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Koul P, Collins MK, Bielinski TM, Goren O, Weiner GM, Griessenauer CJ, Noto A, Schirmer C, Hendrix P. Comparative Analysis of Mechanical Thrombectomy Outcomes of Middle Cerebral Artery M1, M2 Superior, and M2 Inferior Occlusion Strokes. World Neurosurg 2024; 189:e878-e887. [PMID: 38986952 DOI: 10.1016/j.wneu.2024.07.028] [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: 06/15/2024] [Accepted: 07/02/2024] [Indexed: 07/12/2024]
Abstract
BACKGROUND The M1 middle cerebral artery (MCA) commonly bifurcates into M2 superior and M2 inferior segments. However, MCA anatomy is highly variable rendering classification for mechanical thrombectomy trials difficult. This study explored safety and effectiveness of M2 MCA stroke thrombectomy stratified by M2 MCA anatomy. METHODS Cases of large vessel occlusion strokes treated by mechanical thrombectomy between February 2016 and August 2022 were reviewed (N = 784). M1 (n = 431) and M2 (n = 118) MCA occlusions were assessed. Among M2 MCA occlusions, only prototypical MCA bifurcation anatomy cases were included (n = 99). Dominance was assessed based on angiography. Procedural and outcome data were compared between M1, M2 superior, and M2 inferior MCA occlusions. RESULTS Baseline demographics and periprocedural criteria of M2 superior (n = 56) and M2 inferior (n = 43) occlusion mechanical thrombectomies were comparable. The occluded branch was dominant in 41/43 (95.3%) M2 inferior cases, but in only 37/56 (66.1%) M2 superior cases (P < 0.001). The 90-day favorable functional outcome (modified Rankin Scale score 0-2) and mortality (modified Rankin Scale score 6) rates were 60.0% and 8.9% in M2 superior, 42.9% and 32.6% in M2 inferior, and 44.1% and 26.0% in M1 (n = 431) cases. Compared with M2 superior cases, in M2 inferior cases, favorable outcome rates were lower (P = 0.094) and mortality rates were higher (P = 0.003) and resembled M1 rates (P = 0.750 and P = 0.355, respectively). CONCLUSIONS In the setting of prototypical MCA bifurcation anatomy, thrombectomy of dominant M2 inferior occlusions had outcome rates similar to M1 occlusions. In contrast, M2 superior occlusions had significantly lower mortality rates and a trend toward better favorable functional outcome rates.
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Affiliation(s)
- Prateeka Koul
- Department of Neurosurgery, Geisinger, Danville, Pennsylvania, USA
| | - Malie K Collins
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Tyler M Bielinski
- Geisinger Commonwealth School of Medicine, Scranton, Pennsylvania, USA
| | - Oded Goren
- Department of Neurosurgery, Geisinger, Danville, Pennsylvania, USA
| | - Gregory M Weiner
- Department of Neurosurgery, Geisinger, Wilkes-Barre, Pennsylvania, USA
| | - Christoph J Griessenauer
- Department of Neurosurgery, Christian Doppler Klinik, Paracelsus Medical University, Salzburg, Austria
| | - Anthony Noto
- Department of Neurology, Geisinger, Danville, Pennsylvania, USA
| | - Clemens Schirmer
- Department of Neurosurgery, Geisinger, Wilkes-Barre, Pennsylvania, USA
| | - Philipp Hendrix
- Department of Neurosurgery, Geisinger, Danville, Pennsylvania, USA.
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2
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Xu Y, Liu X, Li H. A comparison of endovascular therapy and medical management in patients with large vessel occlusion mild stroke treated between 2015 and 2023: a systematic review and meta-analysis. J Stroke Cerebrovasc Dis 2024; 33:107721. [PMID: 38616013 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107721] [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: 07/27/2023] [Revised: 04/10/2024] [Accepted: 04/11/2024] [Indexed: 04/16/2024] Open
Abstract
OBJECTIVE Endovascular therapy (EVT) is recommended for patients with acute large-vessel occlusion (LVO) However, its efficacy and safety compared to medical management (MM) in patients with a National Institutes of Health Stroke Scale (NIHSS) score of ≤6 remains unclear. This meta-analysis compared EVT with medical MM in patients with large vessel occlusion mild stroke treated between 2015 and 2023, following the publication of the first randomized controlled trial. MATERIALS AND METHODS Biomedical database searches (inception to March 21, 2023) retrieved articles reporting favorable functional outcome(modified Rankin Scale [mRS] 0-1) and functional independence (mRS 0-2), 90-day mortality and symptomatic intracranial hemorrhage (sICH). We followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA) to maintain methodological rigor and transparency in our meta-analysis. RESULTS We conducted a meta-analysis of 22 studies (4,985 patients) to reveal no significant differences in favorable functional outcomes and independence across all groups. However, in patients treated between 2015 and 2023, EVT exhibited a higher risk of 90-day mortality (Odds Ratio [OR] = 1.84, 95% Confidence Interval [CI] [1.10, 3.07], p = 0.02) and sICH (OR = 3.36, 95% CI [1.96, 6.66], p < 0.01). EVT correlated with elevated sICH in the anterior circulation (OR=2.94, 95%CI [1.82, 4.74], p<0.01) regardless of the proximal (OR=2.20, 95%CI [1.04, 4.69], p=0.04) or distal (OR=3.44, 95%CI [1.43, 8.32], p<0.01) location of the occlusion. EVT correlated with elevated sICH rates in patients treated within 6 hours of symptom onset or those with NHISS≤5. CONCLUSION In patients treated between 2015 and 2023, EVT and MM did not differ in efficacy in acute LVO mild stroke; MM associated with better safety outcomes. Rigorous randomized controlled trials are warranted.
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Affiliation(s)
- Yiqiao Xu
- Beijing Shijitan Hospital, Capital Medical University, Beijing 100038, PR China; Capital Medical University, Beijing, PR China
| | - Xin Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, PR China
| | - Hao Li
- Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, PR China; China National Clinical Research Center for Neurological Diseases, Beijing, PR China.
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3
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Chen KC, Chen PH, Jhou HJ. Correspondence on the article ''Endovascular treatment versus medical management for mild stroke with acute anterior circulation large vessel occlusion: a meta-analysis''. J Neurointerv Surg 2024:jnis-2024-021514. [PMID: 38360062 DOI: 10.1136/jnis-2024-021514] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2024] [Accepted: 01/22/2024] [Indexed: 02/17/2024]
Affiliation(s)
- Kuan-Chih Chen
- Department of Emergency and Critical Care Medicine, Changhua Christian Hospital, Changhua, Taiwan
- School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
| | - Po-Huang Chen
- Division of Hematology and Oncology, Department of Internal Medicine, Tri-Service General Hospital, National Defense Medical Cente, Taipei, Taiwan
| | - Hong-Jie Jhou
- School of Medicine, Kaohsiung Medical University, Kaohsiung, Taiwan
- Department of Neurology, Changhua Christian Hospital, Changhua, Taiwan
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4
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Kunst M, Gupta R, Coombs LP, Delfino JG, Khan A, Berglar I, Kozak B, Small JE, Gillis L, Noonan P, Fang J, Pai V, Tilkin M, Allen B, Dreyer K, Wald C. Real-World Performance of Large Vessel Occlusion Artificial Intelligence-Based Computer-Aided Triage and Notification Algorithms-What the Stroke Team Needs to Know. J Am Coll Radiol 2024; 21:329-340. [PMID: 37196818 DOI: 10.1016/j.jacr.2023.04.003] [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: 12/02/2022] [Revised: 03/21/2023] [Accepted: 04/06/2023] [Indexed: 05/19/2023]
Abstract
PURPOSE To evaluate the real-world performance of two FDA-approved artificial intelligence (AI)-based computer-aided triage and notification (CADt) detection devices and compare them with the manufacturer-reported performance testing in the instructions for use. MATERIALS AND METHODS Clinical performance of two FDA-cleared CADt large-vessel occlusion (LVO) devices was retrospectively evaluated at two separate stroke centers. Consecutive "code stroke" CT angiography examinations were included and assessed for patient demographics, scanner manufacturer, presence or absence of CADt result, CADt result, and LVO in the internal carotid artery (ICA), horizontal middle cerebral artery (MCA) segment (M1), Sylvian MCA segments after the bifurcation (M2), precommunicating part of cerebral artery, postcommunicating part of the cerebral artery, vertebral artery, basilar artery vessel segments. The original radiology report served as the reference standard, and a study radiologist extracted the above data elements from the imaging examination and radiology report. RESULTS At hospital A, the CADt algorithm manufacturer reports assessment of intracranial ICA and MCA with sensitivity of 97% and specificity of 95.6%. Real-world performance of 704 cases included 79 in which no CADt result was available. Sensitivity and specificity in ICA and M1 segments were 85.3% and 91.9%. Sensitivity decreased to 68.5% when M2 segments were included and to 59.9% when all proximal vessel segments were included. At hospital B the CADt algorithm manufacturer reports sensitivity of 87.8% and specificity of 89.6%, without specifying the vessel segments. Real-world performance of 642 cases included 20 cases in which no CADt result was available. Sensitivity and specificity in ICA and M1 segments were 90.7% and 97.9%. Sensitivity decreased to 76.4% when M2 segments were included and to 59.4% when all proximal vessel segments are included. DISCUSSION Real-world testing of two CADt LVO detection algorithms identified gaps in the detection and communication of potentially treatable LVOs when considering vessels beyond the intracranial ICA and M1 segments and in cases with absent and uninterpretable data.
