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Rodriguez Calienes A, Galecio-Castillo M, Petersen NH, Ribo M, Farooqui M, Hassan AE, Jumaa MA, Divani AA, Abraham MG, Fifi JT, Guerrero WR, Malik AM, Siegler JE, Nguyen TN, Sheth S, Yoo AJ, Linares G, Janjua N, Quispe-Orozco D, Lu Y, Vivanco-Suarez J, Dibas M, Mokin M, Yavagal DR, Jovin TG, Ortega-Gutierrez S. Mediation Analysis of Acute Carotid Stenting in Tandem Lesions: Effect on Functional Outcome in a Multicenter Registry. Neurology 2024; 103:e209617. [PMID: 38959444 DOI: 10.1212/wnl.0000000000209617] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/05/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Current evidence suggests that acute carotid artery stenting (CAS) for cervical lesions is associated with better functional outcomes in patients with acute stroke with tandem lesions (TLs) treated with endovascular therapy (EVT). However, the underlying causal pathophysiologic mechanism of this relationship compared with a non-CAS strategy remains unclear. We aimed to determine whether, and to what degree, reperfusion mediates the relationship between acute CAS and functional outcome in patients with TLs. METHODS This subanalysis stems from a multicenter retrospective cohort study across 16 stroke centers from January 2015 to December 2020. Patients with anterior circulation TLs who underwent EVT were included. Successful reperfusion was defined as a modified Thrombolysis in Cerebral Infarction scale ≥2B by the local team at each participating center. Mediation analysis was conducted to examine the potential causal pathway in which the relationship between acute CAS and functional outcome (90-day modified Rankin Scale) is mediated by successful reperfusion. RESULTS A total of 570 patients were included, with a median age (interquartile range) of 68 (59-76), among whom 180 (31.6%) were female. Among these patients, 354 (62.1%) underwent acute CAS and 244 (47.4%) had a favorable functional outcome. The remaining 216 (37.9%) patients were in the non-CAS group. The CAS group had significantly higher rates of successful reperfusion (91.2% vs 85.1%; p = 0.025) and favorable functional outcomes (52% vs 29%; p = 0.003) compared with the non-CAS group. Successful reperfusion was a strong predictor of functional outcome (adjusted common odds ratio [acOR] 4.88; 95% CI 2.91-8.17; p < 0.001). Successful reperfusion partially mediated the relationship between acute CAS and functional outcome, as acute CAS remained significantly associated with functional outcome after adjustment for successful reperfusion (acOR 1.89; 95% CI 1.27-2.83; p = 0.002). Successful reperfusion explained 25% (95% CI 3%-67%) of the relationship between acute CAS and functional outcome. DISCUSSION In patients with TL undergoing EVT, successful reperfusion predicted favorable functional outcomes when CAS was performed compared with non-CAS. A considerable proportion (25%) of the treatment effect of acute CAS on functional outcome was found to be mediated by improvement of successful reperfusion rates.
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Affiliation(s)
- Aaron Rodriguez Calienes
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Milagros Galecio-Castillo
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Nils H Petersen
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Marc Ribo
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Mudassir Farooqui
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Ameer E Hassan
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Mouhammad A Jumaa
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Afshin A Divani
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Michael G Abraham
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Johanna T Fifi
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Waldo R Guerrero
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Amer M Malik
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - James E Siegler
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Thanh N Nguyen
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Sunil Sheth
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Albert J Yoo
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Guillermo Linares
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Nazli Janjua
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Darko Quispe-Orozco
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Yujing Lu
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Juan Vivanco-Suarez
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Mahmoud Dibas
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Maxim Mokin
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Dileep R Yavagal
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Tudor G Jovin
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
| | - Santiago Ortega-Gutierrez
- From the Departments of Neurology (A.R.C., M.G.-C., M.F., D.Q.-O., Y.L., J.V.-S., M.D., S.O.-G.), Neurosurgery (S.O.-G.), and Radiology (S.O.-G.), University of Iowa Hospitals and Clinics, Iowa City; Neuroscience, Clinical Effectiveness, and Public Health Research Group (A.R.C.), Universidad Cientifica del Sur, Lima, Peru; Department of Neurology (N.H.P.), Yale University School of Medicine, New Haven, CT; Department of Neurology (M.R.), Hospital Vall d'Hebron, Barcelona, Spain; Department of Neurology (A.E.H.), Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX; Department of Neurology (M.A.J.), ProMedica Toledo Hospital, OH; Department of Neurology (A.A.D.), University of New Mexico Health Science Center, Albuquerque; Department of Neurology (M.G.A.), University of Kansas Medical Center, Kansas City; Department of Neurosurgery (J.T.F.), Icahn School of Medicine at Mount Sinai, New York, NY; Department of Neurology and Brain Repair (W.R.G., M.M.), University of South Florida, Tampa; Department of Neurology (A.M.M., D.R.Y.), University of Miami Miller School of Medicine, FL; Cooper Neurological Institute (J.E.S., T.G.J.), Cooper University Hospital, Camden, NJ; Department of Neurology (T.N.N.), Boston Medical Center, MA; Department of Neurology (S.S.), UT Health McGovern Medical School, Houston; Texas Stroke Institute (A.J.Y.), Dallas-Fort Worth, TX; Department of Neurology (G.L.), Saint Louis University, MO; Asia Pacific Comprehensive Stroke Institute (N.J.), Pomona Valley Hospital Medical Center, CA
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Mendes GN, Jacquin G, Katsanos AH, Singh N, Stotts G, Ferguson DB, Yip S, Poppe AY. Safety of acute internal carotid artery stenting during endovascular thrombectomy in patients with acute ischemic stroke: a retrospective analysis of the OPTIMISE registry. J Neurointerv Surg 2024:jnis-2024-021915. [PMID: 38937083 DOI: 10.1136/jnis-2024-021915] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2024] [Accepted: 06/14/2024] [Indexed: 06/29/2024]
Abstract
BACKGROUND The optimal management of tandem carotid lesions during endovascular thrombectomy (EVT) remains uncertain. The safety and efficacy of acute carotid artery stenting (aCAS) are debated, including safety concerns such as procedural complications and symptomatic intracerebral hemorrhage (sICH). We aimed to assess aCAS safety among EVT-treated patients using a large Canadian registry. METHODS We retrospectively analyzed the OPTIMISE registry and compared adult patients undergoing EVT and aCAS versus EVT only. The primary outcome was a composite of in-hospital death, long-term care facility destination at discharge, sICH, or any EVT-related procedural complications. Secondary outcomes included individual components of the primary outcome, EVT workflow times, final modified Thrombolysis in Cerebral Ischemia score and 90-day modified Rankin Scale score. Statistical significance was evaluated by a multivariate logistic regression model. RESULTS 4205 patients were included (330 with EVT-aCAS and 3875 with EVT-only). Both groups were similar with regard to baseline National Institutes of Health Stroke Scale score, Alberta Stroke Program Early CT Score and use of IV thrombolysis, but differed in age (EVT-aCAS group 67.2±12.1 years vs EVT-only group 71.3±14.1 years, P<0.001), proportion of women (28.2% vs 53.3%, P<0.001), and occlusion location (internal carotid artery terminus 44% vs 16%, P<0.001). The EVT-aCAS group showed a non-significant increase in odds of composite safety outcomes (adjusted OR 1.35 (95% CI 0.97 to 1.84), P=0.06) with a significantly higher proportion of procedural complications (10.0% vs 6.2%, P=0.002). CONCLUSION In a large national registry, EVT-aCAS was associated with a higher proportion of unfavorable safety outcomes, driven by more frequent procedural complications. Further research is needed to clarify the role of aCAS in tandem occlusion stroke.
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Affiliation(s)
- George Nilton Mendes
- Neurosciences Axis, Centre de Recherche du CHUM, Montreal, Quebec, Canada
- Neurosciences, Centre Hospitalier de L'Universite de Montreal, Montreal, Quebec, Canada
| | - Grégory Jacquin
- Neurosciences Axis, Centre de Recherche du CHUM, Montreal, Quebec, Canada
- Neurosciences, Centre Hospitalier de L'Universite de Montreal, Montreal, Quebec, Canada
| | - Aristeidis H Katsanos
- Medicine (Neurology), McMaster University Faculty of Health Sciences, Hamilton, Ontario, Canada
| | - Nishita Singh
- Internal Medicine (Neurology), University of Manitoba Max Rady College of Medicine, Winnipeg, Manitoba, Canada
| | - Grant Stotts
- Medicine, University of Ottawa, Ottawa, Ontario, Canada
- Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Darren B Ferguson
- Diagnostic Radiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Samuel Yip
- Medicine (Neurology), The University of British Columbia, Vancouver, British Columbia, Canada
| | - Alexandre Y Poppe
- Neurosciences Axis, Centre de Recherche du CHUM, Montreal, Quebec, Canada
- Neurosciences, Centre Hospitalier de L'Universite de Montreal, Montreal, Quebec, Canada
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3
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Cappellari M, Pracucci G, Saia V, Mandruzzato N, Valletta F, Sallustio F, Casetta I, Fainardi E, Da Ros V, Diomedi M, Capasso F, Nencini P, Vallone S, Bigliardi G, Tessitore A, La Spina P, Bracco S, Tassi R, Bergui M, Cerrato P, Ruggiero M, Longoni M, Castellan L, Malfatto L, Saletti A, De Vito A, Menozzi R, Scoditti U, Simonetti L, Zini A, Lafe E, Cavallini A, Lazzarotti GA, Giannini N, Boghi A, Naldi A, Romano D, Napoletano R, Comai A, Franchini E, Cavasin N, Critelli A, Giorgianni A, Cariddi LP, Semeraro V, Boero G, Zimatore DS, Petruzzellis M, Biraschi F, Nicolini E, Pedicelli A, Frisullo G, Calzoni A, Tassinari T, Gallesio I, Sepe F, Filauri P, Sacco S, Lozupone E, Rizzo A, Besana M, Giossi A, Pavia M, Invernizzi P, Amistà P, Russo M, Florio F, Inchingolo V, Filizzolo M, Mannino M, Mangiafico S, Toni D. Thrombectomy in ischemic stroke patients with tandem occlusion in the posterior versus anterior circulation. Neurol Sci 2024:10.1007/s10072-024-07638-x. [PMID: 38890169 DOI: 10.1007/s10072-024-07638-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: 01/02/2024] [Accepted: 06/07/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Mechanical thrombectomy (MT) was found to be beneficial in acute ischemic stroke patients with anterior tandem occlusion (a-TO). Instead, little is known about the effectiveness of MT in stroke patients with posterior tandem occlusion (p-TO). We aimed to compare MT within 24 h from last known well time in ischemic stroke patients with p-TO versus a-TO. METHODS We conducted a cohort study on prospectively collected data of patients registered in the Italian Registry of Endovascular Treatment in Acute Stroke (IRETAS) who were treated with MT within 24 h from last known well time for acute ischemic stroke with p-TO (n = 275) or a-TO (n = 1853). RESULTS After adjustment for unbalanced pre-procedure variables (year 2015-2021, age, sex, NIHSS score, ASPECTS, and time strata for puncture groin) and pre-stroke mRS score as pre-defined predictor, p-TO was significantly associated with lower probability of mRS score 0-2 (OR 0.415, 95% CI 0.268-0.644) and with higher risk of death (OR 2.813, 95% CI 2.080-3.805) at 3 months. After adjustment for unbalanced procedural and post-procedure variables (IVT, general anesthesia, TICI 3, and 24-h HT) and pre-stroke mRS score as pre-defined predictor, association between p-TO and lower probability of mRS score 0-2 (OR 0.444, 95% CI 0.304-0.649) and association between p-TO and with higher risk of death (OR 2.971, 95% CI 1.993-4.429) remained significant. CONCLUSIONS MT within 24 h from last known well time in ischemic stroke patients with p-TO versus a-TO was associated with worse outcomes at 3 months.
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Affiliation(s)
- Manuel Cappellari
- Stroke Unit, DAI Di Neuroscienze, Azienda Ospedaliera Universitaria Integrata, Piazzale A. Stefani 1, 37126, Verona, Italy.
