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Fujiwara S, Matsuoka Y, Ohara N, Hijikata Y, Imamura H, Yamamoto Y, Ariyoshi K, Kawamoto M, Sakai N, Ohta T. Comorbidity burden and outcomes after mechanical thrombectomy for large vessel occlusion: A retrospective analysis. J Stroke Cerebrovasc Dis 2024; 33:107778. [PMID: 38795797 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107778] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Revised: 03/29/2024] [Accepted: 05/16/2024] [Indexed: 05/28/2024] Open
Abstract
OBJECTIVES Patients with acute ischemic stroke (AIS) often have an accumulation of pre-existing comorbidities, but its clinical impact on outcomes after mechanical thrombectomy (MT) remains unknown. Therefore, we examined whether comorbidity burden before AIS onset could predict clinical outcomes after MT. METHODS In this retrospective cohort, we enrolled consecutive patients with community-onset AIS who underwent MT between April 2016 and December 2021. To evaluate each patient's comorbidity burden, we calculated Charlson comorbidity index (CCI), then classified the patients into the High CCI (≥ 3) and the Low CCI (< 3) groups. The primary outcome was a good neurological outcome at 90 days, defined as a modified Rankin scale 0-2 or no worse than the previous daily conditions. All-cause mortality at 90 days and hemorrhagic complications after MT were also compared between the two groups. We estimated the odds ratios and their confidence intervals using a multivariable logistic regression model. RESULTS A total of 388 patients were enrolled, of whom 86 (22.2%) were classified into the High CCI group. Patients in the High CCI group were less likely to achieve a good neurological outcome (adjusted odds ratio of 0.26 [95% confidence interval, 0.12-0.58]). Moreover, symptomatic intracranial hemorrhage was more common in the High CCI (14.0% vs. 4.6%; adjusted odds ratio, 4.10 [95% confidence interval, 1.62-10.3]). CONCLUSIONS Comorbidity burden assessed by CCI was associated with clinical outcomes after MT. CCI has the potential to become a simple and valuable tool for predicting neurological prognosis among patients with AIS and MT.
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Affiliation(s)
- Satoru Fujiwara
- Department of Neurology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yoshinori Matsuoka
- Department of Emergency Medicine, Kobe City Medical Center General Hospital, Kobe, Japan; Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan; Department of Research Support, Center for Clinical Research and Innovation, Kobe City Medical Center General Hospital, Kobe, Japan.
| | - Nobuyuki Ohara
- Department of Neurology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Yasukazu Hijikata
- Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Hirotoshi Imamura
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan; Department of Neurosurgery, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Yosuke Yamamoto
- Department of Healthcare Epidemiology, Graduate School of Medicine and Public Health, Kyoto University, Kyoto, Japan
| | - Koichi Ariyoshi
- Department of Emergency Medicine, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Michi Kawamoto
- Department of Neurology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Tsuyoshi Ohta
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
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Parvathy G, Kamaraj B, Sah B, Maheshwari A, Alexander A, Dixit V, Mumtaz H, Saqib M. Emerging artificial intelligence-aided diagnosis and management methods for ischemic strokes and vascular occlusions: A comprehensive review. World Neurosurg X 2024; 22:100303. [PMID: 38510336 PMCID: PMC10951088 DOI: 10.1016/j.wnsx.2024.100303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 02/21/2024] [Indexed: 03/22/2024] Open
Abstract
Large-vessel occlusion (LVO) stroke is a promising field for the use of AI, especially machine learning (ML) because optimal results are highly dependent on timely diagnosis, communication, and treatment. In order to better understand the current state of artificial intelligence (AI) in relation to LVO strokes, its efficacy, and potential future applications, we searched relevant literature to perform a comprehensive evaluation of the topic. The databases PubMed, Embase, and Scopus were extensively searched for this review. Studies were then screened using title and abstract criteria and duplicate studies were excluded. By using pre-established inclusion and exclusion criteria, it was decided whether or not to include full-text papers in the final analysis. The studies were analyzed, and the relevant information was retrieved. In recognizing LVO on computed tomography, ML approaches were very accurate. There is a shortage of AI applications for thrombectomy patient selection, despite the fact that certain research accurately evaluates individual patient eligibility for endovascular therapy. Machine learning algorithms may reasonably predict clinical and angiographic outcomes as well as associated factors. AI has shown promise in the diagnosis and treatment of people who have just suffered a stroke. However, the usefulness of AI in management and forecasting remains restricted, necessitating more studies into machine learning applications that can guide decision making in the future.
