1
|
Sembill JA, Sprügel MI, Haupenthal D, Kremer S, Knott M, Mühlen I, Kallmünzer B, Kuramatsu JB. Endovascular thrombectomy in patients with anterior circulation stroke: an emulated real-world comparison. Neurol Res Pract 2024; 6:37. [PMID: 39049127 PMCID: PMC11270839 DOI: 10.1186/s42466-024-00331-6] [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: 04/09/2024] [Accepted: 06/21/2024] [Indexed: 07/27/2024] Open
Abstract
BACKGROUND Endovascular thrombectomy (EVT) has been proven effective in anterior circulation stroke due to large vessel occlusion (LVO). However, translation from randomized clinical trials (RCTs) with highly selected patients to real-world requires confirmation, particularly to identify associations outside of strict selection criteria. AIMS This study aims to compare functional outcomes after EVT in real-world with those reported in RCTs, and to identify associations with functional outcome after EVT outside RCT-criteria. METHODS This study analyzed longitudinal German real-world data from the Stroke Research Consortium in Northern Bavaria (STAMINA) cohort from January, 2015 to June, 2019. We conducted a trial emulation, comparing patients with anterior circulation stroke and LVO meeting selection criteria for RCTs investigating EVT (1) predominantly within 6 hours with those from HERMES meta-analysis, and (2) within 6-24 hours with those from AURORA meta-analysis. We (3) analyzed treatment effects of EVT and association with functional outcome in patients treated outside RCT criteria. RESULTS Of 598 patients, 281 (47.0%) met RCT-criteria for treatment within 6 hours (hereinafter STAMINA-HERMES), 74 (12.4%) met RCT-criteria for treatment within 6-24 hours (STAMINA-AURORA), and 277 (46.3%) patients received EVT outside RCT-criteria. We observed no difference in rates of functional independence or mortality, comparing STAMINA-HERMES with HERMES meta-analysis (mRS 0-1: n=120/281 [43%] vs. 291/633 [46%], p=0.36; mortality: n=34/281 [12%] vs. 97/633 [15%], p=0.20), and STAMINA-AURORA with AURORA meta-analysis (mRS 0-1: n=26/74 [35%] vs. 122/266 [46%], p=0.10, mortality: n=10/74 [14%] vs. 45/266 [17%], p=0.48). Patients treated outside RCT-criteria had worse outcome (mRS 0-1: n=38/277 [14%], mortality: n=90/277 [32%], both p<0.001); possibly driven by pre-existing functional dependence (n=172/277 [62%]). Compared to matched controls, EVT outside of RCT-criteria was associated with lower mortality (absolute treatment effect: -14%, 95% Confidence Interval [CI] -23 to -5, p<0.01), but not with recovery to functional independence or premorbid functional status (treatment effect: 4%, CI -4 to 11, p=0.34), which was associated with lower NIHSS (Odds ratio [OR] 0.86, CI 0.80-0.92, p<0.001) and age (OR 0.95, CI 0.93-0.98, p=0.002). CONCLUSIONS Translation of EVT outcomes reported in RCTs into real-world is possible, however, almost half of patients did not meet trial criteria. Identification of patients who functionally benefit from frequently performed EVT outside RCT-criteria requires further investigation. TRIAL REGISTRATION Clinicaltrials.gov, NCT04357899.
Collapse
Affiliation(s)
- Jochen A Sembill
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany.
| | - Maximilian I Sprügel
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - David Haupenthal
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Svenja Kremer
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Michael Knott
- Department of Neuroradiology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Iris Mühlen
- Department of Neuroradiology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Bernd Kallmünzer
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| | - Joji B Kuramatsu
- Department of Neurology, Friedrich-Alexander-Universität Erlangen-Nürnberg (FAU), Schwabachanlage 6, 91054, Erlangen, Germany
| |
Collapse
|
2
|
Beckonert NM, Weller JM, Alegiani AC, Boeckh-Behrens T, Deb-Chatterji M, Hamann GF, Krause LU, Lehnen NC, Nitsch L, Poli S, Riedel C, Tiedt S, Zweynert S, Petzold GC, Dorn F, Bode FJ. Endovascular treatment of primary M3 occlusion stroke in clinical practice: analysis of the German Stroke Registry. Neurol Res Pract 2024; 6:36. [PMID: 39020409 PMCID: PMC11256396 DOI: 10.1186/s42466-024-00330-7] [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: 03/28/2024] [Accepted: 06/10/2024] [Indexed: 07/19/2024] Open
Abstract
BACKGROUND Endovascular treatment (ET) options for acute stroke due to distal middle cerebral artery occlusions are rapidly evolving, but data on outcome and safety are sparse. We therefore performed an analysis of patients undergoing ET for primary M3 occlusions in routine clinical practice in a nationwide registry. METHODS Patients enrolled between 01/20 and 12/21 in the prospective, multicenter German Stroke Registry-Endovascular Treatment (GSR-ET) were screened for mechanical thrombectomy performed for primary M3 occlusion. We analyzed neurological deficit as measured by the National Institute of Health Stroke Scale (NIHSS), symptomatic intracranial hemorrhage (sICH), thrombectomy technique, successful reperfusion (modified Thrombolysis in Cerebral Infarction [mTICI] score of 2b-3) and functional outcome as measured by the modified Rankin Scale (mRS) at discharge and 90 days. RESULTS Out of 5574 patients, 11 patients (0.2%, median age 80 years, 54.5% female) underwent ET for primary M3 occlusion. All patients had pre-admission mRS ≤ 1, median NIHSS on admission was 8, and successful reperfusion was achieved in 6/11 patients (54.5%). While no vasospasm, dissection or perforation was reported, symptomatic intracranial hemorrhage occurred in 2 patients (18.2%). Favorable outcome (mRS ≤ 2) was achieved in 6/11 patients (54.5%) at 90-day follow-up. CONCLUSIONS ET for primary M3 occlusions is rarely performed. While technically feasible, the procedure's potential benefits must be carefully weighed against its associated risks, including clinically relevant complications. Caution and further research is needed to optimize patient selection for this intervention. TRIAL REGISTRATION GSR-ET; ClinicalTrials.gov Identifier: NCT03356392; Trial Registration Date: 11/29/2017.
Collapse
Affiliation(s)
- Niklas M Beckonert
- Department of Vascular Neurology, University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany.
- Vascular Neurology Research Group, German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany.
| | - Johannes M Weller
- Department of Vascular Neurology, University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Anna C Alegiani
- Department of Neurology, Asklepios Klinik Altona, Hamburg, Germany
| | - Tobias Boeckh-Behrens
- Department of Diagnostic and Interventional Neuroradiology, Klinikum Rechts Der Isar, Technical University Munich, Munich, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Hospital Schleswig Holstein Campus Kiel, Kiel, Germany
| | - Gerhard F Hamann
- Department of Neurology and Neurological Rehabilitation, Bezirkskrankenhaus Günzburg, Günzburg, Germany
| | - Lars U Krause
- Department of Neurology, Klinikum Osnabrück, Osnabrück, Germany
| | - Nils C Lehnen
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Louisa Nitsch
- Department of Vascular Neurology, University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| | - Sven Poli
- Department of Vascular Neurology, Eberhard-Karls University, Tuebingen, Germany
| | - Christian Riedel
- Department of Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research, Klinikum Der Universität München, Ludwig-Maximilians-Universität LMU, Munich, Germany
| | - Sarah Zweynert
- Department of Neurology, University Hospital Berlin Charité, Berlin, Germany
| | - Gabor C Petzold
- Department of Vascular Neurology, University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
- Vascular Neurology Research Group, German Center for Neurodegenerative Diseases (DZNE), Bonn, Germany
| | - Franziska Dorn
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Felix J Bode
- Department of Vascular Neurology, University Hospital Bonn, Venusberg Campus 1, 53127, Bonn, Germany
| |
Collapse
|
3
|
Schulze-Zachau V, Brehm A, Ntoulias N, Krug N, Tsogkas I, Blackham KA, Möhlenbruch MA, Jesser J, Cervo A, Kreiser K, Althaus K, Maslias E, Michel P, Saliou G, Riegler C, Nolte CH, Maier I, Jamous A, Rautio R, Ylikotila P, Fargen KM, Wolfe SQ, Castellano D, Boghi A, Kaiser DPO, Cuberi A, Kirschke JS, Schwarting J, Limbucci N, Renieri L, Al Kasab S, Spiotta AM, Fragata I, Rodriquez-Ares T, Maurer CJ, Berlis A, Moreu M, López-Frías A, Pérez-García C, Commodaro C, Pileggi M, Mascitelli J, Giordano F, Casagrande W, Purves CP, Bester M, Flottmann F, Kan PT, Edhayan G, Hofmeister J, Machi P, Kaschner M, Weiss D, Katan M, Fischer U, Psychogios MN. Incidence and outcome of perforations during medium vessel occlusion compared with large vessel occlusion thrombectomy. J Neurointerv Surg 2024; 16:775-780. [PMID: 37524518 DOI: 10.1136/jnis-2023-020531] [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: 05/04/2023] [Accepted: 07/19/2023] [Indexed: 08/02/2023]
Abstract
BACKGROUND Vessel perforation during thrombectomy is a severe complication and is hypothesized to be more frequent during medium vessel occlusion (MeVO) thrombectomy. The aim of this study was to compare the incidence and outcome of patients with perforation during MeVO and large vessel occlusion (LVO) thrombectomy and to report on the procedural steps that led to perforation. METHODS In this multicenter retrospective cohort study, data of consecutive patients with vessel perforation during thrombectomy between January 1, 2015 and September 30, 2022 were collected. The primary outcomes were independent functional outcome (ie, modified Rankin Scale 0-2) and all-cause mortality at 90 days. Binomial test, chi-squared test and t-test for unpaired samples were used for statistical analysis. RESULTS During 25 769 thrombectomies (5124 MeVO, 20 645 LVO) in 25 stroke centers, perforation occurred in 335 patients (1.3%; mean age 72 years, 62% female). Perforation occurred more often in MeVO thrombectomy (2.4%) than in LVO thrombectomy (1.0%, p<0.001). More MeVO than LVO patients with perforation achieved functional independence at 3 months (25.7% vs 10.9%, p=0.001). All-cause mortality did not differ between groups (overall 51.6%). Navigation beyond the occlusion and retraction of stent retriever/aspiration catheter were the two most common procedural steps that led to perforation. CONCLUSIONS In our cohort, perforation was approximately twice as frequent in MeVO than in LVO thrombectomy. Efforts to optimize the procedure may focus on navigation beyond the occlusion site and retraction of stent retriever/aspiration catheter. Further research is necessary in order to identify thrombectomy candidates at high risk of intraprocedural perforation and to provide data on the effectiveness of endovascular countermeasures.
Collapse
Affiliation(s)
- Victor Schulze-Zachau
- Diagnostic and Interventional Neuroradiology Department, Radiology and Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
| | - Alex Brehm
- Diagnostic and Interventional Neuroradiology Department, Radiology and Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
| | - Nikolaos Ntoulias
- Diagnostic and Interventional Neuroradiology Department, Radiology and Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
| | - Nadja Krug
- Diagnostic and Interventional Neuroradiology Department, Radiology and Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
| | - Ioannis Tsogkas
- Diagnostic and Interventional Neuroradiology Department, Radiology and Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
| | - Kristine Ann Blackham
- Diagnostic and Interventional Neuroradiology Department, Radiology and Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
| | - Markus A Möhlenbruch
- Vascular & Interventional Neuroradiology Section, Minimal Invasive NeuroTherapy Center, University Hospital Heidelberg, Heidelberg, Germany
| | - Jessica Jesser
- Vascular & Interventional Neuroradiology Section, Minimal Invasive NeuroTherapy Center, University Hospital Heidelberg, Heidelberg, Germany
| | - Amedeo Cervo
- Neuroradiology Department, Niguarda Hospital, Milan, Italy
| | - Kornelia Kreiser
- Radiology and Neuroradiology Clinic, RKU - Universitäts- und Rehabilitationskliniken Ulm gGmbH, Ulm, Germany
| | | | - Errikos Maslias
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
- UNIL - Université de Lausanne, Lausanne, Switzerland
| | - Patrik Michel
- Department of Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
- UNIL - Université de Lausanne, Lausanne, Switzerland
| | - Guillaume Saliou
- UNIL - Université de Lausanne, Lausanne, Switzerland
- Diagnostic and Interventional Radiology, Centre Hospitalier Universitaire Vaudois, Lausanne, Switzerland
| | - Christoph Riegler
- Department of Neurology with Experimental Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology with Experimental Neurology, Charité Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Ilko Maier
- Department of Neurology, University Medical Center Göttingen, Göttingen, Germany
| | - Ala Jamous
- Department of Diagnostic & Interventional Neuroradiology, University Medical Center Göttingen, Göttingen, Germany
| | - Riitta Rautio
- Department of Radiology, Turku University Hospital, Turku, Finland
| | | | - Kyle M Fargen
- Neurological Surgery and Radiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Stacey Q Wolfe
- Neurological Surgery and Radiology, Wake Forest University School of Medicine, Winston-Salem, North Carolina, USA
| | - Davide Castellano
- Department of Interventional Radiology and Neuroradiology, Ospedale San Giovanni Bosco, Turin, Italy
| | - Andrea Boghi
- Department of Interventional Radiology and Neuroradiology, Ospedale San Giovanni Bosco, Turin, Italy
| | - Daniel P O Kaiser
- Department of Neuroradiology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Ani Cuberi
- Department of Radiology, University Hospital Carl Gustav Carus, Dresden, Germany
| | - Jan S Kirschke
- Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Julian Schwarting
- Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar der Technischen Universität München, Munich, Germany
| | - Nicola Limbucci
- Department of Neurovascular Intervention, Azienda Ospedaliero Universitaria Careggio, Florence, Italy
| | - Leonardo Renieri
- Department of Neurovascular Intervention, Azienda Ospedaliero Universitaria Careggio, Florence, Italy
| | - Sami Al Kasab
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Alejandro M Spiotta
- Department of Neurosurgery, Medical University of South Carolina, Charleston, South Carolina, USA
| | - Isabel Fragata
- Department of Neuroradiology, Centro Hospitalar Universitario de Lisboa Central EPE, Lisbon, Portugal
- NOVA Medical School, Lisbon, Portugal
| | - Tania Rodriquez-Ares
- Department of Neuroradiology, Centro Hospitalar Universitario de Lisboa Central EPE, Lisbon, Portugal
| | - Christoph Johannes Maurer
- Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Germany
| | - Ansgar Berlis
- Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Augsburg, Augsburg, Germany
| | - Manuel Moreu
- Neurointerventional Unit, Radiology Department, Hospital Clinico Universitario San Carlos, Madrid, Spain
| | - Alfonso López-Frías
- Neurointerventional Unit, Radiology Department, Hospital Clinico Universitario San Carlos, Madrid, Spain
| | - Carlos Pérez-García
- Neurointerventional Unit, Radiology Department, Hospital Clinico Universitario San Carlos, Madrid, Spain
| | - Christian Commodaro
- Diagnostic and Interventional Neuroradiology Department, Neurocenter of Southern Switzerland EOC, Lugano, Switzerland
| | - Marco Pileggi
- Diagnostic and Interventional Neuroradiology Department, Neurocenter of Southern Switzerland EOC, Lugano, Switzerland
| | - Justin Mascitelli
- Department of Neurosurgery, The University of Texas Health Science Center at San Antonio, San Antonio, Texas, USA
| | - Flavio Giordano
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, Azienda Ospedaliera di Rilievo Nazionale Antonio Cardarelli, Naples, Italy
| | - Walter Casagrande
- Neurosurgery Department, Hospital General de Agudos Juan A Fernandez, Buenos Aires, Argentina
| | - Cynthia P Purves
- Neurosurgery Department, Hospital General de Agudos Juan A Fernandez, Buenos Aires, Argentina
| | - Maxim Bester
- Diagnostic and Interventional Neuroradiology Department, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Diagnostic and Interventional Neuroradiology Department, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter T Kan
- Department of Neurosurgery, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Gautam Edhayan
- Department of Radiology, The University of Texas Medical Branch at Galveston, Galveston, Texas, USA
| | - Jeremy Hofmeister
- Department of Radiology and Medical Informatics, Geneva University Hospitals, Geneva, Switzerland
| | - Paolo Machi
- Department of Radiology and Medical Informatics, Geneva University Hospitals, Geneva, Switzerland
| | - Marius Kaschner
- Department of Diagnostic and Interventional Radiology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Daniel Weiss
- Department of Diagnostic and Interventional Radiology, Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Mira Katan
- Neurology Clinic, University Hospital Basel, Basel, Switzerland
| | - Urs Fischer
- Neurology Clinic, University Hospital Basel, Basel, Switzerland
| | - Marios-Nikos Psychogios
- Diagnostic and Interventional Neuroradiology Department, Radiology and Nuclear Medicine Clinic, University Hospital Basel, Basel, Switzerland
| |
Collapse
|
4
|
Wischmann J, Masouris I, Keidel L, Tiedt S, Trumm CG, Zimmermann H, Liebig T, Höglinger G, Kellert L. Periprocedural unfractionated heparin bolus during endovascular treatment in acute ischemic stroke does more harm than good. J Neurointerv Surg 2024; 16:781-787. [PMID: 37665652 PMCID: PMC11287633 DOI: 10.1136/jnis-2023-020551] [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: 07/07/2023] [Indexed: 09/06/2023]
Abstract
BACKGROUND Unfractionated heparin (UFH) bolus is occasionally administered during endovascular treatment (EVT) to reduce thrombotic complications in acute ischemic stroke patients. However, the MR CLEAN-MED trial showed an increase in symptomatic intracranial hemorrhages (sICH) and a non-significant shift towards worse functional outcome with UFH administration. We aimed to analyze the impact of periprocedural UFH bolus in a real-world setting in anterior (ACS) and posterior circulation stroke (PCS) patients. METHODS We analyzed data from the German Stroke Registry-Endovascular Treatment using propensity score matching. Primary outcome was the modified Rankin Scale at 3 months, and secondary outcome measures included mortality, angiographic outcomes, post-EVT National Institute of Health Stroke Scale scores and ICH at 24 hours. RESULTS Among 13,082 patients, 7948 with ACS (UFH bolus use in 15%) and 841 with PCS (UFH bolus use in 16.3%) were included in the propensity score matching analysis. Applying MR CLEAN-MED study criteria, UFH bolus was associated with worse functional outcomes (odds ratio [OR] 1.44; 95% CI 1.06-1.96). Analyzing all ACS and PCS patients, UFH bolus did not provide any net benefit. In ACS patients treated with intravenous thrombolysis (IVT), UFH bolus use was associated with worse functional outcomes (OR 2.40; 95% CI 1.34 to 5.06). CONCLUSION Our findings show transferability of the MR CLEAN-MED results into a real-world setting, confirming a negative effect of periprocedural UFH on functional outcome in this subgroup of patients. Considering all ACS and PCS patients, periprocedural UFH did not provide a net benefit and appears to be harmful, particularly in IVT-treated patients.