| | - Giovanni Pracucci
- Department of NEUROFARBA, Neuroscience Section, University of Florence, Florene, Italy
| | - Valentina Saia
- Neurology and Stroke Unit, S. Corona Hospital, Pietra Ligure, Florene, Italy
| | - Nicolò Mandruzzato
- Interventional Neuroradiology, Azienda Ospedaliera Universitaria Integrata, Verona, Italy
| | - Francesco Valletta
- Stroke Unit, DAI Di Neuroscienze, Azienda Ospedaliera Universitaria Integrata, Piazzale A. Stefani 1, 37126, Verona, Italy
| | - Fabrizio Sallustio
- Unità Di Trattamento Neurovascolare, Ospedale Dei Castelli-ASL6, Rome, Italy
| | - Ilaria Casetta
- Neurology Unit, University Hospital Arcispedale S. Anna, Ferrara, Italy
| | - Enrico Fainardi
- Dipartimento Di Scienze Biomediche, Sperimentali E Cliniche, Neuroradiologia, Ospedale Universitario Careggi, Florence, Italy
| | - Valerio Da Ros
- Interventional Radiology Unit, Department of Biomedicine and Prevention, University of Tor Vergata, Rome, Italy
| | - Marina Diomedi
- Department of Systems Medicine, University of Rome Tor Vergata, Rome, Italy
| | - Francesco Capasso
- Neurovascular Interventional Unit, Careggi University Hospital, Rome, Italy
| | - Patrizia Nencini
- Stroke Unit, Azienda Ospedaliero Univarsitaria Careggi, Florence, Italy
| | - Stefano Vallone
- Neuroradiologia, Ospedale Civile Di Baggiovara, AOU Modena, Rome, Italy
| | - Guido Bigliardi
- Neurologia/Stroke Unit, Ospedale Civile Di Baggiovara, AOU Modena, Rome, Italy
| | - Agostino Tessitore
- Neuroradiology Unit, University Hospital ″G. Martino″ Messina, Rome, Italy
| | - Paolino La Spina
- Stroke Unit - Department of Clinical and Experimental Medicine, University of Messina, Rome, Italy
| | - Sandra Bracco
- UO Neurointerventistica, Ospedale S. Maria Delle Scotte-University Hospital, Siena, Italy
| | - Rossana Tassi
- Stroke Unit, Ospedale S. Maria Delle Scotte-University Hospital, Siena, Italy
| | - Mauro Bergui
- Università Torino Dipartimento Di Neuroscienze, Siena, Italy
| | | | - Maria Ruggiero
- Interventional Neuroradiology, Ospedale Bufalini-AUSL Romagna, Cesena, Italy
| | - Marco Longoni
- Neurology E Stroke Unit, Ospedale Bufalini-AUSL Romagna, Cesena, Italy
| | - Lucio Castellan
- Department of Neuroradiology, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Laura Malfatto
- Neurology and Stroke Unit, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
| | - Andrea Saletti
- Azienda Ospedaliero Universitaria Di Ferrara-Neuroradiologia- Dipartimento Di Radiologia, Genoa, Italy
| | | | | | | | - Luigi Simonetti
- Department of Neuroradiology, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Maggiore Hospital, Bologna, Italy
| | - Andrea Zini
- Department of Neurology and Stroke Center, IRCCS Istituto Delle Scienze Neurologiche Di Bologna, Maggiore Hospital, Bologna, Italy
| | - Elvis Lafe
- UOC Radiologia Diagnostica Per Immagini 2, Neuroradiologia, Policlinico IRCCS San Matteo, Bologna, Italy
| | - Anna Cavallini
- UO Neurologia d'Urgenza E Stroke Unit, IRCCS Fondazione Mondino, Pavia, Italy
| | | | - Nicola Giannini
- Centre of Cerebrovascular Disorders, Unit of Neurology, University Hospital of Pisa, Pavia, Italy
| | - Andrea Boghi
- SC Radiologia E Neuroradiologia, Ospedale San Giovanni Bosco Torino, Pavia, Italy
| | - Andrea Naldi
- S.C. Neurologia 2, Ospedale San Giovanni Bosco Torino, Pavia, Italy
| | - Daniele Romano
- UOSD Radiologia Interventistica Vascolare Ed Extravascolare, AOU San Giovanni Di Dio E Ruggi Di Aragona, Salerno, Italy
| | - Rosa Napoletano
- UOSD Stroke Unit AOU San Giovanni Di Dio E Ruggi d'Aragona, Salerno, Italy
| | - Alessio Comai
- Servizio Di Neuroradiologia, Ospedale Provinciale Di Bolzano, Salerno, Italy
| | | | - Nicola Cavasin
- Neuroradiology, Ospedale Dell'Angelo Mestre, Salerno, Italy
| | - Adriana Critelli
- Neurology and Stroke Unit, Ospedale Dell'Angelo Mestre, Salerno, Italy
| | - Andrea Giorgianni
- UOC Neuroradiologia ASST Sette Laghi, Circolo Hospital, Varese, Italy
| | | | | | | | | | | | - Francesco Biraschi
- Department of Human Neurosciences, Interventional Neuroradiology, Universita Degli Studi Di Roma Sapienza, Rome, Lazio, Italy
| | - Ettore Nicolini
- Emergency Department Stroke Unit, Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
| | - Alessandro Pedicelli
- Dipartimento Di Diagnostica Per Immagini, Radioterapia, Oncologia Ed Ematologia, UOSA Neuroradiologia Interventistica, Fondazione Policlinico Universitario A.Gemelli IRCCS, Rome, Italy
| | | | - Andrea Calzoni
- Neuroradiologia Diagnostica E Interventistica, Santa Corona Hospital, Pietra Ligure (SV), Rome, Italy
| | - Tiziana Tassinari
- Neurology and Stroke Unit, S. Corona Hospital, Pietra Ligure, Florene, Italy
| | - Ivan Gallesio
- Neuroradiology Unit AO, ″SS Antonio E Biagio E C. Arrigo″ Alessandria, Rome, Italy
| | - Federica Sepe
- Neurology Unit AO, ″SS Antonio E Biagio E C. Arrigo″ Alessandria, Rome, Italy
| | - Pietro Filauri
- Neuroradiology Unit, Presidio Ospedaliero SS. Filippo E Nicola, Avezzano, Italy
| | - Simona Sacco
- Neuroscience Section, Department of Applied Clinical Sciences and Biotechnology, University of L'Aquila, Avezzano, Italy
| | - Emilio Lozupone
- Department of Neuroradiology, Vito Fazzi Hospital, Lecce, Italy
| | - Annalisa Rizzo
- Department of Neurology, Vito Fazzi Hospital, Lecce, Italy
| | - Michele Besana
- U.O Neuroradiologia, Dipartimento Di Neuroscienze, Presidio Ospedaliero Di Cremona, ASST Cremona, Lecce, Italy
| | - Alessia Giossi
- U.O Neurologia, Presidio Ospedaliero Di Cremona, ASST Cremona, Lecce, Italy
| | - Marco Pavia
- UO Neuroradiologia, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Paolo Invernizzi
- UO Neurologia, Istituto Ospedaliero Fondazione Poliambulanza, Brescia, Italy
| | - Pietro Amistà
- Neuroradiology Unit, Ospedale S. Maria Della Misericordia, Rovigo, Italy
| | - Monia Russo
- Neurology Unit, Ospedale S. Maria Della Misericordia, Rovigo, Italy
| | - Francesco Florio
- UO Radiologia Interventistica, IRCCS Casa Sollievo Della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | - Vincenzo Inchingolo
- UO Neurologia, IRCCS Casa Sollievo Della Sofferenza, San Giovanni Rotondo, Foggia, Italy
| | - Marco Filizzolo
- UO Radiologia, Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Marina Mannino
- UO Neurologia, Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
| | - Salvatore Mangiafico
- Interventional Neuroradiology Consultant at IRCCS NeuromedPozzilli (IS), and Adjunct Professor of Interventional Neuroradiology at,, Tor Vergata University, Sapienza University and S. Andrea Hospital, Rome, Italy
| | - Danilo Toni
- Emergency Department Stroke Unit, Department of Human Neurosciences, Sapienza University of Rome, Rome, Italy
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4
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Riegler C, von Rennenberg R, Bollweg K, Nguyen TN, Kleine JF, Tiedt S, Audebert HJ, Siebert E, Nolte CH. Endovascular therapy in patients with internal carotid artery occlusion and patent circle of Willis. J Neurointerv Surg 2024; 16:644-651. [PMID: 37491381 PMCID: PMC11228208 DOI: 10.1136/jnis-2023-020556] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2023] [Accepted: 06/24/2023] [Indexed: 07/27/2023]
Abstract
BACKGROUND Occlusion of the internal carotid artery (ICA) may extend into the middle or anterior cerebral artery (ICA-T) or be confined to the intracranial (ICA-I) or extracranial segment (ICA-E). While there is excellent evidence for endovascular therapy (EVT) in ICA-T occlusions, studies on EVT in non-tandem ICA-I or ICA-E occlusions are scarce. OBJECTIVE To characterize EVT-treated patients with ICA-I- and ICA-E occlusion by comparing them with ICA-T occlusions. METHODS The German Stroke Registry (GSR), a national, multicenter, prospective registry was searched for EVT-treated patients with isolated ICA occlusion between June 2015 and December 2021. We stratified patients by ICA occlusion site: (a) ICA-T, (b) ICA-I, (c) ICA-E. Baseline factors, procedural variables, technical (modified Thrombolysis in Cerebral Infarction (mTICI)), and functional outcomes (modified Rankin scale score at 3 months) were analyzed. RESULTS Of 13 082 GSR patients, 2588 (19.8%) presented with an isolated ICA occlusion, thereof 1946 (75.2%) ICA-T, 366 (14.1%) ICA-I, and 276 (10.7%) ICA-E patients. The groups differed in age (77 vs 76 vs 74 years, Ptrend=0.02), sex (53.4 vs 48.9 vs 43.1% female, Ptrend<0.01), and stroke severity (median National Institutes of Health Stroke Scale score at admission 17 vs 14 vs 13 points, Ptrend<0.001). In comparison with ICA-T occlusions, both ICA-I and ICA-E occlusions had lower rates of successful recanalization (mTICI 2b/3: 85.4% vs 80.4% vs 76.3%; aOR (95% CI for ICA-I vs ICA-T 0.71 (0.53 to 0.95); aOR (95% CI) for ICA-E vs ICA-T 0.57 (0.42 to 0.78)). In adjusted analyses, ICA-E occlusion was associated with worse outcome when compared with ICA-T occlusion (mRS ordinal shift, cOR (95% CI) 0.70 (0.52 to 0.93)). CONCLUSION Patient characteristics and outcomes differ substantially between ICA-T, ICA-I, and ICA-E occlusions. These results warrant further studies on EVT in ICA-I and ICA-E patients.
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Affiliation(s)
- Christoph Riegler
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitatsmedizin Berlin, Berlin, Germany
| | - Regina von Rennenberg
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitatsmedizin Berlin, Berlin, Germany
| | - Kerstin Bollweg
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitatsmedizin Berlin, Berlin, Germany
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, Boston, Massachusetts, USA
- Department of Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts, USA
| | - Justus F Kleine
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Steffen Tiedt
- Institute for Stroke and Dementia Research, University Hospital, Ludwig Maximilians University Munich, Munich, Germany
| | - Heinrich J Audebert
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitatsmedizin Berlin, Berlin, Germany
| | - Eberhard Siebert
- Department of Neuroradiology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
| | - Christian H Nolte
- Department of Neurology, Charité - Universitätsmedizin Berlin, Corporate member of Freie Universität Berlin and Humboldt Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité Universitatsmedizin Berlin, Berlin, Germany
- Berlin Insititute of Health at Charité, Universitätsmedizin Berlin, Berlin, Germany
- Deutsches Zentrum für Herz-Kreislaufforschung (DZHK), Berlin, Germany
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5
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Deliktas Y, Derraz I, Finitsis S, Caroff J, Bourcier R, Soize S, Moulin S, Richard S, Marnat G, Hoferica M, Cognard C, Desilles JP, Anadani M, Olivot JM, Casolla B, Consoli A, Lapergue B, Gory B. Clinical and safety outcomes of acute stenting plus thrombectomy for carotid tandem lesions with large ischemic core. J Neurointerv Surg 2024:jnis-2024-021517. [PMID: 38839283 DOI: 10.1136/jnis-2024-021517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/24/2024] [Accepted: 05/14/2024] [Indexed: 06/07/2024]
Abstract
BACKGROUND We evaluated the clinical and safety outcomes of emergent carotid artery stenting (eCAS) plus endovascular thrombectomy (EVT) among patients with anterior tandem lesion (TL) and large ischemic core (LIC). METHODS This retrospective study included consecutive stroke patients enrolled in the Endovascular Treatment in Ischemic Stroke Registry in France between January 2015 and June 2023. We compared the outcomes of carotid stenting vs no stenting in tandem lesion with pre-treatment LIC (Alberta Stroke Program Early CT Score (ASPECTS) 3-5) and stenting in tandem lesion vs thrombectomy alone for isolated intracranial occlusions with pre-treatment LIC. Primary outcome was a score of 0 to 3 on the modified Rankin scale (mRS) at 90 days. Multivariable mixed-effects logistic regression was performed. RESULTS Among 218 tandem patients with LIC, 55 were treated with eCAS plus EVT. The eCAS group had higher odds of 90-day mRS 0-3 (adjusted Odds Ratio (aOR) 2.40, 95% confidence interval (CI) 1.10 to 5.21; p=0.027). There were no differences in the risk of any intracerebral hemorrhage (OR 1.41, 95% CI 0.69 to 2.86; p=0.346), parenchymal hematoma (aOR 1.216, 95% CI 0.49 to 3.02; p=0.675), symptomatic intracerebral hemorrhage (aOR 1.45, 95% CI 0.60 to 3.48; p=0.409), or 90-day mortality (aOR 0.74, 95% CI 0.33 to 1.68; p=0.472). eCAS was associated with a higher rate of carotid patency at day 1 (aOR 3.54, 95% CI 1.14 to 11.01; p=0.028). Safety outcomes were similar between EVT+eCAS group in TL-LIC and EVT alone group in isolated intracranial occlusions with LIC. CONCLUSION eCAS appears to be a safe and effective strategy in patients with TL and LIC volume.
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Affiliation(s)
- Yakub Deliktas
- Diagnostic and Therapeutic Neuroradiology, CHRU Nancy, Nancy, France
| | - Imad Derraz
- Neuroradiology, Centre Hospitalier Universitaire de Montpellier, Montpellier, France
| | - Stephanos Finitsis
- Neuroradiology, Aristotle University of Thessaloniki, Ahepa Hospital, Thessaloniki, Greece
| | - Jildaz Caroff
- Interventional Neuroradiology - NEURI Brain Vascular Center, Hôpital Bicêtre, Le Kremlin Bicêtre, France
| | | | | | | | | | - Gaultier Marnat
- Interventional and Diagnostic Neuroradiology, Bordeaux University Hospital, Bordeaux, France
| | - Matúš Hoferica
- Diagnostic and Therapeutic Neuroradiology, Hôpital Purpan, Toulouse, France
| | - Christophe Cognard
- Diagnostic and Therapeutic Neuroradiology, Hôpital Purpan, Toulouse, France
| | - Jean-Philippe Desilles
- Interventional Neuroradiology, Fondation Ophtalmologique Adolphe de Rothschild, Paris, France
| | - Mohammad Anadani
- Department of Neurosciences, Intent Medical Group, NorthShore University HealthSystem, Arlington Heights, Illinois, USA
| | | | | | - Arturo Consoli
- Diagnostic and Interventional Neuroradiology, Hôpital Foch, Suresnes, France
| | | | - Benjamin Gory
- Diagnostic and Therapeutic Neuroradiology, CHRU Nancy, Nancy, France
- Université de Lorraine, INSERM U1254, IADI, Nancy, France
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6
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Mujanovic A, Dobrocky T, Pfeilschifter W, Remonda L, Caroff J, Behme D, Seiffge DJ, Cereda CW, Kägi G, Leyon J, Piechowiak EI, Costalat V, Wagner J, Chabert E, Meinel TR, Jansen O, Alonso A, Loehr C, Liebeskind DS, Gralla J, Fischer U, Kaesmacher J. Value of intravenous alteplase before thrombectomy among patients with tandem lesions and emergent carotid artery stenting: A subgroup analysis of the SWIFT DIRECT trial. Eur J Neurol 2024; 31:e16256. [PMID: 38409874 PMCID: PMC11235868 DOI: 10.1111/ene.16256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Revised: 01/26/2024] [Accepted: 02/07/2024] [Indexed: 02/28/2024]
Abstract
BACKGROUND AND PURPOSE The value of intravenous thrombolysis (IVT) in eligible tandem lesion patients undergoing endovascular treatment (EVT) is unknown. We investigated treatment effect heterogeneity of EVT + IVT versus EVT-only in tandem lesion patients. Additional analyses were performed for patients undergoing emergent internal carotid artery (ICA) stenting. METHODS SWIFT DIRECT randomized IVT-eligible patients to either EVT + IVT or EVT-only. Primary outcome was 90-day functional independence (modified Rankin Scale score 0-2) after the index event. Secondary endpoints were reperfusion success, 24 h intracranial hemorrhage rate, and 90-day all-cause mortality. Interaction models were fitted for all predefined outcomes. RESULTS Among 408 included patients, 63 (15.4%) had a tandem lesion and 33 (52.4%) received IVT. In patients with tandem lesions, 20 had undergone emergent ICA stenting (EVT + IVT: 9/33, 27.3%; EVT: 11/30, 36.7%). Tandem lesion did not show treatment effect modification of IVT on rates of functional independence (tandem lesion EVT + IVT vs. EVT: 63.6% vs. 46.7%, non-tandem lesion EVT + IVT vs. EVT: 65.6% vs. 58.2%; p for interaction = 0.77). IVT also did not increase the risk of intracranial hemorrhage among tandem lesion patients (tandem lesion EVT + IVT vs. EVT: 34.4% vs. 46.7%, non-tandem lesion EVT + IVT vs. EVT: 33.5% vs. 26.3%; p for interaction = 0.15). No heterogeneity was noted for other endpoints (p for interaction > 0.05). CONCLUSIONS No treatment effect heterogeneity of EVT + IVT versus EVT-only was observed among tandem lesion patients. Administering IVT in patients with anticipated emergent ICA stenting seems safe, and the latter should not be a factor to consider when deciding to administer IVT before EVT.