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Shibuya K, Hasegawa H, Suzuki T, Takahashi H, Nishiyama K, Oishi M, Fujii Y. Investigation of Mechanical Thrombectomy in Elderly Patients over 85 Years Old: A Multicenter Study. Neurol Med Chir (Tokyo) 2023; 63:393-399. [PMID: 37380448 PMCID: PMC10556208 DOI: 10.2176/jns-nmc.2023-0039] [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: 03/02/2023] [Accepted: 04/19/2023] [Indexed: 06/30/2023] Open
Abstract
In Japan, which has a super-aging society, there are increasing opportunities to perform mechanical thrombectomy for the elderly; however, there is no recorded evidence of thrombectomy for the elderly. This study examined the usefulness of thrombectomy in the elderly. We retrospectively analyzed patient data using a multicenter acute ischemic stroke registry (NGT-FAST). We examined outcomes in patients 75 years and older who underwent thrombectomies between January 1, 2021, and December 31, 2021. The patients were divided into two groups: the 75-84-year-old group and the 85+-year-old group. There was no difference in the pretreatment National Institutes of Health Stroke Scale score or Alberta Stroke Program Early Computed Tomography Score between the two groups, but the 85+-year-old group had a significantly lower rate of pre-stroke modified Rankin Scale (mRS) score of 0-2. There were no differences in time from onset to treatment or effective recanalization rate, but complications tended to be more common in the 85+-year-old group. The number of patients with a good outcome at discharge (an mRS score of 0-3) was significantly lower in the 85+-year-old group than in the 75-84-year-old group. In addition, 90.9% of patients in the 85+-year-old group with a pre-stroke mRS score of 3 deteriorated after treatment. The pre-stroke mRS score is very important in determining the indication for thrombectomy in the elderly because their preoperative condition is more likely to influence the outcome than that of younger patients.
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Affiliation(s)
- Kohei Shibuya
- Department of Neurosurgery, Brain Research Institute, Niigata University
| | - Hitoshi Hasegawa
- Department of Neurosurgery, Brain Research Institute, Niigata University
| | - Tomoaki Suzuki
- Department of Neurosurgery, Brain Research Institute, Niigata University
| | - Haruhiko Takahashi
- Department of Neurosurgery, Brain Research Institute, Niigata University
| | - Kei Nishiyama
- Department of Emergency Medicine, Niigata University
| | - Makoto Oishi
- Department of Neurosurgery, Brain Research Institute, Niigata University
| | - Yukihiko Fujii
- Department of Neurosurgery, Brain Research Institute, Niigata University
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Rohmann JL, Huerta-Gutierrez R, Audebert HJ, Kurth T, Piccininni M. Adjusted horizontal stacked bar graphs (“Grotta bars”) for consistent presentation of observational stroke study results. Eur Stroke J 2023; 8:370-379. [PMID: 37021164 PMCID: PMC10069225 DOI: 10.1177/23969873221149464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Accepted: 12/16/2022] [Indexed: 01/15/2023] Open
Abstract
Background: Modified Rankin Scale (mRS) scores are used to measure functional outcomes after stroke. Researchers create horizontal stacked bar graphs (nicknamed “Grotta bars”) to illustrate distributional differences in scores between groups. In well-conducted randomized controlled trials, Grotta bars have a causal interpretation. However, the common practice of exclusively presenting unadjusted Grotta bars in observational studies can be misleading in the presence of confounding. We demonstrated this problem and a possible solution using an empirical comparison of 3-month mRS scores among stroke/TIA patients discharged home versus elsewhere after hospitalization. Patients and methods: Using data from the Berlin-based B-SPATIAL registry, we estimated the probability of being discharged home conditional on prespecified measured confounding factors and generated stabilized inverse probability of treatment (IPT) weights for each patient. We visualized mRS distributions by group with Grotta bars for the IPT-weighted population in which measured confounding was removed. We then used ordinal logistic regression to quantify unadjusted and adjusted associations between being discharged home and the 3-month mRS score. Results: Of 3184 eligible patients, 2537 (79.7%) were discharged home. In the unadjusted analyses, those discharged home had considerably lower mRS compared with patients discharged elsewhere (common odds ratio, cOR = 0.13, 95% CI: 0.11–0.15). After removing measured confounding, we obtained substantially different mRS distributions, visually apparent in the adjusted Grotta bars. No statistically significant association was found after confounding adjustment (cOR = 0.82, 95% CI: 0.60–1.12). Discussion and conclusion: The practice of presenting only unadjusted stacked bar graphs for mRS scores together with adjusted effect estimates in observational studies can be misleading. IPT weighting can be implemented to create Grotta bars that account for measured confounding, which are more consistent with the presentation of adjusted results in observational studies.