Collapse
Affiliation(s)
- Johannes Wischmann
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Ilias Masouris
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Linus Keidel
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Steffen Tiedt
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
- Institute for Stroke and Dementia Research (ISD), LMU University Hospital, LMU Munich, Munich, Germany
| | - Christoph G Trumm
- Institute of Neuroradiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Hanna Zimmermann
- Institute of Neuroradiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Thomas Liebig
- Institute of Neuroradiology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Günter Höglinger
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| | - Lars Kellert
- Department of Neurology, LMU University Hospital, LMU Munich, Munich, Germany
| |
Collapse
|
5
|
Santo BA, Poppenberg KE, Ciecierska SS, Lim J, Baig AA, Jaikumar V, Raygor KP, Patel TR, Shah M, Levy EI, Siddiqui AH, Tutino VM. Decoding Molecular Mechanisms Underlying Outcomes After Ischemic Stroke Thrombectomy by RNA Sequencing of Retrieved Clots. Mol Diagn Ther 2024; 28:469-477. [PMID: 38769267 DOI: 10.1007/s40291-024-00716-y] [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] [Accepted: 05/01/2024] [Indexed: 05/22/2024]
Abstract
BACKGROUND Transcriptomic profiling has emerged as a powerful tool for exploring the molecular landscape of ischemic stroke clots and providing insights into the pathophysiological mechanisms underlying stroke progression and recovery. In this study, we aimed to investigate the relationship between stroke clot transcriptomes and stroke thrombectomy outcome, as measured by early neurological improvement (ENI) 30 (i.e., a 30% reduction in NIHSS at 24 h post-thrombectomy). HYPOTHESIS We hypothesized that there exist distinct clot gene expression patterns between good and poor neurological outcomes. METHODS Transcriptomic analysis of 32 stroke clots retrieved by mechanical thrombectomy was conducted. Transcriptome data of these clots were analyzed to identify differentially expressed genes (DEGs), defined as those with a log(fold-change) ≥ 1.5 and q < 0.05 between samples with good and poor early neurological outcomes. Gene ontology and bioinformatics analyses were performed on genes with p < 0.01 to identify enriched biological processes and Ingenuity Pathway Analysis canonical pathways. Moreover, AUC analysis assessed the predictive power of DEGs for 90-day function outcome (mRS ≤ 2) and cellular composition of clot was predicted using CIBERSORT. We also assessed whether differential enrichment of immune cell types could indicate patient survival. RESULTS A total of 41 DEGs were identified. Bioinformatics showed that enriched biological processes and pathways emphasized the chronic immune response and matrix metalloproteinase inhibition. Moreover, 25 of the DEGs were found to be significant predictors of 90-day mRS. These genes were indicative of monocytes enrichment and neutrophil depletion in patients with poorer outcomes. CONCLUSION Our study revealed a distinct gene expression pattern and dysregulated biological pathways associated with ENI. This expression pattern was also predictive of long-term outcome, suggesting a biological link between those ENIs and 90-day mRS.
Collapse
Affiliation(s)
- Briana A Santo
- Canon Stroke and Vascular Research Center, University at Buffalo, 875 Ellicott Street, Buffalo, NY, 14203, USA
- Department of Pathology and Anatomical Sciences, University at Buffalo, Buffalo, NY, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Kerry E Poppenberg
- Canon Stroke and Vascular Research Center, University at Buffalo, 875 Ellicott Street, Buffalo, NY, 14203, USA
| | - Shiau-Sing Ciecierska
- Canon Stroke and Vascular Research Center, University at Buffalo, 875 Ellicott Street, Buffalo, NY, 14203, USA
| | - Jaims Lim
- Canon Stroke and Vascular Research Center, University at Buffalo, 875 Ellicott Street, Buffalo, NY, 14203, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Ammad A Baig
- Canon Stroke and Vascular Research Center, University at Buffalo, 875 Ellicott Street, Buffalo, NY, 14203, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Vinay Jaikumar
- Canon Stroke and Vascular Research Center, University at Buffalo, 875 Ellicott Street, Buffalo, NY, 14203, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Kunal P Raygor
- Canon Stroke and Vascular Research Center, University at Buffalo, 875 Ellicott Street, Buffalo, NY, 14203, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Tatsat R Patel
- Canon Stroke and Vascular Research Center, University at Buffalo, 875 Ellicott Street, Buffalo, NY, 14203, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Munjal Shah
- Canon Stroke and Vascular Research Center, University at Buffalo, 875 Ellicott Street, Buffalo, NY, 14203, USA
| | - Elad I Levy
- Canon Stroke and Vascular Research Center, University at Buffalo, 875 Ellicott Street, Buffalo, NY, 14203, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Adnan H Siddiqui
- Canon Stroke and Vascular Research Center, University at Buffalo, 875 Ellicott Street, Buffalo, NY, 14203, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA
| | - Vincent M Tutino
- Canon Stroke and Vascular Research Center, University at Buffalo, 875 Ellicott Street, Buffalo, NY, 14203, USA.
- Department of Pathology and Anatomical Sciences, University at Buffalo, Buffalo, NY, USA.
- Department of Neurosurgery, University at Buffalo, Buffalo, NY, USA.
| |
Collapse
|
6
|
Buecke P, Cohen J, Klisch J, Felber S, Bäzner H, Henkes H. The History of Endovascular Stroke Treatment: From Local Intraarterial Fibrinolysis to Stent Retriever Thrombectomy. ROFO-FORTSCHR RONTG 2024; 196:682-689. [PMID: 38065543 DOI: 10.1055/a-2206-6223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/26/2024]
Affiliation(s)
- Philipp Buecke
- Department of Neurology, Inselspital University Hospital Bern, Switzerland
| | - José Cohen
- Department of Neurosurgery, Hadassah Medical Center, Hebrew University Jerusalem, Israel
| | - Joachim Klisch
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, HELIOS Klinikum Erfurt, Germany
| | - Stephan Felber
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, Stiftungsklinikum Mittelrhein Koblenz, Germany
| | | | - Hans Henkes
- Neuroradiological Clinic, Klinikum Stuttgart, Germany
- Medical Faculty, Universität Duisburg-Essen, Germany
| |
Collapse
|
7
|
Riegler C, von Rennenberg R, Bollweg K, Nguyen TN, Kleine JF, Tiedt S, Audebert HJ, Siebert E, Nolte CH. Endovascular therapy in patients with internal carotid artery occlusion and patent circle of Willis. J Neurointerv Surg 2024; 16:644-651. [PMID: 37491381 PMCID: PMC11228208 DOI: 10.1136/jnis-2023-020556] [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: 05/10/2023] [Accepted: 06/24/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Occlusion of the internal carotid artery (ICA) may extend into the middle or anterior cerebral artery (ICA-T) or be confined to the intracranial (ICA-I) or extracranial segment (ICA-E). While there is excellent evidence for endovascular therapy (EVT) in ICA-T occlusions, studies on EVT in non-tandem ICA-I or ICA-E occlusions are scarce. OBJECTIVE To characterize EVT-treated patients with ICA-I- and ICA-E occlusion by comparing them with ICA-T occlusions. METHODS The German Stroke Registry (GSR), a national, multicenter, prospective registry was searched for EVT-treated patients with isolated ICA occlusion between June 2015 and December 2021. We stratified patients by ICA occlusion site: (a) ICA-T, (b) ICA-I, (c) ICA-E. Baseline factors, procedural variables, technical (modified Thrombolysis in Cerebral Infarction (mTICI)), and functional outcomes (modified Rankin scale score at 3 months) were analyzed. RESULTS Of 13 082 GSR patients, 2588 (19.8%) presented with an isolated ICA occlusion, thereof 1946 (75.2%) ICA-T, 366 (14.1%) ICA-I, and 276 (10.7%) ICA-E patients. The groups differed in age (77 vs 76 vs 74 years, Ptrend=0.02), sex (53.4 vs 48.9 vs 43.1% female, Ptrend<0.01), and stroke severity (median National Institutes of Health Stroke Scale score at admission 17 vs 14 vs 13 points, Ptrend<0.001). In comparison with ICA-T occlusions, both ICA-I and ICA-E occlusions had lower rates of successful recanalization (mTICI 2b/3: 85.4% vs 80.4% vs 76.3%; aOR (95% CI for ICA-I vs ICA-T 0.71 (0.53 to 0.95); aOR (95% CI) for ICA-E vs ICA-T 0.57 (0.42 to 0.78)). In adjusted analyses, ICA-E occlusion was associated with worse outcome when compared with ICA-T occlusion (mRS ordinal shift, cOR (95% CI) 0.70 (0.52 to 0.93)). CONCLUSION Patient characteristics and outcomes differ substantially between ICA-T, ICA-I, and ICA-E occlusions. These results warrant further studies on EVT in ICA-I and ICA-E patients.
Collapse
Affiliation(s)
- Christoph Riegler
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitatsmedizin Berlin, Berlin, Germany
| | - Regina von Rennenberg
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitatsmedizin Berlin, Berlin, Germany
| | - Kerstin Bollweg
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitatsmedizin Berlin, Berlin, Germany
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, Boston, Massachusetts, USA
- Department of Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Justus F Kleine
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research, University Hospital, Ludwig Maximilians University Munich, Munich, Germany
| | - Heinrich J Audebert
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitatsmedizin Berlin, Berlin, Germany
| | - Eberhard Siebert
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitatsmedizin Berlin, Berlin, Germany
- Berlin Insititute of Health at Charité, Universitätsmedizin Berlin, Berlin, Germany
- Deutsches Zentrum für Herz-Kreislaufforschung (DZHK), Berlin, Germany
| |
Collapse
|
8
|
Bourgeois-Beauvais Q, Sellin D, Arnaud I, Tuttle C, Landais A, Lannuzel A, Signate A, Berge J, Iosif C. Initiation of mechanical thrombectomy in an insular setting with helicopter transfer: a 2-year experience from the first, complete, tertiary stroke center in the Caribbean. J Neurointerv Surg 2024:jnis-2024-021703. [PMID: 38876783 DOI: 10.1136/jnis-2024-021703] [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: 03/12/2024] [Accepted: 05/29/2024] [Indexed: 06/16/2024]
Abstract
BACKGROUND This is the first cohort study of patients treated with mechanical thrombectomy (MT) for acute ischemic stroke in the French West Indies, with a mothership center and helicopter transfer. OBJECTIVE To describe the population and to evaluate imaging, clinical, and time metric outcomes, in order to assess the feasibility and adjust the territorial organization. METHODS In this observational study, we retrospectively analyzed our prospectively collected data of a population of consecutive patients treated with MT for anterior and posterior circulation large vessel occlusions. Primary outcome was 3-month functional independence (modified Rankin Scale score ≤2). Secondary outcomes included aerial and terrestrial times of arrival, in-hospital delays, demographics, imaging and clinical data at onset, discharge, and at 3 months. We compared the results of the mothership and drip-and-ship paradigms. RESULTS Between January 2020 and December 2021, 223 patients were included (74% mothership, 26% drip-and-ship). Mean National Institutes of Health Stroke Scale (NIHSS) score of the population was 16 before MT, with significant reduction (NIHSS score 6) at discharge (9 mothership, 12 drip-and-ship, P=0.025). There was significant difference in onset-to-operation room times among the two centers (335 min mothership, 500 min drip-and-ship, P=0.004). Successful recanalization (modified Thrombolysis in Cerebral Infarction score 2b-3) was 80.3%. Functional independence at 3 months was 35%, symptomatic intracranial hemorrhage was 11%, and the complication rate was 9.4%, all without statistically significant difference between the two groups. CONCLUSION The population has distinct risk factors. MT with helicopter transfer is feasible in the French West Indies. Reduction of prehospital and in-hospital times is mandatory; evaluation of the territorial strategy is underway, to avoid over-selection of transferred patients.
Collapse
Affiliation(s)
| | - Doriane Sellin
- Neurology, University Hospital of Martinique, Fort de France, France
| | - Isaure Arnaud
- Neurology, University Hospital of Martinique, Fort de France, France
| | - Celia Tuttle
- Diagnostic and Interventional Radiology, University Hospital of Martinique, Fort de France, France
| | - Anne Landais
- Neurology, University Hospital of Guadeloupe, Point a Pitre, France
| | - Annie Lannuzel
- Neurology, University Hospital of Guadeloupe, Point a Pitre, France
- School of Medicine, Universite des Antilles UFR Medecine Hyacinthe Bastaraud, Pointe-a-Pitre, Guadeloupe
| | - Aissatou Signate
- Neurology, University Hospital of Martinique, Fort de France, France
| | - Jerome Berge
- Neuroradiology, Centre Hospitalier Universitaire Bordeaux GH Pellegrin, Bordeaux, Aquitaine, France
| | - Christina Iosif
- Diagnostic and Interventional Radiology, University Hospital of Martinique, Fort de France, France
- School of Medicine, Universite des Antilles UFR Medecine Hyacinthe Bastaraud, site de Martinique, Fort de France, France
| |
Collapse
|
9
|
Mak A, Matouk CC, Avery EW, Behland J, Haider SP, Frey D, Madai VI, Vajkoczy P, Griessenauer CJ, Zand R, Hendrix P, Abedi V, Sanelli PC, Falcone GJ, Petersen N, Sansing LH, Sheth KN, Payabvash S, Malhotra A. Automated detection of early signs of irreversible ischemic change on CTA source images in patients with large vessel occlusion. PLoS One 2024; 19:e0304962. [PMID: 38870240 PMCID: PMC11175522 DOI: 10.1371/journal.pone.0304962] [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: 09/25/2023] [Accepted: 05/21/2024] [Indexed: 06/15/2024] Open
Abstract
PURPOSE To create and validate an automated pipeline for detection of early signs of irreversible ischemic change from admission CTA in patients with large vessel occlusion (LVO) stroke. METHODS We retrospectively included 368 patients for training and 143 for external validation. All patients had anterior circulation LVO stroke, endovascular therapy with successful reperfusion, and follow-up diffusion-weighted imaging (DWI). We devised a pipeline to automatically segment Alberta Stroke Program Early CT Score (ASPECTS) regions and extracted their relative Hounsfield unit (rHU) values. We determined the optimal rHU cut points for prediction of final infarction in each ASPECT region, performed 10-fold cross-validation in the training set, and measured the performance via external validation in patients from another institute. We compared the model with an expert neuroradiologist for prediction of final infarct volume and poor functional outcome. RESULTS We achieved a mean area under the receiver operating characteristic curve (AUC), accuracy, sensitivity, and specificity of 0.69±0.13, 0.69±0.09, 0.61±0.23, and 0.72±0.11 across all regions and folds in cross-validation. In the external validation cohort, we achieved a median [interquartile] AUC, accuracy, sensitivity, and specificity of 0.71 [0.68-0.72], 0.70 [0.68-0.73], 0.55 [0.50-0.63], and 0.74 [0.73-0.77], respectively. The rHU-based ASPECTS showed significant correlation with DWI-based ASPECTS (rS = 0.39, p<0.001) and final infarct volume (rS = -0.36, p<0.001). The AUC for predicting poor functional outcome was 0.66 (95%CI: 0.57-0.75). The predictive capabilities of rHU-based ASPECTS were not significantly different from the neuroradiologist's visual ASPECTS for either final infarct volume or functional outcome. CONCLUSIONS Our study demonstrates the feasibility of an automated pipeline and predictive model based on relative HU attenuation of ASPECTS regions on baseline CTA and its non-inferior performance in predicting final infarction on post-stroke DWI compared to an expert human reader.
Collapse
Affiliation(s)
- Adrian Mak
- Department of Radiology and Biomedical Imaging, Section of Neuroradiology, Yale School of Medicine, New Haven, CT, United States of America
- CLAIM—Charité Lab for Artificial Intelligence in Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Charles C. Matouk
- Department of Neurosurgery, Division of Neurovascular Surgery, Yale University School of Medicine, New Haven, CT, United States of America
| | - Emily W. Avery
- Department of Radiology and Biomedical Imaging, Section of Neuroradiology, Yale School of Medicine, New Haven, CT, United States of America
| | - Jonas Behland
- Department of Radiology and Biomedical Imaging, Section of Neuroradiology, Yale School of Medicine, New Haven, CT, United States of America
- CLAIM—Charité Lab for Artificial Intelligence in Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Stefan P. Haider
- Department of Radiology and Biomedical Imaging, Section of Neuroradiology, Yale School of Medicine, New Haven, CT, United States of America
- Department of Otorhinolaryngology, LMU Clinic of Ludwig-Maximilians-University of Munich, Munich, Germany
| | - Dietmar Frey
- CLAIM—Charité Lab for Artificial Intelligence in Medicine, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Vince I. Madai
- QUEST Center for Responsible Research, Berlin Institute of Health (BIH), Charité Universitätsmedizin Berlin, Berlin, Germany
- School of Computing and Digital Technology, Faculty of Computing, Engineering and the Built Environment, Birmingham City University, Birmingham, United Kingdom
| | - Peter Vajkoczy
- Department of Neurosurgery, Charité Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph J. Griessenauer
- Research Institute of Neurointervention, Paracelsus Medical University, Salzburg, Austria
- Department of Neurosurgery, Paracelsus Medical University, Salzburg, Austria
| | - Ramin Zand
- Department of Neurology, Geisinger Medical Center, Danville, PA, United States of America
- Department of Neurology, Pennsylvania State University, State College, PA, United States of America
| | - Philipp Hendrix
- Department of Neurosurgery, Geisinger Medical Center, Danville, PA, United States of America
- Department of Neurosurgery, Saarland University Medical Center, Homburg, Germany
| | - Vida Abedi
- Department of Public Health Sciences, The Pennsylvania State University, Hershey, PA, United States of America
- Department of Molecular and Functional Genomics, Geisinger Medical Center, Danville, PA, United States of America
| | - Pina C. Sanelli
- Department of Radiology, Northwell Health Feinstein Institutes for Medical Research, Manhasset, New York, United States of America
| | - Guido J. Falcone
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT, United States of America
| | - Nils Petersen
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT, United States of America
| | - Lauren H. Sansing
- Division of Stroke and Vascular Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT, United States of America
| | - Kevin N. Sheth
- Division of Stroke and Vascular Neurology, Department of Neurology, Yale University School of Medicine, New Haven, CT, United States of America
| | - Seyedmehdi Payabvash
- Department of Radiology and Biomedical Imaging, Section of Neuroradiology, Yale School of Medicine, New Haven, CT, United States of America
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Section of Neuroradiology, Yale School of Medicine, New Haven, CT, United States of America
| |
Collapse
|
10
|
Adusumilli G, Pederson JM, Hardy N, Kallmes KM, Hutchison K, Kobeissi H, Heiferman DM, Heit JJ. Mechanical thrombectomy in anterior vs. posterior circulation stroke: A systematic review and meta-analysis. Interv Neuroradiol 2024; 30:307-316. [PMID: 35549748 PMCID: PMC11310733 DOI: 10.1177/15910199221100796] [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: 04/12/2021] [Revised: 05/27/2021] [Accepted: 06/02/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND High-quality evidence exists for mechanical thrombectomy (MT) treatment of acute ischemic stroke (AIS) due to large vessel occlusion of the anterior circulation (AC-LVO). The evidence for MT treatment of posterior circulation large vessel occlusion (PC-LVO) is weaker, largely drawn from lower quality studies specific to PC-LVO and extrapolated from findings in AC-LVO, and ambiguous with regards to technical success. We performed a systematic review and meta-analysis to compare the technical success and functional outcomes of MT in PC-LVO versus AC-LVO patients. METHODS We identified comparative studies reporting on patients treated with MT in AC-LVO versus PC-LVO. The primary outcome of interest was thrombolysis in cerebral infarction (TICI) ≥ 2b. Secondary outcomes included rates of TICI 3, 90-day functional independence, first-pass-effect, average number of passes, and 90-day mortality. A separate random effects model was fit for each outcome measure. RESULTS Twenty studies with 12,911 patients, 11,299 (87.5%) in the AC-LVO arm and 1612 (12.5%) in the PC-LVO arm, were included. AC-LVO and PC-LVO patients had comparable rates of successful recanalization [OR = 1.02 [95% CI: 0.79-1.33], p = 0.848). However, the AC-LVO group had greater odds of 90-day functional independence (OR = 1.26 [95% CI: 1.00; 1.59], p = 0.050) and lower odds of 90-day mortality (OR = 0.58 [95% CI: 0.43; 0.79], p = 0.002). CONCLUSIONS MT achieves similar rates of recanalization with a similar safety profile in PC-LVO and AC-LVO patients. Patients with PC-LVO are less likely to achieve functional independence after MT. Future studies should identify PC-LVO patients who are likely to achieve favourable functional outcomes.