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Affiliation(s)
- Adnan Mujanovic
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern InselspitalUniversity of BernBernSwitzerland
| | - Tomas Dobrocky
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern InselspitalUniversity of BernBernSwitzerland
| | - Waltraud Pfeilschifter
- Department of Neurology, University Hospital FrankfurtGoethe UniversityFrankfurt am MainGermany
| | - Luca Remonda
- Department of NeuroradiologyCantonal Hospital AarauAarauSwitzerland
| | - Jildaz Caroff
- Department of Interventional Neuroradiology, NEURI Brain Vascular Center, Bicêtre HospitalParis‐Saclay UniversityLe Kremlin‐BicêtreFrance
| | - Daniel Behme
- Department for Neuroradiology, Otto von Guericke University Hospital MagdeburgUniversity of MagdeburgMagdeburgGermany
| | - David J. Seiffge
- Department of Neurology, University Hospital Bern InselspitalUniversity of BernBernSwitzerland
| | - Carlo W. Cereda
- Stroke Center, Neurology, Neurocenter of Southern Switzerland (EOC)LuganoSwitzerland
| | - Georg Kägi
- Department of NeurologyCantonal Hospital St. Gallen, University of St. GallenSt. GallenSwitzerland
| | - Joe Leyon
- Department of NeuroradiologySt. George's University HospitalLondonUK
| | - Eike I. Piechowiak
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern InselspitalUniversity of BernBernSwitzerland
| | - Vincent Costalat
- Department of NeuroradiologyUniversity Hospital MontpellierMontpellierFrance
| | - Judith Wagner
- Department of NeurologyKepler University Hospital, Johannes Kepler University LinzLinzAustria
- Department of Neurology, Evangelisches Klinikum GelsenkirchenAcademic Hospital University Essen‐DuisburgGelsenkirchenGermany
| | - Emmanuel Chabert
- Department of NeuroradiologyUniversity Hospital Clermont‐FerrandClermont‐FerrandFrance
| | - Thomas R. Meinel
- Department of Neurology, University Hospital Bern InselspitalUniversity of BernBernSwitzerland
| | - Olav Jansen
- Department of Radiology and NeuroradiologyUniversity Hospital Schleswig‐Holstein, University of KielKielGermany
| | - Angelika Alonso
- Department of Neurology, Medical Faculty MannheimUniversity of HeidelbergMannheimGermany
| | - Christian Loehr
- Department of Radiology and NeuroradiologyKlinikum VestRecklinghausenGermany
| | - David S. Liebeskind
- Department of Neurology and Comprehensive Stroke Center, David Geffen School of MedicineUniversity of California, Los AngelesLos AngelesUSA
| | - Jan Gralla
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern InselspitalUniversity of BernBernSwitzerland
| | - Urs Fischer
- Department of Neurology, University Hospital Bern InselspitalUniversity of BernBernSwitzerland
- Department of NeurologyUniversity Hospital Basel, University of BaselBaselSwitzerland
| | - Johannes Kaesmacher
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Bern InselspitalUniversity of BernBernSwitzerland
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7
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Huber C, Berberat J, Sassenburg R, Pflugi S, Anon J, Diepers M, Andereggen L, Kahles T, Luft AR, Nedeltchev K, Remonda L, Gruber P. Age and Stroke Severity Matter Most for Clinical Outcome in Acute Arteriosclerotic Tandem Lesions. J Clin Med 2024; 13:2315. [PMID: 38673587 PMCID: PMC11050763 DOI: 10.3390/jcm13082315] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 04/12/2024] [Accepted: 04/13/2024] [Indexed: 04/28/2024] Open
Abstract
Background: Tandem lesions (TLs) cause up to 15-30% of all acute ischemic strokes (AISs). Endovascular treatment (EVT) is regarded as the first-line treatment; however, uncertainties remain with respect to the treatment and predictive outcome parameters. Here, we aimed to identify the clinical and demographic factors associated with functional short- and long-term outcomes in AIS patients with arteriosclerotic TLs undergoing EVT. Methods: This was a retrospective, mono-centric cohort study of 116 consecutive AIS patients with arteriosclerotic TLs who were endovascularly treated at a stroke center, with analysis of the relevant demographic, procedural, and imaging data. Results: A total of 116 patients were included in this study, with a median age of 72 years (IQR 63-80), 31% of whom were female (n = 36). The median NIHSS on admission was 14 (IQR 7-19), with a median ASPECT score of 9 (IQR 8-10) and median NASCET score of 99% (IQR 88-100%). A total of 52% of the patients received intravenous thrombolysis. In 77% (n = 89) of the patients, an antegrade EVT approach was used, with a good recanalization (mTICI2b3) achieved in 83% of patients (n = 96). Symptomatic intracerebral hemorrhage occurred in 12.7% (n = 15) of patients. A favorable outcome (mRS0-2) and mortality at 3 months were obtained for 40% (n = 47) and 28% of patients (n = 32), respectively. Age and NIHSS on admission were strongly associated with outcome parameters. Diabetes mellitus and previous neurological disorders were independently associated with long-term mortality (median 11 months, IQR 0-42). Conclusions: Younger age, lower stroke severity, and good recanalization were found to be independently associated with a favorable outcome. In contrast, older age, higher stroke severity, previous neurological disorders, and diabetes were correlated with mortality. The endovascular treatment of acute arteriosclerotic tandem lesions is feasible and relatively safe.
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Affiliation(s)
- Cyrill Huber
- Department of Neuroradiology, Kantonsspital Aarau, University of Zurich, Tellstrasse 21, 5001 Aarau, Switzerland;
| | - Jatta Berberat
- Department of Neuroradiology, Kantonsspital Aarau, 5001 Aarau, Switzerland; (J.B.); (R.S.); (J.A.); (M.D.); (L.R.)
| | - Renske Sassenburg
- Department of Neuroradiology, Kantonsspital Aarau, 5001 Aarau, Switzerland; (J.B.); (R.S.); (J.A.); (M.D.); (L.R.)
| | - Stefanie Pflugi
- Department of Neuroradiology, Kantonsspital Aarau, 5001 Aarau, Switzerland; (J.B.); (R.S.); (J.A.); (M.D.); (L.R.)
| | - Javier Anon
- Department of Neuroradiology, Kantonsspital Aarau, 5001 Aarau, Switzerland; (J.B.); (R.S.); (J.A.); (M.D.); (L.R.)
| | - Michael Diepers
- Department of Neuroradiology, Kantonsspital Aarau, 5001 Aarau, Switzerland; (J.B.); (R.S.); (J.A.); (M.D.); (L.R.)
| | - Lukas Andereggen
- Department of Neurosurgery, Kantonsspital Aarau, University of Bern, 3012 Bern, Switzerland;
| | - Timo Kahles
- Department of Neurology, Kantonsspital Aarau, University of Basel, 4001 Basel, Switzerland;
| | - Andreas R. Luft
- Department of Neurology, University Hospital Zurich, University of Zurich, 8952 Zurich, Switzerland;
- Cereneo, Center for Neurology and Rehabilitation, 6354 Vitznau, Switzerland
| | - Krassen Nedeltchev
- Department of Neurology, Kantonsspital Aarau, University of Bern, 3012 Bern, Switzerland;
| | - Luca Remonda
- Department of Neuroradiology, Kantonsspital Aarau, 5001 Aarau, Switzerland; (J.B.); (R.S.); (J.A.); (M.D.); (L.R.)
| | - Philipp Gruber
- Department of Neuroradiology, Kantonsspital Aarau, University of Zurich, Tellstrasse 21, 5001 Aarau, Switzerland;
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8
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Bala F, Almekhlafi M, Singh N, Alhabli I, Ademola A, Coutts SB, Deschaintre Y, Khosravani H, Appireddy R, Moreau F, Phillips S, Gubitz G, Tkach A, Catanese L, Dowlatshahi D, Medvedev G, Mandzia J, Pikula A, Shankar J, Williams H, Field TS, Manosalva A, Siddiqui M, Zafar A, Imoukhoude O, Hunter G, Benali F, Horn M, Hill MD, Shamy M, Sajobi TT, Buck BH, Swartz RH, Menon BK, Poppe AY. Safety and efficacy of tenecteplase versus alteplase in stroke patients with carotid tandem lesions: Results from the AcT trial. Int J Stroke 2024; 19:322-330. [PMID: 37731173 PMCID: PMC10903116 DOI: 10.1177/17474930231205208] [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: 07/26/2023] [Accepted: 09/05/2023] [Indexed: 09/22/2023]
Abstract
BACKGROUND Carotid tandem lesions ((TL) ⩾70% stenosis or occlusion) account for 15-20% of acute stroke with large vessel occlusion. AIMS We investigated the safety and efficacy of intravenous tenecteplase (0.25 mg/kg) versus intravenous alteplase (0.9 mg/kg) in patients with carotid TL. METHODS This is a substudy of the alteplase compared with the tenecteplase trial. Patients with ⩾70% stenosis of the extracranial internal carotid artery (ICA) and concomitant occlusion of the intracranial ICA, M1 or M2 segments of the middle cerebral artery on baseline computed tomography angiography (CTA) were included. Primary outcome was 90-day-modified Rankin Scale (mRS) 0-1. Secondary outcomes were mRS 0-2, mortality, and symptomatic ICH (sICH). Angiographic outcomes were successful recanalization (revised Arterial Occlusive Lesion (rAOL) 2b-3) on first and successful reperfusion (eTICI 2b-3) on final angiographic acquisitions. Multivariable mixed-effects logistic regression was performed. RESULTS Among 1577 alteplase versus tenecteplase randomized controlled trial (AcT) patients, 128 (18.8%) had carotid TL. Of these, 93 (72.7%) underwent intravenous thrombolysis plus endovascular thrombectomy (IVT + EVT), while 35 (27.3%) were treated with IVT alone. In the IVT + EVT group, tenecteplase was associated with higher odds of 90-day-mRS 0-1 (46.0% vs. 32.6%, adjusted OR (aOR) 3.21; 95% CI = 1.06-9.71) compared with alteplase. No statistically significant differences in rates of mRS 0-2 (aOR 1.53; 95% CI = 0.51-4.55), initial rAOL 2b-3 (16.3% vs. 28.6%), final eTICI 2b-3 (83.7% vs. 85.7%), and mortality (18.0% vs. 16.3%) were found. SICH only occurred in one patient. There were no differences in outcomes between thrombolytic agents in the IVT-only group. CONCLUSION In patients with carotid TL treated with EVT, intravenous tenecteplase may be associated with similar or better clinical outcomes, similar angiographic reperfusion rates, and safety outcomes as compared with alteplase.
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Affiliation(s)
- Fouzi Bala
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Diagnostic and Interventional Neuroradiology Department, University Hospital of Tours, Tours, France
| | - Mohammed Almekhlafi
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Nishita Singh
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Ibrahim Alhabli
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Ayoola Ademola
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Shelagh B Coutts
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Yan Deschaintre
- Centre Hospitalier de l’Université de Montréal (CHUM), Montreal, QC, Canada
| | - Houman Khosravani
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Ramana Appireddy
- Division of Neurology, Department of Medicine, Queen’s University, Kingston, ON, Canada
| | | | | | - Gord Gubitz
- Queen Elizabeth II Health Sciences Centre, Halifax, NS, Canada
| | | | - Luciana Catanese
- Hamilton Health Sciences, McMaster University, Hamilton, ON, Canada
| | - Dar Dowlatshahi
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - George Medvedev
- The University of British Columbia, Vancouver, BC, Canada
- Fraser Health Authority, New Westminster, BC, Canada
| | - Jennifer Mandzia
- London Health Sciences Centre, Western University, London, ON, Canada
| | - Aleksandra Pikula
- Toronto Western Hospital, University of Toronto, Toronto, ON, Canada
| | - Jay Shankar
- University of Manitoba, Winnipeg, MB, Canada
| | | | - Thalia S Field
- Vancouver Stroke Program, Division of Neurology, The University of British Columbia, Vancouver, BC, Canada
| | | | | | - Atif Zafar
- St. Michael’s Hospital, Toronto, ON, Canada
| | | | - Gary Hunter
- University of Saskatchewan, Saskatoon, SK, Canada
| | - Faysal Benali
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - MacKenzie Horn
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Michael D Hill
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Michel Shamy
- Department of Medicine, University of Ottawa, Ottawa, ON, Canada
| | - Tolulope T Sajobi
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Brian H Buck
- Division of Neurology, Department of Medicine, University of Alberta, Edmonton, AB, Canada
| | - Richard H Swartz
- Sunnybrook Health Sciences Centre, University of Toronto, Toronto, ON, Canada
| | - Bijoy K Menon
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
| | - Alexandre Y Poppe
- Centre Hospitalier de l’Université de Montréal (CHUM), Montreal, QC, Canada
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9
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Garayzade R, Berlis A, Schiele S, Ertl M, Schneider H, Müller G, Maurer CJ. Efficacy and Safety Outcomes for Acute Ischemic Stroke Patients Treated with Intravenous Infusion of Tirofiban After Emergent Carotid Artery Stenting. Clin Neuroradiol 2024; 34:163-172. [PMID: 37796321 PMCID: PMC10881598 DOI: 10.1007/s00062-023-01350-7] [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: 04/05/2023] [Accepted: 09/14/2023] [Indexed: 10/06/2023]
Abstract
INTRODUCTION Emergent stenting of the extracranial internal carotid artery (ICA) in stroke patients requires antiplatelet therapy to prevent in-stent thrombosis with a higher risk of intracranial haemorrhage. AIM OF THE STUDY Assess the efficacy and safety of emergent carotid stenting with intravenous tirofiban in acute ischemic stroke patients. METHODS Primary endpoint: symptomatic hemorrhage. Secondary endpoints: 90-day functional outcome and mortality. RESULTS Of the 62 patients, 21 (34%) received tirofiban as a single antiplatelet, and 41 (66%) received combined therapy. Premedication with anticoagulants and antiplatelets was significantly more frequent in the tirofiban-only group. The rate of symptomatic haemorrhage was significantly lower in the tirofiban-only group than in the combined group (4.8% vs. 27%, p = 0.046). The patients with tirofiban alone had a significantly better functional outcome at day 90 than the combined group (52% vs. 24%, p = 0.028). Mortality was equal (24%) in both groups. Pre-interventional NIHSS score (p = 0.003), significant blood pressure fluctuations (p = 0.012), tandem occlusion (p = 0.023), and thrombolysis (p = 0.044) showed relevant influence on the rate of symptomatic hemorrhage in the entire patient cohort. CONCLUSIONS A single antiplatelet therapy with tirofiban regardless of the premedication may improve the functional outcome in patients with stroke due to acute extracranial carotid lesion and emergent carotid stenting with lower rates of serious intracranial haemorrhage. For patients with high pre-interventional NIHSS score, tandem occlusion and after pre-interventional thrombolysis, caution is advised. Additionally, strict blood pressure monitoring should be conducted during the first 72 h after intervention.
