigate the relationship between occlusion location, NWU and ischemic lesion growth. A total of 685 patients met inclusion criteria. Early ischemic lesion NWU was higher in patients with pLVO compared with dLVO (7.7% vs 3.9%, P < .001). The relationship between occlusion location and NWU was partially mediated by arterial collateral status. NWU was associated with absolute ischemic lesion growth between admission and follow-up imaging (β estimate, 5.50, 95% CI, 3.81-7.19, P < .001). This study establishes a framework for the relationship between occlusion location, arterial collateral status, early ischemic lesion NWU and ischemic lesion growth. Future prognostic thresholds for NWU might be optimized by adjusting for the occlusion location.
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Affiliation(s)
- Laurens Winkelmeier
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeremy J Heit
- Department of Neuroradiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Gabriel Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Julia Prüter
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christian Heitkamp
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maximilian Schell
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gregory W Albers
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Maarten G Lansberg
- Department of Neurology, Stanford University School of Medicine, Stanford, CA, USA
| | - Max Wintermark
- Department of Neuroradiology, MD Anderson, Houston, Texas, USA
| | - André Kemmling
- Department of Neuroradiology, University Marburg, Marburg, Germany
| | | | - Adrien Guenego
- Department of Neuroradiology, Erasme Medical Center, Brussels, Belgium
| | - Daniel Paech
- Clinic for Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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Viticchi G, Falsetti L, Altamura C, Di Felice C, Vernieri F, Bartolini M, Silvestrini M. Impact of carotid stenosis on the outcome of stroke patients submitted to reperfusion treatments: a narrative review. Rev Neurosci 2024; 35:575-583. [PMID: 38459676 DOI: 10.1515/revneuro-2024-0002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Accepted: 02/18/2024] [Indexed: 03/10/2024]
Abstract
Intravenous thrombolysis (IT) and mechanical thrombectomy (MD) are the two interventional approaches that have changed the outcome of patients with acute ischemic stroke (AIS). Ipsilateral and contralateral carotid stenosis (ICS, CCS) play an important role in regulating cerebral hemodynamics, both in chronic and acute situations such as AIS. Several studies have explored their role in the incidence and severity of stroke, but very few have investigated the possible impact of ICS and CCS on the efficacy of interventional procedures. The purpose of this review was to I) highlight the incidence and prevalence of carotid stenosis (CS); II) assess the impact of ICS and CCS on cerebral hemodynamics; III) evaluate the effect of carotid stenosis on the efficacy of interventional therapies (IT and MT) for AIS; and IV) report therapeutic complications related to CS. We searched PubMed/Medline for case reports, reviews, and original research articles on English-language review topics during the period from January 1, 2000 to October 1, 2023. CS is associated with 15-20 % of the total number of AIS. ICS and CCS had a negative influence on both cerebral hemodynamics before AIS and outcome after interventional procedures (IT, MT alone or in bridging). Available data on cerebral hemodynamics and efficacy of interventional therapies for AIS suggest a negative role of CS. Therefore, early diagnosis of CS may be considered relevant to preventive and post-stroke treatment strategies.
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Affiliation(s)
- Giovanna Viticchi
- Neurological Clinic, Experimental and Clinical Medicine Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
| | - Lorenzo Falsetti
- Clinica Medica, Clinical and Molecular Sciences Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
| | - Claudia Altamura
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, via Álvaro del Portillo n.200, 00128, Rome, Italy
| | - Chiara Di Felice
- Neurological Clinic, Experimental and Clinical Medicine Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
| | - Fabrizio Vernieri
- Unit of Headache and Neurosonology, Department of Medicine and Surgery, Fondazione Policlinico Universitario Campus Bio-Medico, via Álvaro del Portillo n.200, 00128, Rome, Italy
| | - Marco Bartolini
- Neurological Clinic, Experimental and Clinical Medicine Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
| | - Mauro Silvestrini
- Neurological Clinic, Experimental and Clinical Medicine Department, Marche Polytechnic University, via Conca n.1, 60100, Ancona, Italy
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Pérez-Mato M, López-Arias E, Bugallo-Casal A, Correa-Paz C, Arias S, Rodríguez-Yáñez M, Santamaría-Cadavid M, Campos F. New Perspectives in Neuroprotection for Ischemic Stroke. Neuroscience 2024; 550:30-42. [PMID: 38387732 DOI: 10.1016/j.neuroscience.2024.02.017] [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: 11/01/2023] [Revised: 02/12/2024] [Accepted: 02/16/2024] [Indexed: 02/24/2024]
Abstract
The constant failure of new neuroprotective therapies for ischemic stroke has partially halted the search for new therapies in recent years, mainly because of the high investment risk required to develop a new treatment for a complex pathology, such as stroke, with a narrow intervention window and associated comorbidities. However, owing to recent progress in understanding the stroke pathophysiology, improvement in patient care in stroke units, development of new imaging techniques, search for new biomarkers for early diagnosis, and increasingly widespread use of mechanical recanalization therapies, new opportunities have opened for the study of neuroprotection. This review summarizes the main protective agents currently in use, some of which are already in the clinical evaluation phase. It also includes an analysis of how recanalization therapies, new imaging techniques, and biomarkers have improved their efficacy.
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Affiliation(s)
- María Pérez-Mato
- Translational Stroke Laboratory Group (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Esteban López-Arias
- Translational Stroke Laboratory Group (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Ana Bugallo-Casal
- Translational Stroke Laboratory Group (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Clara Correa-Paz
- Translational Stroke Laboratory Group (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain
| | - Susana Arias
- Stroke Unit, Department of Neurology, Hospital Clínico Universitario, 15706 Santiago de Compostela, Spain
| | - Manuel Rodríguez-Yáñez
- Stroke Unit, Department of Neurology, Hospital Clínico Universitario, 15706 Santiago de Compostela, Spain
| | - María Santamaría-Cadavid
- Stroke Unit, Department of Neurology, Hospital Clínico Universitario, 15706 Santiago de Compostela, Spain
| | - Francisco Campos
- Translational Stroke Laboratory Group (TREAT), Clinical Neurosciences Research Laboratory (LINC), Health Research Institute of Santiago de Compostela (IDIS), 15706 Santiago de Compostela, Spain; Universidade de Santiago de Compostela, 15782 Santiago de Compostela, Spain.
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Wang L, Lyu J, Han D, Bian X, Zhang D, Wang H, Hao F, Duan L, Ma L, Lou X. Imaging Assessments and Clinical Significance of Brain Frailty in Moyamoya Disease. AJNR Am J Neuroradiol 2024; 45:855-862. [PMID: 38782594 DOI: 10.3174/ajnr.a8232] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2023] [Accepted: 02/09/2024] [Indexed: 05/25/2024]
Abstract
BACKGROUND AND PURPOSE Imaging assessment of brain frailty in ischemic stroke has been extensively studied, while the correlation between brain frailty and Moyamoya disease remains obscure. This study aimed to investigate the imaging characteristics of brain frailty and its clinical applications in Moyamoya disease. MATERIALS AND METHODS This study included 60 patients with Moyamoya disease (107 hemispheres). All patients were divided into stroke and nonstroke groups based on clinical symptoms and imaging findings. The modified brain frailty score was adapted to consider 4 imaging signs: white matter hyperintensity, enlargement of perivascular space, old vascular lesions, and cerebral microbleed. The relative CBF of the MCA territory was quantified using pseudocontinuous arterial-spin labeling. Surgical outcome after revascularization surgery was defined by the Matsushima grade. RESULTS The relative CBF of the MCA territory decreased as the modified brain frailty score and periventricular white matter hyperintensity grades increased (ρ = -0.22, P = .02; ρ = -0.27, P = .005). Clinically, the modified brain frailty score could identify patients with Moyamoya disease with stroke (OR = 2.00, P = .02). Although the modified brain frailty score showed no predictive value for surgical outcome, basal ganglia enlargement of the perivascular space had a significant correlation with the postoperative Matsushima grade (OR = 1.29, P = .03). CONCLUSIONS The modified brain frailty score could reflect a cerebral perfusion deficit and clinical symptoms of Moyamoya disease, and its component basal ganglia enlargement of perivascular space may be a promising marker to predict surgical outcome and thus aid future clinical decision-making.
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Affiliation(s)
- Liuxian Wang
- From the Department of Radiology (L.X.W., J.H.L., D.S.H., X.B.B., D.K.Z., H.W., L.M., X.L.), Chinese PLA General Hospital/Chinese PLA Medical School, Beijing, China
| | - Jinhao Lyu
- From the Department of Radiology (L.X.W., J.H.L., D.S.H., X.B.B., D.K.Z., H.W., L.M., X.L.), Chinese PLA General Hospital/Chinese PLA Medical School, Beijing, China
| | - Dongshan Han
- From the Department of Radiology (L.X.W., J.H.L., D.S.H., X.B.B., D.K.Z., H.W., L.M., X.L.), Chinese PLA General Hospital/Chinese PLA Medical School, Beijing, China
| | - Xiangbing Bian
- From the Department of Radiology (L.X.W., J.H.L., D.S.H., X.B.B., D.K.Z., H.W., L.M., X.L.), Chinese PLA General Hospital/Chinese PLA Medical School, Beijing, China
| | - Dekang Zhang
- From the Department of Radiology (L.X.W., J.H.L., D.S.H., X.B.B., D.K.Z., H.W., L.M., X.L.), Chinese PLA General Hospital/Chinese PLA Medical School, Beijing, China
| | - Hui Wang
- From the Department of Radiology (L.X.W., J.H.L., D.S.H., X.B.B., D.K.Z., H.W., L.M., X.L.), Chinese PLA General Hospital/Chinese PLA Medical School, Beijing, China
| | - Fangbin Hao
- Department of Neurosurgery (F.B.H., L.D.), Chinese PLA General Hospital/Chinese PLA Medical School, Beijing, China
| | - Lian Duan
- Department of Neurosurgery (F.B.H., L.D.), Chinese PLA General Hospital/Chinese PLA Medical School, Beijing, China
| | - Lin Ma
- From the Department of Radiology (L.X.W., J.H.L., D.S.H., X.B.B., D.K.Z., H.W., L.M., X.L.), Chinese PLA General Hospital/Chinese PLA Medical School, Beijing, China
| | - Xin Lou
- From the Department of Radiology (L.X.W., J.H.L., D.S.H., X.B.B., D.K.Z., H.W., L.M., X.L.), Chinese PLA General Hospital/Chinese PLA Medical School, Beijing, China
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Arba F, Ferretti S, Leigh R, Fara A, Warach SJ, Luby M, Lees KR, Dawson J. Cerebral Small Vessel Disease and Infarct Growth in Acute Ischemic Stroke Treated with Intravenous Thrombolysis. Transl Stroke Res 2024:10.1007/s12975-024-01277-2. [PMID: 38963535 DOI: 10.1007/s12975-024-01277-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2024] [Revised: 06/03/2024] [Accepted: 06/29/2024] [Indexed: 07/05/2024]
Abstract
We investigated relations between cerebral small vessel disease (cSVD) markers and evolution of the ischemic tissue from ischemic core to final infarct in people with acute ischemic stroke treated with intravenous thrombolysis. Data from the Stroke Imaging Repository (STIR) and Virtual International Stroke Trials Archive (VISTA) were used. Any pre-existing lacunar infarcts and white matter hyperintensities (WMH) were assessed on magnetic resonance (MR) before thrombolytic therapy. Acute ischemic core and final infarct volume were then assessed by two independent radiologists. The relationship among baseline markers of cSVD, acute ischemic core volume, final infarct volume, infarct growth (IG = final infarct - ischemic core), and infarct growth ratio (IGR = final infarct/ischemic core) was then assessed using linear and ordinal regression adjusted for age, sex, onset-to-treatment time, and stroke severity. We included 165 patients, mean (± SD) age 69.5 (± 15.7) years, 74 (45%) males, mean (± SD) ischemic core volume 25.48 (± 42.22) ml, final infarct volume 52.06 (± 72.88) ml, IG 26.58 (± 51.02) ml, IGR 8.23 (± 38.12). Seventy (42%) patients had large vessel occlusion, 20 (12%) acute small subcortical infarct. WMHs were present in 131 (79%) and lacunar infarcts in 61 (37%) patients. Final infarct volumes were 53.8 ml and 45.2 ml (WMHs/no WMHs), p = 0.139, and 24.6 ml and 25.9 ml (lacunar infarcts/no lacunar infarcts), p = 0.842. In linear and ordinal regression analyses, presence of lacunar infarcts was associated with smaller IG (β = - 0.17; p = 0.024; cOR = 0.52; 95%CI = 0.28-0.96, respectively) and WMHs were associated with smaller IGR (β = - 0.30; p = 0.004; cOR = 0.27; 95%CI = 0.11-0.69, respectively). In people with acute ischemic stroke treated with intravenous thrombolysis, cSVD features were associated with smaller growth of the acute ischemic area, suggesting less salvageable tissue at time of reperfusion therapy.
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Affiliation(s)
- Francesco Arba
- Stroke Unit, Careggi University Hospital, Florence, Italy.
| | - Simone Ferretti
- NEUROFARBA Department, University of Florence, Careggi University Hospital, Florence, Italy
| | - Richard Leigh
- National Institute of Neurological Diseases and Stroke (NINDS), National Institutes of Health, Bethesda, MD, USA
| | - Andreia Fara
- National Institute of Neurological Diseases and Stroke (NINDS), National Institutes of Health, Bethesda, MD, USA
| | - Steven J Warach
- Department of Neurology, Dell Medical School, University of Texas at Austin, Austin, TX, USA
| | - Marie Luby
- National Institute of Neurological Disorders and Stroke (NINDS), National Institutes of Health (NIH), Bethesda, MD, USA
| | - Kennedy R Lees
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Jesse Dawson
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
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Tymianski M. Role of Neuroprotective Approaches in the Recanalization Era. Stroke 2024; 55:1927-1931. [PMID: 38323414 DOI: 10.1161/strokeaha.123.044229] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2024]
Affiliation(s)
- Michael Tymianski
- Department of Surgery, University of Toronto, ON, Canada. Krembil Research Institute, University Health Network, Toronto, ON, Canada
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Goyal M, Hill MD, Ospel JM. Designing clinical trials for bridging cerebroprotection in the era of mechanical thrombectomy: are we missing the point? J Neurointerv Surg 2024:jnis-2024-022009. [PMID: 38937085 DOI: 10.1136/jnis-2024-022009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/13/2024] [Indexed: 06/29/2024]
Affiliation(s)
- Mayank Goyal
- Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
| | - Michael D Hill
- Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Clinical Neurosciences, Foothills Medical Centre, Calgary, Alberta, Canada
| | - Johanna M Ospel
- Diagnostic Imaging, University of Calgary, Calgary, Alberta, Canada
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Joundi RA, Hill MD, Stang J, Nicol D, Yu AYX, Kapral MK, King JA, Halabi ML, Smith EE. Association Between Time to Treatment With Endovascular Thrombectomy and Home-Time After Acute Ischemic Stroke. Neurology 2024; 102:e209454. [PMID: 38848515 DOI: 10.1212/wnl.0000000000209454] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/09/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Home-time is a patient-prioritized stroke outcome that can be derived from administrative data linkages. The effect of faster time-to-treatment with endovascular thrombectomy (EVT) on home-time after acute stroke is unknown. METHODS We used the Quality Improvement and Clinical Research registry to identify a cohort of patients who received EVT for acute ischemic stroke between 2015 and 2022 in Alberta, Canada. We calculated days at home in the first 90 days after stroke. We used ordinal regression across 6 ordered categories of home-time to evaluate the association between onset-to-arterial puncture and higher home-time, adjusting for age, sex, rural residence, NIH Stroke Scale, comorbidities, intravenous thrombolysis, and year of treatment. We used restricted cubic splines to assess the nonlinear relationship between continuous variation in time metrics and higher home-time, and also reported the adjusted odds ratios within time categories. We additionally evaluated door-to-puncture and reperfusion times. Finally, we analyzed home-time with zero-inflated models to determine the minutes of earlier treatment required to gain 1 day of home-time. RESULTS We had 1,885 individuals in our final analytic sample. There was a nonlinear increase in home-time with faster treatment when EVT was within 4 hours of stroke onset or 2 hours of hospital arrival. There was a higher odds of achieving more days at home when onset-to-puncture time was <2 hours (adjusted odds ratio 2.36, 95% CI 1.77-3.16) and 2 to <4 hours (1.37, 95% CI 1.11-1.71) compared with ≥6 hours, and when door-to-puncture time was <1 hour (aOR 2.25, 95% CI 1.74-2.90), 1 to <1.5 hours (aOR 1.89, 95% CI 1.47-2.41), and 1.5 to <2 hours (1.35, 95% CI 1.04-1.76) compared with ≥2 hours. Results were consistent for reperfusion times. For every hour of faster treatment within 6 hours of stroke onset, there was an estimated increase in home-time of 4.7 days, meaning that approximately 1 day of home-time was gained for each 12.8 minutes of faster treatment. DISCUSSION Faster time-to-treatment with EVT for acute stroke was associated with greater home-time, particularly within 4 hours of onset-to-puncture and 2 hours of door-to-puncture time. Within 6 hours of stroke onset, each 13 minutes of faster treatment is associated with a gain of 1 day of home-time.
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Affiliation(s)
- Raed A Joundi
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Ontario; Departments of Clinical Neurosciences (M.D.H., E.E.S.) and Community Health Sciences (E.E.S.), Cumming School of Medicine, University of Calgary; Data and Analytics (DnA) (J.S., D.N.) and Cardiovascular Health and Stroke Strategic Clinical Network (M.-L.H.), Alberta Health Services; ICES (A.Y.X.Y., M.K.K.), Toronto; Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto; Sunnybrook Health Sciences Centre (A.Y.X.Y.), Ontario; Department of Medicine (A.Y.X.Y.), Division of Neurology, University of Toronto; Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario; Alberta Strategy for Patient Oriented Research Support Unit Data Platform (J.A.K.); and Provincial Research Data Services (J.A.K.), Alberta Health Services, Canada
| | - Michael D Hill
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Ontario; Departments of Clinical Neurosciences (M.D.H., E.E.S.) and Community Health Sciences (E.E.S.), Cumming School of Medicine, University of Calgary; Data and Analytics (DnA) (J.S., D.N.) and Cardiovascular Health and Stroke Strategic Clinical Network (M.-L.H.), Alberta Health Services; ICES (A.Y.X.Y., M.K.K.), Toronto; Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto; Sunnybrook Health Sciences Centre (A.Y.X.Y.), Ontario; Department of Medicine (A.Y.X.Y.), Division of Neurology, University of Toronto; Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario; Alberta Strategy for Patient Oriented Research Support Unit Data Platform (J.A.K.); and Provincial Research Data Services (J.A.K.), Alberta Health Services, Canada
| | - Jillian Stang
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Ontario; Departments of Clinical Neurosciences (M.D.H., E.E.S.) and Community Health Sciences (E.E.S.), Cumming School of Medicine, University of Calgary; Data and Analytics (DnA) (J.S., D.N.) and Cardiovascular Health and Stroke Strategic Clinical Network (M.-L.H.), Alberta Health Services; ICES (A.Y.X.Y., M.K.K.), Toronto; Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto; Sunnybrook Health Sciences Centre (A.Y.X.Y.), Ontario; Department of Medicine (A.Y.X.Y.), Division of Neurology, University of Toronto; Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario; Alberta Strategy for Patient Oriented Research Support Unit Data Platform (J.A.K.); and Provincial Research Data Services (J.A.K.), Alberta Health Services, Canada
| | - Dana Nicol
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Ontario; Departments of Clinical Neurosciences (M.D.H., E.E.S.) and Community Health Sciences (E.E.S.), Cumming School of Medicine, University of Calgary; Data and Analytics (DnA) (J.S., D.N.) and Cardiovascular Health and Stroke Strategic Clinical Network (M.-L.H.), Alberta Health Services; ICES (A.Y.X.Y., M.K.K.), Toronto; Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto; Sunnybrook Health Sciences Centre (A.Y.X.Y.), Ontario; Department of Medicine (A.Y.X.Y.), Division of Neurology, University of Toronto; Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario; Alberta Strategy for Patient Oriented Research Support Unit Data Platform (J.A.K.); and Provincial Research Data Services (J.A.K.), Alberta Health Services, Canada
| | - Amy Ying Xin Yu
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Ontario; Departments of Clinical Neurosciences (M.D.H., E.E.S.) and Community Health Sciences (E.E.S.), Cumming School of Medicine, University of Calgary; Data and Analytics (DnA) (J.S., D.N.) and Cardiovascular Health and Stroke Strategic Clinical Network (M.-L.H.), Alberta Health Services; ICES (A.Y.X.Y., M.K.K.), Toronto; Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto; Sunnybrook Health Sciences Centre (A.Y.X.Y.), Ontario; Department of Medicine (A.Y.X.Y.), Division of Neurology, University of Toronto; Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario; Alberta Strategy for Patient Oriented Research Support Unit Data Platform (J.A.K.); and Provincial Research Data Services (J.A.K.), Alberta Health Services, Canada
| | - Moira K Kapral
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Ontario; Departments of Clinical Neurosciences (M.D.H., E.E.S.) and Community Health Sciences (E.E.S.), Cumming School of Medicine, University of Calgary; Data and Analytics (DnA) (J.S., D.N.) and Cardiovascular Health and Stroke Strategic Clinical Network (M.-L.H.), Alberta Health Services; ICES (A.Y.X.Y., M.K.K.), Toronto; Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto; Sunnybrook Health Sciences Centre (A.Y.X.Y.), Ontario; Department of Medicine (A.Y.X.Y.), Division of Neurology, University of Toronto; Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario; Alberta Strategy for Patient Oriented Research Support Unit Data Platform (J.A.K.); and Provincial Research Data Services (J.A.K.), Alberta Health Services, Canada
| | - James A King
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Ontario; Departments of Clinical Neurosciences (M.D.H., E.E.S.) and Community Health Sciences (E.E.S.), Cumming School of Medicine, University of Calgary; Data and Analytics (DnA) (J.S., D.N.) and Cardiovascular Health and Stroke Strategic Clinical Network (M.-L.H.), Alberta Health Services; ICES (A.Y.X.Y., M.K.K.), Toronto; Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto; Sunnybrook Health Sciences Centre (A.Y.X.Y.), Ontario; Department of Medicine (A.Y.X.Y.), Division of Neurology, University of Toronto; Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario; Alberta Strategy for Patient Oriented Research Support Unit Data Platform (J.A.K.); and Provincial Research Data Services (J.A.K.), Alberta Health Services, Canada
| | - Mary-Lou Halabi
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Ontario; Departments of Clinical Neurosciences (M.D.H., E.E.S.) and Community Health Sciences (E.E.S.), Cumming School of Medicine, University of Calgary; Data and Analytics (DnA) (J.S., D.N.) and Cardiovascular Health and Stroke Strategic Clinical Network (M.-L.H.), Alberta Health Services; ICES (A.Y.X.Y., M.K.K.), Toronto; Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto; Sunnybrook Health Sciences Centre (A.Y.X.Y.), Ontario; Department of Medicine (A.Y.X.Y.), Division of Neurology, University of Toronto; Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario; Alberta Strategy for Patient Oriented Research Support Unit Data Platform (J.A.K.); and Provincial Research Data Services (J.A.K.), Alberta Health Services, Canada
| | - Eric E Smith
- From the Division of Neurology (R.A.J.), Hamilton Health Sciences, McMaster University & Population Health Research Institute, Ontario; Departments of Clinical Neurosciences (M.D.H., E.E.S.) and Community Health Sciences (E.E.S.), Cumming School of Medicine, University of Calgary; Data and Analytics (DnA) (J.S., D.N.) and Cardiovascular Health and Stroke Strategic Clinical Network (M.-L.H.), Alberta Health Services; ICES (A.Y.X.Y., M.K.K.), Toronto; Department of Medicine (Neurology) (A.Y.X.Y.), University of Toronto; Sunnybrook Health Sciences Centre (A.Y.X.Y.), Ontario; Department of Medicine (A.Y.X.Y.), Division of Neurology, University of Toronto; Department of Medicine (General Internal Medicine) (M.K.K.), University of Toronto-University Health Network, Ontario; Alberta Strategy for Patient Oriented Research Support Unit Data Platform (J.A.K.); and Provincial Research Data Services (J.A.K.), Alberta Health Services, Canada
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Munsch F, Planes D, Fukutomi H, Marnat G, Courret T, Micard E, Chen B, Seners P, Dubos J, Planche V, Coupé P, Dousset V, Lapergue B, Olivot JM, Sibon I, Thiebaut De Schotten M, Tourdias T. Dynamic Evolution of Infarct Volumes at MRI in Ischemic Stroke Due to Large Vessel Occlusion. Neurology 2024; 102:e209427. [PMID: 38815232 DOI: 10.1212/wnl.0000000000209427] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2024] Open
Abstract
BACKGROUND AND OBJECTIVES The typical infarct volume trajectories in stroke patients, categorized as slow or fast progressors, remain largely unknown. This study aimed to reveal the characteristic spatiotemporal evolutions of infarct volumes caused by large vessel occlusion (LVO) and show that such growth charts help anticipate clinical outcomes. METHODS We conducted a secondary analysis from prospectively collected databases (FRAME, 2017-2019; ETIS, 2015-2022). We selected acute MRI data from anterior LVO stroke patients with witnessed onset, which were divided into training and independent validation datasets. In the training dataset, using Gaussian mixture analysis, we classified the patients into 3 growth groups based on their rate of infarct growth (diffusion volume/time-to-imaging). Subsequently, we extrapolated pseudo-longitudinal models of infarct growth for each group and generated sequential frequency maps to highlight the spatial distribution of infarct growth. We used these charts to attribute a growth group to the independent patients from the validation dataset. We compared their 3-month modified Rankin scale (mRS) with the predicted values based on a multivariable regression model from the training dataset that used growth group as an independent variable. RESULTS We included 804 patients (median age 73.0 years [interquartile range 61.2-82.0 years]; 409 men). The training dataset revealed nonsupervised clustering into 11% (74/703) slow, 62% (437/703) intermediate, and 27% (192/703) fast progressors. Infarct volume evolutions were best fitted with a linear (r = 0.809; p < 0.001), cubic (r = 0.471; p < 0.001), and power (r = 0.63; p < 0.001) function for the slow, intermediate, and fast progressors, respectively. Notably, the deep nuclei and insular cortex were rapidly affected in the intermediate and fast groups with further cortical involvement in the fast group. The variable growth group significantly predicted the 3-month mRS (multivariate odds ratio 0.51; 95% CI 0.37-0.72, p < 0.0001) in the training dataset, yielding a mean area under the receiver operating characteristic curve of 0.78 (95% CI 0.66-0.88) in the independent validation dataset. DISCUSSION We revealed spatiotemporal archetype dynamic evolutions following LVO stroke according to 3 growth phenotypes called slow, intermediate, and fast progressors, providing insight into anticipating clinical outcome. We expect this could help in designing neuroprotective trials aiming at modulating infarct growth before EVT.