Collapse
Affiliation(s)
- Gautam Adusumilli
- Department of Radiology and Neurosurgery, Stanford University, Stanford, CA, USA
| | - John M Pederson
- Nested Knowledge, Inc, St Paul, MN, USA
- Superior Medical Experts, St Paul, MN, USA
| | | | | | | | - Hassan Kobeissi
- Central Michigan University College of Medicine, Mt. Pleasant, MI, USA
| | | | - Jeremy J Heit
- Department of Radiology and Neurosurgery, Stanford University, Stanford, CA, USA
| |
Collapse
|
11
|
Huhtakangas JK, Saaresranta T, Huhtakangas M, Haapea M, Huhtakangas J. Thrombolysis treatment protected impairment of functional ability, quality of life and fatigue seven years after stroke. J Stroke Cerebrovasc Dis 2024; 33:107707. [PMID: 38561166 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107707] [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: 12/08/2023] [Revised: 03/19/2024] [Accepted: 03/29/2024] [Indexed: 04/04/2024] Open
Abstract
OBJECTIVES We studied quality of life, functional outcome, depression, and fatigue of ischemic stroke patients treated with or without thrombolysis seven years post-stroke. MATERIALS AND METHODS A total of 204 ischemic stroke patients treated with or without thrombolysis during 2013-2015. After seven years the 136 survivors were assessed with telephone interview, which included questions about subjective quality of life (European Quality of Life-5 Dimensions), depression, fatigue with Fatigue Severity Scale, functional ability assessed with Barthel Index and Modified Rankin Scale, living conditions, need of care, and medical aids. RESULTS At admission patients with thrombolysis had higher National Institutes of Health Stroke Scale scores compared with those not treated with thrombolysis. At seven years post-stroke, 99% of alive patients answered the questionnaires. There were no group differences concerning functional outcome, quality of life, depression, fatigue, or insomnia. The Barthel Index was normal in both groups. The quality of life was good in both groups without group differences in any domains. Of all patients, 68% reported no problems in usual activities, and 61% were without pain. Anxiety or depression were experienced by 19% of all stroke patients, while fatigue was present in 32% of cases. CONCLUSIONS Seven years post-stroke the quality of life was good and functional outcome remained in good level in both study groups. One third experienced fatigue, while every fifth experienced depression. The thrombolysis treatment seems to protect from decreased quality of life, fatigue, and decreased mobility, self-care, and usual activities despite more severe stroke.
Collapse
Affiliation(s)
| | - Tarja Saaresranta
- Sleep Research Center, University of Turku, Lämmikäisenkatu 3B, Turku FI-20520, Finland; Division of Medicine, Department of Pulmonary Diseases, Turku University Hospital, Turku, Finland
| | - Moona Huhtakangas
- Welfare State Research and Reform, Finnish Institute for Health and Welfare, Helsinki, Finland
| | - Marianne Haapea
- Research Service Unit, Oulu University Hospital, University of Oulu, MRC Oulu, Finland
| | - Juha Huhtakangas
- Department of Neurology, Neurocenter, Oulu University Hospital, Oulu, Finland; Research Unit of Clinical Medicine, Faculty of Medicine, University of Oulu, Oulu Finland.
| |
Collapse
|
12
|
Gyawali P, Lillicrap TP, Esperon CG, Bhattarai A, Bivard A, Spratt N. Whole Blood Viscosity and Cerebral Blood Flow in Acute Ischemic Stroke. Semin Thromb Hemost 2024; 50:580-591. [PMID: 37813371 DOI: 10.1055/s-0043-1775858] [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: 10/11/2023]
Abstract
Existing effective treatments for ischemic stroke restore blood supply to the ischemic region using thrombolysis or mechanical removal of clot. However, it is increasingly recognized that successful removal of occlusive thrombus from the large artery-recanalization, may not always be accompanied by successful restoration of blood flow to the downstream tissues-reperfusion. Ultimately, brain tissue survival depends on cerebral perfusion, and a functioning microcirculation. Because capillary diameter is often equal to or smaller than an erythrocyte, microcirculation is largely dependent on erythrocyte rheological (hemorheological) factors such as whole blood viscosity (WBV). Several studies in the past have demonstrated elevated WBV in stroke compared with healthy controls. Also, elevated WBV has shown to be an independent risk factor for stroke. Elevated WBV leads to endothelial dysfunction, decreases nitric oxide-dependent flow-mediated vasodilation, and promotes hemostatic alterations/thrombosis, all leading to microcirculation sludging. Compromised microcirculation further leads to decreased cerebral perfusion. Hence, modulating WBV through pharmacological agents might be beneficial to improve cerebral perfusion in stroke. This review discusses the effect of elevated WBV on endothelial function, hemostatic alterations, and thrombosis leading to reduced cerebral perfusion in stroke.
Collapse
Affiliation(s)
- Prajwal Gyawali
- Heart and Stroke Program, Hunter Medical Research Institute and School of Health and Medical Sciences, University of Southern Queensland, Toowoomba, Queensland, Australia
| | - Thomas P Lillicrap
- Heart and Stroke Program, Department of Neurology, Hunter Medical Research Institute, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Carlos G Esperon
- Heart and Stroke Program, Department of Neurology, Hunter Medical Research Institute, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| | - Aseem Bhattarai
- Department of Biochemistry, Institute of Medicine, Kathmandu, Nepal
| | - Andrew Bivard
- Department of Neurology, Royal Melbourne Hospital, Parkville, Victoria, Australia
| | - Neil Spratt
- Heart and Stroke Program, Department of Neurology, Hunter Medical Research Institute, School of Biomedical Sciences and Pharmacy, University of Newcastle, John Hunter Hospital, New Lambton Heights, New South Wales, Australia
| |
Collapse
|
13
|
Santo BA, Poppenberg KE, Ciecierska SSK, Baig AA, Raygor KP, Patel TR, Shah M, Levy EI, Siddiqui AH, Tutino VM. Hybrid Clot Histomic-Transcriptomic Models Predict Functional Outcome After Mechanical Thrombectomy in Acute Ischemic Stroke. Neurosurgery 2024:00006123-990000000-01180. [PMID: 38829781 DOI: 10.1227/neu.0000000000003003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 03/29/2024] [Indexed: 06/05/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Histologic and transcriptomic analyses of retrieved stroke clots have identified features associated with patient outcomes. Previous studies have demonstrated the predictive capacity of histology or expression features in isolation. Few studies, however, have investigated how paired histologic image features and expression patterns from the retrieved clots can improve understanding of clot pathobiology and our ability to predict long-term prognosis. We hypothesized that computational models trained using clot histomics and mRNA expression can predict early neurological improvement (ENI) and 90-day functional outcome (modified Rankin Scale Score, mRS) better than models developed using histological composition or expression data alone. METHODS We performed paired histological and transcriptomic analysis of 32 stroke clots. ENI was defined as a delta-National Institutes of Health Stroke Score/Scale > 4, and a good long-term outcome was defined as mRS ≤2 at 90 days after procedure. Clots were H&E-stained and whole-slide imaged at 40×. An established digital pathology pipeline was used to extract 237 histomic features and to compute clot percent composition (%Comp). When dichotomized by either the ENI or mRS thresholds, differentially expressed genes were identified as those with absolute fold-change >1.5 and q < 0.05. Machine learning with recursive feature elimination (RFE) was used to select clot features and evaluate computational models for outcome prognostication. RESULTS For ENI, RFE identified 9 optimal histologic and transcriptomic features for the hybrid model, which achieved an accuracy of 90.8% (area under the curve [AUC] = 0.98 ± 0.08) in testing and outperformed models based on histomics (AUC = 0.94 ± 0.09), transcriptomics (AUC = 0.86 ± 0.16), or %Comp (AUC = 0.70 ± 0.15) alone. For mRS, RFE identified 7 optimal histomic and transcriptomic features for the hybrid model. This model achieved an accuracy of 93.7% (AUC = 0.94 ± 0.09) in testing, also outperforming models based on histomics (AUC = 0.90 ± 0.11), transcriptomics (AUC = 0.55 ± 0.27), or %Comp (AUC = 0.58 ± 0.16) alone. CONCLUSION Hybrid models offer improved outcome prognostication for patients with stroke. Identified digital histology and mRNA signatures warrant further investigation as biomarkers of patient functional outcome after thrombectomy.
Collapse
Affiliation(s)
- Briana A Santo
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
- Department of Pathology and Anatomical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, New York, USA
| | - Kerry E Poppenberg
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
- Department of Pathology and Anatomical Sciences, University at Buffalo, Buffalo, New York, USA
| | | | - Ammad A Baig
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, New York, USA
| | - Kunal P Raygor
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, New York, USA
| | - Tatsat R Patel
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, New York, USA
| | - Munjal Shah
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
| | - Elad I Levy
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, New York, USA
| | - Adnan H Siddiqui
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, New York, USA
| | - Vincent M Tutino
- Canon Stroke and Vascular Research Center, University at Buffalo, Buffalo, New York, USA
- Department of Pathology and Anatomical Sciences, University at Buffalo, Buffalo, New York, USA
- Department of Neurosurgery, University at Buffalo, Buffalo, New York, USA
| |
Collapse
|
14
|
Wang H, Xu L, Dong L, Li Y, Liu H, Xiao G. Effect of heart rate on poor outcome in stroke patients treated with intra-arterial thrombectomy. BMC Neurol 2024; 24:164. [PMID: 38773425 PMCID: PMC11106893 DOI: 10.1186/s12883-024-03662-8] [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: 06/08/2023] [Accepted: 04/30/2024] [Indexed: 05/23/2024] Open
Abstract
BACKGROUND AND PURPOSE The relationship between heart rate and the prognosis of patients with large vessel occlusion strokes treated with mechanical thrombectomy (MT) is not well established. This study aimed to evaluate the association of mean heart rate and heart rate variability (HRV) with the clinical outcomes after MT therapy. METHODS Acute ischemic stroke patients undergoing MT therapy were prospectively recruited from March 2020 to November 2022. Their heart rate was collected every hour for the initial 72 h after MT procedure, and the variability of heart rate was measured by standard deviation (SD) and coefficient of variation (CV). All-cause mortality and worsening of functional outcome (change in modified Rankin Scale (mRS) score) at 3-month were captured. Binary logistic regression was used to evaluate the association between heart rate indicators and all-cause mortality. Ordinal logistic regression was used to evaluate the association between heart rate indicators and worsening of functional outcome. RESULTS Among 191 MT-treated patients, 51(26.7%) patients died at 3-month after stroke. Increased mean heart rate per 10-bpm, heart rate SD and CV per 5-unit were all associated with the increased risk of mortality (adjusted hazard ratio [aHR] with 95% CI: 1.29 [1.09-1.51], 1.19 [1.07-1.32], 1.14 [1.03-1.27]; respectively). Patients in the highest tertile of heart rate SD had an increased risk of mortality (4.62, 1.70-12.52). After using mRS as a continuous variable, we found increased mean heart rate per 10-bpm, heart rate SD and CV per 5-unit were associated with the worsening of functional outcome (adjusted odds ratio [aOR] with 95% CI: 1.35 [1.11-1.64], 1.27 [1.05-1.53], 1.19 [1.02-1.40]; respectively). A linear relationship was observed between mean heart rate or heart rate SD and mortality; while all of the heart rate measures in this study showed a linear relationship with the worsening of functional outcome. CONCLUSIONS Higher mean heart rate and HRV were associated with the increased risk of 3-month all-cause mortality and worse functional outcome after MT therapy for AIS patients.
Collapse
Affiliation(s)
- Huaishun Wang
- Second Affiliated Hospital of Soochow University, Suzhou, 215004, China
| | - Longdong Xu
- Second Affiliated Hospital of Soochow University, Suzhou, 215004, China
- fifth People's Hospital of Changshu, Suzhou, 215004, China
| | - Li Dong
- Second Affiliated Hospital of Soochow University, Suzhou, 215004, China
| | - Yingzi Li
- Second Affiliated Hospital of Soochow University, Suzhou, 215004, China
| | - Huihui Liu
- Second Affiliated Hospital of Soochow University, Suzhou, 215004, China.
| | - Guodong Xiao
- Second Affiliated Hospital of Soochow University, Suzhou, 215004, China.
| |
Collapse
|
15
|
Wischmann J, Zimmermann H, Keidel L, Liebig T, Nolte CH, Kellert L. Aspiration only versus stent retriever only thrombectomy in basilar artery occlusion: a propensity score-matched analysis of the German Stroke Registry. J Neurointerv Surg 2024:jnis-2024-021797. [PMID: 38772571 DOI: 10.1136/jnis-2024-021797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 04/24/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND Endovascular treatment has become the standard care for acute basilar artery occlusion (BAO). Uncertainty persists about the optimal thrombectomy technique. OBJECTIVE To compare aspiration thrombectomy with stent retriever thrombectomy in patients with BAO in a multicenter real-world patient population. METHODS We analyzed data from the German Stroke Registry-Endovascular Treatment (GSR-ET). Patients with isolated BAO who underwent either aspiration or stent retriever thrombectomy were compared, including propensity score matching (PSM). The primary outcome measure was the modified Rankin Scale shift analysis at 90 days. Secondary outcomes included symptomatic intracranial hemorrhage (sICH), procedure complications, and metrics. RESULTS Of 13 082 patients in the GSR-ET, 387 patients (mean age 72.0±13.1 years; 45.0% female) fulfilled the inclusion criteria. The thrombectomy technique was aspiration only in 195 (50.4%) and stent retriever only in 192 (49.6%) patients. Functional outcome did not differ between the groups, either before (common OR (cOR) 0.94; 95% CI 0.64 to 1.38) or after PSM (cOR=1.37; 95% CI 0.90 to 2.09). There was no significant difference in sICH (2.6 vs 5.5%; P=0.231; OR=0.46; 95% CI 0.14 to 1.47), but aspiration thrombectomy demonstrated fewer procedure-related complications (4.6% vs 12.5%; P=0.017), a shorter procedure duration (24 vs 48 min; P<0.001), and higher first pass recanalization rates (75.1% vs 44.8%; P<0.001). CONCLUSIONS In this study both aspiration and stent retriever thrombectomy showed equal efficacy in terms of functional outcome in patients with BAO. However, procedure complications and metrics might favor aspiration over stent retriever thrombectomy.
Collapse
Affiliation(s)
- Johannes Wischmann
- Department of Neurology, Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
| | - Hanna Zimmermann
- Institute for Neuroradiology, Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
| | - Linus Keidel
- Department of Neurology, Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
| | - Thomas Liebig
- Institute for Neuroradiology, Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
| | - Christian H Nolte
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité - Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site, Berlin, Germany
| | - Lars Kellert
- Department of Neurology, Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
| |
Collapse
|
16
|
Kniep H, Meyer L, Broocks G, Bechstein M, Austein F, McDonough RV, Brekenfeld C, Flottmann F, Deb-Chatterji M, Alegiani A, Hanning U, Thomalla G, Fiehler J, Gellissen S. How much of the outcome improvement after successful recanalization is explained by follow-up infarct volume reduction? J Neurointerv Surg 2024; 16:459-465. [PMID: 37230748 DOI: 10.1136/jnis-2023-020296] [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: 03/08/2023] [Accepted: 05/15/2023] [Indexed: 05/27/2023]
Abstract
BACKGROUND Follow-up infarct volume (FIV) is used as surrogate for treatment efficiency in mechanical thrombectomy (MT). However, previous works suggest that MT-related FIV reduction has only limited association with outcome comparing MT independently of recanalization success versus medical care. It remains unclear to what extent the relationship between successful recanalization versus persistent occlusion and functional outcome is explained by FIV reduction. OBJECTIVE To determine whether FIV mediates the relationship between successful recanalization and functional outcome. METHODS All patients from our institution enrolled in the German Stroke Registry (May 2015-December 2019) with anterior circulation stroke; availability of the relevant clinical data, and follow-up-CT were analyzed. The effect of FIV reduction on functional outcome (90-day modified Rankin Scale (mRS) score ≤2) after successful recanalization (Thrombolysis in Cerebral Infarction ≥2b) was quantified using mediation analysis. RESULTS 429 patients were included, of whom, 309 (72 %) had successful recanalization and 127 (39%) had good functional outcome. Good outcome was associated with age (OR=0.89, P<0.001), pre-stroke mRS score (OR=0.38, P<0.001), FIV (OR=0.98, P<0.001), hypertension (OR=2.08, P<0.05), and successful recanalization (OR=3.57, P<0.01). Using linear regression in the mediator pathway, FIV was associated with Alberta Stroke program Early CT Score (coefficient (Co)=-26.13, P<0.001), admission National Institutes of Health Stroke Scale score (Co=3.69, P<0.001), age (Co=-1.18, P<0.05), and successful recanalization (Co=-85.22, P<0.001). Successful recanalization increased the probability of good outcome by 23 percentage points (pp) (95% CI 16pp to 29pp). 56% (95% CI 38% to 78%) of the improvement in good outcome was explained by FIV reduction. CONCLUSION 56% (95% CI 38% to 78%) of outcome improvement after successful recanalization was explained by FIV reduction. Results corroborate pathophysiological assumptions and confirm the value of FIV as an imaging endpoint in clinical trials. 44% (95% CI 22% to 62%) of the improvement in outcome was not explained by FIV reduction and reflects the remaining mismatch between radiological and clinical outcome measures.
Collapse
Affiliation(s)
- Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Friederike Austein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Rosalie V McDonough
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Schleswig-Holstein Campus Kiel, Kiel, Schleswig-Holstein, Germany
| | - Anna Alegiani
- Department of Neurology, Asklepios Klinik Altona, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Goetz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Gellissen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
17
|
Ordies S, De Brauwer T, De Beule T, Van Poucke S, Bekelaar K, Van Bylen B, Mesotten D. The effect of anesthesia on hemodynamics and outcome of patients undergoing thrombectomy after acute ischemic stroke: a retrospective analysis. Acta Neurol Belg 2024; 124:523-531. [PMID: 37857938 DOI: 10.1007/s13760-023-02399-4] [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: 05/10/2023] [Accepted: 09/26/2023] [Indexed: 10/21/2023]
Abstract
BACKGROUND Anesthesia during thrombectomy remains a matter of debate. We retrospectively investigated the influence of intraprocedural blood pressure and type of anaesthetic agent on 3-month functional outcome and mortality in stroke patients undergoing mechanical thrombectomy under general anesthesia in a single center study. METHODS All patients suffering from stroke who presented between January 2019 and July 2021 at Ziekenhuis Oost-Limburg Genk, Belgium and who received thrombectomy were included. Patient's characteristics and outcome data had been collected for benchmarking. Detailed perioperative data were exported from the electronic anesthesia records and clinically validated. Patients were stratified by peri-operative presence of hypotension (MAP < 65 mmHg at any time point) versus no-hypotension (MAP ≥ 65 mmHg). RESULTS All 98 patients received mechanical thrombectomy under general anesthesia. Thirty-six percent (n = 35) was hypotensive peri-operatively at any time point. Proportion of sevoflurane use was higher in non-hypotensive patients compared to hypotensive patients (73% (n = 45) vs. 51% (n = 18), p = 0.04). Peri-operative use of vasopressors was higher in the hypotensive group compared to non-hypotensive (88% (n = 30) vs. 63% (n = 39), p = 0.008). Proportion of patients with good functional outcome at 3 months (mRS 0-2) was higher in non-hypotensive patients compared to hypotensive patients 44% (n = 27) vs. 24% (n = 8), p < 0.05. 90-day mortality was lower in non-hypotensive patients compared to hypotensive patients 21% (n = 13) vs. 43% (n = 15), (p = 0.02). CONCLUSION Patients who are hypotensive at any given time during thrombectomy under general anesthesia may have worse neurological outcome compared to non-hypotensive patients. The best anaesthetic management for mechanical thrombectomy needs to be clarified prospectively in large multicenter studies.
