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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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2
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Adusumilli G, Pederson JM, Hardy N, Kallmes KM, Hutchison K, Kobeissi H, Heiferman DM, Heit JJ. Mechanical thrombectomy in anterior vs. posterior circulation stroke: A systematic review and meta-analysis. Interv Neuroradiol 2024; 30:307-316. [PMID: 35549748 PMCID: PMC11310733 DOI: 10.1177/15910199221100796] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Revised: 05/27/2021] [Accepted: 06/02/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND High-quality evidence exists for mechanical thrombectomy (MT) treatment of acute ischemic stroke (AIS) due to large vessel occlusion of the anterior circulation (AC-LVO). The evidence for MT treatment of posterior circulation large vessel occlusion (PC-LVO) is weaker, largely drawn from lower quality studies specific to PC-LVO and extrapolated from findings in AC-LVO, and ambiguous with regards to technical success. We performed a systematic review and meta-analysis to compare the technical success and functional outcomes of MT in PC-LVO versus AC-LVO patients. METHODS We identified comparative studies reporting on patients treated with MT in AC-LVO versus PC-LVO. The primary outcome of interest was thrombolysis in cerebral infarction (TICI) ≥ 2b. Secondary outcomes included rates of TICI 3, 90-day functional independence, first-pass-effect, average number of passes, and 90-day mortality. A separate random effects model was fit for each outcome measure. RESULTS Twenty studies with 12,911 patients, 11,299 (87.5%) in the AC-LVO arm and 1612 (12.5%) in the PC-LVO arm, were included. AC-LVO and PC-LVO patients had comparable rates of successful recanalization [OR = 1.02 [95% CI: 0.79-1.33], p = 0.848). However, the AC-LVO group had greater odds of 90-day functional independence (OR = 1.26 [95% CI: 1.00; 1.59], p = 0.050) and lower odds of 90-day mortality (OR = 0.58 [95% CI: 0.43; 0.79], p = 0.002). CONCLUSIONS MT achieves similar rates of recanalization with a similar safety profile in PC-LVO and AC-LVO patients. Patients with PC-LVO are less likely to achieve functional independence after MT. Future studies should identify PC-LVO patients who are likely to achieve favourable functional outcomes.
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Affiliation(s)
- Gautam Adusumilli
- Department of Radiology and Neurosurgery, Stanford University, Stanford, CA, USA
| | - John M Pederson
- Nested Knowledge, Inc, St Paul, MN, USA
- Superior Medical Experts, St Paul, MN, USA
| | | | | | | | - Hassan Kobeissi
- Central Michigan University College of Medicine, Mt. Pleasant, MI, USA
| | | | - Jeremy J Heit
- Department of Radiology and Neurosurgery, Stanford University, Stanford, CA, USA
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Räty S, Virtanen P, Ritvonen J, Georgiopoulos G, Sairanen T, Lindsberg PJ, Strbian D. IV Thrombolysis in Basilar Artery Occlusion: Outcomes and Comparison With Endovascular Thrombectomy. Neurology 2024; 102:e209249. [PMID: 38531004 DOI: 10.1212/wnl.0000000000209249] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2023] [Accepted: 01/08/2024] [Indexed: 03/28/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Recanalization is considered a prerequisite for favorable outcome in basilar artery occlusion (BAO). Intravenous thrombolysis (IVT) has been successfully used for eligible patients with BAO well beyond the 4.5-hour time window but has been largely underrepresented in the best medical management arms in recent randomized controlled trials of recanalization therapy in BAO. We aimed to analyze the outcomes of patients with BAO treated with IVT only and to compare IVT with endovascular thrombectomy (EVT). METHODS This observational single-center, retrospective cohort study included consecutive patients with BAO treated with IVT and/or EVT up to 48 hours of symptom onset during 1995-2022. The primary outcome was favorable functional outcome (modified Rankin Scale 0-3) at 3 months collected by a stroke physician by phone. In the first part, we described the outcomes and factors associated with functional outcome in the IVT-only cohort during 1995-2022. In the second part, we used doubly robust inverse probability-weighted regression adjustment models to compare functional outcome of patients treated with IVT vs EVT+/-IVT during 2010-2022. RESULTS In the whole cohort of 376 patients with acute BAO treated with recanalization therapy, 245 (65.2%) received only IVT. In the IVT-only cohort, most patients had moderate-to-severe clinical presentation (median NIH Stroke Scale 18) but no extensive early ischemic changes in the posterior circulation on admission. Half of them had onset-to-treatment time over 6 hours. 46.5% of the IVT-treated patients achieved 3-month favorable functional outcome, whereas mortality was 35.9%. sICH occurred in 11.1%. In a multivariable analysis, younger age, milder symptom severity, and less baseline ischemic changes predicted favorable functional outcome. In the 2010-2022 cohort, when compared with patients treated with EVT+/-IVT (n = 121), the IVT-only cohort (n = 122) had higher odds for favorable functional outcome (IVT 58.2% vs EVT 43.0% (aOR 2.82 [95% CI 1.31-6.05]). DISCUSSION IVT alone produced outcomes comparable with those in recent trials of endovascular BAO recanalization. Furthermore, in head-to-head comparison in our cohort, the IVT-only approach was more often associated with favorable outcome than EVT+/-IVT. Thus, it should not be overlooked as the first-line recanalization therapy in acute BAO, even in longer time windows. CLASSIFICATION OF EVIDENCE This study provides Class IV evidence that tPA is as effective as thrombectomy for basilar artery thrombosis.
