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Chong JSX, Phillips T, Massarotto A, Ghia D. Outcomes of endovascular thrombectomy for ischaemic stroke among nonagenarians with and without pre-existing dependency. J Stroke Cerebrovasc Dis 2024; 33:107722. [PMID: 38616014 DOI: 10.1016/j.jstrokecerebrovasdis.2024.107722] [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: 01/28/2024] [Revised: 04/03/2024] [Accepted: 04/11/2024] [Indexed: 04/16/2024] Open
Abstract
BACKGROUND Our aim was to compare the outcomes of treatment with endovascular thrombectomy for pre-stroke dependent versus pre-stroke independent among the very elderly ≥90 years. METHODS A retrospective cohort study was performed on 106 patients ≥90 years who underwent endovascular thrombectomy for ischaemic stroke in Western Australia between June 2016 and September 2021. Patient, stroke and procedural details along with inpatient progress and outcome at 90 days were recorded. Patients were divided into Group A (pre-stroke modified Rankin Scale 0-2) and Group B (pre-stroke modified Rankin Scale >2). Primary outcome measure was functional status at 90 days post-stroke, with favourable clinical outcome defined as a 90-day mRS category equal to the patients' respective pre-stroke mRS category. Secondary outcome measures include successful reperfusion, symptomatic intracranial haemorrhage, hospital length-of-stay, change in accommodation to an aged care facility, and mortality during admission, at 90 days and one year. RESULTS 61 patients were allocated to Group A and 45 to Group B. There was none with pre-stroke mRS 5. Group B had more pre-existing cognitive impairment, aged care facility residents, higher median age and lower Alberta Stroke Program Early CT Score. For primary outcome measure, 38 % of patients in Group A and 49 % in Group B achieved a favourable clinical outcome. The difference was not significant (p=0.3408). For secondary outcome measures, Group B had a significantly higher 90-day mortality rate at 47 % versus 24 % in Group A (p=0.03). All other secondary outcome measures were similar between the two groups. These include the rate of successful reperfusion and symptomatic intracranial haemorrhage, hospital length-of-stay, new transition into an aged care facility, inpatient mortality rate and 1-year mortality rate. CONCLUSION When treated with endovascular thrombectomy for ischaemic stroke, nonagenarians with pre-existing dependency achieved a rate of favourable functional outcome comparable with their independent peers, although they also had higher 90-day mortality rate.
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Affiliation(s)
| | - Timothy Phillips
- Interventional Neuroradiologist, Neurological Intervention & Imaging Service of WA, Australia.
| | | | - Darshan Ghia
- Fiona Stanley Hospital, and Senior Clinical Lecturer, University of Western Australia, Australia.
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Scoppettuolo P, Raymackers JM, Rutgers MP, Poma JF, Goffette P, Hammer F, Peeters A. Utility of A 2L 2 score in acute ischemic stroke patient triage: the "H.uni" experience. Acta Neurol Belg 2024:10.1007/s13760-024-02591-0. [PMID: 38935263 DOI: 10.1007/s13760-024-02591-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2023] [Accepted: 06/18/2024] [Indexed: 06/28/2024]
Abstract
BACKGROUND AND AIMS Two or more National Institutes of Health Stroke Scale (NIHSS) points on each motor items (A2L2 score) have shown good accuracy in predicting large vessel occlusion (LVO) in the prehospital setting of acute ischemic stroke (AIS) care. We aimed to study this score for LVO prediction in our stroke network and predictors of poor outcome (PO) after mechanical thrombectomy (MT). METHODS From our Safe Implementation of Thrombolysis in Stroke (SITS) registry including patients receiving reperfusion therapy for AIS, we retrospectively computed the A2L2 score from the admission NIHSS to test the diagnostic accuracy for LVO prediction. Multivariable analysis for independent predictors of LVO on the entire cohort and PO from patients with LVO were performed. RESULTS From the 853 patients with AIS (67% LVO), A2L2 was positive in 52%. A2L2 score (Odds ratio [OR] 4.6;95%CI 3.36-6.34), smoking (OR 2.1;95%CI 1.14-3.85), atrial fibrillation (OR 1.6;95%CI1.1-2.4) and younger age (OR 0.98;95%CI0.97-0.99) were independent predictors of LVO. A2L2 score showed 82%/49% positive/negative predictive values with 66% accuracy (64%/72% sensitivity/specificity) for LVO prediction. Age (OR 1.05;95%CI 1.03-1.07), atrial fibrillation (OR 4.85;95%CI 1.5-15.7), diabetes (OR 2.62;95% CI 1.14-6.05), dyslipidemia (OR 2;95% CI 1.04-3.87), A2L2 score (OR 2.68;95% CI 1.45-4.98), longer onset-to-groin time (OR 1.003;95% CI 1.001-1.01), MT procedure (OR 1.01;95%CI 1.003-1.02) general anaesthesia (OR 2.06;95% CI 1.1-3.83) and symptomatic intracranial hemorrhage (OR 12.10;95%CI 3.15-46.44) were independent predictors of PO. CONCLUSIONS A2L2 score independently predicted LVO and PO after MT. Patient characteristics and procedural factors determined PO of LVO patients after MT.
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Affiliation(s)
- Pasquale Scoppettuolo
- Neurology Department - Cliniques Universitaires Saint Luc, H.uni - UCLouvain, Brussels, Belgium.
| | - Jean-Marc Raymackers
- Neurology Department - Clinique Saint-Pierre Ottignies, H.uni - UCLouvain, Ottignies, Belgium
| | | | - Jean-François Poma
- Neurology Department - Clinique Saint Jean, H.uni - UCLouvain, Brussels, Belgium
| | - Pierre Goffette
- Radiology Department - Cliniques, Universitaires Saint Luc, H.uni - UCLouvain, Brussels, Belgium
| | - Frank Hammer
- Radiology Department - Cliniques, Universitaires Saint Luc, H.uni - UCLouvain, Brussels, Belgium
| | - André Peeters
- Neurology Department - Cliniques Universitaires Saint Luc, H.uni - UCLouvain, Brussels, Belgium
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3
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Zeng H, Zhou J, Xue Q, Zhao F, Liu T, Zhu Q. Clinical Observation of Infarct Volume ≥150 mL in Endovascular Thrombectomy Treatment. Neurologist 2024:00127893-990000000-00144. [PMID: 38888296 DOI: 10.1097/nrl.0000000000000574] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/20/2024]
Abstract
OBJECTIVES Whether patients with infarct volume ≥150 mL could benefit from endovascular thrombectomy (EVT) remains unclear. METHODS Patients (n=104) with anterior circulation Alberta Stroke Program Early Computed Tomography Score <6 were screened for infarct volume ≥150 mL using the Pullicino formula × (1-22%). The following were compared with the baseline at 90 days: the modified Rankin scale score (mRS) ≤3, mortality rate, symptomatic intracranial hemorrhage and any intracranial hemorrhage within 48 hours, and modified Thrombolysis in Cerebral Infarction (mTICI) ≥2b between the EVT and drug therapy (DT) groups. RESULTS In patients with infarct volumes ≥150 mL, mRS≤3 at 90 days was higher in the EVT group than in the DT group [adjusted odds risk (aOR), 5.52; 95% CI: 1.10-28.24, P=0.04), and mTICI ≥2b at 82.8%. Intracranial hemorrhage within 48 hours occurred in 7 (24.1%) patients in the EVT group and 5 (14.7%) in the DT group (aOR, 0.75; 95% CI: 0.16-3.46; P=0.71). Older age (aOR, 0.94; 95% CI: 0.90-0.99, P=0.01), EVT treatment (aOR, 4.51; 95% CI: 1.60-12.78, P=0.01), and infarct volume ≥150 mL (aOR, 0.11; 95% CI: 0.04-0.31, P<0.01) were significantly associated with patient prognosis. CONCLUSIONS Patients with infarct volume ≥150 mL who received EVT had a higher proportion of mRS≤3 compared with those who received DT. However, there was no statistically significant difference in intracranial hemorrhage and death between the groups. EVT, smaller infarct volume, and younger age were associated with a good prognosis. The findings require large sample data verification.