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Affiliation(s)
- Mara Kunst
- Neuroradiology Section Head, Lahey Hospital and Medical Center, Burlington, Massachusetts
| | - Rajiv Gupta
- Neuroradiology Section Head, Massachusetts General Hospital, Boston, Massachusetts
| | | | - Jana G Delfino
- US Food and Drug Administration, Silver Spring, Maryland
| | - Amir Khan
- US Food and Drug Administration, Silver Spring, Maryland
| | - Inka Berglar
- Massachusetts General Hospital, Boston, Massachusetts
| | | | - Juan E Small
- Lahey Hospital and Medical Center, Burlington, Massachusetts
| | | | - Patrick Noonan
- US Food and Drug Administration, Silver Spring, Maryland
| | - Junyong Fang
- US Food and Drug Administration, Silver Spring, Maryland
| | - Vinay Pai
- US Food and Drug Administration, Silver Spring, Maryland
| | | | - Bibb Allen
- American College of Radiology; Chief Medical Officer of the ACR Data Science Institute
| | - Keith Dreyer
- Chief Data Science Officer, Vice Chairman of Radiology, Massachusetts General Hospital, Boston, Massachusetts
| | - Christoph Wald
- Chairman of Radiology, Lahey Hospital and Medical Center, Burlington, Massachusetts; and Chair, ACR Commission on Informatics
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5
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Loh EDW, Toh KZX, Kwok GYR, Teo YH, Teo YN, Goh C, Syn NL, Ho AFW, Sia CH, Sharma VK, Tan BY, Yeo LL. Endovascular therapy for acute ischemic stroke with distal medium vessel occlusion: a systematic review and meta-analysis. J Neurointerv Surg 2023; 15:e452-e459. [PMID: 36539273 DOI: 10.1136/jnis-2022-019717] [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: 10/03/2022] [Accepted: 12/02/2022] [Indexed: 12/24/2022]
Abstract
AIMS Endovascular therapy (EVT) for distal medium vessel occlusions (DMVOs) is a potential frontier of acute ischemic stroke (AIS) treatment, but its efficacy against best medical therapy (BMT) remains unknown. We performed a systematic review and meta-analysis evaluating the efficacy and safety of EVT versus BMT in primary DMVO. METHODS We systematically searched PubMed, Cochrane Library and Embase, from inception to August 14, 2022, for studies comparing EVT with BMT in DMVO-AIS. We adopted the Distal Thrombectomy Summit Group's definition of DMVO. Efficacy outcomes were functional independence (90-day modified Rankin Scale (mRS) 0-2) and excellent functional outcomes (90-day mRS 0-1). Safety outcomes were symptomatic intracranial hemorrhage (sICH) and 90-day mortality. RESULTS Fourteen observational and two randomized-controlled studies were included, with 1202 patients receiving EVT and 1267 receiving BMT. After trim-and-fill correction, EVT achieved significantly better odds of functional independence than BMT (adjusted OR 1.61, 95% CI 1.06 to 2.43). There were no significant differences in overall excellent functional outcomes (OR 1.23, 95% CI 0.88 to 1.71), sICH (OR 1.44, 95% CI 0.78 to 2.66), and mortality (OR 1.03, 95% CI 0.73 to 1.45). Stratified by EVT method, mechanical thrombectomy±intra-arterial thrombolysis achieved more excellent functional outcomes than BMT (OR 1.59, 95% CI 1.13 to 2.23). In mild strokes (National Institutes of Health Stroke Scale score <6), EVT caused significantly more sICH (OR 6.30, 95% CI 1.55 to 25.64). CONCLUSIONS EVT shows promising efficacy benefit over BMT for primary DMVO-AIS. Further randomized controlled trials are necessary to evaluate the efficacy and safety of EVT in DMVO-AIS.
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Affiliation(s)
- Enver De Wei Loh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Keith Zhi Xian Toh
- Lee Kong Chian School of Medicine, Nanyang Technological University, Singapore
| | - Gabriel Yi Ren Kwok
- Institute of Health Sciences Education, Barts and The London School of Medicine and Dentistry, Queen Mary University of London, London, UK
| | - Yao Hao Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Yao Neng Teo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Claire Goh
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
| | - Nicholas L Syn
- Department of Surgery, National University Health System, Singapore
| | - Andrew Fu-Wah Ho
- Department of Emergency Medicine, Singapore General Hospital, Singapore
- Pre-hospital & Emergency Research Centre, Duke-National University of Singapore Medical School, Singapore
| | - Ching-Hui Sia
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Department of Cardiology, National University Heart Centre, Singapore
| | - Vijay Kumar Sharma
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Benjamin Yq Tan
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
| | - Leonard Ll Yeo
- Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore
- Division of Neurology, Department of Medicine, National University Hospital, Singapore
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6
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Qin B, Zhang Y, Liang S, Liang H, Tang S, Liang Z. Endovascular treatment versus medical management for mild stroke with acute anterior circulation large vessel occlusion: a meta-analysis. J Neurointerv Surg 2023; 15:e475-e483. [PMID: 36813553 DOI: 10.1136/jnis-2022-019959] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/09/2023] [Indexed: 02/24/2023]
Abstract
BACKGROUND The effectiveness of endovascular treatment (EVT) in patients with mild stroke (National Institutes of Health Stroke Scale score ≤5) and acute anterior circulation large vessel occlusion (AACLVO) remains unknown. OBJECTIVE To conduct a meta-analysis to compare the efficacy and safety of EVT in patients with mild stroke and AACLVO. METHODS EMBASE, Cochrane Library, PubMed, and Clinicaltrials.gov databases were searched until October 2022. Both retrospective and prospective studies which compared the clinical outcomes between EVT and medical treatment were included. ORs and 95% confidence intervals (CIs) for excellent and favorable functional outcomes, symptomatic intracranial hemorrhage (ICH), and mortality were pooled using a random-effects model. A propensity score (PS)-based methods adjusted analysis was also performed. RESULTS 4335 patients from 14 studies were included. In patients with mild stroke and AACLVO, EVT presented no marked differences in excellent and favorable functional outcomes and mortality compared with medical treatment. A higher risk of symptomatic ICH (OR=2.79; 95% CI 1.49 to 5.24; P=0.001) was observed with EVT. Subgroup analysis revealed that EVT had potential benefit for proximal occlusions with excellent functional outcomes (OR=1.68; 95% CI 1.01 to 2.82; P=0.05). Similar results were observed when PS-based methods adjusted analysis was used. CONCLUSION EVT did not significantly benefit clinical functional outcomes in comparison with medical treatment in patients with mild stroke and AACLVO. However, it may improve functional outcomes when treating patients with proximal occlusion, despite being associated with an increased risk of symptomatic ICH. Stronger evidence from ongoing randomized controlled trials is required.
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Affiliation(s)
- Bin Qin
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Yunli Zhang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Shuolin Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Huo Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Shiting Tang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
| | - Zhijian Liang
- Department of Neurology, The First Affiliated Hospital of Guangxi Medical University, Nanning, China
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7
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Palazzo P, Padlina G, Dobrocky T, Strambo D, Seners P, Mechtouff L, Turc G, Rosso C, Almiri W, Antonenko K, Laksiri N, Sibon I, Detante O, Mordasini P, Michel P, Heldner MR. Relevance of National Institutes of Health Stroke Scale subitems for best revascularization therapy in minor stroke patients with large vessel occlusion: An observational multicentric study. Eur J Neurol 2023; 30:3741-3750. [PMID: 37517048 DOI: 10.1111/ene.16009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/30/2023] [Revised: 06/30/2023] [Accepted: 07/27/2023] [Indexed: 08/01/2023]
Abstract
BACKGROUND AND PURPOSE The best management of acute ischemic stroke patients with a minor stroke and large vessel occlusion is still uncertain. Specific clinical and radiological data may help to select patients who would benefit from endovascular therapy (EVT). We aimed to evaluate the relevance of National Institutes of Health Stroke Scale (NIHSS) subitems for predicting the potential benefit of providing EVT after intravenous thrombolysis (IVT; "bridging treatment") versus IVT alone. METHODS We extracted demographic, clinical, risk factor, radiological, revascularization and outcome data of consecutive patients with M1 or proximal M2 middle cerebral artery occlusion and admission NIHSS scores of 0-5 points, treated with IVT ± EVT between May 2005 and March 2021, from nine prospectively constructed stroke registries at seven French and two Swiss comprehensive stroke centers. Adjusted interaction analyses were performed between admission NIHSS subitems and revascularization modality for two primary outcomes at 3 months: non-excellent functional outcome (modified Rankin Scale score 2-6) and difference in NIHSS score between 3 months and admission. RESULTS Of the 533 patients included (median age 68.2 years, 46% women, median admission NIHSS score 3), 136 (25.5%) initially received bridging therapy and 397 (74.5%) received IVT alone. Adjusted interaction analysis revealed that only facial palsy on admission was more frequently associated with excellent outcome in patients treated by IVT alone versus bridging therapy (odds ratio 0.47, 95% confidence interval 0.24-0.91; p = 0.013). Regarding NIHSS difference at 3 months, no single NIHSS subitem interacted with type of revascularization. CONCLUSIONS This retrospective multicenter analysis found that NIHSS subitems at admission had little value in predicting patients who might benefit from bridging therapy as opposed to IVT alone. Further research is needed to identify better markers for selecting EVT responders with minor strokes.