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Affiliation(s)
- Fanny Munsch
- From the Institut de Bio-imagerie IBIO (F.M., J.D., V.D., T.T.), University Bordeaux; Neuroimagerie Diagnostique et Thérapeutique (D.P., G.M., T.C., V.D., T.T.), CHU de Bordeaux, France; Kansai Electric Power Hospital (H.F.), Osaka, Japan; Inserm CIC-IT U1433 (E.M., B.C.), CHRU Nancy; Institut de Psychiatrie et Neurosciences de Paris (IPNP) (P.S.), INSERM U1266; Département de Neurologie (P.S.), Hopital Fondation Rothschild, Paris; Institut des Maladies Neurodégénératives (V.P.), CNRS, UMR 5293, Bordeaux INP (P.C.), LABRI, CNRS, UMR5800, and Neurocentre Magendie (V.D., T.T.), INSERM U1215, Univ. Bordeaux; Service de Neurologie et Unité de Neuro Vasculaire (B.L.), Hôpital FOCH, Suresnes; Unité Neurovasculaire (J.M.O.), CHU de Toulouse; Unité Neurovasculaire (I.S.), CHU de Bordeaux; CNRS (M.T.D.S.), UMR-5293, Univ. Bordeaux; and Brain Connectivity and Behaviour Laboratory (M.T.D.S.), Paris, France
| | - David Planes
- From the Institut de Bio-imagerie IBIO (F.M., J.D., V.D., T.T.), University Bordeaux; Neuroimagerie Diagnostique et Thérapeutique (D.P., G.M., T.C., V.D., T.T.), CHU de Bordeaux, France; Kansai Electric Power Hospital (H.F.), Osaka, Japan; Inserm CIC-IT U1433 (E.M., B.C.), CHRU Nancy; Institut de Psychiatrie et Neurosciences de Paris (IPNP) (P.S.), INSERM U1266; Département de Neurologie (P.S.), Hopital Fondation Rothschild, Paris; Institut des Maladies Neurodégénératives (V.P.), CNRS, UMR 5293, Bordeaux INP (P.C.), LABRI, CNRS, UMR5800, and Neurocentre Magendie (V.D., T.T.), INSERM U1215, Univ. Bordeaux; Service de Neurologie et Unité de Neuro Vasculaire (B.L.), Hôpital FOCH, Suresnes; Unité Neurovasculaire (J.M.O.), CHU de Toulouse; Unité Neurovasculaire (I.S.), CHU de Bordeaux; CNRS (M.T.D.S.), UMR-5293, Univ. Bordeaux; and Brain Connectivity and Behaviour Laboratory (M.T.D.S.), Paris, France
| | - Hikaru Fukutomi
- From the Institut de Bio-imagerie IBIO (F.M., J.D., V.D., T.T.), University Bordeaux; Neuroimagerie Diagnostique et Thérapeutique (D.P., G.M., T.C., V.D., T.T.), CHU de Bordeaux, France; Kansai Electric Power Hospital (H.F.), Osaka, Japan; Inserm CIC-IT U1433 (E.M., B.C.), CHRU Nancy; Institut de Psychiatrie et Neurosciences de Paris (IPNP) (P.S.), INSERM U1266; Département de Neurologie (P.S.), Hopital Fondation Rothschild, Paris; Institut des Maladies Neurodégénératives (V.P.), CNRS, UMR 5293, Bordeaux INP (P.C.), LABRI, CNRS, UMR5800, and Neurocentre Magendie (V.D., T.T.), INSERM U1215, Univ. Bordeaux; Service de Neurologie et Unité de Neuro Vasculaire (B.L.), Hôpital FOCH, Suresnes; Unité Neurovasculaire (J.M.O.), CHU de Toulouse; Unité Neurovasculaire (I.S.), CHU de Bordeaux; CNRS (M.T.D.S.), UMR-5293, Univ. Bordeaux; and Brain Connectivity and Behaviour Laboratory (M.T.D.S.), Paris, France
| | - Gaultier Marnat
- From the Institut de Bio-imagerie IBIO (F.M., J.D., V.D., T.T.), University Bordeaux; Neuroimagerie Diagnostique et Thérapeutique (D.P., G.M., T.C., V.D., T.T.), CHU de Bordeaux, France; Kansai Electric Power Hospital (H.F.), Osaka, Japan; Inserm CIC-IT U1433 (E.M., B.C.), CHRU Nancy; Institut de Psychiatrie et Neurosciences de Paris (IPNP) (P.S.), INSERM U1266; Département de Neurologie (P.S.), Hopital Fondation Rothschild, Paris; Institut des Maladies Neurodégénératives (V.P.), CNRS, UMR 5293, Bordeaux INP (P.C.), LABRI, CNRS, UMR5800, and Neurocentre Magendie (V.D., T.T.), INSERM U1215, Univ. Bordeaux; Service de Neurologie et Unité de Neuro Vasculaire (B.L.), Hôpital FOCH, Suresnes; Unité Neurovasculaire (J.M.O.), CHU de Toulouse; Unité Neurovasculaire (I.S.), CHU de Bordeaux; CNRS (M.T.D.S.), UMR-5293, Univ. Bordeaux; and Brain Connectivity and Behaviour Laboratory (M.T.D.S.), Paris, France
| | - Thomas Courret
- From the Institut de Bio-imagerie IBIO (F.M., J.D., V.D., T.T.), University Bordeaux; Neuroimagerie Diagnostique et Thérapeutique (D.P., G.M., T.C., V.D., T.T.), CHU de Bordeaux, France; Kansai Electric Power Hospital (H.F.), Osaka, Japan; Inserm CIC-IT U1433 (E.M., B.C.), CHRU Nancy; Institut de Psychiatrie et Neurosciences de Paris (IPNP) (P.S.), INSERM U1266; Département de Neurologie (P.S.), Hopital Fondation Rothschild, Paris; Institut des Maladies Neurodégénératives (V.P.), CNRS, UMR 5293, Bordeaux INP (P.C.), LABRI, CNRS, UMR5800, and Neurocentre Magendie (V.D., T.T.), INSERM U1215, Univ. Bordeaux; Service de Neurologie et Unité de Neuro Vasculaire (B.L.), Hôpital FOCH, Suresnes; Unité Neurovasculaire (J.M.O.), CHU de Toulouse; Unité Neurovasculaire (I.S.), CHU de Bordeaux; CNRS (M.T.D.S.), UMR-5293, Univ. Bordeaux; and Brain Connectivity and Behaviour Laboratory (M.T.D.S.), Paris, France
| | - Emilien Micard
- From the Institut de Bio-imagerie IBIO (F.M., J.D., V.D., T.T.), University Bordeaux; Neuroimagerie Diagnostique et Thérapeutique (D.P., G.M., T.C., V.D., T.T.), CHU de Bordeaux, France; Kansai Electric Power Hospital (H.F.), Osaka, Japan; Inserm CIC-IT U1433 (E.M., B.C.), CHRU Nancy; Institut de Psychiatrie et Neurosciences de Paris (IPNP) (P.S.), INSERM U1266; Département de Neurologie (P.S.), Hopital Fondation Rothschild, Paris; Institut des Maladies Neurodégénératives (V.P.), CNRS, UMR 5293, Bordeaux INP (P.C.), LABRI, CNRS, UMR5800, and Neurocentre Magendie (V.D., T.T.), INSERM U1215, Univ. Bordeaux; Service de Neurologie et Unité de Neuro Vasculaire (B.L.), Hôpital FOCH, Suresnes; Unité Neurovasculaire (J.M.O.), CHU de Toulouse; Unité Neurovasculaire (I.S.), CHU de Bordeaux; CNRS (M.T.D.S.), UMR-5293, Univ. Bordeaux; and Brain Connectivity and Behaviour Laboratory (M.T.D.S.), Paris, France
| | - Bailiang Chen
- From the Institut de Bio-imagerie IBIO (F.M., J.D., V.D., T.T.), University Bordeaux; Neuroimagerie Diagnostique et Thérapeutique (D.P., G.M., T.C., V.D., T.T.), CHU de Bordeaux, France; Kansai Electric Power Hospital (H.F.), Osaka, Japan; Inserm CIC-IT U1433 (E.M., B.C.), CHRU Nancy; Institut de Psychiatrie et Neurosciences de Paris (IPNP) (P.S.), INSERM U1266; Département de Neurologie (P.S.), Hopital Fondation Rothschild, Paris; Institut des Maladies Neurodégénératives (V.P.), CNRS, UMR 5293, Bordeaux INP (P.C.), LABRI, CNRS, UMR5800, and Neurocentre Magendie (V.D., T.T.), INSERM U1215, Univ. Bordeaux; Service de Neurologie et Unité de Neuro Vasculaire (B.L.), Hôpital FOCH, Suresnes; Unité Neurovasculaire (J.M.O.), CHU de Toulouse; Unité Neurovasculaire (I.S.), CHU de Bordeaux; CNRS (M.T.D.S.), UMR-5293, Univ. Bordeaux; and Brain Connectivity and Behaviour Laboratory (M.T.D.S.), Paris, France
| | - Pierre Seners
- From the Institut de Bio-imagerie IBIO (F.M., J.D., V.D., T.T.), University Bordeaux; Neuroimagerie Diagnostique et Thérapeutique (D.P., G.M., T.C., V.D., T.T.), CHU de Bordeaux, France; Kansai Electric Power Hospital (H.F.), Osaka, Japan; Inserm CIC-IT U1433 (E.M., B.C.), CHRU Nancy; Institut de Psychiatrie et Neurosciences de Paris (IPNP) (P.S.), INSERM U1266; Département de Neurologie (P.S.), Hopital Fondation Rothschild, Paris; Institut des Maladies Neurodégénératives (V.P.), CNRS, UMR 5293, Bordeaux INP (P.C.), LABRI, CNRS, UMR5800, and Neurocentre Magendie (V.D., T.T.), INSERM U1215, Univ. Bordeaux; Service de Neurologie et Unité de Neuro Vasculaire (B.L.), Hôpital FOCH, Suresnes; Unité Neurovasculaire (J.M.O.), CHU de Toulouse; Unité Neurovasculaire (I.S.), CHU de Bordeaux; CNRS (M.T.D.S.), UMR-5293, Univ. Bordeaux; and Brain Connectivity and Behaviour Laboratory (M.T.D.S.), Paris, France
| | - Johanna Dubos
- From the Institut de Bio-imagerie IBIO (F.M., J.D., V.D., T.T.), University Bordeaux; Neuroimagerie Diagnostique et Thérapeutique (D.P., G.M., T.C., V.D., T.T.), CHU de Bordeaux, France; Kansai Electric Power Hospital (H.F.), Osaka, Japan; Inserm CIC-IT U1433 (E.M., B.C.), CHRU Nancy; Institut de Psychiatrie et Neurosciences de Paris (IPNP) (P.S.), INSERM U1266; Département de Neurologie (P.S.), Hopital Fondation Rothschild, Paris; Institut des Maladies Neurodégénératives (V.P.), CNRS, UMR 5293, Bordeaux INP (P.C.), LABRI, CNRS, UMR5800, and Neurocentre Magendie (V.D., T.T.), INSERM U1215, Univ. Bordeaux; Service de Neurologie et Unité de Neuro Vasculaire (B.L.), Hôpital FOCH, Suresnes; Unité Neurovasculaire (J.M.O.), CHU de Toulouse; Unité Neurovasculaire (I.S.), CHU de Bordeaux; CNRS (M.T.D.S.), UMR-5293, Univ. Bordeaux; and Brain Connectivity and Behaviour Laboratory (M.T.D.S.), Paris, France
| | - Vincent Planche
- From the Institut de Bio-imagerie IBIO (F.M., J.D., V.D., T.T.), University Bordeaux; Neuroimagerie Diagnostique et Thérapeutique (D.P., G.M., T.C., V.D., T.T.), CHU de Bordeaux, France; Kansai Electric Power Hospital (H.F.), Osaka, Japan; Inserm CIC-IT U1433 (E.M., B.C.), CHRU Nancy; Institut de Psychiatrie et Neurosciences de Paris (IPNP) (P.S.), INSERM U1266; Département de Neurologie (P.S.), Hopital Fondation Rothschild, Paris; Institut des Maladies Neurodégénératives (V.P.), CNRS, UMR 5293, Bordeaux INP (P.C.), LABRI, CNRS, UMR5800, and Neurocentre Magendie (V.D., T.T.), INSERM U1215, Univ. Bordeaux; Service de Neurologie et Unité de Neuro Vasculaire (B.L.), Hôpital FOCH, Suresnes; Unité Neurovasculaire (J.M.O.), CHU de Toulouse; Unité Neurovasculaire (I.S.), CHU de Bordeaux; CNRS (M.T.D.S.), UMR-5293, Univ. Bordeaux; and Brain Connectivity and Behaviour Laboratory (M.T.D.S.), Paris, France
| | - Pierrick Coupé
- From the Institut de Bio-imagerie IBIO (F.M., J.D., V.D., T.T.), University Bordeaux; Neuroimagerie Diagnostique et Thérapeutique (D.P., G.M., T.C., V.D., T.T.), CHU de Bordeaux, France; Kansai Electric Power Hospital (H.F.), Osaka, Japan; Inserm CIC-IT U1433 (E.M., B.C.), CHRU Nancy; Institut de Psychiatrie et Neurosciences de Paris (IPNP) (P.S.), INSERM U1266; Département de Neurologie (P.S.), Hopital Fondation Rothschild, Paris; Institut des Maladies Neurodégénératives (V.P.), CNRS, UMR 5293, Bordeaux INP (P.C.), LABRI, CNRS, UMR5800, and Neurocentre Magendie (V.D., T.T.), INSERM U1215, Univ. Bordeaux; Service de Neurologie et Unité de Neuro Vasculaire (B.L.), Hôpital FOCH, Suresnes; Unité Neurovasculaire (J.M.O.), CHU de Toulouse; Unité Neurovasculaire (I.S.), CHU de Bordeaux; CNRS (M.T.D.S.), UMR-5293, Univ. Bordeaux; and Brain Connectivity and Behaviour Laboratory (M.T.D.S.), Paris, France
| | - Vincent Dousset
- From the Institut de Bio-imagerie IBIO (F.M., J.D., V.D., T.T.), University Bordeaux; Neuroimagerie Diagnostique et Thérapeutique (D.P., G.M., T.C., V.D., T.T.), CHU de Bordeaux, France; Kansai Electric Power Hospital (H.F.), Osaka, Japan; Inserm CIC-IT U1433 (E.M., B.C.), CHRU Nancy; Institut de Psychiatrie et Neurosciences de Paris (IPNP) (P.S.), INSERM U1266; Département de Neurologie (P.S.), Hopital Fondation Rothschild, Paris; Institut des Maladies Neurodégénératives (V.P.), CNRS, UMR 5293, Bordeaux INP (P.C.), LABRI, CNRS, UMR5800, and Neurocentre Magendie (V.D., T.T.), INSERM U1215, Univ. Bordeaux; Service de Neurologie et Unité de Neuro Vasculaire (B.L.), Hôpital FOCH, Suresnes; Unité Neurovasculaire (J.M.O.), CHU de Toulouse; Unité Neurovasculaire (I.S.), CHU de Bordeaux; CNRS (M.T.D.S.), UMR-5293, Univ. Bordeaux; and Brain Connectivity and Behaviour Laboratory (M.T.D.S.), Paris, France
| | - Bertrand Lapergue
- From the Institut de Bio-imagerie IBIO (F.M., J.D., V.D., T.T.), University Bordeaux; Neuroimagerie Diagnostique et Thérapeutique (D.P., G.M., T.C., V.D., T.T.), CHU de Bordeaux, France; Kansai Electric Power Hospital (H.F.), Osaka, Japan; Inserm CIC-IT U1433 (E.M., B.C.), CHRU Nancy; Institut de Psychiatrie et Neurosciences de Paris (IPNP) (P.S.), INSERM U1266; Département de Neurologie (P.S.), Hopital Fondation Rothschild, Paris; Institut des Maladies Neurodégénératives (V.P.), CNRS, UMR 5293, Bordeaux INP (P.C.), LABRI, CNRS, UMR5800, and Neurocentre Magendie (V.D., T.T.), INSERM U1215, Univ. Bordeaux; Service de Neurologie et Unité de Neuro Vasculaire (B.L.), Hôpital FOCH, Suresnes; Unité Neurovasculaire (J.M.O.), CHU de Toulouse; Unité Neurovasculaire (I.S.), CHU de Bordeaux; CNRS (M.T.D.S.), UMR-5293, Univ. Bordeaux; and Brain Connectivity and Behaviour Laboratory (M.T.D.S.), Paris, France
| | - Jean Marc Olivot
- From the Institut de Bio-imagerie IBIO (F.M., J.D., V.D., T.T.), University Bordeaux; Neuroimagerie Diagnostique et Thérapeutique (D.P., G.M., T.C., V.D., T.T.), CHU de Bordeaux, France; Kansai Electric Power Hospital (H.F.), Osaka, Japan; Inserm CIC-IT U1433 (E.M., B.C.), CHRU Nancy; Institut de Psychiatrie et Neurosciences de Paris (IPNP) (P.S.), INSERM U1266; Département de Neurologie (P.S.), Hopital Fondation Rothschild, Paris; Institut des Maladies Neurodégénératives (V.P.), CNRS, UMR 5293, Bordeaux INP (P.C.), LABRI, CNRS, UMR5800, and Neurocentre Magendie (V.D., T.T.), INSERM U1215, Univ. Bordeaux; Service de Neurologie et Unité de Neuro Vasculaire (B.L.), Hôpital FOCH, Suresnes; Unité Neurovasculaire (J.M.O.), CHU de Toulouse; Unité Neurovasculaire (I.S.), CHU de Bordeaux; CNRS (M.T.D.S.), UMR-5293, Univ. Bordeaux; and Brain Connectivity and Behaviour Laboratory (M.T.D.S.), Paris, France
| | - Igor Sibon
- From the Institut de Bio-imagerie IBIO (F.M., J.D., V.D., T.T.), University Bordeaux; Neuroimagerie Diagnostique et Thérapeutique (D.P., G.M., T.C., V.D., T.T.), CHU de Bordeaux, France; Kansai Electric Power Hospital (H.F.), Osaka, Japan; Inserm CIC-IT U1433 (E.M., B.C.), CHRU Nancy; Institut de Psychiatrie et Neurosciences de Paris (IPNP) (P.S.), INSERM U1266; Département de Neurologie (P.S.), Hopital Fondation Rothschild, Paris; Institut des Maladies Neurodégénératives (V.P.), CNRS, UMR 5293, Bordeaux INP (P.C.), LABRI, CNRS, UMR5800, and Neurocentre Magendie (V.D., T.T.), INSERM U1215, Univ. Bordeaux; Service de Neurologie et Unité de Neuro Vasculaire (B.L.), Hôpital FOCH, Suresnes; Unité Neurovasculaire (J.M.O.), CHU de Toulouse; Unité Neurovasculaire (I.S.), CHU de Bordeaux; CNRS (M.T.D.S.), UMR-5293, Univ. Bordeaux; and Brain Connectivity and Behaviour Laboratory (M.T.D.S.), Paris, France
| | - Michel Thiebaut De Schotten
- From the Institut de Bio-imagerie IBIO (F.M., J.D., V.D., T.T.), University Bordeaux; Neuroimagerie Diagnostique et Thérapeutique (D.P., G.M., T.C., V.D., T.T.), CHU de Bordeaux, France; Kansai Electric Power Hospital (H.F.), Osaka, Japan; Inserm CIC-IT U1433 (E.M., B.C.), CHRU Nancy; Institut de Psychiatrie et Neurosciences de Paris (IPNP) (P.S.), INSERM U1266; Département de Neurologie (P.S.), Hopital Fondation Rothschild, Paris; Institut des Maladies Neurodégénératives (V.P.), CNRS, UMR 5293, Bordeaux INP (P.C.), LABRI, CNRS, UMR5800, and Neurocentre Magendie (V.D., T.T.), INSERM U1215, Univ. Bordeaux; Service de Neurologie et Unité de Neuro Vasculaire (B.L.), Hôpital FOCH, Suresnes; Unité Neurovasculaire (J.M.O.), CHU de Toulouse; Unité Neurovasculaire (I.S.), CHU de Bordeaux; CNRS (M.T.D.S.), UMR-5293, Univ. Bordeaux; and Brain Connectivity and Behaviour Laboratory (M.T.D.S.), Paris, France
| | - Thomas Tourdias
- From the Institut de Bio-imagerie IBIO (F.M., J.D., V.D., T.T.), University Bordeaux; Neuroimagerie Diagnostique et Thérapeutique (D.P., G.M., T.C., V.D., T.T.), CHU de Bordeaux, France; Kansai Electric Power Hospital (H.F.), Osaka, Japan; Inserm CIC-IT U1433 (E.M., B.C.), CHRU Nancy; Institut de Psychiatrie et Neurosciences de Paris (IPNP) (P.S.), INSERM U1266; Département de Neurologie (P.S.), Hopital Fondation Rothschild, Paris; Institut des Maladies Neurodégénératives (V.P.), CNRS, UMR 5293, Bordeaux INP (P.C.), LABRI, CNRS, UMR5800, and Neurocentre Magendie (V.D., T.T.), INSERM U1215, Univ. Bordeaux; Service de Neurologie et Unité de Neuro Vasculaire (B.L.), Hôpital FOCH, Suresnes; Unité Neurovasculaire (J.M.O.), CHU de Toulouse; Unité Neurovasculaire (I.S.), CHU de Bordeaux; CNRS (M.T.D.S.), UMR-5293, Univ. Bordeaux; and Brain Connectivity and Behaviour Laboratory (M.T.D.S.), Paris, France
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12
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Rodriguez-Calienes A, Galecio-Castillo M, Vivanco-Suarez J, Mohamed GA, Toth G, Sarraj A, Pujara D, Chowdhury AA, Farooqui M, Ghannam M, Samaniego EA, Jovin TG, Ortega-Gutierrez S. Endovascular thrombectomy beyond 24 hours from last known well: a systematic review with meta-analysis. J Neurointerv Surg 2024; 16:670-676. [PMID: 37355251 DOI: 10.1136/jnis-2023-020443] [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: 04/13/2023] [Accepted: 06/04/2023] [Indexed: 06/26/2023]
Abstract
BACKGROUND Different studies have demonstrated the benefit of endovascular treatment (EVT) up to 24 hours after acute ischemic stroke (AIS) onset. Recent cohort observational studies suggest that patients with large vessel occlusion AIS may benefit from EVT beyond 24 hours from the last known well (LKW) when adequately selected. We aimed to examine the safety and efficacy of EVT beyond 24 hours from LKW using a meta-analysis of all the literature available. METHODS A systematic search from inception to April 2023 was conducted for studies including AIS patients with EVT beyond 24 hours from LKW in Medline, Embase, Scopus, and Web of Science. Outcomes of interest included favorable functional outcome (90-day modified Rankin scale (mRS) 0-2), successful reperfusion (modified Thrombolysis in Cerebral Infarction (mTICI) 2b-3), symptomatic intracerebral hemorrhage (sICH), and 90-day mortality. Data were pooled using a random-effects model. RESULTS Twelve studies with 894 patients were included. The rate of favorable functional outcome was 40% (95% CI 31% to 49%; I2=76%). The rate of successful reperfusion was 83% (95% CI 80% to 85%; I2=0%). The sICH rate was 7% (95% CI 5% to 9%; I2=0%) and the 90-day mortality rate was 28% (95% CI 24% to 33%; I2=0%). There was no significant difference in favorable outcomes (OR=0.69; 95% CI 0.41 to 1.14) and 90-day mortality (OR=1.35; 95% CI 0.90 to 2.00) among patients who underwent EVT <24 hours versus >24 hours. CONCLUSIONS EVT beyond 24 hours from LKW may achieve favorable clinical outcomes and high reperfusion rates, with acceptable intracranial hemorrhage rates in selected patients. Considering the current certainty of the evidence and heterogenous individual study results, larger prospective trials are warranted.