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Affiliation(s)
- Hai Zeng
- Department of Neurosurgery, Second Hospital of Shanxi Medical University, Taiyuan
| | - Jia Zhou
- Department of Neurosurgery, Second Hospital of Shanxi Medical University, Taiyuan
| | - Qing Xue
- Department of Neurology, Yuncheng Central Hospital, Shanxi Province, Yuncheng, China
| | - Fengli Zhao
- Department of Neurology, Yuncheng Central Hospital, Shanxi Province, Yuncheng, China
| | - Tingyu Liu
- Department of Neurosurgery, Second Hospital of Shanxi Medical University, Taiyuan
| | - Qingfeng Zhu
- Department of Neurosurgery, Second Hospital of Shanxi Medical University, Taiyuan
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Puggaard R, Laugesen NG, Hansen K, Brandt AH, Stavngaard T, Truelsen TC. Outcome and safety of mechanical thrombectomy in patients with acute ischemic stroke due to internal carotid artery dissection. Interv Neuroradiol 2024:15910199241261753. [PMID: 38870399 DOI: 10.1177/15910199241261753] [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: 06/15/2024] Open
Abstract
BACKGROUND Mechanical thrombectomy (MT) in patients with symptoms of acute ischemic stroke (AIS) due to internal carotid artery dissection (ICAD) remains controversial. In this study, we present clinical outcome and safety of MT in acute ICAD compared to other acute carotid artery pathology. METHODS Patients with symptoms of AIS due to internal carotid artery pathology, treated with MT from 2017-2021, were categorized as ICAD or non-ICAD. Baseline and procedural characteristics, complications, and functional outcome at 90 days were compared between the two groups. Factors associated with a favorable outcome (modified Rankin Scale 0-2) were analyzed using multivariate logistic regression. Safety analyses included in-stent thrombosis, perforation, intracranial hemorrhage, and mortality. RESULTS Sixty-seven ICAD patients (14.8%) and 387 non-ICAD patients (85.2%) were enrolled. ICAD patients were younger, median age 53 years (interquartile range (IQR) 47-61) vs. non-ICAD 72 years (IQR 64-79), p < 0.001. Favorable outcome was more common in ICAD patients, 49 ICAD patients (76.6%) vs. 158 non-ICAD patients (42.4%), p < 0.001. Post-procedural symptomatic intracranial hemorrhage occurred in 41 patients, 5 (7.5%) ICAD patients vs. 36 (9.3%) non-ICAD patients, p = 0.6. Mortality differed significantly, 6 (9%) ICAD patients vs. 94 (24.3%) non-ICAD patients, p = 0.01. ICAD was not associated with functional outcome in multivariate analysis, OR = 1.25 [95%confidence interval:0.55-2.86]. CONCLUSION ICAD patients achieved a better 90-day functional outcome compared with non-ICAD patients. ICAD patients did not perform worse in safety measures than non-ICAD patients. Our data provide indirect evidence that MT is of clinical benefit in ICAD patients with symptoms of AIS.
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Affiliation(s)
- Rikke Puggaard
- Cerebrovascular Research Unit Rigshospitalet, Department of Neurology, Rigshospitalet, Copenhagen, Denmark
| | - Nicolaj Grønbæk Laugesen
- Cerebrovascular Research Unit Rigshospitalet, Department of Neurology, Rigshospitalet, Copenhagen, Denmark
| | - Klaus Hansen
- Cerebrovascular Research Unit Rigshospitalet, Department of Neurology, Rigshospitalet, Copenhagen, Denmark
- Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Andreas H Brandt
- Neurovascular Section, Department of Radiology, Rigshospitalet, Copenhagen, Denmark
| | - Trine Stavngaard
- Neurovascular Section, Department of Radiology, Rigshospitalet, Copenhagen, Denmark
| | - Thomas C Truelsen
- Cerebrovascular Research Unit Rigshospitalet, Department of Neurology, Rigshospitalet, Copenhagen, Denmark
- Faculty of Health Sciences, University of Copenhagen, Copenhagen, Denmark
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Shen H, Huasen BB, Killingsworth MC, Bhaskar SMM. Introducing the Futile Recanalization Prediction Score (FRPS): A Novel Approach to Predict and Mitigate Ineffective Recanalization after Endovascular Treatment of Acute Ischemic Stroke. Neurol Int 2024; 16:605-619. [PMID: 38921949 PMCID: PMC11206671 DOI: 10.3390/neurolint16030045] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2024] [Revised: 05/22/2024] [Accepted: 05/28/2024] [Indexed: 06/27/2024] Open
Abstract
Objective: This study aims to develop and validate the Futile Recanalization Prediction Score (FRPS), a novel tool designed to predict the severity risk of FR and aid in pre- and post-EVT risk assessments. Methods: The FRPS was developed using a rigorous process involving the selection of predictor variables based on clinical relevance and potential impact. Initial equations were derived from previous meta-analyses and refined using various statistical techniques. We employed machine learning algorithms, specifically random forest regression, to capture nonlinear relationships and enhance model performance. Cross-validation with five folds was used to assess generalizability and model fit. Results: The final FRPS model included variables such as age, sex, atrial fibrillation (AF), hypertension (HTN), diabetes mellitus (DM), hyperlipidemia, cognitive impairment, pre-stroke modified Rankin Scale (mRS), systolic blood pressure (SBP), onset-to-puncture time, sICH, and NIHSS score. The random forest model achieved a mean R-squared value of approximately 0.992. Severity ranges for FRPS scores were defined as mild (FRPS < 66), moderate (FRPS 66-80), and severe (FRPS > 80). Conclusions: The FRPS provides valuable insights for treatment planning and patient management by predicting the severity risk of FR. This tool may improve the identification of candidates most likely to benefit from EVT and enhance prognostic accuracy post-EVT. Further clinical validation in diverse settings is warranted to assess its effectiveness and reliability.