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Affiliation(s)
- Rana Garayzade
- Department of diagnostic and interventional Radiology and Neuroradiology, Augsburg University Hospital, Augsburg, Germany.
| | - Ansgar Berlis
- Department of diagnostic and interventional Radiology and Neuroradiology, Augsburg University Hospital, Augsburg, Germany
| | - Stefan Schiele
- Institute of Mathematics, Augsburg University, Augsburg, Germany
| | - Michael Ertl
- Department of Neurology, Augsburg University Hospital, Augsburg, Germany
| | - Hauke Schneider
- Department of Neurology, Augsburg University Hospital, Augsburg, Germany
| | - Gernot Müller
- Institute of Mathematics, Augsburg University, Augsburg, Germany
| | - Christoph J Maurer
- Department of diagnostic and interventional Radiology and Neuroradiology, Augsburg University Hospital, Augsburg, Germany
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10
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ter Schiphorst A, Turc G, Hassen WB, Oppenheim C, Baron JC. Incidence, severity and impact on functional outcome of persistent hypoperfusion despite large-vessel recanalization, a potential marker of impaired microvascular reperfusion: Systematic review of the clinical literature. J Cereb Blood Flow Metab 2024; 44:38-49. [PMID: 37871624 PMCID: PMC10905632 DOI: 10.1177/0271678x231209069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2023] [Revised: 09/02/2023] [Accepted: 10/02/2023] [Indexed: 10/25/2023]
Abstract
The reported incidence of persistent hypoperfusion despite complete recanalization as surrogate for impaired microvascular reperfusion (IMR) has varied widely among clinical studies, possibly due to differences in i) definition of complete recanalization, with only recent Thrombolysis in Cerebral Infarction (TICI) grading schemes allowing distinction between complete (TICI3) and partial recanalization with distal occlusions (TICI2c); ii) operational definition of IMR; and iii) consideration of potential alternative causes for hypoperfusion, notably carotid stenosis, re-occlusion and post-thrombectomy hemorrhage. We performed a systematic review to identify clinical studies that carried out brain perfusion imaging within 72 hrs post-thrombectomy for anterior circulation stroke and reported hypoperfusion rates separately for TICI3 and TICI2c grades. Authors were contacted if this data was missing. We identified eight eligible articles, altogether reporting 636 patients. The incidence of IMR after complete recanalization (i.e., TICI3) tended to decrease with the number of considered alternative causes of hypoperfusion: range 12.5-42.9%, 0-31.6% and 0-9.1% in articles that considered none, two or all three causes, respectively. No study reported the impact of IMR on functional outcome separately for TICI-3 patients. Based on this systematic review, IMR in true complete recanalization appears relatively rare, and reported incidence highly depends on definition used and consideration of confounding factors.
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Affiliation(s)
- Adrien ter Schiphorst
- Department of Neurology, University Hospital of Montpellier, CHU Gui de Chauliac, Montpellier, France
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Université Paris Cité, Inserm U1266, FHU NeuroVasc, Paris, France
| | - Wagih Ben Hassen
- Department of Neuroradiology, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Université Paris Cité, Inserm U1266, Paris, France
| | - Catherine Oppenheim
- Department of Neuroradiology, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Université Paris Cité, Inserm U1266, Paris, France
| | - Jean-Claude Baron
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, Hôpital Sainte-Anne, Université Paris Cité, Inserm U1266, FHU NeuroVasc, Paris, France
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11
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Al-Salihi MM, Saha R, Ayyad A, Al-Jebur MS, Al-Salihi Y, Roy A, Dalal SS, Qureshi AI. General Anesthesia Versus Conscious Sedation for Acute Ischemic Stroke Endovascular Therapy: A Meta Analysis of Randomized Controlled Trials. World Neurosurg 2024; 181:161-170.e2. [PMID: 37931874 DOI: 10.1016/j.wneu.2023.10.143] [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: 07/17/2023] [Revised: 10/30/2023] [Accepted: 10/31/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Endovascular thrombectomy (E.V.T.) is the primary treatment for acute ischemic stroke (AIS). Nevertheless, the optimal choice of anesthetic modality during E.V.T. remains uncertain. This systematic review and meta-analysis aim to summarize existing literature from randomized controlled trials (RCTs) to guide the selection of the most appropriate anesthetic modality for AIS patients undergoing E.V.T. METHODS By a thorough search strategy, RCTs comparing general anesthesia (G.A.) and conscious sedation (C.S.) in E.V.T. for AIS patients were identified. Eligible studies were independently screened, and relevant data were extracted. The analysis employed pooled risk ratio for dichotomous outcomes and the mean difference for continuous ones. RCTs quality was assessed using the Cochrane Risk of Bias assessment tool 1. RESULTS In the functional independence outcome (mRS scores 0-2), the pooled analysis did not favor either G.A. or C.S. arms, with an RR of 1.10 [0.95, 1.27] (P = 0.19). Excellent (mRS 0-1) and poor (≥3) recovery outcomes did not significantly differ between G.A. and C.S. groups, with RR values of 1.03 [0.80, 1.33] (P = 0.82) and 0.93 [0.84, 1.03] (P = 0.16), respectively. Successful recanalization significantly favored G.A. over C.S. (RR 1.13 [1.07, 1.20], P > 0.001). CONCLUSIONS G.A. had superior recanalization rates in AIS patients undergoing endovascular therapy, but functional outcomes, mortality, and NIHSS scores were similar. Secondary outcomes showed no significant differences, except for a higher risk of hypotension with G.A. More trials are required to determine the optimal anesthesia approach for thrombectomy in AIS patients.
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Affiliation(s)
- Mohammed Maan Al-Salihi
- Department of Neurological Surgery, School of Medicine and Public Health, University of Wisconsin, Madison, Wisconsin, USA.
| | - Ram Saha
- Department of Neurology, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Ali Ayyad
- Department of Neurosurgery, Hamad General Hospital, Doha, Qatar; Department of Neurosurgery, Saarland University Hospital, Homburg, Germany
| | | | | | - Anil Roy
- Department of Neurosurgery, School of Medicine, Virginia Commonwealth University, Richmond, Virginia, USA
| | - Shamser Singh Dalal
- Department of Radiology, School of Medicine, University of Virginia, Charlottesville, Virginia, USA
| | - Adnan I Qureshi
- Zeenat Qureshi Stroke Institute and University of Missouri, Columbia, Missouri, USA
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12
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Di Donna A, Muto G, Giordano F, Muto M, Guarnieri G, Servillo G, De Mase A, Spina E, Leone G. Diagnosis and management of tandem occlusion in acute ischemic stroke. Eur J Radiol Open 2023; 11:100513. [PMID: 37609048 PMCID: PMC10440394 DOI: 10.1016/j.ejro.2023.100513] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Revised: 07/31/2023] [Accepted: 08/07/2023] [Indexed: 08/24/2023] Open
Abstract
Approximately 20-30% of patients with acute ischemic stroke, caused by large intracranial vessel occlusion, have a tandem lesion, defined as simultaneous presence of high-grade stenosis or occlusion of the cervical internal carotid artery and thromboembolic occlusion of the intracranial terminal internal carotid artery or its branches, usually the middle cerebral artery. Patients with tandem lesions have usually worse outcomes than patients with single intracranial occlusions, and intravenous thrombolysis is less effective in these patients. Although endovascular thrombectomy is currently a cornerstone therapy in the management of acute ischemic stroke due to large vessel occlusion, the optimal management of extracranial carotid lesions in tandem occlusion remains controversial. Acute placement of a stent in the cervical carotid artery lesion is the most used therapeutic strategy compared with stented balloon angioplasty and thrombectomy alone without carotid artery revascularization; however, treatment strategies in these patients are often more complex than with single occlusion, so treatment decisions can change based on clinical and technical considerations. The aim of this review is to analyze the results of different studies and trials, investigating the periprocedural neurointerventional management of patients with tandem lesions and the safety, efficacy of the different technical strategies available as well as their impact on the clinical outcome in these patients, to strengthen current recommendations and thus optimize patient care.
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Affiliation(s)
- Antonio Di Donna
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Gianluca Muto
- Division of Diagnostic and Interventional Neuroradiology, Geneva University Hospitals, 1205 Geneva, Switzerland
| | - Flavio Giordano
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Massimo Muto
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Gianluigi Guarnieri
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Giovanna Servillo
- Unit of Neurorology and Stroke Unit, Department of Emergency and Acceptance, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Antonio De Mase
- Unit of Neurorology and Stroke Unit, Department of Emergency and Acceptance, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Emanuele Spina
- Unit of Neurorology and Stroke Unit, Department of Emergency and Acceptance, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
| | - Giuseppe Leone
- Unit of Interventional Neuroradiology, Department of Advanced Diagnostic and Therapeutic Technologies, A.O.R.N. Antonio Cardarelli Hospital, Via Cardarelli 1, Naples 80131, Italy
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13
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Keil F, Stahn S, Reitz SC, Lieschke F, du Mesnil de Rochemont R, Hattingen E, Berkefeld J. Elective carotid stenting fulfills quality standards defined in guidelines. ROFO-FORTSCHR RONTG 2023. [PMID: 37963550 DOI: 10.1055/a-2175-4029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2023]
Abstract
PURPOSE According to evidence from randomized trials and current guidelines, elective carotid artery stenting (CAS) is still considered second-line therapy compared with carotid endarterectomy (CEA). However, the publication of randomized comparative trials for patients with symptomatic stenoses occurred well over 10 years ago. In view of problems regarding German quality assurance when differentiating elective from emergency interventions and low case numbers for CAS indications, it seemed reasonable to present neurologically controlled CAS results and to investigate whether elective CAS consistently fulfills the strict quality criteria and what differences exist with respect to emergency CAS interventions in acute ischemic stroke. MATERIALS AND METHODS Between 01/2012 and 07/2022, 141 elective CAS procedures were performed to treat patients with symptomatic (n = 123) and asymptomatic (n = 18) stenoses. Protection by a filter system was achieved in 134 of these elective procedures (95 %). During the same period, 158 patients underwent carotid stenting for acute stroke. Complication rates were determined using neurologically controlled data. CAS-related complications (stent thrombosis, stent-associated vascular damage, thromboembolism, and symptomatic hemorrhage) were extracted from emergency interventions, and clinical outcome (NIHSS progression) was determined during the inpatient stay. RESULTS The rate of stroke and death determined during the inpatient stay for elective symptomatic patients was 0.8 %. Early treatment within the first 7 days after the index event, age > 70 years, and operator experience were not significant risk factors for the occurrence of complications. No complications were observed after CAS of asymptomatic stenoses. The procedure-related complication rate for emergency procedures was 7.8 %, which was significantly higher than after elective CAS, as expected (p < 0.006). CONCLUSION Even with limited indications and limited case numbers, compliance with the strict quality criteria of the current S3 Guideline 2022 for elective CAS interventions is possible for both symptomatic and asymptomatic stenoses in an experienced center. Emergency CAS interventions have significantly higher complication rates under other conditions and must be considered separately with regard to quality assurance. KEY POINTS · Elective carotid stenting fulfills the strict quality criteria of the current S3 guideline 2022.. · Emergency carotid stenting has significantly higher complication rates than elective procedures.. · Elective and emergency carotid stenting cannot be meaningfully compared.. CITATION FORMAT · Keil F, Stahn S, Reitz SC et al. Elective carotid stenting fulfills quality standards defined in guidelines. Fortschr Röntgenstr 2023; DOI: 10.1055/a-2175-4029.
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Affiliation(s)
- Fee Keil
- Neuroradiology, Hospital of the Goethe University Frankfurt Institute of Neuroradiology, Frankfurt am Main, Germany
| | - Simon Stahn
- Radiology, Hospital Nordwest Frankfurt, Germany
| | - Sarah Christina Reitz
- Neurosurgery, Hospital of the Goethe University Frankfurt Center of Neurology and Neurosurgery, Frankfurt am Main, Germany
| | - Franziska Lieschke
- Neurology, Hospital of the Goethe University Frankfurt Center of Neurology and Neurosurgery, Frankfurt am Main, Germany
| | | | - Elke Hattingen
- Neuroradiology, Hospital of the Goethe University Frankfurt Institute of Neuroradiology, Frankfurt am Main, Germany
| | - Joachim Berkefeld
- Neuroradiology, Hospital of the Goethe University Frankfurt Institute of Neuroradiology, Frankfurt am Main, Germany
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14
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Gao J, Jing Z, Huang S, Yang J, Guan M, Zhang S, Li H, Li Y, Lu K, Yang M, Huang L. Comparison of clinical outcomes in patients with acute ischemic stroke who underwent endovascular treatment using different perfusion modalities: a real-world multicenter study. Front Neurol 2023; 14:1275715. [PMID: 37954641 PMCID: PMC10634531 DOI: 10.3389/fneur.2023.1275715] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Accepted: 09/28/2023] [Indexed: 11/14/2023] Open
Abstract
Background Advanced perfusion modalities are increasingly popular for various diseases. However, few studies have focused on contrasting perfusion patterns. Objective This study aimed to compare the time efficiency and clinical outcomes of patients with acute ischemic stroke (AIS) who underwent endovascular treatment (EVT) before one-stop arterial spin labeling (ASL) and computed tomography perfusion (CTP) protocols. Methods This study retrospectively included 326 patients with AIS who had accepted EVT within 24 h of onset from four comprehensive stroke centers between October 2017 and September 2022. After 1:1 matching of the propensity scores, 202 patients were separated into two groups: the ASL group (n = 101) and the CTP group (n = 101). Results Functional independence at 90 days (modified Rankin Scale [mRS] 0-2; p = 0.574), onset-to-puncture time (p = 0.231), door-to-puncture time (p = 0.136), and door-to-perfusion time (p = 0.646) were not significantly different between the two groups. The proportion of EVT complications (31.7% in the ASL group vs. 14.9% in the CTP group, p = 0.005) and symptomatic intracranial hemorrhage (sICH) at 24 h (23.8% in the ASL group vs. 9.9% in the CTP group, p = 0.008) in the CTP group were lower than the ASL group. The ischemic core volume was a common predictor of favorable outcomes in both ASL (p < 0.001) and CTP (p < 0.001) groups. Conclusion There were no significant differences in time efficiency and efficacy outcomes between the two groups of patients receiving one-stop ASL and CTP. The proportion of sICH at 24 h and EVT complications of patients in the CTP group was lower than the ASL group. The ischemic core volume was an independent predictor for favorable outcomes.
