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Strbian D, Tsivgoulis G, Ospel J, Räty S, Cimflova P, Georgiopoulos G, Ullberg T, Arquizan C, Gralla J, Zelenak K, Hussain S, Fiehler J, Michel P, Turc G, van Zwam WH. European Stroke Organisation (ESO) and European Society for Minimally Invasive Neurological Therapy (ESMINT) guideline on acute management of basilar artery occlusion. J Neurointerv Surg 2024; 16:e7. [PMID: 39043395 PMCID: PMC11347260 DOI: 10.1136/jnis-2024-022053] [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: 05/28/2024] [Accepted: 06/11/2024] [Indexed: 07/25/2024]
Abstract
The aim of the present European Stroke Organisation (ESO) guideline is to provide evidence-based recommendations on the acute management of patients with basilar artery occlusion (BAO). These guidelines were prepared following the Standard Operational Procedure of the ESO and according to the GRADE methodology.Although BAO accounts for only 1-2% of all strokes, it has very poor natural outcome. We identified 10 relevant clinical situations and formulated the corresponding Population Intervention Comparator Outcomes (PICO) questions, based on which a systematic literature search and review was performed. The working group consisted of 10 voting members (five representing ESO and five representing the European Society of Minimally Invasive Neurological Therapy (ESMINT)) and three non-voting junior members. The certainty of evidence was generally very low. In many PICOs, available data were scarce or lacking, hence, we provided expert consensus statements.First, we compared intravenous thrombolysis (IVT) to no IVT, but specific BAO-related data do not exist. Yet, historically, IVT was standard of care for BAO patients who were also included (although in small numbers) in IVT trials. Non-randomized studies of IVT-only cohorts showed a high proportion of favorable outcomes. Expert Consensus suggests using IVT up to 24 hours unless otherwise contraindicated. We further suggest IVT plus endovascular treatment (EVT) over direct EVT. EVT on top of best medical treatment (BMT) was compared with BMT alone within 6 and 6-24 hours from last seen well. In both time windows, we observed a different effect of treatment depending on a) the region where the patients were treated (Europe vs Asia), b) on the proportion of IVT in the BMT arm, and c) on the initial stroke severity. In case of high proportion of IVT in the BMT group and in patients with a National Institutes of Health Stroke Scale (NIHSS) score below 10, EVT plus BMT was not found better than BMT alone. Based on very low certainty of evidence, we suggest EVT+BMT over BMT alone (this is based on results of patients with at least 10 NIHSS points and a low proportion of IVT in BMT). For patients with an NIHSS score below 10, we found no evidence to recommend EVT over BMT. In fact, BMT was non-significantly better and safer than EVT. Furthermore, we found a stronger treatment effect of EVT+BMT over BMT alone in proximal and middle locations of BAO compared with distal location. While recommendations for patients without extensive early ischemic changes in the posterior fossa can, in general, follow those of other PICOs, we formulated an Expert Consensus Statement suggesting against reperfusion therapy in those with extensive bilateral and/or brainstem ischemic changes. Another Expert Consensus suggests reperfusion therapy regardless of collateral scores. Based on limited evidence, we suggest direct aspiration over stent retriever as the first-line strategy of mechanical thrombectomy. As an Expert Consensus, we suggest rescue percutaneous transluminal angioplasty and/or stenting after a failed EVT procedure. Finally, based on very low certainty of evidence, we suggest add-on antithrombotic treatment during EVT or within 24 hours after EVT in patients with no concomitant IVT and in whom EVT was complicated (defined as failed or imminent re-occlusion, or need for additional stenting or angioplasty).
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Affiliation(s)
- Daniel Strbian
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Georgios Tsivgoulis
- Second Department of Neurology, 'Attikon' University Hospital of Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - Johanna Ospel
- Neuroradiology, Department of Diagnostic Imaging, Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - Silja Räty
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Petra Cimflova
- Foothills Medical Centre, University of Calgary, Calgary, Alberta, Canada
| | - Georgios Georgiopoulos
- Department of Physiology, School of Medicine, University of Patras, Patras, Greece
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Teresa Ullberg
- Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund and Malmö, Sweden
| | - Caroline Arquizan
- Department of Neurology, Hôpital Gui de Chauliac, INSERM U1266, Montpellier, France
| | - Jan Gralla
- Neuroradiology, Inselspital, University of Bern, Bern, Switzerland
| | - Kamil Zelenak
- Clinic of Radiology, Jessenius Faculty of Medicine, Comenius University, Martin, Slovakia
| | | | | | - Patrik Michel
- Department of Clinical Neuroscience, Lausanne University Hospital and University of Lausanne, Bâtiment Hospitalier Principal, Lausanne, Switzerland
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, INSERM U1266, Université Paris Cité, FHU NeuroVasc, Paris, France
| | - Wim H van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Center, Maastricht, Netherlands
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2
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Strbian D, Tsivgoulis G, Ospel J, Räty S, Cimflova P, Georgiopoulos G, Ullberg T, Arquizan C, Gralla J, Zeleňák K, Hussain S, Fiehler J, Michel P, Turc G, Van Zwam W. European stroke organisation and European society for minimally invasive neurological therapy guideline on acute management of basilar artery occlusion. Eur Stroke J 2024:23969873241257223. [PMID: 38752743 DOI: 10.1177/23969873241257223] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/24/2024] Open
Abstract
The aim of the present European Stroke Organisation (ESO) guideline is to provide evidence-based recommendations on the acute management of patients with basilar artery occlusion (BAO). These guidelines were prepared following the Standard Operational Procedure of the ESO and according to the GRADE methodology. Although BAO accounts for only 1%-2% of all strokes, it has very poor natural outcome. We identified 10 relevant clinical situations and formulated the corresponding Population Intervention Comparator Outcomes (PICO) questions, based on which a systematic literature search and review was performed. The working group consisted of 10 voting members (five representing ESO and five ESMINT) and three non-voting junior members. The certainty of evidence was generally very low. In many PICOs, available data were scarce or lacking, hence, we provided expert consensus statements. First, we compared intravenous thrombolysis (IVT) to no IVT, but specific BAO-related data do not exist. Yet, historically, IVT was standard of care for BAO patients who were also included (albeit in small numbers) in IVT trials. Non-randomised studies of IVT-only cohorts showed high proportion of favourable outcomes. Expert Consensus suggests using IVT up to 24 h unless otherwise contraindicated. We further suggest IVT plus endovascular treatment (EVT) over direct EVT. EVT on top of best medical treatment (BMT) was compared to BMT alone within 6 and 6-24 h from last seen well. In both time windows, we observed a different effect of treatment depending on (a) the region where the patients were treated (Europe vs. Asia), (b) on the proportion of IVT in the BMT arm, and (c) on the initial stroke severity. In case of high proportion of IVT in the BMT group and in patients with NIHSS below 10, EVT plus BMT was not found better than BMT alone. Based on very low certainty of evidence, we suggest EVT + BMT over BMT alone (i.e. based on results of patients with at least 10 NIHSS points and a low proportion of IVT in BMT). For patients with an NIHSS below 10, we found no evidence to recommend EVT over BMT. In fact, BMT was non-significantly better and safer than EVT. Furthermore, we found a stronger treatment effect of EVT + BMT over BMT alone in proximal and middle locations of BAO compared to distal location. While recommendations for patients without extensive early ischaemic changes in the posterior fossa can, in general, follow those of other PICOs, we formulated an Expert Consensus Statement suggesting against reperfusion therapy in those with extensive bilateral and/or brainstem ischaemic changes. Another Expert Consensus suggests reperfusion therapy regardless of collateral scores. Based on limited evidence, we suggest direct aspiration over stent retriever as the first-line strategy of mechanical thrombectomy. As an Expert Consensus, we suggest rescue percutaneous transluminal angioplasty and/or stenting after a failed EVT procedure. Finally, based on very low certainty of evidence, we suggest add-on antithrombotic treatment during EVT or within 24 h after EVT in patients with no concomitant IVT and in whom EVT was complicated (defined as failed or imminent re-occlusion, or need for additional stenting or angioplasty).
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Affiliation(s)
- Daniel Strbian
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Georgios Tsivgoulis
- Second Department of Neurology, 'Attikon' University Hospital of Athens, National and Kapodistrian University of Athens, Athens, Greece
| | - Johanna Ospel
- Neuroradiology, Department of Diagnostic Imaging, Foothills Medical Center, University of Calgary, Calgary, AB, Canada
| | - Silja Räty
- Department of Neurology, Helsinki University Central Hospital, Helsinki, Finland
| | - Petra Cimflova
- Foothills Medical Center, University of Calgary, Calgary, AB, Canada
| | - Georgios Georgiopoulos
- Department of Physiology, School of Medicine, University of Patras, Greece
- School of Biomedical Engineering and Imaging Sciences, King's College London, London, UK
| | - Teresa Ullberg
- Department of Clinical Sciences Lund, Lund University, Skane University Hospital, Lund and Malmö, Malmö, Sweden
| | - Caroline Arquizan
- Department of Neurology, Hôpital Gui de Chauliac, INSERM U1266, Montpellier, France
| | - Jan Gralla
- Neuroradiology, Inselspital, University of Bern, Bern, Switzerland
| | - Kamil Zeleňák
- Clinic of Radiology, Jessenius Faculty of Medicine, Comenius University, Martin, Slovakia
| | | | | | - Patrik Michel
- Department of Clinical Neuroscience, Lausanne University Hospital and University of Lausanne, Bâtiment Hospitalier Principal, Lausanne, Switzerland
| | - Guillaume Turc
- Department of Neurology, GHU Paris Psychiatrie et Neurosciences, INSERM U1266, Université Paris Cité, FHU NeuroVasc, Paris, France
| | - Wim Van Zwam
- Department of Radiology and Nuclear Medicine, Maastricht University Medical Centre, Maastricht, The Netherlands
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Gupta D, D’Anna L, Klein P, Araujo-Contreras R, Kaliaev A, Abdalkader M, Hu W, Nguyen TN. Endovascular Treatment for Basilar Artery Occlusion. J Clin Med 2024; 13:4153. [PMID: 39064193 PMCID: PMC11278164 DOI: 10.3390/jcm13144153] [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: 05/10/2024] [Revised: 06/24/2024] [Accepted: 07/04/2024] [Indexed: 07/28/2024] Open
Abstract
Basilar artery occlusion (BAO) is a neurological emergency associated with a high risk for adverse outcomes. This review provides evidence on the therapeutic efficacy of intravenous thrombolysis (IVT) and endovascular therapy (EVT) in the treatment of BAO. Historically considered the primary intervention for acute ischemic stroke, IVT has been progressively combined with EVT, which has emerged from recent studies demonstrating clinical benefits, notably in patients presenting with severe stroke. Several randomised controlled trials have shown that EVT improves patient outcomes in select clinical contexts. Future research directions could address therapeutic treatment thresholds, combination strategies, and long-term outcomes.