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Affiliation(s)
- Aaron Rodriguez-Calienes
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
- Neuroscience, Clinical Effectiveness and Public Health Research Group, Universidad Científica del Sur, Lima, Peru
| | | | - Juan Vivanco-Suarez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Ghada A Mohamed
- Department of Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Gabor Toth
- Cerebrovascular Center, Cleveland Clinic, Cleveland, Ohio, USA
| | - Amrou Sarraj
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Deep Pujara
- Department of Neurology, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
| | - Aj A Chowdhury
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Mudassir Farooqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Malik Ghannam
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Edgar A Samaniego
- Department of Neurology, Neurosurgery & Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Tudor G Jovin
- Cooper Neurological Institute, Cooper University Hospital, Camden, New Jersey, USA
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Neurosurgery & Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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13
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Bani-Sadr A, Mechtouff L, Hermier M, Eker OF, Rascle L, de Bourguignon C, Boutelier T, Martin A, Tommasino E, Ong E, Fontaine J, Cho TH, Derex L, Nighoghossian N, Berthezene Y. Cerebral collaterals are associated with pre-treatment brain-blood barrier permeability in acute ischemic stroke patients. Eur Radiol 2024:10.1007/s00330-024-10830-4. [PMID: 38861162 DOI: 10.1007/s00330-024-10830-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2023] [Revised: 04/08/2024] [Accepted: 05/16/2024] [Indexed: 06/12/2024]
Abstract
INTRODUCTION To investigate the relationship between collaterals and blood-brain barrier (BBB) permeability on pre-treatment MRI in a cohort of acute ischemic stroke (AIS) patients treated with thrombectomy. METHODS We conducted a retrospective analysis of the HIBISCUS-STROKE cohort, a single-center observational study that enrolled patients treated with thrombectomy from 2016 to 2022. Dynamic-susceptibility MRIs were post-processed to generate K2 maps with arrival-time correction, which were co-registered with apparent diffusion coefficient (ADC) maps. The 90th percentile of K2 was extracted from the infarct core-defined by an ADC ≤ 620 × 10-6 mm2/s with manual adjustments-and expressed as a percentage change compared to the contralateral white matter. Collaterals were assessed using pre-thrombectomy digital subtraction arteriography with an ASITN/SIR score < 3 defining poor collaterals. RESULTS Out of 249 enrolled, 101 (40.6%) were included (median age: 72.0 years, 52.5% of males, median NIHSS score at admission: 15.0). Patients with poor collaterals (n = 44) had worse NIHSS scores (median: 16.0 vs 13.0, p = 0.04), larger infarct core volumes (median: 43.7 mL vs 9.5 mL, p < 0.0001), and higher increases in K2 (median: 346.3% vs 152.7%, p = 0.003). They were less likely to achieve successful recanalization (21/44 vs 51/57, p < 0.0001) and experienced more frequent hemorrhagic transformation (16/44 vs 9/57, p = 0.03). On multiple variable analysis, poor collaterals were associated with larger infarct cores (odds ratio (OR) = 1.12, 95% confidence interval (CI): [1.07, 1.17], p < 0.0001) and higher increases in K2 (OR = 6.63, 95% CI: [2.19, 20.08], p = 0.001). CONCLUSION Poor collaterals are associated with larger infarct cores and increased BBB permeability at admission MRI. CLINICAL RELEVANCE STATEMENT Poor collaterals are associated with a larger infarct core and increased BBB permeability at admission MRI of AIS patients treated with thrombectomy. These findings may have translational interests for extending thrombolytic treatment eligibility and developing neuroprotective strategies. KEY POINTS In AIS, collaterals and BBB disruption have been both linked to hemorrhagic transformation. Poor collaterals were associated with larger ischemic cores and increased BBB permeability on pre-treatment MRI. These findings could contribute to hemorrhagic transformation risk stratification, thereby refining clinical decision-making for reperfusion therapies.
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Affiliation(s)
- Alexandre Bani-Sadr
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, Bron, France.
- CREATIS Laboratory, CNRS UMR 5220, INSERM U1294, Claude Bernard Lyon I University, Villeurbanne, France.
| | - Laura Mechtouff
- Stroke Department, East Group Hospital, Hospices Civils de Lyon, Bron, France
- CarMeN Laboratory, INSERM U1060/INRA U1397, Claude Bernard Lyon I University, Bron, France
| | - Marc Hermier
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, Bron, France
| | - Omer F Eker
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, Bron, France
- CREATIS Laboratory, CNRS UMR 5220, INSERM U1294, Claude Bernard Lyon I University, Villeurbanne, France
| | - Lucie Rascle
- Stroke Department, East Group Hospital, Hospices Civils de Lyon, Bron, France
| | | | | | - Anna Martin
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, Bron, France
| | - Emanuele Tommasino
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, Bron, France
| | - Elodie Ong
- Stroke Department, East Group Hospital, Hospices Civils de Lyon, Bron, France
| | - Julia Fontaine
- Stroke Department, East Group Hospital, Hospices Civils de Lyon, Bron, France
| | - Tae-Hee Cho
- Stroke Department, East Group Hospital, Hospices Civils de Lyon, Bron, France
- CarMeN Laboratory, INSERM U1060/INRA U1397, Claude Bernard Lyon I University, Bron, France
| | - Laurent Derex
- Stroke Department, East Group Hospital, Hospices Civils de Lyon, Bron, France
| | - Norbert Nighoghossian
- Stroke Department, East Group Hospital, Hospices Civils de Lyon, Bron, France
- CarMeN Laboratory, INSERM U1060/INRA U1397, Claude Bernard Lyon I University, Bron, France
| | - Yves Berthezene
- Department of Neuroradiology, East Group Hospital, Hospices Civils de Lyon, Bron, France
- CREATIS Laboratory, CNRS UMR 5220, INSERM U1294, Claude Bernard Lyon I University, Villeurbanne, France
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14
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Balaji PG, Bhimrao LS, Yadav AK. Revolutionizing Stroke Care: Nanotechnology-Based Brain Delivery as a Novel Paradigm for Treatment and Diagnosis. Mol Neurobiol 2024:10.1007/s12035-024-04215-3. [PMID: 38829514 DOI: 10.1007/s12035-024-04215-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Accepted: 05/03/2024] [Indexed: 06/05/2024]
Abstract
Stroke, a severe medical condition arising from abnormalities in the coagulation-fibrinolysis cycle and metabolic processes, results in brain cell impairment and injury due to blood flow obstruction within the brain. Prompt and efficient therapeutic approaches are imperative to control and preserve brain functions. Conventional stroke medications, including fibrinolytic agents, play a crucial role in facilitating reperfusion to the ischemic brain. However, their clinical efficacy is hampered by short plasma half-lives, limited brain tissue distribution attributed to the blood-brain barrier (BBB), and lack of targeted drug delivery to the ischemic region. To address these challenges, diverse nanomedicine strategies, such as vesicular systems, polymeric nanoparticles, dendrimers, exosomes, inorganic nanoparticles, and biomimetic nanoparticles, have emerged. These platforms enhance drug pharmacokinetics by facilitating targeted drug accumulation at the ischemic site. By leveraging nanocarriers, engineered drug delivery systems hold the potential to overcome challenges associated with conventional stroke medications. This comprehensive review explores the pathophysiological mechanism underlying stroke and BBB disruption in stroke. Additionally, this review investigates the utilization of nanocarriers for current therapeutic and diagnostic interventions in stroke management. By addressing these aspects, the review aims to provide insight into potential strategies for improving stroke treatment and diagnosis through a nanomedicine approach.
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Affiliation(s)
- Paul Gajanan Balaji
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER), Raebareli (An Institute of National Importance under Department of Pharmaceuticals, Ministry of Chemicals and Fertilizers, GOI), A Transit Campus at Bijnor-Sisendi Road, Near CRPF Base Camp, Sarojini Nagar, Lucknow, 226002, Uttar Pradesh, India
| | - Londhe Sachin Bhimrao
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER), Raebareli (An Institute of National Importance under Department of Pharmaceuticals, Ministry of Chemicals and Fertilizers, GOI), A Transit Campus at Bijnor-Sisendi Road, Near CRPF Base Camp, Sarojini Nagar, Lucknow, 226002, Uttar Pradesh, India
| | - Awesh K Yadav
- Department of Pharmaceutics, National Institute of Pharmaceutical Education and Research (NIPER), Raebareli (An Institute of National Importance under Department of Pharmaceuticals, Ministry of Chemicals and Fertilizers, GOI), A Transit Campus at Bijnor-Sisendi Road, Near CRPF Base Camp, Sarojini Nagar, Lucknow, 226002, Uttar Pradesh, India.
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15
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Ademola A, Bala F, Menon BK, Thornton J, Casetta I, Nannoni S, Goyal M, Herlihy D, Fainardi E, Power S, Saia V, Hegarty A, Pracucci G, Demchuk A, Mangiafico S, Boyle K, Michel P, Hildebrand KA, Sajobi TT, Hill MD, Toni D, Murphy S, Kim BJ, Almekhlafi MA. Workflow and Outcome of Thrombectomy in Late Time Window: A Pooled Multicenter Analysis. Can J Neurol Sci 2024:1-7. [PMID: 38639107 DOI: 10.1017/cjn.2024.60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
BACKGROUND We investigated the impact of workflow times on the outcomes of patients treated with endovascular thrombectomy (EVT) in the late time window. METHODS Individual patients' data who underwent EVT in the late time window (onset to imaging >6 hours) were pooled from seven registries and randomized clinical trials. Multiple time intervals were analyzed. Mixed-effects logistic regression was used to estimate the likelihood of functional independence at 90 days (modified Rankin Scale 0-2). Mixed-effects negative binomial regression was used to evaluate the relationship between patient characteristics and workflow time intervals. RESULTS 608 patients were included. The median age was 70 years (IQR: 58-71), 307 (50.5%) were female, and 310 (53.2%) had wake-up strokes. Successful reperfusion was achieved in 493 (81.2%) patients, and 262 (44.9%) achieved 90-day mRS 0-2. The estimated odds of functional independence decreased by 13% for every 30 minute delay from emergency department (ED) arrival to imaging time and by 7% from ED arrival to the end of EVT in the entire cohort. Also, the estimated odds of functional independence decreased by 33% for every 30 minute delay in the interval from arterial puncture to end of EVT, 16% in the interval from arrival in ED to end of EVT and 6% in the interval from stroke onset to end of EVT among patients who had a wake-up stroke. CONCLUSION Faster workflow from ED arrival to end of EVT is associated with improved functional independence among stroke patients treated in the late window.
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Affiliation(s)
- Ayoola Ademola
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- McCaig Institute of Bone and Joint, University of Calgary, Calgary, Canada
| | - Fouzi Bala
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - Bijoy K Menon
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
| | - John Thornton
- Neuroradiology Department, Beaumont Hospital, Dublin, Ireland
- Royal College of Surgeons in Ireland, Dublin, Ireland
| | - Ilaria Casetta
- Clinica Neurologica, University of Ferrara, Ferrara, Italy
| | - Stefania Nannoni
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Mayank Goyal
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
| | - Darragh Herlihy
- Neuroradiology Department, Beaumont Hospital, Dublin, Ireland
| | - Enrico Fainardi
- Neuroradiology Unit, Department of Experimental and Clinical Biomedical Sciences, University of Florence, Firenze, Italy
| | - Sarah Power
- Neuroradiology Department, Beaumont Hospital, Dublin, Ireland
| | - Valentina Saia
- Stroke Unit, Santa Corona Hospital, Pietra Ligure, Italy
| | - Aidan Hegarty
- Neuroradiology Department, Beaumont Hospital, Dublin, Ireland
| | | | - Andrew Demchuk
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
| | | | - Karl Boyle
- Department of Geriatric and Stroke Medicine, Beaumont Hospital, Dublin, Ireland
| | - Patrik Michel
- Stroke Center, Neurology Service, Lausanne University Hospital, Lausanne, Switzerland
| | - Kevin A Hildebrand
- McCaig Institute of Bone and Joint, University of Calgary, Calgary, Canada
- Department of Surgery, University of Calgary, Calgary, Canada
| | - Tolulope T Sajobi
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
| | - Michael D Hill
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
| | - Danilo Toni
- Emergency Department, Stroke Unit, Sapienza University Hospital, Rome, Italy
| | - Sean Murphy
- Department of Geriatric and Stroke Medicine, The Mater Misericordiae University Hospital, Dublin, Ireland
- School of Medicine, Royal College of Surgeons in Ireland, Dublin, Ireland
- School of Medicine, University College Dublin, Dublin, Ireland
| | - Beom Joon Kim
- Department of Neurology and Cerebrovascular Center, Seoul National University Bundang Hospital, Seongnam-si, Korea
| | - Mohammed A Almekhlafi
- Department of Community Health Sciences, University of Calgary, Calgary, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Canada
- Department of Radiology, University of Calgary, Calgary, Canada
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16
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Knezic A, Budusan E, Saez NJ, Broughton BRS, Rash LD, King GF, Widdop RE, McCarthy CA. Hi1a Improves Sensorimotor Deficit following Endothelin-1-Induced Stroke in Rats but Does Not Improve Functional Outcomes following Filament-Induced Stroke in Mice. ACS Pharmacol Transl Sci 2024; 7:1043-1054. [PMID: 38638162 PMCID: PMC11022283 DOI: 10.1021/acsptsci.3c00328] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2023] [Revised: 02/07/2024] [Accepted: 03/04/2024] [Indexed: 04/20/2024]
Abstract
Activation of acid-sensing ion channel 1a (ASIC1a) plays a major role in mediating acidosis-induced neuronal injury following a stroke. Therefore, the inhibition of ASIC1a is a potential therapeutic avenue for the treatment of stroke. Venom-peptide Hi1a, a selective and highly potent ASIC1a inhibitor, reduces the infarct size and functional deficits when injected into the brain after stroke in rodents. However, its efficacy when administered using a clinically relevant route of administration remains to be established. Therefore, the current investigation aims to examine the efficacy of systemically administered Hi1a, using two different models of stroke in different species. Mice were subjected to the filament model of middle cerebral artery occlusion (MCAO) and treated with Hi1a systemically using either a single- or multiple-dosing regimen. 24 h poststroke, mice underwent functional testing, and the brain infarct size was assessed. Rats were subjected to endothelin-1 (ET-1)-induced MCAO and treated with Hi1a intravenously 2 h poststroke. Rats underwent functional tests prior to and for 3 days poststroke, when infarct volume was assessed. Mice receiving Hi1a did not show any improvements in functional outcomes, despite a trend toward reduced infarct size. This trend for reduced infarct size in mice was consistent regardless of the dosing regimen. There was also a trend toward lower infarct size in rats treated with Hi1a. More specifically, Hi1a reduced the amount of damage occurring within the somatosensory cortex, which was associated with an improved sensorimotor function in Hi1a-treated rats. Thus, this study suggests that Hi1a or more brain-permeable ASIC1a inhibitors are a potential stroke treatment.