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Affiliation(s)
- Jessica L Rohmann
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Institute of Public Health, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Rodrigo Huerta-Gutierrez
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Institute of Public Health, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Heinrich J Audebert
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Klinik und Hochschulambulanz für Neurologie, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Tobias Kurth
- Institute of Public Health, Charité – Universitätsmedizin Berlin, Berlin, Germany
| | - Marco Piccininni
- Center for Stroke Research Berlin, Charité – Universitätsmedizin Berlin, Berlin, Germany
- Institute of Public Health, Charité – Universitätsmedizin Berlin, Berlin, Germany
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Inoue M, Ota T, Hara T, Shigeta K, Kamiya Y, Arakawa H, Aoki R, Tsuruta W, Ichijo M, Kaneko J, Shiokawa Y, Hirano T. An Initial High National Institutes of Health Stroke Scale Score and Any Intracranial Hemorrhage Are Independent Factors for a Poor Outcome in Nonagenarians Treated with Thrombectomy for Acute Large Vessel Occlusion: The Tokyo/Tama-REgistry of Acute Endovascular Thrombectomy (TREAT) Study. World Neurosurg 2022; 165:e325-e330. [PMID: 35717017 DOI: 10.1016/j.wneu.2022.06.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/01/2022] [Revised: 06/07/2022] [Accepted: 06/08/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Mechanical thrombectomy (MT) is effective in acute ischemic stroke patients ≥80 years old with large vessel occlusion (LVO). However, data for patients ≥90 years old remain very limited, and factors influencing functional outcomes are unclear. This study aimed to investigate factors influencing functional outcomes in patients ≥90 years old treated with MT for acute LVO. METHODS This retrospective observational study used prospectively collected data from the Tokyo/tama-REgistry of Acute endovascular Thrombectomy (TREAT) study. Inclusion criteria were as follows: 1) patients ≥90 years old treated with MT for LVO and 2) prestroke modified Rankin Scale (mRS) score, 0-3. The functional outcome was defined based on the mRS score at 90 days after the procedure: good functional outcome, mRS score 0-3 and poor functional outcome, mRS score 4-6. RESULTS Data were analyzed for 104 patients ≥90 years old. The good functional outcome was observed in 25 patients (24.0%), and the poor functional outcome was observed in the remaining 79 patients. Significant differences were identified in initial National Institutes of Health Stroke Scale (NIHSS) score, modified Thrombolysis in Cerebral Infarction grade 2b-3, modified Thrombolysis in Cerebral Infarction grade 3, and any intracranial hemorrhage and hemorrhagic infarction in univariate analyses. Multivariable analysis confirmed the initial NIHSS score (odds ratio, 1.08; 95% confidence interval, 1.01-1.17; P = 0.045) and any intracranial hemorrhage (odds ratio, 11.6; 95% confidence interval, 1.43-95.0; P = 0.022) as independent factors for the functional outcome. CONCLUSIONS An initial high NIHSS score and any intracranial hemorrhage are independent factors for the poor functional outcome in acute ischemic stroke patients ≥90 years old treated with MT.
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Affiliation(s)
- Masato Inoue
- Department of Neurosurgery, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan.
| | - Takahiro Ota
- Department of Neurosurgery, Tokyo Metropolitan Tama Medical Center, Tokyo, Japan
| | - Tetsuo Hara
- Department of Neurosurgery, Center Hospital of the National Center for Global Health and Medicine, Tokyo, Japan
| | - Keigo Shigeta
- Department of Neurosurgery, National Hospital Organization Disaster Medical Center, Tokyo, Japan
| | - Yuki Kamiya
- Department of Neurology, Showa University Koto Toyosu Hospital, Tokyo, Japan
| | - Hideki Arakawa
- Department of Neurosurgery, Omori Red Cross Hospital, Tokyo, Japan
| | - Rie Aoki
- Department of Neurosurgery, Tokai University Hachioji Hospital, Tokyo, Japan
| | - Wataro Tsuruta
- Department of Endovascular Neurosurgery, Toranomon Hospital, Tokyo, Japan
| | - Masahiko Ichijo
- Department of Neurology, Musashino Red Cross Hospital, Tokyo, Japan
| | - Junya Kaneko
- Department of Emergency and Critical Care Medicine, Nippon Medical School Tama Nagayama Hospital, Tokyo, Japan
| | | | - Teruyuki Hirano
- Department of Stroke and Cerebrovascular Medicine, Kyorin University, Tokyo, Japan
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Rotschild O, Honig A, Hallevi H, Horev A, Seyman E, Ben-Assayag E, Jonas-Kimchi T, Sadeh U, Cohen J, Leker RR, Molad J. Endovascular thrombectomy is beneficial for functional nonagenarians - a multicenter cohort analysis. J Stroke Cerebrovasc Dis 2022; 31:106699. [PMID: 36054973 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 07/19/2022] [Accepted: 08/01/2022] [Indexed: 10/14/2022] Open
Abstract
INTRODUCTION The use of endovascular thrombectomy (EVT) has dramatically increased in recent years. However, most existing studies used an upper age limit of 80 and data regarding the safety and efficacy of EVT among nonagenarians is still lacking. METHODS 767 consecutive patients undergoing EVT for large vessel occlusion (LVO) in three participating centers were recruited into a prospective ongoing database. Demographic, clinical and imaging characteristics were documented. Statistical analysis was done to evaluate EVT outcome among nonagenarians compared to younger patients. RESULTS The current analysis included 41 (5.4%) patients older than 90 years. Compared to younger patients, nonagenarians were more often female (78% versus 50.3%, p ≤ 0.001), had worse baseline mRS scores (2 [0-3] versus 0 [0-2], p < 0.001), higher rates of hypertension and hyperlipidemia and a higher admission NIHSS (20 [14-23] versus 16 [11-20], p < 0.001). No differences were found between groups regarding the involved vessel, stroke etiology, time from symptoms to door or symptoms to EVT, successful recanalization rates and hemorrhagic transformation rates. Nonagenarians had worse mRS at 90 days (5 [3-6] versus 3 [2-5], p = 0.001), similar discharge NIHSS (5 [1-11] versus 4 [1-11], p = 0.78) and higher mortality rates (36.6% versus 15.8%, p < 0.001). All nonagenarians with baseline mRS 4 have died within 90 days. 36.4% of nonagenarian patients with baseline MRS of 3 or less had favorable outcome. DISCUSSION This study demonstrates that nonagenarian stroke patients with baseline mRS of 3 or less benefit from EVT with no significant difference in the rate of favorable outcome compared to octogenarians.