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Affiliation(s)
- Devansh Gupta
- Smt. Kashibai Navale Medical College and General Hospital, Pune 411041, India;
| | | | - Piers Klein
- Department of Neurology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA 02118, USA; (P.K.); (R.A.-C.)
- Department of Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA 02118, USA; (A.K.); (M.A.)
| | - Robert Araujo-Contreras
- Department of Neurology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA 02118, USA; (P.K.); (R.A.-C.)
| | - Artem Kaliaev
- Department of Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA 02118, USA; (A.K.); (M.A.)
| | - Mohamad Abdalkader
- Department of Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA 02118, USA; (A.K.); (M.A.)
| | - Wei Hu
- The First Affiliated Hospital of University of Science and Technology of China, Hefei 230026, China;
| | - Thanh N. Nguyen
- Department of Neurology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA 02118, USA; (P.K.); (R.A.-C.)
- Department of Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA 02118, USA; (A.K.); (M.A.)
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Hirota S, Fujita K, Ishiwada T, Takahashi S, Hirai S, Sagawa H, Wakabayashi H, Aoyama J, Fujii S, Yamaoka H, Yoshimura M, Shigeta K, Sato Y, Sawada K, Yamada K, Yamamura T, Ishii Y, Obata Y, Hara M, Kawano Y, Yamamoto S, Nemoto S, Sumita K. Contact aspiration for basilar artery occlusion safely reduces the puncture-to-recanalization time. Clin Neurol Neurosurg 2024; 242:108331. [PMID: 38795688 DOI: 10.1016/j.clineuro.2024.108331] [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: 04/03/2024] [Revised: 04/25/2024] [Accepted: 05/11/2024] [Indexed: 05/28/2024]
Abstract
OBJECTIVE Effective thrombectomies in the posterior circulation remain controversial. Previous reports have demonstrated the superiority of contact aspiration in anterior circulation. Aspiration catheters and stent retrievers are often used alone on a global scale, while combined techniques are commonly used in Japan. This study evaluated the effect of first-line contact aspiration with other strategies for the treatment of basilar artery occlusion. METHODS The primary outcome was the frequency of the first-pass effect, and the secondary outcome was the time from puncture to the first-pass effect. A multicenter observational registry including 16 Japanese stroke centers was used. Between December 2013 and February 2021, enrolled patients underwent endovascular thrombectomy for basilar artery occlusion. The efficacy of contact aspiration compared to other methods (including stent retrievers and combined techniques) was evaluated. RESULTS Eighty-four patients were included, all of whom had achieved effective recanalization. Twenty-six patients were treated with contact aspiration, 13 with combined technique, and 45 with stent retrievers. The two groups: contact aspiration and non-contact aspiration, had different backgrounds. Both had similar frequencies of effective recanalization and first-pass effects. The contact aspiration group experienced better functional outcomes without statistical significance, while this strategy was significantly associated with a shorter puncture-to-recanalization time (38 vs. 55 minutes, P=0.036). In particular, in the 55 patients with the first-pass effect, multivariate Cox proportional hazard analysis showed that contact aspiration was significantly associated with a shorter time from puncture to first-pass effect, independent of age and etiology of large-artery atherosclerosis (hazard ratio 2.02, 95% confidence intervals 1.10-3.69, P=0.023). CONCLUSION This study suggested that contact aspiration for basilar artery occlusion may shorten the puncture-to-first-pass effect, compared to stent retrievers and combined techniques.
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Affiliation(s)
- Shin Hirota
- Department of Neurosurgery, Tsuchiura Kyodo General Hospital, 4-1-1 Otsuno, Tsuchiura-shi, Ibaraki 300-0028, Japan.
| | - Kyohei Fujita
- Department of Endovascular Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan.
| | - Tadahiro Ishiwada
- Department of Neurosurgery, Shioda Memorial Hospital, 550-1 Kori, Choseigun Nagaramachi, Chiba 297-0203, Japan
| | - Satoru Takahashi
- Department of Endovascular Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan.
| | - Sakyo Hirai
- Department of Endovascular Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan.
| | - Hirotaka Sagawa
- Department of Endovascular Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan.
| | - Hikaru Wakabayashi
- Department of Endovascular Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan.
| | - Jiro Aoyama
- Department of Endovascular Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan.
| | - Shoko Fujii
- Department of Endovascular Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan.
| | - Hiroto Yamaoka
- Department of Endovascular Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan
| | - Masataka Yoshimura
- Department of Neurosurgery, Tsuchiura Kyodo General Hospital, 4-1-1 Otsuno, Tsuchiura-shi, Ibaraki 300-0028, Japan.
| | - Keigo Shigeta
- Department of Neurosurgery, National Hospital Organization Disaster Medical Center, 3256 Midorimachi, Tachikawa-shi, Tokyo 190-0014, Japan
| | - Yohei Sato
- Department of Neurosurgery, Japanese Red Cross Musashino Hospital, 1-26-1 Kyonancho, Musashino-shi, Tokyo 180-8610, Japan.
| | - Kana Sawada
- Department of Neurosurgery, Tokyo Bay Urayasu Ichikawa Medical Center, 3-4-32 Todaijima, Urayasu-shi, Chiba 279-0001, Japan.
| | - Kenji Yamada
- Department of Neurosurgery, Shuuwa General Hospital, 1200 Yaharashinden, Kasukabe-shi, Saitama 344-0035, Japan.
| | - Toshihiro Yamamura
- Department of Neurosurgery, Soka Municipal Hospital, 2-21-1 Souka, Souka-shi, Saitama 340-8560, Japan
| | - Yosuke Ishii
- Department of Neurosurgery, Kanto Rosai Hospital, 1-1 Kizukisumiyoshicho, Nakahara-ku, Kawasaki, Kanagawa 211-0021, Japan
| | - Yoshiki Obata
- Department of Neurosurgery, Tokyo-Kita Medical Center, 4-17-56 Akabanedai, Kita-ku, Tokyo 115-0053, Japan
| | - Mutsuya Hara
- Department of Neurosurgery, Tokyo Metropolitan Toshima Hospital, 33-1 Sakaemachi, Itabashi-ku, Tokyo 173-0015, Japan.
| | - Yoshihisa Kawano
- Department of Neurosurgery, JA Toride Medical Center, 2-1-1 Hongo, Toride-shi, Ibaraki 302-0022, Japan
| | - Shinji Yamamoto
- Department of Neurosurgery, Tsuchiura Kyodo General Hospital, 4-1-1 Otsuno, Tsuchiura-shi, Ibaraki 300-0028, Japan.
| | - Shigeru Nemoto
- Department of Neurosurgery, Kanto Rosai Hospital, 1-1 Kizukisumiyoshicho, Nakahara-ku, Kawasaki, Kanagawa 211-0021, Japan.
| | - Kazutaka Sumita
- Department of Endovascular Surgery, Tokyo Medical and Dental University, 1-5-45 Yushima, Bunkyo-ku, Tokyo 113-8510, Japan.
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Karlsson A, Jood K, Björkman-Burtscher I, Rentzos A. Stent retriever versus aspiration based thrombectomy: impact on first pass reperfusion, procedure time, and clinical outcomes in large vessel occlusion. Nationwide registry based cohort study. J Neurointerv Surg 2024:jnis-2024-021793. [PMID: 38906687 DOI: 10.1136/jnis-2024-021793] [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: 03/30/2024] [Accepted: 05/30/2024] [Indexed: 06/23/2024]
Abstract
BACKGROUND First pass reperfusion (FPR), defined as near complete reperfusion (extended Treatment in Cerebral Ischemia (eTICI) score 2c/3) in a single attempt without rescue therapy has been proposed as a quality metric. However, it remains unclear if the thrombectomy method influences clinical outcome and FPR rate. This study evaluates whether stent retriever and aspiration based thrombectomy differ in FPR rate, technical and clinical outcomes in FPR, and multiple pass reperfusion (MPR). METHODS This retrospective, nationwide, multicenter registry study included consecutive patients with proximal anterior or posterior circulation stroke, treated between 2018 and 2021 in Sweden. Outcome measures were FPR rate, procedure time, early neurological improvement (≥4 points on National Institutes of Health Stroke Scale (NIHSS) or a score of 0-1 at 24 hours), favorable functional outcome (modified Rankin Scale score of 0-2 or no decline at 90 days), and mortality at 90 days. RESULTS Of 3309 patients (median age 75, median NIHSS 16), 1990 underwent stent retriever and 1319 aspiration based thrombectomy as the firstline method. No difference in FPR rate was observed. Aspiration based thrombectomy showed a shorter procedure time in the FPR group (crude OR (cOR) 6.4 min (95% CI 3.4 to 9.3), adjusted OR (aOR) 8.7 min (95% CI 1.8 to 15.6)) and MPR group (cOR 9.7 min (95% CI 4.0 to 15.4), aOR 17.4 min (95% CI 9.6 to 25.2)), and association with early neurological improvement (cOR 1.21 (95% CI 1.03 to 1.42), aOR 1.40 (95% CI 1.18 to 1.67)) and favorable functional outcome (aOR 1.22 (95% CI 1.01 to 1.47)). CONCLUSIONS Our findings suggest that aspiration based thrombectomy was associated with a shorter procedure time and better clinical outcomes than treatment with a stent retriever. No difference was found in FPR rate.