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Affiliation(s)
- Paola Palazzo
- Department of Clinical Neurosciences, Neurology Service, Stroke Centre, Lausanne University Hospital, Lausanne, Switzerland
| | - Giovanna Padlina
- Stroke Research Center Bern, Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Tomas Dobrocky
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Davide Strambo
- Department of Clinical Neurosciences, Neurology Service, Stroke Centre, Lausanne University Hospital, Lausanne, Switzerland
| | - Pierre Seners
- Neurology Department, Hôpital Fondation A. de Rothschild, Paris, France
| | | | - Guillaume Turc
- Department of Neurology, Hopital Sainte-Anne, Universite de Paris and Department of Neurology, GHU Paris Psychiatrie et Neurosciences Inserm U1266, Universite Paris Cite FHU NeuroVasc, Paris, France
| | - Charlotte Rosso
- Inserm U 1127, CNRS UMR 7225, Sorbonne Université, UPMC Univ Paris 06 UMR S 1127, Institut du Cerveau et de la Moelle épinière (ICM) and APHP-Urgences Cérébro-Vasculaires, Hôpital Pitié-Salpêtrière, Paris, France
| | - William Almiri
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Kateryna Antonenko
- Stroke Research Center Bern, Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
| | - Nadia Laksiri
- Neurology Department, La Timone University Hospital, Marseille, France
| | - Igor Sibon
- Department of Neurology, Stroke Unit, CHU Bordeaux, Bordeaux, France
| | - Olivier Detante
- Neurology Department, Stroke Unit, Inserm U1216, CHU Grenoble Alpes, University Grenoble Alpes, Grenoble Institut des Neurosciences, Grenoble, France
| | - Pasquale Mordasini
- Department of Diagnostic and Interventional Neuroradiology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
- Department of Neuroradiology, St. Gallen Kantonsspital, St. Gallen, Switzerland
| | - Patrik Michel
- Department of Clinical Neurosciences, Neurology Service, Stroke Centre, Lausanne University Hospital, Lausanne, Switzerland
| | - Mirjam R Heldner
- Stroke Research Center Bern, Department of Neurology, Inselspital, University Hospital and University of Bern, Bern, Switzerland
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8
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Alexandre AM, Colò F, Brunetti V, Valente I, Frisullo G, Pedicelli A, Scarcia L, Rollo C, Falcou A, Milonia L, Andrighetti M, Piano M, Macera A, Commodaro C, Ruggiero M, Da Ros V, Bellini L, Lazzarotti GA, Cosottini M, Caragliano AA, Vinci SL, Gabrieli JD, Causin F, Panni P, Roveri L, Limbucci N, Arba F, Pileggi M, Bianco G, Romano DG, Diana F, Semeraro V, Burdi N, Ganimede MP, Lozupone E, Fasano A, Lafe E, Cavallini A, Russo R, Bergui M, Calabresi P, Della Marca G, Broccolini A. Mechanical thrombectomy in minor stroke due to isolated M2 occlusion: a multicenter retrospective matched analysis. J Neurointerv Surg 2023; 15:e198-e203. [PMID: 36223995 DOI: 10.1136/jnis-2022-019557] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 09/29/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND The purpose of this study was to evaluate the effectiveness of mechanical thrombectomy (MT) in patients with isolated M2 occlusion and minor symptoms and identify possible baseline predictors of clinical outcome. METHODS The databases of 16 high-volume stroke centers were retrospectively screened for consecutive patients with isolated M2 occlusion and a baseline National Institutes of Health Stroke Scale (NIHSS) score ≤5 who received either early MT (eMT) or best medical management (BMM) with the possibility of rescue MT (rMT) on early neurological worsening. Because our patients were not randomized, we used propensity score matching (PSM) to estimate the treatment effect of eMT compared with the BMM/rMT. The primary clinical outcome measure was a 90-day modified Rankin Scale score of 0-1. RESULTS 388 patients were initially selected and, after PSM, 100 pairs of patients receiving eMT or BMM/rMT were available for analysis. We found no significant differences in clinical outcome and in safety measures between patients receiving eMT or BMM/rMT. Similar results were also observed after comparison between eMT and rMT. Concerning baseline predicting factors of outcome, the involvement of the M2 inferior branch was associated with a favorable outcome. CONCLUSION Our multicenter retrospective analysis has shown no benefit of eMT in minor stroke patients with isolated M2 occlusion over a more conservative therapeutic approach. Although our results must be viewed with caution, in these patients it appears reasonable to consider BMM as the first option and rMT in the presence of early neurological deterioration.
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Affiliation(s)
- Andrea M Alexandre
- Neuroradiology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Valerio Brunetti
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Iacopo Valente
- Neuroradiology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giovanni Frisullo
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Alessandro Pedicelli
- Neuroradiology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Luca Scarcia
- Catholic University School of Medicine, Rome, Italy
| | | | - Anne Falcou
- Stroke Unit, University Hospital Policlinico Umberto I, Rome, Italy
| | - Luca Milonia
- Interventional Neuroradiology, University Hospital Policlinico Umberto I, Rome, Italy
| | | | - Mariangela Piano
- Neuroradiology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Antonio Macera
- Neuroradiology Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | | | | | - Valerio Da Ros
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Rome, Italy
| | - Luigi Bellini
- Department of Biomedicine and Prevention, University Hospital of Rome "Tor Vergata", Rome, Italy
| | - Guido A Lazzarotti
- Neuroradiology Unit, Azienda Ospedaliero Universitaria Pisana (AOUP), Pisa, Italy
| | - Mirco Cosottini
- Neuroradiology Unit, Azienda Ospedaliero Universitaria Pisana (AOUP), Pisa, Italy
| | | | - Sergio L Vinci
- Neuroradiology Unit, AOU Policlinico G. Martino, Messina, Italy
| | - Joseph D Gabrieli
- Neuroradiology Unit, Policlinico Universitario di Padova, Padia, Italy
| | - Francesco Causin
- Neuroradiology Unit, Policlinico Universitario di Padova, Padia, Italy
| | - Pietro Panni
- Interventional Neuroradiology Unit, IRCCS San Raffaele University Hospital, Milan, Italy
| | - Luisa Roveri
- Neurology Unit, IRCCS San Raffaele University Hospital, Milan, Italy
| | - Nicola Limbucci
- Interventional Neurovascular Unit, A.O.U. Careggi, Florence, Italy
| | | | - Marco Pileggi
- Neuroradiology Unit, Neurocenter of Southern Switzerland-EOC, Lugano, Switzerland
| | - Giovanni Bianco
- Stroke Center, Neurocenter of Southern Switzerland-EOC, Lugano, Switzerland
| | - Daniele G Romano
- Neuroradiology Unit, AOU S Giovanni di Dio e Ruggi di Aragona, Salerno, Italy
| | - Francesco Diana
- Neuroradiology Unit, AOU S Giovanni di Dio e Ruggi di Aragona, Salerno, Italy
| | - Vittorio Semeraro
- Interventional Radiology Unit, "SS Annunziata" Hospital, Taranto, Italy
| | - Nicola Burdi
- Interventional Radiology Unit, "SS Annunziata" Hospital, Taranto, Italy
| | | | | | | | - Elvis Lafe
- Neuroradiology Unit, IRCCS Policlinico San Matteo, Pavia, Italy
| | - Anna Cavallini
- Cerebrovascular Diseases Unit, IRCCS Fondazione Mondino, Pavia, Italy
| | - Riccardo Russo
- Neuroradiology Unit, Azienda Ospedaliera Città della Salute e della Scienza, Turin, Italy
| | - Mauro Bergui
- Neuroradiology Unit, Azienda Ospedaliera Città della Salute e della Scienza, Turin, Italy
| | - Paolo Calabresi
- Catholic University School of Medicine, Rome, Italy
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Giacomo Della Marca
- Catholic University School of Medicine, Rome, Italy
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | - Aldobrando Broccolini
- Catholic University School of Medicine, Rome, Italy
- Neurology Unit, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
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9
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Yedavalli V, Hamam O, Mohseni A, Chen K, Wang R, Heo HY, Heit J, Marsh EB, Llinas R, Urrutia V, Xu R, Gonzalez F, Albers G, Hillis A, Nael K. Pretreatment brain CT perfusion thresholds for predicting final infarct volume in distal medium vessel occlusions. J Neuroimaging 2023; 33:968-975. [PMID: 37357133 DOI: 10.1111/jon.13142] [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: 05/30/2023] [Revised: 06/12/2023] [Accepted: 06/15/2023] [Indexed: 06/27/2023] Open
Abstract
BACKGROUND AND PURPOSE Quantitative CT perfusion (CTP) thresholds for assessing the extent of ischemia in patients with acute ischemic stroke (AIS) have been established; relative cerebral blood flow (rCBF) <30% is typically used for estimating estimated ischemic core volume and Tmax (time to maximum) >6 seconds for critical hypoperfused volume in AIS patients with large vessel occlusion (LVO). In this study, we aimed to identify the optimal threshold values for patients presenting with AIS secondary to distal medium vessel occlusions (DMVOs). METHODS In this retrospective study, consecutive AIS patients with anterior circulation DMVO who underwent pretreatment CTP and follow-up MRI/CT were included. The CTP data were processed by RAPID (iSchemaView, Menlo Park, CA) to generate estimated ischemic core volumes using rCBF <20%, <30%, <34%, and <38% and critical hypoperfused volumes using Tmax (seconds) >4, >6, >8, and >10. Final infarct volumes (FIVs) were obtained from follow-up MRI/CT within 5 days of symptom onset. Diagnostic performance between CTP thresholds and FIV was assessed in the successfully and unsuccessfully recanalized groups. RESULTS Fifty-five patients met our inclusion criteria (32 female [58.2%], 68.0 ± 12.1 years old [mean ± SD]). Recanalization was attempted with intravenous tissue-type plasminogen activator and mechanical thrombectomy in 27.7% and 38.1% of patients, respectively. Twenty-five patients (45.4%) were successfully recanalized. In the successfully recanalized patients, no CTP threshold significantly outperformed what is used in LVO setting (rCBF < 30%). All rCBF CTP thresholds demonstrated fair diagnostic performances for predicting FIV. In unsuccessfully recanalized patients, all Tmax CTP thresholds strongly predicted FIV with relative superiority of Tmax >10 seconds (area under the receiver operating characteristic curve = .875, p = .001). CONCLUSION In AIS patients with DMVOs, longer Tmax delays than Tmax > 6 seconds, most notably, Tmax > 10 seconds, best predict FIV in unsuccessfully recanalized patients. No CTP threshold reliably predicts FIV in the successfully recanalized group nor significantly outperformed rCBF < 30%.