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Affiliation(s)
- Silja Räty
- From the Departments of Neurology (S.R., J.R., T.S., P.J.L., D.S.) and Radiology (P.V.), Helsinki University Hospital and University of Helsinki, Finland; Department of Clinical Therapeutics (G.G.), National and Kapodistrian University of Athens, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College London; and Institute of Cardiovascular Science (G.G.), University College London, United Kingdom
| | - Pekka Virtanen
- From the Departments of Neurology (S.R., J.R., T.S., P.J.L., D.S.) and Radiology (P.V.), Helsinki University Hospital and University of Helsinki, Finland; Department of Clinical Therapeutics (G.G.), National and Kapodistrian University of Athens, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College London; and Institute of Cardiovascular Science (G.G.), University College London, United Kingdom
| | - Juhani Ritvonen
- From the Departments of Neurology (S.R., J.R., T.S., P.J.L., D.S.) and Radiology (P.V.), Helsinki University Hospital and University of Helsinki, Finland; Department of Clinical Therapeutics (G.G.), National and Kapodistrian University of Athens, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College London; and Institute of Cardiovascular Science (G.G.), University College London, United Kingdom
| | - Georgios Georgiopoulos
- From the Departments of Neurology (S.R., J.R., T.S., P.J.L., D.S.) and Radiology (P.V.), Helsinki University Hospital and University of Helsinki, Finland; Department of Clinical Therapeutics (G.G.), National and Kapodistrian University of Athens, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College London; and Institute of Cardiovascular Science (G.G.), University College London, United Kingdom
| | - Tiina Sairanen
- From the Departments of Neurology (S.R., J.R., T.S., P.J.L., D.S.) and Radiology (P.V.), Helsinki University Hospital and University of Helsinki, Finland; Department of Clinical Therapeutics (G.G.), National and Kapodistrian University of Athens, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College London; and Institute of Cardiovascular Science (G.G.), University College London, United Kingdom
| | - Perttu J Lindsberg
- From the Departments of Neurology (S.R., J.R., T.S., P.J.L., D.S.) and Radiology (P.V.), Helsinki University Hospital and University of Helsinki, Finland; Department of Clinical Therapeutics (G.G.), National and Kapodistrian University of Athens, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College London; and Institute of Cardiovascular Science (G.G.), University College London, United Kingdom
| | - Daniel Strbian
- From the Departments of Neurology (S.R., J.R., T.S., P.J.L., D.S.) and Radiology (P.V.), Helsinki University Hospital and University of Helsinki, Finland; Department of Clinical Therapeutics (G.G.), National and Kapodistrian University of Athens, Greece; School of Biomedical Engineering and Imaging Sciences (G.G.), King's College London; and Institute of Cardiovascular Science (G.G.), University College London, United Kingdom
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Borończyk M, Kuźniak M, Borończyk A, Żak A, Binek Ł, Wagner-Kusz A, Lasek-Bal A. Efficacy and safety of mechanical thrombectomy in the posterior cerebral circulation-a single center study. Sci Rep 2024; 14:7700. [PMID: 38565588 PMCID: PMC10987592 DOI: 10.1038/s41598-024-57963-6] [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: 09/11/2023] [Accepted: 03/23/2024] [Indexed: 04/04/2024] Open
Abstract
Mechanical thrombectomy (MT) is the current standard treatment for strokes in the anterior cerebral circulation (AMT) and has recently been proven to be beneficial in the posterior circulation strokes (PMT). Our study aims to evaluate parameters for favorable outcomes in PMT-patients and to compare the clinical characteristics of individuals who received AMT and PMT. For this purpose, we confronted AMT and PMT-receipients and performed a multivariate regression analysis to assess the influence of factors on favorable outcomes in the study group and in the AMT and PMT subgroups. When analysing 623 MT-patients, those who received PMT had significantly lower admission National Institutes of Health Stroke Scale (NIHSS) scores (9 vs. 13; p < 0.001) and 24 h post-MT (7 vs. 12; p = 0.006). Key parameters influencing the favorable outcomes of PMT at discharge and at 90th day include: NIHSS scores (OR: 0.865, 95% CI: 0.813-0.893, and OR: 0.900, 95% CI: 0.861-0.925), MT time (OR: 0.993, 95% CI: 0.987-0.998 and OR: 0.993, 95% CI: 0.990-0.997), and leukocytosis (OR: 0.961, 95% CI: 0.928-0.988 and OR: 0.974, 95% CI: 0.957-0.998). Different clinical profiles exist between AMT and PMT-recipients, with the neurological status post-MT being decisive for the prognosis. Several factors play an important role in predicting outcome, especially in the PMT group.