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Affiliation(s)
- Helen Shen
- Global Health Neurology Lab, Sydney, NSW 2150, Australia
- South West Sydney Clinical Campuses, UNSW Medicine and Health, University of New South Wales (UNSW), Sydney, NSW 2170, Australia
| | - Bella B. Huasen
- Department of Interventional Neuroradiology, Lancashire Teaching Hospitals NHS Foundation Trust, Preston PR2 9HT, UK
- Edinburgh Medical School, College of Medicine and Veterinary Medicine, University of Edinburgh, Edinburgh EH16 4UX, UK
| | - Murray C. Killingsworth
- South West Sydney Clinical Campuses, UNSW Medicine and Health, University of New South Wales (UNSW), Sydney, NSW 2170, Australia
- Ingham Institute for Applied Medical Research, Cell-Based Disease Intervention Group, Clinical Sciences Stream, Liverpool, NSW 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW 2170, Australia
- Department of Anatomical Pathology, NSW Health Pathology, Correlative Microscopy Facility, Ingham Institute for Applied Medical Research and Western Sydney University, Liverpool, NSW 2170, Australia
| | - Sonu M. M. Bhaskar
- Global Health Neurology Lab, Sydney, NSW 2150, Australia
- South West Sydney Clinical Campuses, UNSW Medicine and Health, University of New South Wales (UNSW), Sydney, NSW 2170, Australia
- Ingham Institute for Applied Medical Research, Cell-Based Disease Intervention Group, Clinical Sciences Stream, Liverpool, NSW 2170, Australia
- NSW Brain Clot Bank, NSW Health Pathology, Sydney, NSW 2170, Australia
- Department of Neurology & Neurophysiology, Liverpool Hospital, South West Sydney Local Health District, Liverpool, NSW 2170, Australia
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6
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van Voorst H, Hoving JW, Koopman MS, Daems JD, Peerlings D, Buskens E, Lingsma H, Marquering HA, de Jong HWAM, Berkhemer OA, van Zwam WH, van Walderveen MAA, van den Wijngaard IR, Dippel DWJ, Yoo AJ, Campbell B, Kunz WG, Majoie CB, Emmer BJ. Costs and health effects of CT perfusion-based selection for endovascular thrombectomy within 6 hours of stroke onset: a model-based health economic evaluation. J Neurol Neurosurg Psychiatry 2024; 95:515-527. [PMID: 38124162 DOI: 10.1136/jnnp-2023-331862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 11/19/2023] [Indexed: 12/23/2023]
Abstract
BACKGROUND Although CT perfusion (CTP) is often incorporated in acute stroke workflows, it remains largely unclear what the associated costs and health implications are in the long run of CTP-based patient selection for endovascular treatment (EVT) in patients presenting within 6 hours after symptom onset with a large vessel occlusion. METHODS Patients with a large vessel occlusion were included from a Dutch nationwide cohort (n=703) if CTP imaging was performed before EVT within 6 hours after stroke onset. Simulated cost and health effects during 5 and 10 years follow-up were compared between CTP based patient selection for EVT and providing EVT to all patients. Outcome measures were the net monetary benefit at a willingness-to-pay of €80 000 per quality-adjusted life year, incremental cost-effectiveness ratio), difference in costs from a healthcare payer perspective (ΔCosts) and quality-adjusted life years (ΔQALY) per 1000 patients for 1000 model iterations as outcomes. RESULTS Compared with treating all patients, CTP-based selection for EVT at the optimised ischaemic core volume (ICV≥110 mL) or core-penumbra mismatch ratio (MMR≤1.4) thresholds resulted in losses of health (median ΔQALYs for ICV≥110 mL: -3.3 (IQR: -5.9 to -1.1), for MMR≤1.4: 0.0 (IQR: -1.3 to 0.0)) with median ΔCosts for ICV≥110 mL of -€348 966 (IQR: -€712 406 to -€51 158) and for MMR≤1.4 of €266 513 (IQR: €229 403 to €380 110)) per 1000 patients. Sensitivity analyses did not yield any scenarios for CTP-based selection of patients for EVT that were cost-effective for improving health, including patients aged ≥80 years CONCLUSION: In EVT-eligible patients presenting within 6 hours after symptom onset, excluding patients based on CTP parameters was not cost-effective and could potentially harm patients.
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Affiliation(s)
- Henk van Voorst
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, North Holland, The Netherlands
- Department of Biomedical Engineering and Physics, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Jan W Hoving
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, North Holland, The Netherlands
| | - Miou S Koopman
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, North Holland, The Netherlands
| | - Jasper D Daems
- Department of Neurology, Erasmus University Medical Center, Rotterdam, The Netherlands
- Department of Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Daan Peerlings
- Department of Radiology, University Medical Center Utrecht, Utrecht, Utrecht, The Netherlands
| | - Erik Buskens
- Epidemiology, University Medical Centre Groningen, Groningen, Groningen, The Netherlands
| | - Hester Lingsma
- Public Health, Erasmus University Medical Center, Rotterdam, The Netherlands
| | - Henk A Marquering
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, North Holland, The Netherlands
- Biomedical Engineering and Physics, Amsterdam UMC Location AMC, Amsterdam, North Holland, The Netherlands
| | | | - Olvert A Berkhemer
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
- Department of Radiology and Nuclear Medicine, Erasmus MC University Medical Center, Rotterdam, The Netherlands
| | - Wim H van Zwam
- Radiology, Maastricht University Medical Center, Maastricht, The Netherlands
| | | | - Ido R van den Wijngaard
- Neurology, HMC Westeinde, The Hague, Zuid-Holland, The Netherlands
- Neurology, Leiden University, Leiden, The Netherlands
| | | | - Albert J Yoo
- Neurointervention, Texas Stroke Institute, Plano, Texas, USA
| | - Bruce Campbell
- The Royal Melbourne Hospital, Parkville, Melbourne, Australia
| | | | - Charles B Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, North Holland, The Netherlands
| | - Bart J Emmer
- Department of Radiology and Nuclear Medicine, Amsterdam UMC Location AMC, Amsterdam, North Holland, The Netherlands
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D'Anna L, Barba L, Foschi M, Romoli M, Abu-Rumeileh S, Dolkar T, Vittay O, Dixon L, Bentley P, Brown Z, Hall C, Halse O, Jamil S, Jenkins H, Kalladka D, Kwan J, Malik A, Patel M, Rane N, Roi D, Singh A, Venter M, Banerjee S, Lobotesis K. Safety and outcomes of different endovascular treatment techniques for anterior circulation ischaemic stroke in the elderly: data from the Imperial College Thrombectomy Registry. J Neurol 2024; 271:1366-1375. [PMID: 37982851 PMCID: PMC10896784 DOI: 10.1007/s00415-023-12077-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/30/2023] [Revised: 10/18/2023] [Accepted: 10/19/2023] [Indexed: 11/21/2023]
Abstract
BACKGROUND Although previous studies investigated the main predictors of outcomes after endovascular thrombectomy (EVT) in patients aged 80 years and older, less is known about the impact of the procedural features on outcomes in elderly patients. The aim of this study was to investigate the influence of EVT technical procedures on the main 3-month outcomes in a population of patients aged 80 years and older. METHODS This observational, prospective, single-centre study included consecutive patients with acute LVO ischaemic stroke of the anterior circulation. The study outcomes were functional independence at 3 months after EVT (defined as a mRS score of 0-2), successful reperfusion (mTICI ≥ 2b), incidence of haeamorrhagic transformation, and 90-day all cause of mortality. RESULTS Our cohort included 497 patients with acute ischaemic stroke due to LVO treated with EVT. Among them, 105 (21.1%) patients were aged ≥ 80 years. In the elderly group, multivariable regression analysis showed that thromboaspiration technique vs stent-retriever was the single independent predictor of favourable post-procedural TICI score (OR = 7.65, 95%CI = 2.22-26.32, p = 0.001). CONCLUSIONS Our study suggests that EVT for LVO stroke in the elderly could be safe. The use of thromboaspiration was associated with positive reperfusion outcome in this population. Further studies in larger series are warranted to confirm the present results and to evaluate the safety and efficacy of EVT in the elderly and oldest adults.
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Affiliation(s)
- Lucio D'Anna
- Stroke Centre, Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, Fulham Palace Road, London, W6 8RF, UK.
- Department of Brain Sciences, Imperial College London, London, UK.