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Affiliation(s)
- Jiali Gao
- Department of Neurology, Clinical Neuroscience Institute, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Zhen Jing
- Department of Neurology, Clinical Neuroscience Institute, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Shengming Huang
- Department of Neurology, Clinical Neuroscience Institute, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Jiajie Yang
- Department of Neurology, Clinical Neuroscience Institute, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Min Guan
- Department of Neurology, Clinical Neuroscience Institute, First Affiliated Hospital of Jinan University, Guangzhou, China
| | - Shijun Zhang
- Department of Neurology, The Fourth Affiliated Hospital of Guangzhou Medical University, Guangzhou, China
| | - Hao Li
- Department of Neurology, Maoming People’s Hospital, Maoming, China
| | - Yongxin Li
- Department of Neurology, Shunde Hospital of Southern Medical University, Foshan, China
| | - Kui Lu
- Department of Neurology, Zhongshan People’s Hospital, Zhongshan, China
| | - Ming Yang
- Neuroblem Limited Company, Shanghai, China
| | - Li’an Huang
- Department of Neurology, Clinical Neuroscience Institute, First Affiliated Hospital of Jinan University, Guangzhou, China
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15
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Rodriguez-Calienes A, Galecio-Castillo M, Farooqui M, Hassan AE, Jumaa MA, Divani AA, Ribo M, Abraham M, Petersen NH, Fifi J, Guerrero WR, Malik AM, Siegler JE, Nguyen TN, Yoo AJ, Linares G, Janjua N, Quispe-Orozco D, Tekle WG, Alhajala H, Ikram A, Rizzo F, Qureshi A, Begunova L, Matsouka S, Vigilante N, Salazar-Marioni S, Abdalkader M, Gordon W, Soomro J, Turabova C, Vivanco-Suarez J, Mokin M, Yavagal DR, Jovin T, Sheth S, Ortega-Gutierrez S. Safety Outcomes of Mechanical Thrombectomy Versus Combined Thrombectomy and Intravenous Thrombolysis in Tandem Lesions. Stroke 2023; 54:2522-2533. [PMID: 37602387 PMCID: PMC10599264 DOI: 10.1161/strokeaha.123.042966] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2023] [Accepted: 07/11/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND We aimed to describe the safety and efficacy of mechanical thrombectomy (MT) with or without intravenous thrombolysis (IVT) for patients with tandem lesions and whether using intraprocedural antiplatelet therapy influences MT's safety with IVT treatment. METHODS This is a subanalysis of a pooled, multicenter cohort of patients with acute anterior circulation tandem lesions treated with MT from 16 stroke centers between January 2015 and December 2020. Primary outcomes included symptomatic intracranial hemorrhage (sICH) and parenchymal hematoma type 2. Additional outcomes included hemorrhagic transformation, successful reperfusion (modified Thrombolysis in Cerebral Infarction score 2b-3), complete reperfusion (modified Thrombolysis in Cerebral Infarction score 3), favorable functional outcome (90-day modified Rankin Scale score 0-2), excellent functional outcome (90-day modified Rankin Scale score 0-1), in-hospital mortality, and 90-day mortality. RESULTS Of 691 patients, 512 were included (218 underwent IVT+MT and 294 MT alone). There was no difference in the risk of sICH (adjusted odds ratio [aOR], 1.22 [95% CI, 0.60-2.51]; P=0.583), parenchymal hematoma type 2 (aOR, 0.99 [95% CI, 0.47-2.08]; P=0.985), and hemorrhagic transformation (aOR, 0.95 [95% CI, 0.62-1.46]; P=0.817) between the IVT+MT and MT alone groups after adjusting for confounders. Administration of IVT was associated with an increased risk of sICH in patients who received intravenous antiplatelet therapy (aOR, 3.04 [95% CI, 0.99-9.37]; P=0.05). The IVT+MT group had higher odds of a 90-day modified Rankin Scale score 0 to 2 (aOR, 1.72 [95% CI, 1.01-2.91]; P=0.04). The odds of successful reperfusion, complete reperfusion, 90-day modified Rankin Scale score 0 to 1, in-hospital mortality, or 90-day mortality did not differ between the IVT+MT versus MT alone groups. CONCLUSIONS Our study showed that the combination of IVT with MT for tandem lesions did not increase the overall risk of sICH, parenchymal hematoma type 2, or overall hemorrhagic transformation independently of the cervical revascularization technique used. However, intraprocedural intravenous antiplatelet therapy during acute stent implantation might be associated with an increased risk of sICH in patients who received IVT before MT. Importantly, IVT+MT treatment was associated with a higher rate of favorable functional outcomes at 90 days.
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Affiliation(s)
- Aaron Rodriguez-Calienes
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City
- Department of Neuroscience, Clinical Effectiveness and Public Health Research Group, Universidad Científica del Sur, Lima, Peru
| | | | - Mudassir Farooqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City
| | - Ameer E. Hassan
- Department of Neurology, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX
| | | | - Afshin A. Divani
- Department of Neurology, University of New Mexico Health Science Center, Albuquerque
| | - Marc Ribo
- Department of Neurology, Hospital Vall d’Hebron, Barcelona, Spain
| | - Michael Abraham
- Department of Neurology, University of Kansas Medical Center
| | - Nils H. Petersen
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Johanna Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York
| | - Waldo R. Guerrero
- Department of Neurology and Brain Repair, University of South Florida, Tampa
| | - Amer M. Malik
- Department of Neurology, University of Miami Miller School of Medicine, FL
| | - James E. Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ
- Cooper Medical School of Rowan University, Candem, NJ
| | | | | | | | - Nazli Janjua
- Asia Pacific Comprehensive Stroke Institute, Pomona Valley Hospital Medical Center, CA
| | - Darko Quispe-Orozco
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City
| | - Wondwossen G. Tekle
- Department of Neurology, Valley Baptist Medical Center/University of Texas Rio Grande Valley, Harlingen, TX
| | | | - Asad Ikram
- Department of Neurology, University of New Mexico Health Science Center, Albuquerque
| | - Federica Rizzo
- Department of Neurology, Hospital Vall d’Hebron, Barcelona, Spain
| | - Abid Qureshi
- Department of Neurology, University of Kansas Medical Center
| | - Liza Begunova
- Department of Neurology, Yale University School of Medicine, New Haven, CT
| | - Stavros Matsouka
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York
| | | | | | | | - Weston Gordon
- Department of Neurology, Saint Louis University, St. Louis, MO
| | | | - Charoskon Turabova
- Asia Pacific Comprehensive Stroke Institute, Pomona Valley Hospital Medical Center, CA
| | - Juan Vivanco-Suarez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City
| | - Maxim Mokin
- Department of Neurology and Brain Repair, University of South Florida, Tampa
| | - Dileep R. Yavagal
- Department of Neurology, University of Miami Miller School of Medicine, FL
| | - Tudor Jovin
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ
| | - Sunil Sheth
- Department of Neurology, UT Health McGovern Medical School, Houston, TX
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Neurosurgery & Radiology, University of Iowa Hospitals and Clinics, Iowa City
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16
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Meyer L, Politi M, Alexandrou M, Roth C, Kastrup A, Mpotsaris A, Hanning U, Flottmann F, Brekenfeld C, Deb-Chatterji M, Thomalla G, Kniep H, Faizy TD, Bechstein M, Broocks G, Herzberg M, Feil K, Kellert L, Dorn F, Zeleňák K, Fiehler J, Papanagiotou P. Endovascular treatment of acute tandem lesions in patients with mild anterior circulation stroke. J Neurointerv Surg 2023; 15:e136-e141. [PMID: 36028317 DOI: 10.1136/jnis-2022-019239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2022] [Accepted: 08/06/2022] [Indexed: 11/04/2022]
Abstract
BACKGROUND In patients with mild strokes the risk-benefit ratio of endovascular treatment (EVT) for tandem lesions has yet to be evaluated outside of current guideline recommendations. This study investigates the frequency as well as procedural and safety outcomes in daily clinical practice. METHODS Using data from the German Stroke Registry-Endovascular Treatment (GSR-ET) we analyzed patients with anterior circulation stroke due to tandem-lesions and mild deficits. These patients were defined as ≤5 on the National Institutes of Health Stroke Scale (NIHSS). Recanalization was assessed with the modified Thrombolysis in Cerebral Infarction Scale (mTICI). Early neurological and long-term functional outcomes were assessed with the NIHSS change and modified Rankin scale (mRS), respectively. Safety assessment included periprocedural complications and the rate of symptomatic intracerebral hemorrhage (sICH). RESULTS A total of 61 patients met the inclusion criteria and were treated endovascularly for tandem lesions. The median age was 68 (IQR:59-76) and 32.9% (20) were female. Patients were admitted to the hospital with a median NIHSS score of 4 (IQR:2-5) and a median Alberta Stroke Programme Early CT Score (ASPECTS) of 9 (IQR:8-10). Successful recanalization (mTICI 2b-3) was observed in 86.9% (53). NIHSS decreased non-significantly (p=0.382) from baseline to two points (IQR:1-9) at discharge. Excellent (mRS≤1) and favorable (mRS≤2) long-term functional outcome at 90-days was 55.8% (29) and 69.2% (36), respectively. Mortality rates at 90-days were 9.6% (5) and sICH occurred in 8.2% (5). CONCLUSIONS EVT for tandem lesions in patients with mild anterior circulation stroke appears to be feasible but may lead to increased rates of sICH. Further studies comparing endovascular with best medical treatment (BMT) especially investigating the risk of periprocedural hemorrhagic complications, are needed.
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Affiliation(s)
- Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Maria Politi
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte gGmbH, Bremen, Germany
- Interventional Radiology Unit, Evangelismos General Hospital, Athens, Greece
| | - Maria Alexandrou
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte gGmbH, Bremen, Germany
| | - Christian Roth
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte gGmbH, Bremen, Germany
| | - Andreas Kastrup
- Department of Neurology, Hospital Bremen-Mitte gGmbH, Bremen, Germany
| | - Anastasios Mpotsaris
- Department of Diagnostic and Interventional Neuroradiology, University Hospital of Magdeburg, Magdeburg, Germany
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Fabian Flottmann
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Caspar Brekenfeld
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Milani Deb-Chatterji
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Goetz Thomalla
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Helge Kniep
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Tobias D Faizy
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Matthias Bechstein
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Moriz Herzberg
- Department of Radiology, University Hospital Würzburg, Würzburg, Germany
- Institute of Neuroradiology, Ludwig Maximilians Universität, München, Germany
| | - Katharina Feil
- Department of Neurology, Ludwig Maximilians Universität, München, Germany
- Department of Neurology and Stroke, Eberhard-Karls University, Tübingen, Germany
| | - Lars Kellert
- Department of Neurology, Ludwig Maximilians Universität, München, Germany
| | - Franziska Dorn
- Institute of Neuroradiology, Ludwig Maximilians Universität, München, Germany
- Department of Neuroradiology, University Hospital Bonn, Bonn, Germany
| | - Kamil Zeleňák
- Clinic of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Martin, Slovakia
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Panagiotis Papanagiotou
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte gGmbH, Bremen, Germany
- Department of Radiology, Areteion University Hospital, National and Kapodistrian University of Athens, Athens, Greece
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17
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Rodriguez-Calienes A, Hassan AE, Siegler JE, Galecio-Castillo M, Farooqui M, Jumaa MA, Janjua N, Divani AA, Ribo M, Abraham M, Petersen NH, Fifi J, Guerrero WR, Malik AM, Nguyen TN, Sheth S, Yoo AJ, Linares G, Lu Y, Vivanco-Suarez J, Ortega-Gutierrez S. Mechanical thrombectomy beyond 24 hours from last known well in tandem lesions: A multicenter cohort study. Interv Neuroradiol 2023:15910199231196960. [PMID: 37642978 DOI: 10.1177/15910199231196960] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/31/2023] Open
Abstract
BACKGROUND While recent studies suggest a benefit of mechanical thrombectomy (MT) for the treatment of patients with isolated large vessel occlusions presenting after 24 hours from the last known well (LKW), the effect of MT for acute cervical tandem lesions (TLs) beyond 24 hours remains unknown. We aimed to evaluate the safety and effectiveness of MT beyond 24 hours of LKW in patients with TLs. METHODS We conducted a subanalysis study of patients with anterior circulation TL enrolled in a large, multicenter registry between January 2015 and December 2020. Patients were divided into 2 groups: MT beyond 24 hours versus MT 0-24-hour window. Outcomes of interest were functional independence (90-day modified Rankin scale 0-2), complete reperfusion (modified thrombolysis in cerebral infarction 3), delta NIH Stroke Scale (NIHSS), symptomatic intracranial hemorrhage (sICH), parenchymal hematoma 2 (PH2), in-hospital mortality, and 90-day mortality. Inverse probability of treatment weighting (IPTW) was used to balance the groups. RESULTS Overall, 589 participants were included, with 33 treated beyond 24 hours and 556 treated in the 0-24-hour window. After IPTW, we found no significant difference in the rates of achieving functional independence (odds ratio (OR) = 0.51; 95% confidence interval (CI) 0.22-1.16; p = 0.108), complete reperfusion (OR = 1.35; 95% CI 0.60-3.05; p = 0.464), sICH (OR = 1.96; 95% CI 0.37-10.5; p = 0.429), delta NIHSS (β = -3.61; 95% CI -8.11 to 0.87; p = 0.114), PH2 (OR = 1.46; 95% CI 0.29-7.27; p = 0.642), in-hospital mortality (OR = 1.74; 95% CI 0.52-5.86; p = 0.370), or 90-day mortality (OR = 1.37; 95% CI 0.49-3.83; p = 0.544) across both time windows. CONCLUSIONS Our results suggest that MT appears to benefit patients with TLs beyond 24 hours from LKW. Future prospective studies are warranted.