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Affiliation(s)
- Michał Borończyk
- Students' Scientific Association, Department of Neurology, Faculty of Health Sciences in Katowice, Medical University of Silesia, 40-055, Katowice, Poland
| | - Mikołaj Kuźniak
- Students' Scientific Association, Department of Neurology, Faculty of Health Sciences in Katowice, Medical University of Silesia, 40-055, Katowice, Poland
| | - Agnieszka Borończyk
- Students' Scientific Association, Department of Neurology, Faculty of Health Sciences in Katowice, Medical University of Silesia, 40-055, Katowice, Poland
| | - Amadeusz Żak
- Department of Neurology, Faculty of Health Sciences in Katowice, Medical University of Silesia, Katowice, Poland
- Upper-Silesian Medical Centre, Silesian Medical University in Katowice, Katowice, Poland
| | - Łukasz Binek
- Upper-Silesian Medical Centre, Silesian Medical University in Katowice, Katowice, Poland
| | - Anna Wagner-Kusz
- Department of Neurology, Faculty of Health Sciences in Katowice, Medical University of Silesia, Katowice, Poland
- Upper-Silesian Medical Centre, Silesian Medical University in Katowice, Katowice, Poland
| | - Anetta Lasek-Bal
- Department of Neurology, Faculty of Health Sciences in Katowice, Medical University of Silesia, Katowice, Poland.
- Upper-Silesian Medical Centre, Silesian Medical University in Katowice, Katowice, Poland.
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Halúsková S, Herzig R, Mikulík R, Bělašková S, Reiser M, Jurák L, Václavík D, Bar M, Klečka L, Řepík T, Šigut V, Tomek A, Hlinovský D, Šaňák D, Vyšata O, Vališ M, Investigators OBOTCSITS. Intravenous Thrombolysis in Posterior versus Anterior Circulation Stroke: Clinical Outcome Differs Only in Patients with Large Vessel Occlusion. Biomedicines 2024; 12:404. [PMID: 38398006 PMCID: PMC10887309 DOI: 10.3390/biomedicines12020404] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2024] [Revised: 01/31/2024] [Accepted: 02/07/2024] [Indexed: 02/25/2024] Open
Abstract
The safety and efficacy of intravenous thrombolysis (IVT) are well established in anterior circulation stroke (ACS) but are much less clear for posterior circulation stroke (PCS). The aim of this study was to evaluate the occurrence of parenchymal hematoma (PH) and 3-month clinical outcomes after IVT in PCS and ACS. In an observational, cohort multicenter study, we analyzed data from ischemic stroke patients treated with IVT prospectively collected in the SITS (Safe Implementation of Treatments in Stroke) registry in the Czech Republic between 2004 and 2018. Out of 10,211 patients, 1166 (11.4%) had PCS, and 9045 (88.6%) ACS. PH was less frequent in PCS versus ACS patients: 3.6 vs. 5.9%, odds ratio (OR) = 0.594 in the whole set, 4.4 vs. 7.8%, OR = 0.543 in those with large vessel occlusion (LVO), and 2.2 vs. 4.7%, OR = 0.463 in those without LVO. At 3 months, PCS patients compared with ACS patients achieved more frequently excellent clinical outcomes (modified Rankin scale [mRS] 0-1: 55.5 vs. 47.6%, OR = 1.371 in the whole set and 49.2 vs. 37.6%, OR = 1.307 in those with LVO), good clinical outcomes (mRS 0-2: 69.9 vs. 62.8%, OR = 1.377 in the whole set and 64.5 vs. 50.5%, OR = 1.279 in those with LVO), and had lower mortality (12.4 vs. 16.6%, OR = 0.716 in the whole set and 18.4 vs. 25.5%, OR = 0.723 in those with LVO) (p < 0.05 in all cases). In PCS versus ACS patients, an extensive analysis showed a lower risk of PH both in patients with and without LVO, more frequent excellent and good clinical outcomes, and lower mortality 3 months after IVT in patients with LVO.
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Affiliation(s)
- Simona Halúsková
- Department of Neurology, Faculty of Medicine in Hradec Králové, Charles University, 500 03 Hradec Králové, Czech Republic; (S.H.)
- Department of Neurology, Faculty of Health Studies, Pardubice University and Pardubice Hospital, 532 10 Pardubice, Czech Republic
| | - Roman Herzig
- Department of Neurology, Faculty of Medicine in Hradec Králové, Charles University, 500 03 Hradec Králové, Czech Republic; (S.H.)
- Department of Neurology, Comprehensive Stroke Center, University Hospital Hradec Králové, 500 05 Hradec Králové, Czech Republic
- Research Institute for Biomedical Science, 500 02 Hradec Králové, Czech Republic
| | - Robert Mikulík
- International Clinical Research Center, St. Anne’s University Hospital in Brno, 602 00 Brno, Czech Republic
| | - Silvie Bělašková
- International Clinical Research Center, St. Anne’s University Hospital in Brno, 602 00 Brno, Czech Republic
| | - Martin Reiser
- Department of Neurology, Comprehensive Stroke Center, Hospital České Budějovice, 370 01 České Budějovice, Czech Republic
| | - Lubomír Jurák
- Neurocenter, Regional Hospital Liberec, 460 63 Liberec, Czech Republic
| | - Daniel Václavík
- Department of Neurology, Faculty of Medicine in Hradec Králové, Charles University, 500 03 Hradec Králové, Czech Republic; (S.H.)