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Affiliation(s)
- Vivek Yedavalli
- Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Omar Hamam
- Department of Radiology, Massachusetts General Hospital, Cambridge, Massachusetts, USA
| | - Alireza Mohseni
- Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Kwan Chen
- Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Richard Wang
- Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Hye-Young Heo
- Department of Radiology and Radiological Sciences, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Jeremy Heit
- Department of Radiology, Division of Neuroimaging and Neurointervention, Stanford Neuroscience Health Center, Palo Alto, California, USA
| | | | - Raf Llinas
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Victor Urrutia
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Fernando Gonzalez
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Greg Albers
- Department of Radiology, Division of Neuroimaging and Neurointervention, Stanford Neuroscience Health Center, Palo Alto, California, USA
| | - Argye Hillis
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Kambiz Nael
- Department of Radiology, David Geffen School of Medicine at UCLA, Los Angeles, California, USA
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10
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Werdiger F, Gotla S, Visser M, Kolacz J, Yogendrakumar V, Beharry J, Valente M, Sharobeam A, Parsons MW, Bivard A. Automated occlusion detection for the diagnosis of acute ischemic stroke: A detailed performance review. Eur J Radiol 2023; 164:110845. [PMID: 37148842 DOI: 10.1016/j.ejrad.2023.110845] [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: 10/28/2022] [Revised: 04/15/2023] [Accepted: 04/20/2023] [Indexed: 05/08/2023]
Abstract
INTRODUCTION Stroke is a leading cause of adult disability and death worldwide. Automated detection of stroke on brain imaging has promise in a time critical environment. We present a method for the automated detection of intracranial occlusions on dynamic CT Angiography (CTA) causing acute ischemic stroke. METHODS We derived dynamic CTA images from CT Perfusion (CTP) data and utilised advanced image processing to enhance and display major cerebral blood vessels for symmetry analysis. We reviewed the performance of the algorithm on a cohort of 207 patients from the International Stroke Perfusion Imaging Registry (INSPIRE), with Large Vessel Occlusion (LVO) and non-LVO strokes. Included in the data were images with chronic stroke, various artefacts, incomplete vessel occlusions, and images of poorer quality. All images were annotated by stroke experts. In addition, each image was graded in terms of the difficulty of the task of occlusion detection. Performance was evaluated on the overall cohort, and with respect to occlusion location, collateral grade, and task difficulty. We also evaluated the impact of including additional perfusion data. RESULTS Images with a rating of lower difficulty achieved a sensitivity and specificity of 96% and 90%, respectively, while images with a moderate difficulty rating achieved 88% and 50%, respectively. For cases of high difficulty, where more than two experts or additional data were required to reach consensus, sensitivity and specificity was 53% and 11%. The addition of perfusion data to the dCTA images increased the specificity by 38%. CONCLUSION We have provided an unbiased interpretation of algorithm performance. Further developments include generalising to conventional CTA and employing the algorithm in a clinical setting for prospective studies.
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Affiliation(s)
- Freda Werdiger
- Melbourne Brain Centre at Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia.
| | - Sunay Gotla
- Southwestern Sydney Clinical School, University of New South Wales, Sydney, Australia
| | - Milanka Visser
- Melbourne Brain Centre at Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - James Kolacz
- Melbourne Brain Centre at Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Vignan Yogendrakumar
- Melbourne Brain Centre at Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - James Beharry
- Melbourne Brain Centre at Royal Melbourne Hospital, Melbourne, Australia
| | - Michael Valente
- Melbourne Brain Centre at Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Angelos Sharobeam
- Melbourne Brain Centre at Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
| | - Mark W Parsons
- Apollo Medical Imaging, Melbourne, Australia; Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia; Department of Neurology, Liverpool Hospital, NSW, Australia
| | - Andrew Bivard
- Melbourne Brain Centre at Royal Melbourne Hospital, Melbourne, Australia; Department of Medicine, University of Melbourne, Melbourne, Australia
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11
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Lin CH, Saver JL, Ovbiagele B, Tang SC, Lee M, Liebeskind DS. Effects of endovascular therapy for mild stroke due to proximal or M2 occlusions: meta-analysis. J Neurointerv Surg 2023; 15:350-354. [PMID: 35292565 PMCID: PMC10086511 DOI: 10.1136/neurintsurg-2022-018662] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2022] [Accepted: 02/18/2022] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To conduct a meta-analysis to evaluate the effect of endovascular therapy (EVT) in mild acute ischemic stroke (AIS) due to proximal versus distal occlusions. METHODS We searched PubMed, Embase, the Cochrane Library, and clinicaltrials.gov from January 2000 to September 2021 to identify studies comparing EVT versus best medical management (BMM) in AIS with National Institutes of Health Stroke Scale (NIHSS) scores ≤5 due to proximal internal carotid artery (ICA) or M1 versus distal M2 occlusions. We included studies that reported the number of patients with proximal or distal occlusions separately and reported the number of patients with freedom of disability (modified Rankin Scale (mRS) score 0-1) or functional independence (mRS score 0-2) at 90 days in proximal or M2 occlusions, respectively. OR with 95% CI was used. RESULTS We identified six studies with 653 proximal ICA and M1 occlusion patients and 666 distal M2 occlusion patients. Pooled results showed EVT versus BMM was associated with a higher rate of being disability-free in patients with proximal occlusions (OR 1.58, 95% CI 1.09 to 2.30), but was associated with a lower rate of being disability-free in patients with M2 occlusions (OR 0.70, 95% CI 0.49 to 0.99). Effect of EVT in proximal versus distal occlusions was substantially different (P for interaction=0.002). A similar pattern was seen for functional independence (P for interaction=0.05). CONCLUSIONS For patients with mild AIS, observational data suggest that EVT may be beneficial for proximal ICA or M1 but not for distal M2 occlusions. Randomized trials are needed to confirm these findings. PROSPERO REGISTRATION NUMBER CRD42021281034.