Collapse
Affiliation(s)
- Sofie Ordies
- Department of Anaesthesiology, Emergency Medicine, Intensive Care Medicine and Multidisciplinary Pain Centre, Ziekenhuis Oost-Limburg, Genk, Belgium.
- University Hospitals Leuven, Leuven, Belgium.
| | - Thomas De Brauwer
- Department of Anaesthesiology, Emergency Medicine, Intensive Care Medicine and Multidisciplinary Pain Centre, Ziekenhuis Oost-Limburg, Genk, Belgium
- University Hospitals Leuven, Leuven, Belgium
| | - Tom De Beule
- Department of Neuroradiology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Sven Van Poucke
- Department of Anaesthesiology, Emergency Medicine, Intensive Care Medicine and Multidisciplinary Pain Centre, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Kim Bekelaar
- Department of Neurology, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Ben Van Bylen
- Department of Anaesthesiology, Emergency Medicine, Intensive Care Medicine and Multidisciplinary Pain Centre, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Dieter Mesotten
- Department of Anaesthesiology, Emergency Medicine, Intensive Care Medicine and Multidisciplinary Pain Centre, Ziekenhuis Oost-Limburg, Genk, Belgium
- Faculty of Medicine and Life Sciences, University of Hasselt, Diepenbeek, Belgium
| |
Collapse
|
18
|
Alhazmi H, Ameen OK, Almalki Z, Alanazi A, Albalawi A, Alshanqiti M, Almalki K, Alsaleh A, Khayat A, Ibrahim H, Almulhim IA, Jubran A, Almodarra N, Almansour N, Alnaaim SA, Al-Senani F, Shuaib A, Muthana J, Alotaibi M. Endovascular thrombectomy for acute ischemic stroke in Saudi Arabia: A single-center experience. J Stroke Cerebrovasc Dis 2024; 33:107552. [PMID: 38277959 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107552] [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: 07/23/2023] [Revised: 12/17/2023] [Accepted: 12/22/2023] [Indexed: 01/28/2024] Open
Abstract
PURPOSE This study aimed to investigate the outcomes of endovascular thrombectomy-treated patients in King Fahad Medical City, Riyadh, Saudi Arabia. METHODS A retrospective cohort study of acute ischemic stroke patients treated with endovascular thrombectomy. Patients were included in the study between January 2015 and December 2022. Good outcomes were defined as a modified Rankin Scale (mRS) of 0-2 at 90 days. Multivariate logistic regression analysis was performed to identify the independent factors associated with good outcomes. RESULTS During the study period, 369 patients with acute ischemic stroke (mean ± SD age, 61/- 15.1 yrs; 55.4 % male) underwent mechanical thrombectomy. Median National Institute of Health Stroke Scale (NIHSS) 15. Intravenous thrombolysis was administered to 34.5 % of the patients. Successful recanalization in the anterior circulation was achieved in 84.8 % of patients. Data from mRS performed after 90 days in the anterior circulation were available for 71.2 % of the patients. Of these, 41 % showed a good outcome, and the mortality rate was 22.4 %. The significant factors associated with good outcomes were age, NIHSS score, Alberta Stroke Program Early Computed Tomography Score (ASPECTS), and short arterial puncture to recanalization. CONCLUSION The number of patients who underwent endovascular thrombectomy has increased over time. The treatment outcomes and mortality were comparable with those of previous endovascular thrombectomy registries despite the high prevalence of DM, lower ASPECT score, and prolonged onset-to-recanalization time.
Collapse
Affiliation(s)
- Hanan Alhazmi
- National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia.
| | - Omar K Ameen
- National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ziyad Almalki
- Department of Clinical Pharmacy, College of Pharmacy, Prince Sattam bin Abdulaziz University, Alkharj 11942, Saudi Arabia
| | - Abdulmajeed Alanazi
- National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ali Albalawi
- National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Mahmoud Alshanqiti
- National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Khalid Almalki
- National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ali Alsaleh
- National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Alaa Khayat
- National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Hatim Ibrahim
- National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ibrahim A Almulhim
- Department of Medical Imaging, Diagnostic & Interventional Neuroradiology section, King Fahad Medical City, Riyadh, Saudi Arabia; Department of Interventional Neuroradiology, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Abdulrahman Jubran
- Department of Medical Imaging, Diagnostic & Interventional Neuroradiology section, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Nehal Almodarra
- National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Nouf Almansour
- National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Saud A Alnaaim
- Assistant professor, College of Medicine, Clinical Neuroscience department, King Faisal University, Hofuf, Saudi Arabia
| | - Fahmi Al-Senani
- National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Ashfaq Shuaib
- Stroke Program, Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Jamal Muthana
- National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia
| | - Mohammed Alotaibi
- National Neuroscience Institute, King Fahad Medical City, Riyadh, Saudi Arabia; Neurology Section, Department of Medicine, Faculty of Medicine, King Saud University, Riyadh, Saudi Arabia
| |
Collapse
|
19
|
Palsson F, Forkert ND, Meyer L, Broocks G, Flottmann F, Maros ME, Bechstein M, Winkelmeier L, Schlemm E, Fiehler J, Gellißen S, Kniep HC. Prediction of tissue outcome in acute ischemic stroke based on single-phase CT angiography at admission. Front Neurol 2024; 15:1330497. [PMID: 38566856 PMCID: PMC10985353 DOI: 10.3389/fneur.2024.1330497] [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: 10/30/2023] [Accepted: 03/05/2024] [Indexed: 04/04/2024] Open
Abstract
Introduction In acute ischemic stroke, prediction of the tissue outcome after reperfusion can be used to identify patients that might benefit from mechanical thrombectomy (MT). The aim of this work was to develop a deep learning model that can predict the follow-up infarct location and extent exclusively based on acute single-phase computed tomography angiography (CTA) datasets. In comparison to CT perfusion (CTP), CTA imaging is more widely available, less prone to artifacts, and the established standard of care in acute stroke imaging protocols. Furthermore, recent RCTs have shown that also patients with large established infarctions benefit from MT, which might not have been selected for MT based on CTP core/penumbra mismatch analysis. Methods All patients with acute large vessel occlusion of the anterior circulation treated at our institution between 12/2015 and 12/2020 were screened (N = 404) and 238 patients undergoing MT with successful reperfusion were included for final analysis. Ground truth infarct lesions were segmented on 24 h follow-up CT scans. Pre-processed CTA images were used as input for a U-Net-based convolutional neural network trained for lesion prediction, enhanced with a spatial and channel-wise squeeze-and-excitation block. Post-processing was applied to remove small predicted lesion components. The model was evaluated using a 5-fold cross-validation and a separate test set with Dice similarity coefficient (DSC) as the primary metric and average volume error as the secondary metric. Results The mean ± standard deviation test set DSC over all folds after post-processing was 0.35 ± 0.2 and the mean test set average volume error was 11.5 mL. The performance was relatively uniform across models with the best model according to the DSC achieved a score of 0.37 ± 0.2 after post-processing and the best model in terms of average volume error yielded 3.9 mL. Conclusion 24 h follow-up infarct prediction using acute CTA imaging exclusively is feasible with DSC measures comparable to results of CTP-based algorithms reported in other studies. The proposed method might pave the way to a wider acceptance, feasibility, and applicability of follow-up infarct prediction based on artificial intelligence.
Collapse
Affiliation(s)
- Frosti Palsson
- deCODE Genetics Inc., Reykjavik, Iceland
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Nils D. Forkert
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Alberta Children’s Hospital Research Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Máté E. Maros
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laurens Winkelmeier
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Eckhard Schlemm
- Department of Neurology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Gellißen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge C. Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
20
|
Nashed JY, Shearer KT, Wang JZ, Chen Y, Cook EE, Champagne AA, Coverdale NS, Fernandez-Ruiz J, Striver SI, Flanagan JR, Gallivan JP, Cook DJ. Spontaneous Behavioural Recovery Following Stroke Relates to the Integrity of Parietal and Temporal Regions. Transl Stroke Res 2024; 15:127-139. [PMID: 36542292 DOI: 10.1007/s12975-022-01115-3] [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: 06/08/2022] [Revised: 11/29/2022] [Accepted: 12/03/2022] [Indexed: 12/24/2022]
Abstract
Stroke is a devastating disease that results in neurological deficits and represents a leading cause of death and disability worldwide. Following a stroke, there is a degree of spontaneous recovery of function, the neural basis of which is of great interest among clinicians in their efforts to reduce disability following stroke and enhance rehabilitation. Conventionally, work on spontaneous recovery has tended to focus on the neural reorganization of motor cortical regions, with comparably little attention being paid to changes in non-motor regions and how these relate to recovery. Here we show, using structural neuroimaging in a macaque stroke model (N = 31) and by exploiting individual differences in spontaneous behavioural recovery, that the preservation of regions in the parietal and temporal cortices predict animal recovery. To characterize recovery, we performed a clustering analysis using Non-Human Primate Stroke Scale (NHPSS) scores and identified a good versus poor recovery group. By comparing the preservation of brain volumes in the two groups, we found that brain areas in integrity of brain areas in parietal, temporal and somatosensory cortex were associated with better recovery. In addition, a decoding approach performed across all subjects revealed that the preservation of specific brain regions in the parietal, somatosensory and medial frontal cortex predicted recovery. Together, these findings highlight the importance of parietal and temporal regions in spontaneous behavioural recovery.
Collapse
Affiliation(s)
- Joseph Y Nashed
- Department of Translational Medicine, Queen's University, 18 Stuart Street, Room 230, Botterell Hall, Kingston, Ontario, K7L 3N6, Canada
- Centre of Neuroscience Studies, Queen's University, Kingston, Ontario, K7L 3N6, Canada
- School of Medicine, Queen's University, Kingston, Ontario, K7L 3N6, Canada
| | - Kaden T Shearer
- Centre of Neuroscience Studies, Queen's University, Kingston, Ontario, K7L 3N6, Canada
- School of Medicine, Queen's University, Kingston, Ontario, K7L 3N6, Canada
| | - Justin Z Wang
- School of Medicine, Queen's University, Kingston, Ontario, K7L 3N6, Canada
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, M5T 1P5, Canada
| | - Yining Chen
- School of Medicine, Queen's University, Kingston, Ontario, K7L 3N6, Canada
| | - Elise E Cook
- Centre of Neuroscience Studies, Queen's University, Kingston, Ontario, K7L 3N6, Canada
| | - Allen A Champagne
- School of Medicine, Queen's University, Kingston, Ontario, K7L 3N6, Canada
| | - Nicole S Coverdale
- Centre of Neuroscience Studies, Queen's University, Kingston, Ontario, K7L 3N6, Canada
| | - Juan Fernandez-Ruiz
- Departamento de Fisiología, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City, Mexico
| | - Shirley I Striver
- Division of Neurosurgery, Department of Surgery, Queen's University, Kingston, Ontario, K7L 2V7, Canada
| | - J Randal Flanagan
- Centre of Neuroscience Studies, Queen's University, Kingston, Ontario, K7L 3N6, Canada
- Department of Psychology, Queen's University, Kingston, Ontario, K7L 3N6, Canada
| | - Jason P Gallivan
- Centre of Neuroscience Studies, Queen's University, Kingston, Ontario, K7L 3N6, Canada
- Department of Psychology, Queen's University, Kingston, Ontario, K7L 3N6, Canada
- Department of Biomedical and Molecular Sciences, Queen's University, Kingston, Ontario, K7L 3N6, Canada
| | - Douglas J Cook
- Department of Translational Medicine, Queen's University, 18 Stuart Street, Room 230, Botterell Hall, Kingston, Ontario, K7L 3N6, Canada.
- Centre of Neuroscience Studies, Queen's University, Kingston, Ontario, K7L 3N6, Canada.
- School of Medicine, Queen's University, Kingston, Ontario, K7L 3N6, Canada.
- Division of Neurosurgery, Department of Surgery, Queen's University, Kingston, Ontario, K7L 2V7, Canada.
| |
Collapse
|
21
|
Brugnara G, Engel A, Jesser J, Ringleb PA, Purrucker J, Möhlenbruch MA, Bendszus M, Neuberger U. Cortical atrophy on baseline computed tomography imaging predicts clinical outcome in patients undergoing endovascular treatment for acute ischemic stroke. Eur Radiol 2024; 34:1358-1366. [PMID: 37581657 PMCID: PMC10853300 DOI: 10.1007/s00330-023-10107-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2023] [Revised: 06/05/2023] [Accepted: 07/01/2023] [Indexed: 08/16/2023]
Abstract
OBJECTIVE Multiple variables beyond the extent of recanalization can impact the clinical outcome after acute ischemic stroke due to large vessel occlusions. Here, we assessed the influence of small vessel disease and cortical atrophy on clinical outcome using native cranial computed tomography (NCCT) in a large single-center cohort. METHODS A total of 1103 consecutive patients who underwent endovascular treatment (EVT) due to occlusion of the middle cerebral artery territory were included. NCCT data were visually assessed for established markers of age-related white matter changes (ARWMC) and brain atrophy. All images were evaluated separately by two readers to assess the inter-observer variability. Regression and machine learning models were built to determine the predictive relevance of ARWMC and atrophy in the presence of important baseline clinical and imaging metrics. RESULTS Patients with favorable outcome presented lower values for all measured metrics of pre-existing brain deterioration (p < 0.001). Both ARWMC (p < 0.05) and cortical atrophy (p < 0.001) were independent predictors of clinical outcome at 90 days when controlled for confounders in both regression analyses and led to a minor improvement of prediction accuracy in machine learning models (p < 0.001), with atrophy among the top-5 predictors. CONCLUSION NCCT-based cortical atrophy and ARWMC scores on NCCT were strong and independent predictors of clinical outcome after EVT. CLINICAL RELEVANCE STATEMENT Visual assessment of cortical atrophy and age-related white matter changes on CT could improve the prediction of clinical outcome after thrombectomy in machine learning models which may be integrated into existing clinical routines and facilitate patient selection. KEY POINTS • Cortical atrophy and age-related white matter changes were quantified using CT-based visual scores. • Atrophy and age-related white matter change scores independently predicted clinical outcome after mechanical thrombectomy and improved machine learning-based prediction models. • Both scores could easily be integrated into existing clinical routines and prediction models.
Collapse
Affiliation(s)
- Gianluca Brugnara
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- Division of Computational Neuroimaging, Heidelberg University Hospital, Heidelberg, Germany
| | - Adrian Engel
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
- Department of Neurosurgery, Essen University Hospital, Essen, Germany
| | - Jessica Jesser
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | | | - Jan Purrucker
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Markus A Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany
| | - Ulf Neuberger
- Department of Neuroradiology, Heidelberg University Hospital, Im Neuenheimer Feld 400, 69120, Heidelberg, Germany.
- Division of Computational Neuroimaging, Heidelberg University Hospital, Heidelberg, Germany.
| |
Collapse
|
22
|
Deguchi I, Osada T, Nakagami T, Kohyama S, Takahashi S. A Study of Factors Affecting Functional Outcomes in Patients With Successful Recanalization by Mechanical Thrombectomy. Cureus 2024; 16:e54085. [PMID: 38487124 PMCID: PMC10937116 DOI: 10.7759/cureus.54085] [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: 02/11/2024] [Indexed: 03/17/2024] Open
Abstract
BACKGROUND AND PURPOSE Reperfusion therapy is typically performed in cases with acute cerebral infarction. Mechanical thrombectomy (MT) achieves superior recanalization and favorable outcomes. However, some patients have poor functional prognosis despite successful recanalization. We investigated factors affecting functional prognosis after MT with good reperfusion. METHODS Among the 205 consecutive cases with ischemic stroke treated with MT at our center from January 1, 2019 to March 31, 2021, 168 with successful recanalization were included. Factors affecting early neurological improvement (ENI) and modified Rankin Scale (mRS) scores were reviewed retrospectively. RESULTS There were 93 (55%) cases with ENI and 75 (45%) without ENI. The times from onset to recombinant tissue-type plasminogen activator administration and recanalization in ENI cases were shorter than those in non-ENI cases. However, non-ENI cases had significantly higher Fazekas grades for white matter lesions. In multivariate analysis, the Fazekas grade was related to ENI (odds ratio [OR]=0.572, 95% confidence interval [CI]=0.345-0.948). The mRS score at discharge was 0-2 in 64 cases (good outcome) and 3-6 in 104 cases (poor outcome). Patients with a poor outcome had a significantly higher age, National Institutes of Health Stroke Scale (NIHSS) score, and Fazekas grade. Multivariate analysis revealed that the NIHSS score (OR=1.073, 95% CI=1.020-1.129) and Fazekas grade (OR=2.162, 95% CI=1.458-3.205) at hospitalization affected the mRS score at discharge. CONCLUSION There is a correlation of greater severity of white matter lesions with poorer ENI and clinical outcomes at discharge post-MT.
Collapse
Affiliation(s)
- Ichiro Deguchi
- Departments of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Hidaka, JPN
| | - Takashi Osada
- Departments of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Hidaka, JPN
| | - Toru Nakagami
- Departments of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Hidaka, JPN
| | - Shinya Kohyama
- Department of Endovascular Neurosurgery, Saitama Medical University International Medical Center, Hidaka, JPN
| | - Shinichi Takahashi
- Departments of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Hidaka, JPN
| |
Collapse
|
23
|
Kim JE, Lee RP, Yazigi E, Atta L, Feghali J, Pant A, Jain A, Levitan I, Kim E, Patel K, Kannapadi N, Shah P, Bibic A, Hou Z, Caplan JM, Gonzalez LF, Huang J, Xu R, Fan J, Tyler B, Brem H, Boussiotis VA, Jantzie L, Robinson S, Koehler RC, Lim M, Tamargo RJ, Jackson CM. Soluble PD-L1 reprograms blood monocytes to prevent cerebral edema and facilitate recovery after ischemic stroke. Brain Behav Immun 2024; 116:160-174. [PMID: 38070624 PMCID: PMC11220828 DOI: 10.1016/j.bbi.2023.12.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Revised: 11/20/2023] [Accepted: 12/04/2023] [Indexed: 01/21/2024] Open
Abstract
Acute cerebral ischemia triggers a profound inflammatory response. While macrophages polarized to an M2-like phenotype clear debris and facilitate tissue repair, aberrant or prolonged macrophage activation is counterproductive to recovery. The inhibitory immune checkpoint Programmed Cell Death Protein 1 (PD-1) is upregulated on macrophage precursors (monocytes) in the blood after acute cerebrovascular injury. To investigate the therapeutic potential of PD-1 activation, we immunophenotyped circulating monocytes from patients and found that PD-1 expression was upregulated in the acute period after stroke. Murine studies using a temporary middle cerebral artery (MCA) occlusion (MCAO) model showed that intraperitoneal administration of soluble Programmed Death Ligand-1 (sPD-L1) significantly decreased brain edema and improved overall survival. Mice receiving sPD-L1 also had higher performance scores short-term, and more closely resembled sham animals on assessments of long-term functional recovery. These clinical and radiographic benefits were abrogated in global and myeloid-specific PD-1 knockout animals, confirming PD-1+ monocytes as the therapeutic target of sPD-L1. Single-cell RNA sequencing revealed that treatment skewed monocyte maturation to a non-classical Ly6Clo, CD43hi, PD-L1+ phenotype. These data support peripheral activation of PD-1 on inflammatory monocytes as a therapeutic strategy to treat neuroinflammation after acute ischemic stroke.