| | - Lorenzo Barba
- Department of Neurology, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Matteo Foschi
- Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Michele Romoli
- Neurology and Stroke Unit, Department of Neuroscience, Bufalini Hospital, AUSL Romagna, Cesena, Italy
| | - Samir Abu-Rumeileh
- Department of Neurology, Martin-Luther-University Halle-Wittenberg, Halle (Saale), Germany
| | - Tsering Dolkar
- Stroke Centre, Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, Fulham Palace Road, London, W6 8RF, UK
| | - Orsolya Vittay
- Stroke Centre, Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, Fulham Palace Road, London, W6 8RF, UK
| | - Luke Dixon
- Neuroradiology, Department of Imaging, Charing Cross Hospital, Imperial College London, NHS Healthcare Trust, London, UK
| | - Paul Bentley
- Stroke Centre, Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, Fulham Palace Road, London, W6 8RF, UK
| | - Zoe Brown
- Stroke Centre, Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, Fulham Palace Road, London, W6 8RF, UK
| | - Charles Hall
- Neuroradiology, Department of Imaging, Charing Cross Hospital, Imperial College London, NHS Healthcare Trust, London, UK
| | - Omid Halse
- Stroke Centre, Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, Fulham Palace Road, London, W6 8RF, UK
| | - Sohaa Jamil
- Stroke Centre, Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, Fulham Palace Road, London, W6 8RF, UK
| | - Harri Jenkins
- Stroke Centre, Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, Fulham Palace Road, London, W6 8RF, UK
| | - Dheeraj Kalladka
- Stroke Centre, Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, Fulham Palace Road, London, W6 8RF, UK
| | - Joseph Kwan
- Stroke Centre, Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, Fulham Palace Road, London, W6 8RF, UK
| | - Abid Malik
- Stroke Centre, Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, Fulham Palace Road, London, W6 8RF, UK
| | - Maneesh Patel
- Neuroradiology, Department of Imaging, Charing Cross Hospital, Imperial College London, NHS Healthcare Trust, London, UK
| | - Neil Rane
- Neuroradiology, Department of Imaging, Charing Cross Hospital, Imperial College London, NHS Healthcare Trust, London, UK
| | - Dylan Roi
- Neuroradiology, Department of Imaging, Charing Cross Hospital, Imperial College London, NHS Healthcare Trust, London, UK
| | - Abhinav Singh
- Neuroradiology, Department of Imaging, Charing Cross Hospital, Imperial College London, NHS Healthcare Trust, London, UK
| | - Marius Venter
- Stroke Centre, Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, Fulham Palace Road, London, W6 8RF, UK
| | - Soma Banerjee
- Stroke Centre, Department of Stroke and Neuroscience, Charing Cross Hospital, Imperial College London NHS Healthcare Trust, Fulham Palace Road, London, W6 8RF, UK
- Department of Brain Sciences, Imperial College London, London, UK
| | - Kyriakos Lobotesis
- Neuroradiology, Department of Imaging, Charing Cross Hospital, Imperial College London, NHS Healthcare Trust, London, UK
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8
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Yang X, Sun D, Huo X, Raynald R, Jia B, Tong X, Wang A, Ma N, Gao F, Mo D, Miao Z. Futile reperfusion of endovascular treatment for acute anterior circulation large vessel occlusion in the ANGEL-ACT registry. J Neurointerv Surg 2023; 15:e363-e368. [PMID: 36693725 DOI: 10.1136/jnis-2022-019874] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Accepted: 12/26/2022] [Indexed: 01/25/2023]
Abstract
BACKGROUND Some patients with large vessel occlusion (LVO) still cannot achieve functional independence despite successful reperfusion after endovascular treatment (EVT), named futile reperfusion. We aimed to explore the incidence and predictors of futile reperfusion of EVT for anterior circulation LVO in the Chinese population based on a nationwide prospective multicenter registry. METHODS We selected patients from the ANGEL-ACT (Endovascular Treatment Key Technique and Emergency Workflow Improvement of Acute Ischemic Stroke) registry. Successful reperfusion was defined as modified Treatment In Cerebral Ischemia (mTICI) 2b-3 after EVT, and functional independence was defined as 90-day modified Rankin Scale (mRS) 0-2. A multivariable regression model was performed to identify the independent predictors of futile reperfusion in anterior circulation LVO patients. RESULTS A total of 1158 anterior circulation LVO patients were included in our study. 600 of the 1158 patients (51.8%) suffered futile reperfusion. Age ≥69 (adjusted OR (aOR) 1.69, 95% CI 1.21 to 2.35, P=0.002), baseline National Institutes of Health Stroke Scale (NIHSS) ≥14 (aOR 2.36, 95% CI 1.71 to 3.27, P<0.001), baseline serum glucose ≥6.5 mmol/L (aOR 1.73, 95% CI 1.27 to 2.36, P=0.001), drip and ship (aOR 1.56, 95% CI 1.11 to 2.18, P=0.011), and general anesthesia (aOR 2.28, 95% CI 1.66 to 3.14, P<0.001) were associated with a high risk of futile reperfusion in the anterior LVO patients after EVT, whereas baseline Alberta Stroke Program Early CT Score (ASPECTS) ≥8 (aOR 0.65, 95% CI 0.47 to 0.91, P=0.011) and complete reperfusion (aOR 0.62, 95% CI 0.43 to 0.89, P=0.010) were associated with a low risk of futile reperfusion in the anterior LVO patients after EVT. CONCLUSIONS In the ANGEL-ACT registry, 51.8% of anterior circulation LVO patients suffered futile reperfusion after EVT. Age ≥69 years, baseline NIHSS ≥14, baseline serum glucose ≥6.5 mmol/L, drip and ship, general anesthesia, baseline ASPECTS <8, and incomplete reperfusion were the independent predictors of futile reperfusion.
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Affiliation(s)
- XinGuang Yang
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
- Department of Neurology, Sun Yat-Sen Memorial Hospital, Sun Yat-sen University, Guangzhou, Guangdong, China
| | - Dapeng Sun
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiaochuan Huo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Raynald Raynald
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - BaiXue Jia
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xu Tong
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Anxin Wang
- China National Clinical Research Center for Neurological Diseases, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Ning Ma
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Feng Gao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Dapeng Mo
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Zhongrong Miao
- Department of Interventional Neuroradiology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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9
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Michelard M, Detante O, Heck O, Marcel S, Vadot W, Gavazzi G, Papassin J. Thrombolysis and thrombectomy for stroke in octogenarians and nonagenarians: A regional observational study. Rev Neurol (Paris) 2023; 179:1068-1073. [PMID: 37596186 DOI: 10.1016/j.neurol.2023.03.023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2022] [Revised: 02/24/2023] [Accepted: 03/01/2023] [Indexed: 08/20/2023]
Abstract
INTRODUCTION Elderly patients are a growing population in stroke units, characterized by higher frailty, but underrepresented in clinical trials about acute care. We investigated efficacy of intravenous thrombolysis (IVT) and mechanical thrombectomy (MT) in elderlies in current practice. METHODS We assessed consecutive patients with acute ischemic stroke (AIS) hospitalized in the four stroke units of the French Northern Alps Emergency Network between 2015 and 2020. We compared baseline characteristics, early neurological evolution and outcome of patients aged 80-89 and≥90years old (yo). RESULTS Among 8367 patients, 2744 (32.8%) were 80-89 yo and 541 (6.5%) were≥90 yo. IVT and/or MT were performed in 787 patients≥80 yo (632 patients aged 80-89, 155 patients aged>90). Early neurological improvement was more frequent in patients≥80 yo treated by IVT and/or MT compared to untreated patients (45.6% versus 38.4%, P=0.002). After adjustment, reperfusion treatments improved likelihood of good outcome at discharge (OR=2.0 [1.6-2.7]) and reduced in-hospital mortality (OR=0.5 [0.4-0.7]). Age and initial NIHSS score were independent factors of poor functional outcome at discharge and in-hospital mortality. The rate of successful recanalization was comparable between octogenarians and nonagenarians (87% versus 85.2%, P=0.8). Octogenarians had better functional outcome at discharge compared to nonagenarians [modified Rankin scale (mRS) 0-2: 36% versus 25.7%, P=0.02], whatever IVT or MT strategy. In-hospital mortality was lower for octogenarians compared to nonagenarians (19.5% versus 27.1%, P=0.04). DISCUSSION IVT and MT improve early neurological recovery and functional outcome at discharge of both octogenarians and nonagenarians in current practice. Despite a poorer outcome for nonagenarians than octogenarians, these reperfusion treatments should not be withheld on the basis of age only.
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Affiliation(s)
- M Michelard
- Medical intensive care unit, Grenoble Alpes University Hospital, Grenoble, France
| | - O Detante
- Stroke unit, Grenoble Alpes University Hospital, Grenoble, France; Université Grenoble Alpes, Inserm, U1216, CHU Grenoble Alpes, Grenoble Institut Neurosciences, 38000 Grenoble, France
| | - O Heck
- Neuroradiology, Grenoble Alpes University Hospital, Grenoble, France
| | - S Marcel
- Stroke unit, Métropole Savoie Hospital, 73000 Chambéry, France
| | - W Vadot
- Stroke unit, Annecy-Genevois Hospital, Annecy, France
| | - G Gavazzi
- Geriatric department, Grenoble Alpes University Hospital, Grenoble, France
| | - J Papassin
- Stroke unit, Métropole Savoie Hospital, 73000 Chambéry, France.