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Affiliation(s)
- Adriana Knezic
- Cardiovascular Disease Program, Monash Biomedicine
Discovery Institute (BDI), Department of Pharmacology, Monash
University, Clayton, VIC 3800, Australia
| | - Elena Budusan
- School of Biomedical Sciences, Faculty of Medicine,
The University of Queensland, St Lucia, QLD 4072,
Australia
| | - Natalie J. Saez
- Institute for Molecular Bioscience, The
University of Queensland, St Lucia, QLD 4072,
Australia
- Australian Research Council Centre of Excellence for
Innovations in Peptide and Protein Science, The University of
Queensland, St Lucia, QLD 4072, Australia
| | - Brad R. S. Broughton
- Cardiovascular Disease Program, Monash Biomedicine
Discovery Institute (BDI), Department of Pharmacology, Monash
University, Clayton, VIC 3800, Australia
| | - Lachlan D. Rash
- School of Biomedical Sciences, Faculty of Medicine,
The University of Queensland, St Lucia, QLD 4072,
Australia
| | - Glenn F. King
- Institute for Molecular Bioscience, The
University of Queensland, St Lucia, QLD 4072,
Australia
- Australian Research Council Centre of Excellence for
Innovations in Peptide and Protein Science, The University of
Queensland, St Lucia, QLD 4072, Australia
| | - Robert E. Widdop
- Cardiovascular Disease Program, Monash Biomedicine
Discovery Institute (BDI), Department of Pharmacology, Monash
University, Clayton, VIC 3800, Australia
| | - Claudia A. McCarthy
- Cardiovascular Disease Program, Monash Biomedicine
Discovery Institute (BDI), Department of Pharmacology, Monash
University, Clayton, VIC 3800, Australia
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17
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Luo X, Yang B, Yuan J, An H, Xie D, Han Q, Zhou S, Yue C, Sang H, Qiu Z, Kong Z, Shi Z. Decompressive craniectomy for patients with malignant infarction of the middle cerebral artery: A pooled analysis of two randomized controlled trials. J Stroke Cerebrovasc Dis 2024; 33:107719. [PMID: 38604351 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107719] [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: 11/09/2023] [Revised: 04/06/2024] [Accepted: 04/08/2024] [Indexed: 04/13/2024] Open
Abstract
BACKGROUND Decompressive craniectomy (DC) reduces mortality without increasing the risk of very severe disability among patients with life-threatening massive cerebral infarction. However, its efficacy was demonstrated before the era of endovascular thrombectomy trials. It remains uncertain whether DC improves the prognosis of patients with malignant middle cerebral artery (MCA) infarction receiving endovascular therapy. METHODS We pooled data from two trials (DEVT and RESCUE BT studies in China) and patients with malignant MCA infarction were included to assess outcomes and heterogeneity of DC therapy effect. Patients with herniation were dichotomized into DC and conservative groups according to their treatment strategy. The primary outcome was the rate of mortality at 90 days. Secondary outcomes included disability level at 90 days as measured by the modified Rankin Scale score (mRS) and quality-of-life score. The associations of DC with clinical outcomes were performed using multivariable logistic regression. RESULTS Of 98 patients with herniation, 37 received DC surgery and 61 received conservative treatment. The median (interquartile range) was 70 (62-76) years and 40.8% of the patients were women. The mortality rate at 90 days was 59.5% in the DC group compared with 85.2% in the conservative group (adjusted odds ratio, 0.31 [95% confidence interval (CI), 0.10-0.94]; P=0.04). There were 21.6% of patients in the DC group and 6.6% in the conservative group who had a mRS score of 4 (moderately severe disability); and 10.8% and 4.9%, respectively, had a score of 5 (severe disability). The quality-of-life score was higher in the DC group (0.00 [0.00-0.14] vs 0.00 [0.00-0.00], P=0.004), but DC treatment was not associated with better quality-of-life score in multivariable analyses (adjusted β Coefficient, 0.02 [95% CI, -0.08-0.11]; p=0.75). CONCLUSIONS DC was associated with decreased mortality among patients with malignant MCA infarction who received endovascular therapy. The majority of survivors remained moderately severe disability and required improvement on quality of life. CLINICAL TRIAL REGISTRATION The DEVT trial: http://www.chictr.org. Identifier, ChiCTR-IOR-17013568. The RESCUE BT trial: URL: http://www.chictr.org. Identifier, ChiCTR-INR-17014167.
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Affiliation(s)
- Xiaojun Luo
- Department of Cerebrovascular Diseases, Guangyuan Central Hospital, Guangyuan, China
| | - Bo Yang
- Department of Neurology, The First Affiliated Hospital of Henan Polytechnic University (Jiaozuo Second People's Hospital), Jiaozuo, China
| | - Junjie Yuan
- Department of Neurology, The 925th Hospital of The People's Liberation Army, Guiyang, China; Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing, China
| | - Huijie An
- Department of Pharmacy, General Hospital of Southern Theatre Command, PLA, Guangzhou, China
| | - Dongjing Xie
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing, China
| | - Qin Han
- Department of Neurology, The 903rd Hospital of The People's Liberation Army, Hangzhou, China
| | - Simin Zhou
- Department of Neurosurgery, The 904th Hospital of The People's Liberation Army, Wuxi, China
| | - Chengsong Yue
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing, China
| | - Hongfei Sang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing, China
| | - Zhongming Qiu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital of Army Medical University (Third Military Medical University), Chongqing, China
| | - Zhenyu Kong
- Department of Neurology, The First Affiliated Hospital of Henan Polytechnic University (Jiaozuo Second People's Hospital), Jiaozuo, China
| | - Zhonghua Shi
- Department of Neurosurgery, The 904th Hospital of The People's Liberation Army, 101 North Xinyuan Road, Wuxi, China.
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18
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Klapproth S, Meyer L, Kniep H, Bechstein M, Kyselyova A, Hanning U, Schön G, Rimmele L, Fiehler J, Broocks G. Effect of short- versus long-term serum glucose levels on early ischemic water homeostasis and functional outcome in patients with large vessel occlusion stroke. Eur J Neurol 2024; 31:e16166. [PMID: 38015448 PMCID: PMC11235831 DOI: 10.1111/ene.16166] [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: 08/25/2023] [Revised: 11/08/2023] [Accepted: 11/09/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND AND PURPOSE In ischemic stroke, the impact of short- versus long-term blood glucose level (BGL) on early lesion pathophysiology and functional outcome has not been assessed. The purpose of this study was to directly compare the effect of long-term blood glucose (glycated hemoglobin [HbA1c]) versus serum BGL on early edema formation and functional outcome. METHODS Anterior circulation ischemic stroke patients who underwent mechanical thrombectomy after multimodal computed tomography (CT) on admission were analyzed. Endpoints were early ischemic cerebral edema, measured by quantitative net water uptake (NWU) on initial CT and functional independence at Day 90. RESULTS A total of 345 patients were included. Patients with functional independence had significantly lower baseline NWU (3.1% vs. 8.3%; p < 0.001) and lower BGL (113 vs. 123 mg/dL; p < 0.001) than those without functional independence, while HbA1c levels did not differ significantly (5.7% vs. 5.8%; p = 0.15). A significant association was found for NWU and BGL (ß = 0.02, 95% confidence interval [CI] 0.006-0.03; p = 0.002), but not for HbA1c and NWU (ß = -0.16, 95% CI -0.53-0.21; p = 0.39). Mediation analysis showed that 67% of the effect of BGL on functional outcome was mediated by early edema formation. CONCLUSION Aggravated early edema and worse functional outcome was associated with elevated short-term serum BGL, but not with HbA1c levels. Hence, the link between short-term BGL and early edema development might be used as a target for adjuvant therapy in patients with ischemic stroke.
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Affiliation(s)
- Susan Klapproth
- Department of Diagnostic and Interventional NeuroradiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Lukas Meyer
- Department of Diagnostic and Interventional NeuroradiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Helge Kniep
- Department of Diagnostic and Interventional NeuroradiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional NeuroradiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Anna Kyselyova
- Department of Diagnostic and Interventional NeuroradiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Uta Hanning
- Department of Diagnostic and Interventional NeuroradiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Gerhard Schön
- Institute of Medical Biometry and EpidemiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Leander Rimmele
- Department of NeurologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Jens Fiehler
- Department of Diagnostic and Interventional NeuroradiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional NeuroradiologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
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19
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Nguyen TQ, Tran MH, Phung HN, Nguyen KV, Tran HTM, Walter S, Hoang DCB, Pham BN, Truong ALT, Tran VT, Nguyen TN, Pham AL, Nguyen HT. Endovascular treatment for acute ischemic stroke beyond the 24-h time window: Selection by target mismatch profile. Int J Stroke 2024; 19:305-313. [PMID: 37807200 DOI: 10.1177/17474930231208817] [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] [Indexed: 10/10/2023]
Abstract
INTRODUCTION Endovascular treatment for acute ischemic stroke patients with large vessel occlusion (LVO) has been established as a promising clinical intervention within a late time window of 6-24 h after symptom onset. Patients with slow progression, however, may still benefit from endovascular treatment beyond the 24-h time window (very late window). AIM The aim of this study is to report insight into the potential clinical benefits of endovascular treatment for acute ischemic stroke beyond 24 h from symptom onset. METHODS A retrospective analysis was performed on consecutive patients undergoing endovascular treatment for acute anterior circulation LVO ischemic stroke beyond 24 h. Participants were recruited between July 2019 and November 2020. Patients were selected based on the DAWN/DEFUSE 3 criteria (Perfusion-RAPID, iSchemaView) and patients receiving treatment beyond 24 h were compared to a group of patients receiving endovascular treatment between 6 and 24 h after symptom onset. The primary outcome was the proportion of patients with functional independence at 90 days (modified Rankin Scale score of 0-2). The secondary outcomes were shift modified Rankin Scale (mRS) analysis and successful reperfusion was defined by thrombolysis in cerebral infarction (TICI) 2b-3 on the final procedure. Safety outcomes were symptomatic intracranial hemorrhage and death at the 90-day follow-up. Propensity score (PS)-matched analyses were employed to rectify the imbalanced baseline characteristics between the two groups. RESULTS A total of 166 patients were recruited with a median age of 63.0 (56.0-69.0) and 28.9% of all patients were females. Patients in the beyond 24-h group had a longer onset-to-groin time (median = 27.2 vs 14.3 h, p < 0.001) than those in the 6- to 24-h group. There were no statistically significant differences between the two groups in National Institutes of Health Stroke Scale (NIHSS) (median = 12.0 vs 15.0, p = 0.37), perfusion imaging characteristics (core: median = 11.0 vs 9.0 mL, p = 0.86; mismatch volume: median = 106.0 vs 96.0, p = 0.44; mismatch ratio = 6.46 vs 7.24, p = 0.91), and perfusion-to-groin time (median = 72.5 vs 76.0 min, p = 0.77). No significant differences were noted among patients between the two groups in the primary endpoint functional independence analysis (50.0% vs 46.6%, p = 0.77) and in the safety endpoint analysis: mortality (15.0% vs 11.0%, p = 0.71) or symptomatic hemorrhage (0% vs 3.42%, p > 0.999). In PS-matched analyses, there were no significant differences among patients between the two groups in functional independence (50.0% vs 54.8%, p = 0.74), mortality (16.7% vs 9.68%, p = 0.50), or symptomatic hemorrhage (0% vs 6.45%, p = 0.53). CONCLUSION Endovascular treatment can be performed safely and effectively in LVO patients beyond 24 h from symptom onset when selected by target mismatch profile. The clinical outcome of these patients was comparable to those treated in the 6- to 24-h window. Larger studies are needed to confirm these findings.
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Affiliation(s)
- Trung Quoc Nguyen
- Department of Cerebrovascular Disease, 115 People's Hospital, Ho Chi Minh City, Vietnam
- University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Mai Hoang Tran
- School of Public Health, Griffith University, Gold Coast, QLD, Australia
| | - Hai Ngoc Phung
- School of Medicine and Dentistry, Griffith University, Gold Coast, QLD, Australia
| | - Khang Vinh Nguyen
- Department of Neurology, University Medical Center, University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Hang T Minh Tran
- Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
| | - Silke Walter
- Department of Neurology, Saarland University Hospital, Homburg, Germany
| | - Dinh C Bao Hoang
- Department of Neurology, Tam Anh Hospital, Ho Chi Minh City, Vietnam
| | - Binh Nguyen Pham
- Department of Cerebrovascular Disease, 115 People's Hospital, Ho Chi Minh City, Vietnam
| | - Anh Le Tuan Truong
- Department of Cerebrovascular Disease, 115 People's Hospital, Ho Chi Minh City, Vietnam
| | - Vu Thanh Tran
- Department of Neurointervention, 115 People's Hospital, Ho Chi Minh City, Vietnam
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - An Le Pham
- University of Medicine and Pharmacy at Ho Chi Minh City, Ho Chi Minh City, Vietnam
| | - Huy-Thang Nguyen
- Department of Cerebrovascular Disease, 115 People's Hospital, Ho Chi Minh City, Vietnam
- Pham Ngoc Thach University of Medicine, Ho Chi Minh City, Vietnam
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20
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Navi BB, Bach I, Czap AL, Wang M, Yamal JM, Jacob AP, Parker SA, Rajan SS, Mir S, Sherman C, Willey JZ, Saver JL, Gonzalez MO, Singh N, Jones WJ, Ornelas D, Gonzales NR, Alexandrov AW, Alexandrov AV, Nour M, Spokoyny I, Mackey J, Collins SQ, Silnes K, Fink ME, English J, Barazangi N, Bratina PL, Volpi J, Rao CPV, Griffin L, Persse D, Grotta JC. Strokes Averted by Intravenous Thrombolysis: A Secondary Analysis of a Prospective, Multicenter, Controlled Trial of Mobile Stroke Units. Ann Neurol 2024; 95:347-361. [PMID: 37801480 DOI: 10.1002/ana.26816] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 09/29/2023] [Accepted: 09/30/2023] [Indexed: 10/08/2023]
Abstract
OBJECTIVE This study was undertaken to examine averted stroke in optimized stroke systems. METHODS This secondary analysis of a multicenter trial from 2014 to 2020 compared patients treated by mobile stroke unit (MSU) versus standard management. The analytical cohort consisted of participants with suspected stroke treated with intravenous thrombolysis. The main outcome was a tissue-defined averted stroke, defined as a final diagnosis of stroke with resolution of presenting symptoms/signs by 24 hours attributed to thrombolysis and no acute infarction/hemorrhage on imaging. An additional outcome was stroke with early symptom resolution, defined as a final diagnosis of stroke with resolution of presenting symptoms/signs by 24 hours attributed to thrombolysis. RESULTS Among 1,009 patients with a median last known well to thrombolysis time of 87 minutes, 159 (16%) had tissue-defined averted stroke and 276 (27%) had stroke with early symptom resolution. Compared with standard management, MSU care was associated with more tissue-defined averted stroke (18% vs 11%, adjusted odds ratio [aOR] = 1.82, 95% confidence interval [CI] = 1.13-2.98) and stroke with early symptom resolution (31% vs 21%, aOR = 1.74, 95% CI = 1.12-2.61). The relationships between thrombolysis treatment time and averted/early recovered stroke appeared nonlinear. Most models indicated increased odds for stroke with early symptom resolution but not tissue-defined averted stroke with earlier treatment. Additionally, younger age, female gender, hyperlipidemia, lower National Institutes of Health Stroke Scale, lower blood pressure, and no large vessel occlusion were associated with both tissue-defined averted stroke and stroke with early symptom resolution. INTERPRETATION In optimized stroke systems, 1 in 4 patients treated with thrombolysis recovered within 24 hours and 1 in 6 had no demonstrable brain injury on imaging. ANN NEUROL 2024;95:347-361.
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Affiliation(s)
- Babak B Navi
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Ivo Bach
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX
| | - Alexandra L Czap
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX
| | - Mengxi Wang
- Department of Biostatistics and Data Science, UTHealth School of Public Health, Houston, TX
| | - Jose-Miguel Yamal
- Department of Biostatistics and Data Science, UTHealth School of Public Health, Houston, TX
| | - Asha P Jacob
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX
| | | | - Suja S Rajan
- Department of Biostatistics and Data Science, UTHealth School of Public Health, Houston, TX
| | - Saad Mir
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Carla Sherman
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Joshua Z Willey
- Department of Neurology, Columbia University Irving Medical Center, New York, NY
| | - Jeffrey L Saver
- Department of Neurology, Ronald Reagan UCLA Medical Center, Los Angeles, CA
| | - Michael O Gonzalez
- Department of Biostatistics and Data Science, UTHealth School of Public Health, Houston, TX
| | - Noopur Singh
- Department of Biostatistics and Data Science, UTHealth School of Public Health, Houston, TX
| | | | - David Ornelas
- Department of Neurology, University of Colorado, Aurora, CO
| | | | - Anne W Alexandrov
- Department of Neurology, College of Nursing and College of Medicine, University of Tennessee Health Science Center, Memphis, TN
| | - Andrei V Alexandrov
- Department of Neurology, University of Arizona, Banner University Medical Center, Phoenix, AZ
| | - May Nour
- Department of Neurology, Ronald Reagan UCLA Medical Center, Los Angeles, CA
| | - Ilana Spokoyny
- Department of Neurology, Mills Peninsula Medical Center, Burlingame, CA
| | - Jason Mackey
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN
| | - Sarah Q Collins
- Department of Neurology, Indiana University School of Medicine, Indianapolis, IN
| | - Kelly Silnes
- University of Buckingham Medical School, Buckingham, UK
| | - Mathew E Fink
- Clinical and Translational Neuroscience Unit, Feil Family Brain and Mind Research Institute and Department of Neurology, Weill Cornell Medicine, New York, NY
| | - Joey English
- Department of Neurology, Mills Peninsula Medical Center, Burlingame, CA
| | - Nobl Barazangi
- Department of Neurology, Mills Peninsula Medical Center, Burlingame, CA
| | - Patti L Bratina
- Department of Neurology, UTHealth McGovern Medical School, Houston, TX
| | - Jay Volpi
- Department of Neurology, Houston Methodist Hospital, Houston, TX
| | - Chethan P V Rao
- Department of Neurology, Baylor College of Medicine, Houston, TX
| | | | - David Persse
- Department of Emergency Medicine, Baylor College of Medicine, Houston, TX
| | - James C Grotta
- Clinical Innovation and Research Institute, Memorial Hermann Hospital-Texas Medical Center, Houston, TX
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21
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Kurniawan M, Mulya Saputri K, Mesiano T, Yunus RE, Permana AP, Sulistio S, Ginanjar E, Hidayat R, Rasyid A, Harris S. Efficacy of endovascular therapy for stroke in developing country: A single-centre retrospective observational study in Indonesia from 2017 to 2021. Heliyon 2024; 10:e23228. [PMID: 38192863 PMCID: PMC10772374 DOI: 10.1016/j.heliyon.2023.e23228] [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: 06/09/2022] [Revised: 11/27/2023] [Accepted: 11/29/2023] [Indexed: 01/10/2024] Open
Abstract
Background Indonesia as a developing nation faces a plethora of challenges in applying endovascular therapy (EVT), mostly due to the lack of physicians specialized in neuro-intervention, high operational cost, and time limitation. The efficacy of EVT in improving functional outcomes of stroke in developing countries has not been previously studied. Methods This retrospective cohort study was conducted at Dr. Cipto Mangunkusumo Hospital (Jakarta, Indonesia) from January 2017 to December 2021. Large vessel occlusion (LVO) diagnosis was established based on a combination of clinical and imaging characteristics. We assessed patients' functional independence on day-90 based on modified Rankin Scale (mRS) between the endovascular treatment group and the conservative group (those receiving intravascular thrombolysis or medical treatment only). Functional independence was defined as mRS ≤2. Results Among 111 stroke patients with LVO, we included 32 patients in the EVT group and 50 patients in the conservative group for this study. Patients with younger age (p = 0.004), lower hypertension rate (p < 0.001), higher intubation rate (p = 0.014), and earlier onset of stroke were observed in the EVT group. The proportion of mRS ≤2 at day-90 in the EVT group was higher than the conservative group (28.1 % vs. 18.0 %; p = 0.280). Patients within mRS ≤2 group had earlier onset-to-puncture time (p = 0.198), onset-to-recanalization time (p = 0.341), lower NIHSS (p = 0.026) and higher ASPECTS (p = 0.001) on admission. In multivariate analysis, ASPECTS (aOR 2.43; 95%CI 1.26-4.70; p = 0.008) defined functional independence in the EVT group. Conclusion The endovascular therapy group had a higher proportion of mRS ≤2 at day-90 than the conservative group despite its statistical insignificance.
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Affiliation(s)
- Mohammad Kurniawan
- Department of Neurology, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Kevin Mulya Saputri
- Department of Neurology, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Taufik Mesiano
- Department of Neurology, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Reyhan E. Yunus
- Department of Radiology, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Affan P. Permana
- Department of Neurosurgery, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Septo Sulistio
- Department of Emergency Medicine, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Eka Ginanjar
- Department of Internal Medicine, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Rakhmad Hidayat
- Department of Neurology, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Al Rasyid
- Department of Neurology, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
| | - Salim Harris
- Department of Neurology, Dr. Cipto Mangunkusumo Hospital, Faculty of Medicine, Universitas Indonesia, Jakarta, Indonesia
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22
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Shaban A, Al Kasab S, Chalhoub RM, Bass E, Maier I, Psychogios MN, Alawieh A, Wolfe SQ, Arthur AS, Dumont TM, Kan P, Kim JT, De Leacy R, Osbun JW, Rai AT, Jabbour P, Park MS, Crosa RJ, Mascitelli JR, Levitt MR, Polifka AJ, Casagrande W, Yoshimura S, Matouk C, Williamson R, Gory B, Mokin M, Fragata I, Romano DG, Chowdhry SA, Moss M, Behme D, Limaye K, Spiotta AM, Samaniego EA. Mechanical thrombectomy for large vessel occlusion strokes beyond 24 hours. J Neurointerv Surg 2023; 15:e331-e336. [PMID: 36593118 DOI: 10.1136/jnis-2022-019372] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 12/08/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND Recent clinical trials have shown that mechanical thrombectomy is superior to medical management for large vessel occlusion for up to 24 hours from onset. Our objective is to examine the safety and efficacy of thrombectomy beyond the standard of care window. METHODS A retrospective review was undertaken of the multicenter Stroke Thrombectomy and Aneurysm Registry (STAR). We identified patients who underwent mechanical thrombectomy for large vessel occlusion beyond 24 hours. We selected a matched control group from patients who underwent thrombectomy in the 6-24-hour window. We used functional independence at 3 months as our primary outcome measure. RESULTS We identified 121 patients who underwent thrombectomy beyond 24 hours and 1824 in the 6-24-hour window. We selected a 2:1 matched group of patients with thrombectomy 6-24 hours as a comparison group. Patients undergoing thrombectomy beyond 24 hours were less likely to be independent at 90 days (18 (18.8%) vs 73 (34.9%), P=0.005). They had higher odds of mortality at 90 days in the adjusted analysis (OR 2.34, P=0.023). Symptomatic intracerebral hemorrhage and other complications were similar in the two groups. In a multivariate analysis only lower number of attempts was associated with good outcomes (OR 0.27, P=0.022). CONCLUSIONS Mechanical thrombectomy beyond 24 hours appears to be safe and tolerable with no more hemorrhages or complications compared with standard of care thrombectomy. Outcomes and mortality in this time window are worse compared with an earlier time window, but the rates of good outcomes may justify this therapy in selected patients.