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Affiliation(s)
- Ofer Rotschild
- Department of Stroke & Neurology, Tel-Aviv Sourasky Medical Center, 6 Weizmann Street, Tel-Aviv 64239, Israel
| | - Asaf Honig
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Hen Hallevi
- Department of Stroke & Neurology, Tel-Aviv Sourasky Medical Center, 6 Weizmann Street, Tel-Aviv 64239, Israel; Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Anat Horev
- Department of Neurology, Soroka- University Medical Center, Beer-Sheva, Israel
| | - Estelle Seyman
- Department of Stroke & Neurology, Tel-Aviv Sourasky Medical Center, 6 Weizmann Street, Tel-Aviv 64239, Israel
| | - Einor Ben-Assayag
- Department of Stroke & Neurology, Tel-Aviv Sourasky Medical Center, 6 Weizmann Street, Tel-Aviv 64239, Israel; Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Tali Jonas-Kimchi
- Department of Radiology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Udi Sadeh
- Department of Radiology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Jose Cohen
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ronen R Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Jeremy Molad
- Department of Stroke & Neurology, Tel-Aviv Sourasky Medical Center, 6 Weizmann Street, Tel-Aviv 64239, Israel.
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Fujiwara S, Sakai N, Imamura H, Ohara N, Tanaka K, Yamagami H, Matsumoto Y, Takeuchi M, Uchida K, Yoshimura S, Morimoto T. Association between anemic status on admission and clinical outcomes of acute large vessel occlusion. J Neurol Sci 2022; 440:120343. [PMID: 35872473 DOI: 10.1016/j.jns.2022.120343] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2022] [Revised: 05/20/2022] [Accepted: 07/13/2022] [Indexed: 10/17/2022]
Abstract
BACKGROUND Anemia is a frequently observed condition, but its clinical impact on large vessel occlusion (LVO) remains unclear. We examined the association between anemic status on admission and clinical outcomes of LVO in a real-world setting. METHODS We conducted a post-hoc analysis of the RESCUE-Japan Registry 2, a nationwide registry which enrolled 2408 consecutive patients with LVO who were admitted within 24 h of onset. The patients were classified into anemia (<11 g/dL) and no-anemia (≥11 g/dL) groups according to their hemoglobin level on admission. The primary outcome was defined as a modified Rankin Scale of 0-2 at day 90. RESULTS Among the 2373 patients with available baseline hemoglobin data, 307 (13.0%) were classified in the anemia group. Anemia was associated with a lower likelihood of the primary outcome (adjusted odds ratio [OR]: 0.68; 95% confidence interval [CI]: 0.47-0.98) and higher mortality within 90 days (adjusted OR: 1.48; 95% CI: 1.01-2.17). Subgroup analyses showed that the likelihood of achieving the primary outcome between the two groups was different between men and women (P for interaction = 0.049), those with Alberta Stroke Program Early CT Score (ASPECTS) <6 and ASPECTS ≥6 (P for interaction = 0.02), and those with National Institute of Health Stroke Scale (NIHSS) ≥16 and NIHSS < 16 (P for interaction = 0.005). CONCLUSIONS Anemic state on admission was associated with poorer clinical outcomes of LVO in real-world clinical practice. The effects of anemic status were larger in LVO patients with lower NIHSS or higher ASPECTS.
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Affiliation(s)
- Satoru Fujiwara
- Department of Neurology, Kobe City Medical Center General Hospital, Kobe, Japan; Department of Clinical Epidemiology, Hyogo Medical University, Nishinomiya, Japan
| | - Nobuyuki Sakai
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Hirotoshi Imamura
- Department of Neurosurgery, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Nobuyuki Ohara
- Department of Neurology, Kobe City Medical Center General Hospital, Kobe, Japan
| | - Kanta Tanaka
- Division of Stroke Care Unit, National Cerebral and Cardiovascular Center, Suita, Japan
| | - Hiroshi Yamagami
- Department of Stroke Neurology, National Hospital Organization Osaka National Hospital, Osaka, Japan
| | - Yasushi Matsumoto
- Department of Neuroendovascular Therapy, Kohnan Hospital, Miyagi, Japan
| | | | - Kazutaka Uchida
- Department of Clinical Epidemiology, Hyogo Medical University, Nishinomiya, Japan; Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Shinichi Yoshimura
- Department of Neurosurgery, Hyogo Medical University, Nishinomiya, Japan
| | - Takeshi Morimoto
- Department of Clinical Epidemiology, Hyogo Medical University, Nishinomiya, Japan.