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Affiliation(s)
- Chun-Hsien Lin
- Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital Chiayi Branch, Puzi, Taiwan
| | - Jeffrey L Saver
- Neurology, UCLA, Los Angeles, California, USA.,Comprehensive Stroke Center and Neurology, David Geffen School of Medicine, Los Angeles, California, USA
| | - Bruce Ovbiagele
- University of California San Francisco, San Francisco, California, USA
| | - Sung-Chun Tang
- Stroke Center and Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Meng Lee
- Neurology, Chang Gung University College of Medicine, Chang Gung Memorial Hospital Chiayi Branch, Puzi, Taiwan
| | - David S Liebeskind
- Neurology, UCLA, Los Angeles, California, USA.,Comprehensive Stroke Center and Neurology, David Geffen School of Medicine, Los Angeles, California, USA
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12
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Endovascular treatment achieves better outcomes than best medical management in patients with M2 occlusion and high stroke severity: a meta-analysis. J Neurol 2023; 270:2924-2937. [PMID: 36862149 DOI: 10.1007/s00415-023-11653-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2022] [Revised: 02/24/2023] [Accepted: 02/25/2023] [Indexed: 03/03/2023]
Abstract
BACKGROUND The lack of randomized evidence makes it difficult to establish reliable treatment recommendations for patients with M2 occlusion. This study aims to compare the efficacy and safety of endovascular treatment (EVT) with best medical management (BMM) in patients with M2 occlusion, and to investigate whether the optimal treatment varies according to stroke severity. METHODS Comprehensive literature retrieval was conducted to identify studies that directly compared the outcomes of EVT and BMM. According to stroke severity, the study population were classified into those with moderate-severe stroke and those with mild stroke. National Institute of Health Stroke Scale (NIHSS) scores ≥ 6 was defined as moderate-severe stroke, and NIHSS scores 0-5 as mild stroke. Random-effects meta-analyses were performed to measure the symptomatic intracranial hemorrhage (sICH) within 72 h, and the modified Rankin Scale (mRS) scores 0-2 and the mortality at 90 days. RESULTS Totally, 20 studies were identified, including 4358 patients. In the moderate-severe stroke population, the EVT had 82% higher odds for mRS scores 0-2 (OR 1.82, 95% CI 1.34-2.49) and a 43% lower odds for mortality (OR 0.57, 95% CI 0.39-0.82) compared with the BMM. However, no difference was found in the sICH rate (OR 0.88, 95% CI 0.44-1.77). In the mild stroke population, no differences were observed in the mRS scores 0-2 (OR 0.81, 95% CI 0.59-1.10) or mortality (OR 1.23, 95% CI 0.72-2.10) between EVT and BMM, whereas EVT was associated with higher sICH rate (OR 4.21, 95% CI 1.86-9.49). CONCLUSION EVT may be only beneficial for patients with M2 occlusion and high stroke severity, but not for those with NIHSS scores 0-5.
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13
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Schwarz G, Cascio Rizzo A, Matusevicius M, Giussani G, Invernizzi P, Melis F, Lesko N, Toni D, Agostoni EC, Ahmed N. Reperfusion Treatments in Disabling Versus Nondisabling Mild Stroke due to Anterior Circulation Vessel Occlusion. Stroke 2023; 54:743-750. [PMID: 36848431 DOI: 10.1161/strokeaha.122.041772] [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: 03/01/2023]
Abstract
BACKGROUND The benefit of distinguishing between disabling versus nondisabling deficit in mild acute ischemic stroke due to endovascular thrombectomy-targetable vessel occlusion (EVT-tVO; including anterior circulation large and medium-vessel occlusion) is unknown. We compared safety and efficacy of acute reperfusion treatments in disabling versus nondisabling mild EVT-tVO. METHODS From the Safe Implementation of Treatments in Stroke-International Stroke Thrombolysis Register, we included consecutive acute ischemic stroke patients (2015-2021) treated within 4.5 hours, with full NIHSS items availability and score ≤5, evidence of intracranial internal carotid artery, M1, A1-2, or M2-3 occlusion. After propensity score matching, we compared efficacy (3-month modified Rankin Scale score of 0-1, modified Rankin Scale score of 0-2, and early neurological improvement) and safety (nonhemorrhagic early neurological deterioration, any intracerebral or subarachnoid hemorrhage, symptomatic intracranial hemorrhage, and death at 3-month) outcomes in disabling versus nondisabling patients-adopting an available definition. RESULTS We included 1459 patients. Propensity score matched analysis of disabling versus nondisabling EVT-tVO (n=336 per group) found no significant differences in efficacy (modified Rankin Scale score 0-1: 67.4% versus 71.5%, P=0.336; modified Rankin Scale score 0-2: 77.1% versus 77.6%, P=0.895; early neurological improvement: 38.3% versus 44.4%, P=0.132) and safety (nonhemorrhagic early neurological deterioration: 8.5% versus 8.0%, P=0.830; any intracerebral hemorrhage or subarachnoid hemorrhage: 12.5% versus 13.3%, P=0.792; symptomatic intracranial hemorrhage: 2.6% versus 3.4%, P=0.598; and 3-month death: 9.8% versus 9.2%, P=0.844) outcomes. CONCLUSIONS We found similar safety and efficacy outcomes after acute reperfusion treatment in disabling versus nondisabling mild EVT-tVO; our findings suggest to adopt similar acute treatment approaches in the 2 groups. Randomized data are needed to clarify the best reperfusion treatment in mild EVT-tVO.
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Affiliation(s)
- Ghil Schwarz
- Department of Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy (G.S., A.C.R., G.G., E.C.A.).,Stroke Research Centre, University College London, Institute of Neurology, UK (G.S.)
| | - Angelo Cascio Rizzo
- Department of Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy (G.S., A.C.R., G.G., E.C.A.)
| | - Marius Matusevicius
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (M.M., N.A.).,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (M.M., N.A.)
| | - Giuditta Giussani
- Department of Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy (G.S., A.C.R., G.G., E.C.A.).,Department of Neurology - Stroke Unit, Ospedale San Giuseppe MultiMedica IRCCS, Milano, Italy (G.G.)
| | - Paolo Invernizzi
- Neuroradiology and Neurology Units, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy (P.I.)
| | - Fabio Melis
- S.S. Neurovascolare, ASL Città di Torino, Ospedale Maria Vittoria, Italia (F.M.)
| | - Norbert Lesko
- Department of Neurology, P.J. Safarik University, Kosice, Slovakia (N.L.)
| | - Danilo Toni
- Emergency Department Stroke Unit, Department of Human Neurosciences, Sapienza University of Rome, Italy (D.T.)
| | - Elio Clemente Agostoni
- Department of Neurology and Stroke Unit, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy (G.S., A.C.R., G.G., E.C.A.)
| | - Niaz Ahmed
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden (M.M., N.A.).,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (M.M., N.A.)
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14
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Yedavalli VS, Hamam O, Gudenkauf J, Wang R, Llinas R, Marsh EB, Caplan J, Nael K, Urrutia V. Assessing the Efficacy of Mechanical Thrombectomy in Patients with an NIHSS < 6 Presenting with Proximal Middle Cerebral Artery Vessel Occlusion as Compared to Best Medical Management. Brain Sci 2023; 13:brainsci13020214. [PMID: 36831757 PMCID: PMC9953866 DOI: 10.3390/brainsci13020214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/13/2023] [Revised: 01/23/2023] [Accepted: 01/25/2023] [Indexed: 02/03/2023] Open
Abstract
BACKGROUND AND PURPOSE Minor acute ischemic stroke (AIS) patients-defined by an NIHSS score < 6-presenting with proximal middle cerebral artery large vessel occlusions (MCA-LVO) is a subgroup for which treatment is still debated. Although these patients present with minor symptoms initially, studies have shown that several patients afflicted with MCA-LVO in this subgroup experience cognitive and functional decline. Although mechanical thrombectomy (MT) is the standard of care for patients with an NIHSS score of 6 or higher, treatment in the minor stroke subgroup is still being explored. The purpose of this preliminary study is to report our center's experience in evaluating the potential benefit of mechanical thrombectomy (MT) in minor stroke patients when compared to medical management (MM). METHODS We performed a retrospective study with two comprehensive stroke centers within our hospital enterprise of consecutive patients presenting with minor AIS secondary to MCA-LVO (defined as M1 or proximal M2 segments of MCA). We subsequently evaluated patients who received MT versus those who received MM. RESULTS Between January 2017 and July 2021, we identified 46 AIS patients (11 treated with MT and 35 treated with MM) who presented with an NIHSS score < 6 secondary to MCA-LVO (47.8% 22/46 female, mean age 62.3 years, range 49-75 years). MT was associated with a significantly lower mRS at 90 days (median: 1.0 [IQR 0.0-2.0] versus 3.0 [IQR 1.0-4.0], p = <0.001), a favorable NIHSS shift (-4.0 [IQR -10.0--2.0] versus 0.0 [IQR -2.0-1.0], p = 0.002), favorable NIHSS shift dichotomization (5/11, 45.5% versus 3/35, 8.6%, p = 0.003) and favorable mRS dichotomization (7/11, 63.6% versus 14/35, 40.0%, p = 0.024). CONCLUSIONS In our center's preliminary experience, for AIS patients presenting with an NIHSS score < 6 secondary to MCA-LVO, MT may be associated with improved clinical outcomes when compared to MM only.