Collapse
Affiliation(s)
- Jennifer E Kim
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Ryan P Lee
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Eli Yazigi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Lyla Atta
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, the United States of America; Center for Computational Biology, Whiting School of Engineering, Johns Hopkins University, Baltimore, MD, the United States of America; Medical Scientist Training Program, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - James Feghali
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Ayush Pant
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America; Medical Scientist Training Program, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Aanchal Jain
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Idan Levitan
- Department of Neurosurgery, Rabin Medical Center, Sackler Medical School, Petah Tikva, Israel
| | - Eileen Kim
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Kisha Patel
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Nivedha Kannapadi
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Pavan Shah
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Adnan Bibic
- F.M. Kirby Research Center for Functional Brain Imaging, Kennedy Krieger Institute, Baltimore, MD, the United States of America; The Russell H. Morgan Department of Radiology and Radiological Science, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Zhipeng Hou
- Department of Radiology, School of Medicine, Johns Hopkins University, Baltimore, MD, the United States of America
| | - Justin M Caplan
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - L Fernando Gonzalez
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Judy Huang
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Jean Fan
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, MD, the United States of America
| | - Betty Tyler
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Henry Brem
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Vassiliki A Boussiotis
- Division of Hematology-Oncology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, the United States of America
| | - Lauren Jantzie
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America; Departments of Pediatrics, Johns Hopkins University School of Medicine, Maryland, the United States of America; Kennedy Krieger Institute, Maryland, the United States of America; Department of Neurology, Johns Hopkins University School of Medicine, Maryland, the United States of America
| | - Shenandoah Robinson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America; Departments of Pediatrics, Johns Hopkins University School of Medicine, Maryland, the United States of America; Kennedy Krieger Institute, Maryland, the United States of America; Department of Neurology, Johns Hopkins University School of Medicine, Maryland, the United States of America
| | - Raymond C Koehler
- Departments of Anesthesiology and Critical Care Medicine, Johns Hopkins University, School of Medicine, Baltimore, MD, the United States of America
| | - Michael Lim
- Department of Neurosurgery, Stanford University School of Medicine, Stanford, CA, the United States of America
| | - Rafael J Tamargo
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America
| | - Christopher M Jackson
- Department of Neurosurgery, Johns Hopkins University School of Medicine, Baltimore, MD, the United States of America.
| |
Collapse
|
24
|
Sporns PB, Fischer U, Katan M, Ospel JM, Brehm A, Tsogkas I, Holodinsky JK, Kamal N, Fiehler J, Psychogios MN. Simulation of transportation of acute stroke patients in border regions. Sci Rep 2024; 14:1736. [PMID: 38242912 PMCID: PMC10798996 DOI: 10.1038/s41598-024-51959-y] [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: 05/22/2023] [Accepted: 01/11/2024] [Indexed: 01/21/2024] Open
Abstract
Determining the optimal transportation for each stroke patient is critically important to achieve the best possible outcomes. In border regions the next comprehensive stroke center may be just across an international border, but bureaucratic and financial hurdles may prevent a simple transfer to the next stroke center. We hypothesized that in regions close to international borders, patients may benefit from an "open border, closed transfer scenario", meaning that patients in whom a large vessel occlusion (LVO) is detected in the primary stroke center will benefit from a transfer to the nearest stroke center offering endovascular thrombectomy-even if this may be across a national border. We used the Swiss-German-French trinational region as an example for a region with several international borders within close proximity to one another, and compared two feasible scenarios; (a) a "closed borders, open transfer" scenario, where the patient is transported to any center in the same country, (b) an "open border, closed transfer" scenario, where patients are always transported to the nearby primary stroke center first and then to the nearest comprehensive stroke center in either the same or a neighboring country and (c) and "open borders, open transfer" scenario. The outcome of interest was the predicted probability of acute ischemic stroke patients to achieve a good outcome using a conditional probability model which predicts the likelihood of excellent outcome (modified Rankin scale score of 0-1 at 90 days post-stroke) for patients with suspected LVO. Results were modeled in a virtual map from which the ideal transport concept emerged. For an exemplary LVO stroke patient in Germany, the probability of a good outcome was higher in an open border, closed transfer scenario than with closed borders, open transfer (33.1 vs. 30.1%). Moreover, time to EVT would decrease from 232 min in the first scenario to 169 min in an open border, closed transfer scenario. The catchment area of the University Hospital Basel was almost double the size in an open border, closed transfer scenario compared to closed borders (1674 km2 vs. 2897 km2) and would receive transfers from 3 primary stroke centers in other countries (2 in Germany and 1 in France). Stroke patients showed a higher likelihood of good outcome in the "open border" scenarios without transfer restrictions to a specific healthcare system. This probably has implications for stroke treatment in all border regions where EVT eligible stroke patients may benefit from transport to the closest EVT capable center whenever possible, regardless of whether this hospital is located in the same or a neighboring country/jurisdiction.
Collapse
Affiliation(s)
- Peter B Sporns
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, 4031, Basel, Switzerland.
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
| | - Urs Fischer
- Department of Neurology, University Hospital of Basel, 4031, Basel, Switzerland
| | - Mira Katan
- Department of Neurology, University Hospital of Basel, 4031, Basel, Switzerland
| | - Johanna M Ospel
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, 4031, Basel, Switzerland
| | - Alex Brehm
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, 4031, Basel, Switzerland
| | - Ioannis Tsogkas
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, 4031, Basel, Switzerland
| | - Jessalyn K Holodinsky
- Department of Clinical Neurosciences, Cumming School of Medicine, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Noreen Kamal
- Department of Industrial Engineering, Faculty of Engineering, Dalhousie University, Halifax, NS, Canada
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marios-Nikos Psychogios
- Department of Neuroradiology, Clinic for Radiology & Nuclear Medicine, University Hospital Basel, 4031, Basel, Switzerland
| |
Collapse
|
25
|
Feldman MJ, Koester SW, Chaliff RS, Yengo-Kahn A, Wong G, Roth S, Longo M, Fusco MR, Froehler MT, Chitale R. Oral health and functional outcomes following mechanical thrombectomy for ischemic stroke. J Neurointerv Surg 2023; 15:e409-e413. [PMID: 36849247 DOI: 10.1136/jnis-2022-019392] [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: 10/26/2022] [Accepted: 02/14/2023] [Indexed: 02/28/2023]
Abstract
BACKGROUND An association between poor dentition and the risk of ischemic stroke has previously been reported in the literature. In this study we assessed oral hygiene (OH), including tooth loss and the presence of dental disease, to determine if an association exists with functional outcomes following mechanical thrombectomy (MT) for large-vessel ischemic stroke. METHODS A retrospective review was conducted of consecutive adult patients at a single comprehensive stroke center who underwent MT from 2012 to 2018. Inclusion criteria included availability of CT imaging to radiographically assess OH. A multivariate analysis was performed, with the primary outcome being 90-day post-thrombectomy modified Rankin Scale (mRS) score >2. RESULTS A total of 276 patients met the inclusion criteria. The average number of missing teeth was significantly higher in patients with a poor functional outcome (mean (SD) 10 (11) vs 4 (6), p<0.001). The presence of dental disease was associated with poor functional outcome, including cavities (21 (27%) vs 13 (8%), p<0.001), periapical infection (18 (23%) vs 11 (6.7%), p<0.001), and bone loss (27 (35%) vs 11 (6.7%), p<0.001). Unadjusted, missing teeth was a univariate predictor of poor outcome (OR 1.09 (95% CI 1.06 to 1.13), p<0.001). After adjustment for recanalization scores and use of tissue plasminogen activator (tPA), missing teeth remained a predictor of poor outcome (OR 1.07 (95% CI 1.03 to 1.11), p<0.001). CONCLUSION Missing teeth and the presence of dental disease are inversely correlated with functional independence following MT, independent of thrombectomy success or tPA status.
Collapse
Affiliation(s)
- Michael J Feldman
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Stefan W Koester
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Ryan S Chaliff
- Department of Oral and Maxillofacial Surgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Aaron Yengo-Kahn
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Gunther Wong
- Vanderbilt University School of Medicine, Nashville, Tennessee, USA
| | - Steven Roth
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael Longo
- Department of Neurosurgery, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Matthew R Fusco
- Vanderbilt Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Michael T Froehler
- Vanderbilt Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - Rohan Chitale
- Vanderbilt Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| |
Collapse
|
26
|
Qiu K, Jia ZY, Cao Y, Zhao LB, Zu Q, Shi HB, Liu S. Emergency admission plasma D-dimer: a novel predictor for symptomatic intracranial hemorrhage after thrombectomy in acute ischemic stroke. J Neurointerv Surg 2023; 15:e375-e380. [PMID: 36604175 DOI: 10.1136/jnis-2022-019719] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2022] [Accepted: 12/23/2022] [Indexed: 01/07/2023]
Abstract
BACKGROUND Symptomatic intracranial hemorrhage (sICH) is a common and severe complication in patients with acute ischemic stroke (AIS) after treatment with thrombectomy. OBJECTIVE To explore the ability of admission plasma D-dimer levels to predict sICH after thrombectomy. METHODS Between February 2018 and August 2021, consecutive patients with AIS who underwent thrombectomy at our single comprehensive stroke center were retrospectively enrolled. sICH was defined according to the criterion of the Heidelberg Bleeding Classification. Logistic regression analysis was performed to determine the risk factors of sICH. The overall discriminative ability of D-dimer levels in predicting sICH was evaluated by adopting a receiver operating characteristic (ROC) curve. RESULTS Of the 395 enrolled patients, 48 (12.2%) had sICH. Patients with sICH were older (72.9 vs 69.3 years, P=0.037), more often female (62.5% vs 45.5%, P=0.027), had higher D-dimer levels (2.70 vs 0.74 mg/L, P<0.001), higher National Institutes of Health Stroke Scale score (20 vs 15, P<0.001), lower Alberta Stroke Program Early CT Score (8 vs 9, P<0.001), a higher proportion of internal carotid artery occlusions (56.2% vs 30.3%, P<0.001), and less commonly had large-artery atherosclerosis stroke etiology (12.5% vs 32.3%, P=0.010) than patients without sICH. After adjustment for potential confounders, D-dimer levels (adjusted OR=2.45, 95% CI 1.75 to 3.43, P<0.001) remained significantly associated with sICH. Based on the ROC, the D-dimer as a predictor for predicting sICH, presented with a specificity of 86.2%, a negative predictive value of 94.6%, and an area under the curve of 0.774. CONCLUSION Elevated admission D-dimer levels are an independent predictor of sICH in patients with AIS after thrombectomy.
Collapse
Affiliation(s)
- Kai Qiu
- Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Zhen Yu Jia
- Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Yuezhou Cao
- Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Lin-Bo Zhao
- Department of Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, JiangSu, China
| | - Qingquan Zu
- Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Hai-Bin Shi
- Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| | - Sheng Liu
- Department of Interventional Radiology, The First Affiliated Hospital with Nanjing Medical University, Nanjing, China
| |
Collapse
|
27
|
Kniep H, Meyer L, Broocks G, Faizy TD, Bechstein M, Brekenfeld C, Flottmann F, van Horn N, Geest V, Winkelmeier L, Alegiani A, Deb-Chatterji M, Hanning U, Thomalla G, Fiehler J, Gellissen S. Thrombectomy in M2 occlusion compared to M1 occlusion: treatment effects of Thrombolysis In Cerebral Infarction (TICI) 2b and TICI 3 recanalization on functional outcome. J Neurointerv Surg 2023; 15:e438-e445. [PMID: 36990689 PMCID: PMC10803999 DOI: 10.1136/jnis-2022-019898] [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: 11/20/2022] [Accepted: 02/14/2023] [Indexed: 03/31/2023]
Abstract
BACKGROUND Emerging data suggest that mechanical thrombectomy (MT) might also be safe and efficient for medium and distal occlusions. This study aims to compare average treatment effects on functional outcome of different degrees of recanalization after MT in patients with M2 occlusion and M1 occlusion. METHODS All patients enrolled in the German Stroke Registry (GSR) between June 2015 and December 2021 were analyzed. Inclusion criteria were stroke with primary M1 occlusion or M2 occlusion, and availability of relevant clinical data. 4259 patients were included, thereof 1353 with M2 occlusion and 2906 with M1 occlusion. Treatment effects were analyzed using double-robust inverse-probability-weighted regression-adjustment (IPWRA) estimators to control for confounding covariates. Binarized endpoint metrics were defined as good outcome with modified Rankin Scale (mRS) ≤2 at 90 days, and linearized endpoint metrics were defined as mRS shift pre-stroke to 90 days. Effects were evaluated for near complete recanalization (Thrombolysis In Cerebral Infarction scale (TICI) 2b) and complete recanalization (TICI 3). RESULTS Treatment effect estimation for TICI ≥2b versus TICI <2b in M2 occlusions showed an increase in the probability of a good outcome from 27% to 47% with a number-needed-to-treat (NNT) of 5. For M1 occlusions the probability of a good outcome increased from 16% to 38% with NNT 4.5. TICI 3 versus TICI 2b increased the probability of a good outcome by 7 percentage points in M1 occlusions; for M2 occlusions the beneficial effect was not significant. CONCLUSIONS Results suggest that successful recanalization with TICI ≥2b versus TICI <2b after MT in M2 occlusions provides significant patient benefit with treatment effects comparable to M1 occlusions. The probability of functional independence increased by 20 percentage points (NNT 5) and stroke-related mRS increase was reduced by 0.9 mRS points. In contrast to M1 occlusions, complete recanalization TICI 3 versus TICI 2b had lower additional beneficial effect.
Collapse
Affiliation(s)
- Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Radiology, Stanford University School of Medicine, Stanford, California, USA
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Noel van Horn
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Vincent Geest
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laurens Winkelmeier
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Alegiani
- Department of Neurology, Asklepios Klinik Altona, Hamburg, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Goetz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Susanne Gellissen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
28
|
Marko M, Goyal M, Ospel JM, Singh N, Venema E, Nogueira RG, Demchuk AM, McTaggart RA, Poppe AY, Menon BK, Zerna C, Mulder M, Dippel DW, Lingsma HF, Roozenbeek B, Tymianski M, Hill MD. Predicting outcome in acute stroke with large vessel occlusion-application and validation of MR PREDICTS in the ESCAPE-NA1 population. Interv Neuroradiol 2023:15910199231221491. [PMID: 38115793 DOI: 10.1177/15910199231221491] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2023] Open
Abstract
BACKGROUND Predicting outcome after endovascular treatment for acute ischemic stroke is challenging. We aim to investigate differences between predicted and observed outcomes in patients with acute ischemic stroke treated with endovascular treatment and to evaluate the performance of a validated outcome prediction score. PATIENTS AND METHODS MR PREDICTS is an outcome prediction tool based on a logistic regression model designed to predict the treatment benefit of endovascular treatment based on the MR CLEAN and HERMES populations. ESCAPE-NA1 is a randomized trial of nerinetide vs. placebo in patients with acute stroke and large vessel occlusion. We applied MR PREDICTS to patients in the control arm of ESCAPE-NA1. Model performance was assessed by calculating its discriminative ability and calibration. RESULTS Overall, 556/1105 patients (50.3%) in the ESCAPE-NA1-trial were randomized to the control arm, 435/556 (78.2%) were treated within 6 h of symptom onset. Good outcome (modified Rankin scale 0-2) at 3 months was achieved in 275/435 patients (63.2%), the predicted probability of good outcome was 52.5%. Baseline characteristics were similar in the study and model derivation cohort except for age (ESCAPE-NA1: mean: 70 y vs. HERMES: 66 y), hypertension (72% vs. 57%), and collaterals (good collaterals, 15% vs. 44%). Compared to HERMES we observed higher rates of successful reperfusion (TICI 2b-3, ESCAPE-NA1: 87% vs. HERMES: 71%) and faster times from symptom onset to reperfusion (median: 201 min vs. 286 min). Model performance was good, indicated by a c-statistic of 0.76 (95%confidence interval: 0.71-0.81). CONCLUSION Outcome-prediction using models created from HERMES data, based on information available in the emergency department underestimated the actual outcome in patients with acute ischemic stroke and large vessel occlusion receiving endovascular treatment despite overall good model performance, which might be explained by differences in quality of and time to reperfusion. These findings underline the importance of timely and successful reperfusion for functional outcomes in acute stroke patients.
Collapse
Affiliation(s)
- Martha Marko
- Department of Neurology, Medical University of Vienna, Wien, Austria
| | - Mayank Goyal
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Johanna M Ospel
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Nishita Singh
- Department of Clinical Neurosciences, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada
| | - Esmee Venema
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Emergency Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Raul G Nogueira
- Emory University School of Medicine, Grady Memorial Hospital, Atlanta, USA
| | - Andrew M Demchuk
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Ryan A McTaggart
- Warren Alpert School of Medicine, Brown University, Providence, RI, USA
| | - Alexandre Y Poppe
- Department of Medicine (Neurology), Centre Hospitalier de l'Université de Montréal, QC, Calgary, Canada
| | - Bijoy K Menon
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Charlotte Zerna
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
| | - Maxim Mulder
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Diederik Wj Dippel
- Department of Emergency Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | - Bob Roozenbeek
- Department of Public Health, Erasmus MC University Medical Center, Rotterdam, the Netherlands
- Department of Radiology & Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, the Netherlands
| | | | - Michael D Hill
- Department of Clinical Neurosciences, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Radiology, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary, Calgary, Canada
- Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada
| |
Collapse
|
29
|
Loo JH, Leow AS, Jing M, Sia CH, Chan BP, Seet RC, Teoh HL, Meyer L, Fiehler J, Papanagiotou P, Kastrup A, Mpotsaris A, Maus V, Yapici F, Simonato D, Gabrieli JD, Cester G, Bhogal P, Spooner O, Nikola C, Joshi A, Lee TH, Wu J, Chen Y, Yang S, Sharma VK, Tan BY, Yeo LL. Impact of atrial fibrillation on the treatment effect of bridging thrombolysis in ischemic stroke patients undergoing endovascular thrombectomy: a multicenter international cohort study. J Neurointerv Surg 2023; 15:1274-1279. [PMID: 36609541 DOI: 10.1136/jnis-2022-019590] [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: 09/06/2022] [Accepted: 12/23/2022] [Indexed: 01/09/2023]
Abstract
BACKGROUND The role of bridging intravenous thrombolysis (IVT) before endovascular thrombectomy (EVT) in the treatment of acute ischemic stroke (AIS) remains debatable. Atrial fibrillation (AF) associated strokes may be associated with reduced treatment effect from IVT. This study compares the effect of bridging IVT in AF and non-AF patients. METHODS This retrospective cohort study comprised anterior circulation large vessel occlusion (LVO) AIS patients receiving EVT alone or bridging IVT plus EVT within 6 hours of symptom onset. Primary outcome was good functional outcome defined as modified Rankin Scale (mRS) 0-2 at 90 days. Secondary outcomes were successful reperfusion defined as expanded Thrombolysis In Cerebral Infarction (eTICI) grading ≥2b flow, symptomatic intracerebral hemorrhage (sICH), and in-hospital mortality. RESULTS We included 705 patients (314 AF and 391 non-AF patients). The mean age was 68.6 years and 53.9% were male. The odds of good functional outcomes with bridging IVT was higher in the non-AF (adjusted odds ratio (aOR) 2.28, 95% CI 1.06 to 4.91, P=0.035) compared with the AF subgroups (aOR 1.89, 95% CI 0.89 to 4.01, P=0.097). However, this did not constitute a significant effect modification by the presence of AF on bridging IVT (interaction aOR 0.12, 95% CI -1.94 to 2.18, P=0.455). The rate of successful reperfusion, sICH, and mortality were similar between bridging IVT and EVT for both AF and non-AF patients. CONCLUSION The presence of AF did not modify the treatment effect of bridging IVT. Further individual patient data meta-analysis of randomized trials may shed light on the comparative efficacy of bridging IVT in AF versus non-AF LVO strokes.