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Affiliation(s)
- Aaron Rodriguez-Calienes
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
- Neuroscience, Clinical Effectiveness and Public Health Research Group, Universidad Cientifica del Sur, Lima, Peru
| | - Ameer E Hassan
- Department of Neurology, Valley Baptist Medical Center / University of Texas Rio Grande Valley, Harlingen, TX, USA
| | - James E Siegler
- Cooper Neurological Institute, Cooper University Hospital, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ, USA
| | | | - Mudassir Farooqui
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | | | - Nazli Janjua
- Asia Pacific Comprehensive Stroke Institute, Pomona Valley Hospital Medical Center, Pomona, CA, USA
| | - Afshin A Divani
- Department of Neurology, University of New Mexico Health Science Center, Albuquerque, NM, USA
| | - Marc Ribo
- Department of Neurology, Hospital Vall d'Hebron, Barcelona, Spain
| | - Michael Abraham
- Department of Neurology, University of Kansas Medical Center, Kansas City, KS, USA
| | - Nils H Petersen
- Department of Neurology, Yale University School of Medicine, New Haven, CT, USA
| | - Johanna Fifi
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Waldo R Guerrero
- Department of Neurology and Brain Repair, University of South Florida, Tampa, FL, USA
| | - Amer M Malik
- Department of Neurology, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Thanh N Nguyen
- Department of Radiology, Boston Medical Center, Boston, MA, USA
| | - Sunil Sheth
- Department of Neurology, UT Health McGovern Medical School, Houston, TX, USA
| | - Albert J Yoo
- Texas Stroke Institute, Dallas-Fort Worth, TX, USA
| | | | - Yujing Lu
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Juan Vivanco-Suarez
- Department of Neurology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
| | - Santiago Ortega-Gutierrez
- Department of Neurology, Neurosurgery & Radiology, University of Iowa Hospitals and Clinics, Iowa City, IA, USA
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18
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Raha O, Hall C, Malik A, D'Anna L, Lobotesis K, Kwan J, Banerjee S. Advances in mechanical thrombectomy for acute ischaemic stroke. BMJ MEDICINE 2023; 2:e000407. [PMID: 37577026 PMCID: PMC10414072 DOI: 10.1136/bmjmed-2022-000407] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 05/25/2023] [Indexed: 08/15/2023]
Abstract
Mechanical thrombectomy is a ground breaking treatment for acute ischaemic stroke caused by occlusion of a large vessel. Its efficacy over intravenous thrombolysis has been proven in multiple trials with a lower number needed to treat than percutaneous coronary intervention for acute myocardial infarction. However, access to this key treatment modality remains limited with a considerable postcode lottery across the UK and many parts of the world. The evidence base for mechanical thrombectomy dates back to 2015. Since then, there have been important advances in establishing and widening the criteria for treatment. This narrative review aims to summarise the current evidence base and latest advances for physicians and academics with an interest in recanalisation treatments for acute ischaemic stroke.
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Affiliation(s)
- Oishik Raha
- Imperial Stroke Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Charles Hall
- Interventional Neuroradiology, Imperial College Healthcare NHS Trust, London, UK
| | - Abid Malik
- Imperial Stroke Centre, Imperial College Healthcare NHS Trust, London, UK
| | - Lucio D'Anna
- Imperial Stroke Centre, Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
| | - Kyriakos Lobotesis
- Interventional Neuroradiology, Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
| | - Joseph Kwan
- Imperial Stroke Centre, Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
| | - Soma Banerjee
- Imperial Stroke Centre, Imperial College Healthcare NHS Trust, London, UK
- Imperial College London, London, UK
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19
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Yogendrakumar V, Churilov L, Mitchell PJ, Kleinig TJ, Yassi N, Thijs V, Wu T, Shah D, Bailey P, Dewey HM, Choi PMC, Ma A, Wijeratne T, Garcia-Esperon C, Cloud G, Chandra RV, Cordato DJ, Yan B, Sharma G, Desmond PM, Parsons MW, Donnan GA, Davis SM, Campbell BCV. Safety and Efficacy of Tenecteplase and Alteplase in Patients With Tandem Lesion Stroke: A Post Hoc Analysis of the EXTEND-IA TNK Trials. Neurology 2023; 100:e1900-e1911. [PMID: 36878701 PMCID: PMC10159769 DOI: 10.1212/wnl.0000000000207138] [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: 07/06/2022] [Accepted: 01/18/2023] [Indexed: 03/08/2023] Open
Abstract
BACKGROUND AND OBJECTIVES The safety and efficacy of tenecteplase (TNK) in patients with tandem lesion (TL) stroke is unknown. We performed a comparative analysis of TNK and alteplase in patients with TLs. METHODS We first compared the treatment effect of TNK and alteplase in patients with TLs using individual patient data from the EXTEND-IA TNK trials. We evaluated intracranial reperfusion at initial angiographic assessment and 90-day modified Rankin scale (mRS) with ordinal logistic and Firth regression models. Because 2 key outcomes, mortality and symptomatic intracranial hemorrhage (sICH), were few in number among those who received alteplase in the EXTEND-IA TNK trials, we generated pooled estimates for these outcomes by supplementing trial data with estimates of incidence obtained through a meta-analysis of studies identified in a systematic review. We then calculated unadjusted risk differences to compare the pooled estimates for those receiving alteplase with the incidence observed in the trial among those receiving TNK. RESULTS Seventy-one of 483 patients (15%) in the EXTEND-IA TNK trials possessed a TL. In patients with TLs, intracranial reperfusion was observed in 11/56 (20%) of TNK-treated patients vs 1/15 (7%) alteplase-treated patients (adjusted odds ratio 2.19; 95% CI 0.28-17.29). No significant difference in 90-day mRS was observed (adjusted common odds ratio 1.48; 95% CI 0.44-5.00). A pooled study-level proportion of alteplase-associated mortality and sICH was 0.14 (95% CI 0.08-0.21) and 0.09 (95% CI 0.04-0.16), respectively. Compared with a mortality rate of 0.09 (95% CI 0.03-0.20) and an sICH rate of 0.07 (95% CI 0.02-0.17) in TNK-treated patients, no significant difference was observed. DISCUSSION Functional outcomes, mortality, and sICH did not significantly differ between patients with TLs treated with TNK and those treated with alteplase. CLASSIFICATION OF EVIDENCE This study provides Class III evidence that TNK is associated with similar rates of intracranial reperfusion, functional outcome, mortality, and sICH compared with alteplase in patients with acute stroke due to TLs. However, the CIs do not rule out clinically important differences. TRIAL REGISTRATION INFORMATION: clinicaltrials.gov/ct2/show/NCT02388061; clinicaltrials.gov/ct2/show/NCT03340493.
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Affiliation(s)
- Vignan Yogendrakumar
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia.
| | - Leonid Churilov
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Peter J Mitchell
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Timothy J Kleinig
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Nawaf Yassi
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Vincent Thijs
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Teddy Wu
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Darshan Shah
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Peter Bailey
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Helen M Dewey
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Philip M C Choi
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Alice Ma
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Tissa Wijeratne
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Carlos Garcia-Esperon
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Geoffrey Cloud
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Ronil V Chandra
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Dennis J Cordato
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Bernard Yan
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Gagan Sharma
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Patricia M Desmond
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Mark W Parsons
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Geoffrey A Donnan
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Stephen M Davis
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
| | - Bruce C V Campbell
- From the Department of Medicine and Neurology (V.Y., L.C., N.Y., B.Y., G.S., M.W.P., G.A.D., S.M.D., B.C.V.C.), Melbourne Brain Centre at the Royal Melbourne Hospital, Parkville; Melbourne Medical School (L.C., V.T.), University of Melbourne, Heidelberg; Department of Radiology (P.J.M., B.C.V.C.), Royal Melbourne Hospital, University of Melbourne, Parkville; Department of Neurology (T.J.K., B.Y., P.M.D.), Royal Adelaide Hospital; Population Health and Immunity Division (N.Y.), The Walter and Eliza Hall Institute of Medical Research, Parkville; Florey Institute of Neuroscience and Mental Health (V.T.), University of Melbourne, Parkville, Australia; Department of Neurology (T. Wu), Christchurch Hospital, New Zealand; Department of Neurology (D.S.), Princess Alexandra Hospital, Brisbane; Department of Neurology (P.B.), Gold Coast University Hospital, Southport; Department of Neurosciences (H.M.D., P.M.C.C.), Eastern Health and Eastern Health Clinical School, Monash University, Clayton; Royal North Shore Hospital (A.M.), New South Wales; Department of Medicine and Neurology (T. Wijeratne), Melbourne Medical School, The University of Melbourne and Western Health, Sunshine Hospital, St Albans; Department of Neurology (C.G.-E.), John Hunter Hospital, Newcastle, New South Wales; Department of Neurology (G.C.), Alfred Hospital, Melbourne; Department of Neuroscience (G.C.), Central Clinical School, Monash University, Melbourne; NeuroInterventional Radiology Unit (R.V.C.), Monash Health, Monash University; and Department of Neurology (D.J.C., M.W.P.), Liverpool Hospital, University of New South Wales, Sydney, Australia
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Sepp D, Berndt M, Mönch S, Ikenberg B, Wunderlich S, Maegerlein C, Zimmer C, Boeckh-Behrens T, Friedrich B. Outcome and risk of hemorrhage in patients with tandem lesions after endovascular treatment: A propensity score-matched case-control study. Heliyon 2023; 9:e14508. [PMID: 36942245 PMCID: PMC10024127 DOI: 10.1016/j.heliyon.2023.e14508] [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: 09/09/2022] [Revised: 02/26/2023] [Accepted: 03/08/2023] [Indexed: 03/16/2023] Open
Abstract
Objectives Endovascular treatment of acute stroke patients with large vessel occlusions is well established. But tandem lesions of the internal carotid artery and the intracranial anterior circulation remain a challenge regarding the technical conditions and the putative higher risk of hemorrhage due to often required antiplatelet therapy.This study aims to evaluate the clinical outcome and the risk of hemorrhage after endovascular treatment of tandem lesions, with special regard to the periprocedural antiplatelet regimen. Materials and Methods In this retrospective study, we included 63 consecutive stroke patients with endovascular treated tandem lesions. One hundred eleven patients with a solitary intracranial occlusion were matched using a "propensity score-matched analysis" with the covariates sex, age, wake-up stroke, iv-thrombolysis and NIHSS. Results Rates of successful recanalization (mTICI 2b/3) and periprocedural complications were equal in both groups (P = 0.19; P = 0.35). The rate of good clinical outcome (mRS≤2) was similar, and the incidence of symptomatic hemorrhages was not significantly different (7.9% tandem lesions vs. 5.4% isolated intracranial occlusion, P = 0.51). Even intensified antiplatelet therapy in patients with tandem lesions did not increase the rate of symptomatic intracranial hemorrhages (P = 0.87). Conclusions Clinical outcome and symptomatic intracranial hemorrhages did not differ significantly between endovascular treated patients with tandem lesions and matched patients with solitary intracranial occlusions, regardless of the antiplatelet regimen. Therefore, the complex technical requirements for recanalization of a tandem lesion and the putative higher risk should not result in reluctant treatment that would decrease the chance of a good clinical outcome.
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Affiliation(s)
- Dominik Sepp
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
- Corresponding author. Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, Technical University of Munich, Ismaninger Straße 22, 81675, Munich, Germany.
| | - Maria Berndt
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Sebastian Mönch
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Benno Ikenberg
- Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Silke Wunderlich
- Department of Neurology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Claus Zimmer
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Tobias Boeckh-Behrens
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
| | - Benjamin Friedrich
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University of Munich, Munich, Germany
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21
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Enriquez BAB, Nome T, Nome CG, Tennøe B, Lund CG, Beyer MK, Skjelland M, Aamodt AH. Predictors of outcome after endovascular treatment for tandem occlusions: a single center retrospective analysis. BMC Neurol 2023; 23:82. [PMID: 36849925 PMCID: PMC9969668 DOI: 10.1186/s12883-023-03127-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 02/15/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND The endovascular treatment procedure in tandem occlusions (TO) is complex compared to single occlusion (SO) and optimal management remains uncertain. The aim of this study was to identify clinical and procedural factors that may be associated to efficacy and safety in the management of TO and compare functional outcome in TO and SO stroke patients. METHODS This is a retrospective single center study of medium (MeVO) and large vessel occlusion (LVO) of the anterior circulation. Clinical, imaging, and interventional data were analyzed to identify predictive factors for symptomatic intracranial hemorrhage (sICH) and functional outcome after endovascular treatment (EVT) in TO. Functional outcome in TO and SO patients was compared. RESULTS Of 662 anterior circulation stroke patients with MeVO and LVO stroke, 90 (14%) had TO. Stenting was performed in 73 (81%) of TO patients. Stent thromboses occurred in 8 (11%) patients. Successful reperfusion with modified thrombolysis in cerebral infarction (mTICI) ≥ 2b was achieved in 82 (91%). SICH occurred in seven (8%). The strongest predictors for sICH were diabetes mellitus and number of stent retriever passes. Good functional clinical outcome (mRS ≤ 2) at 90-day follow up was similar in TO and SO patients (58% vs 59% respectively). General anesthesia (GA) was associated with good functional outcome whereas hemorrhage in the infarcted tissue, lower mTICI score and history of smoking were associated with poor outcome. CONCLUSIONS The risk of sICH was increased in patients with diabetes mellitus and those with extra stent-retriever attempts. Functional clinical outcomes in patients with TO were comparable to patients with SO.
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Affiliation(s)
| | - Terje Nome
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway.
| | - Cecilie G. Nome
- grid.55325.340000 0004 0389 8485Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway ,grid.5510.10000 0004 1936 8921Division of Anatomy, Department of Molecular Medicine, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Bjørn Tennøe
- grid.55325.340000 0004 0389 8485Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Christian G. Lund
- grid.55325.340000 0004 0389 8485Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Mona K. Beyer
- grid.55325.340000 0004 0389 8485Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway ,grid.5510.10000 0004 1936 8921Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Mona Skjelland
- grid.55325.340000 0004 0389 8485Department of Neurology, Oslo University Hospital, Oslo, Norway ,grid.5510.10000 0004 1936 8921Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Anne Hege Aamodt
- grid.55325.340000 0004 0389 8485Department of Neurology, Oslo University Hospital, Oslo, Norway
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22
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Lacidogna G, Pitocchi F, Mascolo AP, Marrama F, D’Agostino F, Rocco A, Mori F, Maestrini I, Sabuzi F, Cavallo A, Morosetti D, Garaci F, Di Giuliano F, Floris R, Sallustio F, Diomedi M, Da Ros V. CT Perfusion as a Predictor of the Final Infarct Volume in Patients with Tandem Occlusion. J Pers Med 2023; 13:jpm13020342. [PMID: 36836576 PMCID: PMC9964425 DOI: 10.3390/jpm13020342] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 02/01/2023] [Accepted: 02/08/2023] [Indexed: 02/18/2023] Open
Abstract
BACKGROUND CT perfusion (CTP) is used in patients with anterior circulation acute ischemic stroke (AIS) for predicting the final infarct volume (FIV). Tandem occlusion (TO), involving both intracranial large vessels and the ipsilateral cervical internal carotid artery could generate hemodynamic changes altering perfusion parameters. Our aim is to evaluate the accuracy of CTP in the prediction of the FIV in TOs. METHODS consecutive patients with AIS due to middle cerebral artery occlusion, referred to a tertiary stroke center between March 2019 and January 2021, with an automated CTP and successful recanalization (mTICI = 2b - 3) after endovascular treatment were retrospectively included in the tandem group (TG) or in the control group (CG). Patients with parenchymal hematoma type 2, according to ECASS II classification of hemorrhagic transformations, were excluded in a secondary analysis. Demographic, clinical, radiological, time intervals, safety, and outcome measures were collected. RESULTS among 319 patients analyzed, a comparison between the TG (N = 22) and CG (n = 37) revealed similar cerebral blood flow (CBF) > 30% (29.50 ± 32.33 vs. 15.76 ± 20.93 p = 0.18) and FIV (54.67 ± 65.73 vs. 55.14 ± 64.64 p = 0.875). Predicted ischemic core (PIC) and FIV correlated in both TG (tau = 0.761, p < 0.001) and CG (tau = 0.315, p = 0.029). The Bland-Altmann plot showed agreement between PIC and FIV for both groups, mainly in the secondary analysis. CONCLUSION automated CTP could represent a good predictor of FIV in patients with AIS due to TO.