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Affiliation(s)
- Amir Shaban
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Sami Al Kasab
- Neurology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Reda M Chalhoub
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Eric Bass
- Department of Radiology, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Ilko Maier
- Neurology, University Medicine Goettingen, Goettingen, Germany
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic of Radiology and Nuclear Medicine, University Hospital Basel, Basel, Switzerland
| | - Ali Alawieh
- Neurosurgery, Emory University, Atlanta, Georgia, USA
| | - Stacey Q Wolfe
- Neurosurgery, Wake Forest School of Medicine, Winston Salem, North Carolina, USA
| | - Adam S Arthur
- Semmes-Murphey Neurologic and Spine Institute, Memphis, Tennessee, USA
- Neurosurgery, University of Tennessee Health Science Center, Memphis, Tennessee, USA
| | - Travis M Dumont
- Department of Surgery, Division of Neurosurgery, University of Arizona/Arizona Health Science Center, Tucson, Arizona, USA
| | - Peter Kan
- Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Joon-Tae Kim
- Chonnam National University Hospital, Seol, Korea (the Republic of)
| | - Reade De Leacy
- Neurosurgery, Icahn School of Medicine at Mount Sinai, NEW YORK, New York, USA
| | - Joshua W Osbun
- Neurosurgery, Washington University in Saint Louis School of Medicine, Saint Louis, Missouri, USA
| | - Ansaar T Rai
- Department of Neurointerventional Radiology, West Virginia University, Morgantown, West Virginia, USA
| | - Pascal Jabbour
- Neurological surgery, Thomas Jefferson University, Philadelphia, Pennsylvania, USA
| | - Min S Park
- Neurosurgery, Barrow Neurological Institute, Phoenix, Arizona, USA
| | | | - Justin R Mascitelli
- Department of Neurosurgery, University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Michael R Levitt
- Neurological Surgery, University of Washington School of Medicine, Seattle, Washington, USA
| | - Adam J Polifka
- Department of Neurosurgery, University of Florida, Gainesville, Florida, USA
| | | | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo College of Medicine, Nishinomiya, Hyogo, Japan
| | - Charles Matouk
- Neurosurgery, Yale University, New Haven, Connecticut, USA
| | - Richard Williamson
- Stroke & Cerebrovascular Center, Baptist Medical Center Jacksonville, Jacksonville, Florida, USA
| | - Benjamin Gory
- Department of Diagnostic and Interventional Neuroradiology, CHRU Nancy, Nancy, Lorraine, France
| | - Maxim Mokin
- Neurosurgery, University of South Florida College of Medicine, Tampa, Florida, USA
| | - Isabel Fragata
- Neuroradiology, Centro Hospitalar de Lisboa Central, Lisboa, Portugal
| | - Daniele G Romano
- Policlinico "Santa Maria alle Scotte", Unit of Neuroimaging and Neurointervention Siena, IT, University Hospital of Siena, Siena, Italy
| | | | - Mark Moss
- Washington Regional Medical Center, Fayetteville, Arkansas, USA
| | - Daniel Behme
- Department of Neuroradiology, University Hospital Magdeburg, Magdeburg, Sachsen-Anhalt, Germany
| | - Kaustubh Limaye
- Neurology, Indiana University Bloomington, Bloomington, Indiana, USA
| | - Alejandro M Spiotta
- Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Edgar A Samaniego
- Neurology, Radiology and Neurosurgery, The University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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23
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Marnat G, Kaesmacher J, Buetikofer L, Sibon I, Saleme S, Pop R, Henon H, Michel P, Mazighi M, Kulcsar Z, Janot K, Machi P, Pikula A, Gentric JC, Hernández-Pérez M, Krause LU, Turc G, Liebeskind DS, Gralla J, Fischer U. Interaction between intravenous thrombolysis and clinical outcome between slow and fast progressors undergoing mechanical thrombectomy: a post-hoc analysis of the SWIFT-DIRECT trial. J Neurointerv Surg 2023; 16:45-52. [PMID: 37055063 DOI: 10.1136/jnis-2023-020113] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2023] [Accepted: 03/30/2023] [Indexed: 04/15/2023]
Abstract
BACKGROUND In proximal occlusions, the effect of reperfusion therapies may differ between slow or fast progressors. We investigated the effect of intravenous thrombolysis (IVT) (with alteplase) plus mechanical thrombectomy (MT) versus thrombectomy alone among slow versus fast stroke progressors. METHODS The SWIFT-DIRECT trial data were analyzed: 408 patients randomized to IVT+MT or MT alone. Infarct growth speed was defined by the number of points of decay in the initial Alberta Stroke Program Early CT Score (ASPECTS) divided by the onset-to-imaging time. The primary endpoint was 3-month functional independence (modified Rankin scale 0-2). In the primary analysis, the study population was dichotomized into slow and fast progressors using median infarct growth velocity. Secondary analysis was also conducted using quartiles of ASPECTS decay. RESULTS We included 376 patients: 191 IVT+MT, 185 MT alone; median age 73 years (IQR 65-81); median initial National Institutes of Health Stroke Scale (NIHSS) 17 (IQR 13-20). The median infarct growth velocity was 1.2 points/hour. Overall, we did not observe a significant interaction between the infarct growth speed and the allocation to either randomization group on the odds of favourable outcome (P=0.68). In the IVT+MT group, odds of any intracranial hemorrhage (ICH) were significantly lower in slow progressors (22.8% vs 36.4%; OR 0.52, 95% CI 0.27 to 0.98) and higher among fast progressors (49.4% vs 26.8%; OR 2.62, 95% CI 1.42 to 4.82) (P value for interaction <0.001). Similar results were observed in secondary analyses. CONCLUSION In this SWIFT-DIRECT subanalysis, we did not find evidence for a significant interaction of the velocity of infarct growth on the odds of favourable outcome according to treatment by MT alone or combined IVT+MT. However, prior IVT was associated with significantly reduced occurrence of any ICH among slow progressors whereas this was increased in fast progressors.
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Affiliation(s)
- Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, University Hospital Centre Bordeaux, Bordeaux, Aquitaine, France
| | | | - Lukas Buetikofer
- CTU Bern, University of Bern, Bern, Switzerland, Bern, Switzerland
| | | | - Suzana Saleme
- Interventional Neuroradiology, CHU Limoges, Limoges, France
| | - Raoul Pop
- Department of Neuroradiolology, CHU Strasbourg, Strasbourg, France
| | - Hilde Henon
- Department of Vascular Neurology, Centre Hospitalier Regional Universitaire de Lille, Lille, France
| | - Patrik Michel
- Neurology Servcie, University of Lausanne, Lausanne, Switzerland
| | - Mikaël Mazighi
- Departement of Interventional Neuroradiology, Fondation Rothschild Hospital, Paris, France
- Neurology, GH Lariboisiere Fernand-Widal, Paris, France
| | | | - Kevin Janot
- Neuroradiology, University Hospital of Tours, Tours, France
| | - Paolo Machi
- Neuroradiology, Geneva University Hospitals, Geneve, Switzerland
| | | | | | | | - Lars Udo Krause
- Neurology, Osnabruck Hospital, Osnabruck, Niedersachsen, Germany
| | - Guillaume Turc
- Neurology, GHU Paris Psychiatrie et Neurosciences, Paris, France
- Université Paris Cité, Paris, France
- INSERM U1266, Paris, France
- FHU Neurovasc, Paris, France
| | - David S Liebeskind
- Department of Neurology, University of California Los Angeles, Los Angeles, California, USA
| | - Jan Gralla
- Department for Diagnostic and Interventional Neuroradiology, Inselspital, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital and University of Bern, Bern, Switzerland
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Ha SH, Jeong S, Park JY, Chang JY, Kang DW, Kwon SU, Kim JS, Kim BJ. Association between arterial tortuosity and early neurological deterioration in lenticulostriate artery infarction. Sci Rep 2023; 13:19865. [PMID: 37963951 PMCID: PMC10646100 DOI: 10.1038/s41598-023-47281-8] [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: 05/08/2023] [Accepted: 11/11/2023] [Indexed: 11/16/2023] Open
Abstract
Early neurological deterioration (END) in lenticulostriate artery (LSA) infarction is associated with perforating artery hypoperfusion. As middle cerebral artery (MCA) tortuosity may alter hemodynamics, we investigated the association between MCA tortuosity and END in LSA infarction. We reviewed patients with acute LSA infarction without significant MCA stenosis. END was defined as an increase of ≥ 2 or ≥ 1 in the National Institutes of Health Stroke Scale (NIHSS) total or motor score, respectively, within first 72 h. The MCA tortuosity index (actual /straight length) was measured. Stroke mechanisms were categorized as branch atheromatous disease (BAD; lesions > 10 mm and 4 axial slices) and lipohyalinotic degeneration (LD; lesion smaller than BAD). Factors associated with END in LD and BAD were investigated. END occurred in 104/390 (26.7%) patients. A high MCA tortuosity index (adjusted odds ratio, aOR 10.63, 95% confidence interval [2.57-44.08], p = 0.001) was independently associated with END. In patients with BAD, high initial NIHSS score (aOR 1.40 [1.03-1.89], p = 0.031) and presence of parental artery disease (stenosis < 50%; aOR 10.38 [1.85-58.08], p = 0.008) were associated with END. In patients with LD, high MCA tortuosity (aOR 41.78 [7.37-237.04], p < 0.001) was associated with END. The mechanism causing END in patients with LD and BAD may differ.
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Affiliation(s)
- Sang Hee Ha
- Department of Neurology, Asan Medical Center, University of Ulsan, 388-1 Pungnap-Dong, Songpa-Gu, Seoul, 138-736, Korea
- Department of Neurology, Gil Medical Center, Gachon University, Incheon, South Korea
| | - Soo Jeong
- Department of Neurology, Hanyang University College of Medicine, Seoul, South Korea
| | - Jae Young Park
- Department of Neurology, Asan Medical Center, University of Ulsan, 388-1 Pungnap-Dong, Songpa-Gu, Seoul, 138-736, Korea
| | - Jun Young Chang
- Department of Neurology, Asan Medical Center, University of Ulsan, 388-1 Pungnap-Dong, Songpa-Gu, Seoul, 138-736, Korea
| | - Dong-Wha Kang
- Department of Neurology, Asan Medical Center, University of Ulsan, 388-1 Pungnap-Dong, Songpa-Gu, Seoul, 138-736, Korea
| | - Sun U Kwon
- Department of Neurology, Asan Medical Center, University of Ulsan, 388-1 Pungnap-Dong, Songpa-Gu, Seoul, 138-736, Korea
| | - Jong S Kim
- Department of Neurology, Gangneung Asan Hospital, University of Ulsan, Gangneung, Gangwon-Do, South Korea
| | - Bum Joon Kim
- Department of Neurology, Asan Medical Center, University of Ulsan, 388-1 Pungnap-Dong, Songpa-Gu, Seoul, 138-736, Korea.
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25
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Consoli A, Pileggi M, Hasan AH, Rahman MH, Venier A, Sgreccia A, Pizzuto S, Coskun O, Di Maria F, Scarcia L, Lapergue B, Rodesch G, Bracard S, Chen B. Unfavorable clinical outcomes in patients with good collateral scores following endovascular treatment for acute ischemic stroke of the anterior circulation: The UNCLOSE study. Interv Neuroradiol 2023:15910199231212519. [PMID: 37936414 DOI: 10.1177/15910199231212519] [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: 11/09/2023] Open
Abstract
BACKGROUND Patients with acute ischemic stroke secondary to large vessel occlusions and good collaterals are frequently associated with favorable outcomes after mechanical thrombectomy, although poor outcomes are observed also in this subgroup. We aimed to investigate the factors associated with unfavorable outcomes (modified Rankin Scale3-6) in this specific subgroup of patients. METHODS In total, 219 patients (117 females) with anterior circulation stroke and good collaterals (American Society for Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology grades 3-4), treated by mechanical thrombectomy between 2016 and 2021 at our institution were included in this study. Clinical files and neuroimaging were retrospectively reviewed. Univariate and multivariate analyses were performed to identify the predictors of unfavorable outcomes in the overall population (primary endpoint). Secondary endpoints focused on the analysis of the predictors of unfavorable outcomes in the subgroup of successfully recanalized patients, mortality, and symptomatic intracerebral hemorrhages in the overall population. RESULTS Poor outcome was observed in 47% of the patients despite the presence of good collaterals. Older age (p < 0.001), higher baseline National Institute of Health stroke scale (p < 0.001), no intravenous thrombolysis administration (p = 0.004), > 3 passes (p = 0.01), and secondary transfers (p < 0.001) were associated with the primary endpoint. The multivariate analysis showed a predictive effect of modified treatment in cerebral infarction 2b-3 and of first pass effect on symptomatic intracerebral hemorrhage. CONCLUSIONS Despite good collaterals, defined through the American Society for Interventional and Therapeutic Neuroradiology/Society of Interventional Radiology scale, poor outcomes occurred in almost half of the patients. Patients with good collaterals not receiving intravenous thrombolysis were significantly associated with unfavorable outcomes, whereas first pass effect was not significantly correlated with clinical outcome in this specific cohort of patients. Different methods to assess collaterals should also be investigated.
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Affiliation(s)
- Arturo Consoli
- Interventional and Diagnostic Neuroradiology Department, Foch Hospital, Suresnes, France
- CIC-IT IADI Laboratory, Université de Lorraine, CHRU de Nancy, Nancy, France
| | - Marco Pileggi
- Interventional and Diagnostic Neuroradiology Department, Foch Hospital, Suresnes, France
- Diagnostic and Interventional Neuroradiology, Neurocenter of Southern Switzerland, EOC, Lugano, Switzerland
| | - Atm Hasibul Hasan
- Interventional and Diagnostic Neuroradiology Department, Foch Hospital, Suresnes, France
- National Institute of Neurosciences and Hospital, Dhaka, Bangladesh
| | - Mohammad H Rahman
- Interventional and Diagnostic Neuroradiology Department, Foch Hospital, Suresnes, France
- National Institute of Neurosciences and Hospital, Dhaka, Bangladesh
| | - Alice Venier
- Interventional and Diagnostic Neuroradiology Department, Foch Hospital, Suresnes, France
| | - Alessandro Sgreccia
- Interventional and Diagnostic Neuroradiology Department, Foch Hospital, Suresnes, France
| | - Silvia Pizzuto
- Interventional and Diagnostic Neuroradiology Department, Foch Hospital, Suresnes, France
| | - Oguzhan Coskun
- Interventional and Diagnostic Neuroradiology Department, Foch Hospital, Suresnes, France
| | - Federico Di Maria
- Interventional and Diagnostic Neuroradiology Department, Foch Hospital, Suresnes, France
| | - Luca Scarcia
- Interventional and Diagnostic Neuroradiology Department, Foch Hospital, Suresnes, France
- Institute of Radiology, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Bertrand Lapergue
- Department of Neurology and Stroke Unit, Foch Hospital, Suresnes, France
| | - Georges Rodesch
- Interventional and Diagnostic Neuroradiology Department, Foch Hospital, Suresnes, France
| | - Serge Bracard
- CIC-IT IADI Laboratory, Université de Lorraine, CHRU de Nancy, Nancy, France
- Interventional and Diagnostic Neuroradiology Department, CHRU de Nancy, Nancy, France
| | - Bailiang Chen
- CIC-IT IADI Laboratory, Université de Lorraine, CHRU de Nancy, Nancy, France
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26
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Galecio-Castillo M, Quispe-Orozco D, Farooqui M, Dajles A, Vivanco-Suarez J, Rodriguez-Calienes A, Prasad A, Begunova L, Petersen NH, Ortega-Gutierrez S. Association between intraprocedural drops in blood pressure and infarct growth rate patterns after acute large-vessel occlusions. J Neurointerv Surg 2023:jnis-2023-020899. [PMID: 37923382 PMCID: PMC11271969 DOI: 10.1136/jnis-2023-020899] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/09/2023] [Accepted: 10/17/2023] [Indexed: 11/07/2023]
Abstract
BACKGROUND Infarct growth rate (IGR) differs among patients with acute ischemic stroke due to large vessel occlusion (LVO-AIS), and this variability has critical clinical repercussions. We explored IGR patterns and their association with blood pressure during endovascular therapy (EVT). METHODS This is a two-center cohort observational study that included consecutive anterior circulation LVO-AIS patients who underwent EVT and achieved modified Thrombolysis in Cerebral Infarction (mTICI) 2 c-3. Initial and final infarct volumes (FIV) were defined using admission computed tomography perfusion (CTP) defined as relative cerebral blood flow (rCBF) <30%, and diffusion-weighted imaging-magnetic resonance imaging (DWI-MRI) at 24 hours post-EVT. We categorized IGR patterns as exponential (ExpIGR) and Non-exponential (NonExp) based on their growth curves. We then dichotomized ExpIGR clinical significance based on the association of infarct growth with 90-day Modified Rankin Score (mRS) as ExpIGR-A (>13 mL) and ExpIGR-B (<13 mL). Intraprocedural blood pressure (BP) drops were calculated as the difference between median arterial pressure (MAP) at admission and the lowest intraprocedural MAP reading before recanalization, and the area between admission MAP threshold and all lower measurements of intraprocedural MAP. Logistic and linear regression were used to investigate associations between variables of interest. RESULTS Of 159 modified Thrombolysis in Cerebral Infarction (mTICI) 2 c-3 patients, we found that 36% demonstrated ExpIGR-A, 31% ExpIGR-B, and 32.7% NonExp patterns. The Exp-A and Exp-B groups differed significantly in National Institutes of Health Stroke Scale (NIHSS) score, Alberta Stroke Program Early CT Score (ASPECTS), glucose, and FIV. The Exp-A and NonExp groups differed in rCBF <30% vol, and time of stroke onset (SO) to admission CTP; and the Exp-B and NonExp groups in NIHSS, rCBF <30%, Tmax <6 s volume, collateral flow measured by hypoperfusion intensity ratio (HIR), and FIV. Hypotensive MAP area (HMA) was independently associated with an ExpIGR-A pattern. Infarct volume increased by 1 mL per 100 units of hypotensive area and 4.2 mL per 0.1 units of HIR, with a significant interaction between both variables. CONCLUSION After an LVO-AIS, the IGR can be differentiated into two distinct exponential and non-exponential patterns. A subgroup of patients with the exponential pattern experienced clinically meaningful infarct growth rates between CTP acquisition and reperfusion and seem to be highly vulnerable to episodes of sustained intraprocedural BP drops during EVT.
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Affiliation(s)
| | | | - Mudassir Farooqui
- Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | - Andres Dajles
- Biostatistics, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
| | | | | | - Ayush Prasad
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Liza Begunova
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Nils H Petersen
- Department of Neurology, Yale School of Medicine, New Haven, Connecticut, USA
| | - Santiago Ortega-Gutierrez
- Neurology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
- Neurosurgery and Radiology, University of Iowa Hospitals and Clinics, Iowa City, Iowa, USA
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27
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Chen M, Meis J, Potreck A, Sauer LD, Kieser M, Bendszus M, Wick W, Ringleb PA, Möhlenbruch MA, Schönenberger S. Effect of Individualized Versus Standardized Blood Pressure Management During Endovascular Stroke Treatment on Clinical Outcome: A Randomized Clinical Trial. Stroke 2023; 54:2755-2765. [PMID: 37732489 DOI: 10.1161/strokeaha.123.044062] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 08/24/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Optimal blood pressure (BP) management during endovascular stroke treatment is not well established. We studied whether an individualized approach for managing BP during endovascular stroke treatment gives a better clinical outcome than an approach with standardized systolic BP targets. METHODS The INDIVIDUATE study (Individualized Blood Pressure Management During Endovascular Treatment of Acute Ischemic Stroke Under Procedural Sedation) is a randomized clinical trial with a prospective randomized open blinded end point (PROBE) design. Patients were recruited between October 1, 2020 and July 7, 2022 at a single center at a tertiary care university hospital. Patients were eligible, when they were suffering from acute ischemic stroke of the anterior circulation with occlusions of the internal carotid artery and middle cerebral artery and a National Institutes of Health Stroke Scale score of ≥8 receiving endovascular stroke treatment in procedural sedation. The intervention consists of an individualized BP management strategy, where preinterventional baseline systolic BP (SBP) values are used as intraprocedural BP targets. As a control, the standard treatment aims to maintain the intraprocedural SBP between 140 and 180 mm Hg. The main prespecified outcome is the proportion of favorable functional outcomes 90 days after stroke, defined as a modified Rankin Scale score of 0 to 2. RESULTS Two hundred fifty patients were enrolled and included in the analysis, mean (SD) age was 77 (12) years, 142 (57%) patients were women, and mean (SD) National Institutes of Health Stroke Scale score on admission was 17 (5.2). In all, 123 (49%) patients were treated with individualized and 127 (51%) with standard BP management. Mean (SD) intraprocedural SBP was similar in the individualized versus standard BP management group (157 [19] versus 154 [18] mm Hg; P=0.16). The rate of favorable functional outcome after 3 months was not significantly different between the individualized versus the standard BP management group (25% versus 24%; adjusted odds ratio, 0.81 [95% CI, 0.41-1.61]; P=0.56). CONCLUSIONS Among patients treated with endovascular stroke treatment due to an acute ischemic stroke of the anterior circulation, no significant difference was seen between the individualized BP management strategy, where intraprocedural SBP was targeted to baseline values, and the standardized regimen of targeting SBP between 140 and 180 mm Hg. REGISTRATION URL: https://www. CLINICALTRIALS gov; Unique identifier: NCT04578288.