Collapse
Affiliation(s)
- Jing Hong Loo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | | | - Mingxue Jing
- National University Health System Singapore, Singapore
| | - Ching-Hui Sia
- National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre, Singapore
| | - Bernard Pl Chan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Raymond Cs Seet
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Medicine, Division of Neurology, National University Hospital, Singapore
| | - Hock-Luen Teoh
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Neuroradiology, Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Panagiotis Papanagiotou
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte, Bremen, Germany
- First Department of Radiology, School of Medicine, National & Kapodistrian University of Athens, Athens, Greece
| | - Andreas Kastrup
- Department of Neurology, Hospital Bremen-Mitte, Bremen, Germany
| | | | - Volker Maus
- Department of Radiology, Neuroradiology and Nuclear Medicine, Knappschaftskrankenhaus Langendreer, Ruhr-University Bochum, Bochum, Germany
| | - Furkan Yapici
- Department of Radiology, Neuroradiology and Nuclear Medicine, Knappschaftskrankenhaus Langendreer, Ruhr-University Bochum, Bochum, Germany
| | - Davide Simonato
- Departmento of Neuroradiology, University Hospital of Padua, Padua, Italy
| | - Joseph D Gabrieli
- Departmento of Neuroradiology, University Hospital of Padua, Padua, Italy
| | - Giacomo Cester
- Departmento of Neuroradiology, University Hospital of Padua, Padua, Italy
| | - Pervinder Bhogal
- Department of Stroke Medicine, Royal London Hospital, London, UK
| | - Oliver Spooner
- Department of Stroke Medicine, Royal London Hospital, London, UK
| | - Christos Nikola
- Department of Stroke Medicine, Royal London Hospital, London, UK
| | - Abhishek Joshi
- Department of Stroke Medicine, Royal London Hospital, London, UK
| | - Tsong-Hai Lee
- Department of Neurology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Jiale Wu
- School of Medicine, Shaoguan University, Shaoguan, Guangdong, China
| | - Yimin Chen
- Department of Neurology, Foshan Sanshui District People's Hospital, Foshan, Guangdong Province, China
| | - Shuiquan Yang
- Department of Neurology, Foshan Sanshui District People's Hospital, Foshan, Guangdong Province, China
| | - Vijay Kumar Sharma
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Benjamin Yq Tan
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Leonard Ll Yeo
- Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| |
Collapse
|
30
|
Yoshie T, Ueda T, Hasegawa Y, Takeuchi M, Morimoto M, Tsuboi Y, Yamamoto R, Kaku S, Ayabe J, Akiyama T, Yamamoto D, Mori K, Kagami H, Ito H, Onodera H, Kaga Y, Ohtsubo H, Tatsuno K, Usuki N, Takaishi S, Yamano Y. Ischemic stroke patients with low DWI ASPECTS scores require puncture to recanalization within 30 min for large vessel occlusion. J Neurol Sci 2023; 454:120852. [PMID: 37924594 DOI: 10.1016/j.jns.2023.120852] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2023] [Revised: 09/24/2023] [Accepted: 10/22/2023] [Indexed: 11/06/2023]
Abstract
BACKGROUND The clinical benefits of faster recanalization in acute large vessel occlusion are well recognized, but the optimal procedure time remains uncertain. The aim of this study was to identify patient characteristics that necessitate puncture-to-recanalization (P-R) time within 30 min to achieve favorable outcome. METHODS We evaluated the patients from a prospective, multicenter, observational registry of acute ischemic stroke patients. The study included patients who underwent endovascular therapy for ICA or MCA M1 occlusion and achieved successful recanalization. Patients were categorized into subgroups based on pre-treatment characteristics and the frequency of favorable outcomes was compared between P-R time < 30 min and ≥ 30 min. Interaction terms were incorporated into the models to assess the correlation between each patient characteristic and P-R time. RESULTS A total of 1053 patients were included in the study. Univariate analysis within each subgroup revealed a significant association between P-R < 30 min and favorable outcomes in patients with DWI ASPECTS ≤6, age > 85 and NIHSS ≥16. In the multivariable analysis, NIHSS, age, time from symptom recognition to puncture, and DWI ASPECTS were significant independent predictors of favorable outcomes. Notably, only DWI ASPECTS exhibited interaction terms with P-R < 30 min. The multivariable analysis indicated that P-R < 30 min was an independent predictor for favorable outcome in DWI ASPECTS ≤6 group, whereas not in DWI ≥7. CONCLUSIONS P-R time < 30 min is predictive of favorable outcomes; however, the effect depends on DWI ASPECTS. Target P-R time < 30 min is appropriate for patients with DWI ASPECTS ≤6.
Collapse
Affiliation(s)
- Tomohide Yoshie
- Department of Strokology and Neuroendovascular Therapy, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan.
| | - Toshihiro Ueda
- Department of Strokology and Neuroendovascular Therapy, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan
| | - Yasuhiro Hasegawa
- Department of Neurology, St. Marianna University School of Medicine, Kawasaki, Japan
| | | | - Masafumi Morimoto
- Department of Neurosurgery, Yokohama Shintoshi Neurosurgical Hospital, Yokohama, Japan
| | - Yoshifumi Tsuboi
- Department of Neurosurgery, Kawasaki Saiwai Hospital, Kawasaki, Japan
| | - Ryoo Yamamoto
- Department of Neurology, Yokohama Brain and Spine Center, Yokohama, Japan
| | - Shogo Kaku
- Department of Neurosurgery, Neurosurgical East Yokohama Hospital, Yokohama, Japan
| | - Junichi Ayabe
- Department of Neurosurgery, Yokosuka Kyosai Hospital, Yokohama, Japan
| | - Takekazu Akiyama
- Department of Neurosurgery, Akiyama Neurosurgical Hospital, Yokohama, Japan
| | - Daisuke Yamamoto
- Department of Neurosurgery, Kitasato University Hospital, Sagamihara, Japan
| | - Kentaro Mori
- Department of Neurosurgery, Yokohama Sakae Kyosai Hospital, Yokohama, Japan
| | - Hiroshi Kagami
- Department of Neurosurgery, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan
| | - Hidemichi Ito
- Department of Neurosurgery, St. Marianna University School of Medicine, Kawasaki, Japan
| | - Hidetaka Onodera
- Department of Neurosurgery, St. Marianna University Yokohama Seibu Hospital, Yokohama, Japan
| | - Yasuyuki Kaga
- Department of Neurology, St. Marianna University School of Medicine, Kawasaki, Japan; ESP corporation, Tokyo, Japan
| | - Haruki Ohtsubo
- Department of Strokology and Neuroendovascular Therapy, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan
| | - Kentaro Tatsuno
- Department of Strokology and Neuroendovascular Therapy, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan
| | - Noriko Usuki
- Department of Strokology and Neuroendovascular Therapy, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan
| | - Satoshi Takaishi
- Department of Strokology and Neuroendovascular Therapy, Stroke Center, St. Marianna University Toyoko Hospital, Kawasaki, Japan
| | - Yoshihisa Yamano
- Department of Neurology, St. Marianna University School of Medicine, Kawasaki, Japan
| |
Collapse
|
31
|
Riegler C, Siebert E, Kleine JF, Nolte CH. Thrombus migration in ischemic stroke due to large vessel occlusion: a question of time. J Neurointerv Surg 2023; 15:e216-e222. [PMID: 36319085 PMCID: PMC10646911 DOI: 10.1136/jnis-2022-019365] [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: 07/08/2022] [Accepted: 10/08/2022] [Indexed: 05/20/2023]
Abstract
BACKGROUND Thrombus migration (TM) is frequently observed in large vessel occlusion (LVO) ischemic stroke to be treated by endovascular thrombectomy (EVT). TM may impede complete recanalization and hereby worsen clinical outcomes. This study aimed to delineate factors associated with TM and clarify its impact on technical and functional outcome. METHODS All patients undergoing EVT due to LVO in the anterior circulation at two tertiary stroke centers between October 2015 and December 2020 were included. Source imaging data of all individuals were assessed regarding occurrence of TM by raters blinded to clinical data. Patient data were gathered as part of the German Stroke Registry, a multicenter, prospective registry assessing real-world outcomes. Technical outcome was assessed by modified Thrombolysis in Cerebral Infarction scale (mTICI). Functional outcome was assessed by modified Rankin Scale (mRS) at 3 months. RESULTS The study consisted of 512 individuals, of which 71 (13.8%) displayed TM. In adjusted analyses, TM was associated with longer time from primary imaging to reassessment in the angio suite (aOR 2.37 (1.47 to 3.84) per logarithmic step) and intravenous thrombolysis (IVT; aOR 4.07 (2.17 to 7.65)). In individuals with IVT, a needle-to-groin time >1 hour was associated with higher odds for TM (aOR 2.60 (1.20 to 5.99)). TM was associated with lack of complete recanalization (aORmTICI3 0.46 (0.24 to 0.90)) but TM did not worsen odds for good clinical outcome (aORmRS≤2_d90 0.89 (0.47 to 1.68)). CONCLUSIONS TM is associated with IVT and longer time between sequential assessments of thrombus location. Consequently, TM may be of high relevance in patients with drip-and-ship treatment.
Collapse
Affiliation(s)
- Christoph Riegler
- Klinik und Hochschulambulanz für Neurologie, Charite Universitatsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Eberhard Siebert
- Institut für Neuroradiologie, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Justus F Kleine
- Institut für Neuroradiologie, Charite Universitatsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Klinik und Hochschulambulanz für Neurologie, Charite Universitatsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charite Universitatsmedizin Berlin, Berlin, Germany
| |
Collapse
|
32
|
Kniep H, Meyer L, Broocks G, Bechstein M, Guerreiro H, Winkelmeier L, Brekenfeld C, Flottmann F, Deb-Chatterji M, Alegiani A, Hanning U, Thomalla G, Fiehler J, Gellißen S. Predictors of functional outcome after thrombectomy for M2 occlusions: a large scale experience from clinical practice. Sci Rep 2023; 13:18740. [PMID: 37907482 PMCID: PMC10618211 DOI: 10.1038/s41598-023-45232-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 10/17/2023] [Indexed: 11/02/2023] Open
Abstract
Mechanical thrombectomy (MT) for acute ischemic stroke with medium vessel occlusions is still a matter of debate. We sought to identify factors associated with clinical outcome after MT for M2-occlusions based on data from the German Stroke Registry-Endovascular Treatment (GSR-ET). All patients prospectively enrolled in the GSR-ET from 05/2015 to 12/2021 were analyzed (NCT03356392). Inclusion criteria were primary M2-occlusions and availability of relevant clinical data. Factors associated with excellent/good outcome (modified Rankin scale mRS 0-1/0-2), poor outcome/death (mRS 5-6) and mRS-increase pre-stroke to day 90 were determined in multivariable logistic regression. 1348 patients were included. 1128(84%) had successful recanalization, 595(44%) achieved good outcome, 402 (30%) had poor outcome. Successful recanalization (odds ratio [OR] 4.27 [95% confidence interval 3.12-5.91], p < 0.001), higher Alberta stroke program early CT score (OR 1.25 [1.18-1.32], p < 0.001) and i.v. thrombolysis (OR 1.28 [1.07-1.54], p < 0.01) increased probability of good outcome, while age (OR 0.95 [0.94-0.95], p < 0.001), higher pre-stroke-mRS (OR 0.36 [0.31-0.40], p < 0.001), higher baseline NIHSS (OR 0.89 [0.88-0.91], p < 0.001), diabetes (OR 0.52 [0.42-0.64], p < 0.001), higher number of passes (OR 0.75 [0.70-0.80], p < 0.001) and intracranial hemorrhage (OR 0.26 [0.14-0.46], p < 0.001) decreased the probability of good outcome. Additional predictors of mRS-increase pre-stroke to 90d were dissections, perforations (OR 1.59 [1.11-2.29], p < 0.05) and clot migration, embolization (OR 1.67 [1.21-2.30], p < 0.01). Corresponding to large-vessel-occlusions, younger age, low pre-stroke-mRS, low severity of acute clinical disability, i.v. thrombolysis and successful recanalization were associated with good outcome while diabetes and higher number of passes decreased probability of good outcome after MT in M2 occlusions. Treatment related complications increased probability of mRS increase pre-stroke to 90d.
Collapse
Affiliation(s)
- Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Helena Guerreiro
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Laurens Winkelmeier
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Alegiani
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Neurology, Asklepios Klinik Altona, Hamburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Susanne Gellißen
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| |
Collapse
|
33
|
Burbano VG, Wölfer TA, Vlegels N, Quandt F, Zimmermann H, Wischmann J, Kellert L, Liebig T, Dimitriadis K, Saver JL, Tiedt S. Association of the time of day of EVT with clinical outcomes and benefit from successful recanalization after stroke. Ann Clin Transl Neurol 2023; 10:1917-1923. [PMID: 37607113 PMCID: PMC10578882 DOI: 10.1002/acn3.51877] [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: 06/30/2023] [Accepted: 08/04/2023] [Indexed: 08/24/2023] Open
Abstract
Experimental and neuroimaging studies suggest an influence of the time of day on acute infarct growth, but whether this could inform patient selection for acute treatments is uncertain. In a multicenter cohort of 9357 stroke patients undergoing endovascular treatment, morning treatment (05:00-10:59) was associated with lowest 90-day mRS scores (adjusted odds ratio, 1.27 [95% CI, 1.08-1.47]; p = 0.004). The association between successful recanalization and outcome was stronger in morning compared to evening-treated patients (pia = 0.046) with treatment benefit persisting until 24 h for morning-treated compared to 11.5 h for evening-treated patients suggesting that the time of day might inform patient selection for EVT.
Collapse
Affiliation(s)
- Vanessa Granja Burbano
- Institute for Stroke and Dementia Research (ISD)LMU University Hospital, LMU MunichMunichGermany
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA)MunichGermany
| | - Teresa A. Wölfer
- Institute for Stroke and Dementia Research (ISD)LMU University Hospital, LMU MunichMunichGermany
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA)MunichGermany
| | - Naomi Vlegels
- Institute for Stroke and Dementia Research (ISD)LMU University Hospital, LMU MunichMunichGermany
| | - Fanny Quandt
- Department of NeurologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Hanna Zimmermann
- Institute of NeuroradiologyLMU University Hospital, LMU MunichMunichGermany
| | | | - Lars Kellert
- Department of NeurologyLMU University Hospital, LMU MunichMunichGermany
| | - Thomas Liebig
- Institute of NeuroradiologyLMU University Hospital, LMU MunichMunichGermany
| | - Konstantinos Dimitriadis
- Institute for Stroke and Dementia Research (ISD)LMU University Hospital, LMU MunichMunichGermany
- Department of NeurologyLMU University Hospital, LMU MunichMunichGermany
| | - Jeffrey L. Saver
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA)MunichGermany
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of MedicineUniversity of California Los AngelesLos AngelesCaliforniaUSA
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research (ISD)LMU University Hospital, LMU MunichMunichGermany
- Consortium International pour la Recherche Circadienne sur l'AVC (CIRCA)MunichGermany
| | | |
Collapse
|
34
|
McCusker RJ, Chinchilli VM, Fritch CD, Kochar PS, Sharma S. Demonstrating the Value of Routine Anesthesiologist Involvement in Acute Stroke Care: A Retrospective Chart Review. J Neurosurg Anesthesiol 2023; 35:406-411. [PMID: 37442782 DOI: 10.1097/ana.0000000000000927] [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: 01/11/2023] [Accepted: 05/18/2023] [Indexed: 07/15/2023]
Abstract
INTRODUCTION The value of routine involvement of anesthesiologists during endovascular thrombectomy (EVT) for acute ischemic stroke has not been clearly demonstrated. At some institutions, anesthesiologists are involved only as needed, while at other institutions, anesthesiologists are involved from the beginning for every EVT. METHODS We retrospectively analyzed the workflow, intraprocedural variables and complications, and outcomes in acute ischemic stroke patients undergoing EVT at a comprehensive stroke center after implementation of routine involvement of an anesthesia team and compared this cohort with patients who received care from sedation-trained nurses working under the supervision of neurointerventionalists with the involvement of anesthesiologists on an as-needed basis. RESULTS Routine involvement of anesthesiologists was associated with improved workflow performance measures, including decreased median door-to-arterial puncture time (68 min; interquartile range (IQR), 15.5-94.5 min vs. 81 min; IQR, 53-104 min; P =0.001), in-room to arterial puncture time (11 min; IQR, 8-14 min vs. 15 min; IQR, 9-21 min; P <0.0001), and procedure time (51 min; IQR, 40-64 min vs. 60 min; IQR, 40-88.5 min; P =0.007). It was also associated with a nonsignificant trend towards lower rates of desaturation events (8.2% vs. 3.4%; P =0.082) and lower rates of conversion to general anesthesia (1.7% vs. 0%; P =0.160). Ninety-day modified Rankin scores were similar regardless of provider type. CONCLUSION Implementation of routine involvement of an anesthesia team during EVT was not associated with improved outcomes but was associated with improved efficiency and greater adherence to guidelines-based physiological parameters, supporting the routine involvement of anesthesiologists during EVT.
Collapse
Affiliation(s)
| | - Vernon M Chinchilli
- Department of Public Health Sciences, Penn State College of Medicine, Hershey, PA
| | | | - Puneet S Kochar
- Department of Neuroradiology, Penn State Health Milton S. Hershey Medical Center
| | - Sonal Sharma
- Department of Anesthesiology and Perioperative Medicine
| |
Collapse
|
35
|
Hassan AE, Fifi JT, Zaidat OO. Aspiration thrombectomy with the Penumbra System for patients with stroke and late onset to treatment: a subset analysis of the COMPLETE registry. Front Neurol 2023; 14:1239640. [PMID: 37794880 PMCID: PMC10546392 DOI: 10.3389/fneur.2023.1239640] [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: 06/13/2023] [Accepted: 08/08/2023] [Indexed: 10/06/2023] Open
Abstract
Background The purpose of this study was to report the safety and performance of aspiration thrombectomy with the Penumbra System for patients with acute ischemic stroke (AIS) due to anterior circulation large vessel occlusion (LVO) and late onset to treatment. Methods This is a retrospective subset analysis of a global prospective multicenter registry (COMPLETE) that enrolled adults with AIS due to LVO and a pre-stroke modified Rankin Scale score (mRS) of 0 or 1 who were treated first-line with aspiration thrombectomy either alone (A Direct Aspiration First Pass Technique [ADAPT]) or in combination with the 3D Revascularization Device (ADAPT + 3D). This subset analysis included all patients in the registry who had anterior circulation LVO, an Alberta Stroke Program Early CT Score of at least 6, and late onset to treatment (>6 h from stroke onset to puncture). Results Of the 650 patients in the COMPLETE registry, 167 were included in this subset analysis. The rate of successful revascularization (modified thrombolysis in cerebral infarction score 2b-3 achieved) at the end of the procedure was 83.2%, the rate of good functional outcome (mRS 0-2) at 90 days was 55.4%, and the all-cause mortality rate at 90 days was 14.4%. No device-related serious adverse events (SAEs) occurred. Procedure-related SAEs occurred in 9 patients (5.4%) within 24 h and in 12 patients (7.2%) overall. The rate of successful revascularization was higher for patients treated first-line with ADAPT (88.0%) than for patients treated first-line with ADAPT + 3D (75.0%; p = 0.035); no significant difference was observed between the ADAPT and ADAPT + 3D groups for any other primary or secondary outcome. Conclusion For patients with AIS due to anterior circulation LVO and with late onset to treatment, aspiration thrombectomy with the Penumbra System appears to be safe and effective. The rates of good functional outcome and all-cause mortality from this study compared favorably with those rates from the medical management arms of the DAWN and DEFUSE-3 studies. Clinical trial registration https://www.clinicaltrials.gov, NCT03464565.