- Department of Neurology, Comprehensive Stroke Center, University Hospital Hradec Králové, 500 05 Hradec Králové, Czech Republic
- Department of Clinical Neurosciences, Faculty of Medicine, University of Ostrava, 708 00 Ostrava, Czech Republic
- Research and Training Institute Agel, Stroke Center, Department of Neurology, Hospital Ostrava Vítkovice, 703 00 Ostrava, Czech Republic
| | - Michal Bar
- Department of Neurology, Comprehensive Stroke Center, Faculty of Medicine, University of Ostrava and University Hospital Ostrava, 708 52 Ostrava, Czech Republic
| | - Lukáš Klečka
- Stroke Center, Department of Neurology, City Hospital Ostrava, 703 00 Ostrava, Czech Republic
| | - Tomáš Řepík
- Department of Neurology, Comprehensive Stroke Center, University Hospital in Pilsen and Faculty of Medicine in Pilsen, Charles University, 323 00 Pilsen, Czech Republic
| | - Vladimír Šigut
- Stroke Center, Department of Neurology, Krnov Hospital, 794 01 Krnov, Czech Republic
| | - Aleš Tomek
- Department of Neurology, Comprehensive Stroke Center, Charles University 2nd Faculty of Medicine, Motol University Hospital, 150 06 Prague, Czech Republic
| | - David Hlinovský
- Stroke Center, Department of Neurology, Thomayer University Hospital, 140 59 Prague, Czech Republic
| | - Daniel Šaňák
- Department of Neurology, Comprehensive Stroke Center, Faculty of Medicine and Dentistry, Palacký University and University Hospital Olomouc, 779 00 Olomouc, Czech Republic
| | - Oldřich Vyšata
- Department of Neurology, Faculty of Medicine in Hradec Králové, Charles University, 500 03 Hradec Králové, Czech Republic; (S.H.)
- Department of Neurology, Comprehensive Stroke Center, University Hospital Hradec Králové, 500 05 Hradec Králové, Czech Republic
| | - Martin Vališ
- Research Institute for Biomedical Science, 500 02 Hradec Králové, Czech Republic
- International Clinical Research Center, St. Anne’s University Hospital in Brno, 602 00 Brno, Czech Republic
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6
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Knapen RR, Pirson FAV, Langezaal LC, Brouwer J, Majoie CB, Emmer BJ, Vos JA, van Doormaal PJ, Yoo AJ, Bruggeman AA, Lycklama à Nijeholt GJ, van der Leij C, van Oostenbrugge RJ, van Zwam WH, Schonewille WJ. Intravenous Thrombolysis Before Endovascular Treatment in Posterior Circulation Occlusions: A MR CLEAN Registry Study. Stroke 2024; 55:403-412. [PMID: 38174571 PMCID: PMC10802980 DOI: 10.1161/strokeaha.123.043777] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 10/31/2023] [Accepted: 11/09/2023] [Indexed: 01/05/2024]
Abstract
BACKGROUND The effectiveness of intravenous thrombolysis (IVT) before endovascular treatment (EVT) has been investigated in randomized trials and meta-analyses. These studies mainly concerned anterior circulation occlusions. We aimed to investigate clinical, technical, and safety outcomes of IVT before EVT in posterior circulation occlusions in a nationwide registry. METHODS Patients were included from the MR CLEAN Registry (Multicenter Randomized Clinical Trial of Endovascular Treatment for Acute Ischemic Stroke in the Netherlands), a nationwide, prospective, multicenter registry of patients with acute ischemic stroke due to a large intracranial vessel occlusion receiving EVT between 2014 and 2019. All patients with a posterior circulation occlusion were included. Primary outcome was a shift toward better functional outcome on the modified Rankin Scale at 90 days. Secondary outcomes were favorable functional outcome (modified Rankin Scale scores, 0-3), occurrence of symptomatic intracranial hemorrhages, successful reperfusion (extended Thrombolysis in Cerebral Ischemia ≥2B), first-attempt successful reperfusion, and mortality at 90 days. Regression analyses with adjustments based on univariable analyses and literature were applied. RESULTS A total of 248 patients were included, who received either IVT (n=125) or no IVT (n=123) before EVT. Results show no differences in a shift on the modified Rankin Scale (adjusted common odds ratio, 1.04 [95% CI, 0.61-1.76]). Although symptomatic intracranial hemorrhages occurred more often in the IVT group (4.8% versus 2.4%), regression analysis did not show a significant difference (adjusted odds ratio, 1.65 [95% CI, 0.33-8.35]). Successful reperfusion, favorable functional outcome, first-attempt successful reperfusion, and mortality did not differ between patients treated with and without IVT. CONCLUSIONS We found no significant differences in clinical, technical, and safety outcomes between patients with a large vessel occlusion in the posterior circulation treated with or without IVT before EVT. Our results are in line with the literature on the anterior circulation.