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Affiliation(s)
- Min Chen
- Department of Neurology (M.C., W.W., P.A.R., S.S.), Heidelberg University Hospital, Germany
| | - Jan Meis
- Institute of Medical Biometry, University of Heidelberg, Germany (J.M., L.D.S., M.K.)
| | - Arne Potreck
- Department of Neuroradiology (A.P., M.B., M.A.M.), Heidelberg University Hospital, Germany
| | - Lukas D Sauer
- Institute of Medical Biometry, University of Heidelberg, Germany (J.M., L.D.S., M.K.)
| | - Meinhard Kieser
- Institute of Medical Biometry, University of Heidelberg, Germany (J.M., L.D.S., M.K.)
| | - Martin Bendszus
- Department of Neuroradiology (A.P., M.B., M.A.M.), Heidelberg University Hospital, Germany
| | - Wolfgang Wick
- Department of Neurology (M.C., W.W., P.A.R., S.S.), Heidelberg University Hospital, Germany
| | - Peter A Ringleb
- Department of Neurology (M.C., W.W., P.A.R., S.S.), Heidelberg University Hospital, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology (A.P., M.B., M.A.M.), Heidelberg University Hospital, Germany
| | - Silvia Schönenberger
- Department of Neurology (M.C., W.W., P.A.R., S.S.), Heidelberg University Hospital, Germany
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28
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Wang X, Li Y, Lu Z, Jian Y, Han N, Zhao L, Dang M, Wu Y, Li T, Feng Y, Yang Y, Huang W, Zhang L, Wang H, Zhang R, Chang M, Zhang G. Endovascular recanalization in patients with severely disabling non-acute ischemic stroke. J Neurointerv Surg 2023; 15:e282-e288. [PMID: 36597954 DOI: 10.1136/jnis-2022-019346] [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: 07/04/2022] [Accepted: 11/13/2022] [Indexed: 12/12/2022]
Abstract
BACKGROUND It is unclear whether patients with severely disabling ischemic stroke (SDIS-that is, modified Rankin scale (mRS) scores of 3-5) benefit from non-acute endovascular recanalization (ER). OBJECTIVE To determine the effect of non-acute ER or medical treatment in severely disabled patients with non-acute ischemic stroke (mRS scores of 3-5). METHODS Between January 2018 and August 2021, non-acute patients with SDIS and large vessel occlusion were collected from two regional stroke centers. Patients who met the inclusion and exclusion criteria were assigned to two groups based on whether they underwent ER (ER group) or not (medical group). The primary functional outcome was the mRS score at 90 days. The primary safety outcomes were the recurrence of stroke and mortality. RESULTS Of the 325 patients with hypoperfusion cerebral infarction caused by large vessel occlusion, 63 met the inclusion criteria (32 patients in the ER group, 31 patients in the medical group). A favorable outcome (mRS score ≤2) occurred more often in the ER group than in the medical group (59.4% vs 22.6%, respectively; OR=0.12, 95% CI 0.02 to 0.58; P<0.01). There were no significant differences in new-onset ischemic stroke (6.3% vs 3.2%, respectively; P=1.000), symptomatic intracerebral hemorrhage (12.5% vs 0%, respectively; P=0.113), or mortality within 90 days (6.3% vs 6.5%, respectively; P=1.000) between the two groups. Preoperative mRS scores (OR=7.34, 95% CI 1.56 to 34.5; P=0.02) and ER (OR=0.12, 95% CI 0.02 to 0.58; P<0.01) were significantly associated with outcome. CONCLUSION Our data suggest that patients with SDIS (mRS score 3-5) with smaller infarct cores and better collateral circulation can benefit from non-acute ER, with no additional perioperative complications or mortality.
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Affiliation(s)
- Xiaoya Wang
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Ye Li
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Ziwei Lu
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Yating Jian
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Nannan Han
- Department of Neurology, Xi'an No.3 Hospital, The Affiliated Hospital of Northwest University, Xi'an, Shannxi, China
| | - Lili Zhao
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Meijuan Dang
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Yulun Wu
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Tao Li
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Yuxuan Feng
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Yang Yang
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Wei Huang
- Department of Medical Imaging, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shannxi, China
| | - Lei Zhang
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Huqing Wang
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Ru Zhang
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
| | - Mingze Chang
- Department of Neurology, Xi'an No.3 Hospital, The Affiliated Hospital of Northwest University, Xi'an, Shannxi, China
| | - Guilian Zhang
- Department of Neurology, The Second Affiliated Hospital of Xi'an Jiaotong University, Xi'an, Shaanxi, China
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29
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Shourav MMI, Anisetti B, Godasi RR, Mateti N, Salem AM, Huynh T, Meschia JF, Lin MP. Association between left atrial enlargement and poor cerebral collaterals in large vessel occlusion. J Stroke Cerebrovasc Dis 2023; 32:107372. [PMID: 37738918 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107372] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Revised: 09/01/2023] [Accepted: 09/13/2023] [Indexed: 09/24/2023] Open
Abstract
OBJECTIVES Left atrial enlargement (LAE) is a known risk factor for atrial fibrillation, a common cause of large vessel occlusion (LVO) leading to ischemic stroke. While robust cerebral collaterals protect penumbral tissue from infarction, the effect of structural heart disease on cerebral collaterals remains uncertain. This study aims to investigate the association between LAE and cerebral collaterals in patients with acute LVO stroke. MATERIALS AND METHODS We conducted a retrospective study of consecutive patients with middle cerebral and/or internal carotid LVO who underwent endovascular thrombectomy (EVT) between 2012 to 2020. Consecutive patients with echocardiography and computed tomography angiography (CTA) of the head were included. Multivariate logistic regression analysis was performed to evaluate the relationship between LAE and poor cerebral collaterals, adjusting for demographics (age, sex, race) and vascular risk factors (hypertension, diabetes and smoking). RESULTS The study included 235 patients with mean age of 69±15 years and an initial mean National Institutes of Health Stroke Scale score of 18. Of these, 89 (37.9 %) had LAE, and 105 (44.7 %) had poor collaterals. Patients with LAE were more likely to have poor collaterals compared to those without LAE (58.4 % vs 36.3 %, P = 0.001). LAE was independently associated with higher odds of poor collaterals (odds ratio, 2.47; P = 0.001), even after adjusting for covariables (odds ratio 1.84, P = 0.048). CONCLUSIONS Our study demonstrated a significant association between LAE and poor cerebral collaterals in patients with LVO stroke undergoing EVT. Further research is warranted to explore potential shared mechanisms, such as endothelial dysfunction, underlying this heart-brain association.
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Affiliation(s)
| | - Bhrugun Anisetti
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, United States
| | - Raja R Godasi
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, United States
| | - Nihas Mateti
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, United States
| | - Amr M Salem
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, United States
| | - Thien Huynh
- Department of Radiology, Mayo Clinic, Jacksonville, Florida, United States
| | - James F Meschia
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, United States
| | - Michelle P Lin
- Department of Neurology, Mayo Clinic, Jacksonville, Florida, United States.
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30
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Broocks G, Meyer L, Bechstein M, Hanning U, Kniep HC, Schlemm E, Kyselyova AA, Winkelmeier L, Schön G, Fiehler J, Kemmling A. Investigating Neurologic Improvement After IV Thrombolysis: The Effect of Time From Stroke Onset vs Imaging-Based Tissue Clock. Neurology 2023; 101:e1678-e1686. [PMID: 37657940 PMCID: PMC10624495 DOI: 10.1212/wnl.0000000000207714] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 06/12/2023] [Indexed: 09/03/2023] Open
Abstract
BACKGROUND AND OBJECTIVES Time from stroke onset is associated with clinical response to intravenous thrombolysis (IVT) with alteplase and is therefore used to select patients for treatment. Alternatively, neuroimaging may be used for treatment in the uncertain or extended time window. We hypothesized that the patient-specific imaging indicator of ischemic lesion progression ("tissue clock") using CT perfusion (CTP) or quantitative net water uptake (NWU) is a predictor of early neurologic improvement (ENI) independent of time. METHODS Observational study of anterior circulation ischemic stroke patients with proximal vessel occlusion and known time from symptom onset triaged by multimodal CT undergoing endovascular treatment. Quantitative NWU using an established threshold (11.5%) or CTP lesion core mismatch (EXTEND criteria) was used to estimate ischemic lesion progression. The treatment effect of IVT depending on lesion progression defined by tissue clock vs time clock was assessed by inverse probability weighting (IPW). End points were binarized ENI and functional independence at day 90. RESULTS Four hundred nine patients were included, of which 223 (54.5%) received IVT. The proportion of patients within an early time window (<4.5 hours), low NWU, and CTP mismatch were 45.0%, 86.5%, and 80.3%. In IPW, IVT was associated with higher rates of ENI (%-difference: 7.3%, p = 0.02). For patients with CTP mismatch or low NWU, IVT was associated with a 9.6% or 7.2% higher rate of ENI, which was different than the effect of IVT in patients without CTP mismatch or high NWU (-9.3%/-7.3%; p = 0.004/p = 0.03), whereas early treatment window did not modify the effect of IVT. DISCUSSION CT-based measures of the "tissue clock" might identify patients who benefit from IVT more accurately than conventional time windows. Considering the high number of patients with early "tissue clock" (low NWU/CTP mismatch) within an extended time window, considerable benefit from IVT using imaging indicators of the "tissue clock" may be achieved.
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Affiliation(s)
- Gabriel Broocks
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany.
| | - Lukas Meyer
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany
| | - Matthias Bechstein
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany
| | - Uta Hanning
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany
| | - Helge C Kniep
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany
| | - Eckhard Schlemm
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany
| | - Anna A Kyselyova
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany
| | - Laurens Winkelmeier
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany
| | - Gerhard Schön
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany
| | - Jens Fiehler
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany
| | - Andre Kemmling
- From the Departments of Neuroradiology (G.B., A.A.K.), Diagnostic and Interventional Neuroradiology (L.M., M.B., U.H., H.C.K., L.W., J.F.), Neurology (E.S.) and Institute for Medical Biometry and Epidemiology (G.S.), University Medical Center Hamburg-Eppendorf; and Department of Neuroradiology (A.K.), University Marburg, Germany
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Dehkharghani S, Vogel A, Jandhyala N, Chung C, Shu L, Frontera J, Yaghi S. Continued Infarction Growth and Penumbral Consumption After Reperfusion in Vaccine-Naive Patients With COVID-19: A Case-Control Study. AJR Am J Roentgenol 2023; 221:517-525. [PMID: 37195793 DOI: 10.2214/ajr.23.29296] [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] [Indexed: 05/18/2023]
Abstract
BACKGROUND. Neurologic sequelae of SARS-CoV-2 include potentially malignant cerebrovascular events arising from complex hemodynamic, hematologic, and inflammatory processes occurring in concert. OBJECTIVE. This study concerns the hypothesis that despite angiographic reperfusion COVID-19 promotes continued consumption of at-risk tissue volumes after acute ischemic stroke (AIS), yielding critical insights into prognostication and monitoring paradigms in vaccine-naive patients experiencing AIS. METHODS. This retrospective study compared 100 consecutive COVID-19 patients with AIS presenting between March 2020 and April 2021 with a contemporaneous cohort of 282 AIS patients without COVID-19. Reperfusion classes were dichotomized into positive (extended thrombolysis in cerebral ischemia [eTICI] score = 2c-3) and negative (eTICI score < 2c) groups. All patients underwent endovascular therapy after initial CT perfusion imaging (CTP) to document infarction core and total hypoperfusion volumes. RESULTS. Ten COVID-positive (mean age ± SD, 67 ± 12 years; seven men, three women) and 144 COVID-negative patients (mean age, 71 ± 16 years; 76 men, 68 women) undergoing endovascular reperfusion, with antecedent CTP and follow-up imaging, comprised the final dataset. Initial infarction core and total hypoperfusion volumes (mean ± SD) were 1.5 ± 18 mL and 85 ± 100 mL in COVID-negative patients and 30.5 ± 34 mL and 117 ± 80.5 mL in COVID-positive patients, respectively. Final infarction volumes were significantly larger in patients with COVID-19, with median volumes of 77.8 mL versus 18.2 mL among control patients (p = .01), as were normalized measures of infarction growth relative to baseline infarction volume (p = .05). In adjusted logistic parametric regression models, COVID positivity emerged as a significant predictor for continued infarct growth (OR, 5.10 [95% CI, 1.00-25.95]; p = .05). CONCLUSION. These findings support the potentially aggressive clinical course of cerebrovascular events in patients with COVID-19, suggesting greater infarction growth and ongoing consumption of at-risk tissues, even after angiographic reperfusion. CLINICAL IMPACT. SARS-CoV-2 infection may promote continued infarction progression despite angiographic reperfusion in vaccine-naive patients with large-vessel occlusion AIS. The findings carry potential implications for prognostication, treatment selection, and surveillance for infarction growth among revascularized patients in future waves of infection by novel viral strains.
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Affiliation(s)
- Seena Dehkharghani
- Department of Radiology, New York University Langone Medical Center, Center for Biomedical Imaging, 660 1st Ave, 2nd Fl, New York, NY 10016
- Department of Neurology, New York University Langone Health, New York, NY
| | - Andre Vogel
- Department of Radiology, New York University Grossman School of Medicine, New York, NY
| | - Nora Jandhyala
- Department of Radiology, New York University Grossman School of Medicine, New York, NY
| | - Charlotte Chung
- Department of Radiology, New York University Langone Medical Center, Center for Biomedical Imaging, 660 1st Ave, 2nd Fl, New York, NY 10016
| | - Liqi Shu
- Department of Neurology, Brown University, Providence, RI
| | - Jennifer Frontera
- Department of Neurology, New York University Langone Health, New York, NY
| | - Shadi Yaghi
- Department of Neurology, Brown University, Providence, RI
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Mansour M. Reperfusion Therapies in Acute Ischemic Stroke Beyond the Conventional Time Window: A Narrative Review. Cureus 2023; 15:e45864. [PMID: 37881372 PMCID: PMC10597672 DOI: 10.7759/cureus.45864] [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] [Accepted: 09/24/2023] [Indexed: 10/27/2023] Open
Abstract
Stroke is the second most common cause of death worldwide, with 50% of survivors experiencing long-term disability. For more than two decades, treatment with intravenous thrombolysis (IVT) and mechanical endovascular thrombectomy (MET), the only approved stroke reperfusion therapies, was restricted to patients within the 4.5-6 hour time window, respectively. Therefore, patients who presented with acute ischemic stroke (AIS) beyond the conventional time window were excluded from reperfusion treatment. This narrative review aims to review the scientific literature on the possibilities of reperfusion therapies for patients who present with an unknown time of stroke onset, and those with stroke onset beyond the conventional 4.5-6 hour time window. Beyond the conventional time window, the eligibility of patients for IVT or MET, the two main therapeutic procedures, is decided based on the concept of penumbral imaging. Penumbral imaging identifies patients with hypoperfused but viable brain tissue, who could benefit from reperfusion. On the other hand, clock-based DWI-fluid-attenuated inversion recovery (FLAIR) magnetic resonance imaging (MRI) can detect stroke that has occurred within 4.5 hours in patients with an unknown time of onset, including patients who awaken with stroke. The introduction of penumbral imaging and MRI-based tissue clocking as imaging biomarkers for stroke has revolutionized stroke therapy, potentially allowing for personalized treatment of eligible stroke patients.
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Affiliation(s)
- Mohammad Mansour
- Department of General Medicine, University of Debrecen, Debrecen, HUN
- Department of General Medicine, Jordan University Hospital, Amman, JOR
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33
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Galecio-Castillo M, Farooqui M, Hassan AE, Jumaa MA, Divani AA, Ribo M, Abraham M, Petersen NH, Fifi JT, Guerrero WR, Malik AM, Siegler JE, Nguyen TN, Sheth S, Yoo AJ, Linares G, Janjua N, Quispe-Orozco D, Tekle W, Zaidi SF, Sabbagh SY, Olivé-Gadea M, Barkley T, Leacy RD, Sprankle KW, Abdalkader M, Salazar-Marioni S, Soomro J, Gordon W, Turabova C, Vivanco-Suarez J, Rodriguez-Calienes A, Mokin M, Yavagal DR, Jovin T, Ortega-Gutierrez S. Clinical and Safety Outcomes of Endovascular Therapy 6 to 24 Hours After Large Vessel Occlusion Ischemic Stroke With Tandem Lesions. J Stroke 2023; 25:378-387. [PMID: 37607694 PMCID: PMC10574302 DOI: 10.5853/jos.2023.00759] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2023] [Revised: 05/09/2023] [Accepted: 05/25/2023] [Indexed: 08/24/2023] Open
Abstract
BACKGROUND AND PURPOSE Effect of endovascular therapy (EVT) in acute large vessel occlusion (LVO) patients with tandem lesions (TLs) within 6-24 hours after last known well (LKW) remains unclear. We evaluated the clinical and safety outcomes among TL-LVO patients treated within 6-24 hours. METHODS This multicenter cohort was divided into two groups, based on LKW to puncture time: early window (<6 hours), and late window (6-24 hours). Primary clinical and safety outcomes were 90-day functional independence measured by the modified Rankin Scale (mRS: 0-2) and symptomatic intracranial hemorrhage (sICH). Secondary outcomes were successful reperfusion (modified Thrombolysis in Cerebral Infarction score ≥2b), first-pass effect, early neurological improvement, ordinal mRS, and in-hospital and 90-day mortality. RESULTS Of 579 patients (median age 68, 32.1% females), 268 (46.3%) were treated in the late window and 311 (53.7%) in the early window. Late window group had lower median National Institutes of Health Stroke Scale score at admission, Alberta Stroke Program Early Computed Tomography Score, rates of intravenous thrombolysis, and higher rates for perfusion imaging. After adjusting for confounders, the odds of 90-day mRS 0-2 (47.7% vs. 45.0%, adjusted odds ratio [aOR] 0.71, 95% confidence interval [CI] 0.49-1.02), favorable shift in mRS (aOR 0.88, 95% CI 0.44-1.76), and sICH (3.7% vs. 5.2%, aOR 0.56, 95% CI 0.20-1.56) were similar in both groups. There was no difference in secondary outcomes. Increased time from LKW to puncture did not predicted the probability of 90-day mRS 0-2 (aOR 0.99, 95% CI 0.96-1.01, for each hour delay) among patients presenting <24 hours. CONCLUSION EVT for acute TL-LVO treated within 6-24 hours after LKW was associated with similar rates of clinical and safety outcomes, compared to patients treated within 6 hours.
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Affiliation(s)
| | - Mudassir Farooqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Ameer E. Hassan
- Department of Neurology, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX, USA
| | | | - Afshin A. Divani
- Department of Neurology, University of New Mexico Health Science Center, Albuquerque, NM, USA
| | - Marc Ribo
- Department of Neurology, Hospital Vall d’Hebron, Barcelona, Spain
| | - Michael Abraham
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Nils H. Petersen
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Johanna T. Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Waldo R. Guerrero
- Department of Neurology and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Amer M. Malik
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - James E. Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | - Thanh N. Nguyen
- Department of Neurology, Boston Medical Center, Boston, MA, USA
| | - Sunil Sheth
- Department of Neurology, UT Health McGovern Medical School, Houston, TX, USA
| | | | | | - Nazli Janjua
- Asia Pacific Comprehensive Stroke Institute, Pomona Valley Hospital Medical Center, Pomona, CA, USA
| | - Darko Quispe-Orozco
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Wondwossen Tekle
- Department of Neurology, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - Syed F. Zaidi
- Department of Neurology, ProMedica Toledo Hospital, Toledo, OH, USA
| | - Sara Y. Sabbagh
- Department of Neurology, University of New Mexico Health Science Center, Albuquerque, NM, USA
| | | | - Tiffany Barkley
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Reade De Leacy
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | | | | | | | - Jazba Soomro
- Texas Stroke Institute, Dallas-Fort Worth, TX, USA
| | - Weston Gordon
- Department of Neurology, Saint Louis University, St. Louis, MO, USA
| | - Charoskhon Turabova
- Asia Pacific Comprehensive Stroke Institute, Pomona Valley Hospital Medical Center, Pomona, CA, USA
| | - Juan Vivanco-Suarez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | - Maxim Mokin
- Department of Neurology and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Dileep R. Yavagal
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Tudor Jovin
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ, USA
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Mohammaden MH, Haussen DC, Pisani L, Al-Bayati AR, Bhatt NR, Jillella DV, Bianchi NA, Belagaje SR, Frankel MR, Nogueira RG. Characterizing Fast and Slow Progressors in Anterior Circulation Large Vessel Occlusion Strokes. Interv Neuroradiol 2023; 29:379-385. [PMID: 35379038 PMCID: PMC10399496 DOI: 10.1177/15910199221083100] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 01/31/2022] [Indexed: 01/15/2023] Open
Abstract
BACKGROUND AND PURPOSE Infarct growth rate (IGR) in acute ischemic stroke is highly variable. We sought to evaluate impact of symptom-reperfusion time on outcomes in patients undergoing mechanical thrombectomy (MT). METHODS A prospectively maintained database from January,2012-August,2020 was reviewed. All patients with isolated MCA-M1 occlusion who achieved complete reperfusion(mTICI2C-3), had a witnessed symptom onset and follow-up MRI were included. IGR was calculated as final infarct volume (FIV)(ml)/symptom onset to reperfusion time(hours) and was dichotomized according to the median value into slow-(SP) versus fast-progressors (FP). The primary analysis aimed to evaluate the impact of symptom-reperfusion time on 90-day mRS in SP and FP. Secondary analysis was performed to identify predictors of IGR. RESULTS A total of 137 patients were eligible for analysis. Mean age was 63 ± 15.4 years and median IGR was 5.13ml/hour. SP(n = 69) had higher median ASPECTS, lower median rCBF<30% lesion volume, higher proportion of favorable collaterals and hypoperfusion intensity ratio (HIR)<0.4, higher minimal mean arterial blood pressure before reperfusion, and lower rates of general anesthesia compared to FP(n = 68). Symptom-reperfusion time was comparable between both groups. SP had higher rates of 90-day mRS0-2(71.9%vs.38.9%,aOR;7.226,95%CI[2.431-21.482],p < 0.001) and lower median FIV. Symptom-reperfusion time was associated with 90-day mRS0-2 in FP (aOR;0.541,95%CI[0.309-0.946],p = 0.03) but not in SP (aOR;0.874,95%CI[0.742-1.056],p = 0.16). On multivariable analysis, high ASPECTS and favorable collaterals in the NCCT/CTA model, and low rCBF<30% and HIR<0.4 in the CTP model were independent predictors of SP. CONCLUSIONS The impact of symptom-reperfusion time on outcomes significantly varies across slow-versus fast-progressors. ASPECTS, collateral score, rCBF<30%, and HIR define stroke progression profile.