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Adcock AK, Schwamm LH, Smith EE, Fonarow GC, Reeves MJ, Xu H, Matsouaka RA, Xian Y, Saver JL. Trends in Use, Outcomes, and Disparities in Endovascular Thrombectomy in US Patients With Stroke Aged 80 Years and Older Compared With Younger Patients. JAMA Netw Open 2022; 5:e2215869. [PMID: 35671055 PMCID: PMC9175073 DOI: 10.1001/jamanetworkopen.2022.15869] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
Abstract
IMPORTANCE Patients aged 80 years and older were often excluded or underrepresented in pivotal endovascular thrombectomy (EVT) trials. Accordingly, trends in frequency, outcomes, and disparities of EVT use merit close analysis. OBJECTIVE To delineate temporal trends in EVT use, outcomes, and disparities among patients with acute ischemic stroke aged 80 years and older vs those younger than 80 years. DESIGN, SETTING, AND PARTICIPANTS A US nationwide retrospective cohort study using prospectively collected data was conducted in patients admitted with a primary diagnosis of acute ischemic stroke between April 1, 2012, and June 30, 2019. Data were obtained from hospitals participating in the Get With the Guidelines-Stroke (GWTG-Stroke) program, which is a stroke quality improvement registry, with data collected prospectively, sponsored by the American Heart Association/American Stroke Association. Data analysis was conducted from November 2, 2020, to June 25, 2021. EXPOSURES Potentially eligible for EVT based on arrival within 6 hours and National Institutes of Health Stroke Scale score greater than or equal to 6. MAIN OUTCOMES AND MEASURES Efficacy outcomes included discharge to home, independent ambulation at discharge, and functional independence (modified Rankin Scale score 0-2) at discharge. Safety outcomes included in-hospital mortality, combined in-hospital mortality or discharge to hospice, and symptomatic intracranial hemorrhage. RESULTS Among 302 965 patients with ischemic stroke meeting study criteria as potentially eligible for EVT admitted to 614 GWTG-Stroke hospitals, 14.0% (42 422) received EVT (21 634 women [51.0%]), including 10.7% (12 768 of 119 453) of patients aged 80 years and older (median [IQR] age, 85 [82-89] years) and 16.2% (29 654 of 183 512) of patients younger than 80 years (median [IQR] age, 65 [56-73] years). Among patients aged 80 years and older, EVT rates increased substantially during the study period, from 3.3% in early 2012 to 20.8% in early 2019. By study end, the relative rate of EVT among eligible patients aged 80 years and older compared with those younger than 80 years increased from 0.49 (3.3% vs 6.7%) to 0.76 (20.8% vs 27.3%). Older patients had worse outcomes at discharge compared with younger patients, including discharge to home: 12.5% vs 31.1% (adjusted odds ratio [aOR], 0.43; 95% CI, 0.40-0.46), functional independence (modified Rankin Scale score 0-2): 10.9% vs 26.6% (aOR, 0.45; 95% CI, 0.41-0.49), and inpatient death or discharge to hospice, 34.5% vs 16.1% (aOR, 2.22; 95% CI, 2.09-2.36). Symptomatic intracranial hemorrhage rates did not differ significantly (6.9% vs 6.5%; aOR, 1.04; 95% CI, 0.94-1.14). CONCLUSIONS AND RELEVANCE In this cohort study, use of EVT among individuals aged 80 years and older increased substantially from 2012 to 2019, although the rate remained lower than in younger patients. Although favorable functional outcomes at discharge were lower and combined mortality or discharge to hospice was higher in the older patients, the risk of symptomatic intracranial hemorrhage was not increased.