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10
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Terceño M, Bashir S, Puig J, I-Estadella JD, Murias E, Jiménez JM, Díaz EG, Monso JF, Bravo-Rey I, Romero V, Werner M, López-Rueda A, Román LS, Anadaluz JB, Doncel-Moriano A, Rosati S, Pérez-García C, Remollo S, Caamaño IR, Aixut S, Chaparro OSC, Garcia JMS, Porto-Álvarez J, Mendez-Cendón JC, Rayon-Aledo JC, Aguilar Y, Parrilla G, Castaño M, Serena J, Silva Y. Impact of Balloon Guide Catheters in Elderly Patients Treated with Mechanical Thrombectomy: Insights from the ROSSETTI Registry. AJNR Am J Neuroradiol 2023; 44:1275-1281. [PMID: 37827717 PMCID: PMC10631533 DOI: 10.3174/ajnr.a8003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 08/17/2023] [Indexed: 10/14/2023]
Abstract
BACKGROUND AND PURPOSE Several nonrandomized studies have demonstrated the effectiveness of balloon guide catheters in treating patients with anterior circulation large-vessel occlusion. However, their impact on the elderly populations has been underreported. We aimed to analyze the effect of balloon guide catheters in a cohort of elderly patients (80 years of age or older) with anterior circulation large-vessel occlusion. MATERIALS AND METHODS Consecutive patients from June 2019 to June 2022 were collected from the ROSSETTI Registry. Demographic and clinical data, angiographic endovascular technique, and clinical outcome were compared between balloon guide catheter and non-balloon guide catheter groups. We studied the association between balloon guide catheters and the rate of complete recanalization after a single first-pass effect modified TICI 2c-3, as well as their association with functional independence at 3 months. RESULTS A total of 808 patients were included during this period, 465 (57.5%) of whom were treated with balloon guide catheters. Patients treated with balloon guide catheters were older, had more neurologic severity at admission and lower baseline ASPECTS, and were less likely to receive IV fibrinolytics. No differences were observed in terms of the modified first-pass effect between groups (45.8 versus 39.9%, P = .096). In the multivariable regression analysis, balloon guide catheter use was not independently associated with a modified first-pass effect or the final modified TICI 2c-3, or with functional independence at 3 months. CONCLUSIONS In our study, balloon guide catheter use during endovascular treatment of anterior circulation large-vessel occlusion in elderly patients did not predict the first-pass effect, near-complete final recanalization, or functional independence at 3 months. Further studies, including randomized clinical trials, are needed to confirm these results.
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Affiliation(s)
- Mikel Terceño
- From the Stroke Unit, Department of Neurology (M.T., S.B., J.S., Y.S.), Hospital Universitari Doctor Josep Trueta de, Girona, Girona Biomedical Research Institute, Girona, Spain
| | - Saima Bashir
- From the Stroke Unit, Department of Neurology (M.T., S.B., J.S., Y.S.), Hospital Universitari Doctor Josep Trueta de, Girona, Girona Biomedical Research Institute, Girona, Spain
| | - Josep Puig
- Department of Radiology (J.P.), Hospital Universitari de Girona Doctor Josep Trueta, Girona, Catalunya, Spain
| | - Josep Daunis- I-Estadella
- Department of Computer Science (J.D.-I.-E.), Applied Mathematics and Statistics, University of Girona, Girona, Catalunya, Spain
| | - Eduardo Murias
- Department of Radiology (E.M., J.M.J.), Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Jose María Jiménez
- Department of Radiology (E.M., J.M.J.), Hospital Universitario Central de Asturias, Oviedo, Asturias, Spain
| | - Eva González Díaz
- Department of Interventional Neuroradiology (E.G.D., J.F.M.), Department of Radiology, Cruces University Hospital, Barakaldo, PaísVasco, Spain
| | - Jon Fondevila Monso
- Department of Interventional Neuroradiology (E.G.D., J.F.M.), Department of Radiology, Cruces University Hospital, Barakaldo, PaísVasco, Spain
| | - Isabel Bravo-Rey
- Diagnostic and Therapeutical Neuroradiology Unit (I.B.-R., V.R.), Reina Sofia University Hospital, Cordoba, Andalucía, Spain
| | - Veredas Romero
- Diagnostic and Therapeutical Neuroradiology Unit (I.B.-R., V.R.), Reina Sofia University Hospital, Cordoba, Andalucía, Spain
| | - Mariano Werner
- Neurointerventional Department CDI (M.W.), Hospital Clinic de Barcelona, Barcelona, Spain
| | - Antonio López-Rueda
- Department of Interventional Neuroradiology (A.L.-R., L.S.R., J.B.A.), Clinic University Hospital, Barcelona, Barcelona, Spain
| | - Luis San Román
- Department of Interventional Neuroradiology (A.L.-R., L.S.R., J.B.A.), Clinic University Hospital, Barcelona, Barcelona, Spain
| | - Jordi Blasco Anadaluz
- Department of Interventional Neuroradiology (A.L.-R., L.S.R., J.B.A.), Clinic University Hospital, Barcelona, Barcelona, Spain
| | | | - Santiago Rosati
- Department of Interventional Neurorradiology (S.R., C.P.-G.), Department of Radiology, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Carlos Pérez-García
- Department of Interventional Neurorradiology (S.R., C.P.-G.), Department of Radiology, Hospital Universitario Clínico San Carlos, Madrid, Spain
| | - Sebastian Remollo
- Department of Interventional Neuroradiology (S.R., I.R.C.), Hospital universitari Germans Trias i Pujol, Badalona, Spain
| | - Isabel Rodríguez Caamaño
- Department of Interventional Neuroradiology (S.R., I.R.C.), Hospital universitari Germans Trias i Pujol, Badalona, Spain
| | - Sonia Aixut
- Department of Interventional Neuroradiology (S.A., O.S.C.C.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | - Oscar Sabino Chirife Chaparro
- Department of Interventional Neuroradiology (S.A., O.S.C.C.), Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Jacobo Porto-Álvarez
- Department of Neuroradiology (J.P.-A.), Complexo Hospitalario Universitario de Santiago de, Compostela, Galicia, Spain
| | - Jose Carlos Mendez-Cendón
- Interventional Neuroradiology Unit (J.C.M.-C.), Department of Radiology, Hospital Ramón y Cajal, Madrid, Spain
| | - Jose Carlos Rayon-Aledo
- Department of Interventional Neuroradiology (J.C.R.-A.), Hospital General Universitario de Alicante, Alicante, Valenciana, Spain
| | - Yeray Aguilar
- Department of Radiology (Y.A.), Hospital Universitario Insular de Gran Canaria, Las Palmas de Gran Canaria, Spain
| | - Guillermo Parrilla
- Department of Interventional Neuroradiology (G.P.), Department of Radiology, Hospital Clínico Universitario Virgen de la, Murcia, Spain
| | - Miguel Castaño
- Department of Interventional Neuroradiology (M.S.), Hospital Clínico Universitario de Salamanca, Salamanca, Spain
| | - Joaquín Serena
- From the Stroke Unit, Department of Neurology (M.T., S.B., J.S., Y.S.), Hospital Universitari Doctor Josep Trueta de, Girona, Girona Biomedical Research Institute, Girona, Spain
| | - Yolanda Silva
- From the Stroke Unit, Department of Neurology (M.T., S.B., J.S., Y.S.), Hospital Universitari Doctor Josep Trueta de, Girona, Girona Biomedical Research Institute, Girona, Spain
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11
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Broderick JP, Silva GS, Selim M, Kasner SE, Aziz Y, Sutherland J, Jauch EC, Adeoye OM, Hill MD, Mistry EA, Lyden PD, Mocco J, Smith EM, Hernandez-Jimenez M, Deljkich E, Kamel H. Enhancing Enrollment in Acute Stroke Trials: Current State and Consensus Recommendations. Stroke 2023; 54:2698-2707. [PMID: 37694403 PMCID: PMC10542906 DOI: 10.1161/strokeaha.123.044149] [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] [Indexed: 09/12/2023]
Abstract
The Stroke Treatment Academic Industry Roundtable (STAIR) convened a session and workshop regarding enrollment in acute stroke trials during the STAIR XII meeting on March 22, 2023. This forum brought together stroke physicians and researchers, members of the National Institute of Neurological Disorders and Stroke, industry representatives, and members of the US Food and Drug Administration to discuss the current status and opportunities for improving enrollment in acute stroke trials. The workshop identified the most relevant issues impacting enrollment in acute stroke trials and addressed potential action items for each. Focus areas included emergency consent in the United States and other countries; careful consideration of eligibility criteria to maximize enrollment and representativeness; investigator, study coordinator, and pharmacist availability outside of business hours; trial enthusiasm/equipoise; site start-up including contractual issues; site champions; incorporation of study procedures into standard workflow as much as possible; centralized enrollment at remote sites by study teams using telemedicine; global trials; and coenrollment in trials when feasible. In conclusion, enrollment of participants is the lifeblood of acute stroke trials and is the rate-limiting step for testing an exciting array of new approaches to improve patient outcomes. In particular, efforts should be undertaken to broaden the medical community's understanding and implementation of emergency consent procedures and to adopt designs and processes that are easily incorporated into standard workflow and that improve trials' efficiencies and execution. Research and actions to improve enrollment in ongoing and future trials will improve stroke outcomes more broadly than any single therapy under consideration.