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Affiliation(s)
- Vivek Srikar Yedavalli
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Hospital, 600 N Wolfe Street, Baltimore, MD 21287, USA
| | - Omar Hamam
- Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD 21205, USA
| | - Julie Gudenkauf
- Department Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Richard Wang
- Department of Radiology and Radiological Sciences, Johns Hopkins Medicine, Baltimore, MD 21205, USA
| | - Rafael Llinas
- Department Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Elisabeth Breese Marsh
- Department Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Justin Caplan
- Department Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Kambiz Nael
- Department of Radiology, University of California, Los Angeles, CA 90095, USA
| | - Victor Urrutia
- Department Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, MD 21287, USA
- Correspondence:
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15
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Ozkara BB, Karabacak M, Hamam O, Wang R, Kotha A, Khalili N, Hoseinyazdi M, Chen MM, Wintermark M, Yedavalli VS. Prediction of Functional Outcome in Stroke Patients with Proximal Middle Cerebral Artery Occlusions Using Machine Learning Models. J Clin Med 2023; 12:jcm12030839. [PMID: 36769491 PMCID: PMC9918022 DOI: 10.3390/jcm12030839] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/02/2023] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 01/24/2023] Open
Abstract
At present, clinicians are expected to manage a large volume of complex clinical, laboratory, and imaging data, necessitating sophisticated analytic approaches. Machine learning-based models can use this vast amount of data to create forecasting models. We aimed to predict short- and medium-term functional outcomes in acute ischemic stroke (AIS) patients with proximal middle cerebral artery (MCA) occlusions using machine learning models with clinical, laboratory, and quantitative imaging data as inputs. Included were consecutive AIS patients with MCA M1 and proximal M2 occlusions. The XGBoost, LightGBM, CatBoost, and Random Forest were used to predict the outcome. Minimum redundancy maximum relevancy was used for selecting features. The primary outcomes were the National Institutes of Health Stroke Scale (NIHSS) shift and the modified Rankin Score (mRS) at 90 days. The algorithm with the highest area under the receiver operating characteristic curve (AUROC) for predicting the favorable and unfavorable outcome groups at 90 days was LightGBM. Random Forest had the highest AUROC when predicting the favorable and unfavorable groups based on the NIHSS shift. Using clinical, laboratory, and imaging parameters in conjunction with machine learning, we accurately predicted the functional outcome of AIS patients with proximal MCA occlusions.
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Affiliation(s)
- Burak B. Ozkara
- Department of Neuroradiology, MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Mert Karabacak
- Department of Neurosurgery, Mount Sinai Health System, New York, NY 10029, USA
| | - Omar Hamam
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Richard Wang
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Apoorva Kotha
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Neda Khalili
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Meisam Hoseinyazdi
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, MD 21287, USA
| | - Melissa M. Chen
- Department of Neuroradiology, MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Max Wintermark
- Department of Neuroradiology, MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Vivek S. Yedavalli
- Russell H. Morgan Department of Radiology and Radiological Sciences, Johns Hopkins Hospital, Baltimore, MD 21287, USA
- Correspondence:
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16
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Khunte M, Wu X, Koo A, Payabvash S, Matouk C, Heit JJ, Wintermark M, Albers GW, Sanelli PC, Gandhi D, Malhotra A. Cost-effectiveness of thrombectomy in patients with minor stroke and large vessel occlusion: effect of thrombus location on cost-effectiveness and outcomes. J Neurointerv Surg 2023; 15:39-45. [PMID: 35022300 DOI: 10.1136/neurintsurg-2021-018375] [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: 10/30/2021] [Accepted: 12/18/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND To evaluate the cost-effectiveness of endovascular thrombectomy (EVT) to treat large vessel occlusion (LVO) in patients with acute, minor stroke (National Institute of Health Stroke Scale (NIHSS) <6) and impact of occlusion site. METHODS A Markov decision-analytic model was constructed accounting for both costs and outcomes from a societal perspective. Two different management strategies were evaluated: EVT and medical management. Base case analysis was done for three different sites of occlusion: proximal M1, distal M1 and M2 occlusions. One-way, two-way and probabilistic sensitivity analyses were performed. RESULTS Base-case calculation showed EVT to be the dominant strategy in 65-year-old patients with proximal M1 occlusion and NIHSS <6, with lower cost (US$37 229 per patient) and higher effectiveness (1.47 quality-adjusted life years (QALYs)), equivalent to 537 days in perfect health or 603 days in modified Rankin score (mRS) 0-2 health state. EVT is the cost-effective strategy in 92.7% of iterations for patients with proximal M1 occlusion using a willingness-to-pay threshold of US$100 000/QALY. EVT was cost-effective if it had better outcomes in 2%-3% more patients than intravenous thrombolysis (IVT) in absolute numbers (base case difference -16%). EVT was cost-effective when the proportion of M2 occlusions was less than 37.1%. CONCLUSIONS EVT is cost-effective in patients with minor stroke and LVO in the long term (lifetime horizon), considering the poor outcomes and significant disability associated with non-reperfusion. Our study emphasizes the need for caution in interpreting previous observational studies which concluded similar results in EVT versus medical management in patients with minor stroke due to a high proportion of patients with M2 occlusions in the two strategies.
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Affiliation(s)
- Mihir Khunte
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Xiao Wu
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, California, USA
| | - Andrew Koo
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Seyedmehdi Payabvash
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Charles Matouk
- Department of Neurosurgery, Yale University School of Medicine, New Haven, Connecticut, USA
| | - Jeremy J Heit
- Radiology, Neuroadiology and Neurointervention Division, Stanford University, Stanford, California, USA
| | - Max Wintermark
- Department of Neuroradiology, MD Anderson, Houston, TX, USA
| | - Gregory W Albers
- Department of Neurology and Neurosurgery, Stanford University, Stanford, California, USA
| | - Pina C Sanelli
- Hofstra Northwell School of Medicine at Hofstra University, Hempstead, New York, USA
| | - Dheeraj Gandhi
- Department of Interventional Neuroradiology, University of Maryland, Baltimore, Maryland, USA
| | - Ajay Malhotra
- Department of Radiology and Biomedical Imaging, Yale University School of Medicine, New Haven, Connecticut, USA
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17
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Sakai Y, Yoshikawa G, Koizumi S, Ishikawa O, Saito A, Sato K. Complete Recanalization in Mechanical Thrombectomy Is Associated with Favorable Functional Outcome for M2 Occlusions. JOURNAL OF NEUROENDOVASCULAR THERAPY 2022; 17:15-21. [PMID: 37501883 PMCID: PMC10370515 DOI: 10.5797/jnet.oa.2022-0057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 10/13/2022] [Indexed: 07/29/2023]
Abstract
Objective There are insufficient coherent reports on mechanical thrombectomy (MT) for occlusion of the second segment of the middle cerebral artery (M2 occlusion) in a real-world clinical setting. We evaluated the efficacy and safety of MT for M2 occlusions and compared the primary thrombectomy strategies (stent retriever, aspiration catheter, and combined technique) to analyze factors predicting good functional outcomes. Methods We evaluated background factors, preprocedural factors, procedural factors, and procedural time for patients who underwent MT for M2 occlusions from our retrospective cohort. According to the modified Rankin Scale (mRS) score three months after MT, patients were divided into good (mRS ≤2) and poor (mRS ≥3) prognosis groups. Results A total of 29 patients (median age, 78 years; 11 [37.9%] females) were included in the study. In this cohort, rates of successful reperfusion, thrombolysis in cerebral infarction (TICI) 3, postprocedural hemorrhage (PPH), and symptomatic PPH were 82.8, 34.5, 31.0, and 0%, respectively. Good prognoses were achieved in 13 (45%) cases. A prognostic factor of MT for M2 occlusions is TICI 3 from multivariate analysis (OR, 11.7; 95% CI, 1.003-136; p = 0.0497). There was no statistically significant difference in the functional outcome three months after MT based on the choice of the primary thrombectomy strategy. Conclusion MT for M2 occlusions is a reliable and relatively safe procedure. The presence of TICI 3 was a prognostic factor in this cohort. Future studies are warranted to investigate the optimal thrombectomy strategy for medium vessel occlusion.