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Affiliation(s)
- Amelia K. Adcock
- Department of Neurology, West Virginia University School of Medicine, Morgantown
| | - Lee H. Schwamm
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Eric E. Smith
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Gregg C. Fonarow
- Division of Cardiology, University of California, Los Angeles
- Section Editor, Health Care Quality and Guidelines, JAMA Cardiology
| | - Mathew J. Reeves
- Department of Epidemiology, Michigan State University, East Lansing
| | - Haolin Xu
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
| | | | - Ying Xian
- Duke Clinical Research Institute, Duke University, Durham, North Carolina
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Inoue H, Oomura M, Nishikawa Y, Mase M, Matsukawa N. Successful Mechanical Thrombectomy for Acute Middle Cerebral Artery Occlusion in a Centenarian. Cureus 2022; 14:e22071. [PMID: 35308732 PMCID: PMC8920831 DOI: 10.7759/cureus.22071] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2022] [Indexed: 11/28/2022] Open
Abstract
Clinical trials have proven the efficacy and beneficial therapeutic outcomes of endovascular therapy in patients with major arterial occlusion. However, its efficacy for very elderly patients, such as nonagenarians or centenarians, is not well established. In this case report, we describe the successful use of mechanical thrombectomy for the management of stroke in a centenarian. The 100-year-old woman with severe right-sided paralysis and total aphasia was admitted to our hospital approximately 30 min from the onset of symptoms. The National Institutes of Health Stroke Scale score was 24 at admission, and three-dimensional computed tomography angiography revealed occlusion in the M1 segment of left middle cerebral artery. She had persistent atrial fibrillation and was diagnosed with colon cancer one month prior to the admission. The modified Rankin Scale score before the stroke was 1, and she was generally independent. The patient successfully underwent mechanical thrombectomy, and recanalization with thrombolysis in cerebral infarction grade 3 was accomplished 129 minutes after the onset. The patient made a remarkable recovery with a National Institutes of Health Stroke Scale score of 4 at 48 h and was discharged home with a modified Rankin Scale score of 2 on day 8. Thus, mechanical thrombectomy can be performed with a good outcome even in centenarians.
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Affiliation(s)
- Hiroyasu Inoue
- Neurology, Nagoya City University Graduate School of Medical Sciences, Nagoya, JPN
| | - Masahiro Oomura
- Neurology, Nagoya City University Graduate School of Medical Sciences, Nagoya, JPN
| | - Yusuke Nishikawa
- Neurosurgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, JPN
| | - Mitsuhito Mase
- Neurosurgery, Nagoya City University Graduate School of Medical Sciences, Nagoya, JPN
| | - Noriyuki Matsukawa
- Neurology, Nagoya City University Graduate School of Medical Sciences, Nagoya, JPN
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Pilotto A, Brass C, Fassbender K, Merzou F, Morotti A, Kämpfer N, Siniscalchi A, Padovani A, Lochner P. Premorbid frailty predicts short- and long-term outcomes of reperfusion treatment in acute stroke. J Neurol 2022; 269:3338-3342. [PMID: 35039903 DOI: 10.1007/s00415-022-10966-7] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2021] [Revised: 01/03/2022] [Accepted: 01/06/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND Frailty is the most important short- and long-term predictor of disability in the elderly and, thus, might influence the clinical outcome of acute treatment of stroke. OBJECTIVE To evaluate whether frailty predicts short- and long-term all-cause mortality and neurological recovery in elderly patients who underwent reperfusion acute treatment of stroke. METHODS The study included consecutive patients older than 65 years who underwent reperfusion treatment in a single stroke unit from 2015 to 2016. Predictors of stroke outcomes were assessed including demographics, baseline NIHSS, time to needle, treatment and medical complications. Premorbid frailty was assessed with a comprehensive geriatric assessment including functional, nutritional, cognitive, social and comorbidities status. At three and twelve months, all-cause death and clinical recovery (using modified Rankin scale, mRS) were evaluated. RESULTS One-hundred and two patients who underwent acute reperfusion treatment for stroke entered the study (mean age 77.5, 65-94 years). Frailty was diagnosed in 32 out of 102 patients and associated with older age (p = 0.001) but no differences in baseline NIHSS score, vascular risk profile or treatment management strategy. Frailty status was associated with worse improvement at 24 h and higher in-hospital mortality. At follow-up, frail patients showed poorer survival at 3 (25% vs 3%, p = 0.008) and 12 (38% vs 7%, p = 0.001) months. Frailty was the best predictor of neurological recovery at one year follow-up (mRS 3.2 ± 1.9 vs 1.9 ± 1.9). DISCUSSION Frailty is an important predictor of efficacy of acute treatment of stroke beyond classical predictors of stroke outcomes. Larger longitudinal studies are, thus, warranted to evaluate the risk-benefit of reperfusion treatment in the growing elderly frail population.
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Affiliation(s)
- Andrea Pilotto
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, P.zale Spedali Civili, 1-25213, Brescia, Italy. .,FERB Onlus, Ospedale S. Isidoro, Trescore Balneario, Bergamo, Italy.