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Affiliation(s)
- Adrian Karlsson
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Radiology, Section of Diagnostic and Interventional Neuroradiology, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Katarina Jood
- Department of Neurology, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
- Department of Clinical Neuroscience, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Isabella Björkman-Burtscher
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Radiology, Section of Diagnostic and Interventional Neuroradiology, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
| | - Alexandros Rentzos
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
- Department of Radiology, Section of Diagnostic and Interventional Neuroradiology, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
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Dallas J, Nguyen VN, Sequeiros JM, Graham S, Burns-Martin J, Goyal N, Khatibi K. Distal mechanical thrombectomy using beveled tip aspiration zoom catheters: A preliminary study. Interv Neuroradiol 2024:15910199241258289. [PMID: 38831628 DOI: 10.1177/15910199241258289] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/05/2024] Open
Abstract
INTRODUCTION Distal medium vessel occlusion (DVO) thrombectomy has been shown to be efficacious with safety profiles comparable to large vessel occlusion (LVO) thrombectomy. A novel, highly-trackable, bevel-tipped Zoom 35 catheter can be used as an aspiration catheter for DVO thrombectomy. METHODS This is a retrospective, single-arm, multi-institutional observational study evaluating the efficacy and safety of aspiration thrombectomy for DVO using the Zoom 35 catheter. Patient demographics, presenting and discharge NIHSS, primary and rescue thrombectomy, site of occlusion, TICI score, and intracranial hemorrhage were chart abstracted. Descriptive statistics were used to evaluate the efficacy and safety of thrombectomy. RESULTS Fourteen patients (mean age 66.64 ± 13.75 years) were included. The mean NIHSS at presentation was 10.79 ± 5.48, and the mean ASPECTS was 9.00 ± 0.89. Nine patients (64.3%) received tPA. Primary occlusion location was M3 in nine cases (64.3%), M2/M3 junction in two cases (14.3%), A2 in one case (7.1%), A3 in one case (7.1%), and P1 in one case (7.1%). TICI scores were 3 in seven cases (50.0%), 2C in three cases (21.4%), and 2B in four cases (28.6%). There was one postoperative SAH (7.1%) and one asymptomatic ICH (7.1%). Mean discharge NIHSS was 3.38 ± 4.44, with a mean decrease of 7.31 from presentation (p < 0.0001, t-test). CONCLUSION Zoom 35 beveled-tip aspiration microcatheters are highly trackable and associated with improved radiographic and clinical outcomes for the treatment of DVO with a good safety profile.
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Affiliation(s)
- Jonathan Dallas
- Department of Neurological Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - Vincent N Nguyen
- Department of Neurological Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
| | - Joel M Sequeiros
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Shelby Graham
- University of Tennessee Health Science Center College of Medicine, Memphis, TN, USA
| | - Jared Burns-Martin
- New York Institute of Technology College of Medicine, Glen Head, NY, USA
| | - Nitin Goyal
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Kasra Khatibi
- Department of Neurological Surgery, Keck School of Medicine of University of Southern California, Los Angeles, CA, USA
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7
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Wischmann J, Zimmermann H, Keidel L, Liebig T, Nolte CH, Kellert L. Aspiration only versus stent retriever only thrombectomy in basilar artery occlusion: a propensity score-matched analysis of the German Stroke Registry. J Neurointerv Surg 2024:jnis-2024-021797. [PMID: 38772571 DOI: 10.1136/jnis-2024-021797] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2024] [Accepted: 04/24/2024] [Indexed: 05/23/2024]
Abstract
BACKGROUND Endovascular treatment has become the standard care for acute basilar artery occlusion (BAO). Uncertainty persists about the optimal thrombectomy technique. OBJECTIVE To compare aspiration thrombectomy with stent retriever thrombectomy in patients with BAO in a multicenter real-world patient population. METHODS We analyzed data from the German Stroke Registry-Endovascular Treatment (GSR-ET). Patients with isolated BAO who underwent either aspiration or stent retriever thrombectomy were compared, including propensity score matching (PSM). The primary outcome measure was the modified Rankin Scale shift analysis at 90 days. Secondary outcomes included symptomatic intracranial hemorrhage (sICH), procedure complications, and metrics. RESULTS Of 13 082 patients in the GSR-ET, 387 patients (mean age 72.0±13.1 years; 45.0% female) fulfilled the inclusion criteria. The thrombectomy technique was aspiration only in 195 (50.4%) and stent retriever only in 192 (49.6%) patients. Functional outcome did not differ between the groups, either before (common OR (cOR) 0.94; 95% CI 0.64 to 1.38) or after PSM (cOR=1.37; 95% CI 0.90 to 2.09). There was no significant difference in sICH (2.6 vs 5.5%; P=0.231; OR=0.46; 95% CI 0.14 to 1.47), but aspiration thrombectomy demonstrated fewer procedure-related complications (4.6% vs 12.5%; P=0.017), a shorter procedure duration (24 vs 48 min; P<0.001), and higher first pass recanalization rates (75.1% vs 44.8%; P<0.001). CONCLUSIONS In this study both aspiration and stent retriever thrombectomy showed equal efficacy in terms of functional outcome in patients with BAO. However, procedure complications and metrics might favor aspiration over stent retriever thrombectomy.
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Affiliation(s)
- Johannes Wischmann
- Department of Neurology, Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
| | - Hanna Zimmermann
- Institute for Neuroradiology, Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
| | - Linus Keidel
- Department of Neurology, Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
| | - Thomas Liebig
- Institute for Neuroradiology, Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
| | - Christian H Nolte
- Department of Neurology, Charité - Universitätsmedizin Berlin, Berlin, Germany
- Center for Stroke Research Berlin (CSB), Charité - Universitätsmedizin Berlin, Berlin, Germany
- Berlin Institute of Health (BIH) at Charité - Universitätsmedizin Berlin, Berlin, Germany
- German Center for Cardiovascular Research (DZHK), Partner Site, Berlin, Germany
| | - Lars Kellert
- Department of Neurology, Ludwig-Maximilians-University (LMU) Munich, Munich, Germany
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Yang W, Lee RP, Hung AL, Young CC, Sattari SA, Urrutia V, Gailloud PE, Xu R, Caplan J, Gonzalez LF. Cost-Effectiveness of a Direct-Aspiration First-Pass Technique versus Stent Retriever in Mechanical Thrombectomy. World Neurosurg 2024; 183:e495-e501. [PMID: 38159607 DOI: 10.1016/j.wneu.2023.12.129] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Revised: 12/22/2023] [Accepted: 12/23/2023] [Indexed: 01/03/2024]
Abstract
OBJECTIVE A direct-aspiration first-pass technique (ADAPT) in mechanical thrombectomy has been described in recent studies as an efficacious strategy compared with using a stent retriever (SR). We sought to evaluate for cost differences of ADAPT technique versus SR as an initial approach. METHODS We conducted a retrospective analysis of consecutive patients with mechanical thrombectomy at our institution between 2022 and 2023. Patients were grouped into ADAPT with/without SR as a rescue strategy and SR as an initial approach with allowance of concomitant aspiration. Direct cost data (consumables) were obtained. Baseline demographics, stroke metrics, procedure outcomes and cost, and last follow-up outcomes in modified Rankin Scale were compared between 2 groups. RESULTS Fifty-six patients were included. Thirty-seven (66.1%) underwent ADAPT, with 11 (29.7%) eventually requiring an SR. Mean age was 64.8 years. The average National Institutes of Health Stroke Scale score was 13.2 in the ADAPT group and 14.0 in the SR group (P = 0.68), with a similar proportion of tissue plasminogen activator (P = 0.53), site of occlusion (P = 0.66), and tandem occlusion (P = 0.69) between the groups. Recanalization was achieved in 94.6% of all patients, with an average of 1.9 passes, 89.3% being TICI 2B or above, with no differences between the 2 groups. Significantly lower cost (P < 0.01) was observed in ADAPT ($14,243.4) compared with SR ($19,003.6). Average follow-up duration was 180.2 days, with mortality of 23.2%. At last follow-up, 55.4% remained functionally independent (modified Rankin Scale score <3) with no difference (P = 0.56) between the ADAPT (59.5%) and SR (47.4%) groups. CONCLUSIONS Outcomes were comparable between the ADAPT and SR groups. ADAPT reduced procedural consumables cost by approximately $5000 (25%), even if stent retrievers were allowed to be used for rescue. Establishing ADPAT as initial approach may bring significant direct cost savings while obtaining similar outcomes.
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Affiliation(s)
- Wuyang Yang
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Ryan P Lee
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Alice L Hung
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Christopher C Young
- Department of Neurosurgery, The University of Texas MD Anderson Cancer Center, Houston, Texas, USA
| | - Shahab Aldin Sattari
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Victor Urrutia
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Philipe E Gailloud
- Division of Interventional Neuroradiology, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Risheng Xu
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - Justin Caplan
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA
| | - L Fernando Gonzalez
- Department of Neurosurgery, Johns Hopkins School of Medicine, Baltimore, Maryland, USA.
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Alkhiri A, Alamri AF, Alharbi AR, Almaghrabi AA, Alansari N, Niaz AA, Alghamdi BA, Sarraj A, Alhazzani A, Al-Ajlan FS. Endovascular therapy versus best medical management for isolated posterior cerebral artery occlusion: A systematic review and meta-analysis. Eur Stroke J 2024; 9:69-77. [PMID: 37752802 PMCID: PMC10916830 DOI: 10.1177/23969873231201715] [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: 07/31/2023] [Accepted: 08/31/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND AND PURPOSE Isolated posterior cerebral artery occlusions (iPCAO) were underrepresented in pivotal randomized clinical trial (RCTs) of endovascular thrombectomy (EVT) in ischemic stroke, and the benefit of EVT in this population is still indeterminate. We performed a systematic review and a meta-analysis to compare the safety and efficacy of EVT compared to best medical management (BMM) in patients with iPCAO. METHODS We searched Medline/PubMed, Embase, Web of Science, and the Cochrane databases up to May 2023 for eligible studies reporting outcomes of patients with iPCAO treated with EVT or BMM. We pooled odds ratios (ORs) with corresponding 95% confidence intervals (CI) using a random-effects model. RESULTS Seven studies involving 2560 patients were included. EVT was associated with significantly higher likelihood of early neurological improvement (OR, 2.31 [95% CI, 1.38-2.91]; p < 0.00001) and visual field normalization (OR, 3.08 [95% CI, 1.76-5.38]; p < 0.0001) compared to BMM. Rates of good functional outcomes (mRS 0-2) were comparable between the two arms (OR, 0.88 [95% CI, 0.70-1.10]; p = 0.26). Symptomatic intracranial hemorrhage (sICH) was comparable between the two groups (OR, 1.94 [95% CI, 0.96-3.93]; p = 0.07). Mortality was also similar between the two groups (OR, 1.36; [95% CI, 0.77-2.42]; p = 0.29). CONCLUSIONS In patients with iPCAO, EVT was associated with visual and early neurological improvement but with a strong trend toward increased sICH. Survival and functional outcomes may be slightly poorer. The role of EVT in iPCAO remains uncertain.