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Affiliation(s)
- Giordano Lacidogna
- Stroke Center, Department of Systems Medicine, University Hospital of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
- Correspondence: ; Tel.: +39-0620903423
| | - Francesca Pitocchi
- Diagnostic Imaging Unit, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - Alfredo Paolo Mascolo
- Stroke Center, Department of Systems Medicine, University Hospital of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
| | - Federico Marrama
- Stroke Center, Department of Systems Medicine, University Hospital of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
| | - Federica D’Agostino
- Stroke Center, Department of Systems Medicine, University Hospital of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
| | - Alessandro Rocco
- Stroke Center, Department of Systems Medicine, University Hospital of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
| | - Francesco Mori
- Stroke Center, Department of Systems Medicine, University Hospital of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
| | - Ilaria Maestrini
- Stroke Center, Department of Systems Medicine, University Hospital of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
| | - Federico Sabuzi
- Interventional Radiology Unit, Department of Biomedicine and Prevention, University Hospital of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
| | - Armando Cavallo
- Diagnostic Imaging Unit, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - Daniele Morosetti
- Interventional Radiology Unit, Department of Biomedicine and Prevention, University Hospital of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
| | - Francesco Garaci
- Diagnostic Imaging Unit, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - Francesca Di Giuliano
- Diagnostic Imaging Unit, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - Roberto Floris
- Diagnostic Imaging Unit, Department of Biomedicine and Prevention, University of Rome Tor Vergata, Viale Oxford 81, 00133 Rome, Italy
| | - Fabrizio Sallustio
- Stroke Center, Department of Systems Medicine, University Hospital of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
| | - Marina Diomedi
- Stroke Center, Department of Systems Medicine, University Hospital of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
| | - Valerio Da Ros
- Interventional Radiology Unit, Department of Biomedicine and Prevention, University Hospital of Rome “Tor Vergata”, Viale Oxford 81, 00133 Rome, Italy
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23
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Yamashita S, Imahori T, Koyama J, Tanaka K, Okamura Y, Arai A, Iwahashi H, Mori T, Onobuchi K, Sasayama T. Endovascular Treatment of Tandem Atherosclerotic Cervical Internal Carotid Artery Occlusion in the Setting of Acute Ischemic Stroke. Vasc Endovascular Surg 2023; 57:137-148. [PMID: 36189731 DOI: 10.1177/15385744221130865] [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] [Indexed: 01/18/2023]
Abstract
BACKGROUND Among tandem occlusions, atherosclerotic cervical internal carotid artery occlusion (ACICAO) can be technically challenging and associated with its unique complications. We evaluated our experience with endovascular treatment (EVT) of ACICAO in the setting of acute ischemic stroke. METHODS In total, 154 consecutive patients who underwent EVT for acute anterior circulation stroke at our institute were retrospectively reviewed. Patients with tandem ACICAO were analyzed in this study. Procedures, recanalization rates, complications, and prognoses were evaluated. RESULTS Ten patients (6%) of all 154 patients had ACICAO. In nine (90%) of the 10 patients, cervical lesions were successfully crossed and intervened upon. Four patients underwent stenting and five underwent angioplasty alone, followed by intracranial procedure. Eight patients (80%) achieved successful recanalization following mechanical thrombectomy for intracranial occlusion. However, one patient had massive subarachnoid hemorrhage during the procedure and another patient developed massive intracranial hemorrhage after EVT, both after stenting. Four of the five patients who initially underwent angioplasty alone subsequently underwent staged endarterectomy or stenting for residual stenosis on or after the next day. The single patient in whom the cervical lesion could not be crossed and another with reocclusion after EVT underwent a rescue bypass procedure due to persistent ischemic symptoms. After 90 days, four patients (40%) were functionally independent (modified Rankin scale score 0-2). CONCLUSIONS Our experience suggests that EVT for ACICAO is technically feasible; however, it involves the potential risk of several significant complications. To avoid serious hemorrhagic complications, cervical lesions may be better treated with angioplasty alone first.
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Affiliation(s)
- Shunsuke Yamashita
- Department of Neurosurgery, 38303Kobe University Graduate School of Medicine, Hyogo, Japan.,Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | - Taichiro Imahori
- Department of Neurosurgery, 38303Kobe University Graduate School of Medicine, Hyogo, Japan.,Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | - Junji Koyama
- Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | - Kazuhiro Tanaka
- Department of Neurosurgery, 38303Kobe University Graduate School of Medicine, Hyogo, Japan.,Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | - Yusuke Okamura
- Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | - Atsushi Arai
- Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | | | - Tatsuya Mori
- Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | - Kana Onobuchi
- Department of Neurosurgery, 157128Toyooka Hospital, Hyogo, Japan
| | - Takashi Sasayama
- Department of Neurosurgery, 38303Kobe University Graduate School of Medicine, Hyogo, Japan
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24
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Yu M, Ma Y, Ren H, Huang Y, Yin L, Ma L, Wang Y, Luo B, Wang Z. Emergent Management of Tandem Occlusions in Anterior Circulation Stroke: A Single-Centre Experience. World Neurosurg 2023; 170:e491-e499. [PMID: 36396050 DOI: 10.1016/j.wneu.2022.11.040] [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: 09/21/2022] [Revised: 11/09/2022] [Accepted: 11/10/2022] [Indexed: 11/16/2022]
Abstract
OBJECTIVE For anterior circulation tandem occlusions, the optimal management strategy for extracranial carotid lesions is controversial. We aimed to compare the efficacy and safety of acute stenting (AS) with balloon angioplasty (BA) only. METHODS Clinical data were collected from 98 patients with anterior circulation tandem occlusion who underwent endovascular treatment at our center. Of these patients, 64 and 34 were assigned to the AS and BA groups, respectively. The clinical characteristics and outcome data of the 2 groups were analyzed and compared. RESULTS The proportion of patients with good outcomes was 59.2%. The AS group had a higher rate of successful recanalization (98.4% vs. 82.4%, P = 0.007) and a lower rate of occlusion of the responsible vessel at 90 days (14.1% vs. 32.4%, P = 0.039) than the BA group. The AS group was also significantly better than the BA group in terms of good outcomes (67.2% vs. 44.1%, P = 0.027), but there was no significant difference between the 2 groups in terms of 90-day mortality (6.3% vs. 8.8%, P = 0.691) and asymptomatic intracranial hemorrhage (6.3% vs. 5.9%, P = 1.000). Lower baseline National Institutes of Health Stroke Scale scores were associated with good outcomes (P < 0.001), and the presence of symptomatic intracranial hemorrhage was associated with 90-day mortality (P = 0.003). CONCLUSIONS Acute stent placement in patients with acute ischemic stroke due to anterior circulation tandem occlusion may have a better outcome than BA alone, and the safety of both approaches is comparable.
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Affiliation(s)
- Mingsheng Yu
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China; Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Yuxiang Ma
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China; Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Hecheng Ren
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Ying Huang
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Long Yin
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Lin Ma
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Yubo Wang
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Bin Luo
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin, China
| | - Zengguang Wang
- Department of Neurosurgery, Tianjin Medical University General Hospital, Tianjin, China.
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25
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Naylor R, Rantner B, Ancetti S, de Borst GJ, De Carlo M, Halliday A, Kakkos SK, Markus HS, McCabe DJH, Sillesen H, van den Berg JC, Vega de Ceniga M, Venermo MA, Vermassen FEG, Esvs Guidelines Committee, Antoniou GA, Bastos Goncalves F, Bjorck M, Chakfe N, Coscas R, Dias NV, Dick F, Hinchliffe RJ, Kolh P, Koncar IB, Lindholt JS, Mees BME, Resch TA, Trimarchi S, Tulamo R, Twine CP, Wanhainen A, Document Reviewers, Bellmunt-Montoya S, Bulbulia R, Darling RC, Eckstein HH, Giannoukas A, Koelemay MJW, Lindström D, Schermerhorn M, Stone DH. Editor's Choice - European Society for Vascular Surgery (ESVS) 2023 Clinical Practice Guidelines on the Management of Atherosclerotic Carotid and Vertebral Artery Disease. Eur J Vasc Endovasc Surg 2023; 65:7-111. [PMID: 35598721 DOI: 10.1016/j.ejvs.2022.04.011] [Citation(s) in RCA: 205] [Impact Index Per Article: 205.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 04/20/2022] [Indexed: 01/17/2023]
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26
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Filioglo A, Simaan N, Honig A, Heldner M, Pezzini A, Martinez-Majander N, Padjen V, Baumgartner P, Papanagiotou P, Salerno A, Nolte C, Nordanstig A, Engelter S, Zini A, Zedde M, Marto JP, Arnold M, Magoni M, Gensicke H, Cohen J, Leker R. Tandem occlusions involving the internal carotid and anterior cerebral arteries-A rare form of stroke: Results from the multicenter EVATRISP collaboration study. Front Neurol 2022; 13:1024891. [PMID: 36570467 PMCID: PMC9780389 DOI: 10.3389/fneur.2022.1024891] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 11/23/2022] [Indexed: 12/13/2022] Open
Abstract
Background Patients with stroke secondary to isolated anterior cerebral artery (ACA) occlusions have poor outcomes. Whether tandem occlusions (TO) of the extracranial internal carotid (ICA) and the ACA carry even worse outcomes that remain unknown. Methods Patients with TO involving ICA and ACA occlusions were identified from 14 participating centers from the EndoVascular treatment And ThRombolysis in Ischemic Stroke Patients (EVATRISP) project which is a multicenter, observational, cohort study with prospective accrual of data followed by retrospective data analysis. Patients with isolated ACA stroke served as controls. Results Included were 92 patients with isolated ACA and 16 patients with ICA-ACA TO stroke. On univariate analyses, patients with TO had more severe strokes on admission [median NIHSS (IQR) 13.5 (9-21) vs. 8 (5-12), p = 0.003] and were more often treated with thrombectomy (81 vs. 40%, p = 0.002). Mortality rates were higher among TO patients (31 vs. 11%, p = 0.03). Rates of favorable functional outcomes were numerically lower among TO patients (38 vs. 60%) but the difference was not statistically significant (p = 0.09). On multivariate analyses, the presence of TO did not modify the chances for favorable outcomes. Conclusion TO stroke with ICA and isolated ACA involvement is rare and results in more severe initial neurological deficits and higher mortality compared to those seen in patients with isolated ACA stroke.
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Affiliation(s)
- Andrei Filioglo
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Naaem Simaan
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Asaf Honig
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Mirjam Heldner
- Department of Neurology, University Hospital Bern, Bern, Switzerland
| | - Alessandro Pezzini
- Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - Nicolas Martinez-Majander
- Department of Neurology, Helsinki University Hospital and Clinical Neurosciences, University of Helsinki, Helsinki, Finland
| | - Visnja Padjen
- Faculty of Medicine, Neurology Clinic, University Clinical Centre of Serbia, University of Belgrade, Belgrade, Serbia
| | | | - Panagiotis Papanagiotou
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte/Bremen-Ost, Bremen, Germany
| | - Alexander Salerno
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital, University of Lausanne, Lausanne, Switzerland
| | - Christian Nolte
- Department of Neurology, Charité-Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research, Berlin Institute of Health, Berlin, Germany
| | - Annika Nordanstig
- Department of Clinical Neurosciences, Institute of Neurosciences and Physiology, Sahlgrenska Academy at University of Gothenburg, Gothenburg, Sweden
- Department of Neurology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Stefan Engelter
- Stroke Center and Department of Neurology, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Andrea Zini
- Department of Neurology and Stroke Center, IRCCS Istituto delle Scienze Neurologiche di Bologna, Maggiore Hospital, Bologna, Italy
| | - Marialuisa Zedde
- Neurology Unit, Stroke Unit, Azienda Unità Sanitaria Locale-IRCCS di Reggio Emilia, Reggio Emilia, Italy
| | - João Pedro Marto
- Department of Neurology, Hospital de Egas Moniz, Centro Hospitalar Lisboa Ocidental, Lisbon, Portugal
| | - Marcel Arnold
- Department of Neurology, University Hospital Bern, Bern, Switzerland
| | - Mauro Magoni
- Department of Clinical and Experimental Sciences, University of Brescia, ASST Spedali Civili, Brescia, Italy
| | - Henrik Gensicke
- Department of Neurology and Neurorehabilitation, University Department of Geriatric Medicine FELIX PLATTER, University of Basel, Basel, Switzerland
| | - Jose Cohen
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ronen Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
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27
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Bontinis V, Antonopoulos CN, Bontinis A, Koutsoumpelis A, Zymvragoudakis V, Rafailidis V, Giannopoulos A, Stoiloudis P, Ktenidis K. A systematic review and meta-analysis of carotid artery stenting for the treatment of cervical carotid artery dissection. Eur J Vasc Endovasc Surg 2022; 64:299-308. [PMID: 35961627 DOI: 10.1016/j.ejvs.2022.07.048] [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: 03/02/2022] [Revised: 07/14/2022] [Accepted: 07/22/2022] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To assess the efficacy and safety of carotid artery stenting for the treatment of extracranial carotid artery dissection (CAD). DATA SOURCES Systematic review using Medline, Scopus, EMBASE and Cochrane Library. REVIEW METHODS A systematic search was performed according to the Preferred Reporting Items for Systematic reviews and Meta-analysis (PRISMA) statement. Data from the eligible studies were extracted and meta-analyzed. Primary endpoints included postoperative mortality, cerebrovascular events (CE) and modified Rankin Score for neurologic disability (mRS) at 90 days. We performed subgroup analyses between stenting of spontaneous and traumatic CAD, primary stenting versus stenting after failed medical therapy (FMT) and stenting of CAD in the presence of tandem occlusions versus stenting of isolated extracranial CAD. RESULTS Twenty-four studies with 1,224 patients were included. Pooled post-operative mortality, CE and mRS 0-2 rates were 1.71% (95%CI:0.83-2.80), 6.45% (95%CI:2.80-11.10) and 76.13% (95%CI:64.15-86.50), respectively. The pooled stroke rate was 2.16% (95%CI:0.0-6.64). Spontaneous versus traumatic CAD mortality rates were 3.20% (95%CI:1.80-4.88) and 0.00% (95%CI:0.00-1.59) while CE rates were 14.26% (95%CI:6.28-24.36) and 1.64% (95%CI:0.0-6.08). Primary stenting and stenting after FMT mortality rates were 0.63% (95%CI:0.0-5.63) and 0.0% (95%CI:0.0-2.24), while CE rates were 5.02% (95%CI:0.38-12.63) and 3.33% (95%CI:0.12-9.03). Mortality rates for tandem occlusions and isolated extracranial CAD were 5.62% (95%CI:1.76-10.83) and 0.23% (95%CI:0.0-1.88) respectively, while CE rates were 15.28% (95%CI:6.23-26.64) and 1.88% (95%CI:0.23-4.51). The methodological index for non-randomized studies (MINORS) score was 8.66 (low). CONCLUSION Both primary stenting and stenting of spontaneous CAD yielded unfavorable results regarding stent thrombosis and stroke rates. Conversely, stenting following FMT displayed acceptable mortality and complication rates corroborating the use of stenting in the setting of CAD as a second line treatment. Due to the low quality of the included studies, definite conclusions cannot be drawn necessitating further research.