| | - Cora Brass
- Department of Neurology, Kreisklinikum Siegen, Siegen, Germany
| | - Klaus Fassbender
- Department of Neurology, University of the Saarland, Homburg, Saar, Germany
| | - Fatma Merzou
- Department of Neurology, University of the Saarland, Homburg, Saar, Germany
| | - Andrea Morotti
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, P.zale Spedali Civili, 1-25213, Brescia, Italy
| | - Niklas Kämpfer
- Department of Neurology, University of the Saarland, Homburg, Saar, Germany
| | - Antonio Siniscalchi
- Department of Neurology and Stroke Unit, Annunziata Hospital of Cosenza, Cosenza, Italy
| | - Alessandro Padovani
- Neurology Unit, Department of Clinical and Experimental Sciences, University of Brescia, P.zale Spedali Civili, 1-25213, Brescia, Italy
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11
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Yogendrakumar V, Churilov L, Mitchell PJ, Kleinig TJ, Yassi N, Thijs V, Wu TY, Shah DG, Ng FC, Dewey HM, Wijeratne T, Yan B, Desmond PM, Parsons MW, Donnan GA, Davis SM, Campbell BCV. Safety and Efficacy of Tenecteplase in Older Patients With Large Vessel Occlusion: A Pooled Analysis of the EXTEND-IA TNK Trials. Neurology 2022; 98:e1292-e1301. [PMID: 35017305 DOI: 10.1212/wnl.0000000000013302] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2021] [Accepted: 12/27/2021] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Detailed study of tenecteplase (TNK) in patients greater than 80 years of age is limited. The objective of our study was to assess the safety and efficacy of TNK at 0.25 and 0.40 mg/kg doses in patients greater than 80 years with large vessel occlusion. METHODS A pooled analysis of the EXTEND-IA TNK randomized controlled trials (n=502). Patients were adults presenting with ischemic stroke due to occlusion of the intracranial internal carotid, middle cerebral, or basilar artery presenting within 4.5 hours of symptom onset. We compared the treatment effect of TNK 0.25mg/kg, TNK 0.40mg/kg, and alteplase 0.90mg/kg, stratifying for patient age (>80 years). Outcomes evaluated include 90-day modified Rankin scale (mRS), all-cause mortality, and symptomatic ICH. Treatment effect was adjusted for baseline NIHSS, age, and time from symptom onset to puncture via mixed effects proportional odds and logistic regression models. RESULTS In patients >80 years (n=137), TNK 0.25 mg/kg was associated with improved 90-day mRS (median 3 vs. 4, adjusted common OR=2.70, 95% CI: 1.23-5.94) and reduced mortality (aOR=0.34, 95% CI: 0.13-0.91) versus 0.40 mg/kg. TNK 0.25 mg/kg was associated with improved 90-day mRS (median 3 vs. 4, acOR=2.28, 95% CI: 1.03-5.05) versus alteplase. No difference in 90-day mRS or mortality was detected between alteplase and TNK 0.40 mg/kg. Symptomatic ICH was observed in 4 patients treated with TNK 0.40 mg/kg, one patient treated with alteplase and zero patients treated with TNK 0.25 mg/kg. In patients ≤ 80 years, no differences in 90-day mRS, mortality, or symptomatic ICH was observed between TNK 0.25 mg/kg, alteplase, and TNK 0.40 mg/kg. CONCLUSIONS TNK 0.25 mg/kg was associated with improved 90-day mRS and lower mortality in patients greater than 80 years of age. No differences between the doses were observed in younger patients. CLASSIFICATION OF EVIDENCE This study provides Class II evidence that tenecteplase 0.25 mg/kg given before endovascular therapy in patients >80 years old with large vessel occlusion stroke is associated with better functional outcomes at 90 days and reduced mortality when compared to tenecteplase 0.40 mg/kg or alteplase 0.90 mg/kg. TRIAL REGISTRATION ClinicalTrials.gov Identifiers: NCT02388061, NCT03340493 https://www.clinicaltrials.gov/ct2/show/NCT02388061 https://www.clinicaltrials.gov/ct2/show/NCT03340493.