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Affiliation(s)
- Ahmed Alkhiri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Aser F Alamri
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia
- King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | | | - Ahmed A Almaghrabi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Nayef Alansari
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Abdulelah A Niaz
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Basil A Alghamdi
- College of Medicine, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, Saudi Arabia
- King Abdullah International Medical Research Center, Jeddah, Saudi Arabia
| | - Amrou Sarraj
- Department of Neurology, Case Western Reserve University School of Medicine, Cleveland, OH, USA
| | - Adel Alhazzani
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
| | - Fahad S Al-Ajlan
- Neuroscience Center, King Faisal Specialist Hospital and Research Centre, Riyadh, Saudi Arabia
- Alfaisal University, Riyadh, Saudi Arabia
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10
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Su J, Hu X, Chen L, Li R, Tao C, Yin Y, Liu H, Tan X, Hou S, Xie S, Huo L, Zhu Y, Gong D, Hu W. Predictors of good outcomes and mortality after thrombectomy for basilar artery occlusion within 12 hours of onset. J Neurointerv Surg 2024:jnis-2023-021057. [PMID: 38228387 DOI: 10.1136/jnis-2023-021057] [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: 09/22/2023] [Accepted: 11/12/2023] [Indexed: 01/18/2024]
Abstract
BACKGROUND Patients with acute basilar artery occlusion (ABAO) who undergo combined standard medical treatment (SMT) and endovascular thrombectomy (EVT) may still have unsatisfactory outcomes. This study was conducted to identify the factors that may impact their outcomes. METHODS We retrospectively reviewed the data of all patients with ABAO combined with SMT and EVT in the endovascular treatment for acute basilar artery occlusion (ATTENTION) trial. A good outcome is defined as a modified Rankin Scale (mRS) score of 0-3, a poor outcome as mRS score of 4-6, and mortality as death at 90-day follow-up. The study analyzed various factors influencing the patients' good outcomes and mortality. RESULTS The study included 221 patients (148 men and 73 women). Among these patients, 45.7% achieved an mRS score of 0-3, while the overall mortality rate was 37.1% (82/221). A good outcome was significantly associated with younger age (adjusted OR 0.96; 95% CI 0.93 to 0.99; P=0.019), a baseline posterior circulation Alberta Stroke Program Early CT Score (pc-ASPECTS) of 8-10 (adjusted OR 2.34; 95% CI 1.07 to 5.12; P=0.034), and post-procedure pc-ASPECTS of 8-10 (adjusted OR 1.40; 95% CI 1.07 to 1.84; P=0.013). Additionally, time from puncture to reperfusion (adjusted OR 2.02; 95% CI 1.2 to 3.41; P=0.008) and intracranial hemorrhage (adjusted OR 3.59; 95% CI 1.09 to 11.8; P=0.035) were associated with 90-day mortality. CONCLUSIONS Younger age, baseline pc-ASPECTS of 8-10, and higher post-procedure pc-ASPECTS could effectively predict good outcomes for patients with ABAO undergoing EVT. Additionally, a prolonged time from puncture to reperfusion and intracranial hemorrhage can independently predict mortality. TRIAL REGISTRATION NUMBER NCT04751708.
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Affiliation(s)
- Junfeng Su
- Department of Neurology, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, People's Republic of China
| | - Xiaohui Hu
- Department of Neurology, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, People's Republic of China
| | - Li Chen
- Department of Neurology, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, People's Republic of China
| | - Rui Li
- Stroke Center and Department of Neurology, First Affiliated Hospital of the University of Science and Technology of China, Hefei, People's Republic of China
| | - Chunrong Tao
- Stroke Center and Department of Neurology, First Affiliated Hospital of the University of Science and Technology of China, Hefei, People's Republic of China
| | - Yamei Yin
- Stroke Center and Department of Neurology, First Affiliated Hospital of the University of Science and Technology of China, Hefei, People's Republic of China
| | - Huanhuan Liu
- Department of Neurology, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, People's Republic of China
| | - Xianhong Tan
- Department of Neurology, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, People's Republic of China
| | - Siyang Hou
- Department of Neurology, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, People's Republic of China
| | - Sanpin Xie
- Department of Neurology, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, People's Republic of China
| | - Longwen Huo
- Department of Neurology, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, People's Republic of China
| | - Yuyou Zhu
- Stroke Center and Department of Neurology, First Affiliated Hospital of the University of Science and Technology of China, Hefei, People's Republic of China
| | - Daokai Gong
- Department of Neurology, Jingzhou Hospital Affiliated to Yangtze University, Jingzhou, People's Republic of China
| | - Wei Hu
- Stroke Center and Department of Neurology, First Affiliated Hospital of the University of Science and Technology of China, Hefei, People's Republic of China
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11
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Ye G, Cao R, Chen P, Wang H, Wang D, Chen M, Li Z. Network meta-analysis of first-line thrombectomy strategy for acute posterior circulation strokes: a preliminary evaluation for combined approach. Front Neurol 2023; 14:1279233. [PMID: 38020623 PMCID: PMC10654789 DOI: 10.3389/fneur.2023.1279233] [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: 08/17/2023] [Accepted: 10/20/2023] [Indexed: 12/01/2023] Open
Abstract
Objective Thrombectomy may provide superior results compared to best medical care for acute posterior circulation strokes (PCS). Contact aspiration (CA), stent retriever (SR), and combined SR + CA (SRA) are commonly employed as first-line techniques. However, the optimal strategy and the role of SRA remain uncertain. Methods Systematic searching was conducted in three databases (PubMed, Embase, and Cochrane). Network meta-analyzes were performed using random-effects models. The reperfusion and clinical outcomes were compared. Pooled outcomes were presented as odds ratios (OR) with 95% confidence intervals (CI). Rankograms with surface under the cumulative ranking curve (SUCRA) were calculated. Results Seventeen studies were included, involving a total of 645 patients who received first-line CA, 850 patients who received SR, and 166 patients who received SRA. Regarding final recanalization outcomes, both first-line SRA (OR = 3.2, 95%CI 1.4-11.0) and CA (OR = 2.1, 95%CI 1.3-3.7) demonstrated superiority over SR in achieving successful reperfusion [modified Thrombolysis In Cerebral Infarction (mTICI) 2b-3], with values of SUCRA 91.1, 58.5, and 0.4%, respectively. In addition, first-line SRA showed an advantage in achieving final mTICI 2c/3 compared to CA (OR = 3.6, 95%CI 0.99-16.0) and SR (OR = 6.4, 95%CI 1.3-35.0), with SUCRA value of 98.0, 44.7, and 7.2%, respectively. Regarding reperfusion outcome after the first pass, SRA also achieved a higher rate of mTICI 3 than SR (OR = 4.1, 95%CI 1.3-14.0), while CA did not (SUCRA 97.4, 4.6, 48.0%). In terms of safety outcomes, first-line CA was associated with a lower incidence of symptomatic intracranial hemorrhage (sICH) compared to SR (OR = 0.38, 95%CI 0.1-1.0), whereas the SRA technique did not (SUCRA 15.6, 78.6, 55.9%). Regarding clinical prognosis, first-line CA achieved a higher proportion of functional independence (modified Rankin Scale (mRS) 0-2) at 90 days than SR (OR = 1.4, 95%CI 1.1-1.9), whereas SRA did not (SUCRA 90.5, 17.4, 42.1%). Conclusion For acute PCS, a first-line CA strategy yielded better results in terms of final successful reperfusion and 90-day functional independence compared to SR. As the combined technique, first-line SRA was associated with superior first-pass and final reperfusion outcomes compared to SR. However, no significant difference was observed in functional independence achieved by first-line SRA compared to the other two strategies. Further high-quality studies are warranted.
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Affiliation(s)
- Gengfan Ye
- Department of Neurosurgery, Ningbo Medical Center Lihuili Hospital, Ningbo, China
| | - Ruoyao Cao
- Department of Radiology, Beijing Hospital, National Center of Gerontology; Institute of Geriatric Medicine, Chinese Academy of Medical Sciences, Beijing, China
- Graduate School of Peking Union Medical College, Beijing, China
| | - Pandi Chen
- Department of Neurosurgery, Ningbo Medical Center Lihuili Hospital, Ningbo, China
| | - Hongcai Wang
- Department of Neurosurgery, Ningbo Medical Center Lihuili Hospital, Ningbo, China
| | - Dongfeng Wang
- Department of Neurosurgery, Ningbo Medical Center Lihuili Hospital, Ningbo, China
| | - Maosong Chen
- Department of Neurosurgery, Ningbo Medical Center Lihuili Hospital, Ningbo, China
| | - Zhenqiang Li
- Department of Neurosurgery, Ningbo Medical Center Lihuili Hospital, Ningbo, China
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12
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Findlay MC, Grandhi R, Nelson JR, Lucke-Wold B, Chowdhury MAB, Hoh BL, Steinberg J, Santiago-Dieppa D, Khalessi A, Ikeda DS, Ravindra VM. How do children fare compared with adults? Comparing relative outcomes after thrombectomy for acute ischemic stroke due to large-vessel occlusion. J Stroke Cerebrovasc Dis 2023; 32:107350. [PMID: 37717373 DOI: 10.1016/j.jstrokecerebrovasdis.2023.107350] [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: 07/06/2023] [Revised: 08/25/2023] [Accepted: 09/07/2023] [Indexed: 09/19/2023] Open
Abstract
OBJECTIVE Safety and efficacy data for endovascular thrombectomy for acute ischemic stroke secondary to large-vessel occlusion in children are lacking compared with those for adults. We undertook an updated systematic review and meta-analysis of endovascular thrombectomy in children and compared their outcomes with adult data. METHODS We searched PubMed, Medline, and EMBASE databases to identify prospective and retrospective studies describing patients <18 years treated with endovascular thrombectomy for acute ischemic stroke due to large-vessel occlusion. RESULTS Eight pediatric studies were included (n = 192). Most patients were male (53.1 %), experienced anterior circulation large-vessel occlusion (81.8 %), and underwent endovascular thrombectomy by stent retreiver (70.7 %). The primary outcome was change in National Institutes of Health Stroke Scale score from presentation to 24 h after thrombectomy. Secondary outcomes included modified Rankin scale score improvement and 90-day score, recanalization rates, procedural complications, and mortality rates. After treatment, 88.5% of children had successful recanalization; the mean National Institutes of Health Stroke Scale score reduction was 7.37 (95 % CI 5.11-9.63, p < 0.01). The mean reduction of 6.87 (95 %CI 5.00-8.73, p < 0.01) for adults in 5 clinical trials (n = 634) was similar (Qb = 0.11; p = 0.74). Children experienced higher rates of good neurological outcome (76.1 % vs. 46.0 %, p < 0.01) and revascularization (88.5 % vs. 72.3 %, p < 0.01), fewer major periprocedural complications (3.6 % vs. 30.4 %, p < 0.01), and lower mortality (1.0 % vs. 12.9 %, p < 0.01). CONCLUSIONS Endovascular thrombectomy may be safe and effective treatment for acute ischemic stroke due to large-vessel occlusion in children. The aggregated data demonstrated high rates of revascularization, favorable long-term neurological outcomes, and low complication rates.