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Affiliation(s)
- Mahmoud H Mohammaden
- Department of Neurology, Marcus Stroke & Neuroscience Center, Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Diogo C Haussen
- Department of Neurology, Marcus Stroke & Neuroscience Center, Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Leonardo Pisani
- Department of Neurology, Marcus Stroke & Neuroscience Center, Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Alhamza R Al-Bayati
- Department of Neurology, Marcus Stroke & Neuroscience Center, Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Nirav R Bhatt
- Department of Neurology, Marcus Stroke & Neuroscience Center, Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Dinesh V Jillella
- Department of Neurology, Marcus Stroke & Neuroscience Center, Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Nicolas A Bianchi
- Department of Neurology, Marcus Stroke & Neuroscience Center, Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Samir R Belagaje
- Department of Neurology, Marcus Stroke & Neuroscience Center, Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Michael R Frankel
- Department of Neurology, Marcus Stroke & Neuroscience Center, Emory University School of Medicine, Atlanta, GA, USA
- Grady Memorial Hospital, Atlanta, GA, USA
| | - Raul G Nogueira
- University of Pittsburg Medical Center, UPMC Stroke Institute, Pittsburg, PA, USA
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Jitpratoom P, Boonyasiri A. Determinants of urinary tract infection in hospitalized patients with acute ischemic stroke. BMC Neurol 2023; 23:251. [PMID: 37391711 DOI: 10.1186/s12883-023-03296-2] [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: 11/30/2022] [Accepted: 06/20/2023] [Indexed: 07/02/2023] Open
Abstract
BACKGROUND Stroke is a major cause of morbidity and mortality worldwide. Urinary tract infection (UTI) is a common post-acute ischemic stroke (AIS) complication. We assessed the incidence, determinant factors, infection characteristics, post-stroke complications, and outcomes of hospitalized AIS patients with UTI. METHODS This retrospective cohort study included AIS patients admitted within 7 days of stroke onset. The patients were divided into the UTI group and the non-UTI (control) group. Clinical data were collected and compared between the groups. RESULTS There were 342 AIS patients (31 with UTIs and 311 controls). The multivariate analysis showed that an initial National Institutes of Health Stroke Scale (NIHSS) score of ≥ 15 (odds ratio [OR] 5.00, 95% confidence interval [CI] 1.33-18.72) and Foley catheter retention (OR 14.10, 95% CI 3.25-61.28) were risk factors for UTI, whereas smoking (OR 0.08, 95% CI 0.01-0.50), an initial systolic blood pressure (SBP) of > 120 mmHg (OR 0.06, 95% CI 0.01-0.31), and statin use (OR 0.02, 95% CI 0.0006-0.42) were protective factors. Twenty cases (64.5%) were community-acquired and 11 cases (35.3%) were hospital-acquired. Ten patients (32.3%) had catheter-associated UTIs. The most common pathogen was Escherichia coli (13 patients, 41.9%). Post-stroke complications were significantly more common in the UTI group, including pneumonia, respiratory failure, sepsis, brain edema, seizure, symptomatic hemorrhagic transformation, congestive heart failure, atrial fibrillation with a rapid ventricular response, acute kidney injury, and hyponatremia. The median length of stay (LOS) in the UTI group was 12 days versus 3 days in the control group (p < 0.001). The median 3-month modified Rankin Scale score was higher (5 in UTI and 2 in control; p < 0.001) and the median 3-month Barthel Index was lower (0 in UTI and 100 in control; p < 0.001) in the UTI group than in the control group. CONCLUSIONS The risk factors for post-AIS UTI included severe stroke (NIHSS score ≥ 15) and urethral catheter indwelling. An initial SBP of > 120 mmHg and statin use were protective factors. The UTI group had significantly worse post-stroke complications, a longer LOS, and worse 3-month outcomes. Smoking was protective, which requires further investigation.
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Affiliation(s)
| | - Adhiratha Boonyasiri
- Department of Research and Development, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
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36
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De Michele M, Lorenzano S, Bertuccini L, Iosi F, Toni D. " Time lost is clot resolution lost": the neglected perspective of the therapeutic time window for ischemic stroke. Front Neurol 2023; 14:1177609. [PMID: 37292132 PMCID: PMC10244716 DOI: 10.3389/fneur.2023.1177609] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 04/28/2023] [Indexed: 06/10/2023] Open
Affiliation(s)
| | - Svetlana Lorenzano
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Lazio, Italy
| | - Lucia Bertuccini
- Core Facilities, National Institute of Health (ISS), Rome, Lazio, Italy
| | - Francesca Iosi
- Core Facilities, National Institute of Health (ISS), Rome, Lazio, Italy
| | - Danilo Toni
- Department of Human Neurosciences, Sapienza University of Rome, Rome, Lazio, Italy
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37
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Olthuis SGH, Pirson FAV, Pinckaers FME, Hinsenveld WH, Nieboer D, Ceulemans A, Knapen RRMM, Robbe MMQ, Berkhemer OA, van Walderveen MAA, Lycklama À Nijeholt GJ, Uyttenboogaart M, Schonewille WJ, van der Sluijs PM, Wolff L, van Voorst H, Postma AA, Roosendaal SD, van der Hoorn A, Emmer BJ, Krietemeijer MGM, van Doormaal PJ, Roozenbeek B, Goldhoorn RJB, Staals J, de Ridder IR, van der Leij C, Coutinho JM, van der Worp HB, Lo RTH, Bokkers RPH, van Dijk EI, Boogaarts HD, Wermer MJH, van Es ACGM, van Tuijl JH, Kortman HGJ, Gons RAR, Yo LSF, Vos JA, de Laat KF, van Dijk LC, van den Wijngaard IR, Hofmeijer J, Martens JM, Brouwers PJAM, Bulut T, Remmers MJM, de Jong TEAM, den Hertog HM, van Hasselt BAAM, Rozeman AD, Elgersma OEH, van der Veen B, Sudiono DR, Lingsma HF, Roos YBWEM, Majoie CBLM, van der Lugt A, Dippel DWJ, van Zwam WH, van Oostenbrugge RJ. Endovascular treatment versus no endovascular treatment after 6-24 h in patients with ischaemic stroke and collateral flow on CT angiography (MR CLEAN-LATE) in the Netherlands: a multicentre, open-label, blinded-endpoint, randomised, controlled, phase 3 trial. Lancet 2023; 401:1371-1380. [PMID: 37003289 DOI: 10.1016/s0140-6736(23)00575-5] [Citation(s) in RCA: 58] [Impact Index Per Article: 58.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/02/2023] [Revised: 03/11/2023] [Accepted: 03/14/2023] [Indexed: 04/03/2023]
Abstract
BACKGROUND Endovascular treatment for anterior circulation ischaemic stroke is effective and safe within a 6 h window. MR CLEAN-LATE aimed to assess efficacy and safety of endovascular treatment for patients treated in the late window (6-24 h from symptom onset or last seen well) selected on the basis of the presence of collateral flow on CT angiography (CTA). METHODS MR CLEAN-LATE was a multicentre, open-label, blinded-endpoint, randomised, controlled, phase 3 trial done in 18 stroke intervention centres in the Netherlands. Patients aged 18 years or older with ischaemic stroke, presenting in the late window with an anterior circulation large-vessel occlusion and collateral flow on CTA, and a neurological deficit score of at least 2 on the National Institutes of Health Stroke Scale were included. Patients who were eligible for late-window endovascular treatment were treated according to national guidelines (based on clinical and perfusion imaging criteria derived from the DAWN and DEFUSE-3 trials) and excluded from MR CLEAN-LATE enrolment. Patients were randomly assigned (1:1) to receive endovascular treatment or no endovascular treatment (control), in addition to best medical treatment. Randomisation was web based, with block sizes ranging from eight to 20, and stratified by centre. The primary outcome was the modified Rankin Scale (mRS) score at 90 days after randomisation. Safety outcomes included all-cause mortality at 90 days after randomisation and symptomatic intracranial haemorrhage. All randomly assigned patients who provided deferred consent or died before consent could be obtained comprised the modified intention-to-treat population, in which the primary and safety outcomes were assessed. Analyses were adjusted for predefined confounders. Treatment effect was estimated with ordinal logistic regression and reported as an adjusted common odds ratio (OR) with a 95% CI. This trial was registered with the ISRCTN, ISRCTN19922220. FINDINGS Between Feb 2, 2018, and Jan 27, 2022, 535 patients were randomly assigned, and 502 (94%) patients provided deferred consent or died before consent was obtained (255 in the endovascular treatment group and 247 in the control group; 261 [52%] females). The median mRS score at 90 days was lower in the endovascular treatment group than in the control group (3 [IQR 2-5] vs 4 [2-6]), and we observed a shift towards better outcomes on the mRS for the endovascular treatment group (adjusted common OR 1·67 [95% CI 1·20-2·32]). All-cause mortality did not differ significantly between groups (62 [24%] of 255 patients vs 74 [30%] of 247 patients; adjusted OR 0·72 [95% CI 0·44-1·18]). Symptomatic intracranial haemorrhage occurred more often in the endovascular treatment group than in the control group (17 [7%] vs four [2%]; adjusted OR 4·59 [95% CI 1·49-14·10]). INTERPRETATION In this study, endovascular treatment was efficacious and safe for patients with ischaemic stroke caused by an anterior circulation large-vessel occlusion who presented 6-24 h from onset or last seen well, and who were selected on the basis of the presence of collateral flow on CTA. Selection of patients for endovascular treatment in the late window could be primarily based on the presence of collateral flow. FUNDING Collaboration for New Treatments of Acute Stroke consortium, Dutch Heart Foundation, Stryker, Medtronic, Cerenovus, Top Sector Life Sciences & Health, and the Netherlands Brain Foundation.
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Affiliation(s)
- Susanne G H Olthuis
- Department of Neurology, Maastricht University Medical Center+, Maastricht, Netherlands; School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands.
| | - F Anne V Pirson
- Department of Neurology, Maastricht University Medical Center+, Maastricht, Netherlands; School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
| | - Florentina M E Pinckaers
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, Netherlands; School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
| | - Wouter H Hinsenveld
- Department of Neurology, Maastricht University Medical Center+, Maastricht, Netherlands; School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
| | - Daan Nieboer
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Angelique Ceulemans
- Department of Neurology, Maastricht University Medical Center+, Maastricht, Netherlands; School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
| | - Robrecht R M M Knapen
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, Netherlands; School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
| | - M M Quirien Robbe
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, Netherlands; School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
| | - Olvert A Berkhemer
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands; Department of Radiology and Nuclear Medicine, Amsterdam Neurosciences, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
| | | | | | - Maarten Uyttenboogaart
- Department of Neurology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands; Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | | | - P Matthijs van der Sluijs
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Lennard Wolff
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Henk van Voorst
- Department of Radiology and Nuclear Medicine, Amsterdam Neurosciences, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands; Department of Biomedical Engineering and Physics, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
| | - Alida A Postma
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, Netherlands; School for Mental Health and Neuroscience (MHeNs), Maastricht University, Maastricht, Netherlands
| | - Stefan D Roosendaal
- Department of Radiology and Nuclear Medicine, Amsterdam Neurosciences, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
| | - Anouk van der Hoorn
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Bart J Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam Neurosciences, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
| | | | - Pieter-Jan van Doormaal
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Bob Roozenbeek
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Robert-Jan B Goldhoorn
- Department of Neurology, Maastricht University Medical Center+, Maastricht, Netherlands; School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
| | - Julie Staals
- Department of Neurology, Maastricht University Medical Center+, Maastricht, Netherlands; School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
| | - Inger R de Ridder
- Department of Neurology, Maastricht University Medical Center+, Maastricht, Netherlands; School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
| | - Christiaan van der Leij
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, Netherlands
| | - Jonathan M Coutinho
- Department of Neurology, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
| | - H Bart van der Worp
- Department of Neurology and Neurosurgery, Brain Center, University Medical Center Utrecht, Utrecht, Netherlands
| | - Rob T H Lo
- Department of Radiology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Reinoud P H Bokkers
- Department of Radiology, University Medical Center Groningen, University of Groningen, Groningen, Netherlands
| | - Ewoud I van Dijk
- Department of Neurology, Radboud University Medical Center, Nijmegen, Netherlands
| | | | - Marieke J H Wermer
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands
| | | | - Julia H van Tuijl
- Department of Neurology, Elisabeth-TweeSteden Hospital, Tilburg, Netherlands
| | - Hans G J Kortman
- Department of Radiology, Elisabeth-TweeSteden Hospital, Tilburg, Netherlands
| | - Rob A R Gons
- Department of Neurology, Catharina Hospital, Eindhoven, Netherlands
| | - Lonneke S F Yo
- Department of Radiology, Catharina Hospital, Eindhoven, Netherlands
| | - Jan-Albert Vos
- Department of Radiology, Sint Antonius Hospital, Nieuwegein, Netherlands
| | | | | | - Ido R van den Wijngaard
- Department of Neurology, Leiden University Medical Center, Leiden, Netherlands; Department of Neurology, Haaglanden Medical Center, The Hague, Netherlands
| | - Jeannette Hofmeijer
- Department of Neurology, Rijnstate Hospital, Arnhem, Netherlands; Department of Clinical Neurophysiology, University of Twente, Enschede, Netherlands
| | - Jasper M Martens
- Department of Radiology and Nuclear Medicine, Rijnstate Hospital, Arnhem, Netherlands
| | | | - Tomas Bulut
- Department of Radiology, Medisch Spectrum Twente, Enschede, Netherlands
| | | | | | | | | | - Anouk D Rozeman
- Department of Neurology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Otto E H Elgersma
- Department of Radiology, Albert Schweitzer Hospital, Dordrecht, Netherlands
| | - Bas van der Veen
- Department of Neurology, Noordwest ziekenhuisgroep, Alkmaar, Netherlands
| | - Davy R Sudiono
- Department of Radiology, Noordwest ziekenhuisgroep, Alkmaar, Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Yvo B W E M Roos
- Department of Neurology, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
| | - Charles B L M Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam Neurosciences, Amsterdam UMC location University of Amsterdam, Amsterdam, Netherlands
| | - Aad van der Lugt
- Department of Radiology and Nuclear Medicine, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Diederik W J Dippel
- Department of Neurology, Erasmus MC, University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center+, Maastricht, Netherlands; School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
| | - Robert J van Oostenbrugge
- Department of Neurology, Maastricht University Medical Center+, Maastricht, Netherlands; School for Cardiovascular Diseases, Maastricht University, Maastricht, Netherlands
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Pandhi A, Chandra R, Abdulrazzak MA, Alrohimi A, Mahapatra A, Bain M, Moore N, Hussain MS, Bullen J, Toth G. Mechanical thrombectomy for acute large vessel occlusion stroke beyond 24 h. J Neurol Sci 2023; 447:120594. [PMID: 36893513 DOI: 10.1016/j.jns.2023.120594] [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: 10/04/2022] [Revised: 01/20/2023] [Accepted: 02/22/2023] [Indexed: 03/06/2023]
Abstract
BACKGROUND Multiple trials have shown that mechanical thrombectomy (MT) is superior to medical therapy. However, no robust evidence is available regarding MT beyond 24 h. In this study, we aimed to determine the safety and efficacy of endovascular stroke therapy in this late window. METHODS We conducted a retrospective study of prospectively collected data of patients who met extended window trial criteria, but underwent MT beyond 24 h. Safety and efficacy outcomes included symptomatic intracerebral hemorrhage (sICH), procedural complications, number of passes, successful recanalization (mTICI 2b - 3), delta (Δ) NIHSS (baseline-discharge), and favorable outcomes (mRS 0-2 at 90 days). RESULTS A total of 39 patients were included with a median age of 69 years (IQR 61.5, 73.5); 54% were females. Hypertension was present in 76% of patients; 23% were smokers. Half of the patients had M1 occlusion (48.7%). Median preprocedural NIHSS was 11 (IQR 7.0, 19.5). Successful revascularization was achieved in 87%; median number of passes was 2 (IQR 1.0, 3.0). Median ΔNIHSS was 3.0 (IQR -1.5, 8.0). Favorable outcome was achieved in 49% (95% CI: 34%-64%), and 95% were free of complications. A total of 3 patients (7.7%) had sICH. In an exploratory analysis, posterior circulation occlusion was associated with higher mRS at 90 days (OR: 14.7, p = 0.016). Favorable discharge facility was associated with lower mRS at 90 days (OR: 0.11, p = 0.004). CONCLUSIONS Our study showed comparable clinical outcomes of MT beyond 24 h compared to MT trials within 24 h in patients with favorable imaging profile, especially in anterior circulation occlusions.
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Affiliation(s)
- Abhi Pandhi
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Rahul Chandra
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | | | - Anas Alrohimi
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Ashutosh Mahapatra
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Mark Bain
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Nina Moore
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - M Shazam Hussain
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Jennifer Bullen
- Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Gabor Toth
- Cerebrovascular Center, Neurological Institute, Cleveland Clinic, Cleveland, OH, USA.
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39
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Ischemic Lesion Growth in Patients with a Persistent Target Mismatch After Large Vessel Occlusion. Clin Neuroradiol 2023; 33:41-48. [PMID: 35789284 PMCID: PMC10014761 DOI: 10.1007/s00062-022-01180-z] [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: 02/23/2022] [Accepted: 05/11/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Failure to reperfuse a cerebral occlusion resulting in a persistent penumbral pattern has not been fully described. METHODS We retrospectively reviewed patients with anterior large vessel occlusion who did not receive reperfusion, and underwent repeated perfusion imaging, with baseline imaging < 6 h after onset and follow-up scans from 16-168 h. A persistent target mismatch (PTM) was defined as core volume of < 100 mL, mismatch ratio > 1.2, and mismatch volume > 10 mL on follow-up imaging. Patients were divided into PTM or non-PTM groups. Ischemic core and penumbral volumes were compared between baseline and follow-up imaging between the two groups, and collateral flow status assessed using CT perfusion collateral index. RESULTS A total of 25 patients (14 PTM and 11 non-PTM) were enrolled in the study. Median core volumes increased slightly in the PTM group, from 22 to 36 ml. There was a much greater increase in the non-PTM group, from 57 to 190 ml. Penumbral volumes were stable in the PTM group from a median of 79 ml at baseline to 88 ml at follow-up, whereas penumbra was reduced in the non-PTM group, from 120 to 0 ml. Collateral flow status was also better in the PTM group and the median collateral index was 33% compared with 44% in the non-PTM group (p = 0.043). CONCLUSION Multiple patients were identified with limited core growth and large penumbra (persistent target mismatch) > 16 h after stroke onset, likely due to more favorable collateral flow.
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40
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How to Define Fast and Slow Progressors in Any-Type Occlusion Acute Ischemic Stroke. Can J Neurol Sci 2023; 50:268-273. [PMID: 35272725 DOI: 10.1017/cjn.2022.9] [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: 11/07/2022]
Abstract
The variable rate of infarct progression in acute ischemic stroke as assessed by various thresholds excludes a substantial proportion of patients due to time or core constraints. We evaluated 106 patients with any-type occlusion to compare these thresholds and assessed performance of hypoperfusion index (HI) for fast and slow rate of infarct progression. Seven (12.5%) were classified fast progressors and 23 (46%), 25 (50%), 12 (24%), and 33 (66%) slow progressors using different core and time criteria. In comparison, HI categorized 100% (n = 106) of cohort with optimal cutoff 0.5 for any-type occlusion (slow progressors: HI ≤ 0.5), sensitivity/specificity 100%/91%, AUC 0.94, and indicative of eligibility for reperfusion and clinical outcomes (median 90-day modified Rankin Scale; 2 for HI ≤ 0.5 versus 5). Estimation of progressors by HI seems comprehensive but needs external validation.
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41
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Asdaghi N, Wang K, Gardener H, Jameson A, Rose DZ, Alkhachroum A, Gutierrez CM, Hao Y, Mueller-Kronast N, Sur NB, Dong C, Perue GG, LePain M, Koch S, Krementz N, Marulanda-Londoño E, Hanel R, Mehta B, Yavagal DR, Rundek T, Sacco RL, Romano JG. Impact of Time to Treatment on Endovascular Thrombectomy Outcomes in the Early Versus Late Treatment Time Windows. Stroke 2023; 54:733-742. [PMID: 36848428 PMCID: PMC9991076 DOI: 10.1161/strokeaha.122.040352] [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: 06/15/2022] [Accepted: 12/09/2022] [Indexed: 03/01/2023]
Abstract
BACKGROUND The impact of time to treatment on outcomes of endovascular thrombectomy (EVT) especially in patients presenting after 6 hours from symptom onset is not well characterized. We studied the differences in characteristics and treatment timelines of EVT-treated patients participating in the Florida Stroke Registry and aimed to characterize the extent to which time impacts EVT outcomes in the early and late time windows. METHODS Prospectively collected data from Get With the Guidelines-Stroke hospitals participating in the Florida Stroke Registry from January 2010 to April 2020 were reviewed. Participants were EVT patients with onset-to-puncture time (OTP) of ≤24 hours and categorized into early window treated (OTP ≤6 hours) and late window treated (OTP >6 and ≤24 hours). Association between OTP and favorable discharge outcomes (independent ambulation, discharge home and to acute rehabilitation facility) as well as symptomatic intracerebral hemorrhage and in-hospital mortality were examined using multilevel-multivariable analysis with generalized estimating equations. RESULTS Among 8002 EVT patients (50.9% women; median age [±SD], 71.5 [±14.5] years; 61.7% White, 17.5% Black, and 21% Hispanic), 34.2% were treated in the late time window. Among all EVT patients, 32.4% were discharged home, 23.5% to rehabilitation facility, 33.7% ambulated independently at discharge, 5.1% had symptomatic intracerebral hemorrhage, and 9.2% died. As compared with the early window, treatment in the late window was associated with lower odds of independent ambulation (odds ratio [OR], 0.78 [0.67-0.90]) and discharge home (OR, 0.71 [0.63-0.80]). For every 60-minute increase in OTP, the odds of independent ambulation reduced by 8% (OR, 0.92 [0.87-0.97]; P<0.001) and 1% (OR, 0.99 [0.97-1.02]; P=0.5) and the odds of discharged home reduced by 10% (OR, 0.90 [0.87-0.93]; P<0.001) and 2% (OR, 0.98 [0.97-1.00]; P=0.11) in the early and late windows, respectively. CONCLUSIONS In routine practice, just over one-third of EVT-treated patients independently ambulate at discharge and only half are discharged to home/rehabilitation facility. Increased time from symptom onset to treatment is significantly associated with lower chance of independent ambulation and ability to be discharged home after EVT in the early time window.