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Affiliation(s)
- Robrecht R.M.M. Knapen
- Department of Radiology and Nuclear Medicine (R.R.M.M.K., C.v.d.L., W.H.v.Z.), Maastricht University Medical Center, the Netherlands
- School for Cardiovascular Diseases Maastricht (CARIM), Maastricht University, the Netherlands (R.R.M.M.K., R.J.v.O., W.H.v.Z.)
| | - F. Anne V. Pirson
- Department of Neurology (F.A.V.P.), Haaglanden MC, Hague, the Netherlands
| | - Lucianne C.M. Langezaal
- Department of Radiology (L.C.M.L., J.-A.V.), St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Josje Brouwer
- Department of Neurology (J.B.), Amsterdam University Medical Center, University of Amsterdam, the Netherlands
| | - Charles B.L.M. Majoie
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, University of Amsterdam, the Netherlands (C.B.L.M.M., A.A.E.B.)
| | - Bart J. Emmer
- Department of Radiology and Nuclear Medicine (B.J.E.), Amsterdam University Medical Center, University of Amsterdam, the Netherlands
| | - Jan-Albert Vos
- Department of Radiology (L.C.M.L., J.-A.V.), St. Antonius Hospital, Nieuwegein, the Netherlands
| | - Pieter-Jan van Doormaal
- Department of Radiology, Erasmus Medical Center, University Medical Center, Rotterdam, the Netherlands (P.-J.v.D.)
| | - Albert J. Yoo
- Department of Radiology/Neurointervention, Texas Stroke Institute, Dallas-Fort Worth (A.J.Y)
| | - Agnetha A.E. Bruggeman
- Department of Radiology and Nuclear Medicine, Amsterdam University Medical Center, University of Amsterdam, the Netherlands (C.B.L.M.M., A.A.E.B.)
| | | | - Chirstiaan van der Leij
- Department of Radiology and Nuclear Medicine (R.R.M.M.K., C.v.d.L., W.H.v.Z.), Maastricht University Medical Center, the Netherlands
| | - Robert J. van Oostenbrugge
- Department of Neurology (R.J.v.O.), Maastricht University Medical Center, the Netherlands
- School for Cardiovascular Diseases Maastricht (CARIM), Maastricht University, the Netherlands (R.R.M.M.K., R.J.v.O., W.H.v.Z.)
| | - Wim H. van Zwam
- Department of Radiology and Nuclear Medicine (R.R.M.M.K., C.v.d.L., W.H.v.Z.), Maastricht University Medical Center, the Netherlands
- School for Cardiovascular Diseases Maastricht (CARIM), Maastricht University, the Netherlands (R.R.M.M.K., R.J.v.O., W.H.v.Z.)
| | - Wouter J. Schonewille
- Department of Neurology (W.J.S.), St. Antonius Hospital, Nieuwegein, the Netherlands
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7
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Pelletier J, Koyfman A, Long B. Pearls for the Emergency Clinician: Posterior Circulation Stroke. J Emerg Med 2023; 65:e414-e426. [PMID: 37806810 DOI: 10.1016/j.jemermed.2023.07.007] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Revised: 06/29/2023] [Accepted: 07/15/2023] [Indexed: 10/10/2023]
Abstract
BACKGROUND Posterior circulation (PC) stroke in adults is a rare, frequently misdiagnosed, serious condition that carries a high rate of morbidity. OBJECTIVE OF THE REVIEW This review evaluates the presentation, diagnosis, and management of PC stroke in the emergency department (ED) based on current evidence. DISCUSSION PC stroke presents most commonly with dizziness or vertigo and must be distinguished from more benign diagnoses. Emergency clinicians should consider this condition in patients with dizziness, even in younger patients and those who do not have traditional stroke risk factors. Neurologic examination for focal neurologic deficit, dysmetria, dysarthria, ataxia, and truncal ataxia is essential, as is the differentiation of acute vestibular syndrome vs. spontaneous episodic vestibular syndrome vs. triggered episodic vestibular syndrome. The HINTS (head impulse, nystagmus, and test of skew) examination can be useful for identifying dizziness presentations concerning for stroke when performed by those with appropriate training. However, it should only be used in patients with continuous dizziness who have ongoing nystagmus. Contrast tomography (CT), CT angiography, and CT perfusion have limited sensitivity for identifying PC strokes, and although magnetic resonance imaging is the gold standard, it may miss some PC strokes early in their course. Thrombolysis is recommended in patients presenting within the appropriate time window for thrombolytic therapy, and although some data suggest endovascular therapy for basilar artery and posterior cerebral artery infarcts is beneficial, its applicability for all PC strokes remains to be determined. CONCLUSIONS An understanding of PC stroke can assist emergency clinicians in diagnosing and managing this disease.
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Affiliation(s)
- Jessica Pelletier
- Department of Emergency Medicine, Washington University School of Medicine, St Louis, Missouri
| | - Alex Koyfman
- Department of Emergency Medicine, UT Southwestern, Dallas, Texas
| | - Brit Long
- San Antonio Uniformed Services Health Education Consortium, Department of Emergency Medicine, Brooke Army Medical Center, Fort Sam Houston, Texas.