Collapse
Affiliation(s)
- Ameer E. Hassan
- Department of Neurology, University of Texas Rio Grande Valley, Valley Baptist Medical Center, Harlingen, TX, United States
| | - Johanna T. Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Osama O. Zaidat
- Department of Endovascular Neurosurgery, Mercy Health St. Vincent Medical Center, Toledo, OH, United States
| |
Collapse
|
36
|
Meyer L, Politi M, Alexandrou M, Roth C, Kastrup A, Mpotsaris A, Hanning U, Flottmann F, Brekenfeld C, Deb-Chatterji M, Thomalla G, Kniep H, Faizy TD, Bechstein M, Broocks G, Herzberg M, Feil K, Kellert L, Dorn F, Zeleňák K, Fiehler J, Papanagiotou P. Endovascular treatment of acute tandem lesions in patients with mild anterior circulation stroke. J Neurointerv Surg 2023; 15:e136-e141. [PMID: 36028317 DOI: 10.1136/jnis-2022-019239] [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: 06/03/2022] [Accepted: 08/06/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND In patients with mild strokes the risk-benefit ratio of endovascular treatment (EVT) for tandem lesions has yet to be evaluated outside of current guideline recommendations. This study investigates the frequency as well as procedural and safety outcomes in daily clinical practice. METHODS Using data from the German Stroke Registry-Endovascular Treatment (GSR-ET) we analyzed patients with anterior circulation stroke due to tandem-lesions and mild deficits. These patients were defined as ≤5 on the National Institutes of Health Stroke Scale (NIHSS). Recanalization was assessed with the modified Thrombolysis in Cerebral Infarction Scale (mTICI). Early neurological and long-term functional outcomes were assessed with the NIHSS change and modified Rankin scale (mRS), respectively. Safety assessment included periprocedural complications and the rate of symptomatic intracerebral hemorrhage (sICH). RESULTS A total of 61 patients met the inclusion criteria and were treated endovascularly for tandem lesions. The median age was 68 (IQR:59-76) and 32.9% (20) were female. Patients were admitted to the hospital with a median NIHSS score of 4 (IQR:2-5) and a median Alberta Stroke Programme Early CT Score (ASPECTS) of 9 (IQR:8-10). Successful recanalization (mTICI 2b-3) was observed in 86.9% (53). NIHSS decreased non-significantly (p=0.382) from baseline to two points (IQR:1-9) at discharge. Excellent (mRS≤1) and favorable (mRS≤2) long-term functional outcome at 90-days was 55.8% (29) and 69.2% (36), respectively. Mortality rates at 90-days were 9.6% (5) and sICH occurred in 8.2% (5). CONCLUSIONS EVT for tandem lesions in patients with mild anterior circulation stroke appears to be feasible but may lead to increased rates of sICH. Further studies comparing endovascular with best medical treatment (BMT) especially investigating the risk of periprocedural hemorrhagic complications, are needed.
Collapse
Affiliation(s)
- Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maria Politi
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte gGmbH, Bremen, Germany
- Interventional Radiology Unit, Evangelismos General Hospital, Athens, Greece
| | - Maria Alexandrou
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte gGmbH, Bremen, Germany
| | - Christian Roth
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte gGmbH, Bremen, Germany
| | - Andreas Kastrup
- Department of Neurology, Hospital Bremen-Mitte gGmbH, Bremen, Germany
| | - Anastasios Mpotsaris
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Magdeburg, Magdeburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Goetz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Moriz Herzberg
- Department of Radiology, University Hospital Würzburg, Würzburg, Germany
- Institute of Neuroradiology, Ludwig Maximilians Universität, München, Germany
| | - Katharina Feil
- Department of Neurology, Ludwig Maximilians Universität, München, Germany
- Department of Neurology and Stroke, Eberhard-Karls University, Tübingen, Germany
| | - Lars Kellert
- Department of Neurology, Ludwig Maximilians Universität, München, Germany
| | - Franziska Dorn
- Institute of Neuroradiology, Ludwig Maximilians Universität, München, Germany
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Kamil Zeleňák
- Clinic of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Martin, Slovakia
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Panagiotis Papanagiotou
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte gGmbH, Bremen, Germany
- Department of Radiology, Areteion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
| |
Collapse
|
37
|
Bay B, Gloyer NO, Remmel M, Schell M, Zelenak K, Seiffert M, Brunner FJ, Clemmensen P, Reichenspurner H, Blankenberg S, Thomalla G, Fiehler J, Conradi L, Waldeyer C, Flottmann F. Mechanical thrombectomy in ischemic stroke after cardiovascular procedures: a propensity-matched cohort analysis. J Neurointerv Surg 2023; 15:e129-e135. [PMID: 35985838 DOI: 10.1136/jnis-2022-019152] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Accepted: 08/05/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND Stroke after a cardiovascular procedure (CVP) is a devastating complication adversely affecting outcome. Mechanical thrombectomy (MT) has not been investigated systematically in this population. OBJECTIVE To carry out a retrospective study in patients undergoing MT for early stroke after CVP, aiming to further characterize this cohort of patients, and to evaluate the efficacy, safety, procedural characteristics, and outcome of MT. METHODS A single-center stroke registry of patients who received MT was analyzed. Baseline and procedural parameters, mortality, functional outcome, recanalization rates, and complications were evaluated. Propensity score matching was carried out, identifying a control cohort with non-periprocedural large vessel occlusion (LVO). RESULTS Overall 913 patients were included (mean age 73.0 (±13.0) years, 52.5% female, median National Institutes of Health Stroke Scale score 15 (10-19)). Eleven patients with a LVO after a recent (<30 days postoperatively) CVP were identified (n=3 transcatheter aortic valve and n=1 surgical aortic valve replacements (SAVR), n=3 coronary bypass grafting (CABG) surgeries, n=2 SAVR+CABG, and n=2 aortic surgeries). After matching, 8 patients in the CVP group were compared with 16 patients in the matched cohort. Comparable rates of reperfusion were achieved. Time from symptom onset to groin puncture (171.5 min (136.3, 178.3) vs 284.0 min (215.0, 490.5); p=0.039), as well as recanalization (195.0 min (146.0, 201.0) vs 419.0 min (274.0, 613.0); p=0.028) was faster in the CVP group. However, this was not reflected by an improved outcome (modified Rankin Scale score after 90 days: 5.5 (3.3, 6.0) vs 5.0 (4.0, 6.0), mortality after 90 days 50.0% vs 37.5%). Complications did not differ between the groups. CONCLUSIONS Use of MT for LVO stroke in patients after a recent CVP is a safe and efficient treatment in comparison with patients with a non-periprocedural LVO undergoing MT.
Collapse
Affiliation(s)
- Benjamin Bay
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Nils-Ole Gloyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marko Remmel
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maximilian Schell
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kamil Zelenak
- Clinic of Radiology, Jessenius Faculty of Medicine in Martin, Comenius University in Bratislava, Martin, Slovakia
| | - Moritz Seiffert
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Fabian J Brunner
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Peter Clemmensen
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
- Faculty of Health Sciences, Department of Regional Health Research, University of Southern Denmark and Nykoebing Falster Hospital, Odense, Denmark
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Blankenberg
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Goetz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lenard Conradi
- Department of Cardiovascular Surgery, University Heart & Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Christoph Waldeyer
- Department of Cardiology, University Heart & Vascular Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
38
|
Schlemm L, Siebert E, Kleine JF, Riegler C, Bode FJ, Petersens M, Schlemm E, Keil F, Tiedt S, Bohner G, Nolte CH. Decline of thrombolysis rates before endovascular therapy in patients with acute anterior circulation large vessel occlusion ischemic stroke: A multicenter analysis from the German Stroke Registry. Eur Stroke J 2023; 8:610-617. [PMID: 37243508 PMCID: PMC10472953 DOI: 10.1177/23969873231177774] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 05/07/2023] [Indexed: 05/29/2023] Open
Abstract
INTRODUCTION In recent years, the role of intravenous thrombolysis (IVT) before endovascular stroke treatment (EVT) has been discussed intensively. Whether the discussion was accompanied by changing rates of bridging IVT is unknown. METHODS Data were extracted from the prospectively maintained German Stroke Registry, including patients treated with EVT at one of 28 stroke centers in Germany between 2016 and 2021. Primary outcome parameters were the rate of bridging IVT (a) in the entire registry cohort and (b) in patients without formal contraindications to IVT (i.e. recent oral anticoagulants, time window ⩾4.5 h, extensive early ischemic changes) adjusted for demographic and clinical confounders. RESULTS 10,162 patients (52.8% women, median age 77 years, median National Institutes of Health Stroke Scale score 14) were analyzed. In the entire cohort, the rate of bridging IVT decreased from 63.8% in 2016 to 43.6% in 2021 (average absolute annual decrease 3.1%, 95% CI 2.4%-3.8%), while the proportion of patients with at least one formal contraindication increased by only 1.2% annually (95% CI 0.6%-1.9%). Among 5460 patients without record of formal contraindications, the rate of bridging IVT decreased from 75.5% in 2016 to 63.2% in 2021 and was significantly associated with admission date in a multivariable model (average absolute annual decrease 1.4%, 95% CI 0.6%-2.2%). Clinical factors associated with lower odds of bridging IVT included diabetes mellitus, carotid-T-occlusion, dual antiplatelet therapy, and direct admission to a thrombectomy center. CONCLUSION We observed a substantial decline in bridging IVT rates independent of demographic confounders and not explained by an increase in contraindications. This observation deserves further exploration in independent populations.
Collapse
Affiliation(s)
- Ludwig Schlemm
- Institute of Neuroradiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Department of Radiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Eberhard Siebert
- Institute of Neuroradiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Justus F Kleine
- Institute of Neuroradiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christoph Riegler
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health at Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Felix J Bode
- Department of Neurology, Universitätsklinikum Bonn, Bonn, Germany
| | | | - Eckhard Schlemm
- Klinik und Poliklinik Für Neurologie, Kopf- und Neurozentrum, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Fee Keil
- Institute for Neuroradiology, University Hospital, Johann Wolfgang Goethe-University, Frankfurt am Main, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research, Klinikum der Universität München, Ludwig-Maximilians-Universität LMU, Munich, Germany
| | - Georg Bohner
- Institute of Neuroradiology, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité – Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité – Universitätsmedizin Berlin, Berlin, Germany
- German Center for Neurodegenerative Diseases (DZNE), Partner Site Berlin, Berlin, Germany
| |
Collapse
|
39
|
Zidan M, Ghaei S, Bode FJ, Weller JM, Krueger N, Lehnen NC, Petzold GC, Radbruch A, Dorn F, Paech D. Clinical significance and prevalence of subarachnoid hyperdensities on flat detector CT after mechanical thrombectomy: does it really matter? J Neurointerv Surg 2023:jnis-2023-020661. [PMID: 37648432 DOI: 10.1136/jnis-2023-020661] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Accepted: 08/11/2023] [Indexed: 09/01/2023]
Abstract
BACKGROUND Subarachnoid hyperdensities after mechanical thrombectomy (MT) are a common finding. However, it is often regarded as clinically insignificant. OBJECTIVE With this single-center investigation, to identify the prevalence of subarachnoid hyperdensities following MT, associated predictors, and the impact on the clinical outcome of the patients. METHODS 383 patients from the stroke registry were analyzed for the presence of subarachnoid hyperdensities on flat detector CT (FDCT) directly after the completion of MT, and on follow-up dual-energy CT, then classified according to a visual grading scale. 178 patients were included with anterior circulation occlusions. Regression analysis was performed to identify significant predictors, and Kruskal-Wallis analysis and Χ2 test were performed to test the variables among the different groups. The primary outcome was the modified Rankin Scale (mRS) score at 90 days and was analyzed with the Wilcoxon-Mann-Whitney rank-sum test. RESULTS The prevalence of subarachnoid hyperdensities on FDCT was (66/178, 37.1%) with patients experiencing a significant unfavorable outcome (P=0.035). Significantly fewer patients with subarachnoid hyperdensities achieved a mRS score of ≤3 at 90 days 25/66 (37.9%) vs 60/112 (53.6%), P=0.043). In addition, mortality was significantly higher in the subarachnoid hyperdensities group (34.8% vs 19.6%, P=0.024). Distal occlusions and a higher number of device passes were significantly associated with subarachnoid hyperdensities (P=0.026) and (P=0.001), respectively. Patients who received intravenous tissue plasminogen activator had significantly fewer subarachnoid hyperdensities (P=0.029). CONCLUSIONS Postinterventional subarachnoid hyperdensities are a frequent finding after MT and are associated with neurological decline and worse functional outcome. They are more common with distal occlusions and multiple device passes.
Collapse
Affiliation(s)
- Mousa Zidan
- Department of Neuroradiology, University Hospital Bonn, Bonn, Nordrhein-Westfalen, Germany
| | - Shiwa Ghaei
- Department of Neuroradiology, University Hospital Bonn, Bonn, Nordrhein-Westfalen, Germany
| | - Felix J Bode
- Department of Neurology, University Hospital Bonn, Bonn, Germany
| | | | - Nadine Krueger
- Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Nils Christian Lehnen
- Department of Neuroradiology, University Hospital Bonn, Bonn, Nordrhein-Westfalen, Germany
| | - Gabor C Petzold
- Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Alexander Radbruch
- Department of Neuroradiology, University Hospital Bonn, Bonn, Nordrhein-Westfalen, Germany
| | - Franziska Dorn
- Department of Neuroradiology, University Hospital Bonn, Bonn, Nordrhein-Westfalen, Germany
- Department of Neuroradiology, LMU Klinikum der Universität München Medizinische Klinik und Poliklinik IV, Munchen, Bayern, Germany
| | - Daniel Paech
- Department of Neuroradiology, University Hospital Bonn, Bonn, Nordrhein-Westfalen, Germany
- Department of Radiology, German Cancer Research Centre, Heidelberg, Germany
| |
Collapse
|
40
|
Fumadó Navarro J, Lomora M. Mechanoresponsive Drug Delivery Systems for Vascular Diseases. Macromol Biosci 2023; 23:e2200466. [PMID: 36670512 DOI: 10.1002/mabi.202200466] [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: 11/01/2022] [Revised: 01/16/2023] [Indexed: 01/22/2023]
Abstract
Mechanoresponsive drug delivery systems (DDS) have emerged as promising candidates to improve the current effectiveness and lower the side effects typically associated with direct drug administration in the context of vascular diseases. Despite tremendous research efforts to date, designing drug delivery systems able to respond to mechanical stimuli to potentially treat these diseases is still in its infancy. By understanding relevant biological forces emerging in healthy and pathological vascular endothelium, it is believed that better-informed design strategies can be deduced for the fabrication of simple-to-complex macromolecular assemblies capable of sensing mechanical forces. These responsive systems are discussed through insights into essential parameter design (composition, size, shape, and aggregation state) , as well as their functionalization with (macro)molecules that are intrinsically mechanoresponsive (e.g., mechanosensitive ion channels and mechanophores). Mechanical forces, including the pathological shear stress and exogenous stimuli (e.g., ultrasound, magnetic fields), used for the activation of mechanoresponsive DDS are also introduced, followed by in vitro and in vivo experimental models used to investigate and validate such novel therapies. Overall, this review aims to propose a fresh perspective through identified challenges and proposed solutions that could be of benefit for the further development of this exciting field.
Collapse
Affiliation(s)
- Josep Fumadó Navarro
- School of Biological and Chemical Sciences, University of Galway, University Road, Galway, H91 TK33, Ireland
- CÚRAM, SFI Research Centre for Medical Devices, University of Galway, Upper Newcastle, Galway, H91 W2TY, Ireland
| | - Mihai Lomora
- School of Biological and Chemical Sciences, University of Galway, University Road, Galway, H91 TK33, Ireland
- CÚRAM, SFI Research Centre for Medical Devices, University of Galway, Upper Newcastle, Galway, H91 W2TY, Ireland
| |
Collapse
|
41
|
Kelly B, Martinez M, Do H, Hayden J, Huang Y, Yedavalli V, Ho C, Keane PA, Killeen R, Lawlor A, Moseley ME, Yeom KW, Lee EH. DEEP MOVEMENT: Deep learning of movie files for management of endovascular thrombectomy. Eur Radiol 2023; 33:5728-5739. [PMID: 36847835 PMCID: PMC10326097 DOI: 10.1007/s00330-023-09478-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 11/23/2022] [Accepted: 01/19/2023] [Indexed: 03/01/2023]
Abstract
OBJECTIVES Treatment and outcomes of acute stroke have been revolutionised by mechanical thrombectomy. Deep learning has shown great promise in diagnostics but applications in video and interventional radiology lag behind. We aimed to develop a model that takes as input digital subtraction angiography (DSA) videos and classifies the video according to (1) the presence of large vessel occlusion (LVO), (2) the location of the occlusion, and (3) the efficacy of reperfusion. METHODS All patients who underwent DSA for anterior circulation acute ischaemic stroke between 2012 and 2019 were included. Consecutive normal studies were included to balance classes. An external validation (EV) dataset was collected from another institution. The trained model was also used on DSA videos post mechanical thrombectomy to assess thrombectomy efficacy. RESULTS In total, 1024 videos comprising 287 patients were included (44 for EV). Occlusion identification was achieved with 100% sensitivity and 91.67% specificity (EV 91.30% and 81.82%). Accuracy of location classification was 71% for ICA, 84% for M1, and 78% for M2 occlusions (EV 73, 25, and 50%). For post-thrombectomy DSA (n = 194), the model identified successful reperfusion with 100%, 88%, and 35% for ICA, M1, and M2 occlusion (EV 89, 88, and 60%). The model could also perform classification of post-intervention videos as mTICI < 3 with an AUC of 0.71. CONCLUSIONS Our model can successfully identify normal DSA studies from those with LVO and classify thrombectomy outcome and solve a clinical radiology problem with two temporal elements (dynamic video and pre and post intervention). KEY POINTS • DEEP MOVEMENT represents a novel application of a model applied to acute stroke imaging to handle two types of temporal complexity, dynamic video and pre and post intervention. • The model takes as an input digital subtraction angiograms of the anterior cerebral circulation and classifies according to (1) the presence or absence of large vessel occlusion, (2) the location of the occlusion, and (3) the efficacy of thrombectomy. • Potential clinical utility lies in providing decision support via rapid interpretation (pre thrombectomy) and automated objective gradation of thrombectomy outcomes (post thrombectomy).
Collapse
Affiliation(s)
- Brendan Kelly
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA.
- Department of Radiology, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland.
- Insight Centre for Data Analytics, University College Dublin, Belfield, Dublin 4, Ireland.
| | - Mesha Martinez
- Department of Clinical Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Huy Do
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | | | - Yuhao Huang
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Vivek Yedavalli
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Chang Ho
- Department of Clinical Radiology and Imaging Sciences, Indiana University School of Medicine, Indianapolis, IN, USA
| | - Pearse A Keane
- Moorfields Eye Hospital, London, UK
- Institute of Ophthalmology, University College London, London, UK
| | - Ronan Killeen
- Department of Radiology, St Vincent's University Hospital, Elm Park, Dublin 4, Ireland
| | - Aonghus Lawlor
- Insight Centre for Data Analytics, University College Dublin, Belfield, Dublin 4, Ireland
| | - Michael E Moseley
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Kristen W Yeom
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| | - Edward H Lee
- Department of Radiology, Stanford University School of Medicine, Stanford, CA, USA
| |
Collapse
|
42
|
Räty S, Nguyen TN, Nagel S, Puetz V, Alemseged F, Abdalkader M, Schonewille WJ, Strbian D. What Is the Evidence for Endovascular Thrombectomy in Posterior Circulation Stroke? Semin Neurol 2023; 43:345-355. [PMID: 37595603 DOI: 10.1055/s-0043-1771210] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Abstract
Posterior circulation infarcts comprise approximately 25% of ischemic strokes but are less often treated with recanalization therapy and have longer treatment delays compared with anterior circulation strokes. Among posterior circulation strokes, basilar artery occlusion is associated with the most severe deficits and the worst prognosis. Endovascular thrombectomy is a standard of care for patients with anterior circulation large vessel occlusion, but not until recently were the first randomized controlled trials on endovascular thrombectomy in basilar artery occlusion published. Two of the trials were neutral, whereas two others showed better functional outcome after thrombectomy up to 24 hours of symptom onset compared with best medical treatment, which in most cases had low rates of intravenous thrombolysis. According to observational data, thrombectomy seems to be safe also in isolated posterior cerebral artery occlusions and might be an option for selected patients, even if its outcome benefit is yet to be demonstrated.