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Affiliation(s)
- Yu Sakai
- Department of Neurosurgery, Showa General Hospital, Kodaira, Tokyo, Japan
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Gakushi Yoshikawa
- Department of Neurosurgery, Showa General Hospital, Kodaira, Tokyo, Japan
| | - Satoshi Koizumi
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
| | - Osamu Ishikawa
- Department of Neurosurgery, Asama General Hospital, Saku, Nagano, Japan
| | - Akira Saito
- Department of Neurosurgery, Saitama Medical Center, Saitama Medical University, Kawagoe, Saitama, Japan
| | - Katsuya Sato
- Department of Neurosurgery, Faculty of Medicine, The University of Tokyo, Tokyo, Japan
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18
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Kim DY, Baik SH, Jung C, Kim JY, Han SG, Kim BJ, Kang J, Bae HJ, Kim JH. Predictors and Impact of Sulcal SAH after Mechanical Thrombectomy in Patients with Isolated M2 Occlusion. AJNR Am J Neuroradiol 2022; 43:1292-1298. [PMID: 35902120 PMCID: PMC9451639 DOI: 10.3174/ajnr.a7594] [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: 04/07/2022] [Accepted: 06/17/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND PURPOSE Data on SAH after M2 mechanical thrombectomy are limited. We aimed to determine the prevalence of sulcal SAH after mechanical thrombectomy for M2 occlusion, its associated predictors, and the resulting clinical outcome. MATERIALS AND METHODS The study retrospectively reviewed the data of patients with acute ischemic stroke who underwent mechanical thrombectomy for isolated M2 occlusion. The patients were divided into 2 groups according to the presence of sulcal SAH after M2 mechanical thrombectomy. Angiographic and clinical outcomes were compared. Multivariable analysis was performed to identify independent predictors of sulcal SAH and unfavorable outcome (90-day mRS, 3-6). RESULTS Of the 209 enrolled patients, sulcal SAH was observed in 33 (15.8%) patients. The sulcal SAH group showed a higher rate of distal M2 occlusion (69.7% versus 22.7%), a higher of rate of superior division occlusion (63.6% versus 43.8%), and a higher M2 angulation (median, 128° versus 106°) than the non-sulcal SAH group. Of the 33 sulcal SAH cases, 23 (66.7%) were covert without visible intraprocedural contrast extravasation. Distal M2 occlusion (OR, 12.04; 95% CI, 4.56-35.67; P < .001), superior division (OR, 3.83; 95% CI, 1.43-11.26; P = .010), M2 angulation (OR, 1.02; 95% CI, 1.01-1.04; P < .001), and the number of passes (OR, 1.58; 95% CI, 1.22-2.09; P < .001) were independent predictors of sulcal SAH. However, covert sulcal SAH was not associated with an unfavorable outcome (P = .830). CONCLUSIONS After mechanical thrombectomy for M2 occlusion, sulcal SAH was not uncommon and occurred more frequently with distal M2 occlusion, superior division, acute M2 angulation, and multiple thrombectomy passes (≥3). The impact of covert sulcal SAH was mostly benign and was not associated with an unfavorable outcome.
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Affiliation(s)
- D Y Kim
- From the Departments of Radiology (D.Y.K., S.H.B., C.J., J.H.K.)
- Neurology (D.Y.K, J.Y.K, S.-G.H., B.J.K, J.K., H-.J.B), Seoul National University Bundang Hospital, Seongnam, South Korea
| | - S H Baik
- From the Departments of Radiology (D.Y.K., S.H.B., C.J., J.H.K.)
| | - C Jung
- From the Departments of Radiology (D.Y.K., S.H.B., C.J., J.H.K.)
| | - J Y Kim
- Neurology (D.Y.K, J.Y.K, S.-G.H., B.J.K, J.K., H-.J.B), Seoul National University Bundang Hospital, Seongnam, South Korea
| | - S-G Han
- Neurology (D.Y.K, J.Y.K, S.-G.H., B.J.K, J.K., H-.J.B), Seoul National University Bundang Hospital, Seongnam, South Korea
| | - B J Kim
- Neurology (D.Y.K, J.Y.K, S.-G.H., B.J.K, J.K., H-.J.B), Seoul National University Bundang Hospital, Seongnam, South Korea
| | - J Kang
- Neurology (D.Y.K, J.Y.K, S.-G.H., B.J.K, J.K., H-.J.B), Seoul National University Bundang Hospital, Seongnam, South Korea
| | - H-J Bae
- Neurology (D.Y.K, J.Y.K, S.-G.H., B.J.K, J.K., H-.J.B), Seoul National University Bundang Hospital, Seongnam, South Korea
| | - J H Kim
- From the Departments of Radiology (D.Y.K., S.H.B., C.J., J.H.K.)
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19
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Feil K, Matusevicius M, Herzberg M, Tiedt S, Küpper C, Wischmann J, Schönecker S, Mengel A, Sartor‐Pfeiffer J, Berger K, Dimitriadis K, Liebig T, Dieterich M, Mazya M, Ahmed N, Kellert L. Minor stroke in large vessel occlusion: A matched analysis of patients from the German Stroke Registry-Endovascular Treatment (GSR-ET) and patients from the Safe Implementation of Treatments in Stroke-International Stroke Thrombolysis Register (SITS-ISTR). Eur J Neurol 2022; 29:1619-1629. [PMID: 35122371 PMCID: PMC9306813 DOI: 10.1111/ene.15272] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Revised: 01/27/2022] [Accepted: 01/31/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND AND PURPOSE Reperfusion treatment in patients presenting with large vessel occlusion (LVO) and minor neurological deficits is still a matter of debate. We aimed to compare minor stroke patients treated with endovascular thrombectomy (EVT) and intravenous thrombolysis (IVT) or IVT alone. METHODS Patients enrolled in the German Stroke Registry-Endovascular Treatment (GSR-ET) and the Safe Implementation of Treatments in Stroke-International Stroke Thrombolysis Registry (SITS-ISTR) between June 2015 and December 2019 were analyzed. Minor stroke was defined as National Institutes of Health Stroke Scale (NIHSS) score ≤5, and LVO as occlusion of the internal carotid, carotid-T, middle cerebral, basilar, vertebral or posterior cerebral arteries. GSR-ET and SITS-ISTR IVT-treated patients were matched in a 1:1 ratio using propensity-score (PS) matching. The primary outcome was good functional outcome at 3 months (modified Rankin Scale score 0-2). RESULTS A total of 272 GSR-ET patients treated with EVT and IVT (age 68.6 ± 14.0 years, 43.4% female, NIHSS score 4 [interquartile range 2-5]) were compared to 272 IVT-treated SITS-ISTR patients (age 69.4 ± 13.7, 43.4% female, NIHSS score 4 [2-5]). Good functional outcome was seen in 77.0% versus 82.9% (p = 0.119), mortality in 5.9% versus 7.9% (p = 0.413), and intracranial hemorrhage in 8.8% versus 12.5% (p = 0.308) of patients in the GSR-ET versus the SITS-ISTR IVT group, respectively. In a second PS-matched analysis, 624 GSR-ET patients (IVT rate 56.7%) and 624 SITS-ISTR patients (IVT rate 100%), good outcome was more often observed in the SITS-ISTR patients (68.2% vs. 80.9%; p < 0.001), and IVT independently predicted good outcome (odds ratio 2.16, 95% confidence interval 1.43-3.28). CONCLUSIONS Our study suggests similar effectiveness of IVT alone compared to EVT with or without IVT in minor stroke patients. There is an urgent need for randomized controlled trials on this topic.
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Affiliation(s)
- Katharina Feil
- Department of NeurologyLudwig‐Maximilians‐Universitaet (LMU) MunichMunichGermany,Department of Neurology and StrokeEberhard‐Karls University Tuebingen/Universitaetsklinikum Tuebingen (UKT)TuebingenGermany
| | - Marius Matusevicius
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden,Department of Research and EducationKarolinska University HospitalStockholmSweden
| | - Moriz Herzberg
- Institute of NeuroradiologyLMUMunichGermany,Department of RadiologyUniversity HospitalWuerzburgGermany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research (ISD)University HospitalLMU MunichMunichGermany
| | - Clemens Küpper
- Department of NeurologyLudwig‐Maximilians‐Universitaet (LMU) MunichMunichGermany
| | - Johannes Wischmann
- Department of NeurologyLudwig‐Maximilians‐Universitaet (LMU) MunichMunichGermany
| | - Sonja Schönecker
- Department of NeurologyLudwig‐Maximilians‐Universitaet (LMU) MunichMunichGermany
| | - Annerose Mengel
- Department of Neurology and StrokeEberhard‐Karls University Tuebingen/Universitaetsklinikum Tuebingen (UKT)TuebingenGermany
| | - Jennifer Sartor‐Pfeiffer
- Department of Neurology and StrokeEberhard‐Karls University Tuebingen/Universitaetsklinikum Tuebingen (UKT)TuebingenGermany
| | - Katharina Berger
- Department of Neurology and EpileptologyEberhard‐Karls University Tuebingen/Universitaetsklinikum Tuebingen (UKT)TuebingenGermany
| | - Konstantin Dimitriadis
- Institute for Stroke and Dementia Research (ISD)University HospitalLMU MunichMunichGermany
| | | | - Marianne Dieterich
- Department of NeurologyLudwig‐Maximilians‐Universitaet (LMU) MunichMunichGermany,Munich Cluster for Systems Neurology (SyNergy)MunichGermany,German Center for Vertigo and Balance DisordersLMUMunichGermany
| | - Michael Mazya
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden,Department of NeurologyKarolinska University HospitalStockholmSweden
| | - Niaz Ahmed
- Department of Clinical NeuroscienceKarolinska InstitutetStockholmSweden,Department of NeurologyKarolinska University HospitalStockholmSweden
| | - Lars Kellert
- Department of NeurologyLudwig‐Maximilians‐Universitaet (LMU) MunichMunichGermany
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20
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Larsen K, Jæger HS, Hov MR, Thorsen K, Solyga V, Lund CG, Bache KG. Streamlining Acute Stroke Care by Introducing National Institutes of Health Stroke Scale in the Emergency Medical Services: A Prospective Cohort Study. Stroke 2022; 53:2050-2057. [PMID: 35291821 PMCID: PMC9126266 DOI: 10.1161/strokeaha.121.036084] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
National Institutes of Health Stroke Scale (NIHSS) is the most validated clinical scale for stroke recognition, severity grading, and symptom monitoring in acute care and hospital settings. Numerous modified prehospital stroke scales exist, but these scales contain less clinical information and lack compatibility with in-hospital stroke scales. In this real-life study, we aimed to investigate if NIHSS conducted by paramedics in the field is a feasible and accurate prehospital diagnostic tool.