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8
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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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9
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Endovascular Treatment of Basilar Artery Occlusion: What Can We Learn from the Results? MEDICINA (KAUNAS, LITHUANIA) 2022; 59:medicina59010096. [PMID: 36676720 PMCID: PMC9866638 DOI: 10.3390/medicina59010096] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/08/2022] [Revised: 12/27/2022] [Accepted: 12/28/2022] [Indexed: 01/03/2023]
Abstract
Background and Objectives: Current guidelines lack specific endovascular treatment (EVT) recommendations for posterior circulation stroke (PCS). The results of earlier studies are controversial. We aimed to compare early hospital outcomes of stroke caused by large-vessel occlusion (LVO) treated with EVT or bridging therapy (BT) in anterior circulation stroke (ACS) versus PCS (middle cerebral artery occlusion (MCAO) and basilar artery occlusion (BAO), and establish the risk factors for poor outcome. Materials and Methods: we analyzed the data of 279 subjects treated with EVT due to LVO-caused stroke in a comprehensive stroke centre in 2015−2021. The primary outcome was hospital mortality, secondary outcomes were National Institutes of Health Stroke Scale (NIHSS) after 24 h, early neurological deterioration, futile recanalization (FR), the ambulatory outcome at discharge, and complications. Results: BAO presented with higher baseline NIHSS scores (19 vs. 14, p < 0.001), and longer door-to-puncture time (93 vs. 82 min, p = 0.034), compared to MCAO. Hospital mortality and the percentage of FR were the same in BAO and almost two times higher than in MCAO (20.0% vs. 10.3%, p = 0.048), other outcomes did not differ. In BAO, unsuccessful recanalization was the only significant predictor of the lethal outcome, though there were trends for PAD and RF predicting lethal outcome. A trend for higher risk of symptomatic intracranial hemorrhage (sICH) was observed in the BAO group when BT was applied. Nevertheless, neither BT nor sICH predicted lethal outcomes in the BAO group. Conclusions: Compared to the modern gold standard of EVT in the ACS, early outcomes in BAO remain poor, there is a substantial amount of FR. Nevertheless, unsuccessful recanalization remains the strongest predictor of lethal outcomes. BT in PCS might pose a higher risk for sICH, but not the lethal outcome, although this finding requires further investigation in larger trials.
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10
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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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Jahan R, Liebeskind DS, Zaidat OO, Mueller-Kronast NH, Froehler MT, Saver JL. Stent Retriever Thrombectomy for Anterior vs. Posterior Circulation Ischemic Stroke: Analysis of the STRATIS Registry. Front Neurol 2021; 12:706130. [PMID: 34504469 PMCID: PMC8421856 DOI: 10.3389/fneur.2021.706130] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2021] [Accepted: 07/26/2021] [Indexed: 11/13/2022] Open
Abstract
Background and Purpose: The benefits of mechanical thrombectomy (MT) in vertebrobasilar artery occlusions have not been well-studied. We compared clinical, procedural, and safety outcomes of MT for posterior circulation (PC) vs. anterior circulation (AC) occlusions among patients in the STRATIS registry. Methods: Data from STRATIS including patient demographics, procedural characteristics, and outcomes including symptomatic intracranial hemorrhage (sICH) at 24 h, serious adverse events (SAE), substantial reperfusion [modified thrombolysis in cerebral infarction (mTICI) 2b/3], 90-day functional independence [modified Rankin Scale (mRS) 0–2], and 90-day mortality were analyzed. Univariate logistic regression was used to calculate predictors of good clinical outcome. Results: Of 984 STRATIS patients, 43 (4.4%) patients with PC occlusions [mean age 63.0 ± 13.6, 25.6% (11/43) female] and 932 (94.7%) with AC occlusions [mean age 68.5 ± 14.8, 46.9% (437/932) female] were included for analysis. Median National Institutes of Health Stroke Scale (NIHSS) scores at baseline were 17.0 (13.0, 12.0) for the AC group and 12.0 (11.0, 24.0) for the PC group. Time from onset to procedure end was longer for the PC group [median (IQR): 322.0 min (255.0–421.0) vs. 271.0 min (207.0–360.0); p = 0.007]. PC and AC groups had similar rates of substantial reperfusion [89.2% (33/37) vs. 87.7% (684/780)], procedure-related SAE [0.0% (0/43) vs. 1.7% (16/932)], sICH [0.0% (0/38) vs. 1.5% (12/795)], 90-day functional independence [66.7% (26/39) vs. 55.9% (480/858)] and mortality [12.8% (5/39) vs. 15.8% (136/861)]. National Institutes of Health Stroke Scale score and patient sex were significant univariate predictors of good clinical outcome (p < 0.05). Conclusions: Despite longer reperfusion times, MT in PC stroke has similar rates of 90-day functional independence with no significant difference in procedure-related SAE, sICH, or mortality, supporting the use of MT in PC acute ischemic stroke (AIS). Clinical Trial Registration:https://www.clinicaltrials.gov, Identifier: NCT02239640.