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Affiliation(s)
- Joseph P. Broderick
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, Cincinnati, Ohio
| | - Gisele Sampaio Silva
- Federal University of São Paulo, Clinical Trialist/Neurology ,Albert Einstein Hospital, São Paulo, Brazil
| | - Magdy Selim
- Dept. of Neurology, Division of Stroke & Cerebrovascular Disease. Harvard Medical School / Beth Israel Deaconess Med. Ctr
| | - Scott E. Kasner
- Department of Neurology, University of Pennsylvania, Philadelphia, PA, USA
| | - Yasmin Aziz
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, Cincinnati, Ohio
| | | | - Edward C. Jauch
- Chair, Department of Research and Evaluation Sciences, University of North Carolina at MAHEC
| | - Opeolu M. Adeoye
- Department of Emergency Medicine, Washington University School of Medicine, Emergency Physician-in-Chief, Barnes-Jewish Hospital, St. Louis, MO
| | - Michael D. Hill
- Department of Clinical Neurosciences and Hotchkiss Brain Institute, Cumming School of Medicine, University of Calgary and Foothills Medical Centre, Calgary, AB, Canada
| | - Eva A. Mistry
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, Cincinnati, Ohio
| | - Patrick D. Lyden
- Professor of Physiology and Neuroscience, Professor of Neurology, Zilkha Neurogenetic Institute, Keck School of Medicine of USC
| | - J Mocco
- Department of Neurological Surgery, Mount Sinai Health System. Mount Sinai Health System. New York, New York, United States
| | | | - Macarena Hernandez-Jimenez
- Scientific Director, aptaTargets S.L., Av. Cardenal Herrera Oria 298, Madrid, Spain. Pharmacology and Toxicology Department, Complutense University, Av. Complutense s/n, Madrid, Spain
| | | | - Hooman Kamel
- Department of Neurology, Weill Cornell Medicine, New York, NY
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12
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Delgardo M, Rabin G, Tudor T, Tang AJ, Reeves G, Connolly ES. Monitoring risk and preventing ischemic stroke in the very old. Expert Rev Neurother 2023; 23:791-801. [PMID: 37540092 DOI: 10.1080/14737175.2023.2244674] [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: 04/29/2023] [Revised: 07/28/2023] [Accepted: 08/01/2023] [Indexed: 08/05/2023]
Abstract
INTRODUCTION Stroke is a significant cause of death, and the leading cause of severe long-term disability for individuals over 80 (the very old), yet few studies of such risk factors for ischemic stroke, or the known mitigation techniques, in this population, and the evidence base regarding risk modification strategies in this susceptible population can be inconsistent and incomplete. This article examines current guidelines and evidence regarding medical management, lifestyle changes, and psychosocial interactions that can contribute to the primary and secondary prevention of ischemic stroke in the very old. AREAS COVERED The authors conducted a literature search for ischemic stroke prevention and risk assessment in the elderly via PubMed. Furthermore, they describe current strategies for monitoring risk and preventing ischemic stroke in the elderly population. EXPERT OPINION Ischemic stroke poses a significant health risk to the elderly, with prevention relying on managing modifiable risk factors such as hypertension, atrial fibrillation, diabetes, and high cholesterol, as well as promoting healthy lifestyle choices like quitting smoking, regular physical activity and a heart-healthy diet. Healthcare providers must adopt a multifaceted approach, addressing individual and population-level factors while remaining vigilant in monitoring and managing risk factors to reduce the incidence and impact of stroke in older adults.
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Affiliation(s)
- Mychael Delgardo
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Grant Rabin
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Thilan Tudor
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Anthony J Tang
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - Geoffrey Reeves
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
| | - E Sander Connolly
- Department of Neurological Surgery, Columbia University Medical Center, New York, NY, USA
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13
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Alemseged F, Nguyen TN, Coutts SB, Cordonnier C, Schonewille WJ, Campbell BCV. Endovascular thrombectomy for basilar artery occlusion: translating research findings into clinical practice. Lancet Neurol 2023; 22:330-337. [PMID: 36780915 DOI: 10.1016/s1474-4422(22)00483-5] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Revised: 11/09/2022] [Accepted: 11/21/2022] [Indexed: 02/12/2023]
Abstract
BACKGROUND Basilar artery occlusion is a rare and severe condition. The effectiveness of endovascular thrombectomy in patients with basilar artery occlusion was unclear until recently, because these patients were excluded from most trials of endovascular thrombectomy for large-vessel occlusion ischaemic stroke. RECENT DEVELOPMENTS The Basilar Artery International Cooperation Study (BASICS) and the Basilar Artery Occlusion Endovascular Intervention versus Standard Medical Treatment (BEST) trials, specifically designed to investigate the benefit of thrombectomy in patients with basilar artery occlusion, did not find significant evidence of a benefit of endovascular thrombectomy in terms of disability outcomes at 3 months after stroke. However, these trials suggested a potential benefit of endovascular thrombectomy in patients presenting with moderate-to-severe symptoms. Subsequently, the Endovascular Treatment for Acute Basilar Artery Occlusion (ATTENTION) and the Basilar Artery Occlusion Chinese Endovascular (BAOCHE) trials, which compared endovascular thrombectomy versus medical therapy within 24 h of onset, showed clear benefit of endovascular thrombectomy in reducing disability and mortality, particularly in patients with moderate-to-severe symptoms. The risk of intracranial haemorrhage with endovascular thrombectomy was similar to the risk in anterior circulation stroke. Thrombectomy was beneficial regardless of age, baseline characteristics, the presence of intracranial atherosclerotic disease, and time from symptom onset to randomisation. Therefore, the question of whether endovascular thrombectomy is beneficial in basilar artery occlusion now appears to be settled in patients with moderate-to-severe symptoms, and endovascular thrombectomy should be offered to eligible patients. WHERE NEXT?: Key outstanding issues are the potential benefits of endovascular thrombectomy in patients with mild symptoms, the use of intravenous thrombolysis in an extended time window (ie, after 4·5 h of symptom onset), and the optimal endovascular technique for thrombectomy. Dedicated training programmes and automated software to assist with the assessment of imaging prognostic markers could be useful in the selection of patients who might benefit from endovascular thrombectomy. Large international research networks should be built to address knowledge gaps in this field and allow the conduct of clinical trials with fast and consecutive enrolment and a diverse ethnic representation.