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Affiliation(s)
- Karianne Larsen
- The Norwegian Air Ambulance Foundation, Oslo, Norway (K.L., H.S.J., M.R.H., K.T., K.G.B.).,Institute of Basic Medical Sciences, University of Oslo, Norway (K.L., H.S.J., K.G.B.)
| | - Henriette S Jæger
- The Norwegian Air Ambulance Foundation, Oslo, Norway (K.L., H.S.J., M.R.H., K.T., K.G.B.).,Institute of Basic Medical Sciences, University of Oslo, Norway (K.L., H.S.J., K.G.B.)
| | - Maren R Hov
- The Norwegian Air Ambulance Foundation, Oslo, Norway (K.L., H.S.J., M.R.H., K.T., K.G.B.).,Faculty of Health Sciences, Oslo Metropolitan University, Norway (M.R.H.).,Department of Neurology, Oslo University Hospital, Norway (M.R.H., C.G.L.)
| | - Kjetil Thorsen
- The Norwegian Air Ambulance Foundation, Oslo, Norway (K.L., H.S.J., M.R.H., K.T., K.G.B.)
| | - Volker Solyga
- Department of Neurology, Østfold Hospital Trust, Grålum, Norway (V.S.)
| | - Christian G Lund
- Department of Neurology, Oslo University Hospital, Norway (M.R.H., C.G.L.)
| | - Kristi G Bache
- The Norwegian Air Ambulance Foundation, Oslo, Norway (K.L., H.S.J., M.R.H., K.T., K.G.B.).,Institute of Basic Medical Sciences, University of Oslo, Norway (K.L., H.S.J., K.G.B.)
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21
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Sarraj A, Parsons M, Bivard A, Hassan AE, Abraham MG, Wu T, Kleinig T, Lin L, Chen C(A, Levi C, Dong Q, Cheng X, Butcher KS, Choi P, Yassi N, Shah D, Sharma G, Pujara D, Shaker F, Blackburn S, Dewey H, Thijs V, Sitton CW, Donnan GA, Mitchell PJ, Yan B, Grotta JG, Albers GW, Davis SM, Campbell B. Endovascular Thrombectomy versus Medical Management in Isolated
M2
Occlusions: Pooled
Patient‐Level
Analysis from the
EXTEND‐IA
Trials,
INSPIRE
and
SELECT
Studies. Ann Neurol 2022; 91:629-639. [DOI: 10.1002/ana.26331] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2021] [Revised: 01/28/2022] [Accepted: 02/14/2022] [Indexed: 11/10/2022]
Affiliation(s)
- Amrou Sarraj
- Case Western Reserve University, Neurology Cleveland OH USA
- University Hospitals Cleveland Medical Center Cleveland OH USA
| | - Mark Parsons
- The University of New South Wales, Neurology Sydney NSW Australia
| | - Andrew Bivard
- The Melbourne Brain Centre, The Royal Melbourne Hospital University of Melbourne, Neurology Parkville Victoria Australia
- The University of Newcastle, Stroke and Brain Injury Center Callaghan NSW, Australia Australia
| | - Ameer E Hassan
- University of Texas Rio Grande Valley ‐ Valley Baptist Medical Center, Neurology Harlingen TX USA
| | | | - Teddy Wu
- Christchurch Hospital, Neurology Christchurch New Zealand
| | - Timothy Kleinig
- Royal Adelaide Hospital, Neurology Adelaide South Australia Australia
| | - Longting Lin
- John Hunter Hospital University of Newcastle, Neurology Australia
| | | | - Christopher Levi
- John Hunter Hospital University of Newcastle, Neurology Australia
| | - Qiang Dong
- Huashan Hospital Fudan University, Neurology Shanghai China
| | - Xin Cheng
- Huashan Hospital Fudan University, Neurology Shanghai China
| | - Ken S Butcher
- The University of New South Wales, Neurology Sydney NSW Australia
| | - Philip Choi
- Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences Monash University Melbourne Victoria Australia
| | - Nawaf Yassi
- The Melbourne Brain Centre, The Royal Melbourne Hospital University of Melbourne, Neurology Parkville Victoria Australia
- The Walter and Eliza Hall Institute of Medical Research, Population Health and Immunity Division Parkville Australia
| | - Darshan Shah
- Gold Coast University Hospital, Neurology Southport Queensland Australia
| | - Gagan Sharma
- The Melbourne Brain Centre, The Royal Melbourne Hospital University of Melbourne, Neurology Parkville Victoria Australia
| | - Deep Pujara
- University Hospitals Cleveland Medical Center Cleveland OH USA
| | - Faris Shaker
- UTHealth McGovern Medical School, Neurosurgery Houston TX USA
| | | | - Helen Dewey
- Eastern Health Clinical School, Faculty of Medicine, Nursing and Health Sciences Monash University Melbourne Victoria Australia
| | - Vincent Thijs
- Stroke Theme, Florey Institute of Neuroscience and Mental Health University of Melbourne Heidelberg VIC AUS
| | - Clark W Sitton
- UTHealth McGovern Medical School, Diagnostic and Interventional Imaging Houston TX USA
| | - Geoffrey A Donnan
- The Melbourne Brain Centre, The Royal Melbourne Hospital University of Melbourne, Neurology Parkville Victoria Australia
| | - Peter J Mitchell
- The Royal Melbourne Hospital University of Melbourne, Radiology Parkville Victoria Australia
| | - Bernard Yan
- The Melbourne Brain Centre, The Royal Melbourne Hospital University of Melbourne, Neurology Parkville Victoria Australia
| | - James G Grotta
- Memorial Hermann – Texas Medical Center, Neurology Houston TX USA
| | - Gregory W. Albers
- Stanford University Medical Center, Neurology and Neurological Sciences Stanford CA USA
| | - Stephen M Davis
- The Melbourne Brain Centre, The Royal Melbourne Hospital University of Melbourne, Neurology Parkville Victoria Australia
| | - Bruce Campbell
- The Melbourne Brain Centre, The Royal Melbourne Hospital University of Melbourne, Neurology Parkville Victoria Australia
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22
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Volbers B, Gröger R, Engelhorn T, Marsch A, Macha K, Schwab S, Dörfler A, Lang S, Kallmünzer B. Acute Stroke With Large Vessel Occlusion and Minor Clinical Deficits: Prognostic Factors and Therapeutic Implications. Front Neurol 2021; 12:736795. [PMID: 34744977 PMCID: PMC8568768 DOI: 10.3389/fneur.2021.736795] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2021] [Accepted: 09/16/2021] [Indexed: 12/11/2022] Open
Abstract
Background and Purpose: The optimal acute management of patients with large vessel occlusion (LVO) and minor clinical deficits on admission [National Institutes of Health Stroke Scale (NIHSS) ≤ 4] remains to be elucidated. The aim of the present study was to investigate the prognostic factors and therapeutic management of those patients. Methods: In this retrospective cohort study, we investigated (1) all patients with acute ischemic stroke due to an LVO who underwent mechanical thrombectomy (MT) and (2) all patients with minor clinical deficits (NIHSS ≤ 4) on admission due to an LVO between January 2013 and December 2016 at the University Medical Center Erlangen. We dichotomized management of patients with minor deficits treated with MT for analysis according to immediate mechanical thrombectomy (IT) and initial medical management with rescue intervention (MM) in case of secondary deterioration. Primary endpoints were secondary deterioration, in-hospital mortality, and functional outcome on day 90 (dichotomized modified Rankin Scale 0–2: favorable, 3–6: poor). Results: Two hundred twenty-three patients (83% with anterior circulation stroke, 13 (6%) with minor deficits) treated with MT and 88 patients with minor deficits due to LVO [13 (15%) treated with MT] were included. Secondary deterioration (n = 19) was independently associated with poor outcome in patients with minor deficits and LVO [odds ratio (OR), 0.060; 95% confidence interval (CI), 0.013–0.280], which in turn was associated with the occlusion site [especially M1 occlusion: 11 (58%) vs. 3 (4%) in patients without secondary deterioration, p < 0.0001]. IT (n = 8) was associated with a lower intrahospital mortality compared to MM (n = 5; 13 vs. 80%; OR, 0.036; 95% CI, 0.002–0.741). Seven of eight patients with IT survived until discharge, with 29% showing a favorable functional outcome on day 90. Conclusions: Secondary deterioration is associated with poor outcome in patients with LVO and minor deficits, which in turn was associated with occlusion site. Future randomized controlled trials should assess whether selected patients, depending on occlusion site and associated characteristics, may benefit from MT.
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Affiliation(s)
- Bastian Volbers
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany.,Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Rebecca Gröger
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Tobias Engelhorn
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Armin Marsch
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Kosmas Macha
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Stefan Schwab
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Arnd Dörfler
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Stefan Lang
- Department of Neuroradiology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Bernd Kallmünzer
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
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