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Affiliation(s)
- Reza Jahan
- Division of Interventional Neuroradiology, Department of Radiology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - David S Liebeskind
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
| | - Osama O Zaidat
- Department of Neurology, Mercy Health St. Vincent Hospital, Toledo, OH, United States
| | | | - Michael T Froehler
- Cerebrovascular Program, Vanderbilt University Medical Center, Nashville, TN, United States
| | - Jeffrey L Saver
- Department of Neurology, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, CA, United States
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12
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Kuribara T, Iihoshi S, Tsukagoshi E, Teranishi A, Kinoshita Y, Sugasawa S, Kohyama S, Takahashi S, Kurita H. Thrombectomy for acute large vessel occlusion in posterior and anterior circulation: a single institutional retrospective observational study. Neuroradiology 2021; 64:565-574. [PMID: 34477913 PMCID: PMC8850247 DOI: 10.1007/s00234-021-02799-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Accepted: 08/28/2021] [Indexed: 12/04/2022]
Abstract
Purpose Thrombectomy has been the gold standard therapy for anterior circulation occlusion; however, studies regarding thrombectomy in posterior circulation are lacking. In this study, we compared the efficiency of thrombectomy for acute large vessel occlusion between the posterior and anterior circulation at a single institution. Methods We retrospectively analyzed consecutive patients who underwent thrombectomy for acute large vessel occlusion at our institution between August 2014 and April 2021. Differences in the clinical background, time course, and treatment technique and outcomes were evaluated between anterior and posterior circulation occlusions. Results Overall, 353 patients (225 men and 128 women) were included: 314 patients had anterior circulation occlusion and 39 patients had posterior circulation occlusion. Between the patients with anterior and posterior circulation occlusions, the National Institutes of Health Stroke Scale (NIHSS) score (16 [12–21] vs. 29 [19–34], respectively, p < 0.001), door-to-puncture time (65 [45–99] vs. 99 [51–121] min, respectively, p = 0.018), and mortality (22 [7%] vs. 8 [20.5%] patients, respectively, p = 0.010) were significantly different; however, favorable outcome was not significantly different. Conclusion Higher NIHSS score, delayed treatment, and higher mortality were observed in posterior circulation occlusion than in anterior circulation occlusion; successful reperfusion and favorable outcomes were similar between them. Similar favorable outcomes and reperfusion ratio to the anterior circulation might be achieved also in the posterior circulation; however, delayed treatment and the optimal first-pass strategy might need further improvement.
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Affiliation(s)
- Tomoyoshi Kuribara
- Department of Endovascular Neurosurgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan
| | - Satoshi Iihoshi
- Department of Endovascular Neurosurgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan.
| | - Eisuke Tsukagoshi
- Department of Endovascular Neurosurgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan
| | - Akio Teranishi
- Department of Endovascular Neurosurgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan
| | - Yu Kinoshita
- Department of Endovascular Neurosurgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan
| | - Shin Sugasawa
- Department of Endovascular Neurosurgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan
| | - Shinya Kohyama
- Department of Endovascular Neurosurgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan
| | - Shinichi Takahashi
- Department of Neurology and Cerebrovascular Medicine, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
| | - Hiroki Kurita
- Department of Cerebrovascular Surgery, Saitama Medical University International Medical Center, Hidaka, Saitama, Japan
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13
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Alemseged F, Campbell BCV. Tenecteplase Thrombolysis in Posterior Circulation Stroke. Front Neurol 2021; 12:678887. [PMID: 34421787 PMCID: PMC8377762 DOI: 10.3389/fneur.2021.678887] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 06/07/2021] [Indexed: 01/01/2023] Open
Abstract
One in five ischaemic strokes affects the posterior circulation. Basilar artery occlusion is a type of posterior circulation stroke associated with a high risk of disability and mortality. Despite its proven efficacy in ischaemic stroke more generally, alteplase only achieves rapid reperfusion in ~4% of basilar artery occlusion patients. Tenecteplase is a genetically modified variant of alteplase with greater fibrin specificity and longer half-life than alteplase, which can be administered by intravenous bolus. The single-bolus administration of tenecteplase vs. an hour-long alteplase infusion is a major practical advantage, particularly in "drip and ship" patients with basilar artery occlusion who are being transported between hospitals. Other practical advantages include its reduced cost compared to alteplase. The EXTEND-IA TNK trial demonstrated that tenecteplase led to higher reperfusion rates prior to endovascular therapy (22 vs. 10%, non-inferiority p = 0.002, superiority p = 0.03) and improved functional outcomes (ordinal analysis of the modified Rankin Scale, common odds ratio 1.7, 95% CI 1.0-2.8, p = 0.04) compared with alteplase in large-vessel occlusion ischaemic strokes. We recently demonstrated in observational data that tenecteplase was associated with increased reperfusion rates compared to alteplase prior to endovascular therapy in basilar artery occlusion [26% (n = 5/19) of patients thrombolysed with TNK vs. 7% (n = 6/91) thrombolysed with alteplase (RR 4.0 95% CI 1.3-12; p = 0.02)]. Although randomized controlled trials are needed to confirm these results, tenecteplase can be considered as an alternative to alteplase in patients with basilar artery occlusion, particularly in "drip and ship" patients.