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Affiliation(s)
- Fana Alemseged
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia
| | - Thanh N Nguyen
- Department of Neurology and Radiology, Boston Medical Center, Boston University Chobanian and Avedisian School of Medicine, Boston, MA, USA
| | - Shelagh B Coutts
- Departments of Clinical Neurosciences, Radiology, and Community Health Sciences, Cumming School of Medicine, University of Calgary, Calgary, AB, Canada
| | - Charlotte Cordonnier
- Université Lille, INSERM UMR-S1172, Centre Hospitalier Universitaire de Lille, Lille Neuroscience et Cognition, Lille, France
| | | | - Bruce C V Campbell
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Melbourne, VIC, Australia.
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14
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Enriquez BAB, Nome T, Nome CG, Tennøe B, Lund CG, Beyer MK, Skjelland M, Aamodt AH. Predictors of outcome after endovascular treatment for tandem occlusions: a single center retrospective analysis. BMC Neurol 2023; 23:82. [PMID: 36849925 PMCID: PMC9969668 DOI: 10.1186/s12883-023-03127-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2022] [Accepted: 02/15/2023] [Indexed: 03/01/2023] Open
Abstract
BACKGROUND The endovascular treatment procedure in tandem occlusions (TO) is complex compared to single occlusion (SO) and optimal management remains uncertain. The aim of this study was to identify clinical and procedural factors that may be associated to efficacy and safety in the management of TO and compare functional outcome in TO and SO stroke patients. METHODS This is a retrospective single center study of medium (MeVO) and large vessel occlusion (LVO) of the anterior circulation. Clinical, imaging, and interventional data were analyzed to identify predictive factors for symptomatic intracranial hemorrhage (sICH) and functional outcome after endovascular treatment (EVT) in TO. Functional outcome in TO and SO patients was compared. RESULTS Of 662 anterior circulation stroke patients with MeVO and LVO stroke, 90 (14%) had TO. Stenting was performed in 73 (81%) of TO patients. Stent thromboses occurred in 8 (11%) patients. Successful reperfusion with modified thrombolysis in cerebral infarction (mTICI) ≥ 2b was achieved in 82 (91%). SICH occurred in seven (8%). The strongest predictors for sICH were diabetes mellitus and number of stent retriever passes. Good functional clinical outcome (mRS ≤ 2) at 90-day follow up was similar in TO and SO patients (58% vs 59% respectively). General anesthesia (GA) was associated with good functional outcome whereas hemorrhage in the infarcted tissue, lower mTICI score and history of smoking were associated with poor outcome. CONCLUSIONS The risk of sICH was increased in patients with diabetes mellitus and those with extra stent-retriever attempts. Functional clinical outcomes in patients with TO were comparable to patients with SO.
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Affiliation(s)
| | - Terje Nome
- Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway.
| | - Cecilie G. Nome
- grid.55325.340000 0004 0389 8485Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway ,grid.5510.10000 0004 1936 8921Division of Anatomy, Department of Molecular Medicine, Institute of Basic Medical Sciences, Faculty of Medicine, University of Oslo, Oslo, Norway
| | - Bjørn Tennøe
- grid.55325.340000 0004 0389 8485Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway
| | - Christian G. Lund
- grid.55325.340000 0004 0389 8485Department of Neurology, Oslo University Hospital, Oslo, Norway
| | - Mona K. Beyer
- grid.55325.340000 0004 0389 8485Division of Radiology and Nuclear Medicine, Oslo University Hospital, Oslo, Norway ,grid.5510.10000 0004 1936 8921Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Mona Skjelland
- grid.55325.340000 0004 0389 8485Department of Neurology, Oslo University Hospital, Oslo, Norway ,grid.5510.10000 0004 1936 8921Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Anne Hege Aamodt
- grid.55325.340000 0004 0389 8485Department of Neurology, Oslo University Hospital, Oslo, Norway
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15
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Zhai G, Song J, Yu N, Guo C, Liu S, Yue C, Yang D, Xie D, Liu X, Yu S, Lei L. Predictors of Mechanical Thrombectomy for Anterior Circulation Emergent Large-Vessel Occlusion in the Older Adults. Clin Appl Thromb Hemost 2023; 29:10760296231184219. [PMID: 37386776 DOI: 10.1177/10760296231184219] [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: 07/01/2023] Open
Abstract
Few studies have reported the clinical outcomes of older adult patients with acute anterior circulation large-vessel occlusion (LVO) who underwent mechanical thrombectomy (MT). Therefore, we investigated the safety, functional outcomes, and predictors of MT for anterior circulation LVO in older adults. We enrolled patients with acute anterior circulation LVO from May 2018 to October 2021 in this retrospective study. Patients were divided into older (≥80 years) and young (<80 years) groups. Multivariable logistic regression analyses determined the safety, functional outcomes, and predictors of MT for anterior circulation LVO. We divided 1182 patients with acute ischemic stroke into young (18-79 years; 1028 patients) and older (≥80 years; 154 patients) groups. Compared with the young group, the older group had more unfavorable functional outcomes and increased mortality (P = .003). In the older adult patients, lower initial NIHSS score and higher ASPECTS were correlated with good outcomes. On the contrary, higher initial NIHSS score and lower ASPECTS were related to increased mortality. No difference was detected in symptomatic intracranial hemorrhage within 48 h between two groups. Increasing age was associated with lower rates of favorable functional outcomes and higher mortality rates. The lower initial NIHSS score combined with the higher ASPECTS may predict functional outcomes post-thrombectomy in older adults.
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Affiliation(s)
- Guojie Zhai
- Department of Neurology, Suzhou Ninth People's Hospital, Suzhou Ninth Hospital Affiliated to Soochow University, Suzhou, China
| | - Jiaxing Song
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Nizhen Yu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Changwei Guo
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Shuai Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Chengsong Yue
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Dahong Yang
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Dongjing Xie
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Xiang Liu
- Department of Neurology, Xinqiao Hospital and The Second Affiliated Hospital, Army Medical University (Third Military Medical University), Chongqing, China
| | - Shuye Yu
- Department of Neurology, Suzhou Ninth People's Hospital, Suzhou Ninth Hospital Affiliated to Soochow University, Suzhou, China
| | - Lei Lei
- Department of Neurology, Xianyang Hospital of Yan'an University, Xianyang, China
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16
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Xu Q, Hu L, Chen L, Li H, Tian X, Zuo Y, Zhang Y, Zhang X, Sun P, Wang Y, Meng X, Wang A. Low serum magnesium is associated with poor functional outcome in acute ischemic stroke or transient ischemic attack patients. CNS Neurosci Ther 2022; 29:842-854. [PMID: 36415111 PMCID: PMC9928556 DOI: 10.1111/cns.14020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Revised: 09/12/2022] [Accepted: 10/16/2022] [Indexed: 11/24/2022] Open
Abstract
AIM The association between magnesium and outcomes after stroke is uncertain. We aimed to investigate the association of serum magnesium with all-cause mortality and poor functional outcome. METHODS We included patients with acute ischemic stroke (AIS) or transient ischemic attack (TIA) from the China National Stroke Registry III. We used Cox proportional hazards model for all-cause mortality and logistic regression model for poor functional outcome (modified Rankin Scale [mRS] 2-6/3-6) to examine the relationships. RESULTS Among the 6483 patients, the median (interquartile range) magnesium was 0.87 (0.80-0.93) mmol/L. Patients in the first quartile had a higher risk of mRS score 3-6/2-6 at 3 months (adjusted odds ratio [OR]: 1.30; 95% confidence interval [CI]: 1.02, 1.64; adjusted OR: 1.29; 95% CI: 1.04-1.59) compared with those in the fourth quartile. Similar results were found for mRS score 26 at 1 year. The age- and sex-adjusted hazard ratio (HR) with 95% CI in first quartile magnesium was 1.40 (1.02-1.93) for all-cause mortality within 1 year, but became insignificant (HR: 1.03; 95% CI: 0.71-1.50) after adjusting for potential variables. CONCLUSIONS Low serum magnesium was associated with a high risk of poor functional outcome in patients with AIS or TIA.