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Affiliation(s)
- Negar Asdaghi
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL
| | - Kefeng Wang
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL
| | - Hannah Gardener
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL
| | - Angus Jameson
- University of South Florida Morsani College of Medicine, Tampa FL
| | - David Z Rose
- University of South Florida Morsani College of Medicine, Tampa FL
| | - Ayham Alkhachroum
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL
| | - Carolina M. Gutierrez
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL
| | - Ying Hao
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL
| | | | - Nicole B Sur
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL
| | - Chuanhui Dong
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL
| | - Gillian Gordon Perue
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL
| | - Marissa LePain
- Morton Plant Mease Hospitals, BayCare Health System West Region, FL
| | - Sebastian Koch
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL
| | - Nastajjia Krementz
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL
| | | | | | | | - Dileep R Yavagal
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL
| | - Tatjana Rundek
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL
| | - Ralph L. Sacco
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL
| | - Jose G. Romano
- Department of Neurology, Leonard M. Miller School of Medicine, University of Miami, FL
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42
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Nie X, Leng X, Miao Z, Fisher M, Liu L. Clinically Ineffective Reperfusion After Endovascular Therapy in Acute Ischemic Stroke. Stroke 2023; 54:873-881. [PMID: 36475464 DOI: 10.1161/strokeaha.122.038466] [Citation(s) in RCA: 37] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Endovascular treatment is a highly effective therapy for acute ischemic stroke due to large vessel occlusion. However, in clinical practice, nearly half of the patients do not have favorable outcomes despite successful recanalization of the occluded artery. This unfavorable outcome can be defined as having clinically ineffective reperfusion. The objective of the review is to describe clinically ineffective reperfusion after endovascular therapy and its underlying risk factors and mechanisms, including initial tissue damage, cerebral edema, the no-reflow phenomenon, reperfusion injury, procedural features, and variations in postprocedural management. Further research is needed to more accurately identify patients at a high risk of clinically ineffective reperfusion after endovascular therapy and to improve individualized periprocedural management strategies, to increase the chance of achieving favorable clinical outcomes.
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Affiliation(s)
- Ximing Nie
- Department of Neurology (X.N., L.L.), Beijing Tiantan Hospital, Capital Medical University, China.,China National Clinical Research Center for Neurological Diseases, Beijing (X.N., L.L.)
| | - Xinyi Leng
- Department of Medicine and Therapeutics, Prince of Wales Hospital, Chinese University of Hong Kong, SAR (X.L.)
| | - Zhongrong Miao
- Department of Interventional Neuroradiology (Z.M.), Beijing Tiantan Hospital, Capital Medical University, China
| | - Marc Fisher
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA (M.F.)
| | - Liping Liu
- Department of Neurology (X.N., L.L.), Beijing Tiantan Hospital, Capital Medical University, China.,China National Clinical Research Center for Neurological Diseases, Beijing (X.N., L.L.)
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43
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Tiberti G. Cerebral Embolic Protection during TAVR. N Engl J Med 2023; 388:668-669. [PMID: 36791172 DOI: 10.1056/nejmc2215783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/17/2023]
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44
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Kerleroux B, Agripnidis T, Frandon J, Hak JF. Validation of mechanical thrombectomy for patients with Basilar-Artery occlusion. Anaesth Crit Care Pain Med 2023; 42:101185. [PMID: 36509388 DOI: 10.1016/j.accpm.2022.101185] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/06/2022] [Accepted: 12/06/2022] [Indexed: 12/14/2022]
Affiliation(s)
- Basile Kerleroux
- Department of Neuroradiology, APHM La Timone, Marseille, France; Department of Radiology, Centre Hospitalier de Bastia, Bastia, France.
| | - Thibault Agripnidis
- Department of Neuroradiology, APHM La Timone, Marseille, France; LiiE, Aix Marseille University, Marseille, France; CERIMED, Aix Marseille University, 27 Bd Jean Moulin, 13005, Marseille, France
| | - Julien Frandon
- IMAGINE UR UM 103, University of Montpellier, Department of Medical Imaging, Nîmes University Hospital, Nîmes, France
| | - Jean-François Hak
- Department of Neuroradiology, APHM La Timone, Marseille, France; LiiE, Aix Marseille University, Marseille, France; CERIMED, Aix Marseille University, 27 Bd Jean Moulin, 13005, Marseille, France
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45
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Yi T, Zhang Y, Chen WH, Wu YM, Lin DL, Lin XH, Zhang L, Xing PF, Li T, Zhang Y, Wang S, Yang P, Cai MZ, Liu J. Impact of leukoaraiosis in patients with acute ischemic stroke treated with thrombectomy: a post hoc analysis of the DIRECT-MT trial. J Neurointerv Surg 2023; 15:139-145. [PMID: 35101958 DOI: 10.1136/neurintsurg-2021-018293] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2021] [Accepted: 01/09/2022] [Indexed: 01/14/2023]
Abstract
BACKGROUND The influence of leukoaraiosis in patients with acute ischemic stroke (AIS) given intra-arterial treatment (IAT) with or without preceding intravenous thrombolysis (IVT) remains unknown. OBJECTIVE To assess the clinical and radiological outcomes of IAT in patients with or without leukoaraiosis. METHODS Patients of the direct mechanical thrombectomy trial (DIRECT-MT) whose leukoaraiosis grade could be assessed were included. DIRECT-MT was a randomized clinical trial performed in China to assess the effect of direct IAT compared with intravenous thrombolysis plus IAT. We employed the Age-Related White Matter Changes Scale for grading leukoaraiosis (ARWMC, 0 indicates no leukoaraiosis, 1-2 indicates mild-to-moderate leukoaraiosis, and 3 indicates severe leukoaraiosis) based on brain CT. The primary outcome was the score on the modified Rankin Scale (mRS) assessed at 90 days. RESULTS There were 656 patients in the trial, 649 patients who were included, with 432 patients without leukoaraiosis, and 217 (33.4%) patients with leukoaraiosis divided into mild-to-moderate (n=139) and severe groups (n=78). Leukoaraiosis was a predictor of a worse mRS score (adjusted OR (aOR)=0.7 (95% CI 0.5 to 0.8)) and higher mortality (aOR=1.4 (1.1 to 1.9)), but it was not associated with symptomatic intracranial hemorrhage (sICH) (aOR=0.9 (0.5 to 1.5)). IVT preceding IAT did not increase sICH risk for patients with no (aOR=1.4 (0.6 to 3.4)), mild-to-moderate (aOR=1.5 (0.3 to 7.8)), or severe (aOR=1.5 (0.1 to 21.3)) leukoaraiosis. CONCLUSION Patients with leukoaraiosis with AIS due to large vessel occlusion are at increased risk of a poor functional outcome after IAT but demonstrate similar sICH rates, and IVT preceding IAT does not increase the risk of sICH in Chinese patients with leukoaraiosis.
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Affiliation(s)
- Tingyu Yi
- Department of Neurology, Zhangzhou Municipal Hospital of Fujian Province and Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Yongxin Zhang
- Department of Cerebralvascular Disease Center, Changhai Hospital, Shanghai, China
| | - Wen-Huo Chen
- Department of Neurology, Zhangzhou Municipal Hospital of Fujian Province and Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Yan-Min Wu
- Department of Neurology, Zhangzhou Municipal Hospital of Fujian Province and Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Ding-Lai Lin
- Department of Neurology, Zhangzhou Municipal Hospital of Fujian Province and Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Xiao-Hui Lin
- Department of Neurology, Zhangzhou Municipal Hospital of Fujian Province and Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, China
| | - Lei Zhang
- Department of Cerebralvascular Disease Center, Changhai Hospital, Shanghai, China
| | - Peng-Fei Xing
- Department of Cerebralvascular Disease Center, Changhai Hospital, Shanghai, China
| | - Tianxiao Li
- Department of Cerebralvascular Disease Center, Henan Provincial People's Hospital, Zhengzhou, Henan, China
| | - Yongwei Zhang
- Department of Cerebralvascular Disease Center, Changhai Hospital, Shanghai, China
| | - Shouchun Wang
- Department of Neurology and Neuroscience Center, Jilin University First Hospital, Changchun, Jilin, China
| | - Pengfei Yang
- Department of Cerebralvascular Disease Center, Changhai Hospital, Shanghai, China
| | - Ming-Zhi Cai
- Department of Vascular Surgery, Zhangzhou Municipal Hospital of Fujian Province and Zhangzhou Affiliated Hospital of Fujian Medical University, Zhangzhou, Fujian, China
| | - Jianmin Liu
- Department of Cerebralvascular Disease Center, Changhai Hospital, Shanghai, China
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46
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Maïer B, Finitsis S, Mazighi M, Lapergue B, Marnat G, Sibon I, Richard S, Viguier A, Cognard C, Gory B, Olivot JM. The Benefit of a Complete over a Successful Reperfusion Decreases with Time. Ann Neurol 2023; 93:934-941. [PMID: 36640043 DOI: 10.1002/ana.26599] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 01/05/2023] [Indexed: 01/15/2023]
Abstract
OBJECTIVE Time from stroke onset to reperfusion (TSOR) is strongly associated with outcomes after endovascular treatment. A near-to-complete or complete reperfusion (modified Treatment in Cerebral Ischemia [mTICI] 2c-3) is associated with improved outcomes compared with a successful reperfusion (mTICI 2b). However, it is unknown whether this association remains stable as TSOR increases. Therefore, we sought to investigate the association between TSOR and outcomes according to the reperfusion status. METHODS We analyzed data from the Endovascular Treatment in Ischemic Stroke registry, a prospective, observational, multicentric study of acute ischemic stroke patients treated with endovascular treatment in 21 centers in France. We included patients with anterior occlusions (M1, internal carotid artery, tandem), with a known time of symptom onset. Outcomes were early neurological improvement at 24 hours and favorable outcome (modified Rankin Scale between 0 and 2) at 90 days. RESULTS Overall, 4,444 patients were analyzed. Compared with a mTICI 2b, a mTICI 2c-3 at 1 hour was associated with higher mean marginal probabilities of early neurological improvement (25.6%, 95% CI 11.7-39.5, p = 0.0003) and favorable outcome (15.2%, 95% CI 3.0-27.4, p = 0.0143), and progressively declined with TSOR. The benefit of a mTICI 2c-3 over a mTICI 2b was no longer significant regarding the rates of early neurological improvement and favorable outcome after a TSOR of 414 and 344 minutes, respectively. INTERPRETATION The prognostic value of a complete over a successful reperfusion progressively declined with time, and no difference regarding the rates of favorable outcome was observed between a complete and successful reperfusion beyond 5.7 hours. ANN NEUROL 2023.
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Affiliation(s)
- Benjamin Maïer
- Neurology Department, Hôpital Saint-Joseph, Paris, France.,Interventional Neuroradiology Department, Hôpital Fondation A. de Rothschild, Paris, France.,Université Paris-Cité, Paris, France.,Université Paris-Cité and Université Sorbonne Paris Nord, INSERM U1148, LVTS, Paris, France
| | - Stephanos Finitsis
- Aristotle University of Thessaloniki, Ahepa Hospital, Thessaoniki, Greece
| | - Mikael Mazighi
- Neurology Department, Hôpital Saint-Joseph, Paris, France.,Université Paris-Cité, Paris, France.,Université Paris-Cité and Université Sorbonne Paris Nord, INSERM U1148, LVTS, Paris, France.,Neurology Department, Hôpital Lariboisière, Paris, France
| | - Bertrand Lapergue
- Department of Neurology, Foch Hospital, Versailles Saint-Quentin en Yvelines University, Suresnes, France
| | - Gaultier Marnat
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Bordeaux, Bordeaux, France
| | - Igor Sibon
- Neurology Department, University Hospital of Bordeaux, Bordeaux, France
| | - Sebastien Richard
- Department of Neurology, Stroke Unit, Université de Lorraine, Nancy, France.,CIC-P 1433, INSERM U1116, CHRU-Nancy, Nancy, France
| | - Alain Viguier
- Vascular Neurology Department, University Hospital of Toulouse, Toulouse, France
| | | | - Benjamin Gory
- Department of Diagnostic and Therapeutic Neuroradiology, Université de Lorraine, CHRU-Nancy, Nancy, France.,Université de Lorraine, INSERM 1254, IADI, Nancy, France
| | - Jean-Marc Olivot
- Vascular Neurology Department, University Hospital of Toulouse, Toulouse, France
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Scutelnic A, Bracher J, Kreis LA, Beyeler M, Fischer U, Arnold M, Mattle HP, Jung S, Schankin CJ. Symptoms and patterns of symptom propagation in incipient ischemic stroke and migraine aura. Front Hum Neurosci 2023; 16:1077737. [PMID: 36741781 PMCID: PMC9896624 DOI: 10.3389/fnhum.2022.1077737] [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: 10/23/2022] [Accepted: 12/30/2022] [Indexed: 01/14/2023] Open
Abstract
Background and objectives Taking a detailed history of symptoms is important for differentiating incipient ischemic stroke and migraine aura. The aim of our study is to describe in detail symptom type and temporal pattern of symptom evolution (i.e., symptom succession and the time lapse between symptoms) and to identify differentiating clinical features in patients with ischemic stroke and migraine with aura. Methods Consecutive patients with ischemic stroke and migraine with aura were interviewed using a structured questionnaire. Stroke diagnosis was confirmed by imaging and migraine with aura was diagnosed according to the current criteria of the International Headache Society. Wake-up strokes and patients with severe cognitive deficits were excluded. Results In stroke patients and migraine patients, respectively, 50/78 (64%) vs. 123/326 (37%) had one, 18 (23%) vs. 127 (38%) had two, 5 (6%) vs. 69 (21%) had three, 2 (2%) vs. 4 (1%) had four, and 3 (3%) vs. 3 (1%) had five visual symptoms. In respect of sensory symptoms, 76/145 (52.4%) vs. 116/175 (66%) reported paresthesia and 92/145 (63.4%) vs. 132 (75%) numbness. Looking at the beginning, visual symptoms were the first symptom more often in migraine aura than in ischemic stroke (72.1 vs 18.8%, P < 0.001; PPV 86.8%). Sensory (29 vs 13.9%, P = 0.001; PPV 54.8%) and motor symptoms (20.5 vs 1.4%, P < 0.001; PPV 88.9%) were the first symptom more frequently in ischemic stroke. Of patients with consecutive symptoms, 39 of 201 (19%) compared to 34 of 117 (29%) (P = 0.02; PPV 46.6%) reported at least two simultaneous symptoms. A time lapse between symptoms of < 1 min (18.6 vs 6.3%, P < 0.001; PPV 57.1%) and > 360 min (15.8 vs 0%, χ2 = 39.61, P < 0.001; PPV 100%) was more frequent in stroke whereas a time lapse between 5 and 60 min was more frequent in migraine aura (41.1 vs 68.7%, χ2 = 23.52, P < 0.001; PPV 78.7%). Conclusion There is a significant overlap in the clinical presentation of stroke and migraine aura. In particular, a substantial proportion of patients in one group had symptoms that are traditionally attributed to the other group. This study highlights the similarities and differences between symptoms of ischemic stroke and migraine aura and challenges our reasoning in daily clinical practice.
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Affiliation(s)
- Adrian Scutelnic
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland,*Correspondence: Adrian Scutelnic,
| | - Jacqueline Bracher
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Lukas A. Kreis
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Morin Beyeler
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Urs Fischer
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland,Department of Neurology and Stroke Centre, University Hospital Basel and University of Basel, Basel, Switzerland
| | - Marcel Arnold
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Heinrich P. Mattle
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Simon Jung
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
| | - Christoph J. Schankin
- Department of Neurology, Inselspital, Bern University Hospital, University of Bern, Bern, Switzerland
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van der Zijden T, Mondelaers A, Loos C, Voormolen M, Franck C, Niekel M, Jardinet T, Van Thielen T, d'Archambeau O, Menovsky T, Parizel PM. Can angiographic Flat Detector Computed Tomography blood volume measurement be used to predict final infarct size in acute ischemic stroke? Eur J Radiol 2023; 158:110650. [PMID: 36549171 DOI: 10.1016/j.ejrad.2022.110650] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 10/30/2022] [Accepted: 12/10/2022] [Indexed: 12/15/2022]
Abstract
INTRODUCTION AND PURPOSE Flat detector computed tomography (FD-CT) technology is becoming more widely available in the angiography suites of comprehensive stroke centers. In patients with acute ischemic stroke (AIS), who are referred for endovascular therapy (EVT), FD-CT generates cerebral pooled blood volume (PBV) maps, which might help in predicting the final infarct area. We retrospectively analyzed pre- and post-recanalization therapy quantitative PBV measurements in both the infarcted and hypoperfused brain areas of AIS patients referred for EVT. MATERIALS AND METHODS We included AIS patients with large vessel occlusion in the anterior circulation referred for EVT from primary stroke centers to our comprehensive stroke center. The pre- and post-recanalization FD-CT regional relative PBV (rPBV) values were measured between ipsilateral lesional and contralateral non-lesional areas based on final infarct area on post EVT follow-up cross-sectional imaging. Statistical analysis was performed to identify differences in PBV values between infarcted and non-infarcted, recanalized brain areas. RESULTS We included 20 AIS patients. Mean age was 63 years (ranging from 36 to 86 years). The mean pre- EVT rPBV value was 0.57 (±0.40) for infarcted areas and 0.75 (±0.43) for hypoperfusion areas. The mean differences (Δ) between pre- and post-EVT rPBV values for infarcted and hypoperfused areas were respectively 0.69 (±0.59) and 0.69 (±0.90). We found no significant differences (p > 0.05) between pre-EVT rPBV and ΔrPBV values of infarct areas and hypoperfusion areas. CONCLUSION Angiographic PBV mapping is useful for the detection of cerebral perfusion deficits, especially in combination with the fill run images. However, we were not able to distinguish irreversibly infarcted tissue from potentially salvageable, hypoperfused brain tissue based on quantitative PBV measurement in AIS patients.
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Affiliation(s)
- Thijs van der Zijden
- Department of Radiology, Antwerp University Hospital (UZA), 2650 Edegem, Belgium; Department of Medical Imaging, AZ KLINA, 2930 Brasschaat, Belgium.
| | - Annelies Mondelaers
- Department of Radiology, Antwerp University Hospital (UZA), 2650 Edegem, Belgium; Research Group mVision, Faculty of Medicine and Health Sciences, University of Antwerp (UA), 2610 Wilrijk, Belgium
| | - Caroline Loos
- Department of Neurology, Antwerp University Hospital (UZA), 2650 Edegem, Belgium; Research Group Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, (UA), 2610 Wilrijk, Belgium
| | - Maurits Voormolen
- Department of Radiology, Antwerp University Hospital (UZA), 2650 Edegem, Belgium; Research Group mVision, Faculty of Medicine and Health Sciences, University of Antwerp (UA), 2610 Wilrijk, Belgium
| | - Caro Franck
- Department of Radiology, Antwerp University Hospital (UZA), 2650 Edegem, Belgium; Research Group mVision, Faculty of Medicine and Health Sciences, University of Antwerp (UA), 2610 Wilrijk, Belgium
| | - Maarten Niekel
- Department of Radiology, Antwerp University Hospital (UZA), 2650 Edegem, Belgium
| | - Thomas Jardinet
- Department of Radiology, Antwerp University Hospital (UZA), 2650 Edegem, Belgium
| | - Thomas Van Thielen
- Department of Radiology, Antwerp University Hospital (UZA), 2650 Edegem, Belgium; Department of Medical Imaging, AZ KLINA, 2930 Brasschaat, Belgium
| | - Olivier d'Archambeau
- Department of Radiology, Antwerp University Hospital (UZA), 2650 Edegem, Belgium
| | - Tomas Menovsky
- Research Group Translational Neurosciences, Faculty of Medicine and Health Sciences, University of Antwerp, (UA), 2610 Wilrijk, Belgium; Department of Neurosurgery, Antwerp University Hospital (UZA), 2650 Edegem, Belgium
| | - Paul M Parizel
- Research Group mVision, Faculty of Medicine and Health Sciences, University of Antwerp (UA), 2610 Wilrijk, Belgium; Department of Radiology, Royal Perth Hospital and University of Western Australia Medical School, Perth, WA, Australia; Director, Western Australia National Imaging Facility (WA NIF) Node, Perth, WA, Australia
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Abdalkader M, Siegler JE, Lee JS, Yaghi S, Qiu Z, Huo X, Miao Z, Campbell BC, Nguyen TN. Neuroimaging of Acute Ischemic Stroke: Multimodal Imaging Approach for Acute Endovascular Therapy. J Stroke 2023; 25:55-71. [PMID: 36746380 PMCID: PMC9911849 DOI: 10.5853/jos.2022.03286] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2022] [Accepted: 01/04/2023] [Indexed: 02/04/2023] Open
Abstract
Advances in acute ischemic stroke (AIS) treatment have been contingent on innovations in neuroimaging. Neuroimaging plays a pivotal role in the diagnosis and prognosis of ischemic stroke and large vessel occlusion, enabling triage decisions in the emergent care of the stroke patient. Current imaging protocols for acute stroke are dependent on the available resources and clinicians' preferences and experiences. In addition, differential application of neuroimaging in medical decision-making, and the rapidly growing evidence to support varying paradigms have outpaced guideline-based recommendations for selecting patients to receive intravenous or endovascular treatment. In this review, we aimed to discuss the various imaging modalities and approaches used in the diagnosis and treatment of AIS.
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Affiliation(s)
- Mohamad Abdalkader
- Department of Radiology, Boston Medical Center, Boston, MA, USA,Correspondence: Mohamad Abdalkader Department of Radiology, Boston Medical Center, One Boston Medical Center Place, Boston, MA 02118, USA Tel: +1-617-614-4272 E-mail:
| | - James E. Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
| | - Jin Soo Lee
- Department of Neurology, Ajou University Hospital, Ajou University School of Medicine, Suwon, Korea
| | - Shadi Yaghi
- Department of Neurology, Brown University, Providence, RI, USA
| | - Zhongming Qiu
- Department of Neurology, The 903rd Hospital of The Chinese People’s Liberation Army, Hangzhou, China
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Bruce C.V. Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Thanh N. Nguyen
- Department of Radiology, Boston Medical Center, Boston, MA, USA,Department of Neurology, Boston Medical Center, Boston, MA, USA
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Sousa JA, Machado AR, Rito-Cruz L, Paiva-Simões J, Santos-Martins L, Bernardo-Castro S, Martins AI, Brás A, Almendra L, Cecília C, Machado C, Rodrigues B, Galego O, Nunes C, Veiga R, Santo G, Silva F, Machado E, Sargento-Freitas J. Single-phase CT angiography predicts ASPECTS decay and may help determine when to repeat CT before thrombectomy. J Stroke Cerebrovasc Dis 2022; 31:106815. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106815] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2022] [Revised: 09/02/2022] [Accepted: 09/23/2022] [Indexed: 11/21/2022] Open
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