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Affiliation(s)
- Fana Alemseged
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
| | - Bruce C V Campbell
- Department of Medicine and Neurology, Royal Melbourne Hospital, University of Melbourne, Parkville, VIC, Australia
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14
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Mbroh J, Poli K, Tünnerhoff J, Gomez-Exposito A, Wang Y, Bender B, Hempel JM, Hennersdorf F, Feil K, Mengel A, Ziemann U, Poli S. Comparison of Risk Factors, Safety, and Efficacy Outcomes of Mechanical Thrombectomy in Posterior vs. Anterior Circulation Large Vessel Occlusion. Front Neurol 2021; 12:687134. [PMID: 34239498 PMCID: PMC8258169 DOI: 10.3389/fneur.2021.687134] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2021] [Accepted: 05/14/2021] [Indexed: 12/04/2022] Open
Abstract
Background and Purpose: It is believed that stroke occurring due to posterior circulation large vessel occlusion (PCLVO) and that occurring due to anterior circulation large vessel occlusion (ACLVO) differ in terms of their pathophysiology and the outcome of their acute management in relation to endovascular mechanical thrombectomy (MT). Limited sample size and few randomized controlled trials (RCTs) with respect to PCLVO make the safety and efficacy of MT, which has been confirmed in ACLVO, difficult to assess in the posterior circulation. We therefore conducted a meta-analysis to study to which extent MT in PCLVO differs from ACLVO. Materials and Methods: We searched the databases PubMed, Cochrane, and EMBASE for studies published between 2010 and January 2021, with information on risk factors, safety, and efficacy outcomes of MT in PCLVO vs. ACLVO and conducted a systematic review and meta-analysis; we compared baseline characteristics, reperfusion treatment profiles [including rates of intravenous thrombolysis (IVT) and onset-to-IVT and onset-to-groin puncture times], recanalization success [Thrombolysis In Cerebral Infarction scale (TICI) 2b/3], symptomatic intracranial hemorrhage (sICH), and favorable functional outcome [modified Rankin Score (mRS) 0-2] and mortality at 90 days. Results: Sixteen studies with MT PCLVO (1,172 patients) and ACLVO (7,726 patients) were obtained from the search. The pooled estimates showed higher baseline National Institutes of Health Stroke Scale (NIHSS) score (SMD 0.32, 95% CI 0.15-0.48) in the PCLVO group. PCLVO patients received less often IVT (OR 0.65, 95% CI 0.53-0.79). Onset-to-IVT time (SMD 0.86, 95% CI 0.45-1.26) and onset-to-groin puncture time (SMD 0.59, 95% CI 0.33-0.85) were longer in the PCLVO group. The likelihood of obtaining successful recanalization and favorable functional outcome at 90 days was comparable between the two groups. PCLVO was, however, associated with less sICH (OR 0.56, 95% CI 0.37-0.85) but higher mortality (OR 1.92, 95% CI 1.46-2.53). Conclusions: This meta-analysis indicates that MT in PCLVO may be comparably efficient in obtaining successful recanalization and 90 day favorable functional outcome just as in ACLVO. Less sICH in MT-treated PCLVO patients might be the result of the lower IVT rate in this group. Higher baseline NIHSS and longer onset-to-IVT and onset-to-groin puncture times may have contributed to a higher 90 day mortality in PCLVO patients.
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Affiliation(s)
- Joshua Mbroh
- Department of Neurology & Stroke, Eberhard-Karls University, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany
| | - Khouloud Poli
- Department of Neurology & Stroke, Eberhard-Karls University, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany
| | - Johannes Tünnerhoff
- Department of Neurology & Stroke, Eberhard-Karls University, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany
| | - Alexandra Gomez-Exposito
- Department of Neurology & Stroke, Eberhard-Karls University, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany
| | - Yi Wang
- Department of Neurology & Stroke, Eberhard-Karls University, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany
| | - Benjamin Bender
- Department of Neuroradiology, Eberhard-Karls University, Tübingen, Germany
| | | | | | - Katharina Feil
- Department of Neurology & Stroke, Eberhard-Karls University, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany
| | - Annerose Mengel
- Department of Neurology & Stroke, Eberhard-Karls University, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany
| | - Ulf Ziemann
- Department of Neurology & Stroke, Eberhard-Karls University, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany
| | - Sven Poli
- Department of Neurology & Stroke, Eberhard-Karls University, Tübingen, Germany
- Hertie Institute for Clinical Brain Research, Eberhard-Karls University, Tübingen, Germany
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Successful Intravenous Thrombolysis and Endovascular Treatment for Acute Ischemic Stroke in a Patient Pretreated with Ticagrelor: A Case Report and Literature Review. Clin Drug Investig 2021; 41:653-657. [PMID: 34109566 DOI: 10.1007/s40261-021-01047-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/26/2021] [Indexed: 10/21/2022]
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