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Affiliation(s)
- Matthew C Findlay
- School of Medicine, University of Utah, 30 North 1900 East, Salt Lake City, UT 84132, USA
| | - Ramesh Grandhi
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Dr. E, Salt Lake City, UT 84132, USA
| | - Jayson R Nelson
- School of Medicine, University of Utah, 30 North 1900 East, Salt Lake City, UT 84132, USA
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, 1505 SW Archer Rd., Gainesville, FL 32608, USA
| | | | - Brian L Hoh
- Department of Neurosurgery, University of Florida, 1505 SW Archer Rd., Gainesville, FL 32608, USA
| | - Jeffrey Steinberg
- Department of Neurosurgery, University of California San Diego, 9500 Gilman Dr., La Jolla, CA 92093, USA
| | - David Santiago-Dieppa
- Department of Neurosurgery, University of California San Diego, 9500 Gilman Dr., La Jolla, CA 92093, USA
| | - Alexander Khalessi
- Department of Neurosurgery, University of California San Diego, 9500 Gilman Dr., La Jolla, CA 92093, USA
| | - Daniel S Ikeda
- Department of Neurosurgery, Walter Reed National Military Medical Center, 4494 Palmer Rd. N, Bethesda, MD 20814, USA
| | - Vijay M Ravindra
- Department of Neurosurgery, Clinical Neurosciences Center, University of Utah, 175 N. Medical Dr. E, Salt Lake City, UT 84132, USA; Department of Neurosurgery, University of California San Diego, 9500 Gilman Dr., La Jolla, CA 92093, USA; Department of Neurological Surgery, Naval Medical Center San Diego, 34800 Bob Wilson Dr., San Diego, CA 92134, USA.
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13
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Kaneko N, Sakuta K, Imahori T, Gedion H, Ghovvati M, Tateshima S. Devices and Techniques. JOURNAL OF NEUROENDOVASCULAR THERAPY 2023; 17:257-262. [PMID: 38025255 PMCID: PMC10657731 DOI: 10.5797/jnet.ra.2023-0054] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/01/2023] [Accepted: 09/06/2023] [Indexed: 12/01/2023]
Abstract
This extensive review explores the intricacies of the three principal mechanical thrombectomy techniques: the stent retriever technique, contact aspiration technique, and a combined approach, and their application in managing acute ischemic stroke. Each technique operates uniquely on the thrombus, leading to differences in their efficacy. Factors including clot size, clot stiffness, vessel tortuosity, and the angle of interaction between the aspiration catheter and the clot significantly influence these differences. Clinical trials and meta-analyses have shown the overall equivalency of these techniques for the treatments of large vessel occlusion and distal medium vessel occlusions. However, there are nuanced differences that emerge under specific clinical circumstances, highlighting the absence of a one-size-fits-all strategy in acute ischemic stroke management. We emphasize the need for future investigations to elucidate these nuances further, aiming to refine procedural strategies and individualize patient care for optimal outcomes.
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Affiliation(s)
- Naoki Kaneko
- Division of Interventional Neuroradiology, Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Kenichi Sakuta
- Division of Interventional Neuroradiology, Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Taichiro Imahori
- Division of Interventional Neuroradiology, Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
- Department of Neurosurgery, Kita-harima Medical Center, Ono, Hyogo, Japan
| | | | - Mahsa Ghovvati
- Division of Interventional Neuroradiology, Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Satoshi Tateshima
- Division of Interventional Neuroradiology, Department of Radiological Sciences, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
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14
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Mierzwa AT, Al Kasab S, Nelson A, Ortega Gutierrez S, Vivanco-Suarez J, Farooqui M, Jadhav AP, Desai S, Toth G, Alrohimi A, Nguyen TN, Klein P, Abdalkader M, Salahuddin H, Pandey A, Koduri S, Vora N, Aladamat N, Gharaibeh K, Afreen E, Zaidi S, Jumaa M. Comparing Functional Outcomes and Safety Profiles of First-Line Aspiration Thrombectomy Versus Stentriever for Acute Basilar Artery Occlusion: Propensity Analysis of the PC-SEARCH Thrombectomy Registry. Stroke 2023; 54:2512-2521. [PMID: 37747965 DOI: 10.1161/strokeaha.123.043579] [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: 04/17/2023] [Accepted: 08/03/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Aspiration catheters (ASPs) and stentriever thrombectomy devices have comparable safety and efficacy in anterior circulation ischemic strokes. However, there is lack of high-quality comparative data in acute basilar artery occlusions. Our objective is to compare the outcomes and safety of ASPs and stentriever devices in acute basilar artery occlusions. METHODS This is an analysis of the retrospectively established PC-SEARCH Thrombectomy (Posterior-Circulation Ischemic Stroke Evaluation: Analyzing Radiographic and Intraprocedural Predictors for Mechanical Thrombectomy) registry. Patients were dichotomized based on their first-line thrombectomy device (ASP and stentriever) and associated with their 90-day functional outcomes, intraprocedural metrics, and safety measures. Propensity analysis based on unequal baseline characteristics was performed. Consecutive patients with acute basilar artery occlusions who received mechanical thrombectomy were included from January 2015 to December 2021. Patients received either first-line contact aspiration or stentriever mechanical thrombectomy. Primary clinical and safety outcomes were 90-day functional independence measured by a modified Rankin Scale score of 0 to 3 and symptomatic intracranial hemorrhage, respectively. Secondary outcomes included puncture-recanalization times, first-pass recanalization rates, crossovers to other thrombectomy device, and neurological/hospital complications. RESULTS Five hundred eighteen patients were included in the registry, and a total of 383 patients were included (mean [SD] age, 65.5 [15] years; 228 [59%] men) in this analysis. Of these, 219 patients were first-line ASP while 164 patients received first-line stentriever devices. Median premorbid modified Rankin Scale was zero and median presenting National Institutes of Health Stroke Scale was 17 (interquartile range, 8-26). The proportion of favorable functional outcome was similar between the 2 techniques before (47.3% versus 42.5%; odds ratio, 1.22 [95% CI, 0.78-1.89]; P=0.38) and after propensity matching (odds ratio, 1.46 [95% CI, 0.85-2.49]; P=0.17). In our propensity-matched cohorts, puncture-recanalization times (18 versus 52 minutes; P<0.01) favored first-line ASP; however, first-pass recanalization rates (43.5% versus 44.5%; P=0.90) were similar between groups. First-line ASP was associated with higher rates of crossover (22% versus 6%; P<0.01), whereas stentriever was associated with higher rates of symptomatic intracranial hemorrhage (9.8% versus 3.4%; P=0.04). CONCLUSIONS First-line ASP and stentriever methods demonstrated similar functional outcome and recanalization rates. Stentriever methods were associated with higher rates of symptomatic intracranial hemorrhage, whereas ASPs were associated with higher rates of crossover to alternative technique in patients with acute basilar occlusions.
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Affiliation(s)
- Adam T Mierzwa
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, OH (A.T.M., N.A., K.G., E.A., S.Z., M.J.)
- Promedica Stroke Network, Toledo, OH (A.T.M., E.A., S.Z., M.J.)
| | - Sami Al Kasab
- Department of Neurology and Neurosurgery, Medical University of South Carolina, Charleston (S.A.K., A.N.)
| | - Ashley Nelson
- Department of Neurology and Neurosurgery, Medical University of South Carolina, Charleston (S.A.K., A.N.)
| | | | | | | | - Ashutosh P Jadhav
- Department of Neurology, University of Pittsburgh Medical Center, PA (A.P.J., S.D.)
| | - Shashvat Desai
- Department of Neurology, University of Pittsburgh Medical Center, PA (A.P.J., S.D.)
| | - Gabor Toth
- Cleveland Clinic Foundation, OH (G.T., A.A.)
| | | | - Thanh N Nguyen
- Department of Neurology, Radiology, Boston University Chobanian and Avedisian School of Medicine, MA (T.N.N., P.K., M.A.)
| | - Piers Klein
- Department of Neurology, Radiology, Boston University Chobanian and Avedisian School of Medicine, MA (T.N.N., P.K., M.A.)
| | - Mohamad Abdalkader
- Department of Neurology, Radiology, Boston University Chobanian and Avedisian School of Medicine, MA (T.N.N., P.K., M.A.)
| | - Hisham Salahuddin
- Department of Neurology, Antelope Valley Hospital, Los Angeles, CA (H.S.)
| | - Aditya Pandey
- Department of Neurosurgery, University of Michigan, Ann Arbor (A.P., S.K.)
| | - Sravanthi Koduri
- Department of Neurosurgery, University of Michigan, Ann Arbor (A.P., S.K.)
| | - Niraj Vora
- Ohio Health Riverside Methodist Hospital, Columbus (N.V.)
| | - Nameer Aladamat
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, OH (A.T.M., N.A., K.G., E.A., S.Z., M.J.)
| | - Khaled Gharaibeh
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, OH (A.T.M., N.A., K.G., E.A., S.Z., M.J.)
| | - Ehad Afreen
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, OH (A.T.M., N.A., K.G., E.A., S.Z., M.J.)
- Promedica Stroke Network, Toledo, OH (A.T.M., E.A., S.Z., M.J.)
| | - Syed Zaidi
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, OH (A.T.M., N.A., K.G., E.A., S.Z., M.J.)
- Promedica Stroke Network, Toledo, OH (A.T.M., E.A., S.Z., M.J.)
| | - Mouhammad Jumaa
- Department of Neurology, University of Toledo College of Medicine and Life Sciences, OH (A.T.M., N.A., K.G., E.A., S.Z., M.J.)
- Promedica Stroke Network, Toledo, OH (A.T.M., E.A., S.Z., M.J.)