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Affiliation(s)
- Qin Xu
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina,China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Lele Hu
- The Second People's Hospital of GuiyangGuizhouChina
| | - Lu Chen
- Department of NeurologyZiBo Central HospitalZiboChina
| | - Hao Li
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina,China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Xue Tian
- Department of Epidemiology and Health StatisticsSchool of Public Health, Capital Medical UniversityBeijingChina,Beijing Municipal Key Laboratory of Clinical EpidemiologyBeijingChina
| | - Yingting Zuo
- Department of Epidemiology and Health StatisticsSchool of Public Health, Capital Medical UniversityBeijingChina,Beijing Municipal Key Laboratory of Clinical EpidemiologyBeijingChina
| | - Yijun Zhang
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina,China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Xiaoli Zhang
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina,China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Ping Sun
- The Second People's Hospital of GuiyangGuizhouChina
| | - Yongjun Wang
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina,China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina,Advanced Innovation Center for Human Brain ProtectionCapital Medical UniversityBeijingChina,Center for Excellence in Brain Science and Intelligence TechnologyChinese Academy of SciencesShanghaiChina
| | - Xia Meng
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina,China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
| | - Anxin Wang
- Department of Neurology, Beijing Tiantan HospitalCapital Medical UniversityBeijingChina,China National Clinical Research Center for Neurological DiseasesBeijing Tiantan Hospital, Capital Medical UniversityBeijingChina
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17
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Yuan CX, Zhang YN, Chen XY, Hu BL. Association between malnutrition risk and hemorrhagic transformation in patients with acute ischemic stroke. Front Nutr 2022; 9:993407. [PMID: 36276820 PMCID: PMC9579279 DOI: 10.3389/fnut.2022.993407] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2022] [Accepted: 09/09/2022] [Indexed: 11/28/2022] Open
Abstract
Background and aims Malnutrition is a prevalent problem occurring in different diseases. Hemorrhagic transformation (HT) is a severe complication of acute ischemic stroke (AIS). Few studies have evaluated the association between malnutrition risk and hemorrhagic transformation in patients with acute stroke. We aim to investigate the influence of malnutrition risk on the risk of hemorrhagic transformation in patients with AIS. Methods A total of 182 consecutive adults with HT and 182 age- and sex-matched patients with stroke were enrolled in this study. The controlling nutritional status (CONUT) score was calculated to evaluate the malnutrition risk. HT was detected by follow-up imaging assessment and was radiologically classified as hemorrhagic infarction type 1 or 2 or parenchymal hematoma type 1 or 2. Logistic regression models were conducted when participants were divided into different malnutrition risk groups according to the objective nutritional score to assess the risk for HT. Results The prevalence of moderate to severe malnutrition risk in patients with AIS was 12.5%, according to the CONUT score. Univariate analysis showed that the CONUT score is significantly higher in patients with HT than those without HT. After adjusting for potential covariables, the patients with mild risk and moderate to severe malnutrition risk were associated with a higher risk of HT compared to the patients in the normal nutritional status group [odds ratio, 3.180 (95% CI, 1.139–8.874), P = 0.027; odds ratio, 3.960 (95% CI, 1.015–15.453), P = 0.048, respectively]. Conclusion Malnutrition risk, measured by CONUT score, was significantly associated with an increased risk of hemorrhagic transformation in patients with AIS.
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Affiliation(s)
- Cheng-Xiang Yuan
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Yi-Ni Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xuan-Yu Chen
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China
| | - Bei-Lei Hu
- Department of Neurology, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, China,*Correspondence: Bei-Lei Hu
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18
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Rotschild O, Honig A, Hallevi H, Horev A, Seyman E, Ben-Assayag E, Jonas-Kimchi T, Sadeh U, Cohen J, Leker RR, Molad J. Endovascular thrombectomy is beneficial for functional nonagenarians - a multicenter cohort analysis. J Stroke Cerebrovasc Dis 2022; 31:106699. [PMID: 36054973 DOI: 10.1016/j.jstrokecerebrovasdis.2022.106699] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 07/19/2022] [Accepted: 08/01/2022] [Indexed: 10/14/2022] Open
Abstract
INTRODUCTION The use of endovascular thrombectomy (EVT) has dramatically increased in recent years. However, most existing studies used an upper age limit of 80 and data regarding the safety and efficacy of EVT among nonagenarians is still lacking. METHODS 767 consecutive patients undergoing EVT for large vessel occlusion (LVO) in three participating centers were recruited into a prospective ongoing database. Demographic, clinical and imaging characteristics were documented. Statistical analysis was done to evaluate EVT outcome among nonagenarians compared to younger patients. RESULTS The current analysis included 41 (5.4%) patients older than 90 years. Compared to younger patients, nonagenarians were more often female (78% versus 50.3%, p ≤ 0.001), had worse baseline mRS scores (2 [0-3] versus 0 [0-2], p < 0.001), higher rates of hypertension and hyperlipidemia and a higher admission NIHSS (20 [14-23] versus 16 [11-20], p < 0.001). No differences were found between groups regarding the involved vessel, stroke etiology, time from symptoms to door or symptoms to EVT, successful recanalization rates and hemorrhagic transformation rates. Nonagenarians had worse mRS at 90 days (5 [3-6] versus 3 [2-5], p = 0.001), similar discharge NIHSS (5 [1-11] versus 4 [1-11], p = 0.78) and higher mortality rates (36.6% versus 15.8%, p < 0.001). All nonagenarians with baseline mRS 4 have died within 90 days. 36.4% of nonagenarian patients with baseline MRS of 3 or less had favorable outcome. DISCUSSION This study demonstrates that nonagenarian stroke patients with baseline mRS of 3 or less benefit from EVT with no significant difference in the rate of favorable outcome compared to octogenarians.
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Affiliation(s)
- Ofer Rotschild
- Department of Stroke & Neurology, Tel-Aviv Sourasky Medical Center, 6 Weizmann Street, Tel-Aviv 64239, Israel
| | - Asaf Honig
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Hen Hallevi
- Department of Stroke & Neurology, Tel-Aviv Sourasky Medical Center, 6 Weizmann Street, Tel-Aviv 64239, Israel; Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Anat Horev
- Department of Neurology, Soroka- University Medical Center, Beer-Sheva, Israel
| | - Estelle Seyman
- Department of Stroke & Neurology, Tel-Aviv Sourasky Medical Center, 6 Weizmann Street, Tel-Aviv 64239, Israel
| | - Einor Ben-Assayag
- Department of Stroke & Neurology, Tel-Aviv Sourasky Medical Center, 6 Weizmann Street, Tel-Aviv 64239, Israel; Faculty of Medicine, Tel-Aviv University, Tel-Aviv, Israel
| | - Tali Jonas-Kimchi
- Department of Radiology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Udi Sadeh
- Department of Radiology, Tel-Aviv Sourasky Medical Center, Tel-Aviv, Israel
| | - Jose Cohen
- Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Ronen R Leker
- Department of Neurology, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| | - Jeremy Molad
- Department of Stroke & Neurology, Tel-Aviv Sourasky Medical Center, 6 Weizmann Street, Tel-Aviv 64239, Israel.
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