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Affiliation(s)
- Vignan Yogendrakumar
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia
| | - Leonid Churilov
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia.,Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia
| | - Peter J Mitchell
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Timothy J Kleinig
- Department of Neurology, Royal Adelaide Hospital, Adelaide, Australia
| | - Nawaf Yassi
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia.,Population Health and Immunity Division, The Walter and Eliza Hall Institute of Medical Research, Parkville, Australia
| | - Vincent Thijs
- Department of Medicine, Austin Health, University of Melbourne, Heidelberg, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia
| | - Teddy Y Wu
- Department of Neurology, Christchurch Hospital, Christchurch, New Zealand
| | - Darshan G Shah
- Department of Neurology, Princess Alexandra Hospital, Brisbane, Queensland, Australia
| | - Felix C Ng
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia
| | - Helen M Dewey
- Eastern Health and Eastern Health Clinical School, Department of Neurosciences, Monash University, Clayton, Victoria, Australia
| | - Tissa Wijeratne
- Melbourne Medical School, Department of Medicine and Neurology, The University of Melbourne and Western Health, Sunshine Hospital, St Albans Victoria, Australia
| | - Bernard Yan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia.,Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Patricia M Desmond
- Department of Radiology, Royal Melbourne Hospital, University of Melbourne, Parkville, Australia
| | - Mark W Parsons
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia.,Department of Neurology, Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Geoffrey Alan Donnan
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia
| | - Stephen M Davis
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville, Australia.,Florey Institute of Neuroscience and Mental Health, University of Melbourne, Parkville, Australia
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12
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Sudre J, Venditti L, Ancelet C, Chassin O, Sarov M, Smadja D, Chausson N, Lun F, Laine O, Duron E, Verny C, Spelle L, Rouquette A, Legris N, Denier C. Reperfusion therapy for acute ischemic stroke in older people: An observational real-life study. J Am Geriatr Soc 2021; 69:3167-3176. [PMID: 34374987 DOI: 10.1111/jgs.17394] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 06/17/2021] [Accepted: 06/26/2021] [Indexed: 12/17/2022]
Abstract
BACKGROUND While randomized clinical trials have shown the benefit of thrombolysis and endovascular thrombectomy (EVT) in patients with acute ischemic stroke (AIS), we aimed to describe in a real-life study the differences between older (>80 years old) and younger patients treated for AIS. METHODS Thousand patients treated with thrombolysis and/or EVT were consecutively included in a prospective monocentric database (admitted from December 2015 to May 2019 in our comprehensive stroke center). Demographic data with detailed history, baseline physical examinations and treatments, laboratory and imaging data, prestroke functional status, and outcome 3 months after stroke were analyzed. RESULTS Older patients (n = 357) had more baseline comorbidities and lower levels of prestroke independence (modified Rankin scale ≤2; 67.2% vs. 96.1%) and more severe strokes (median National Institute of Health Stroke Score [NIHSS] 15 vs. 12; p < 0.001) than younger patients (n = 643). There was no difference in the reperfusion treatments used or treatment timelines. In older patients, good functional status at 3 months was less common (29.7% vs. 61.3%) and mortality was higher (37.1% vs. 11.4%) than in younger patients. Younger age was independently associated with better prognosis (odds ratio [OR] 0.37, 95% confidence interval [CI]: 0.20-0.67; p = 0.001) and lower mortality (OR 4.38, 95% CI: 2.11-9.09; p < 0.001). Among older adults, features associated with good outcome at 3 months were age (OR 0.89, 95% CI: 0.81-0.97; p = 0.01), initial NIHSS (OR 0.89, 95% CI: 0.83-0.94; p < 0.0001), and absence of severe leukoaraiosis, anticoagulant treatment, and symptomatic intracerebral hemorrhage following reperfusion therapy (respectively, OR 0.42, 95% CI: 0.19-0.93; p = 0.03; OR = 0.07, 95% CI: 0.01-0.70; p = 0.02; and OR = 0.07, 95% CI: 0.01-0.61; p = 0.02). CONCLUSION Although reperfusion therapy was less successful in older patients, these patients may benefit from acute recanalization despite their age. With an increasing older adult population, high-quality prospective studies are still required to better predict functional outcome and clarify the criteria that would allow better selection of appropriate treatment.
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Affiliation(s)
- Justine Sudre
- Department of Neurology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Paris Saclay University, Le Kremlin Bicêtre, France
| | - Laura Venditti
- Department of Neurology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Paris Saclay University, Le Kremlin Bicêtre, France
| | - Claire Ancelet
- Neuroradiology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Paris Saclay University, Le Kremlin Bicêtre, France
| | - Olivier Chassin
- Department of Neurology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Paris Saclay University, Le Kremlin Bicêtre, France
| | - Mariana Sarov
- Department of Neurology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Paris Saclay University, Le Kremlin Bicêtre, France
| | - Didier Smadja
- Department of Neurology, Centre Hospitalier Sud Francilien, Paris Saclay University, Corbeil-Essonnes, France
| | - Nicolas Chausson
- Department of Neurology, Centre Hospitalier Sud Francilien, Paris Saclay University, Corbeil-Essonnes, France
| | - François Lun
- Department of Neurology, Groupe Hospitalier Nord Essonne, Orsay, France
| | - Olga Laine
- Hôpital Gériatrique Les Magnolias, Ballainvilliers, France
| | - Emmanuelle Duron
- Geriatric Center, Paul Brousse Hôpitaux Universitaires Paris Saclay, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, France
| | - Christiane Verny
- Geriatric Center, Bicêtre Hôpitaux Universitaires Paris Saclay, Assistance Publique-Hôpitaux de Paris, Le Kremlin Bicêtre, France
| | - Laurent Spelle
- Neuroradiology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Paris Saclay University, Le Kremlin Bicêtre, France
| | - Alexandra Rouquette
- Public Health and Epidemiology Department, Assistance Publique-Hôpitaux de Paris, Bicêtre Hôpitaux Universitaires Paris Sud, Université Paris Saclay, CESP, Inserm, Le Kremlin Bicêtre, France
| | - Nicolas Legris
- Department of Neurology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Paris Saclay University, Le Kremlin Bicêtre, France
| | - Christian Denier
- Department of Neurology, Bicêtre Hospital, Assistance Publique-Hôpitaux de Paris, Paris Saclay University, Le Kremlin Bicêtre, France
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