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15
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Räty S, Nguyen TN, Nagel S, Puetz V, Alemseged F, Abdalkader M, Schonewille WJ, Strbian D. What Is the Evidence for Endovascular Thrombectomy in Posterior Circulation Stroke? Semin Neurol 2023; 43:345-355. [PMID: 37595603 DOI: 10.1055/s-0043-1771210] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/20/2023]
Abstract
Posterior circulation infarcts comprise approximately 25% of ischemic strokes but are less often treated with recanalization therapy and have longer treatment delays compared with anterior circulation strokes. Among posterior circulation strokes, basilar artery occlusion is associated with the most severe deficits and the worst prognosis. Endovascular thrombectomy is a standard of care for patients with anterior circulation large vessel occlusion, but not until recently were the first randomized controlled trials on endovascular thrombectomy in basilar artery occlusion published. Two of the trials were neutral, whereas two others showed better functional outcome after thrombectomy up to 24 hours of symptom onset compared with best medical treatment, which in most cases had low rates of intravenous thrombolysis. According to observational data, thrombectomy seems to be safe also in isolated posterior cerebral artery occlusions and might be an option for selected patients, even if its outcome benefit is yet to be demonstrated.
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Affiliation(s)
- Silja Räty
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Thanh N Nguyen
- Department of Neurology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | - Simon Nagel
- Department of Neurology, Klinikum Ludwigshafen, Ludwigshafen/Rhein, Germany
- Department of Neurology, Heidelberg University Hospital, Heidelberg, Germany
| | - Volker Puetz
- Department of Neurology, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
- Dresden Neurovascular Center, University Hospital Carl Gustav Carus, Technische Universität Dresden, Dresden, Germany
| | - Fana Alemseged
- Department of Medicine and Neurology, Melbourne Brain Centre at the Royal Melbourne Hospital, University of Melbourne, Parkville, Victoria, Australia
| | - Mohamad Abdalkader
- Department of Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, Massachusetts
| | | | - Daniel Strbian
- Department of Neurology, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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16
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Catalano M, Crimi L, Belfiore G, Grippaldi D, David E, Spatola C, Cristaudo C, Foti PV, Palmucci S, Basile A. Congenital and acquired anomalies of the basilar artery: A pictorial essay. Neuroradiol J 2023:19714009231177412. [PMID: 37210636 DOI: 10.1177/19714009231177412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/22/2023] Open
Abstract
INTRODUCTION The basilar artery is one of the two cases in our body where an arterial vessel is formed by the union of two others - the vertebral arteries. It provides vascular supply to essential structures for the main vital functions; the posterior cerebral arteries originate from it as terminal branches, and form part of the anastomotic circle of Willis. IMAGING FINDINGS Congenital and acquired anomalies of the basilar trunk are described. We provide a schematic and detailed representation of normal anatomical variants - mainly represented by the fenestrated basilar artery or the persistence of carotid-basilar anastomosis; course anomalies are also illustrated, with reference to neuro-vascular conflicts and dolichoectasia. Among congenital anomalies, this pictorial review also shows the variants of the basilar origin, such as in the case of basilar trunk arising from only one of the two vertebral arteries, and the calibre changes - which are represented by aneurysm and hypoplasia. The latter appears to be a risk factor for posterior circulation stroke, when associated with a bilateral posterior foetal variant.Among the acquired forms, this pictorial essay describes some clinical cases of dissections, non-congenital aneurysms, thrombosis and tumour with vascular encasing or compression of basilar artery. CONCLUSION CT angiography and MRI allow us to study the posterior intracranial circulation in detail, providing useful pre-treatment information. Therefore, knowledge of congenital or acquired anomalies of the basilar artery is essential for radiologists, neuroradiologists and neurosurgeons.
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Affiliation(s)
- Marco Catalano
- Department of Medical Surgical Sciences and Advanced Technologies "GF Ingrassia", University Hospital Policlinico "G. Rodolico-San Marco", Italy
| | - Luca Crimi
- Department of Medical Surgical Sciences and Advanced Technologies "GF Ingrassia", University Hospital Policlinico "G. Rodolico-San Marco", Italy
| | - Giuseppe Belfiore
- Department of Medical Surgical Sciences and Advanced Technologies "GF Ingrassia", University Hospital Policlinico "G. Rodolico-San Marco", Italy
| | - Daniele Grippaldi
- Department of Medical Surgical Sciences and Advanced Technologies "GF Ingrassia", University Hospital Policlinico "G. Rodolico-San Marco", Italy
| | - Emanuele David
- Department of Medical Surgical Sciences and Advanced Technologies "GF Ingrassia", University Hospital Policlinico "G. Rodolico-San Marco", Italy
| | - Corrado Spatola
- Department of Medical Surgical Sciences and Advanced Technologies "GF Ingrassia", University Hospital Policlinico "G. Rodolico-San Marco", Italy
| | - Concetto Cristaudo
- UOC Neuroradiologia, Azienda Ospedaliera per L'Emergenza Cannizzaro, Italy
| | - Pietro Valerio Foti
- Department of Medical Surgical Sciences and Advanced Technologies "GF Ingrassia", University Hospital Policlinico "G. Rodolico-San Marco", Italy
| | - Stefano Palmucci
- Department of Medical Surgical Sciences and Advanced Technologies "GF Ingrassia", University Hospital Policlinico "G. Rodolico-San Marco", Italy
| | - Antonio Basile
- Department of Medical Surgical Sciences and Advanced Technologies "GF Ingrassia", University Hospital Policlinico "G. Rodolico-San Marco", Italy
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17
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Siddiqi AZ, Wadhwa A. Treatment of Acute Stroke: Current Practices and Future Horizons. CARDIOVASCULAR REVASCULARIZATION MEDICINE 2023; 49:56-65. [PMID: 36443221 DOI: 10.1016/j.carrev.2022.11.012] [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: 07/20/2022] [Revised: 11/06/2022] [Accepted: 11/22/2022] [Indexed: 11/27/2022]
Abstract
PURPOSE This review will discuss revascularization of acute ischemic stroke (AIS), discussing the concept of the ischemic penumbra and how thrombolysis and thrombectomy take advantage of it. SUMMARY The goal of AIS revascularization is to rescue the ischemic penumbra and the approach to has gone from a time-based to tissue-based approach. Patients must be carefully selected for thrombolysis, which traditionally was limited to those whose last known normal time (LKNT) was known and within 4.5 h. However, newer imaging techniques involving MRI and CT perfusion (CTP) can select patients for thrombolysis whose LKNT is unknown. Alteplase, or tPA, is still the agent of choice for thrombolysis in patients with AIS but tenecteplase (TNK) may be just as effective and more efficient to use. Endovascular thrombectomy (EVT) has shown considerable efficacy for treating large-vessel occlusions and using CTP, patients can be selected for hours after symptom-onset if viable tissue remains. Further research is underway to determine if EVT can be used for medium vessel occlusions and for basilar artery thromboses as well as to determine whether an "EVT-alone" strategy is superior to "tPA + EVT" strategy.
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Affiliation(s)
- A Zohaib Siddiqi
- University of Manitoba Max Rady College of Medicine, Winnipeg, Canada.
| | - Ankur Wadhwa
- University of Manitoba Max Rady College of Medicine, Winnipeg, Canada.
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18
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An Update on the Treatment of Basilar Artery Occlusion. Curr Treat Options Neurol 2023. [DOI: 10.1007/s11940-023-00748-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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19
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Endovascular therapy for stroke due to Basilar Artery Occlusion: Challenges and opportunities. J Neuroradiol 2023; 50:42-43. [PMID: 36528085 DOI: 10.1016/j.neurad.2022.12.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2022] [Revised: 12/12/2022] [Accepted: 12/13/2022] [Indexed: 12/15/2022]
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20
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Terceño M, Silva Y, Bashir S, Chamorro Á, Pérez de la Ossa N, Hernandez-Pérez M, Castaño C, Camps-Renom P, Wenger D, Cardona P, Molina C, Rodríguez-Campello A, Cánovas D, Purroy F, Salvat-Plana M, Serena J, On Behalf Of The Catalan Stroke Code And Reperfusion Consortium Cat-Scr. First pass effect in posterior circulation occlusions: Analysis from the CICAT registry. Int J Stroke 2023; 18:221-228. [PMID: 35272563 DOI: 10.1177/17474930221089772] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
BACKGROUND The first pass effect (FPE) is an independent predictor of functional independence in patients with large vessel occlusion in anterior circulation ischemic strokes. However, whether it predicts outcome in posterior circulation large vessel occlusion (PC-LVO) is uncertain. We aimed to study the frequency, characteristics, and predictors of FPE and its association with clinical outcomes in PC-LVO. METHOD We performed an analysis from the prospective CICAT Registry. All patients with PC-LVO who underwent endovascular therapy between January 2016 and January 2020 were included. A centrally assessed clinical follow-up was performed at 3 months by blinded investigators. FPE was defined as the achievement of modified Thrombolysis In Cerebral Infarction 3 in a single pass of the endovascular thrombectomy device, and multi-pass effect (MPE) if it was achieved in more than one pass. A multivariable analysis was performed to identify whether FPE is an independent predictor of functional independence defined as a modified Rankin Score of 0-2. RESULTS We analyzed data from 265 patients in who FPE was achieved in 105 (39.6%). Patients with FPE were more likely to achieve functional independence compared to the non-FPE group (52.4% vs 25.1%, p < .001) and the MPE group (52.4% vs 26.7%, p < .001). FPE was independently associated with functional independence (adjusted odds ratio (aOR): 2.10, 95% confidence interval (CI) 1.01-4.37) but MPE was not (aOR: 0.92, 95% CI 0.40-2.13). Independent predictors of FPE were the use of direct aspiration, embolic mechanism of stroke, and the absence of general anesthesia (GA) use. CONCLUSIONS FPE is an independent predictor of functional independence in PC-LVO and was associated with a significantly better outcome than MPE.