Collapse
Affiliation(s)
- Silja Räty
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Simon Nagel
- Department of Neurology, Klinikum Ludwigshafen, Ludwigshafen/Rhein, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Volker Puetz
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Dresden Neurovascular Center, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Fana Alemseged
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Mohamad Abdalkader
- Department of Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | | | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| |
Collapse
|
43
|
Lin C, Arevalo A, Nanavati HD. Association of inpatient rehabilitation with functional outcome in patients with stroke receiving mechanical thrombectomy. Neurol Res 2023; 45:578-582. [PMID: 36646651 PMCID: PMC10164039 DOI: 10.1080/01616412.2023.2167534] [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: 06/03/2022] [Accepted: 01/09/2023] [Indexed: 01/18/2023]
Abstract
INTRODUCTION Patients with ischemic strokes that have undergone mechanical thrombectomy (MT) can still have poor functional outcomes. Limited research exists on factors that impact functional outcomes in these patients who are discharged to inpatient rehabilitation. We examined patient characteristics correlated with 90-day outcomes in ischemic stroke patients having undergone MT and undergo acute rehabilitation. METHODS This is a retrospective study of patients (≥18 years) who were consecutively admitted to inpatient rehabilitation after undergoing MT following an ischemic stroke event from 2015 through 2018. Functional outcomes at 90-days were determined by the modified Rankin Score (mRS). Binary logistic regression models were used to measure the association of meaningful Functional Independence Measure (FIM) change with poor-outcome (mRS >2). RESULTS Out of 56 stroke patients undergoing MT, 36 had poor outcome (mRS >2) at 90-days. One unit increase in discharge FIM significantly decreased the likelihood of poor outcome by 4% [aOR = 0.96; 95% CI = 95% CI = 0.92, 0.99]. Admission FIM [aOR = 0.95; 95% CI = 0.90, 1.00] and change in FIM [aOR = 0.97; 95% CI = 0.93, 1.02] were not significantly associated poor outcome in the adjusted models. CONCLUSION Patients with ischemic stroke who received MT who have a worse disability, particularly at discharge, while undergoing inpatient rehabilitation have higher odds of having poor future functional outcomes. This was regardless of age, sex, or race. Future research is needed to understand the mechanisms that can improve functional performance in our patient population at the IRF.
Collapse
Affiliation(s)
- Chen Lin
- Department of Neurology, University of Alabama at Birmingham
| | - Andrea Arevalo
- Department of Neurology, University of Alabama at Birmingham
| | - Hely D. Nanavati
- Department of Epidemiology, University of Alabama at Birmingham
- Department of Biostatistics, University of Alabama at Birmingham
| |
Collapse
|
44
|
Faizy TD, Broocks G, Heit JJ, Kniep H, Flottmann F, Meyer L, Sporns P, Hanning U, Kaesmacher J, Deb-Chatterji M, Vollmuth P, Lansberg MG, Albers GW, Fischer U, Wintermark M, Thomalla G, Fiehler J, Winkelmeier L. Association Between Intravenous Thrombolysis and Clinical Outcomes Among Patients With Ischemic Stroke and Unsuccessful Mechanical Reperfusion. JAMA Netw Open 2023; 6:e2310213. [PMID: 37126350 PMCID: PMC10152307 DOI: 10.1001/jamanetworkopen.2023.10213] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/02/2023] Open
Abstract
Importance Clinical evidence of the potential treatment benefit of intravenous thrombolysis preceding unsuccessful mechanical thrombectomy (MT) is scarce. Objective To determine whether intravenous thrombolysis (IVT) prior to unsuccessful MT improves functional outcomes in patients with acute ischemic stroke. Design, Setting, and Participants Patients were enrolled in this retrospective cohort study from the prospective, observational, multicenter German Stroke Registry-Endovascular Treatment between May 1, 2015, and December 31, 2021. This study compared IVT plus MT vs MT alone in patients with acute ischemic stroke due to anterior circulation large-vessel occlusion in whom mechanical reperfusion was unsuccessful. Unsuccessful mechanical reperfusion was defined as failed (final modified Thrombolysis in Cerebral Infarction grade of 0 or 1) or partial (grade 2a). Patients meeting the inclusion criteria were matched by treatment group using 1:1 propensity score matching. Interventions Mechanical thrombectomy with or without IVT. Main Outcomes and Measures Primary outcome was functional independence at 90 days, defined as a modified Rankin Scale score of 0 to 2. Safety outcomes were the occurrence of symptomatic intracranial hemorrhage and death. Results After matching, 746 patients were compared by treatment arms (median age, 78 [IQR, 68-84] years; 438 women [58.7%]). The proportion of patients who were functionally independent at 90 days was 68 of 373 (18.2%) in the IVT plus MT and 42 of 373 (11.3%) in the MT alone group (adjusted odds ratio [AOR], 2.63 [95% CI, 1.41-5.11]; P = .003). There was a shift toward better functional outcomes on the modified Rankin Scale favoring IVT plus MT (adjusted common OR, 1.98 [95% CI, 1.35-2.92]; P < .001). The treatment benefit of IVT was greater in patients with partial reperfusion compared with failed reperfusion. There was no difference in symptomatic intracranial hemorrhages between treatment groups (AOR, 0.71 [95% CI, 0.29-1.81]; P = .45), while the death rate was lower after IVT plus MT (AOR, 0.54 [95% CI, 0.34-0.86]; P = .01). Conclusions and Relevance These findings suggest that prior IVT was safe and improved functional outcomes at 90 days. Partial reperfusion was associated with a greater treatment benefit of IVT, indicating a positive interaction between IVT and MT. These results support current guidelines that all eligible patients with stroke should receive IVT before MT and add a new perspective to the debate on noninferiority of combined stroke treatment.
Collapse
Affiliation(s)
- Tobias D Faizy
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jeremy J Heit
- Department of Radiology, Stanford University School of Medicine, Stanford, California
| | - Helge Kniep
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lukas Meyer
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter Sporns
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
- Department of Neuroradiology, University Hospital Basel, Basel, Switzerland
| | - Uta Hanning
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Philipp Vollmuth
- Department of Neuroradiology, University Medical Center Heidelberg, Heidelberg, Germany
| | - Maarten G Lansberg
- Department of Neurology and Neurological Science, Stanford University School of Medicine, Stanford, California
| | - Gregory W Albers
- Department of Neurology and Neurological Science, Stanford University School of Medicine, Stanford, California
| | - Urs Fischer
- Department of Neurology, University Medical Center Basel, Basel, Switzerland
| | - Max Wintermark
- Department of Neuroradiology, MD Anderson Cancer Center, Houston, Texas
| | - Götz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Jens Fiehler
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Laurens Winkelmeier
- Department of Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
45
|
Weller JM, Dorn F, Meissner JN, Stösser S, Beckonert NM, Nordsiek J, Kindler C, Deb-Chatterji M, Petzold GC, Bode FJ. Endovascular thrombectomy in young patients with stroke. Int J Stroke 2023; 18:453-461. [PMID: 35912650 DOI: 10.1177/17474930221119602] [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: 11/15/2022]
Abstract
BACKGROUND Endovascular treatment (ET) is standard of care in patients with acute ischemic stroke due to large vessel occlusion, but data on ET in young patients remain limited. AIM We aim to compare outcomes for young stroke patients undergoing ET in a matched cohort. METHODS We analyzed patients from an observational multicenter cohort with acute ischemic stroke and ET, the German Stroke Registry-Endovascular Treatment trial. Baseline characteristics, procedural parameters, and functional outcome at 90 days were compared between young (<50 years) and older (⩾50 years) patients with and without nearest-neighbor 1:1 propensity score matching. RESULTS Out of 6628 acute ischemic stroke patients treated with ET, 363 (5.5%) were young. Young patients differed with regard to prognostic outcome characteristics. Specifically, National Institutes of Health Stroke Scale (NIHSS) at admission was lower (median 13, interquartile range (IQR) 8-17 vs. 15, IQR 9-19, p < 0.001), and prestroke dependence was less frequent (2.9% vs. 12.2%, p < 0.001) than in older patients. Compared to a matched cohort of older patients, ET was faster (time from groin puncture to flow restoration, 35 vs. 45 min, p < 0.001) and intracranial hemorrhage was less frequent in young patients (10.0% vs. 25.9%, p < 0.001). Good functional outcome (modified Rankin Scale (mRS) 0-2) at 3 months was achieved more frequently in young patients (71.6% vs. 44.1%, p < 0.001), and overall mortality was lower (6.7% vs. 25.4%, p < 0.001). Among previously employed young patients (n = 177), 37.9% returned to work at 3-month follow-up, while 74.1% of the remaining patients were still undergoing rehabilitation. CONCLUSION Young stroke patients undergoing ET have better outcomes compared to older patients, even when matched for prestroke condition, comorbidities, and stroke severity. Hence, more liberal guidelines to perform ET for younger patients may have to be established by future studies.
Collapse
Affiliation(s)
- Johannes M Weller
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Franziska Dorn
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Julius N Meissner
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Sebastian Stösser
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Niklas M Beckonert
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Julia Nordsiek
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Christine Kindler
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - Gabor C Petzold
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | - Felix J Bode
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Bonn, Germany
| | | |
Collapse
|
46
|
Kanamoto T, Tateishi Y, Yamashita K, Furuta K, Torimura D, Tomita Y, Hirayama T, Shima T, Nagaoka A, Yoshimura S, Miyazaki T, Ideguchi R, Morikawa M, Morofuji Y, Horie N, Izumo T, Tsujino A. Impact of width of susceptibility vessel sign on recanalization following endovascular therapy. J Neurol Sci 2023; 446:120583. [PMID: 36827810 DOI: 10.1016/j.jns.2023.120583] [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: 09/19/2022] [Revised: 02/05/2023] [Accepted: 02/09/2023] [Indexed: 02/14/2023]
Abstract
BACKGROUND AND PURPOSE We aimed to investigate the relationship between arterial recanalization following endovascular therapy and the susceptibility vessel sign (SVS) length and width on susceptibility-weighted imaging. METHODS We retrospectively evaluated consecutive patients with anterior circulation ischemic stroke who underwent magnetic resonance imaging preceded endovascular therapy, and measured the SVS length and width. Successful recanalization was defined as expanded thrombolysis in cerebral infarction grade of 2b to 3. Logistic regression analysis was executed to determine the independent predictors of successful recanalization and first-pass reperfusion (FPR) after endovascular therapy. RESULTS Among 100 patients, successful recanalization and FPR were observed in 77 and 34 patients, respectively. The median SVS length and width were 10.3 mm (interquartile range, 6.8-14.1 mm) and 4.2 mm (interquartile range, 3.1-5.2 mm), respectively. In multivariate logistic regression analysis, SVS width was associated with successful recanalization (odds ratio, 1.88; 95% confidence interval, 1.14-3.07; p = 0.005) and FPR (odds ratio, 1.38; 95% confidence interval, 1.01-1.89; p = 0.039). The optimal cutoff value for the SVS width to predict successful recanalization and FPR were 4.2 mm and 4.0 mm, respectively. CONCLUSIONS Larger SVS width may predict successful recanalization and FPR following endovascular therapy.
Collapse
Affiliation(s)
- Tadashi Kanamoto
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Yohei Tateishi
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Kairi Yamashita
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Kanako Furuta
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Daishi Torimura
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Yuki Tomita
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Takuro Hirayama
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Tomoaki Shima
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Atsushi Nagaoka
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Shunsuke Yoshimura
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Teiichiro Miyazaki
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Reiko Ideguchi
- Department of Radiology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Minoru Morikawa
- Department of Radiology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Yoichi Morofuji
- Department of Neurosurgery, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan
| | - Nobutaka Horie
- Department of Neurosurgery, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan; Department of Neurosurgery, Hiroshima University, Kasumi 1-2-3 Minami-ku, Hiroshima 734-8551, Japan
| | - Tsuyoshi Izumo
- Department of Neurosurgery, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| | - Akira Tsujino
- Department of Neurology and Strokology, Nagasaki University Hospital, 1-7-1 Sakamoto, Nagasaki 852-8501, Japan.
| |
Collapse
|
47
|
Stösser S, Bode FJ, Meissner JN, Weller JM, Kindler C, Sauer M, Paech D, Riegler C, Nolte CH, Pourian A, Röther J, Selo N, Ernemann U, Poli S, Eckert RM, Bohner G, Scherling K, Dorn F, Petzold GC. Outcome of Stroke Patients with Unknown Onset and Unknown Time Last Known Well Undergoing Endovascular Therapy. Clin Neuroradiol 2023; 33:107-112. [PMID: 35796854 PMCID: PMC10014703 DOI: 10.1007/s00062-022-01188-5] [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: 03/25/2022] [Accepted: 06/13/2022] [Indexed: 11/28/2022]
Abstract
PURPOSE Endovascular treatment (ET) in patients with large vessel occlusion stroke (LVOS) with unknown onset or an extended time window can be safe and effective if patients are selected by defined clinical and imaging criteria; however, it is unclear if these criteria should also be applied to patients with unknown onset and unknown time last known well. In this study, we aimed to assess whether absent information on the time patients were last known to be well impacts outcome in patients with unknown onset LVOS. METHODS We analyzed patients who were enrolled in the German Stroke Registry-Endovascular Treatment between 2015 and 2019. Patients with unknown onset and unknown time last known well (LKWu) were compared to patients with known onset (KO) and to patients with unknown onset but known time last known well (LKWk) regarding clinical and imaging baseline characteristics and outcome. RESULTS Out of 5909 patients, 561 presented with LKWu (9.5%), 1849 with LKWk (31.3%) and 3499 with KO (59.2%). At 90 days, functional independency was less frequent in LKWu (27.0%) compared to KO (42.6%) and LKWk patients (31.8%). These differences were not significant after adjusting for confounders. A main confounder was the initial Alberta stroke program early CT score. CONCLUSION The LKWu patients had a similar outcome after ET as KO and LKWk patients after adjusting for confounders. Thus, ET should not be withheld if the time last known well is unknown. Instead, LKWu patients may be selected for ET using the same criteria as in LKWk patients.
Collapse
Affiliation(s)
- Sebastian Stösser
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany.
| | - Felix J Bode
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Julius N Meissner
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Johannes M Weller
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Christine Kindler
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | - Malte Sauer
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Daniel Paech
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Christoph Riegler
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Christian H Nolte
- Klinik und Hochschulambulanz für Neurologie, Charité-Universitätsmedizin Berlin, corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany.,Center for Stroke Research Berlin (CSB), Charité-Universitätsmedizin Berlin, Berlin, Germany.,Berlin Institute of Health at Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Amitis Pourian
- Department of Neurology, Asklepios Hospital Hamburg Altona, Semmelweis University Campus Hamburg, Hamburg, Germany
| | - Joachim Röther
- Department of Neurology, Asklepios Hospital Hamburg Altona, Semmelweis University Campus Hamburg, Hamburg, Germany
| | - Nadja Selo
- Department of Neuroradiology, University Hospital Tübingen, Tübingen, Germany
| | - Ulrike Ernemann
- Department of Neuroradiology, University Hospital Tübingen, Tübingen, Germany
| | - Sven Poli
- Department of Neurology, University Hospital Tübingen, Tübingen, Germany
| | - Rosa Marie Eckert
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Georg Bohner
- Department of Neuroradiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Korbinian Scherling
- Department of Neuroradiology, Ludwig Maximilians University Munich, Campus Grosshadern, Munich, Germany
| | - Franziska Dorn
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Gabor C Petzold
- Division of Vascular Neurology, Department of Neurology, University Hospital Bonn, Venusberg-Campus 1, 53127, Bonn, Germany
| | | |
Collapse
|
48
|
Kawano D, Fukuda K, Takeshita S, Fukumoto H, Horio Y, Ogata T, Higashi T, Inoue T, Abe H. Pooled blood volume measured by final flat-panel detector computed tomography predicts outcome after endovascular thrombectomy for acute ischemic stroke. World Neurosurg X 2023; 19:100178. [PMID: 37021291 PMCID: PMC10068609 DOI: 10.1016/j.wnsx.2023.100178] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2022] [Revised: 02/27/2023] [Accepted: 03/16/2023] [Indexed: 03/30/2023] Open
Abstract
Background Pooled blood volume (PBV), measured in real-time in the angiography room using an angiography system, correlates with cerebral blood volume (CBV). We examined the usefulness of PBV in endovascular thrombectomy (EVT) for acute ischemic stroke (AIS). Methods EVT for AIS in the anterior circulation (internal carotid artery (ICA) and middle cerebral artery (MCA)) was performed in 31 cases (13 males, 18 females, average age 75.7 years). PBV was acquired using a biplane flat-panel detector (FD) angiographic system. Then, we measured the average PBV value in the M1-6 regions similar to the Alberta Stroke Program Early CT score (ASPECTS) before and after EVT. We investigated factors associated with favorable outcome at 90 days after EVT. Results There were 13 patients (41.9%) in the good outcome group (mRS (modified Rankin Scale) ≦2) and 18 patients (58.1%) in the poor outcome group (mRS>2). In univariate analysis, NIHSS (National Institutes of Health Stroke Scale) (odds ratio [OR] 0.74, 95% CI 0.57-0.87, p < 0.0001) and post PBV value (odds ratio [OR] 1.13, 95% CI 1.03-1.29, p = 0.0086) were significantly associated with good outcome. The good outcome group had significantly higher post-thrombectomy PBV value (3.69 ± 0.32 ml/100 g versus 2.78 ± 0.93 ml/100 g, P = 0.002) compared to that of the poor outcome group. The relationship between pre-thrombectomy PBV value and outcome at 90 days was not significant. Conclusions Post-operative PBV value measured by FD-CT (computed tomography) correlated with 90-day outcome after EVT for AIS. FD-CT-PBV would be one of the good predictors of clinical outcome.
Collapse
|
49
|
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.
Collapse
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
| | | |
Collapse
|
50
|
Start, Stop, Continue? The Benefit of Overlapping Intravenous Thrombolysis and Mechanical Thrombectomy : A Matched Case-control Analysis from the German Stroke Registry. Clin Neuroradiol 2023; 33:187-197. [PMID: 35881162 PMCID: PMC10014683 DOI: 10.1007/s00062-022-01200-y] [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: 05/28/2022] [Accepted: 07/08/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE Here we compare the procedural and clinical outcome of patients undergoing thrombectomy with running thrombolysis to matched controls with completed intravenous therapy and an only marginally overlapping activity. METHODS Patients from 25 sites in Germany were included, who presented with an acute ischemic stroke. Patients' baseline characteristics (including ASPECTS, NIHSS and mRS), grade of reperfusion, and functional outcome 24 h and at day 90 after intervention were extracted from the German Stroke Registry (n = 2566). In a case-control design we stepwise matched the groups due to age, sex and time to groin puncture and time to flow restoration. RESULTS In the initial cohort (overlap group n = 864, control group n = 1702) reperfusion status (median TICI in overlap group vs. control group: 3 vs. 2b), NIHSS after 24 h, early neurological improvement parameters, mRS at 24 h and at day 90 were significantly better in the overlap group (p < 0.001) with a similar risk of bleeding (2.9% vs. 2.4%) and death (18% vs. 22%). After adjustment mRS at day 90 still showed a trend for lower disability scores in the overlap group (3 IQR 1-5 vs. 3 IQR 1-6, p = 0.09). While comparable bleeding risk could be maintained (4% in both groups), there were significantly more deaths in the control group (18% vs. 30%, p = 0.006). CONCLUSION The presented results support the approach of continuing and completing a simultaneous administration of intravenous thrombolysis during mechanical thrombectomy procedures.
Collapse
|