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Affiliation(s)
- Vangelis Bontinis
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece.
| | - Constantine N Antonopoulos
- Department of Vascular Surgery, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Alkis Bontinis
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
| | - Andreas Koutsoumpelis
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
| | - Vassilios Zymvragoudakis
- Department of Vascular Surgery, Guy's and St Thomas' NHS Foundation Trust, London, United Kingdom
| | - Vasileios Rafailidis
- Department of Radiology, Aristotle University of Thessaloniki, School of Medicine, AHEPA University Hospital, Thessaloniki, Greece
| | - Argirios Giannopoulos
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
| | - Panagiotis Stoiloudis
- 2nd Department of Neurology, AHEPA University Hospital, Aristotle University of Thessaloniki
| | - Kiriakos Ktenidis
- Department of Vascular Surgery, Aristotle University of Thessaloniki, AHEPA University General Hospital, Thessaloniki, Greece
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28
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Min X, Du J, Bai X, Wei T, Dmytriw AA, Patel AB, Zhang X, Xu X, Feng Y, Wang T, Wang X, Yang K, Hu W, Yi T, Chen W, Jiao L. Antegrade or Retrograde Approach for the Management of Tandem Occlusions in Acute Ischemic Stroke: A Systematic Review and Meta-Analysis. Front Neurol 2022; 12:757665. [PMID: 35095720 PMCID: PMC8790816 DOI: 10.3389/fneur.2021.757665] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2021] [Accepted: 11/08/2021] [Indexed: 12/12/2022] Open
Abstract
Background: Acute ischemic stroke (AIS) caused by tandem intracranial and extracranial occlusions is not rare. However, optimal strategy between antegrade (extracranial first) or retrograde (intracranial first) approaches still remains elusive. This systematic review and meta-analysis aim to compare the two approaches to provide updated clinical evidence of strategy selection. Methods: PubMed, Ovid, Web of Science, and the Cochrane Library were searched for literature comparing antegrade and retrograde approaches for patients with AIS with concomitant tandem occlusions. Outcomes including successful reperfusion [Throbolysis in Cerebral Infarction (TICI) 2b-3] and 90-day favorable outcome [modified Rankin Scale (mRS) 0-2], any intracerebral hemorrhage, symptomatic intracerebral hemorrhage, procedural complications, and mortality were evaluated. The risk of bias was assessed using the Newcastle-Ottawa Scale and illustrated in the Funnel plot. Heterogeneity was assessed by I 2 statistic. Subgroup and sensitivity analyses were also performed. Results: A total of 11 studies accounting 1,517 patients were included. 831 (55%) patients were treated with an antegrade approach and 686 (45%) patients were treated with the retrograde approach. A higher successful reperfusion rate was achieved in retrograde group than that of antegrade group [83.8 vs. 78.0%; odds ratio (OR): 0.63, 95% CI: 0.40-0.99, p = 0.04]. 90-day favorable outcome (mRS 0-2 at 90 days) also showed significantly higher in retrograde group compared with antegrade group (47.3 vs. 40.2%; OR: 0.72, 95% CI: 0.58-0.89, p = 0.002). The incidence of any intracranial hemorrhage (ICH), symptomatic intracranial hemorrhage, 90-day mortality, and other complications did not differ between two groups. Conclusion: In AIS with tandem occlusions, the retrograde approach might achieve a higher successful reperfusion rate and better functional outcome with a comparable safety profile when compared with an antegrade approach. Further prospective controlled studies with more meticulous design and a higher level of evidence are needed to confirm these results. Systematic Review Registration: "PROSPERO" database (CRD 42020199093), https://www.crd.york.ac.uk/PROSPERO/.
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Affiliation(s)
- Xiaoli Min
- Department of Cerebrovascular Diseases, The Second Affiliated Hospital, Kunming Medical University, Kunming, China.,Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Jianhua Du
- Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
| | - Xuesong Bai
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Tao Wei
- Library, Kunming Medical University, Kunming, China
| | - Adam A Dmytriw
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Aman B Patel
- Neuroendovascular Program, Massachusetts General Hospital, Harvard Medical School, Boston, MA, United States
| | - Xiao Zhang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Xin Xu
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Yao Feng
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Tao Wang
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China
| | - Xue Wang
- Medical Library, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Kun Yang
- Department of Evidence-Based Medicine, Xuanwu Hospital, Capital Medical University, Beijing, China
| | - Weiwu Hu
- Department of Neurology, The First Traditional Chinese Medicine Hospital of Chengde, Chengde, China
| | - Tingyu Yi
- Department of Neurology, Zhangzhou Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Wenhuo Chen
- Department of Neurology, Zhangzhou Affiliated Hospital, Fujian Medical University, Fuzhou, China
| | - Liqun Jiao
- Department of Neurosurgery, Xuanwu Hospital, Capital Medical University, Beijing, China.,China International Neuroscience Institute (China-INI), Beijing, China.,Department of Interventional Neuroradiology, Xuanwu Hospital, Capital Medical University, Beijing, China
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29
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Nagy C, Héger J, Balogh G, Gubucz I, Nardai S, Lenzsér G, Bajzik G, Fehér M, Moizs M, Repa I, Nagy F, Vajda Z. Endovascular Recanalization of Tandem Internal Carotid Occlusions Using the Balloon-assisted Tracking Technique. Clin Neuroradiol 2021; 32:375-384. [PMID: 34546383 DOI: 10.1007/s00062-021-01078-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2021] [Accepted: 07/24/2021] [Indexed: 11/30/2022]
Abstract
PURPOSE Tandem occlusive lesions are responsible for up to 20% of acute ischemic stroke cases and are associated with poor prognosis if complete recanalization cannot be achieved. Endovascular recanalization might be challenging due to difficulties in the safe passage of the occluded plaque at the origin of the internal carotid artery (ICA). The balloon-assisted tracking technique (BAT), where a partially deflated balloon is exposed out of the catheter tip to facilitate its passage through stenosed or spastic arterial segments was introduced by interventional cardiologists and the applicability of the technique has been recently proposed in the field of neurointervention as well. Here we describe our experience using the BAT technique in the endovascular recanalization of tandem occlusive lesions. METHODS Procedures were performed from June 2013 to December 2020 in a single center. Baseline clinical and imaging data, procedural and follow-up details and clinical outcomes were retrospectively collected. RESULTS In this study 107 patients, median age 66 years, median admission NIHSS 14 and median ASPECTS 8 were included. Successful recanalization of the ICA using the BAT technique was achieved in 100 (93%) and successful intracranial revascularization in 88 (82%) patients. There were no complications attributable to the BAT technique. Intraprocedural complications occurred in 9 (8%) patients. Emergent stenting was performed in 40 (37%) at the end of the procedure. Postprocedural adverse events (intracerebral hemorrhage [ICH], malignant infarction) occurred in 6 (5%) patients. Good clinical outcome at 3 months (modified Rankin scale [mRS] 0-2) was 54 (50%) and mortality 26 (24%). Delayed stent placement during follow-up occurred in 21 cases. CONCLUSION Application of BAT technique in tandem occlusions appears feasible, safe, and efficient. Further evaluation of this technique is awaited.
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Affiliation(s)
- Csaba Nagy
- Neurovascular and Interventional Unit, Somogy County Moritz Kaposi Teaching Hospital, Kaposvár, Hungary.,Department of Neurosurgery, University of Pécs, Pécs, Hungary
| | - Júlia Héger
- Department of Emergency Medicine, Somogy County Moritz Kaposi Teaching Hospital, Kaposvár, Hungary
| | - Gábor Balogh
- Department of Surgery, Somogy County Moritz Kaposi Teaching Hospital, Kaposvár, Hungary
| | - István Gubucz
- Neurovascular and Interventional Unit, Somogy County Moritz Kaposi Teaching Hospital, Kaposvár, Hungary.,National Institute of Clinical Neurosciences, Budapest, Hungary
| | - Sándor Nardai
- Neurovascular and Interventional Unit, Somogy County Moritz Kaposi Teaching Hospital, Kaposvár, Hungary
| | - Gábor Lenzsér
- Neurovascular and Interventional Unit, Somogy County Moritz Kaposi Teaching Hospital, Kaposvár, Hungary.,Department of Neurosurgery, University of Pécs, Pécs, Hungary
| | - Gábor Bajzik
- Neurovascular and Interventional Unit, Somogy County Moritz Kaposi Teaching Hospital, Kaposvár, Hungary
| | - Máté Fehér
- Department of Neurosurgery, Somogy County Moritz Kaposi Teaching Hospital, Kaposvár, Hungary
| | - Mariann Moizs
- Neurovascular and Interventional Unit, Somogy County Moritz Kaposi Teaching Hospital, Kaposvár, Hungary
| | - Imre Repa
- Neurovascular and Interventional Unit, Somogy County Moritz Kaposi Teaching Hospital, Kaposvár, Hungary
| | - Ferenc Nagy
- Department of Neurology, Somogy County Moritz Kaposi Teaching Hospital, Kaposvár, Hungary
| | - Zsolt Vajda
- Neurovascular and Interventional Unit, Somogy County Moritz Kaposi Teaching Hospital, Kaposvár, Hungary. .,Department of Neurosurgery, University of Pécs, Pécs, Hungary.
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30
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Affiliation(s)
| | - Ashkan Shoamanesh
- Department of Medicine (Neurology), McMaster University/Population Health Research Institute (A.S.)
| | - Alexandre Y Poppe
- Department of Neurosciences, Centre Hospitalier de l'Université de Montréal (A.Y.P.)
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31
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Magoufis G, Safouris A, Raphaeli G, Kargiotis O, Psychogios K, Krogias C, Palaiodimou L, Spiliopoulos S, Polizogopoulou E, Mantatzis M, Finitsis S, Karapanayiotides T, Ellul J, Bakola E, Brountzos E, Mitsias P, Giannopoulos S, Tsivgoulis G. Acute reperfusion therapies for acute ischemic stroke patients with unknown time of symptom onset or in extended time windows: an individualized approach. Ther Adv Neurol Disord 2021; 14:17562864211021182. [PMID: 34122624 PMCID: PMC8175833 DOI: 10.1177/17562864211021182] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2021] [Accepted: 05/10/2021] [Indexed: 02/05/2023] Open
Abstract
Recent randomized controlled clinical trials (RCTs) have revolutionized acute ischemic stroke care by extending the use of intravenous thrombolysis and endovascular reperfusion therapies in time windows that have been originally considered futile or even unsafe. Both systemic and endovascular reperfusion therapies have been shown to improve outcome in patients with wake-up strokes or symptom onset beyond 4.5 h for intravenous thrombolysis and beyond 6 h for endovascular treatment; however, they require advanced neuroimaging to select stroke patients safely. Experts have proposed simpler imaging algorithms but high-quality data on safety and efficacy are currently missing. RCTs used diverse imaging and clinical inclusion criteria for patient selection during the dawn of this novel stroke treatment paradigm. After taking into consideration the dismal prognosis of nonrecanalized ischemic stroke patients and the substantial clinical benefit of reperfusion therapies in selected late presenters, we propose rescue reperfusion therapies for acute ischemic stroke patients not fulfilling all clinical and imaging inclusion criteria as an option in a subgroup of patients with clinical and radiological profiles suggesting low risk for complications, notably hemorrhagic transformation as well as local or remote parenchymal hemorrhage. Incorporating new data to treatment algorithms may seem perplexing to stroke physicians, since treatment and imaging capabilities of each stroke center may dictate diverse treatment pathways. This narrative review will summarize current data that will assist clinicians in the selection of those late presenters that will most likely benefit from acute reperfusion therapies. Different treatment algorithms are provided according to available neuroimaging and endovascular treatment capabilities.
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Affiliation(s)
- Georgios Magoufis
- Interventional Neuroradiology Unit, Metropolitan Hospital, Piraeus, Greece
| | - Apostolos Safouris
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
- Interventional Neuroradiology Unit, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Guy Raphaeli
- Interventional Neuroradiology Unit, Rabin Medical Center, Beilinson Hospital, Petach-Tikva, Israel
| | | | - Klearchos Psychogios
- Stroke Unit, Metropolitan Hospital, Piraeus, Greece
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Christos Krogias
- Department of Neurology, St. Josef-Hospital, Ruhr University Bochum, Bochum, Germany
| | - Lina Palaiodimou
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Stavros Spiliopoulos
- Second Department of Radiology, Interventional Radiology Unit, “ATTIKON” University General Hospital, Athens, Greece
| | - Eftihia Polizogopoulou
- Emergency Medicine Clinic, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Michael Mantatzis
- Department of Radiology, University Hospital of Alexandroupolis, Democritus University of Thrace, School of Medicine, Alexandroupolis, Greece
| | - Stephanos Finitsis
- Department of Interventional Radiology, AHEPA University General Hospital, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Theodore Karapanayiotides
- Second Department of Neurology, Aristotle University of Thessaloniki, School of Medicine, Faculty of Health Sciences, AHEPA University Hospital, Thessaloniki, Greece
| | - John Ellul
- Department of Neurology, University Hospital of Patras, School of Medicine, University of Patras, Patras, Greece
| | - Eleni Bakola
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Elias Brountzos
- Second Department of Radiology, Interventional Radiology Unit, “ATTIKON” University General Hospital, Athens, Greece
| | - Panayiotis Mitsias
- Department of Neurology Medical School, University of Crete, Heraklion, Crete, Greece
| | - Sotirios Giannopoulos
- Second Department of Neurology, National & Kapodistrian University of Athens, School of Medicine, “Attikon” University Hospital, Athens, Greece
| | - Georgios Tsivgoulis
- Second Department of Neurology, National & Kapodistrian, University of Athens, School of Medicine, “Attikon” University Hospital, Iras 39, Gerakas Attikis, Athens, 15344, Greece
- Department of Neurology, The University of Tennessee Health Science Center, Memphis, TN, USA
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32
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Papanagiotou P, Gory B. The Challenge of an Acute Antithrombotic Regimen for Treatment of Tandem Lesions Stroke. AJNR Am J Neuroradiol 2021; 42:926. [PMID: 33832954 DOI: 10.3174/ajnr.a7122] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Affiliation(s)
- P Papanagiotou
- Department of RadiologyAreteion University Hospital, National and Kapodistrian University of AthensAthens, GreeceDepartment of Diagnostic and Interventional NeuroradiologyHospital Bremen-MitteBremen, Germany
| | - B Gory
- Department of Diagnostic and Therapeutic NeuroradiologyUniversité de LorraineNancy, France
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