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Affiliation(s)
- Mikel Terceño
- Stroke Unit, Department of Neurology, Girona Biomedical Research Institute (IDIBGI), Doctor Josep Trueta Hospital, Girona, Spain.,Interventional Neuroradiology Unit, Department of Neurosciences, Germans Trias i Pujol Hospital, Badalona, Spain
| | - Yolanda Silva
- Stroke Unit, Department of Neurology, Girona Biomedical Research Institute (IDIBGI), Doctor Josep Trueta Hospital, Girona, Spain
| | - Saima Bashir
- Stroke Unit, Department of Neurology, Girona Biomedical Research Institute (IDIBGI), Doctor Josep Trueta Hospital, Girona, Spain
| | - Ángel Chamorro
- Stroke Unit, Department of Neurology, Clinic Hospital, Barcelona, Spain
| | - Natalia Pérez de la Ossa
- Stroke Unit, Department of Neurosciences, Germans Trias i Pujol Hospital, Badalona, Spain.,Stroke Program/Agency for Health Quality and Assessment of Catalonia, Barcelona, Spain
| | - María Hernandez-Pérez
- Stroke Unit, Department of Neurosciences, Germans Trias i Pujol Hospital, Badalona, Spain
| | - Carlos Castaño
- Interventional Neuroradiology Unit, Department of Neurosciences, Germans Trias i Pujol Hospital, Badalona, Spain
| | - Pol Camps-Renom
- Stroke Unit, Department of Neurology, Santa Creu i Sant Pau Hospital, Barcelona, Spain
| | - Denisse Wenger
- Stroke Unit, Department of Neurosciences, Germans Trias i Pujol Hospital, Badalona, Spain
| | - Pere Cardona
- Stroke Unit, Department of Neurology, Bellvitge Hospital, Barcelona, Spain
| | - Carlos Molina
- Stroke Unit, Department of Neurology, Vall d'Hebron Hospital, Barcelona, Spain
| | | | - David Cánovas
- Stroke Unit, Department of Neurology, Parc Taulí Hospital, Sabadell, Spain
| | - Francisco Purroy
- Stroke Unit, Department of Neurology, Arnau de Vilanova Hospital, IRBLleida, University of Lleida, Lleida, Spain
| | - Mercè Salvat-Plana
- Catalan Stroke Programme, Catalan Public Health Department, Barcelona, Spain
| | - Joaquín Serena
- Stroke Unit, Department of Neurology, Girona Biomedical Research Institute (IDIBGI), Doctor Josep Trueta Hospital, Girona, Spain
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21
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Guo X, Xiong Y, Huang X, Pan Z, Kang X, Chen C, Zhou J, Wang C, Lin S, Hu W, Wang L, Zheng F. Aspiration versus stent retriever for posterior circulation stroke: A meta-analysis. CNS Neurosci Ther 2022; 29:525-537. [PMID: 36513959 PMCID: PMC9873527 DOI: 10.1111/cns.14045] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/28/2022] [Revised: 11/15/2022] [Accepted: 11/16/2022] [Indexed: 12/15/2022] Open
Abstract
AIMS New thrombectomy strategies have emerged recently. Differences between posterior circulation stroke management via aspiration and stent retriever remain to be evaluated. We compared the safety and efficacy of aspiration and stent retriever in treating posterior circulation stroke. METHODS Three databases (PubMed, Embase, and Cochrane Library) were systematically searched for studies comparing aspiration and stent retriever in patients with posterior circulation stroke. The modified Newcastle-Ottawa scale was used to assess the risk of bias. A random-effects model was used. RESULTS Fifteen cohort studies with 1451 patients were included. Pooled results showed a significant difference in total complication (odds ratio [OR] 0.48, 95% confidence interval [CI] [0.30, 0.76], p = 0.002). successful recanalization (1.85, [1.30, 2.64], p = 0.0006), favorable outcome (1.30, [1.02, 1.67], p = 0.04), procedure duration (-22.10, [-43.32, -0.88], p = 0.04), complete recanalization (4.96, [1.06, 23.16], p = 0.009), and first-pass effect (2.59, [1.55, 4.32], p = 0.0003) between the aspiration and stent retriever groups, and in favor of aspiration. There was no significant difference in the outcomes of rescue therapy (1.42, [0.66, 3.05], p = 0.37) between the two groups. CONCLUSION Patients with posterior circulation stroke receiving treatment with aspiration achieved better recanalization, first-pass effect, and shorter procedure time. Aspiration may be more secure than a stent retriever.
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Affiliation(s)
- Xiumei Guo
- Department of NeurologyThe Second Affiliated Hospital, Fujian Medical UniversityQuanzhouChina,Department of NeurosurgeryThe Second Affiliated Hospital, Fujian Medical UniversityQuanzhouChina
| | - Yu Xiong
- Department of NeurosurgeryThe Second Affiliated Hospital, Fujian Medical UniversityQuanzhouChina
| | - Xinyue Huang
- Department of NeurosurgeryThe Second Affiliated Hospital, Fujian Medical UniversityQuanzhouChina
| | - Zhigang Pan
- Department of NeurosurgeryThe Second Affiliated Hospital, Fujian Medical UniversityQuanzhouChina
| | - Xiaodong Kang
- Department of NeurosurgeryThe Second Affiliated Hospital, Fujian Medical UniversityQuanzhouChina
| | - Chunhui Chen
- Department of NeurosurgeryThe Second Affiliated Hospital, Fujian Medical UniversityQuanzhouChina
| | - Jianfeng Zhou
- Department of NeurosurgeryThe Second Affiliated Hospital, Fujian Medical UniversityQuanzhouChina
| | - Cui'e Wang
- Department of NeurosurgeryThe Second Affiliated Hospital, Fujian Medical UniversityQuanzhouChina
| | - Shu Lin
- Centre of Neurological and Metabolic ResearchThe Second Affiliated Hospital of Fujian Medical UniversityQuanzhouChina,Diabetes and Metabolism DivisionGarvan Institute of Medical ResearchSydneyNew South WalesAustralia
| | - Weipeng Hu
- Department of NeurosurgeryThe Second Affiliated Hospital, Fujian Medical UniversityQuanzhouChina
| | - Lingxing Wang
- Department of NeurologyThe Second Affiliated Hospital, Fujian Medical UniversityQuanzhouChina
| | - Feng Zheng
- Department of NeurosurgeryThe Second Affiliated Hospital, Fujian Medical UniversityQuanzhouChina
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22
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Kohli GS, Schartz D, Whyte R, Akkipeddi SM, Ellens NR, Bhalla T, Mattingly TK, Bender MT. Endovascular thrombectomy with or without intravenous thrombolysis in acute basilar artery occlusion ischemic stroke: A meta-analysis. J Stroke Cerebrovasc Dis 2022; 31:106847. [DOI: 10.1016/j.jstrokecerebrovasdis.2022.106847] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 10/16/2022] [Accepted: 10/18/2022] [Indexed: 11/06/2022] Open
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23
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Abstract
One-fifth of strokes occur in the territory of the posterior circulation, but
their management, particularly acute reperfusion therapy and neurointervention
procedures for secondary prevention, has received much less attention than
similar interventions for the anterior circulation. In this review, we overview
the treatment of posterior circulation stroke, including both interventions in
the acute setting and secondary prevention. We focus on areas in which the
management of posterior circulation stroke differs from that of stroke in
general and highlight recent advances. Effectiveness of acute revascularization of posterior circulation strokes remains
in large parts unproven. Thrombolysis seems to have similar benefits and lower
hemorrhage risks than in the anterior circulation. The recent ATTENTION and
BAOCHE trials have demonstrated that thrombectomy benefits strokes with basilar
artery occlusion, but its effect on other posterior occlusion sites remains
uncertain. Ischemic and hemorrhagic space-occupying cerebellar strokes can
benefit from decompressive craniectomy. Secondary prevention of posterior circulation strokes includes aggressive
treatment of cerebrovascular risk factors with both drugs and lifestyle
interventions and short-term dual anti-platelet therapy. Randomized controlled
trial (RCT) data suggest basilar artery stenosis is better treated with medical
therapy than stenting, which has a high peri-procedural risk. Limited data from
RCTs in stenting for vertebral stenosis suggest that intracranial stenosis is
currently best treated with medical therapy alone; the situation for
extracranial stenosis is less clear where stenting for symptomatic stenosis is
an option, particularly for recurrent symptoms; larger RCTs are required in this
area.
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Affiliation(s)
- Hugh S Markus
- Department of Clinical Neurosciences, University of Cambridge, Cambridge UK 2152
| | - Patrik Michel
- Stroke Center, Neurology Service, Department of Clinical Neurosciences, Lausanne University Hospital and University of Lausanne, Switzerland
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24
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Lee SJ, Hong JM, Kim JS, Lee JS. Endovascular Treatment for Posterior Circulation Stroke: Ways to Maximize Therapeutic Efficacy. J Stroke 2022; 24:207-223. [PMID: 35677976 PMCID: PMC9194547 DOI: 10.5853/jos.2022.00941] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/15/2022] [Accepted: 05/20/2022] [Indexed: 11/11/2022] Open
Abstract
The efficacy of endovascular treatment (EVT) in patients with posterior circulation stroke has not been proven. Two recent randomized controlled trials failed to show improved functional outcomes after EVT for posterior circulation stroke (PC-EVT). However, promising results for two additional randomized controlled trials have also been presented at a recent conference. Studies have shown that patients undergoing PC-EVT had a higher rate of futile recanalization than those undergoing EVT for anterior circulation stroke. These findings call for further identification of prognostic factors beyond recanalization. The significance of baseline clinical severity, infarct volume, collaterals, time metrics, core-penumbra mismatch, and methods to accurately measure these parameters are discussed. Furthermore, their interplay on EVT outcomes and the potential to individualize patient selection for PC-EVT are reviewed. We also discuss technical considerations for improving the treatment efficacy of PC-EVT.
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Affiliation(s)
- Seong-Joon Lee
- Department of Neurology, Ajou University School of Medicine, Suwon, Korea
| | - Ji Man Hong
- Department of Neurology, Ajou University School of Medicine, Suwon, Korea
| | - Jong S. Kim
- Department of Neurology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Soo Lee
- Department of Neurology, Ajou University School of Medicine, Suwon, Korea
- Correspondence: Jin Soo Lee Department of Neurology, Ajou University School of Medicine, 164 World cup-ro, Yeongtong-gu, Suwon 16499, Korea Tel: +82-31-219-5175 Fax: +82-31-219-5178 E-mail:
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25
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Meyer L, Stracke P, Wallocha M, Broocks G, Sporns P, Piechowiak EI, Kaesmacher J, Maegerlein C, Hernandez Petzsche MR, Dorn F, Zimmermann H, Naziri W, Abdullayev N, Kabbasch C, Behme D, Jamous A, Maus V, Fischer S, Möhlenbruch M, Weyland CS, Langner S, Meila D, Miszczuk M, Siebert E, Lowens S, Krause LU, Yeo L, Tan B, Gopinathan A, Gory B, Galván-Fernández J, Schüller M, Navia P, Raz E, Shapiro M, Arnberg F, Zeleňák K, Martínez-Galdámez M, Kastrup A, Papanagiotou P, Kemmling A, Psychogios M, Andersson T, Chapot R, Fiehler J, Hanning U. Aspiration Versus Stent Retriever Thrombectomy for Distal, Medium Vessel Occlusion Stroke in the Posterior Circulation: A Subanalysis of the TOPMOST Study. Stroke 2022; 53:2449-2457. [PMID: 35443785 DOI: 10.1161/strokeaha.121.037792] [Citation(s) in RCA: 21] [Impact Index Per Article: 10.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The optimal endovascular strategy for reperfusing distal medium-vessel occlusions (DMVO) remains unknown. This study evaluates angiographic and clinical outcomes of thrombectomy strategies in DMVO stroke of the posterior circulation. METHODS TOPMOST (Treatment for Primary Medium Vessel Occlusion Stroke) is an international, retrospective, multicenter, observational registry of patients treated for DMVO between January 2014 and June 2020. This study analyzed endovascularly treated isolated primary DMVO of the posterior cerebral artery in the P2 and P3 segment. Technical feasibility was evaluated with the first-pass effect defined as a modified Thrombolysis in Cerebral Infarction Scale score of 3. Rates of early neurological improvement and functional modified Rankin Scale scores at 90 days were compared. Safety was assessed by the occurrence of symptomatic intracranial hemorrhage and intervention-related serious adverse events. RESULTS A total of 141 patients met the inclusion criteria and were treated endovascularly for primary isolated DMVO in the P2 (84.4%, 119) or P3 segment (15.6%, 22) of the posterior cerebral artery. The median age was 75 (IQR, 62-81), and 45.4% (64) were female. The initial reperfusion strategy was aspiration only in 29% (41) and stent retriever in 71% (100), both achieving similar first-pass effect rates of 53.7% (22) and 44% (44; P=0.297), respectively. There were no significant differences in early neurological improvement (aspiration: 64.7% versus stent retriever: 52.2%; P=0.933) and modified Rankin Scale rates (modified Rankin Scale score 0-1, aspiration: 60.5% versus stent retriever 68.6%; P=0.4). In multivariable logistic regression analysis, the time from groin puncture to recanalization was associated with the first-pass effect (adjusted odds ratio, 0.97 [95% CI, 0.95-0.99]; P<0.001) that in turn was associated with early neurological improvement (aOR, 3.27 [95% CI, 1.16-9.21]; P<0.025). Symptomatic intracranial hemorrhage occurred in 2.8% (4) of all cases. CONCLUSIONS Both first-pass aspiration and stent retriever thrombectomy for primary isolated posterior circulation DMVO seem to be safe and technically feasible leading to similar favorable rates of angiographic and clinical outcome.
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Affiliation(s)
- Lukas Meyer
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (L.M., P.S., G.B., P.S., J.F., U.H.)
| | - Paul Stracke
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (L.M., P.S., G.B., P.S., J.F., U.H.).,Department of Interventional Neuroradiology, University Hospital Muenster, Germany (P.S.).,Department of Diagnostic and Interventional Neuroradiology, University Hospital Basel, Switzerland (P.S., M.P.)
| | - Marta Wallocha
- Department of Endovascular Therapy, Alfried-Krupp Hospital Essen, Germany (M.W., R.C.)
| | - Gabriel Broocks
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (L.M., P.S., G.B., P.S., J.F., U.H.)
| | - Peter Sporns
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (L.M., P.S., G.B., P.S., J.F., U.H.)
| | - Eike I Piechowiak
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland. (E.I.P., J.K.)
| | - Johannes Kaesmacher
- Institute of Diagnostic and Interventional Neuroradiology, Inselspital, Bern University Hospital, University of Bern, Switzerland. (E.I.P., J.K.).,Institute of Diagnostic, Interventional and Pediatric Radiology, Inselspital, Bern University Hospital, University of Bern, Switzerland. (J.K.)
| | - Christian Maegerlein
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany (C.M., M.R.H.P.)
| | - Moritz Roman Hernandez Petzsche
- Department of Diagnostic and Interventional Neuroradiology, Klinikum rechts der Isar, School of Medicine, Technical University Munich, Munich, Germany (C.M., M.R.H.P.)
| | - Franziska Dorn
- Institute of Neuroradiology, University Hospitals, LMU Munich, Germany (F.D., H.Z.)
| | - Hanna Zimmermann
- Institute of Neuroradiology, University Hospitals, LMU Munich, Germany (F.D., H.Z.)
| | - Weis Naziri
- Department of Neuroradiology, Westpfalz-Klinikum, Kaiserslautern, Germany (W.N.).,Department of Neuroradiology, University Hospital Luebeck, Germany (W.N.)
| | - Nuran Abdullayev
- Department of Neuroradiology, University of Cologne, Germany (N.A., C.K.)
| | - Christoph Kabbasch
- Department of Neuroradiology, University of Cologne, Germany (N.A., C.K.)
| | - Daniel Behme
- Institute for Diagnostic and Interventional Neuroradiology, University Hospital Goettingen, Germany (D.B., A.J.)
| | - Ala Jamous
- Institute for Diagnostic and Interventional Neuroradiology, University Hospital Goettingen, Germany (D.B., A.J.)
| | - Volker Maus
- Department of Diagnostic and Interventional Neuroradiology and Nuclear Medicine, Universitätsklinikum Knappschaftskrankenhaus Bochum, Universitätsklinik der Ruhr-Universität Bochum, Germany (V.M., S.F.)
| | - Sebastian Fischer
- Department of Diagnostic and Interventional Neuroradiology and Nuclear Medicine, Universitätsklinikum Knappschaftskrankenhaus Bochum, Universitätsklinik der Ruhr-Universität Bochum, Germany (V.M., S.F.)
| | - Markus Möhlenbruch
- Department of Neuroradiology, Heidelberg University Hospital, Germany (M.M., C.S.W.)
| | - Charlotte S Weyland
- Department of Neuroradiology, Heidelberg University Hospital, Germany (M.M., C.S.W.)
| | - Sönke Langner
- Institute for Diagnostic and Interventional Radiology, Pediatric and Neuroradiology, University Hospital Rostock, Germany (S.L.)
| | - Dan Meila
- Department of Interventional Neuroradiology, Johanna-Étienne-Hospital, Neuss, Germany (D.M.)
| | - Milena Miszczuk
- Institute of Neuroradiology, Charité Universitätsmedizin Berlin, Germany (M.M., E.S.)
| | - Eberhard Siebert
- Institute of Neuroradiology, Charité Universitätsmedizin Berlin, Germany (M.M., E.S.)
| | - Stephan Lowens
- Department of Radiology, Klinikum Osnabrück, Germany. (S.L.)
| | - Lars Udo Krause
- Department of Neurology, Klinikum Osnabrück, Germany. (L.U.K.)
| | - Leonard Yeo
- Division of Neurology, Department of Medicine, National University Health System, Singapore. (L.Y., B.T.).,Yong Loo Lin School of Medicine, National University of Singapore (L.Y., B.T., A.G.)
| | - Benjamin Tan
- Division of Neurology, Department of Medicine, National University Health System, Singapore. (L.Y., B.T.).,Yong Loo Lin School of Medicine, National University of Singapore (L.Y., B.T., A.G.)
| | - Anil Gopinathan
- Department of Diagnostic imaging, National University Health System, Singapore. (A.G.)
| | - Benjamin Gory
- Yong Loo Lin School of Medicine, National University of Singapore (L.Y., B.T., A.G.).,Université de Lorraine, CHRU-Nancy, Department of Diagnostic and Therapeutic Neuroradiology, France (B.G.).,Université de Lorraine, IADI, INSERM U1254, F-54000 Nancy, France (B.G.)
| | - Jorge Galván-Fernández
- Department of Interventional Neuroradiology, Hospital Clínico Universitario de Valladolid, Spain (J.G.-F., M.S., M.M.-G.)
| | - Miguel Schüller
- Department of Interventional Neuroradiology, Hospital Clínico Universitario de Valladolid, Spain (J.G.-F., M.S., M.M.-G.)
| | - Pedro Navia
- Department of Neuroradiology, Hospital Universitario La Paz, Madrid, Spain (P.N.)
| | - Eytan Raz
- Department of Radiology, New York Langone Medical Center (E.R., M.S.)
| | - Maksim Shapiro
- Department of Radiology, New York Langone Medical Center (E.R., M.S.)
| | - Fabian Arnberg
- Department of Neuroradiology, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (F.A., T.A.)
| | - Kamil Zeleňák
- Department of Radiology, Comenius University's Jessenius Faculty of Medicine and University Hospital, Martin, Slovakia (K.Z.)
| | - Mario Martínez-Galdámez
- Department of Interventional Neuroradiology, Hospital Clínico Universitario de Valladolid, Spain (J.G.-F., M.S., M.M.-G.)
| | - Andreas Kastrup
- Department of Neurology, Hospital Bremen-Mitte, Germany (A.K.)
| | - Panagiotis Papanagiotou
- Department of Diagnostic and Interventional Neuroradiology, Hospital Bremen-Mitte, Germany (P.P.).,Department of Radiology, Areteion University Hospital, National and Kapodistrian University of Athens, Greece (P.P.)
| | - André Kemmling
- Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium (T.A.).,Department of Neuroradiology, University Hospital Marburg, Germany (A.K.)
| | - Marios Psychogios
- Department of Diagnostic and Interventional Neuroradiology, University Hospital Basel, Switzerland (P.S., M.P.)
| | - Tommy Andersson
- Department of Neuroradiology, Karolinska University Hospital and Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden (F.A., T.A.).,Department of Medical Imaging, AZ Groeninge, Kortrijk, Belgium (T.A.)
| | - Rene Chapot
- Department of Endovascular Therapy, Alfried-Krupp Hospital Essen, Germany (M.W., R.C.)
| | - Jens Fiehler
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (L.M., P.S., G.B., P.S., J.F., U.H.)
| | - Uta Hanning
- Department of Diagnostic and Interventional Neuroradiology, University Medical Center Hamburg-Eppendorf, Germany (L.M., P.S., G.B., P.S., J.F., U.H.)
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